Health inspection·March 1, 2024

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 record review, abuse policies review, resident council minutes review, written statements review and interview, the facility failed to ensure allegations of verbal allegations were reported to the Administrator in a timely manner and failed to ensure the allegations were reported to the State Survey Agency. This affected two (Residents #1 and #28) of 12 residents interviewed regarding abuse. The facility census was 62. Findings include: 1. Review of Resident #28's open medical record revealed diagnoses including irritable bowel syndrome with diarrhea, obsessive compulsive disorder ( long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both.), somatization disorder (a form of mental illness that causes one or more bodily symptoms, including pain. The symptoms may or may not be traceable to a physical cause.), adjustment disorder with mixed anxiety and depressed mood, histrionic disorder (personality disorder characterized by a pattern of excessive attention-seeking behaviors), and narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance). Review of an annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 had adequate hearing with no hearing devices, was able to make himself understood and was able to understand others. Resident #28 was assessed as cognitively intact. During an interview on 02/27/24 which began at 10:27 A.M., Resident #28 stated the facility had suddenly required two nursing assistants to provide incontinence care for him although he was able to turn in bed and maintain position. Resident #28 stated two staff entered the room one day, with one of the staff members telling the other to just stand there because she was able to provide the incontinence care herself. Resident #28 stated on 02/22/24 State Tested Nursing Assistant (STNA) #100 and STNA #105 entered the room to provide incontinence care. Resident #28 requested STNA #100 provide care and STNA #105 only be in the room to watch. STNA #100 claimed she was going to report this to the Administrator because it meant she had to do all the work. Resident #28 alleged when STNA #100 and STNA #105 left the room he heard STNA #100 state (expletive) you but that she said the actual word. Resident #28 stated he believed it was directed toward him. In regard to the allegation of verbal abuse that Resident #28 stated he heard toward himself on 02/22/24, the facility's self-reported incidents were reviewed with none having been submitted since 10/10/23. Page 1 of 12 365766 365766 03/01/2024 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/27/24 at 3:03 P.M., Corporate Registered Nurse (RN) #110 verified Resident #28 made the allegation of a staff member stating (expletive) you toward him after leaving Resident #28's room. Corporate RN #110 indicated she told Resident #28 she was required to report the allegation and she phoned the facility and reported the allegation to the Director of Nursing (DON) and Administrator. Corporate RN #110 stated she visited the facility later that day and was told by the Administrator that he handled it and his investigation had indicated it had not happened. Corporate RN #110 verified the facility had failed to report the allegation of verbal abuse to the State survey agency. Review of the facility's Resident Abuse Prevention Practices Policy (revised September 2019) revealed verbal abuse was identified as any use of oral, written, or gestured language that willfully included disparaging and/or derogatory terms to the residents or their families or within hearing distance, regardless of their age, ability to comprehend or disability. An allegation of abuse was required to be reported to the State Agency and all regulatory agencies as required by law. Review of the facility's Abuse Allegation Investigation Policy, dated October 2022, revealed the Administrator or designee was responsible for ensuring the allegation was reported to the State agency. After an investigation was completed and findings were documented, a final report was to be submitted to the State Agency. 