Health inspection·September 12, 2019

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to notify the physician when Resident #20 left on a leave of absence (LOA) without her prescribed continuous oxygen. This affected one of three residents reviewed for respiratory care. The facility census was 65. Findings include: Medical record review revealed Resident #20 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), bipolar disease, and anxiety. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/09/19 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating she was alert, oriented and had intact cognition. The MDS further revealed she was receiving oxygen therapy and had not exhibited any rejection of care behaviors. Review of a physician order, dated 07/09/19, revealed staff were to administer continuous oxygen at one to four liters per nasal cannula, to maintain her oxygen saturation levels above 90%. Review of a nursing progress note, dated 06/05/19, revealed Licensed Practical Nurse (LPN) #22 and the Social Service Worker #61 met with Resident #20 to discuss her upcoming LOA from the facility. The resident was planning to leave on Friday and return to the facility on Sunday. The resident stated that she had all necessary equipment needed for her weekend away from the facility including oxygen. She said she understood the risks of leaving the facility for a long period of time. Review of a nursing progress note, dated 08/02/19 at 8:05 A.M., revealed the resident left the facility for a day at an amusement park with her family and left without the continuous oxygen therapy. The resident was educated on the risks of not having oxygen and she expressed understanding. During interview on 09/09/19 at 12:14 P.M., Resident #20 said she notified the facility, in early June 2019, that her personally owned, portable oxygen concentrator utilized for LOAs was broken and that she did not have another source of portable oxygen to use while out of the facility. Interview on 09/10/19 at 3:36 P.M. with the Director of Nursing (DON) revealed the facility does not allow the residents to take facility provided portable oxygen concentrators out of the building for extended LOA's because the equipment is rented. She confirmed Resident #20 left the faciity on [DATE] without an oxygen concentrator and the physician was not notified. The DON confirmed the LOA was planned and the facility did know the resident's personal oxygen concentrator utilized at home for Page 1 of 11 365766 365766 09/12/2019 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0580 LOAs was broken and that she would be without oxygenation throughout the day at the amusement park. Level of Harm - Minimal harm or potential for actual harm Interview on 09/10/19 at 3:45 P.M. with LPN #17 revealed she was Resident #20's nurse the morning of 08/02/19 when she left the facility for an LOA to the amusement park with her family without portable oxygen. LPN #17 verified Resident #20 had a physician order for continuous oxygen at one to four liters per nasal cannula. LPN #17 confirmed she did not notify the physician Resident #20 was leaving the facility without oxygen. Residents Affected - Few During interview on 09/10/19 at 3:35 P.M., LPN #22 said the facility policy would be to call the physician and notify him of the resident's plan to leave the facility without portable, continuous oxygen as ordered. Review of the facility's policy titled, Medication, Leave of Absence, dated September 2005, revealed the facility will assure that the resident will have necessary medications before leaving the facility on LOA or a therapeutic leave. 365766 Page 2 of 11 365766 09/12/2019 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

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 observation, record review and interview, the facility failed to accurately stage Resident #45's pressure ulcer. This affected one of three residents reviewed for pressure ulcers. The facility census was 65. Residents Affected - Few Findings include: Medical record review revealed Resident #45 was admitted on [DATE] with diagnoses including hemiplegia (weakness affecting one side of the body), dementia, and diabetes mellitus. Review of Resident #45's skin/wound assessment note, dated 08/14/19, revealed a pressure ulcer located on the right buttock. It was listed as a Stage 1, an area of intact skin with a localized area of non-blanchable erythema (redness) which in darker skin tones, may appear with persistent red, blue, or purple hues. Measurements were documented as 0.7 centimeters (cm) long by 0.8 cm wide and 0.2 cm deep. The wound was described as being beefy red with granulation tissue noted. The skin/wound assessment incorrectly identified this pressure ulcer as a Stage 1, which would have intact skin. This assessment indicated the pressure ulcer had depth and the skin was not intact. Review of Resident #45's Pressure Ulcer Tracking Grid, dated 09/11/19, revealed the pressure ulcer on the right buttock was documented as a Stage 1. Measurements recorded were 0.3 cm long by 0.2 cm wide and 0.1 cm in depth. This skin/wound assessment incorrectly identified this pressure ulcer