Health inspection·July 18, 2019

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on review of resident funds accounts and interview, the facility failed to deposit the entirety of a resident's funds into her account. This affected one (Resident #24) of six residents whose accounts were reviewed. The facility census was 95 residents. Findings include: During review of Resident #24's account it was noted Resident #24 received a $50.00 credit each month with the exception of two months. In February 2019 no $50.00 credit was listed. In April 2019 a $68.00 credit was posted. On 07/17/19 at 10:32 A.M., Corporate Accounts Receivable personnel #913 verified Resident #24 was not provided her $50.00 in February 2019, stating there had been a change in her liability and there was some confusion regarding her account. Resident #24 had an additional $18.00 of the $50.00 paid in April so the balance due in her account was $32.00. Page 1 of 11 365822 365822 07/18/2019 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on review of resident fund accounts and interview, the facility failed to notify a resident or his guardian when the amount in his account reached $200 less than the limit permitted for Medicaid recipients. This affected one (Resident #45) of six residents whose accounts were reviewed. The facility census was 95 residents. Residents Affected - Few Findings include: Review of Resident #45's quarterly account statements revealed a $1500 credit was posted to his trust on 03/11/19 raising his balance to $1830.02. The account remained over $1800. As of 07/15/19, the balance was $1970.11. On 07/17/19 at 9:30 A.M., Corporate Accounts Receivable personnel #913 said spend down notifications were generally sent out once a resident's balance was within $200 of a $2000 limit. Corporate Accounts Receivable personnel #913 verified Resident #45's balance had exceeded $1800 as of 03/11/19, stating $1500 was deposited from Resident #45's main account from a Medicare overage based on a request from the activity staff to purchase a chair. On 07/17/19 at 10:32 A.M., Corporate Accounts Receivable personnel #913 verified insurance had paid for Resident #45's chair and Resident #45's guardian should have been provided a spend down notification but was not. 365822 Page 2 of 11 365822 07/18/2019 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files and interview, the facility failed to ensure prospective new employees were checked with the nurse aide registry to determine if they had findings of abuse, neglect, exploitation, or misappropriation reported to the nurse aide registry prior to their application and hire at the facility. This had the potential to affect all 95 facility residents. Residents Affected - Many Findings include: On 07/16/19 at 3:25 P.M. during review of personel files, Human Resource staff (HR) #819 said unless a prospective employee was a nursing assistant the facility did not check the nurse aide registry to ensure that applicant did not have findings of abuse, neglect, exploitation, or misappropriation reported to the nurse aide registry prior to their application and hire at the facility. Review of the facility's abuse policy, revised 06/01/17, revealed as part of the screening process multiple interviews of potential employees would be conducted, employment references would be verified, and drug screening would be conducted. Background checks would be conducted on all employees and licenses would be verified with the appropriate boards. The policy did not indicate all employees were to be checked with the nurse aide registry to monitor for any findings of abuse, neglect, exploitation, or misappropriation. On 07/18/19 at 2:20 P.M., during review of a list of personnel with hire dates since the last annual survey (between 06/07/18 and 07/15/19), HR #819 again verified that no employees except STNA's were checked with the nurse aide registry for findings of abuse, neglect, exploitation, or misappropriation. HR #819 said she was unaware of the necessity to check the nurse aide registry for such findings unless a prospective employee was a STNA. On 07/18/19 at 3:26 P.M., HR #819 provided documented evidence that the facility had now checked all the employees currently working at the facility with the nurse aide registry to confirm the current employees had no findings of abuse, neglect, exploitation, or misappropriation reported to the nurse aide registry. This included the following new employees hired since last survey on 06/07/18: seven dietary aides, seven hospitality aides, four housekeepers, two laundry staff, one social service staff, eight licensed practical nurses, and four registered nurses. 365822 Page 3 of 11 365822 07/18/2019 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Residents #28, #30, #40, #87, #106, and #317 were notified in writing the reason for the discharge to the hospital in an easily understood language, and failed to notify the ombudsman's office of the residents discharge to the hospital. This finding affected six (Residents #28, #30, #40, #87, #106, and #317) of six residents reviewed for hospitalization. The facility census was 95 residents. Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, major depressive disorder, and muscle weakness. Review of Resident #30's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #30's progress note dated 07/08/19 at 2:20 P.M. indicated the resident was sent to the hospital on [DATE] and all parties were aware. Interview on 07/17/19 at 12:52 P.M. with Licensed Social Worker (LSW) #803 confirmed the resident, the resident's family, and the ombudsman's office were not notified in writing the reason for the resident's discharge to the hospital in an easily understood language. 2. Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia and diabetes mellitus. The MDS assessment dated [DATE] revealed Resident #28 had severe cognitive impairment and needed staff assistance for his activities of daily living. Review of the Progress Notes dated 04/17/19 to 07/09/19 revealed the Resident was discharged to the hospital and returned to the facility on four separate occassions: 04/17/19 to 04/26/19, 06/01/19 to 06/07/19, 06/19/19 to 06/23/19, and 07/03/19 to 07/09/19. There was no evidence in the resident's record of any written notification to the resident and/or family, or notification of the ombudsman of the discharge to the hospital on [DATE], 06/01/19, 06/19/19, and 07/03/19. Interview on 07/16/19 at 4:36 P.M. with the administrator confirmed the resident, the resident's family, and the ombudsman's office were not notified in writing the reason for the resident's discharge to the hospital in an easily understood language. 3. Review of Resident #106's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including generalized anxiety disorder, iron deficiency anemia, and chronic kidney disease. The MDS assessment dated [DATE] revealed she had impaired cognition and needed staff assistance for her activities of daily living. The Progress Notes from 06/01/19 to 06/13/19 revealed the resident was hospitalized from [DATE] to 06/06/19, and on 06/13/19 after which the resident did not return to the facility. There was no evidence in the resident's record of any written notification to the resident and/or family, or notification of the ombudsman's office of the discharge to the hospital on [DATE] and 06/13/19. Interview on 07/16/19 at 4:36 P.M. with the administrator confirmed the resident, the resident's family and the ombudsman's office were not notified in writing the reason for the resident's discharge to the hospital in an easily understood language. 365822 Page 4 of 11 365822 07/18/2019 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Review of Resident #87s medical record revealed the resident was admitted to the facility on [DATE] with major depressive disorder, autonomic neuropath, and Hypokalemia. Review of Resident #87's MDS 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #87's progress note dated 05/18/19 at 8:37 A.M. indicated the resident was sent to the hospital on [DATE] at 8:00 A.M. Resident 87 was readmitted to the facility from the hospital om 06/09/19. There was no evidence in the resident's record of any written notification to the resident and/or family, or notification of the ombudsman of the discharge to the hospital on [DATE]. Interview on 07/16/19 at 4:36 P.M. with the administrator confirmed the resident, the resident's family, and the ombudsman's office were not notified in writing the reason for the resident's discharge to the hospital in an easily understood language. 5. Review of Resident #317's medical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses including hemiplegia following a cerebral infarction, pleural effusion, and dysphagia. Review of Resident #317's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively impaired. Review of Resident #317's progress note dated 06/26/19 at 2:49 P.M. indicated the resident was sent to the hospital on [DATE]. Resident #317 was readmitted to the facility from the hospital on [DATE]. There was no evidence in the resident's record of any written notification to the resident and/or family, or notification of the ombudsman of the discharge to the hospital on [DATE]. Interview on 07/16/19 at 4:36 P.M. with the Administrator confirmed the resident, the resident's family and the ombudsman's office were not notified in writing the reason for the resident's discharge to the hospital in an easily understood language. 6. Review of Resident #40's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included diabetes, atherosclerotic heart disease, disorder of the veins, and obesity. Review of Resident #40's MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #40's progress note dated 05/03/19 at 7:29 P.M. indicated the resident was sent to the hospital and the family was updated. Interview on 07/17/19 at 12:52 P.M. with LSW #803 confirmed the resident, resident's family, and the ombudsman's office were not notified in writing the reason for the resident's discharge to the hospital in an easily understood language. 