2. Review of Resident Council Minutes dated 12/28/23 indicated a resident reported an STNA verbally abused her and noted the Director of Nursing (DON) was notified. The Problem/Complaint Intake Form generated 12/29/23 indicated Resident #1 stated a staff member swore at her. A social service response indicated Resident #1 was spoken to by the social service designee. The social service statement indicated Resident #1 reported it happened a while ago when the staff member was new to the facility and was learning how Resident #1 preferred her care to be done. The note indicated Resident #1 stated that staff member had given her excellent care. The staff member involved was not identified. Another statement (not signed and no indication who wrote the statement) dated 12/29/23 indicated Resident #1 stated it was a misunderstanding, that the aide was new and did not know how Resident #1 liked to be care for. Resident #1 stated she felt safe. During an interview of Resident #1 on 02/27/24 at 12:01 P.M., prior to questioning about the incident referred to in the resident council meeting minutes, Resident #1 pointed to STNA #115 and stated she called her an expletive. Resident #1's tone had changed to a sharper tone compared to the rest of the conversation. During an interview with Activity Assistant #165 on 02/27/24 at 2:38 P.M., she verified she facilitated the December resident council meeting minutes as Activity Director #170 was not working that day. Activity Assistant #165 stated Resident #1 was hesitant to report the incident for fear of getting anybody in trouble but did state an aide called her a nasty name. Resident #1 would not provide the aide's name at that time. Resident #1 indicated she would like to have the aide explain what happened to upset her so much that the aide would call Resident #1 that name. Resident #1 did indicate she believed it was verbal abuse. Activity Assistant #165 stated she reported the allegation to Activity Director #170 the following day (12/29/23) when she returned to work. Activity Assistant #165 stated she was told the next time such an allegation was made she must report it to another supervisor if Activity Director #170 was not available. During an interview with the Director of Nursing (DON) on 02/27/24 at 2:48 P.M., she stated she was not working in December. She had been told Resident #1 thought an aide called her a name but that 365766 Page 2 of 12 365766 03/01/2024 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not the case. Another witness was in the room. Generally when an allegation of verbal abuse was made, the facility reported the allegation to the State survey agency. During an interview of the Administrator on 02/27/24 at 2:54 P.M., he stated the social worker spoke to Resident #1 and the incident had happened several weeks before it was reported. The name of the aide was not reported at that time and Resident #1 stated she was not afraid. A Facility Reported Incident was not submitted because Resident #1 stated it was a misunderstanding and the staff was providing excellent care. During an interview of Corporate Registered Nurse (RN) #110 on 02/27/24 at 3:03 P.M., she stated she did not know about the allegations made by Resident #1 but the incident was not reported to the State agency. 365766 Page 3 of 12 365766 03/01/2024 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, abuse policies review, resident council minutes review, written statements review and interview, the facility failed to ensure allegations of verbal abuse were thoroughly investigated and failed to remove staff alleged to have committed the abuse pending the completion of a thorough investigation This affected two (Residents #1 and #28) of 12 residents interviewed regarding abuse. The facility census was 62. Residents Affected - Few Findings include: 1. Review of Resident #28's open medical record revealed diagnoses including irritable bowel syndrome with diarrhea, obsessive compulsive disorder ( long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both.), somatization disorder (a form of mental illness that causes one or more bodily symptoms, including pain. The symptoms may or may not be traceable to a physical cause.), adjustment disorder with mixed anxiety and depressed mood, histrionic disorder (personality disorder characterized by a pattern of excessive attention-seeking behaviors), and narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance). Review of a care plan initiated 01/06/22 indicated Resident #28 had a self care deficit as evidenced by weakness related to anxiety disorder, obsessive-compulsive disorder, narcissistic personality disorder and diabetic neuropathy. Interventions included assisting with toileting as applicable and provide only the amount of assistance required to safely perform the task. Review of a care plan initiated 01/06/22 indicated incontinence of bowel due to weakness/psychiatric issues related to anxiety disorder, obsessive-compulsive disorder, narcissistic personality disorder, anemia, severe protein-calorie malnutrition and diabetic neuropathy. Interventions included checking and changing every two hours and as needed. The care plan did not refer to the amount of assistance needed. Review of a care plan initiated 04/07/22 indicated a conflict with staff related to being accusatory of staff, being demanding, being argumentative, refusing medications, refusing showers and or bed baths, refusing to go to doctor's appointments and