Health inspection·July 27, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, staff interview, and policy review, the facility failed to ensure treatments for a pressure ulcer were provided as ordered. This affected one (Resident #8) of one resident reviewed for pressure ulcers. The facility census was 35. Residents Affected - Few Findings include: Review of the medical record for Resident #8 revealed an admission date of 01/25/23, with medical diagnoses of chronic respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and required extensive staff assistance with bed mobility, transfers, incontinence cares, and bathing. Resident #8 was frequently incontinent of bowel, and had an indwelling catheter. Further review of the medical record revealed Resident #8 had a Stage IV pressure ulcer to the sacrum. Review of the Resident #8's physician's orders revealed an order dated 03/15/23 to cleanse sacrum, apply solution soaked kerlix, cover with ABD pad and secure with tape every day and every evening shift. Further review revealed the wound care order was changed on 06/28/23. Review of the March 2023 TAR revealed Resident #8 did not receive treatment to the sacrum pressure ulcer as ordered on 03/05/23, 03/09/23, 03/17/23, 03/26/23, and 03/31/23. Review of the April 2023 TAR revealed Resident #8 did not receive treatments to the sacrum pressure ulcer as ordered on 04/10/23, 04/11/23, 04/14/23, and 04/23/23. Review of the May 2023 TAR revealed Resident #8 did not receive treatments to the sacrum pressure ulcer as ordered on 05/16/23 and 05/20/23. Review of the June TAR revealed Resident #8 did not receive treatments to the sacrum pressure ulcer as ordered on 06/03/23 and 06/27/23. Further review of the medical record for Resident #8 revealed the sacrum wound was evaluated weekly by the wound physician, who documented multiple episodes of debridement of the sacral pressure ulcer from February 2023 to July 2023. Review of the wound physician note dated 07/18/23 revealed Resident #8 had a Stage IV pressure ulcer to sacrum which measured 3.5 cm by 2.7 cm x 3.5 cm and the ulcer had improved. Interview on 07/26/23 at 9:09 A.M. with the Director of Nursing (DON) confirmed Resident #8 did not receive the treatment to his sacral pressure as ordered on the dates stated above in March, April, Page 1 of 9 365744 365744 07/27/2023 Roselawn Manor 420 East Fourth Street Spencerville, OH 45887

F 0686 May, and June 2023. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, Pressure ulcer, revised April 2016, stated all residents with a pressure ulcer would receive interventions and monitoring to promote healing, prevent infection, and prevent new ulcers from developing. Residents Affected - Few 365744 Page 2 of 9 365744 07/27/2023 Roselawn Manor 420 East Fourth Street Spencerville, OH 45887

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure enteral nutrition (tube feeding) was provided as ordered by the physician. This affected one (Resident #193) of two residents reviewed for enteral nutrition. The facility census was 35. Findings include: Review of the medical record for Resident #193 revealed an admission date of 06/27/23 with diagnoses of seizures, gastrostomy (an opening in the stomach for a feeding tube) status, and anoxic brain damage. Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #193 was in a comatose state and was totally dependent on staff for receiving nutrition. Review of the physician order dated 06/27/23 revealed Resident #193 received tube feeding formula Impact Peptide 1.5, 225 milliliters (ml) every four hours via bolus feeding, scheduled at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. daily. Review of the administration times of the tube feeding formula from 07/12/23 to 07/25/23 revealed thirteen instances when the tube feeding was administered late: 07/12/23 scheduled at 12:00 A.M., given at 1:17 A.M. 07/13/23 scheduled at 8:00 A.M., given at 11:53 A.M. 07/13/23 scheduled at 4:00 P.M., given at 5:19 P.M. 07/13/23 scheduled at 12:00 A.M., given at 1:47 A.M. 07/14/23 scheduled at 4:00 A.M., given at 6:18 A.M. 07/14/23 scheduled at 8:00 A.M., given at 10:03 A.M. 07/14/23 scheduled at 12:00 P.M., given at 1:25 P.M. 07/15/23 scheduled at 12:00 P.M., given at 1:19 P.M. 07/15/23 scheduled at 4:00 P.M., given at 5:35 P.M. 07/16/23 scheduled at 4:00 P.M., given at 5:19 P.M. 07/19/23 scheduled at 4:00 A.M., given at 6:10 A.M. 07/19/23 scheduled at 12:00 P.M., given at 2:09 P.M. 07/20/23 scheduled at 12:00 P.M., given at 1:28 P.M. 365744 Page 3 of 9 365744 07/27/2023 Roselawn Manor 420 East Fourth Street Spencerville, OH 45887

