Health inspection·September 19, 2019

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, staff interview, and review of facility policy, the facility failed to issue appropriate notifications of the ending of skilled Medicare Part A services. This affected one resident (48B) of three reviewed for liability notices. The facility identified six residents with Medicare as their primary payer source and discharged from skilled services in the last six months. The total facility census was 47. Residents Affected - Few Findings Include: Review of Resident #48B's Beneficiary Protection Notification Review revealed Medicare Part A skilled services started on 07/09/19 and last day of covered services was 08/16/19. An Advanced Beneficiary Notice of Non-coverage form was provided and signed 08/13/19. Resident #48B chose Option 3 I don't want the therapies listed above. I understand with this choice I am not responsible for payment and cannot appeal to see if Medicare would pay. No Notice of Medicare Non-Coverage (NOMNC) was found. Interview on 09/19/19 at 12:37 P.M. with the Administrator verified the NOMNC form was not provided to Resident #48B and the wrong notification had been provided. The facility was unable to provide evidence a policy was in place for Beneficiary Notification. Page 1 of 15 365849 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 medical record review, staff interview and policy review, the facility failed to provide a written notice of transfer/discharge for one (Resident #25) of three residents reviewed for hospitalization. The facility census was 47. Findings include: Review of the medical record for Resident #25 revealed an admission date of 11/21/18. Diagnoses included malignant neoplasm of unspecified site of right breast, anemia, constipation, lymphedema, major depressive disorder, single episode, dementia in other diseases classified elsewhere without behavioral disturbance, hyperlipidemia, unspecified injury at unspecified level of cervical spinal cord, and essential hypertension. Review of the residents medical record revealed the resident was discharged to the hospital on [DATE] for pitting edema to the right arm, the resident was readmitted on [DATE]. On 06/10/19, the resident was at a lymphedema clinic, was admitted to the hospital from there for bleeding from right arm and readmitted to the facility on [DATE]. Further review revealed the resident was discharged to the hospital on [DATE] due to a large amount of blood and clots from the right posterior shoulder and was readmitted on [DATE]. On 08/21/19, the resident was discharged to the hospital for having profuse bleeding from the right arm that had clots in it and was readmitted on [DATE]. Review of Resident #25's medical record revealed, no documented evidence of written notice of transfer/discharge was given to Resident #25 or their representative on 05/25/19, 06/10/19, 08/01/19 and 08/21/19. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was rarely/never understood. Interview on 09/19/19 at 7:50 A.M., with the Administrator verified the facility had not given Resident #25 or their representative a written notice for transfer/discharge from the facility on 05/25/19, 06/10/19, 08/01/19 and 08/21/19. The facility was unable to provide a policy for transfers/discharges. 365849 Page 2 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy, the facility failed to provide bed-hold policy information to residents at the time of hospital transfer. This affected three (Resident #48A, Resident #13 and Resident #25) of three reviewed for hospitalization. The facility census was 47. Findings include: 1. Review of Resident #48A's medical record revealed an admission date of 05/15/19 and a discharge date of 06/28/19. Diagnoses included chronic respiratory failure, insomnia, acute embolism and thrombosis of deep vein of right lower extremity, type II diabetes, sleep apnea, anemia, major depressive disorder, hyperlipidemia, pain, fibromyalgia, COPD, anxiety disorder, obesity, heart failure, and gout. Review of Resident #48A's Minimum Data Set (MDS) assessment revealed an Entry MDS was completed 05/15/19 and a Discharge Return Not Anticipated MDS was completed 06/21/19. Review of Resident #48A's progress notes revealed Resident #48A was transferred to the hospital on [DATE]. Review of Resident #48A's Hospital Transfer Information revealed Resident #48A was informed in writing of her transfer to the hospital. Resident #48A was her own responsible party. No evidence was found indicating Resident #48A was provided bed hold notification information when she was transferred to the hospital. Interview on 09/18/19 at 1:20 P.M. with the Director of Nursing (DON) verified Resident #48A was not provided a bed hold notification when transferred to the hospital on [DATE]. 