refusing psychiatric services. Interventions included allowing Resident #28 to talk about his feelings and letting the resident know that staff was empathetic and interacting with Resident #28 in a calm, non-threatening manner. The care plan indicated Resident #28 had accused staff of not providing correct care and talking inappropriately toward staff and yelling at the facility doctor. Review of a care plan initiated 04/07/22 indicated Resident #28 had repeatedly called the police and ombudsman. Resident #28 refused to assist with activities of daily living even with goals to discharge home. Resident #28 was being verbally abusive and accusatory towards staff. Interventions indicated, if reasonable, discuss behaviors with the resident and explain/reinforce why the behavior was unacceptable. Review of a care plan initiated 07/18/22 indicated Resident #28 was verbally aggressive with staff related to narcissistic personality disorder. Interventions included analyzing key times, places, circumstances, and triggers and what de-escalated behavior and document the findings. Assess Resident #28's understanding of the situation. Allow time for the resident to express himself and his 365766 Page 4 of 12 365766 03/01/2024 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0610 feelings toward the situation. Level of Harm - Minimal harm or potential for actual harm Review of an annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 had adequate hearing with no hearing devices, was able to make himself understood and was able to understand others. Resident #28 was assessed as cognitively intact. Residents Affected - Few During an interview on 02/27/24 which began at 10:27 A.M., Resident #28 stated the facility had suddenly required two nursing assistants to provide incontinence care for him although he was able to turn in bed and maintain position. Resident #28 stated two staff entered the room one day, with one of the staff members telling the other to just stand there because she was able to provide the incontinence care herself. Resident #28 stated on 02/22/24 State Tested Nursing Assistant (STNA) #100 and STNA #105 entered the room to provide incontinence care. Resident #28 requested STNA #100 provide care and STNA #105 only be in the room to watch. STNA #100 claimed she was going to report this to the Administrator because it meant she had to do all the work. Resident #28 alleged when STNA #100 and STNA #105 left the room he heard STNA #100 state (expletive) you but that she said the actual word. Resident #28 stated he believed it was directed toward him. In regard to the allegation of verbal abuse that Resident #28 stated he heard toward himself on 02/22/24, the facility's self-reported incidents were reviewed with none having been submitted since 10/10/23. Review of a written statement by State Tested Nursing Assistant (STNA) #100 dated 02/22/24 revealed when she was in Resident #28's room - in the hall- she stated That's great to STNA #105 in response to the way Resident #28 was acting about staff not being allowed in his room. STNA #100 denied she used profanity in Resident #28's room or the hall regarding him. During an interview with STNA #100 on 02/29/24 at 9:48 A.M., she verified she was asked to write a statement regarding the allegation but she was never asked to leave the unit/stop providing resident care pending the facility conducting an investigation. STNA #100 stated she did not recall there being anybody in the hall at the time but there was a good possibility there might have been other residents in their rooms. During an interview on 02/27/24 at 3:03 P.M., Corporate Registered Nurse (RN) #110 verified Resident #28 made the allegation of a staff member stating (expletive) you toward him after leaving Resident #28's room. Corporate RN #110 indicated she told Resident #28 she was required to report the allegation and she phoned the facility and reported the allegation to the Director of Nursing (DON) and Administrator. Corporate RN #110 stated she visited the facility later that day and was told by the Administrator that he handled it and his investigation had indicated it had not happened. Corporate RN #110 verified the facility had failed to do a thorough investigation although an investigation should have been completed. During an interview on 02/27/24 at 3:16 P.M., the Administrator verified he had not removed staff from providing care while he conducted an investigation. The Administrator stated he got statements from both aides and they both denied the cursing occurred. The Administrator stated he never had problems with the aides and he knew Resident #28's history so he had no reason to suspect the incident occurred. The Administrator verified no additional residents, staff or visitors were interviewed. Review of a