as a Stage 1, although a depth measurement was recorded indicating the skin was not intact. Observation of incontinence care on 09/11/19 at 2:26 P.M., revealed a Stage 2 pressure ulcer (a partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer with a viable, pink or red moist wound bed, or may present as an intact or open/ruptured blister) located on Resident #45's right buttock. Interview with Registered Nurse (RN) #26 on 09/11/19 at 2:53 P.M. revealed Resident #45's pressure ulcer on the right buttock was open with a depth measuring 0.1 cm. RN #26 verified the pressure ulcer was described as a Stage 1 rather than the correct stage, which was a Stage 2. On 09/12/19 at 12:36 P.M., the Director of Nursing (DON) verified Resident #45's pressure ulcer assessments failed to reflect the correct stage of the ulcer, which was a Stage 2 pressure ulcer. 365766 Page 3 of 11 365766 09/12/2019 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

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 observation, record review and interview, the facility failed to ensure fall safety measures were in place and the plan of care updated for a resident with a history of falls. This affected one (Resident #59) of one resident reviewed for accidents. Findings include: Review of Resident #59 revealed an admission date of 02/12/19. Current diagnoses included dislocation of internal right hip prosthesis, high blood pressure, depression, legally blind, abnormal posture, muscle weakness, lack of coordination, displaced fracture of base of neck of right femur, osteoarthritis, senile degeneration of brain, wedge compression fracture of lumbar vertebra, osteoporosis, chronic kidney disease and repeated falls. The admission Morse Fall Risk assessment indicated the resident was a high fall risk due to previous falls, diagnoses, use of wheelchair and weakness while walking. Review of the 08/09/19 quarterly Minimum Data Set (MDS) assessment revealed Resident #59 was severely cognitively impaired for daily decision making, required extensive assistance of two staff for bed mobility, transfers and toileting, had impairment of the leg/foot on one side of the body and had sustained no falls since the last assessment, which was completed 06/11/19. Review of physician orders included an order on 05/07/19 for Resident #59 not to be in her room in her wheelchair unsupervised, secondary to her poor safety awareness; an order on 05/21/19 for the right side of her bed to be against the wall, a stop sign to be placed on the doorway of room, and for the door to her room to be closed she is out of her room; and an order on 08/24/19 for a personal clip alarm to be attacked to Resident #59 when she's in her bed. Record review revealed Resident #59 sustained 15 falls since admission including a fall from bed on 05/03/19 resulting in a closed displaced fracture of the right femoral neck (hip fracture)and a fall on 05/20/19 from bed resulting in a dislocated hip with a likely fracture of the greater trochanter requiring repair. Review of the plan of care related to her high risk for falls initiated 02/13/19 revealed it was not up to date. The 04/26/19 intervention for a three day trial of a passive infrared sensor to her door was not removed. Interventions initiated after a fall on 08/14/19 for staff to toilet Resident #59 before and after meals, after a fall on 08/24/19 for staff to place a blue floor mat to the left side of her bed and after a fall on 09/03/19 for staff to check the resident every hour while in bed were not added to the fall plan of care. Observation on 09/10/19 at 3:18 P.M. revealed Resident #59 was in her low bed on her right side with the blue mat on the floor. The personal alarm box was draped on the wall with a blinking light. The wire to connect the alarm box to the alarm pad was not attached. The check pad light was blinking. Interviews with Licensed Practical Nurse (LPN) #14 and State Tested Nurse Aide (STNA) #47 at that time verified they could not find a pressure mat in the bed or an alarming floor mat to hook the device to the alarm box. STNA #39 revealed the resident was in bed when she arrived at 2:00 P.M. STNA #39 indicated dayshift put her to bed. All of these staff verified Resident #59 was assisted to bed and the physician ordered alarm was not attached. 365766 Page 4 of 11 365766 09/12/2019 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview 09/10/19 at 3:28 P.M. with STNA #46 revealed she had placed the resident in bed around 1:00 P.M. with the assist of a trainee. STNA #46 revealed she had read the memo about what safety devices the resident was to have but misunderstood it as an alarming floor mat which the resident did not have in place. Observations on 09/09/19 at 10:51 A.M., 09/10/19 at 12:37 P.M. and 3:28 P.m. and on 09/11/19 at 11:08 A.M. revealed there was no stop sign on the resident's door and the door was not closed when she was not in the room. On 09/12/19 at 2:31 P.M., the Director of Nursing (DON) and Registered Nurse #83 verified the stop sign was at the nurse's station and was not on Resident #59's door as ordered and the room door was open. The DON indicated Resident #59 had a new roommate and the new roommate had not been asked about closing the door. The DON verified the door had not been closed per plan of care. The DON verified the fall risk care plan had not been updated to include the last four falls that occurred and the passive infrared sensor, which was trialed for three days, had not been removed from the plan of care. Review of the 12/2012 Falls Management policy indicated interventions should be included on the care plan and all ordered devices must be in place as ordered and monitored to ensure they are in working order. 