Health inspection·May 23, 2019

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 and staff interview the facility failed to provide restorative services as directed for Resident #12. This affected one ( Resident #12) of three reviewed for restorative and range of motion services. Residents Affected - Few Findings include: A medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, atrial fibrillation, dementia, chronic obstructive pulmonary disease, muscle weakness, intervertebral disc degeneration, cardiac pacemaker, and osteoporosis. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #12 had moderately impaired cognition, required extensive assistance of one to two staff members for activities of daily living, had falls prior to admission, and was not receiving physical therapy, occupational therapy, or restorative programs. Review of the restorative program evaluation dated 04/02/19 revealed the referral was made from therapy for Resident #12. The resident needed a range of motion (ROM) program to be provided six to seven days a week for 15 minutes related to reliance on other and the wheelchair. The resident was at risk for a decline related to reliance on others and would show no decline as evident by continuing to assist with dressing Review of the restorative program evaluation dated 04/02/19 revealed the referral was made from therapy for Resident #12. The resident needed an ambulation program six to seven days a week for 15 minutes. The resident was at risk for a decline related reliance on wheelchair and others. The resident was to show no decline as evident by continuing to ambulate with limited assistance. The plan of care dated 04/02/19 revealed Resident #12 required an active ROM and ambulation restorative programs related to reliance on others and the wheelchair. Review of the Restorative programs task manager for Point click care (electronic records) revealed active ROM was attempted with Resident #12 on 04/03/19, 04/04/19, 04/05/19, 04/08/19, 04/09/18, 04/10/19, 04/12/19, 04/13/19, 04/14/19, 04/16/19, 04/17/19, 04/21/19, 04/22/19, and 04/23/19. This equaled five days for the weeks of 04/07/19 to 04/13/19 and three days for the weeks of 04/14/19 to 04/20/19. Review of the Restorative programs task manager for Point Click Care (electronic records) revealed ambulation was attempted with Resident #12 on 04/04/19, 04/08/19, 04/09/19, 04/10/19, 04/12/19, Page 1 of 5 365695 365695 05/23/2019 Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 04/14/19, 04/16/19, 04/07/19, 04/21/19, and 04/23/19. This equaled two four days for the weeks of 04/07/19 to 04/13/19 and three days for the weeks of 04/14/19 to 04/20/19. An interview on 05/23/19 at 12:13 P.M. revealed Registered Nurse (RN) #302 confirmed Resident #12 was to have ROM six to seven days a week and ambulation six to seven days a week. RN #302 indicated there was only one restorative aide and she only worked 5 days a week. The other aides were to pick up the other days and they did not always document when they provided restorative programs. RN #12 verified there was no evidence Resident #12 received restorative services six to seven days a week. 365695 Page 2 of 5 365695 05/23/2019 Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230

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. Based on medical record review and staff interview, the facility failed to ensure new fall interventions were implemented following a resident fall. This affected one (Resident #63) of six residents reviewed for falls. The facility census was 71. Findings include: Review of Resident #63's medical record revealed an admission date of 01/18/19 with diagnoses that included Alzheimer's disease with dementia. A fall risk assessment completed upon admission identified the resident as being at high risk for falls. An admission Minimum Data Set (MDS) assessment identified Resident #76 as having a severely impaired cognition level, requiring extensive staff assistance with transfers and required limited assistance with ambulation. Further review of the medical record identified a fall by Resident #76 on 01/20/19 during independent transfer and ambulation in her room. Review of the progress notes and facility fall investigation found no evidence of any new interventions put into place to prevent future falls. The fall investigation only identified immediate interventions that were put into place such as ice applied, steri-strips applied to a laceration, neurological checks, continued bed alarm use and one on one observation after the fall. On 05/22/19 at 12:30 P.M., interview with the Director of Nursing verified no new intervention was put into place after the fall to prevent Resident #63 from future falls. 365695 Page 3 of 5 365695 05/23/2019 Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230

F 0692 Provide enough food/fluids to maintain a resident's health. 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 and staff interview, the facility failed to ensure supplement administration and intake amount was accurately documented. This affected one (Resident #50) of four residents reviewed for weight loss. The facility census was 71. Residents Affected - Few Findings include: Review of Resident #50's medical record revealed an admission date of 06/21/17 and readmission date of 05/16/19 with diagnoses that included Alzheimer's disease with dementia. Review of weights for Resident #50 identified an 8.3% weight loss over six months on 05/02/19. On 11/02/18 the resident weighed 173 pounds and on 05/02/19 the resident weighed 158.6, a 14.4 pound loss or -8.3%. Further review of the medical record found a dietary note on 05/09/19 addressing the weight loss pattern. The dietician recommended a change in nutritional supplements from Two Cal HN (nutritional supplement drink) 120 milliliters (ml) twice daily to a Frosty Cup (enriched protein ice cream supplement) at dinner and Nutritious Juice drink (nutritional supplement drink) every morning. Review of the physician's orders revealed the Frosty Cup and Nutritious Juice drink supplements were initiated on 05/10/19 at 8:10 A.M. Further review of the medical record revealed Resident #50 was admitted to the hospital on [DATE] at 10:00 P.M. and readmitted to the facility on [DATE] at 5:30 P.M. Review of the supplement administration and intake percentage records under the State Tested Nurse Aide (STNA) Tasks for the period of 05/10/19 to 05/22/19 (Resident #50 was admitted to the hospital 05/11/19 to 05/16/19 and the dates of 05/12/19 to 05/16/19 were not reviewed) revealed supplements were provided with meals on 05/16/19 supper, 05/20/19 lunch, 05/20/19 supper, 05/21/19 lunch and 05/21/19 supper. No evidence was found supplements were provided on 05/10/19, 05/11/19, 05/17/19, 05/18/19, 05/19/19. Additionally, intake amount was completed for supplement one and not supplement two. The information did not identify which supplements were supplement one and supplement two. Interview with the Director of Nursing on 05/22/19 at 12:35 P.M. verified the supplements were not documented as administered on 05/10/19, 05/11/19, 05/17/19, 05/18/19 and 05/19/19. She also verified the supplement intake amount records were recorded only for supplement one and did not indicate which supplement was supplement one and supplement two. 365695 Page 4 of 5 365695 05/23/2019 Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation of posted staffing information, facility policy review and staff interview the facility failed to update the required posted staffing information. This had the potential to affect ass 71 residents currently residing in the facility. Residents Affected - Few An observation on 05/20/19 at 8:40 A.M. of the staffing information posted on the bulletin board revealed it was dated 05/17/19. An interview on 05/20/19 at 8:40 A.M. Secretary #300 verified the posted staffing information was dated 05/17/19. An interview on 05/21/19 at 8:00 A.M. with the Administrator revealed indicated the State Tested Nursing Assistant (STNA) coordinator had taken the weekend staffing down to update them. She verified they had not been updated over the weekend. She verified there was a manager in the building on the weekends who could have updated the required nurse hours posting but had not done so. An interview on 02/21/19 at 8:06 A.M. STNA Coordinator indicated she would post the required nursing hours for Friday Saturday, Sunday, and Monday on Friday. Review of the facility policy dated 01/18, Daily Staff Posting, revealed it was the policy of the facility to follow regulation (483.35) for posting of daily staffing. The posting would include the date, the facility census, the number of staff and total hours schedule of direct care staff, nurses and STNA's for each shift. The posting would be changed daily in the morning by the assigned staff member. The facility would retain this data for a minimum of 18 months. 365695 Page 5 of 5