witness statement by STNA #105 dated 02/22/24 revealed when walking out of a room (did not identify what room), STNA #100 stated that was great. Resident #28 stated when aides had gone to 365766 Page 5 of 12 365766 03/01/2024 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #28's room he informed her that she (STNA #105) was only allowed to watch care being provided and STNA #100 had to provide all care. STNA #105 documented STNA #100 never made any profanities to or about Resident #28. During an interview with STNA #105 on 02/27/24 at 10:02 A.M., she stated the day of the incident she was asked for a written statement but she and STNA #100 continued to finish the shift like normal. Review of the facility's Resident Abuse Prevention Practices policy (rev. September 2019) revealed verbal abuse was identified as any use of oral, written, or gestured language that willfully included disparaging and/or derogatory terms to the residents or their families or within hearing distance, regardless of their age, ability to comprehend or disability. An investigation would begin immediately after receiving a complaint of abuse. Written statements would be taken and interviews conducted from anyone involved or witnessing the event (alleged victim, alleged perpetrator (if known), witnesses and all who might have knowledge of the allegations). An employee accused of the abuse of a resident would be suspended immediately at the time of the complaint, event or incident by the charge nurse on duty until the investigation was completed. Review of the facility's Abuse Allegation Investigation policy, dated October 2022, revealed the Administrator or designee would ensure steps had been taken to protect the resident from further abuse or retaliation during the investigation, ensure the alleged perpetrator was immediately suspended (staff) pending the investigation. The Administrator or designee was responsible for ensuring the allegation was reported to the State agency, and interviewing all staff, residents and other potential witnesses that might have details regarding the allegation or incident. The policy indicated if a staff member was the alleged perpetrator other staff were to be interviewed about their observations of interactions between the alleged perpetrator and this or other residents as applicable. After the investigation was completed and findings were documented, a final report was to be submitted to the State Agency. 2. Review of Resident Council Minutes dated 12/28/23 indicated a resident reported an STNA verbally abused her and noted the Director of Nursing (DON) was notified. The Problem/Complaint Intake Form generated 12/29/23 indicated Resident #1 stated a staff member swore at her. A social service response indicated Resident #1 was spoken to by the social service designee. The social service statement indicated Resident #1 reported it happened a while ago when the staff member was new to the facility and was learning how Resident #1 preferred her care to be done. The note indicated Resident #1 stated that staff member had given her excellent care. The staff member involved was not identified. Another statement (not signed and no indication who wrote the statement) dated 12/29/23 indicated Resident #1 stated it was a misunderstanding, that the aide was new and did not know how Resident #1 liked to be care for. Resident #1 stated she felt safe. During an interview of Resident #1 on 02/27/24 at 12:01 P.M., prior to questioning about the incident referred to in the resident council meeting minutes, Resident #1 pointed to STNA #115 and stated she called her an (expletive). Resident #1's tone had changed to a sharper tone compared to the rest of the conversation. During an interview with STNA #115 on 02/27/24 at 1:39 P.M., STNA #115 stated she and another aide (STNA #120) were providing care to Resident #1 one day when the resident became aggressive then later accused STNA #115 of calling her a name. During an interview with STNA #120 on 02/27/24 at 2:11 P.M. she indicated she was in the room with 365766 Page 6 of 12 365766 03/01/2024 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 and STNA #115 and Resident #1 was informed her head had to be lowered to pull her up in bed. Resident #1 started to yell at STNA #115 who responded she was not trying to be an ass. During an interview of Activity Assistant #165 on 02/27/24 at 2:38 P.M., she verified she facilitated the December resident council meeting minutes as Activity Director #170 was not working that day. Activity Assistant #165 stated Resident #1 was hesitant to report the incident for fear of getting anybody in trouble but did state an aide called her a nasty name. Resident #1 would not provide the aide's name at that time. Resident #1 indicated she would like to have the