2. Review of the medical record for Resident #25 revealed an admission date of 11/21/18. Diagnoses included malignant neoplasm of unspecified site of right breast, anemia, constipation, lymphedema, major depressive disorder, single episode, dementia in other diseases classified elsewhere without behavioral disturbance, hyperlipidemia, unspecified injury at unspecified level of cervical spinal cord, and essential hypertension. Review of the residents medical record revealed the resident was discharged to the hospital on [DATE] for pitting edema to the right arm, the resident was readmitted on [DATE]. On 06/10/19, the resident was at a lymphedema clinic, was admitted to the hospital from there for bleeding from right arm and readmitted to the facility on [DATE]. Further review revealed the resident was discharged to the hospital on [DATE] due to a large amount of blood and clots from the right posterior shoulder and was readmitted on [DATE]. On 08/21/19, the resident was discharged to the hospital for having profuse bleeding from the right arm that had clots in it and was readmitted on [DATE]. Review of the medical record revealed, no documentation of providing Resident #25 or their representative of the bed hold policy on 05/25/19, 06/10/19, 08/01/19 and 08/21/19 when they were transferred to the hospital. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was 365849 Page 3 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0625 rarely/never understood. Level of Harm - Minimal harm or potential for actual harm Interview on 09/19/19 at 7:50 A.M., with the Administrator verified the facility had not been giving bed hold notices from the facility to the residents upon transfer/discharge from the facility. Residents Affected - Few 3. Review of the medical record for Resident #13 revealed for an admission date of 06/21/19. Diagnoses included constipation, type 2 diabetes mellitus without complications, major depressive disorder, recurrent, essential hypertension, chronic obstructive pulmonary disease, dysphagia, chronic kidney disease stage three, metabolic encephalopathy and personal history of transient ischemic attack. Review of the quarterly MDS assessment dated [DATE] revealed Resident #13 was rarely/never understood. Review of the medical record revealed no notice of the bed hold policy was provided to Resident #13 and her representative when she was transferred the the hospital on [DATE]. Interview on 09/19/19 at 7:50 A.M., with the Administrator verified the facility had not been giving bed hold notices from the facility to the residents upon transfer/discharge from the facility. Interview on 09/16/19 at 2:28 P.M. with Resident #13's husband revealed he does not think he ever received a notice about the bed hold policy when his wife was transferred to the hospital on [DATE]. Review of the facility policy titled, Bed-Holds and Returns revised December 2018 revealed prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. 365849 Page 4 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0641 Ensure each resident receives an accurate assessment. 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 facility policy, the facility failed to assess residents for risk of unsafe wandering and continued use of wander guard ankle bracelet alarms as an intervention. This affected one (Resident #18) of one reviewed for wandering and elopement. The facility identified three residents with wander guards in place. The facility census was 47. Residents Affected - Few Findings Include: Review of Resident #18's medical record revealed an admission date of 12/18/15. Diagnoses included heart disease, hypokalemia, dementia, major depressive disorder, hyperlipidemia, hypothyroidism, hypertension, calculus of kidney, and anxiety disorder. Review of Resident #18's physician's order revealed an order dated 05/24/18 for an alert bracelet to the left ankle and to check placement every shift. Check function on night shift for the diagnosis of dementia. Review of Resident #18's Minimum Data Set (MDS) assessments dated 08/07/18, 11/01/18, and 01/29/19, indicated the resident used a wander/elopement alarm daily. Resident #18's 05/18/19 MDS indicated Resident #18 used a wander/elopement alarm less than daily. Resident #18's 04/23/19 MDS indicated Resident #18 did not use a wander/elopement alarm at the time of the review. Review of Resident #18's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #18 was rarely or never understood. Resident #18 had short and long term memory problems. Resident #18 was independent with bed mobility, locomotion, dressing, eating, toilet use, personal hygiene, required supervision with transfers, and walking. Resident #18 displayed no behaviors during the review period. Resident #18 displayed no wandering behaviors during the review period. No wander guards or alarms were documented used at the time of the review. Review of Resident #18's care plan revised 09/03/19 revealed supports and interventions for self-care deficit, nutritional