Health inspection·January 16, 2020

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review, the facility failed to ensure a resident with mental disorders received treatment for the disorder. This affected one (Resident #28) of two sampled residents reviewed for mood and behavior. The facility census was 75. Findings include: Review of Resident #28's medical record revealed he was admitted on [DATE] with diagnoses including dementia, mood disorder, bipolar disorder, anxiety and agitation. Review of Resident #28's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the following: Resident # 28's speech was unclear, he was rarely understood, he rarely understands, his short and long-term memory was impaired, he recalled staff names and faces and had severely impaired decision making. Resident #28 had minimal depression, had no indicators of psychosis, had other behaviors one to three days of the assessment reference period that did not significantly impact him or other residents, he did not reject care and did not wander. Resident #28 required extensive assistance of two staff for bed mobility, transfers, did not walk and was dependent on one staff for locomotion using a wheel chair. Resident #28 received an antipsychotic medication, an antianxiety medication and an antidepressant medication seven of the past seven days. Resident #28 received no psychological therapy. Review of Resident #28 quarterly MDS 3.0 assessment dated [DATE] revealed the following changes; he had moderate depression and expressed no behaviors. Resident #28 was dependent on two staff to transfer. Review of Resident #28's progress notes dated 11/11/19 at 8:30 P.M. revealed he hit Resident #46 in the left shoulder. The residents were separated. Review of the facility's investigation, completed on 11/15/19, revealed a recommendation for psychological assessment. Review of Resident #28's plan of care dated 11/11/19 revealed he was easily annoyed by another resident and had a physical altercation with another resident. The care plan called for psychiatric/psychogeriatric consult as indicated. Review of Resident #28's behavioral health therapy and counseling progress note dated 12/09/19 Page 1 of 5 365791 365791 01/16/2020 Sanctuary at Ohio Valley 2932 South 5th Street Ironton, OH 45638

F 0742 Level of Harm - Minimal harm or potential for actual harm revealed a diagnostic assessment was completed, and an individual treatment plan was developed. Review of Resident #28's individualized service plan dated 12/09/19 called for therapeutic services one to four times a month. There was no evidence therapeutic services were provided after 12/09/19. Residents Affected - Few Observation of Resident #28 on 01/14/20 at 2:56 P.M., on 01/15/20 at 8:39 A.M. and 10:20 A.M. revealed he was in bed asleep. Interview of the Director of Nursing on 01/16/20 at 10:48 A.M. confirmed the behavioral health services were not provided to Resident #28 since 12/09/19. 365791 Page 2 of 5 365791 01/16/2020 Sanctuary at Ohio Valley 2932 South 5th Street Ironton, OH 45638

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 staff interview and medical record review, the facility failed to ensure residents who received psychotropic drugs had target behaviors identified and were monitored for those behaviors. This affected two (Residents #28 and #50) of five sampled residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #28's medical record revealed he was admitted on [DATE] with diagnoses including dementia, mood disorder, bipolar disorder, anxiety and agitation. Review of Resident #28's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the following: Resident # 28's speech was unclear, he was rarely understood, he rarely understands, his short and long-term memory was impaired, he recalled staff names and faces, and had severely impaired decision making. Resident #28 had minimal depression, had no indicators of psychosis, had other behaviors one to three days of the assessment reference period that did not significantly impact him or other residents, he did not reject care and did not wander. Resident #28 required extensive assistance of two staff for bed mobility, transfers, did not walk and was dependent on one staff for locomotion using a wheel chair. Resident #28 received an antipsychotic medication, an antianxiety medication and an antidepressant medication seven out of the past seven days. Review of Resident #28 quarterly MDS 3.0 assessment dated [DATE] revealed the following changes; he had moderate depression and expressed no behaviors. Resident # 28 was dependent on two staff to transfer. Review of Resident #28's plan of care dated 10/10/17 and revised 11/11/19 revealed he had target behaviors of easily annoyed and upset by other residents, physical aggression toward other residents and staff, inappropriate sexual behaviors directed toward staff, and cursing and yelling at others. Review of Resident #28's January 2020 monthly physician orders revealed he received an antidepressant medication (Trazadone) 150 milligrams (mg) at bedtime for depression/behaviors, a mood stabilizing medication (Depakote) 500 mg at bedtime for bipolar disorder with manic episodes with severe psychotic features, an antianxiety medication (Lorazepam) 0.5 mg twice daily for anxiety, and an antipsychotic medication (risperidone) 1 mg twice daily for psychosis. Review of Resident #28's behavior monthly flow sheet for November and December 2019 revealed the identified target behavior was agitation. Review of the January 2020 behavior monthly flow sheet revealed the identified target behaviors were insomnia, restless and anxiety. Interview of State Tested Nursing Assistant (STNA) #24 on 01/15/20 at 2:26 P.M. revealed Resident #28 did not express many behaviors. STNA #24 stated sometimes he would want to leave the facility, he sometimes did not want to be touched, he may think he was younger than he was, and he hits staff occasionally. STNA #24 stated he sleeps during the day and was up at night. Interview of Licensed Practical Nurse (LPN) #9 on 01/15/20 at 2:31 P.M. revealed Resident #28 had behaviors at times, but it was due to his disease because he could not understand what was going on. 365791 Page 3 of 5 365791 01/16/2020 Sanctuary at Ohio Valley 2932 South 5th Street Ironton, OH 45638

