Health inspection·July 2, 2024

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, medical record review, staff interview, and review of the facility wound care policy, the facility failed to ensure pressure ulcer wound dressings and preventative interventions were implemented as ordered by the physician. This affected one (#1) of three sampled residents reviewed for skin integrity and wound prevention in a facility census of 90. Residents Affected - Few Findings include: Review of the medical record revealed Resident #1 admitted to the facility on [DATE] with diagnoses including quadriplegia, cervical spinal cord injury, hypertension, type two diabetes mellitus, history of urinary tract infection, depression, colostomy, and urostomy. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] Resident #1 was assessed with intact cognition, was dependent on staff for activities of daily living including bed mobility, received a therapeutic diet, was identified with no weight loss, and was admitted with a stage three (full-thickness skin loss) and a stage four (full-thickness skin and tissue loss) pressure ulcer. Review of skin grid pressure ulcer forms dated 04/15/24 noted wound measurements of Resident #1 pressure wounds documented as present on admission and original discovery date of 11/29/23. A right ischium stage four pressure ulcer measured 1.7 centimeters (cm) long by (x) 0 .7 cm wide x 2.1 cm deep. A left buttock stage three pressure ulcer measured 1.5 cm long x 1.7 cm wide x 0.1 cm deep. Review of a nursing plan of care dated 05/01/24 revealed a care plan was developed to address Resident #1's risk for further impaired skin integrity related to immobility due to quadriplegia, varicose veins, diabetes mellitus, and being admitted with pressure wounds to the left buttock and right ischium. Interventions included to administer treatments as ordered and monitor for effectiveness, and follow facility policies and protocols for the prevention and treatment of skin breakdown. Review of physician ordered revealed on 05/26/24 the physician changed Resident #1's wound treatment to the right ischium to have staff irrigate/rinse the wound with normal saline, apply Triad (wound cream) to the periwound, pack with Vashe (wound solution) moistened gauze, and cover the wound with silicone bordered foam dressing. The dressing was to be administered every morning and at bedtime scheduled at 10:00 A.M. and 9:00 P.M. and as needed. Resident #1 was evaluated by the wound center physician on 06/21/24 and indicated the wound to the left buttock was closed. An order was give to continue treatment to the area including to irrigate or rinse with normal saline, and cover with sacral silicone. On 06/25/24 the treatment was modified to include instructions for staff to irrigate or rinse with normal saline, apply Triad to the Page 1 of 5 365830 365830 07/02/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0686 periwound, cover with sacral silicone, and apply coconut oil to reddened and dry areas on the buttocks. Level of Harm - Minimal harm or potential for actual harm On 07/01/24 at 9:59 A.M. interview with Resident #1 revealed the wound dressing treatments were not completed the previous day and were last completed on 06/29/24. Residents Affected - Few Observation and interview on 07/01/24 at 10:26 A.M. with Licensed Practical Nurse (LPN) #302, State Tested Nurse Aide (STNA) #204, and STNA #205 noted the dressing to Resident #1's right ischium to be soiled and pealing off the wound with no date or initials indicating when the dressing was last applied. The left hip dressing was not applied. Interview with LPN #302, during the observation, stated she was not aware the left buttock dressing was not applied as ordered and confirmed the right ischium dressing lacked a date or initials of the nurse indicating when the dressing was last changed. Interview with STNA #204 and STNA #205, at the time of the observation, stated they were not aware the right hip dressing was missing, and indicated the previous shift did not report any information related to the wound dressings to them. According to wound measurements obtained on 07/02/24, Resident #1's left buttock wound was healed and the right ischium stage four pressure ulcer measured 1.0 centimeters (cm) long x 0.8 cm wide x 1.5 cm deep. On 07/01/24 at 11:40 A.M., interview with the Director of Nursing (DON) verified Resident #1's wound dressings were not applied as ordered by the physician, and stated the facility wound treatment policy directed staff to apply initials with a date on the dressing at the time of application. Review of the facility wound care policy, revised October 2021, revealed staff are to verify there is a physician's order for the procedure, and when staff prepared to apply a wound dressing, they are to mark the tape with initials and date when the dressing was applied. This deficiency represents non-compliance investigated under Master Complaint Number OH00154646. 