risk, difficulty communicating, risk for falls, cognitive loss, risk for alteration in skin integrity, wandering/pacing related to cognitive deficit, elopement risk (alert bracelet as of 10/05/17), risk for changes in mood, anxiety, resistive/non-compliant with care, risk for adverse effects, and support following daughter passing away. Review of Resident #18's behavior tracking for the last 30 days revealed daily tracking was completed. Review of Resident #18's behaviors for the last 30 days revealed four days of frequent crying. No wandering behaviors were noted. Review of Resident #18's progress notes for the last three months revealed no concerns related to wandering or elopement. Review of Resident #18's assessments revealed no elopement risk assessment was completed for ongoing wander guard use. Review of Resident #18's Treatment Administration Record (TAR) for August 2019 and September 2019 revealed Resident #18's wander guard was checked every night shift for function and every shift for placement as ordered. 365849 Page 5 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 09/16/19 at 1:38 P.M. of Resident #18 found the resident walking back from the dining room to her bedroom. Resident #18 had a wander guard applied to her left ankle. An interview was attempted with Resident #18 but Resident #18 was confused and unable to understand and respond to interview questions. Resident #18 was not wandering and walked directly to her room, and closed the door. Observation on 09/16/19 at 4:25 P.M. of Resident #18 found the resident lying in bed on top of her blankets. Resident #18's wander guard was in place on her left ankle. Resident #18 was awake and confused turning her over-bed light on and off. Observation on 09/17/19 at 10:04 A.M. of Resident #18 found the resident clean, alert, confused, dressed in night clothes, walking around her room adjusting her personal items and muttering to herself. Resident #18 was not exit seeking and was not wandering around the facility. Interview on 09/17/19 at 1:32 P.M. with Licensed Practical Nurse (LPN) #301 revealed Resident #18 displayed no behaviors and wore a wander guard alarm on her left ankle. LPN #301 reported he had not observed Resident #18 wandering or trying to leave the building in the three years LPN #301 had worked at the facility. Interview on 09/17/19 at 1:44 P.M. with State Tested Nursing Assistant (STNA) #103 revealed Resident #18 was cooperative with care and displayed no wandering or exit seeking behaviors. Interview on 09/17/19 at 3:18 P.M. with the Director of Nursing (DON) verified no current wandering risk assessment was completed for Resident #18 for the continued use of the wander guard alarm. Observation on 09/17/19 at 4:50 P.M. of Resident #18 found the resident seated in the dining room waiting for dinner. Resident #18 was dressed, clean, alert and confused. Resident #18 had a wander guard in place on her left ankle. Resident #18 was not wandering or exit seeking. Observation on 09/18/19 at 8:15 A.M. of Resident #18 found the resident eating breakfast in her room. Resident #18 was seated on the side of her bed with her tray table pulled up next to her. Resident #18 was clean, dressed, alert, confused and feeding herself her breakfast. Resident #18's door was partially open and Resident #18 was not wandering or exit seeking. Resident #18 had her wander guard in place on her left ankle. Review of the undated facility policy titled, Elopement/Unsafe Wandering Risk Assessment, revealed Elopement/Unsafe Wandering Risk Assessments would be completed on admission, quarterly, and as needed for a change in resident status. 365849 Page 6 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0679 Provide activities to meet all resident's needs. 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, and staff interview, the facility failed to ensure ongoing individualized activities were provided. This affected one (Resident #34) of twelve residents reviewed for activity involvement in a facility census of 47. Residents Affected - Few Findings include; Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including, dementia, dysphagia, chronic kidney disease, low back pain, muscle weakness, major depression, osteoarthritis, and history of venous thrombosis and embolism. Review of the most current minimum data set assessment (MDS) assessment dated [DATE] revealed Resident #34 had adequate hearing, ability to understand/understood, visual impairment without the use of corrective lenses, severely impaired cognition, no behavioral symptoms including refusal of care, and total dependence on staff for the completion of activities of daily living. Review of the residents plan of care dated 05/25/18 revealed plan of care was developed to address the residents need for redirection related to the diagnosis of Alzheimer's Disease, and dementia. Interventions included, display appropriate response to