Health inspection·April 12, 2018

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, family and staff interviews, the facility failed to implement their abuse policy when an injury of unknown origin was found on one (#31) of two residents reviewed for skin issues. The facility census was 48. Residents Affected - Few Findings included: Review of Resident #31's medical record revealed an admission date of 06/12/17 with diagnoses including chronic obstructive pulmonary disease (COPD), vascular dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severe cognitive impairment. Interview with Resident #31's family member on 04/10/18 at 11:23 A.M., revealed facility staff had made him aware of a bruise on Resident #31's thigh, however did not provide any other specific information. Observation of wound care for Resident #31 by Licensed Practical Nurse (LPN) #19 and Registered Nurse (RN) #1 on 04/10/18 at 1:51 P.M., revealed a large ecchymotic (bruise) area covering Resident #31's left inner thigh from her groin to her knee. Bruising was also noted to the resident's left outer knee. Interview with RN #1 at the time of the observations revealed the bruising was due to the Resident was on a blood thinner (Coumadin). Interview with the Director of Nursing (DON) and Medical Director #101 on 04/12/18 at 9:39 A.M., revealed the DON stated bruising was not a state reportable incident since the Coumadin caused the bruise. The Medical Director confirmed the bruising of Resident #31's inner thigh was of unknown origin, and he could not say an injury did not occur. Interview with RN #1 on 04/12/18 at 9:56 A.M., who was identified by the DON as the staff member who investigated Resident #31's bruise, revealed she had observed the bruise on 04/09/18 and notified the resident's family and physician. RN #1 revealed she had asked Resident #31 if the bruise occurred during care, and if the bruise hurt, and the resident denied both. RN #1 described the bruise as a large purple oval covering Resident # 31's entire left inner thigh. RN #1 and the DON denied any other investigation, or any interviews were completed to determine the cause of the resident's inner thigh bruising. Interview on 04/12/18 at 10:08 A.M., with the Licensed Nursing Home Administrator (LNHA) revealed he was aware of Resident #31's inner thigh bruise by overhearing a night shift nurse talking about it on the phone. The LNHA was uncertain of the date he became aware of the bruising. She further Page 1 of 9 365652 365652 04/12/2018 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed she did not report the injury of unknown origin due to staff reporting it was due to the resident's condition. The LNHA confirmed the location of Resident #31's bruise met the policy criteria for injury of unknown origin, which required investigation and reporting to Ohio Department of Health. Review of facilities Abuse Policy, (undated), revealed an injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Investigation of injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out abuse: injuries include, but are not limited to, bruising of the inner thigh, chest, face, and breast, bruises of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma. The abuse policy also included to report the results of all investigations to the Administrator or his or her designated representative, and to other officials in accordance with State law, including immediate or 24 hour reporting to the State Survey Agency, law enforcement and the follow up report to the State Agency, within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. 365652 Page 2 of 9 365652 04/12/2018 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, family and staff interviews, the facility failed to report and investigate an injury of unknown origin for one (#31) of two residents reviewed for skin issues. The facility census was 48. Findings included: Review of Resident #31's medical record revealed an admission date of 06/12/17 with diagnoses including chronic obstructive pulmonary disease (COPD), vascular dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severe cognitive impairment. Interview with Resident #31's family member on 04/10/18 at 11:23 A.M., revealed facility staff had made him aware of a bruise on Resident #31's thigh, however did not provide any other specific information. Observation of wound care for Resident #31 by Licensed Practical Nurse (LPN) #19 and Registered Nurse (RN) #1 on 04/10/18 at 1:51 P.M., revealed a large ecchymotic (bruise) area covering Resident #31's left inner thigh from her groin to her knee. Bruising was also noted to the resident's left outer knee. Interview with RN #1 at the time of the observations revealed the bruising was due to the Resident was on a blood thinner (Coumadin). Interview