Health inspection·May 2, 2019

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 observation, record review, and staff interview, the facility failed to ensure fall interventions were in place. This affected on (#18) of four residents reviewed for accidents. The facility census was 50. Findings include: Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnosis including fracture of the humerus, left arm, history of falling, osteoarthritis, generalized muscle weakness, insomnia, and difficulty walking. Review of care plan dated 02/10/19 and revised 02/16/19 revealed Resident #18 was at risk for falls due to status post fall with fracture, unsteady gait, use of psychotropic medications, incontinence, impaired safety awareness as resident attempts to transfer self. Interventions included to provide sensor alarm to bed to alert staff of attempted self transfers. Review of 30 day minimum data set (MDS) assessment dated [DATE] revealed severely impaired cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and limited assistance with eating. A wheelchair was utilized for mobility. Review of physician orders dated 04/11/19 revealed Resident #18 was to have a sensor alarm to the bed to alert staff of attempts to transfer/ambulate unassisted. Observation on 04/29/19 at 3:26 P.M. revealed Resident #18 was awake in bed without a sensor alarm to the bed. Resident #18 was unable to be interviewed due to a confused mental status. Resident #18's wheelchair was located next to bed with an alarm located on the wheelchair. Observation on 04/29/19 at 3:33 P.M. revealed Resident #18 had self transferred to the wheelchair. Interview on 04/29/19 at 3:38 P.M. with State Tested Nursing Assistant (STNA) #11 reported Resident #18 was forgetful and self transferred from the bed to the wheelchair. STNA #11 confirmed Resident #18 did not have a sensor alarm in place to the bed to alert staff of attempted self transfers. Page 1 of 3 365652 365652 05/02/2019 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and staff interview, the facility failed to ensure medication administration error rate was five percent (%) or below. 26 medication opportunities were observed with two errors for an error rate of 7.69%. This affected two (#4 and #23) of four residents observed for medication administration. The facility census was 50. Residents Affected - Few Findings include: 1. Observation on 05/01/19 at 8:16 A.M. revealed Licensed Practical Nurse (LPN) #9 administered Calcium 600 milligrams (mg) with Vitamin D 200 international unit (IU) by mouth to Resident #4. Medical record review revealed Resident #4 had a physician order dated 04/11/19 for one tablet of Calcium 600 mg with Vitamin D3 800 IU by mouth daily for osteoporosis. Interview on 05/01/19 at 12:03 P.M., with LPN #9 confirmed Calcium 600 mg with Vitamin D 200 IU was administered to Resident #4 instead of ordered Calcium 600 mg with Vitamin D3 800 IU. 2. Observation on 05/01/19 at 9:39 A.M. revealed LPN #725 administered Fluticasone Propionate nasal spray 50 micrograms (mcg), one spray each nostril, to Resident #23. Medical record review revealed Resident #23 had a physician order dated 01/24/19 for Fluticasone Propionate two sprays in both nostrils once daily for allergic rhinitis. Interview on 05/01/19 at 12:06 P.M. with LPN #725 confirmed Resident #23 received only one spray of Fluticasone Propionate in each nostril instead of the ordered two sprays each nostril. 365652 Page 2 of 3 365652 05/02/2019 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and facility staff interview, the facility failed to maintain separation of clean and soiled linen. This had the potential to affect all 50 residents who reside in the facility. Residents Affected - Many Findings include: Observation of the laundry facility on 04/30/19 with Laundry Worker (LW) #700 at 10:20 A.M. revealed there were 10 bags of hospitality linen (linen for guest who stay at the facility that include sheets, bed spread and towels), seven boxes of various types of round discs that are used on the floor cleaning machine, two plastic containers of drop cloths that are used by maintenance for various projects and two bags of privacy curtains on shelves that were directly across from the washing machines in the washing machine room on the dirty side of the laundry. Interview with LW #700 immediately following the observation confirmed the disc used on the floor cleaning machine that were being stored on the shelves are used throughout the entire building. LW #700 also confirmed the items on the shelves had been stored there for the three years that she had been employed at the facility. The laundry worker confirmed the clean side of laundry started where the dryers were located, and the items are on what was considered the dirty side of laundry. Review of the policy titled Laundry/Linen dated 02/20/2006 revealed to provide a process for the safe and aseptic handling, washing and storage of linen. Separate soiled and clean linen at all times. In the laundry, keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times. 365652 Page 3 of 3