365830 Page 2 of 5 365830 07/02/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on staff interview and review of staffing schedules, the facility failed to ensure staffing included the services of a registered nurse (RN) in-house for at least eight consecutive hours a day, seven days a week. This had the potential to affected all 90 residents residing in the facility. The facility census was 90. Findings include: Review of facility staffing schedules between 06/01/24 and 06/30/24 identified three dates lacking RN coverage for eight consecutive hours. The were no RN hours on 06/09/24, 06/20/24, and 06/27/24 during a 24-hour period. On 07/02/24 at 11:20 A.M., interview with the Director of Nursing (DON) during review of the facility staffing schedules verified three days the facility did not have an RN scheduled in the facility during a 24-hour period. The DON confirmed there was no RN hours on the 06/09/24, 06/20/24, and 06/27/24 staffing schedules for a 24-hour period. This deficiency represents non-compliance investigated under Master Complaint Number OH00154646 and Complaint Number OH00154464. 365830 Page 3 of 5 365830 07/02/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of the facility administration and documentation of medication policy, the facility failed to ensure medications were provided as ordered by the physician. This resulted in a significant medication error when a resident was not administered an antipsychotic medication as prescribed. The affected one (#4) of three residents reviewed for medications in a facility census of 90. Residents Affected - Few Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including, seizure disorder, major depressive disorder with recurrent severe psychotic symptoms, type two diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease, schizoaffective disorder, borderline intellectual functioning, delusional disorders, hypertension, and visual hallucinations. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #4 with intact cognition, a depressed mood two to six days during the assessment period, the resident was independent with activities of daily living and ambulation, and received the antipsychotic, antidepressant, and hypoglycemic medications daily. Review of Resident #4's nursing plan of care dated 10/17/22 revealed a care plan was implemented, and on 05/17/24 was revised, to address Resident #4's behavior problem related to depression with psychotic features, traumatic brain injury, schizoaffective disorder, visual and auditory hallucinations, and delusional disorder. Interventions included to administer medications as ordered and to Monitor/document for side effects and effectiveness. Review of Resident #4's physician orders revealed on 11/11/22 an order was initiated for the administration of the antipsychotic medication Risperdal with instructions to give 0.75 milligrams (mg) by mouth in the morning related to schizoaffective disorder and give 1.5 mg by mouth at bedtime. Review of nursing progress notes revealed on 06/22/24 at 8:20 P.M. Risperdal 1.5 mg was not available for administration. On 06/23/24 at 8:27 A.M. Risperdal 0.75 mg was not available and documented with an, N/A, in the medical record. On 06/29/24 at 11:20 A.M. Risperdal 0.75 mg was documented as on order. Observation on 07/01/24 at 8:40 A.M. revealed Licensed Practical Nurse (LPN) #301 obtained Resident #4's medications from the medication cart. LPN #301 was unable to locate a Risperdal 0.75 mg tablet in the cart and proceeded to the facility medication storage room which contained contingency medications. LPN #301 accessed the contingency medication storage cabinet and discovered two Risperdal drawers were empty. At 8:45 A.M., LPN #301 notified Certified Nurse Practitioner (CNP) #201 to make notification that the medication was not available in the facility for administration. At 9:08 A.M., CNP #201 confirmed the medication was not available in the facility, indicating the medication was not available in a secondary contingency medication location in the facility. On 07/01/24 at 11:45 A.M., during review of Resident #4's medical record with the Director of Nursing (DON), confirmed entries in progress notes indicating Risperdal 0.75 mg and 1.5 mg were not available for administration on 06/22/24, 06/23/24, and 06/29/24. 365830 Page 4 of 5 365830 07/02/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility administration and documentation of medications policy, revised May 2023, noted it is facility policy that every resident receives medications by the licensed nurse as prescribed by a licensed physician or other healthcare provider legally permitted to prescribe medications, safely, properly and in a timely manner, and that medications shall be accurately and completely documented. Documentation must be completed of medications not administered as ordered with the reason why, notifications completed and negative outcome to the resident, if any. This deficiency represents non-compliance investigated under Master Complaint Number OH00154646. 365830 Page 5 of 5