365766 Page 5 of 11 365766 09/12/2019 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide medically-related social services to obtain necessary medical equipment for Resident #20 to use for during a personal leave of absence (LOA) from the facility. This affected one of three residents reviewed for respiratory care. The facility census was 65. Residents Affected - Few Findings include: Medical record review revealed Resident #20 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), bipolar disease, and anxiety. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/09/19 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #20 was alert, oriented and had intact cognition. The MDS further revealed she was receiving oxygen therapy and had not exhibited any rejection of care. Review of a physician order, dated 07/09/19, revealed an order for continuous oxygen at one to four liters per nasal cannula, to maintain oxygen saturation levels above 90%. Review of a nursing progress note, dated 06/05/19, revealed Licensed Practical Nurse (LPN) #22 and the Social Services Worker #61 met with Resident #20 to discuss her upcoming LOA from the facility. The resident was planning to leave on Friday and return to the facility on Sunday. The resident stated that she has all necessary equipment needed for her weekend away from the facility including oxygen and understood the risks of leaving the facility for a long period of time. Review of a nursing progress note, dated 08/02/19 at 8:05 A.M., revealed Resident #20 left the facility for a day at an amusement park with her family. She left the facility without continuous oxygen therapy. The resident was educated on the risks of not having oxygen and she expressed understanding. Review of a nursing progress note, dated 08/03/19 at 7:30 A.M., revealed during the early morning of 08/03/19, the night shift nurse received a call from Resident #20, who was staying with her daughter following a trip to the amusement park the previous day. Resident #20 complained of shortness of breath and she was advised to call 911. Review of a psychosocial progress note, dated 08/06/19, revealed Resident #20 had been admitted to the hospital for her COPD and social services would assist with readjustment upon readmission to the facility. During interview on 09/09/19 at 12:14 P.M., Resident #20 revealed that she notified the facility, in early June 2019, that her personally owned, portable oxygen concentrator was broken and that she did not have another source of oxygen while out of the facility on LOA's with her family. She said Business Office Manager #64 told her that the facility could not allow her to take the oxygen concentrator from the building, for a LOA, because it was rented and could accidentally be broken. Resident #20 said she had spoken with the Business Office Manager #64 and requested assistance with the repair of her portable oxygen concentrator, but was informed that the facility would not cover this expense. Resident #20 said Business Office Manager #64 did not refer her to social services or provide 365766 Page 6 of 11 365766 09/12/2019 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0745 any additional assistance to obtain a portable oxygen concentrator for personal LOAs. Level of Harm - Minimal harm or potential for actual harm Interview on 09/10/19 at 3:36 P.M. with the Director of Nursing (DON) revealed the facility does not allow the residents to take the facility-provided portable oxygen concentrators out of the building for extended leaves, because the equipment is rented. She confirmed Resident #20 left the faciity on [DATE] without a portable oxygen concentrator to go to the amusement park. The DON confirmed the LOA was planned and the facility did know the resident's personal oxygen concentrator, utilized for LOAs, was broken and that she would be without oxygenation throughout the day, until her planned return to the facility later that night. Residents Affected - Few During interview on 09/11/19 at 10:15 A.M., Business Office Manager #64 revealed on the morning of 08/03/19, she was notified by Resident #20's daughter that the facility was restricting her mother from leaving the facility to visit family by not assisting with the provision of portable, continuous oxygen for LOAs. Business Office Manager #64 confirmed that she did not refer the resident to social services or speak to any administrative staff regarding Resident #20's need for assistance for the repair or for obtaining a portable oxygen concentrator for non-medical LOAs. Review of the facility's policy titled, Medication, Leave of Absence, dated September 2005, revealed the facility will assure that the resident will have necessary medications before leaving the facility on an LOA or therapeutic leave. 