F 0758 Level of Harm - Minimal harm or potential for actual harm LPN #9 stated he tried to leave the facility as he was looking for his family. LPN #9 stated he got loud with the staff and sometimes had hit staff. LPN #9 stated Resident #28 did not hallucinate or have delusions. Interview of the Director of Nursing (DON) on 01/16/20 at 10:48 A.M. confirmed there was no evidence the facility monitored Resident #28's behaviors to support the use of his psychoactive medication. Residents Affected - Few 2. Review of Resident #50's medical record revealed he was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia without behavioral disturbance, anxiety disorder, psychotic disorder with hallucinations and major depressive disorder. Review of Resident #50's annual MDS 3.0 assessment dated [DATE] revealed the following; Resident #50 had clear speech, he usually understands, he was understood, and cognition was intact. Resident #50 had minimal depression, no indicators of psychosis, no behaviors and did not reject care. Resident #50 required supervision with set-up help for bed mobility, transfers, walking and for locomotion. Resident #50 received antipsychotic medication, antianxiety medication and antidepressant medication seven of the seven previous days. Review of Resident #50's quarterly MDS 3.0 assessment dated [DATE] revealed the following changes; Resident # 50 was independent with bed mobility, transfers, walking and locomotion. Review of Resident #50's plan of care dated 12/15/18 revealed target behaviors of being withdrawn, showing little interest or pleasure in doing things, fixation of going home, verbal aggression and sexually inappropriate behavior. Review of Resident #50 January 2020 physician orders revealed an antianxiety medication (Ativan) 2 mg every eight hours for anxiety, an antipsychotic medication (Seroquel) 50 mg twice daily for psychotic disorder with delusions, and two antidepressants (Trazodone) 100 mg at bedtime for insomnia and (Zoloft) 0.5 mg daily for depression. Review of Resident #50's behavior monthly flow sheet for November and December 2019 revealed the identified target behaviors were anxiety, delusions and overly concerned with his health. Review of the January 2020 behavior monthly flow sheet revealed the identified target behaviors were agitation, anxiety and restlessness. Interview of STNA #17 on 01/16/20 at 3:00 P.M. revealed Resident #50 had no behaviors, no delusions or hallucinations. STNA #17 stated he was more confused lately and that was not like him. Interview of the LPN #9 on 01/16/20 at 3:15 P.M. revealed Resident #50 would repeat the same thing over and over, he would fixate on calling his wife and wanting to go home. LPN #9 stated Resident #50 did not hallucinate or have delusions. Interview of the DON on 01/16/20 at 2:59 P.M. confirmed there was no evidence the facility monitored Resident #50's behaviors to support the use of his psychoactive medication. 365791 Page 4 of 5 365791 01/16/2020 Sanctuary at Ohio Valley 2932 South 5th Street Ironton, OH 45638

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on resident interview, staff interview and a test tray, the facility failed to ensure food was served at an appetizing temperature. This had the potential to affect all residents except three residents (Resident #17, #48, and #78) who received no food from the kitchen. The facility census was 75. Residents Affected - Many Findings include: Interview of Resident #45 on 01/13/20 at 2:44 P.M. revealed sometimes the hot foods were served cold. A test tray was requested on 01/15/20. The test tray was loaded on to the meal cart at 12:07 P.M. The meal cart arrived on the hallway at 12:08 P.M. The first tray was served at 12:10 P.M., and the last tray was served at 12:30 P.M. The temperature of the food on the test tray at 12:31 P.M. included: the hot ham and cheese sandwich was 110 degrees Fahrenheit (F) and cool to taste, the potato wedges were 108 degrees F and cool to taste, and the milk was 60 degrees F and warm to taste. The temperatures were verified with Licensed Practical Nurse (LPN) #20. The facility identified Residents #17, #48, and #78 did not receive food from the kitchen. Interview of Dietary Manager #30 on 01/16/19 at 9:10 A.M. confirmed the food was not served hot enough. 365791 Page 5 of 5