F 0693 Review of Resident #193's weight history revealed no concerns regarding weight changes. Level of Harm - Minimal harm or potential for actual harm Interview on 07/27/23 at 12:15 P.M. with the Director of Nursing (DON) confirmed 13 instances when tube feeding for Resident #193 was given late. Further interview confirmed tube feeding administration times would follow the standard of practice of the medication must be administered within one hour before or after the scheduled time. Residents Affected - Few Review of the facility policy, Specific Procedures for All Medications, revised 10/17/07, revealed no guidance regarding administration times for medications. 365744 Page 4 of 9 365744 07/27/2023 Roselawn Manor 420 East Fourth Street Spencerville, OH 45887

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a Gradual Dose Reduction (GDR) was attempted on a psychotropic medication in the past year. This affected one (Resident #2) of five residents reviewed for GDRs. The facility census was 35. Findings include: Review of the medical record for Resident #2 revealed an admission date of 01/18/21 with a diagnosis of depression. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 had severely impaired cognition and received an antidepressant. Review of a physician order dated 01/19/21 revealed Resident #2 received Celexa (an anti-depressant) 20 milligrams (mg) by mouth once daily for depression. Review of a Note to Attending Physician/Prescriber form dated 12/30/21 revealed the pharmacist recommended the physician review Resident #2's order for citalopram (generic Celexa) 20 mg. Further review revealed the physician reviewed and signed the form on 01/06/22 and determined Resident #2 was stable on the current dose and was not appropriate for a GDR at that time. Interview on 07/27/23 at 2:29 P.M. with the Director of Nursing confirmed no recommendation for or attempt of a GDR for Resident #2's Celexa was completed since 01/06/22. 365744 Page 5 of 9 365744 07/27/2023 Roselawn Manor 420 East Fourth Street Spencerville, OH 45887

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to administer anti-convulsant medications per physician order. This affected one (Resident #193) of ten residents reviewed for medication administration. The facility census was 35. Residents Affected - Few Findings include: Review of the medical record for Resident #193 revealed an admission date of 06/27/23 with diagnoses of seizures, gastrostomy (an opening in the stomach for a feeding tube) status, and anoxic brain damage. Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #193 was in a comatose state and was totally dependent on staff for all activities of daily life. Review of a physician order dated 06/27/23 revealed Resident #193 received phenytoin (an anti-convulsant medication) 125 milligrams (mg) per 5 milliliters (ml) oral suspension, give 10 ml via percutaneous gastrostomy (PEG) tube three times daily for seizures. The doses were scheduled for morning (4:00 A.M. to 6:00 A.M.), lunch (11:00 A.M. to 1:00 P.M.) and evening (8:00 P.M. to 10:00 P.M.). Special instructions were to hold the tube feeding (TF) one hour before and one hour after the dose of phenytoin. Review of a physician order dated 06/27/23 revealed Resident #193 received TF formula Impact Peptide 1.5, 225 ml every four hours via bolus feeding, scheduled at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. daily. Further review of the physician orders for Resident #193 revealed an order for Dilantin (phenytoin) laboratory level to be drawn at one month after admission, ordered for 07/28/23. Review of the phenytoin and tube feeding administration times from 07/12/23 through 07/24/23 revealed 21 instances (of 41 opportunities) when phenytoin was given within one hour of the TF: Tube feed given on 07/12/23 at 7:58 P.M. Phenytoin given on 07/12/23 at 8:03 P.M. Tube feed given on 07/13/23 at 11:53 A.M. Phenytoin given on 07/13/23 at 12:03 P.M. Tube feed given on 07/13/23 at 7:50 P.M. Phenytoin given on 07/13/23 at 7:54 P.M. Tube feed given on 07/14/23 at 8:24 P.M. Phenytoin given on 07/14/23 at 8:26 P.M. 365744 Page 6 of 9 365744 07/27/2023 Roselawn Manor 420 East Fourth Street Spencerville, OH 45887