situation, recognize persons with whom routinely have contact, respond to questions and statements with appropriate verbalization, will be able to follow simple instructions, would be able to make decisions about activities of daily living and activity choices or preferences, allow adequate time to respond, approach/speak in a calm, positive/reassuring manner, encourage low stress activities such as music, small group activities, provide cueing and prompting for such things as activities, personal care, or room location. Further review of the medical record lacked individualized activity preferences listed. Review of care conference notes from 08/06/19 noted Social Services and Activities to indicate a review of plan of care, and activity schedule noted the resident preferred to do self recreation activities such as watching TV and 1:1 visits. No specifics of individualized activity, TV programming, or 1:1 visit content was documented. Observation on 09/17/19 at 10:25 A.M., revealed Activity Director (AD) #1 was observed reading facility content(chronicle) news paper. At 10:27 A.M., AD #1 left the resident sitting in the room without ongoing activity engagement. Observation on 09/16/19 at 10:57 A.M., 2:15 P.M., 4:12 P.M., 09/17/19 at 10:05 A.M., 10:35 A.M., 1:40 P.M. 4:05 P.M., 5:23 P.M., and 6:02 P.M., the resident was observed in bed or sitting in a reclined geriatric (broda) chair in his room. The television was on at intervals with day time programming. The resident was frequently noted with eyes closed and on interview unaware of television content. On 09/18/19 at 11:37 A.M., the resident was noted in his room with eyes closed sitting in the broda chair with a tv game show. Interview on 09/17/19 at 5:55 P.M., with State Tested Nurse Assistant (STNA) #101 and Assessment Nurse (AN) #200 verified they were unaware of Resident #34's interest and confirmed no there was not a plan of care listing individualized activities. Interview on 09/17/19 at 5:52 P.M., with the Administrator and AD #1 verified there was no specific 365849 Page 7 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0679 plan of care developed to address Resident #34's activity interest and confirmed no specific ongoing activity programming was being provided to Resident #34. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365849 Page 8 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

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 staff interview, the facility failed to provide care and services as ordered and care planned for constipation. This affected one (Resident #25) of five resident's reviewed for unnecessary medications. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record for Resident #25 revealed an admission date of 11/21/18. Diagnoses included malignant neoplasm of unspecified site of right breast, anemia, constipation, lymphedema, major depressive disorder, single episode, dementia in other diseases classified elsewhere without behavioral disturbance, hyperlipidemia, unspecified injury at unspecified level of cervical spinal cord, and essential hypertension. Review of the care plan dated 08/19/19 revealed Resident #25 was on pain medication therapy related to breast cancer, surgical wounds, and lymphedema. Resident #25 was at risk for communication and cognitive deficits in the areas of receptive and expressive language impacting resident's ability to effectively communicate needs and wants, orientation, short term memory, problem solving and sequencing. Cognitive loss as evidenced by poor short term memory and poor judgement related to dementia. Resident #25 was at risk for constipation related to decreased mobility. Goal was resident would pass soft, formed stool at the preferred frequency through the review date. Interventions included follow facility bowel protocol for bowel management. Review of current physician orders revealed there was an order for Milk of Magnesia (laxative) 400 milligram (mg)/five milliliters (ml), take 30 ml daily as needed for constipation and dulcolax suppository 10 mg daily as needed for constipation. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was rarely/never understood. Resident #25 received antidepressant and opioids medications seven days and antibiotics three days during the assessment period. Resident #25 was always incontinent of bowel and bladder. Review of the Activities of Daily Living (ADL) log for Resident #25 revealed there was documentation indicating Resident #25 had a bowel movement on 09/09/19. The documentation further revealed Resident #25 did not have a bowel movement from 09/10/19 to 09/19/19. Review of the Medication Administration Record (MAR) revealed there were no doses of Milk of Magnesia or Dulcolax suppository administered from 09/10/19 to 09/19/19. Interview and Observation on 09/19/19 at 12:00 P.M. with Licensed Practical Nurse (LPN) #302 verified the documentation in the medical record revealed Resident #25 did not have a bowel movement from 09/10/19 to 09/19/19. LPN #302 assessed Resident #25 and revealed she had active bowel sounds and her abdomen was soft. Resident #25 denied pain. LPN #302 administered a dose of Milk of Magnesia at 12:25 P.M. on 09/19/19. Interview on 09/19/19 at 2:00 P.M. with the Director of Nursing (DON) verified the facility does not have a bowel protocol and Resident #25 had care plan interventions to follow the facility bowel protocol. 