Health inspection·June 27, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure residents were notified of the reasons for non-coverage of Medicare funds. This affected two (Residents #22 and #230) of two residents reviewed for liability and beneficiary appeal notices. The census was 26. Residents Affected - Few Findings include: 1. A review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed Resident #22 was not issued the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) cut letter. Her Medicare Part A Skilled Services Episode started 03/18/22 and the last covered day of Part A Service was 04/18/22. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. 2. A review of the SNF Beneficiary Protection Notification Review revealed Resident #230 was not issued the SNFABN or Notice to Medicare Provider Non-coverage (NOMNC) for services that started 04/21/22 and stopped 04/28/22. Resident #230 did not exhaust all benefit days. On 06/23/22 at 2:10 P.M. an interview with Corporate Liaison Business Office Manager (BOM) #300 verified Resident #22 was not issued the SNFABN cut letter until 06/23/22. She also verified Resident #230 was not issued an SNFABN cut letter nor a NOMNC. Page 1 of 7 365835 365835 06/27/2022 Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, family interview and staff interview, the facility failed to provide a clean and safe environment for the residents. This affected three (Residents #11, #25 and #27) of 17 residents reviewed for physical environment. The facility census was 26. Findings include: On 06/21/22 at 11:49 A.M., a telephone interview with an anonymous family member revealed she felt the floors were very dirty and sticky at times and the facility needed additional cleaning. Observations on 06/21/22 at 12:00 P.M. of the room and bathroom for Residents #11, #25 and #27 revealed the floor had dirty spots of food and skid marks. Observations and interviews on 06/23/22 at 11:59 A.M. of rooms for Residents #11, #25 and #27 with the Administrator verified the floors were dirty and in need of stripping for Resident #11, #25, and #27's room and bathroom. The Administrator verified the bathrooms in both rooms had loose baseboards that protruded from the walls. 365835 Page 2 of 7 365835 06/27/2022 Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility's policy and procedure, the facility failed to ensure the physician documented a rationale for pharmacy recommendations. This affected one (Resident #3) out of five residents reviewed for unnecessary medications. The facility census was 26. Findings include: Review of the medical record for Resident #3 revealed an admission date of 11/13/20. Diagnoses included depression, dementia, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had impaired cognition and she had no behaviors. Review of the care plan dated 01/06/20 revealed Resident #3 had a cognitive deficit with the potential for mood/behavior problems. She was at risk for wandering/elopement and wears a wander guard device on her ankle, she received antianxiety and antipsychotic medications and was at risk for adverse effect, and she had the diagnoses of depression, anxiety, Parkinson's disease and dementia. Interventions included ton administer anti-anxiety and antipsychotic medications as ordered and monitor for adverse side effects. Review of Resident #3's physician orders revealed orders for Alprazolam 0.25 milligrams (mg) twice daily for anxiety and Risperidone 0.25 mg at night for dementia. Review of Resident #3's pharmacy recommendations revealed the following: On 04/13/22 the pharmacist recommended a gradual dose reduction for the resident's Risperdal, to change the order from 0.25 mg daily to 0.125 mg daily. The physician declined and no rationale was provided; On 03/16/22, the pharmacist recommended a gradual dose reduction for the resident's Alprazolam, as she was receiving 0.25 mg twice daily. The physician declined and no rationale was provided; On 01/12/22, the pharmacist recommended a gradual dose reduction for the resident's Risperdal, to change the order from 0.25 mg daily to 0.125 mg daily. The physician declined and no rationale was provided; On 12/08/21 the pharmacist recommended a gradual dose reduction for the resident's Alprazolam, as she was receiving 0.25 mg twice daily. The physician declined and no rationale was provided; On 11/10/21, the pharmacist recommended a gradual dose reduction for the resident's Risperdal, to change the order from 0.25 mg daily to 0.125 mg daily. The physician declined and no rationale was provided. Interview on 6/23/22 at 10:19 A.M. with the Director of Nursing (DON) confirmed the physician didn't complete documented rationales for Resident #3's gradual dose reductions on 04/13/22, 03/16/22, 01/12/22, 12/08/21, and 11/10/21 Review of the facility's undated policy and procedure titled Gradual Dose Reduction/Tapering in the Nursing Facility revealed the continued use of medication is in accordance with relevant current standards of practice and the physician has documented the clinical rationale. 365835 Page 3 of 7 365835 06/27/2022 Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and review of the facility's policy and procedure, the facility failed to ensure their medication error rate less than five percent (%). Out of 28 opportunities, there were two errors to equal 7.14% medication error rate. This affected two residents (#8 and #17) out of five residents observed during medication administration. The facility census was 26. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 04/23/21. Diagnoses included legal blindness, presence of intraocular lens, corneal transplant, high blood pressure and open-angle glaucoma. Review of the care plan dated 04/26/21, revealed Resident #17 had an alteration in vision and communication related to legal blindness, glaucoma and bilateral corneal transplant. Interventions included to monitor ocular changes and keep glasses and frequently used objects in a consistent area within reach. Review of Resident #17's physician orders revealed orders to administer Dorzolamide-Timolol 2% - 0.5% one drop to the left eye twice daily for legal blindness. Observation on 06/22/22 at 7:42 A.M. with Registered Nurse (RN) #133 revealed she administered the Dorzolamide-Timolol 2% - 0.5% eye drop to Resident #17's right eye. Interview on 06/22/22 at 7:43 A.M. with RN #133 confirmed she administered the medication in the right eye and it should have been the left eye. She stated Resident #17 receives a lot of eye drops during the day but she didn't think Resident #17 was to receive that specific medication in the right eye at all. 2. Review of the medical record for Resident #8 revealed an admission date of 06/23/16. Diagnoses included adult failure to thrive. Review of the care plan dated 06/09/22 revealed Resident #8 was at risk for malnutrition related to diagnoses including failure to thrive with interventions to administer prescriptions per physician orders. Review of Resident #8's physician orders revealed orders for Vitamin B-12 1,000 micrograms (mcg) with instructions to give two tablets daily for adult failure to thrive. Observation and interview on 06/22/22 at 8:09 A.M. of medication administration for Resident #8 revealed Registered Nurse (RN) #133 prepared the resident's medications. When she prepared his Vitamin B-12 1,000 mcg, she only prepared one. As she was getting ready to go into Resident #8's room, surveyor intervened and the nurse confirmed she only placed one Vitamin B-12 into the pill cup and the order was for two. Review of the facility's policy and procedure titled Medication Administration Policy, dated January 2010, revealed there are five rights of medication administration (right drug, right dose, right resident, right route, and right time) and drug labels should be read carefully and checked against 365835 Page 4 of 7 365835 06/27/2022 Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317

F 0759 the order three times. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365835 Page 5 of 7 365835 06/27/2022 Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317

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, record review, and staff interview, the facility failed to maintain infection control during the medication administration observation when she touched resident's medications with her bare hands and administered them to residents. This affected two (Residents #8 and #19) of five residents observed during medication administration. Furthermore, the facility failed to ensure they initiated and maintained an appropriate Legionella prevention plan. This had the potential to affect all 26 residents residing in the facility. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 12/26/17. Diagnosis included atrial fibrillation (A-Fib). Review of the resident's physician orders revealed orders for Eliquis 2.5 milligrams twice daily for A-Fib. Observation on 06/22/22 at 8:00 A.M. revealed Registered Nurse (RN) #133 preparing Resident #19's medications. She dropped the Eliquis medication onto the top of the medication cart and picked up the medication with her bare hands, put it into the medication cup, and administered the medications to the resident. Interview on 06/22/22 at 8:17 A.M. with RN #133 confirmed she touched Resident #19's medications with her bare hands. 2. Review of the medical record for Resident #8 revealed an admission date of 06/23/16. Diagnoses included epilepsy. Review of the resident's physician orders revealed orders for Divalproex 125 milligrams twice daily for epilepsy. Observation on 06/22/22 at 8:09 A.M. revealed Registered Nurse (RN) #133 preparing Resident #8's medications. She dropped the Divalproex medication onto the top of the medication cart and picked up the medication with her bare hands, put it into the medication cup, and administered the medications to the resident. Interview on 06/22/22 at 8:17 A.M. with RN #133 confirmed she touched Resident #8's medications with her bare hands. 3. Review of the facility's Legionella Prevention Plan revealed the facility had a packet of information pertaining to Legionella, printed from the Centers for Disease Control (CDC), and how the facility could reduce the risk of the infection. Review of the facility's front page of the Water Management Program Binder revealed the previous Administrator signed that she reviewed the plan on 08/04/21 and she stated no changes were to be made to the plan. There was no documented evidence stating what the Legionella Management Plan/Program would be and there was no documented evidence that the facility attempted to test the water for Legionella since September 2017. Review of the facility's form titled Identifying Buildings at Increased Risk revealed the building marked the answer, Yes to two questions, indicating the facility should have a water management program for the building's hot and cold water distribution system. It stated the buildings spa was 365835 Page 6 of 7 365835 06/27/2022 Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many drained between each use. It also stated the facility had emergency water systems such as fire sprinklers, safety showers and eyes wash stations that were regularly tested and the last test was completed was in March 2019. The plan stated the facility would contact [NAME] for Legionella testing on 04/16/19. Review of the [NAME] CDC Legionella Sampling form revealed they were last at the facility on 09/28/17 to test the facility's water systems. Review of the facility's flow sheet to indicate the flow of water through the building, revealed it was for a completely different building. Interview on 06/22/22 at 1:45 P.M. and 2:12 P.M. with the Administrator confirmed there was no Legionella information pertinent to this facility, he stated he didn't know why that book was even here, and he confirmed nothing had been updated in the Legionella book since 2019 even though the previous Administrator supposedly reviewed and approved the plan in 2021. 365835 Page 7 of 7