365766 Page 7 of 11 365766 09/12/2019 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and interview, the facility failed to ensure the attending physician documented rationale in the resident's medical record when declining recommendations by the pharmacist. This affected one (Resident #22) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #22 revealed an admission date of 04/26/17 with diagnoses including vascular dementia with behavioral disturbance, depression, insomnia, dementia with psychosis, and vascular dementia with delusions and delusional disorder. Review of the 07/10/19 quarterly minimum data set assessment revealed the resident was moderately cognitively impaired for daily decision making and displayed no behaviors. This assessment indicated Resident #22 had moods including having little interest or pleasure in doing things, feeling down, and feeling tired or having little energy. There was no evidence of hallucinations, delusions or behaviors. Resident #22 was coded as receiving antipsychotic, antidepressant medications in the seven day look back period. Physician orders included a 11/11/17 order for Remeron, 45 milligrams (mg) for depression and an order on 11/13/17 for Seroquel, an antipsychotic, 25 mg three times a day for vascular dementia. The pharmacy recommendation from 10/09/18 recommended they attempt a dose reduction for the antipsychotic medication, Seroquel 25 mg. The recommendation requested documentation for the clinical reasoning if the dose reduction could not be attempted. The physician wrote, NNO, which means no new orders. No clinical reasoning or rationale was documented. The pharmacy recommendation from 02/07/19 recommended a dose reduction for the antidepressant, Remeron 45 mg daily. The recommendation requested documentation for the clinical reasoning if the dose reduction could not be attempted. The physician wrote, NNO. No clinical reasoning or rationale was documented. The pharmacy recommendation from 04/11/19 again recommended a dose reduction for the medication Seroquel 25 mg. The recommendation requested documentation for the clinical reasoning if the dose reduction could not be attempted. The physician wrote, NNO on Seroquel. No clinical reasoning or rationale was documented. Interview on 09/11/19 at 5:29 P.M. with Registered Nurse (RN) #83 verified there was no rationale given when the physician declined the gradual dose reductions (GDR) for Seroquel and Remeron. There was no evidence a GDR was attempted for the Remeron medication since it was started on 10/09/17. Review of the facility's 01/2014 Antipsychotic Drug Protocol revealed, A gradual dose reduction means, for the purposes, tapering the resident's daily dose to determine if the resident's symptoms can be controlled with a lower dose or to determine if the dose can be eliminated altogether. At a minimum, a resident with a stable condition should be tapered (after no more than six months of therapy) at a minimum of 25 percent (approximately) of the initial dose per month. 365766 Page 8 of 11 365766 09/12/2019 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

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. Based on record review and interview, the facility failed to ensure gradual dose reductions were attempted for antipsychotic medications and failed to monitor behaviors for Resident #22. This affected one of five residents reviewed for unnecessary medications. Findings include: Review of Resident #22 revealed an admission date of 04/26/17 with diagnoses including vascular dementia with behavioral disturbance, depression, insomnia, dementia with psychosis, and vascular dementia with delusional and delusional disorder. A diagnosis of dementia with psychosis was added 05/09/17. Physician orders included an order on 11/11/17 for Remeron, an antidepressant, 45 milligrams (mg) for depression and an order on 11/13/17 for Seroquel, an antipsychotic, 25 mg three times a day for vascular dementia with behavioral disturbance. On 11/27/17 a physician progress note indicated Resident #22 had vascular dementia with delusions and delusional disorder. Pharmacy recommendations on 10/09/18 and 04/11/19 recommended the physician attempt a dose reduction for the antipsychotic, Seroquel 25 mg. These recommendations were declined by the physician without any rationale. On 02/07/19, the pharmacist recommended a dose reduction of the antidepressant, Remeron 45 mg. This recommendation was declined by the physician without any rationale. The 03/28/19 plan of care addressed the psychotropic medication, Seroquel, related to behavior management, due to delusional disorders and psychosis. Interventions included monitoring target behaviors of being demanding of staff, repetitive requests without need and inappropriate response to verbal communication. Review of behavior charting for July 2019 revealed there were four days when behaviors were documented. Resident #22 was described as agitated on the afternoon shift on 07/01/19 with staff intervention