with the Director of Nursing (DON) and Medical Director #101 on 04/12/18 at 9:39 A.M., revealed the DON stated bruising was not a state reportable incident since the Coumadin caused the bruise. The Medical Director confirmed the bruising of Resident #31's inner thigh was of unknown origin, and he could not say an injury did not occur. Interview with RN #1 on 04/12/18 at 9:56 A.M., who was identified by the DON as the staff member who investigated Resident #31's bruise, revealed she had observed the bruise on 04/09/18 and notified the resident's family and physician. RN #1 revealed she had asked Resident #31 if the bruise occurred during care, and if the bruise hurt, and the resident denied both. RN #1 described the bruise as a large purple oval covering Resident # 31's entire left inner thigh. RN #1 and the DON denied any other investigation, or any interviews were completed to determine the cause of the resident's inner thigh bruising. Interview on 04/12/18 at 10:08 A.M., with the Licensed Nursing Home Administrator (LNHA) revealed he was aware of Resident #31's inner thigh bruise by overhearing a night shift nurse talking about it on the phone. The LNHA was uncertain of the date he became aware of the bruising. She further revealed she did not report the injury of unknown origin due to staff reporting it was due to the resident's condition. The LNHA confirmed the location of Resident #31's bruise met the policy criteria for injury of unknown origin, which required investigation and reporting to Ohio Department of Health. Review of facilities Abuse Policy, (undated), revealed An injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury 365652 Page 3 of 9 365652 04/12/2018 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0609 Level of Harm - Minimal harm or potential for actual harm is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Investigation of injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out abuse: injuries include, but are not limited to, bruising of the inner thigh, chest, face, and breast, bruises of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma. Residents Affected - Few 365652 Page 4 of 9 365652 04/12/2018 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews, the facility failed to thoroughly investigate multiple falls for one (#31) of two residents reviewed for falls. The facility census was 48. Findings included: Review of Resident #31's medical record revealed an admission date of 06/12/17 with diagnoses including chronic obstructive pulmonary disease (COPD), vascular dementia, anemia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severe cognitive impairment. Further review of the MDS revealed Resident #31 had falls with, and without injuries. Review of Resident #31's Fall Risk Assessments dated 02/26/18 and 03/22/18 revealed the resident had multiple falls in the last three months. Review of Resident #31's care plan revealed a fall risk plan with interventions including, alarming seat belt, sensor alarm on bed, encourage to reside in common areas, call light in reach, anticipate needs, Dycem to wheelchair, safety education, appropriate footwear, bed bolsters, and review information on past falls to attempt to determine cause of falls. Record possible root causes. Alter, remove any potential causes if possible. Educate resident/family/caregivers/Interdisciplinary team as to the causes. Observation of Resident #31 on 04/10/18 at 12:13 P.M., revealed the resident was up in a wheelchair propelling herself throughout the unit. An alarming Velcro seat belt was observed at the resident's lap and a Dycem (grippy cloth to prevent sliding) could be visualized in the wheelchair seat. Observation of Resident #31's bed revealed an assist bar on each side of her bed, and a bolster on her right side. A fall matt was on the floor beside her bed. Resident #31 was not interviewable, nor could she state what her call light was for. Review of Resident #31's April 2018 physician orders revealed orders related to falls as follows; alarming seat belt to alert staff of attempts to transfer unattended, assist to recliner for restlessness, bed bolsters, bed cane to both sides of bed, Dycem to wheelchair seat, resident to reside in common area after meals due to attempts to self transfer, sensor alarm to bed at all times, and toilet resident after meals. Interview with Registered Nurse (RN) #1 and the Director of Nursing (DON) on 4/12/18 at 11:35 A.M., revealed RN #1 was responsible to investigate facility falls with the DON's oversight. The DON revealed all falls were reviewed every Tuesday by the administrative team, and quarterly by the Quality Assurance (QA) meeting attendees. The following falls were reported and investigated by RN #1 for Resident #31: 1. On 11/17/17 at 6:30 P.M., Resident #31 was found on floor, in her room, next to her wheelchair with no injuries. A sensor alarm was added to her wheelchair. 