365822 Page 5 of 11 365822 07/18/2019 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 interview, the facility failed to provide comprehensive assessments related to medical diagnoses and conditions for one (Resident #157) of 29 residents whose records were reviewed for assessments. The facility census was 95 residents. Residents Affected - Few Findings include: Review of Resident #157's closed medical record revealed an admission date of 06/12/19. Diagnoses included a deep vein thrombosis (DVT - blood clot) of both lower extremities. A list of medications provided by the hospital revealed an order for omnicef 300 milligrams (mg) every twelve hours for seven days. A nutritional assessment dated [DATE] indicated nursing reported Resident #157 had emesis (did not indicate if was an isolated occurrence or if greater than one). Nursing and Resident #157 reported they believed the emesis was related to antibiotic use. A nursing note dated 06/15/19 at 8:40 P.M. indicated Resident #157 was sent to the emergency room after having three episodes of brown liquid emesis. A nursing note dated 8:42 P.M. revealed Resident #157 returned to the facility with an order for zofran for nausea. Resident #157 left the facility against medical advice on 06/18/19. No comprehensive circulatory assessments were documented in relation to Resident #157's DVTs and no comprehensive assessment was noted when Resident #157 was exhibiting emesis (for example, monitoring of abdominal sounds or palpation of the abdomen). On 07/18/19 10:25 A.M., the Director of Nursing (DON) was interviewed and acknowledged there was a lack of circulatory assessments for Resident #157 related to her DVTs. The DON stated the day Resident #157 was sent to the emergency room, the nurse called the DON and reported vital signs to her. The vital signs were blood pressure 142/76, temperature 98.5, heart rate 86, respirations 20, and oxygenation 96% on room air. The DON stated she never saw any documentation from nursing indicating they believed Resident #157's emesis was related to the use of the antibiotic but did not think the dietitian just made it up. The DON verified there was no evidence of physician notification of the emesis or possible relation to the antibiotic. However, the nurse practitioner was notified prior to Resident #157 being sent to the emergency room. The DON verified there was no documentation to indicate the nurse did a comprehensive assessment of Resident #157's bowel sounds or abdominal assessment when she was vomiting. 365822 Page 6 of 11 365822 07/18/2019 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, record review, and interview, the facility failed to ensure the Narcotic Control Records accurately reflected the actual narcotic count following administration of resident narcotics. This affected one (Resident #39) of fourteen residents who received narcotics from medication cart #2. The facility census was 95 residents. Findings include: Observation of medication cart #2 with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #802 on 07/17/19 at 1:30 P.M. revealed, according to the Narcotic Control Record, Resident #39 had twenty-four norco tablets (hydrocodone 7.5 milligrams (mg) - acetaminophen 325 mg) remaining. Observation of the blister pack of norco at that time revealed twenty-three tablets remaining. LPN #802 was interviewed at the time of the findings and stated she had administered one tablet to Resident #39 at 9:00 A.M. and had not signed the Narcotic Control Record. LPN #802 signed the Narcotic Control Record for Resident #39 at the time of the interview. The DON was interviewed on 07/17/19 at 1:30 P.M. and stated the Narcotic Control Record was to be signed when the medication is given. Review of Resident #39's MAR for July 2019 revealed norco had been administered on 07/17/19 at 9:00 A.M. by LPN #802. Review of the undated policy Controlled Substance Administration Documentation Guidelines revealed when a controlled substance is administered, the licensed nurse administering the medication should immediately document on the medication administration record (MAR) and the accountability record. 365822 Page 7 of 11 365822 07/18/2019 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to store and label medications according to accepted professional standards. This affected two (Residents #104 and #12) of four residents who received medications administered by nurses at the facility. This also had the potential to affect 27 residents who received medications held in medication storage cart #2. The facility census was 95 residents. Findings include: 1. Record review revealed Resident #104 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis (MS). Further review of Resident #104's medical record revealed a physician's order dated [DATE] for dimethyl fumarate (Tecfidera) 240 milligrams (mg) delayed release capsule two times a day (for MS). Review of Resident #104's medication administration record (MAR) from [DATE] to [DATE] revealed Tecfidera was administered 34 times. Observation of medication cart #2 on [DATE] at 1:17 P.M. with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #802, revealed an unlabeled bottle of Tecfidera. The bottle was not labeled with a resident name, medication dosage, or date opened. Interview on [DATE] at 1:17 P.M. with LPN #802 revealed the Tecfidera medication was brought in by Resident #104's family and was not labeled with the resident's name, dosage, or date opened. 