F 0760 Tube feed given on 07/15/23 at 1:19 P.M. Level of Harm - Minimal harm or potential for actual harm Phenytoin given on 07/15/23 at 1:21 P.M. Tube feed given on 07/16/23 at 3:52 A.M. Residents Affected - Few Phenytoin given on 07/16/23 at 4:33 A.M. Tube feed given on 07/16/23 at 12:54 P.M. Phenytoin given on 07/16/23 at 12:56 P.M. Tube feed given on 07/16/23 at 7:38 P.M. Phenytoin given on 07/16/23 at 7:41 P.M. Tube feed given on 07/17/23 at 11:28 A.M. Phenytoin given on 07/17/23 at 11:29 A.M. Tube feed given on 07/17/23 at 9:02 P.M. Phenytoin given on 07/17/23 at 9:05 P.M. Tube feed given on 07/18/23 at 3:59 A.M. Phenytoin given on 07/18/23 at 3:59 A.M. Tube feed given on 07/18/23 at 11:48 A.M. Phenytoin given on 07/18/23 at 11:49 A.M. Tube feed given on 07/19/23 at 7:50 P.M. Phenytoin given on 07/19/23 at 7:53 P.M. Tube feed given on 07/20/23 at 1:28 P.M. Phenytoin given on 07/20/23 at 1:30 P.M. Tube feed given on 07/21/23 at 4:16 A.M. Phenytoin given on 07/21/23 at 4:17 A.M. Tube feed given on 07/21/23 at 11:58 A.M. Phenytoin given on 07/21/23 at 11:59 A.M. Tube feed given on 07/22/23 at 12:38 P.M. 365744 Page 7 of 9 365744 07/27/2023 Roselawn Manor 420 East Fourth Street Spencerville, OH 45887

F 0760 Phenytoin given on 07/22/23 at 12:38 P.M. Level of Harm - Minimal harm or potential for actual harm Tube feed given on 07/22/23 at 7:23 P.M. Phenytoin given on 07/22/23 at 7:27 P.M. Residents Affected - Few Tube feed given on 07/23/23 at 12:37 P.M. Phenytoin given on 07/23/23 at 12:37 P.M. Tube feed given on 07/23/23 at 8:16 P.M. Phenytoin given on 07/23/23 at 8:20 P.M. Tube feed given on 07/24/23 at 4:02 A.M. Phenytoin given on 07/24/23 at 4:42 A.M. Tube feed given on 07/24/23 at 8:11 P.M. Phenytoin given on 07/24/23 at 8:13 P.M. Review of the progress notes for Resident #193 from admission to current revealed no seizure incidents. Interview on 07/27/23 at 10:34 A.M. with the Director of Nursing confirmed the phenytoin doses and TF administration occurred without holding the TF for one hour before and after phenytoin administration as ordered on 21 occurrences for the above dates and times between 07/12/23 and 07/24/23. Review of the facility policy, Specific Procedures for All Medications, dated 10/17/07, revealed staff should read the medication label instructions three times prior to administration, and follow administration instructions. 365744 Page 8 of 9 365744 07/27/2023 Roselawn Manor 420 East Fourth Street Spencerville, OH 45887

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff performed proper hand hygiene when preparing meals. This specifically affected one (Resident #16) and had the potential to affect all residents in the facility except seven residents (#22, #31, #32, #33, #34, #36, and #193) identified to receive no meals from the kitchen. The facility census was 35. Findings include: Review of the medical record for Resident #16 revealed an admission date of 08/16/18 with diagnoses of anemia and diabetes. Review of the physician order dated 06/21/23 revealed Resident #16 received a Consistent Carbohydrate Diet (CCD) with mechanical soft textures and thin liquids. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #16 had moderate cognitive impaired and required supervision with setup assistance for eating. No swallowing or weight loss concerns were identified. Observations on 07/26/23 beginning at 11:02 A.M. revealed [NAME] #100 wearing plastic gloves and touching serving utensils for the regular texture chicken and noodles, mechanically altered chicken and noodles, mashed potatoes, green beans, touching plates, and repeatedly opening lids on the steam table. Observation on 07/26/23 at 11:09 A.M. revealed [NAME] #100, wearing the same gloves, opening a bag of hot dog buns, removing a bun from the bag with her gloved hands, opening the bun, and touching the steam table lid to uncover the mechanically altered bratwurst, using a utensil to scoop the bratwurst into the bun, while holding the bun steady with her gloved hand, scooping mashed potatoes onto the plate and handing the plate to the dietary aide to place on the tray cart. Continued observation revealed dietary staff took the cart from the kitchen and delivered it to the hall. Interview on 07/26/23 at 11:11 A.M. with [NAME] #100 confirmed she touched the bun for Resident #16 with the same gloves she had worn while touching serving utensils, plates, and steam table lids. [NAME] #100 further confirmed she should have performed hand hygiene prior to touching Resident #16's ready-to-eat hotdog bun. Further observation revealed [NAME] #100 did not recall Resident #16's meal tray from the tray cart. Observation on 07/26/23 at 11:27 A.M. revealed Resident #16 in his room with a meal tray on his overbed table. Resident #16's plate was empty and spillage from his ground bratwurst was on his gown. Interview at that time with Resident #16 revealed he ate, and enjoyed, the ground bratwurst served in the hotdog bun. Review of the facility policy, Handwashing, revised March 2017, revealed food handlers must wash their hands after touching anything that may contaminate hands, such as dirty equipment, work surfaces, or towels. 365744 Page 9 of 9