2. On 12/08/17 at 11:30 P.M., Resident #31 was found on the floor, in her room, bedside her bed, and stated she fell out of bed. A sensor alarm was added to her bed. 3. On 12/08/17 at 2:00 P.M., an alarm sounded and Resident #31 was found on the floor. in her room, 365652 Page 5 of 9 365652 04/12/2018 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0689 and stated she was trying to get to her clothes. A Dycem cushion was added to her wheelchair. Level of Harm - Minimal harm or potential for actual harm 4. On 12/10/17 at 5:30 P.M., an alarm sounded and Resident #31 was found sitting on her floor, stating she wanted to go to bed. An alarming seat belt was added. Residents Affected - Few 5. On 12/31/17 at 9:50 P.M., Resident #31 was found sitting on the floor matt. There was no documentation the alarm was sounding. Neither was the last time the resident was observed by staff documented. Bed bolsters were added. 6. On 01/12/18 at 9:00 A.M., Resident #31's seatbelt alarm was heard and the resident was found on floor in the bathroom. RN #1 stated staff thought she was attempting to transfer to the toilet and prompted toileting, after each meal was added to fall prevention plan. 7. On 02/21/18 at 3:50 P.M., staff heard yelling and found Resident #31 lying on floor, in her room, near her wheelchair. RN #1 verified previous interventions were not documented in the investigation. Keep in common area when up was added to her plan. 8. On 03/22/18 at 1:30 P.M., Resident #31 was found on the floor, on her knees, next to her bed. It was documented the resident wanted to go to bed. The alarm was sounding. It was noted the resident's shoes were off. RN #1 stated the investigation did not document if the resident was toileted after lunch. Transfer to a recliner in common area was added to fall plan. RN #1 confirmed Resident #31 had eight falls over a four month time frame. The DON revealed Resident #31 refused to sit in the recliner, however, there was no documentation of the refusals. Review of Resident #31's care plan with the DON and RN #1 verified interventions of determining root cause and appropriate foot wear were not addressed in seven of the eight fall investigations. The DON also verified the investigations did not address as to where, or what the resident was doing prior to falls. Interview with the DON on 04/12/18 at 12:29 P.M., confirmed none of the physician progress notes mentioned the multiple falls Resident #31 had, nor did fall meeting notes address the resident's multiple falls. 365652 Page 6 of 9 365652 04/12/2018 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews, review of facility's policies, the facility failed to label, date, and store food in a manner to prevent potentially spoiled items from being served to residents. This had the potential to affect all 48 residents in the facility who received meals from the kitchen. Findings included: 1. During the initial tour of the kitchen with the Dietary Manager on 04/09/18 from 7:10 A.M. to 7:35 A.M., multiple food items were observed without labels or dates. Observation of the food in the walk-in refrigerator revealed a cart identified by the Dietary Manager as left-overs. The cart had trays of chicken and beef stew with no dates. A cart identified by the Dietary Manager as a lunch cart for Monday was not dated. A large container of macaroni and cheese, which the Dietary Manager stated was probably for a meal today, was without a date. Containers of applesauce, prunes and potato salad were observed with no dates. There was a bag of Swiss cheese with no date. Diced celery was in a Ziploc bag, with no date, and one bag, not opened from the supplier, contained diced celery that was brown in color. Bags of onions, carrots, strawberries, spring lettuce and spinach had no dates. There were hard boiled eggs, which the Dietary Manager stated should be discarded after two weeks, dated 03/20/18. Observation of the walk-in freezer revealed a bag of polish sausage with an open date of 02/19/18 and a used by date of 03/21/18. Meat that could not be identified by the Dietary Manager was dated 05/15. The Dietary Manger stated she could not clarify if this date was May 15, 2017 or May 2015 stating all I can say is, it is old. Review of the food storage policy for Labeling, Date Marking and Storage of Leftover, Opened Foods, dated 07/03/07, revealed leftovers shall be stored in containers that are covered and labeled indicating the product name, and date the product was originally served. The use by date for the food should be marked for seven calendar days, and all food should be discarded by the use by date. the policy further revealed date