aide explain what happened to upset her so much that the aide would call the resident that name. Resident #1 did indicate she believed it was verbal abuse. During an interview of the Director of Nursing (DON) on 02/27/24 at 2:48 P.M., she stated she was not working in December. She had been told Resident #1 thought an aide called her a name but that was not the case. Another witness was in the room. Generally, when an allegation of verbal abuse was made, the facility reported the allegation to the State survey agency and documented an investigation. During an interview with the Administrator on 02/27/24 at 2:54 P.M., he stated the social worker spoke to Resident #1 and the incident had happened several weeks before it was reported. The Administrator provided two written statements by a nurse and STNA #115. The Administrator verified no further staff, residents, or potential witnesses were interviewed. During an interview of Corporate Registered Nurse (RN) #110 on 02/27/24 at 3:03 P.M., she stated she did not know about the allegations made by Resident #1 but it did not appear a thorough investigation was completed. During a subsequent interview with the Administrator on 02/27//24 at 3:16 P.M. he verified he did not suspend the STNA accused of calling Resident #1 a derogatory name pending an investigation. 365766 Page 7 of 12 365766 03/01/2024 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

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 Based on medical record review and interview, the facility failed to provide a timely physical therapy (PT) evaluation to assess for a restorative nursing program. This affected one (Resident #28) of three residents reviewed for restorative nursing services. The facility identified 39 residents receiving restorative nursing programs. The facility census was 62. Residents Affected - Few Findings include: Review of Resident #28's open medical record revealed diagnoses including type two diabetes mellitus with diabetic neuropathy, irritable bowel syndrome with diarrhea, anemia, obsessive compulsive disorder, diabetic retinopathy with macular edema in both eyes, somatization disorder, adjustment disorder with mixed anxiety and depressed mood, histrionic personality disorder, and narcissistic personality disorder. A plan of care initiated 05/25/22 and revised on 01/24/24 indicated Resident #28 required an ambulation restorative program due to weakness related to diabetes with neuropathy. A nursing note dated 07/26/23 at 10:03 A.M. indicated Resident #28 requested his restorative program be placed on hold. Restorative staff informed Resident #28 when he wanted to restart the program he could let them know and it would be re-initiated. A nursing note dated 01/19/24 at 10:53 A.M. indicated Resident #28 stated he would do therapy if it could be done on his response times. Therapy was notified. Review of a Physical Therapy (PT) evaluation dated 02/23/24 revealed Resident #28 was referred to PT by nursing per Resident #28's request to re-establish a restorative ambulation program. The therapist documented at the beginning of the evaluation Resident #28 reported he actually just wanted to be able to walk to the bathroom at a one assist level. Resident #28 was able to ambulate to/from the bathroom/bed with a front wheeled walker at a one assist level. Resident #28 reported he did not want any further PT services but would like to ambulate with restorative. Resident #28 was informed he could be a one assist to and from the bathroom with a front wheeled walker and the therapist would develop a restorative program based on distance ambulated during the evaluation and he could progress from there. During an interview with Resident #28 on 02/27/24 beginning at 10:27 A.M., he stated he had not ambulated since June of 2023. He had felt weak and sick and requested his restorative program be placed on hold in July 2023. Resident #28 stated he spoke with the Administrator and Therapy Manager #130 in January 2024 about wanting to have a restorative program for ambulation re-initiated. No action had been taken. Resident #28 stated he phoned the Corporate Registered Nurse (RN) to discuss his concerns and she had Corporate Physical Therapist (PT) #135 evaluate him on 02/23/24. His restorative program was initiated the following day. During an interview on 02/27/24 at 1:50 P.M., Licensed Practical Nurse (LPN) #125 stated she recalled Resident #28 telling her in January 2024 that he wanted to receive therapy/restorative services. LPN #125 stated she informed the restorative aides. During an interview with the Administrator on 02/27/24 at 3:16 P.M. he verified Resident #28 had spoken to him about wanting his restorative program resumed in January but he did not want him to ambulate until a physical therapist had evaluated him which was completed on 02/23/24. The Administrator indicated he was not certain why there was a delay between the time services were requested and the PT evaluation was completed. 