365849 Page 9 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents' smoking materials were kept secured. This affected two residents, (Resident #9 and #199) of two reviewed for smoking. The facility identified nine residents who smoked. The facility census was 47. Findings Include: 1. Review of Resident #199's medical record revealed an admission date of 09/04/19. Diagnosis included type II diabetes, bipolar disorder, major depressive disorder, hypertension, tachycardia, heart disease, hyperlipidemia, fibromyalgia, lupus, and anxiety. Review of Resident #199's smoking assessment dated [DATE] revealed Resident #199 smoked ten or more times per days. Resident #199 was able to light her own cigarettes. Resident #199 needed the facility to store the lighter and cigarettes and had a plan of care in use to assure the resident was safe while smoking. Review of Resident #199's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #199 was cognitively intact. Resident #199 was independent with bed mobility, transfer, locomotion, dressing, eating, toilet use and personal hygiene. Resident #199 required limited assistance with locomotion. Resident #199 displayed hallucinations during the review period. Resident #199 displayed verbal behavioral symptoms directed toward others one to three days during the review period. Review of Resident #199's care plan revised 09/13/19 revealed supports and interventions for smoking which included smoking supervision to be provided at all times and smoking items to be kept at the nurses' station, risk for allergic reaction, potential for impaired skin integrity, potential for altered nutrition, risk for self-care deficit, diabetes, risk for falls, and risk for pain. Observation and interview on 09/16/19 at 11:08 A.M. with Resident #199 revealed the resident had her cigarettes and a lighter lying out on her wheelchair seat. Resident #199 was lying in bed and reported she knew the facility was supposed to keep her smoking materials. Resident #199 reported the staff never asked her for her materials so she didn't give them to them. Resident #199 reported she knew the rules and said she wasn't supposed to have them but she didn't want anyone else to smoke them so she kept them in her room. Resident #199 had nine cigarettes and a lighter in her cigarette box lying on her wheelchair. Resident #199 stated she took her cigarettes and lighter out with her for smoke breaks so the facility knew she had her supplies with her. Interview on 09/16/19 at 11:20 A.M. with State Tested Nursing Assistant (STNA) #105 verified Resident #199 had her cigarettes and lighter and Resident #199's smoking supplies were supposed to be kept locked in the smoking cart. Observation on 09/17/19 at 1:00 P.M. of the smoking process found the nurse unlocked the room and STNA #102 distributed cigarettes to two residents. STNA #102 asked the group who had a lighter because she didn't have one in the cart. None of the residents responded. STNA #102 located a lighter and went out with the residents to supervise the smoking break. STNA #102 was observed lighting 365849 Page 10 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0689 Level of Harm - Minimal harm or potential for actual harm cigarettes for all the residents. Resident #199 was observed smoking cigarettes she had in her possession. Resident #199's cigarettes were not distributed from the smoking cart. Interview on 09/17/19 at 1:17 P.M. with STNA #102 verified Resident #199 brought out her own cigarettes and they were not kept in the locked smoking cart. Residents Affected - Few Observation on 09/18/19 at 9:43 A.M. of Resident #199 found Resident #199 propelling herself from her room, down the hall, and outside to smoke. Resident #199 was observed holding a cigarette. Once outside, Resident #199 got a lighter from the supervising staff and lit the cigarette she had brought out with her. 2. Review of Resident #9's medical record revealed an admission date of 06/15/19. Diagnoses included acute osteomyelitis of left ankle and foot, hyperlipidemia, insomnia, hypertension, tobacco use, type II diabetes, cellulitis of left lower limb, peripheral vascular disease, gangrene, psychoactive substance abuse, atherosclerosis, and absence of left lower limb. Review of Resident #9's smoking assessment completed 06/16/19 revealed Resident #9 smoked one to two times per day. Resident #9 was able to light his own cigarettes and needed the facility to store his lighter and cigarettes. Resident#9's care plan was used to assure Resident #9 was safe while smoking. Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #9 was cognitively intact. Resident #9 required supervision with bed mobility, transfer,walking, locomotion, dressing, toilet use and personal hygiene. Resident #9 displayed behaviors of rejection of care one to three days during the review period. Review of Resident #9's care plan revised 08/30/19 revealed supports and interventions for skin integrity, insomnia, risk for side effects from medications, self-care deficit, resistive to care, peripheral vascular disease, risk for drug addiction, smoking including Resident #9 would have supervision at all times while smoking and smoking items were to be kept at the nurses station. Interview and observation on 09/16/19 at 10:34 A.M. with Resident #9 revealed Resident #9 smoked and kept his cigarettes and lighter on the bedside table. Resident #9 reported he went out to smoke at the smoking times and he was independent with smoking. Interview on 09/16/19 at 10:39 A.M. with Registered Nurse (RN) #300 verified Resident #9 had his box of cigarettes and lighter unsecured on his bedside table. RN #300 disposed of the cigarette remnants and lighter. RN #300 reported education on securing smoking items was provided to Resident #9. Observation on 09/17/19 at 1:00 P.M. of the smoking process found the nurse unlocked the room and STNA #102 distributed cigarettes to two residents. STNA #102 asked the group who had a lighter because she didn't have one in the cart. None of the residents responded. STNA #102 located a lighter and went out with the residents to supervise the smoking break. STNA #102 was observed lighting cigarettes for all the residents. Resident #9 was observed smoking a cigarette he had in his possession. Resident #9's cigarettes were not distributed from the smoking cart. Interview on 09/17/19 at 1:17 P.M. with STNA #102 verified Resident #9 brought out his own cigarettes and they were not kept in the locked smoking cart. 365849 Page 11 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy titled, Smoking Policy and Procedures dated 01/29/19 revealed the facility would supervise all residents while smoking whose assessment showed the need. The facility staff would light all smoking products and provide other assistance and protective devices as needed for supervised smokers. All smoking materials for supervised smokers would be kept in a secured area and distributed by facility staff. No resident would be permitted to carry or have in their possession cigarettes, cigars, pipe tobacco, lighters, matches or other smoking materials if after assessment it was determined they required supervision. 365849 Page 12 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0692 Provide enough food/fluids to maintain a resident's health. 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 dietary menu spreadsheet, the facility failed to ensure residents were provided with adequate nutrition and therapeutic diets. This affected one (Resident #28) of three residents reviewed for nutrition in a facility census of 47. Residents Affected - Few Findings include: Resident #28 admitted to the facility on [DATE] with the diagnoses including, congestive heart failure, dysphagia, depression, acute respiratory failure, history of pulmonary edema, gastrointestinal hemorrhage, anemia, type II diabetes mellitus with neuropathy, end stage renal disease receiving hemodialysis, atrial fibrillation, metabolic encephalopathy, coronary artery disease, arteriovenous fistula, and fibromyalgia. On 02/04/19, a plan of care was implemented to address the residents need for dialysis related to renal failure, hyperlipidemia, proteinuria and adenoma. Interventions included daily weights, diagnostic test as ordered, and attends dialysis on Monday, Wednesday, and Friday. On 03/29/19, a plan of care was developed to address the residents potential for alteration in nutrition. Interventions included assist resident with meals as needed, honor food preferences, and provide diet as ordered. According to dietary communication documentation on 05/29/19, the dietitian made a diet change to a potassium restricted diet. Review of a Hemodialysis communication form dated 08/02/19 noted the dialysis center to indicate nutritional concern of hyperkalemia (elevated potassium blood level). The form indicated the resident must be on a low potassium diet. Post dialysis instructions indicated for dietitians to collaborate on the residents potassium levels. According to the most current Minimum Data Set (MDS) assessment dated [DATE] identified the resident as alert, oriented, able to make needs known, and required limited assistance of one person for the completion of activities of daily living. The assessment also indicated Resident #28 received a therapeutic diet