2. Observation of medication cart #2 on [DATE] at 1:17 P.M. with the DON and LPN #802, revealed a spiriva inhaler for Resident #12 was expired in [DATE]. Review of the medical record for Resident #12 revealed he was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD). Further review of the medical record revealed a physician order dated [DATE] for spiriva handihaler, 18 micrograms (mcg) capsule one inhalation daily. Review of Resident #12's MAR from [DATE] to [DATE] revealed spiriva was administered 16 times. Interview on [DATE] at 1:19 P.M. with the DON verified Resident #12's spiriva inhaler was expired. 3. Observation of medication cart #2 on [DATE] at 1:17 P.M. with the DON and LPN #802, revealed one unpackaged and unlabeled oval, yellow pill in the second drawer and one unpackaged and unlabeled oblong, bright yellow pill in the third short drawer of the medication cart. Interviewed on [DATE] at 1:18 P.M., the DON verified the above findings. 4. Observation of medication cart #2 on [DATE] at 1:17 P.M. with DON and LPN #802, revealed two vials of albuterol sulfate medication in the top short drawer of the cart. The vials did not have a 365822 Page 8 of 11 365822 07/18/2019 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0761 resident label on them. Level of Harm - Minimal harm or potential for actual harm Interviewed on [DATE] at 1:21 P.M., the DON verified the findings of the unlabeled albuterol sulfate vials. Residents Affected - Some 365822 Page 9 of 11 365822 07/18/2019 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on review of the facility assessment and interview, the facility failed to conduct, document, and update a comprehensive facility assessment. This had the potential to affect all 93 residents. Findings include: Review of the Facility Assessment indicated it was last updated on 05/28/18. The Facility Assessment indicated the average number of residents the facility could accommodate for elderly mental health was 12, for therapy services was 40, for nutritional needs was 9, and for dialysis was 4. The Facility Assessment indicated the average nursing staff scheduled on a daily basis. The Facility Assessment was silent as to provision of therapy services, dietary services, and mental health services. The Facility Assessment did not address activity needs, pharmacy services, laboratory services, or social service needs of the residents. The Facility Assessment was silent as to the use of any third party contracts. Health information technology resources were not addressed. On 07/17/19 at 11:37 A.M., the Director of Nursing (DON) and Administrator were interviewed regarding staffing. The Administrator stated as part of evaluating staffing needs, she had discussion with her staff. Through those discussions it was determined the facility needed more nurses. The facility started using agency nurses on 07/08/19. The Administrator verified the Facility Assessment was not updated when the facility planned to use agency staffing. The Administrator stated staff were supposed to meet for the annual update 07/15/19 but did not due to the survey. On 07/17/19 at 12:00 P.M., the Administrator verified the Facility Assessment only addressed need for nursing staff and it could be more comprehensive. Review of contracts with staffing agencies revealed contracts were signed 07/02/19 and 07/09/19. 365822 Page 10 of 11 365822 07/18/2019 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

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 interview, the facility failed to maintain the appropriate infection control procedures during Resident #28's medication administration. This finding affected one (Resident #28) of five residents observed for medication administration. The facility census was 95 residents. Residents Affected - Few Findings include: Observation on 07/15/19 at 10:52 A.M. with Registered Nurse (RN) #801 of Resident #28's medication administration revealed the nurse checked for residual by injecting air into the resident's stomach using a barrel and plunger type of syringe placed into the port of Resident #28's PEG tube (percutaneous endoscopic gastrostomy tube is a flexible feeding tube placed through the abdominal wall and into the stomach allowing nutrition, fluids and/or medications to be placed directly into the stomach). RN #801 removed the plunger from the barrel and placed the plunger on the bedside table. At this point, the nurse put gloves on. The plunger rolled off of the resident's bedside table and onto the resident's bed linens. The nurse picked up the plunger from the bed, placed it back onto the table and continued to administer five medications into the resident's PEG tube. The nurse attempted to administer a sixth medication however the resident's PEG tube clogged and the medication was unable to be administered at this time. Interview on 07/15/19 at 2:04 P.M. with RN #801 confirmed she did not put gloves on prior to checking for placement of Resident #28's PEG tube to prevent cross contamination of the resident's PEG tube during the resident's medication administration, did not disinfect the resident's bedside table and place a barrier on the table prior to placing the medications and barrel/plunger on the table and did not ensure the plunger was cleaned appropriately when the plunger rolled onto the resident's bed linens during the medication administration. 365822 Page 11 of 11