365766 Page 8 of 12 365766 03/01/2024 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Therapy Manager #130 on 02/27/24 at 3:31 P.M., she stated therapy had a large skilled case load in January 2024. Residents who needed Medicare Part B services were placed on a target list and evaluations were completed as time allowed. Since there were no safety concerns communicated for Resident #28 he was not immediately evaluated. Therapy Manager #130 reported Resident #28 had been off the restorative program for a long time and nobody had reported a change in condition. When therapy received referrals it was usually due to documentation of a decline or improvement of a resident. Residents with safety risks were considered a higher priority. During an interview on 02/28/24 at 2:36 P.M., Restorative Aide #140 stated she was informed by a nurse that Resident #28 wanted to be placed back on restorative nursing case load and she informed Restorative Nurse #145. Restorative Nurse #145, who was present, stated she informed the therapy director who did not report Resident #28 would have to be placed on a waiting list. Once a PT evaluation was completed, restorative services began the following day. Restorative Nurse #145 stated staff were surprised since Resident #28 had not ambulated for so long that he was able to ambulate 120 feet on 02/24/24. This deficiency represents non-compliance investigated under Complaint Number OH00151354. 365766 Page 9 of 12 365766 03/01/2024 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and interview, the facility failed to ensure bathing was offered in accordance with bathing schedules and resident preferences. This affected one (Resident #28) of three residents reviewed for activities of daily living. The facility census was 62. Residents Affected - Few Findings include: Review of Resident #28's medical record revealed diagnoses included type two diabetes mellitus with diabetic neuropathy, irritable bowel syndrome with diarrhea, obsessive compulsive disorder, and anxiety disorder. A care plan regarding development of person-centered care, initiated 12/27/21, indicated Resident #28 required two or more assists for bathing. A care plan initiated 01/06/22 indicated a self care deficit with interventions to bathe per Resident #28's preference. A care plan initiated 04/07/22 indicated Resident #28 had a conflict with staff related to being accusatory of staff, being demanding, being argumentative, and refusing showers and/or bed baths. Review of a plan of care note dated 02/16/23 at 2:46 P.M. indicated Resident #28 requested he have one bed bath a week. The following bathing records were located for the past 30 day period: On 01/26/24 at 2:57 P.M., a nursing note indicated Resident #28 refused a shower, stating he was not feeling well. Staff recorded a bath (type not indicated) on 01/27/24. On 02/02/24 an aide documented Resident #28 was totally dependent for bathing (did not indicate the type of bathing provided). On 02/27/24, aides documented on a shower sheet and in the electronic health record task bar that Resident #28 refused a bath. During an interview on 02/27/24 between 10:27 A.M. and 12:00 P.M., Resident #28 was observed lying in bed with a knit cap covering his head and gloves on both hands. Resident #28 stated he would not take showers due to infection control concerns so he was supposed to get bed baths. Resident #28 stated he wore the gloves due to neuropathy in both hands and he was unable to provide his own bath, hair care or shaving. An odor was noted but Resident #28 also had a bowel movement during that time. Resident #28 stated he was not being offered bed baths on a weekly basis. On 03/01/24 at 9:27 A.M., the Director of Nursing (DON) was informed although bathing records had been requested twice, with some information provided, there was no evidence of Resident #28 being offered a bed bath between 02/03/24 and 02/26/24. The DON did not provide any additional information to support Resident #28 received bed baths per his preference or schedule 365766 Page 10 of 12 365766 03/01/2024 Parkside Health Care Center 930 East Park Avenue Columbiana, OH 44408