including redirection and 1:1 care; on 07/04/19 Resident #22 was described as being agitated and demanding on the day and afternoon shift with staff redirecting, calming 1:1 intervention and removal to a low stimulation area with diversion; and on 07/13/19 and 07/14/19 Resident #22 was described as being demanding with staff interventions including redirection, calm with 1:1, remove to low stimulation and diversion. There were no behaviors documented by nursing staff for Resident #22 in August or September of 2019. There were no behaviors documented by the state tested nursing assistants in the last 30 days in their kiosk documentation. There was no evidence facility staff monitored Resident #22 for delusions, as a targeted behavior associated with the psychosis. There was no documentation of any delusions in the medical record. Review of the 07/10/19 quarterly minimum data set assessment revealed the resident was moderately 365766 Page 9 of 11 365766 09/12/2019 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0758 Level of Harm - Minimal harm or potential for actual harm cognitively impaired for daily decision making with no signs or symptoms of behaviors. Resident #22 was documented as having little interest or pleasure in doing things, feeling down, and feeling tired or having little energy. There was no documentation Resident #22 had hallucinations, delusions or behaviors. This assessment indicated Resident #22 received antipsychotic and antidepressant medications in the last seven day review period. Residents Affected - Few There was no evidence of any attempt of a gradual dose reduction of the antidepressant medication, Remeron, since the medication was started on 10/09/17. There was no evidence of any attempt of a gradual dose reduction of the antipsychotic medication, Seroquel, since 11/11/17. Interview 09/11/19 at 5:29 P.M. with RN #83 verified there was no evidence of monitoring for delusional behaviors related to the use of the antipsychotic Seroquel. RN #83 verified no dosage reductions were attempted for Remeron since 10/09/17 or for Seroquel since 11/11/17. Review of the facility's 01/2014 Antipsychotic Drug Protocol revealed, A gradual dose reduction means, for the purposes, tapering the resident's daily dose to determine if the resident's symptoms can be controlled with a lower dose or to determine if the dose can be eliminated altogether. At a minimum, a resident with a stable condition should be tapered (after no more than six months of therapy) at a minimum of 25 percent (approximately) of the initial dose per month. 365766 Page 10 of 11 365766 09/12/2019 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

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 staff interview, the facility failed to properly disinfect the blood sugar testing device, a glucometer. This had the potential to affect eight residents (Resident's #16, #29, #41, #49, #52, #54, #65 and #169) receiving glucometer testing with the glucometer in the medication cart for the East hall and [NAME] short hall. The facility census was 65. Residents Affected - Some Findings include: Observation on 09/10/19 at 3:33 P.M. of glucometer testing, blood sugar testing, was conducted with Licensed Practical Nurse (LPN) #14 on the [NAME] hall. There was one glucometer in the medication cart for use for the residents who received medications from the cart. The cart was used for medications for residents residing on the East and [NAME] halls. LPN #14 indicated the meter had already been cleaned. LPN #14 performed a glucometer test on Resident #29. LPN #14 returned to the medication cart, opened the bottom drawer and pulled out a Clorox bleach wipe manufactured for Clorox Professional Products Company. LPN #14 wiped the surfaces of the outside of the glucometer for less than 10 seconds and placed it on a tissue on the top of the medication cart. LPN #14 threw the bleach wipe in the trash. Observation of the glucometer revealed the glucometer appeared dry in about 15 seconds. The glucometer was picked up and was dry. When asked, LPN #14 verified he/she was unaware of the required contact time for the bleach wipe or any specific amount of contact time needed for proper disinfection of the glucometer. Review of the manufacturer guidelines for the Clorox Healthcare Bleach Germicidal wipes included wipe surface to be disinfected. Use enough wipes for treated surface to remain visibly wet for the contact time listed below. The chart indicated for bloodborne pathogens there should be a one minute contact time. Treated surface must remain visibly wet for a full four minutes. It said to use additional wipes if needed to assure continuous four minute wet contact time. Interview on 09/10/19 at the time of the observation with LPN #14 verified the meter was cleaned with a wipe for several seconds, placed on a tissue and allowed to quickly dry. The process did not meet the manufacturer guidelines for proper disinfection. This had the potential to affect Resident's #16, #29, #41, #49, #52, #54, #65 and #169 who received blood sugar testing with this glucometer from the medication cart for the East and [NAME] short hall. 365766 Page 11 of 11