marking is required for foods that are considered held under refrigeration for more than a cumulative total of 24 hours before service, and all food should be discarded by the use by date. The policy revealed all foods removed from their original packaging shall be clearly marked to indicate the product name, the date the product was placed in the freezer, and use by date. Further review of the policy revealed all food should be discarded by the use by date. 365652 Page 7 of 9 365652 04/12/2018 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interviews, review of facility policy, the facility failed to identify one (#7) of five residents reviewed for unnecessary medications had been receiving antibiotic eye drops continuously, since admission to the facility. The facility census was 48. Residents Affected - Few Findings included: Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including stroke, osteoarthritis, hypothyroidism, and mood disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had severe cognitive impairment. Review of Resident #7's April 2018 medication list revealed an order for Ciloxan (antibiotic) ointment 0.3%, one centimeter to be placed in each eye three times daily. The Ciloxan order had a start date of 11/22/17 with a diagnosis of cataracts. The medical record included documentation of a pharmacist reviewing all medications monthly. Observation of Resident #7 on 04/10/18 12:08 P.M., revealed both of the resident's eyes were red and moist. Resident #7 denied any eye pain, or discomfort at that time. Subsequent observations of Resident #7 on 4/10/18 and 4/11/18 revealed continued eye redness. On 04/11/18 at 3:47 P.M., interview with the Director of Nursing (DON) regarding the facility's Antibiotic Stewardship Program, denied knowledge of Resident #7 receiving antibiotics. The DON stated she reviews an antibiotic report monthly which was obtained through the facility electronic health records, and an antibiotic report of 3/18/18 did not have Resident #7 listed. The DON revealed all antibiotics, including eye drops were tracked by the facility to ensure appropriateness, correct diagnosis, and ordered for an appropriate duration of time. She further revealed infections were reviewed every Tuesday by the administrative team, and then monthly as part of the facility Antibiotic Stewardship Program. Interview again with the DON on 04/12/18 at 8:46 A.M., confirmed the diagnosis of cataracts was not appropriate for the Ciloxan order for Resident #7, and the Ciloxan order should have a stop date, unless ordered prophylactically. Review of the Medscape (online resource tool for healthcare professionals) revealed Ciloxan was used for gram positive, and gram negative bacterial conjunctivitis, bacterial overgrowth could occur with prolonged use, and usual dosage was a half inch ribbon three times a day for two days, then twice a day, for five days. Review of the facility policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes dated March 2018 revealed, All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include the resident's name and medical record number; unit and room number; date symptoms appeared; name of antibiotic (see approved surveillance list); start date of antibiotic; pathogen identified (see approved surveillance list); site of infection; date of culture; stop date; total days of therapy; outcome; and adverse events. The policy also identified during the drug regimen review, the Consultant Pharmacist will identify, and flag orders for antibiotics that are not consistent with antibiotic stewardship practices. 365652 Page 8 of 9 365652 04/12/2018 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based observation and staff interview, the facility failed to maintain wheelchair arm rests in good repair. This affected two (#11 and #31) of 43 residents identified by the facility who used wheelchairs. The facility census was 48. Residents Affected - Few Findings included: Observation of the wheelchair for Resident #11 on 04/09/18 at 9:34 A.M., revealed both arm rests were torn, and the resident stated he had put tape on them. Observations of the wheelchairs for Resident #11 and Resident #31 on 04/12/18 at 9:30 A.M., revealed both arm rests had cracked areas. During an interview with the Maintenance Director on 04/12/18 at 9:45 A.M., revealed the process for fixing or replacing wheelchair arms was for the nursing staff to complete a work order. He further stated he could check through his work orders, however did not think he had any work order regarding armrests of any wheelchairs. The Maintenance Director stated he usually did repairs right way on armrests so the resident did not get a skin tear, and confirmed both wheelchairs of Resident #11 and #31 needed replaced. 365652 Page 9 of 9