and dialysis. On 09/06/19 a dietary communication form noted to please send early breakfast on dialysis days including Monday, Wednesday, and Friday due to the resident being picked up at 5:45 A.M. Review of Resident #28's diet card notes indicated the resident was to receive a mechanical soft, renal diet, nectar thick liquids, and double portions. Special instructions included juice apple nectar thick and double meat at each meal. Observation on 09/17/19 at 11:43 A.M., discovered the resident sitting at the bedside eating lunch provided by the facility. The meal included ground meat, mash potatoes with cheese and lemon meringue pie. Interview with Resident #28 at the time revealed she was not suppose to have potatoes due to being on a special renal diet and the high potassium of the potatoes. According to the dietary spreadsheet for the lunch meal the renal diet was to include mashed cauliflower in place of mashed potatoes. 365849 Page 13 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/17/19 at 11:49 A.M., observation and interview with State Tested Nurse Aide (STNA) #101 verified Resident #28 was not to have potatoes served at meals due to the high level of potassium contained in the food. Additional observation on 09/18/19 at 5:14 A.M. noted the resident sitting at the bedside preparing to attend dialysis. The resident was observed to consume her medications with a strawberry yogurt. No breakfast was observed to be provided. Interview with Resident #28 at the time revealed each dialysis morning no breakfast was provided. On 09/18/19 at 5:30 A.M., interview with the Director of Nursing (DON) verified no breakfast had been provided to the resident prior to departing for dialysis. On 09/19/19 at 10:35 A.M., interview with the Dietary Manager (DM) #1 revealed the most current communication regarding Resident #28 indicated the resident attended dialysis on Monday, Wednesday, and Fridays. Dietary staff were to provide a meal at 10:00 A.M. DM #1 was unaware an early breakfast meal was to be provided due to the resident being picked-up for dialysis at 5:45 A.M. No dietary communication form had been obtained. 365849 Page 14 of 15 365849 09/19/2019 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

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, medical record review, staff interview, and facility medication administration via enteral tube policy review, the facility failed to ensure medications administered via Gastrostomy tube (G-tube) were provided in accordance with facility policy which resulted in a medication error rate of greater than five percent (5%). A total of 28 opportunities were observed with six medication errors for a medication error rate of 21.43 %. This affected one (Resident #13) of four residents reviewed for medication administration. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record for Resident #13 noted the following physician orders; 05/07/19, lexapro 10 milligrams (mg) daily via G-tube, 06/21/19, norvasc 5 mg daily via-G-tube, aspirin 81 mg chewable via G-tube, eliquis 2.5 mg twice daily via G-tube, lisinopril 10 mg once daily via G-tube, and lopressor (metoprolol) 25 mg twice daily via G-tube. On 09/02/19, give 20 milliequivalents (meq) per(/) 15 milliliters (ml) liquid potassium daily via G-tube. No physician order for crushing or cocktailing medications was contained in the medical record. Observation on 09/18/19 at 9:45 A.M. revealed Licensed Practical Nurse (LPN) #204 prepared for the administration of Resident #13's medications via G-tube. LPN #204 obtained liquid suspension potassium 20 meq/15 ml and placed a total dose of 15 ml into a medication cup (cup #1). In a separate medication cup (cup #2), LPN #204 crushed and placed the following medications into the same cup; lopressor 25 mg one tablet, norvasc 5 mg one tablet, chewable aspirin 81 milligrams one tablet, eliquis 2.5 mg one tablet, lexapro 10 mg one tablet, lisinopril 10 mg one tablet. LPN #204 proceeded to Resident #13's room and administered the 15 ml of liquid suspension potassium through the G-tube first. LPN #204 then placed approximately 15 ml of water into cup #2 and administered the medications via the G-tube. Interview on 09/18/19 at 9:57 A.M., with LPN #204 verified Residents#13's medications via G-tube were crushed and placed together as a cocktail. The medications were then administered together. Interview on 09/18/19 at 9:58 A.M, with the Certified Nurse Practitioner (CNP) verified medications provided to Resident #13 should be provided individually and not placed together as a cocktail. Review of the facility general guideline for administering medications via enteral tube policy (revised November 2018) revealed crushed medications are not mixed together unless an order was obtained from the prescriber. Each medication was administered separately to avoid interaction and clumping when possible. 365849 Page 15 of 15