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, review of physician orders, policy review, and interview, the facility failed to ensure medications were available for administration resulting in the omission of four medications being administered out of 25 opportunities resulting in a 16% medication error rate. This affected one (Resident #56) of two residents observed for medication administration. Residents Affected - Few Findings include: During observation of medication administration on 02/27/24 at 8:53 A.M., Licensed Practical Nurse (LPN) #125 was observed preparing medications for administration to Resident #56. LPN #125 searched for, but was unable to locate, the following ordered medications: chewable aspirin 81 milligram (mg), vitamin D 50 micrograms (mcg), bumex 1 mg (mg), fludrocortisone acetate 0.1 mg, and ferrous gluconate 324 mg. LPN #125 stated Resident #56 only had a 14 day supply of medication delivered at any given time. LPN #125 stated she knew she had re-ordered the medications but they were not in the cart. LPN #125 stated when she finished her medication pass she would look to see if any of the medications were available in the starter box. On 02/27/24 at 10:01 A.M., LPN #125 (with assistance of another unidentified nurse) searched the starter box and was able to locate the correct dose of bumex which was administered at 10:06 A.M. The other four medications were not available for administration. At 10:08 A.M. LPN #125 stated pharmacy drop shipped medications in an emergency situation and she would document the medications were held. LPN #125 indicated she would contact pharmacy for delivery that evening. LPN #125 reported she had ordered medications on 02/26/24. (A reorder form with the four medications was unable to be located). Review of the facility's Medication Ordering and Receiving from Pharmacy Provider (not dated) indicated as medication reached a three to five day supply, the reorder sticker is peeled off the prescription and placed on the reorder page. Reorders should be faxed in the morning by 10:00 A.M. Reorders faxed after 10 A.M. would be delivered the next business day unless the medication supply was exhausted and was needed prior to the next delivery. If a new or refill was needed before the next business day, nursing must call the pharmacy and deem the prescription an emergency prescription in order to have it delivered on the same day. The policy indicated for residents who received medication under Medicare Part A pharmacy would deliver medications with a 14 day supply. The medications would be re-ordered by nursing two to four days prior to exhausting the supply. This deficiency represents non-compliance investigated under Complaint Number OH00151064. 365766 Page 11 of 12 365766 03/01/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, and interview, the facility failed to ensure catheter tubing was placed in a manner that would limit the potential for introduction of pathogens. This affected one (Resident #1) of three residents reviewed for urinary tract infections. The facility census was 62. Residents Affected - Few Findings include: Review of Resident #1's open medical record revealed diagnoses including type two diabetes mellitus, flaccid neuropathic bladder, and neuromuscular dysfunction of the bladder. A plan of care related to use of an indwelling catheter was initiated 08/18/23. Interventions included keeping the foley (catheter) tubing free of kinks and keeping the bag covered and off the surface of the floor. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and had an indwelling urinary catheter. A laboratory report for urine collected on 02/19/24 indicated the identification of mixed flora and indicated further work-up and sensitivity testing was not routinely indicated and would not be performed. On 02/27/24 at 9:15 A.M., Resident #1 was observed propelling herself in a wheelchair in the hallway near the therapy department. The urinary catheter tubing was observed dragging on the floor under her wheelchair. At 12:01 P.M., Resident #1 was observed sitting in the wheelchair in her room with the catheter tubing on the floor. While conversing with Resident #64, State Tested Nursing Assistant (STNA) #150 delivered her lunch tray and left the room. On 02/27/24 at 12:10 P.M. STNA #150 was asked to return to Resident #1's room and verified Resident #1's catheter tubing was on the floor. At that time, Resident #1 was eating and STNA #150 stated she would wait until after lunch according to Resident #1's request and reposition the catheter tubing. At 1:50 P.M., Resident #1 was observed being propelled down the hall in the wheelchair. Resident #1 stated it is still not fixed. Observations revealed the catheter tubing was touching the floor. At that time, Licensed Practical Nurse (LPN) #125 verified the catheter tubing was on the floor and instructed a different nursing assistant to go reposition the tubing. Review of the facility's policy, Catheter Management (dated June 2012), revealed instructions to never allow the catheter bag to be raised above the level of the bladder or to let the bag or tubing touch the floor. This deficiency represents non-compliance investigated under Complaint Number OH00151064. 365766 Page 12 of 12