Health inspection·December 19, 2018

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility policy review, the facility failed to ensure activity care plans were person centered for two residents ( #57 and #38) of two reviewed for activities. The facility census was 66. Findings include: 1. Medical record review revealed Resident #57 was admitted to the facility on [DATE]. Medical diagnoses included Alzheimer's Disease and psychotic disorder. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was severely cognitively impaired. Review of care plan dated 12/17/18 revealed Resident #57's was dependent on staff for activities, cognitive stimulation and social interaction related to cognitive deficits. The only intervention was the resident needed assistance with activities of daily living (ADLs) as required during the activity. Interview with Activity Director #223 on 12/18/18 at 11:10 A.M., confirmed the activities care plan for Resident #57 was not person centered. 2. Medical record review for Resident #38 revealed an admission date of 03/15/17 with diagnoses including to dementia, unspecified psychosis not due to a substance or known physiological condition, and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of the care plan dated 06/05/17 revealed the Resident #38 was dependent on staff for activities, cognitive stimulation and social interaction related to cognitive deficits. The interventions listed were to assure the activities the resident was attending were compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed, compatible with individual needs and abilities; and age appropriate. Interview on 12/18/18 at 11:12 A.M., with Activities #223 confirmed care plan for Resident #38 was not person centered and not individualized. Activities #223 revealed there were no known interests documented. Review of the facility policy titled, Care Planning, undated revealed the interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. Page 1 of 5 365894 365894 12/19/2018 MCV Health Care Facilities, Inc 411 Western Row Road Mason, OH 45040

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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, observation, staff interview and facility policy review, the facility failed to provide adequate assistance for activities of daily living (ADLs) for one resident (#40) of two reviewed for ADLs. The facility census was 66. Residents Affected - Few Findings include: Medical record review for Resident #40 revealed an admission date of 06/08/15 with diagnoses including non-Alzheimer's Dementia and psychotic disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #40 was rarely/never understood. She required a limited assistance for transfers. Observation on 12/18/18 at 9:55 A.M., of State Tested Nursing Aide (STNA) #222 revealed the STNA attempted to get Resident #40 out of a chair, in the dining room. The STNA put his left hand underneath her right armpit and attempted to get the resident up and continued to pull her hands apart with his right hand, while still applying pressure under her armpit to raise her up out of the chair. The STNA did not use a gait belt. Interview on 12/18/18 at 10:03 A.M., with STNA #222 verified he should have placed a gait belt around the waist of the resident instead of using his hand with pressure underneath her armpit to raise the resident to a standing position. Review of the facility policy titled, Gait Belt Policy, undated, revealed it was the policy of the facility that nursing staff members utilize gait belts for residents that need hands-on assistance or guidance when ambulating. 365894 Page 2 of 5 365894 12/19/2018 MCV Health Care Facilities, Inc 411 Western Row Road Mason, OH 45040

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based medical records review, observation, and staff interview, the facility failed to obtain an order for oxygen (O2) administration and monitor a resident's oxygen saturation (O2/SATS). This affected one resident (#21) of two residents reviewed for respiratory care. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #21's medical record revealed an admission date of 12/02/15 with diagnoses including Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease (COPD), and hypoxemia (low level of oxygen in the blood). Resident #21 was assessed as being severely cognitively impaired in a comprehensive Minimum Data Set (MDS) assessment dated [DATE]. Further review of Resident #21's medical record revealed no active order for O2 administration. An order was discontinued on 06/23/18 for O2 at two liters per minute, per nasal cannula, as needed to keeps SATS greater than 90% due to non-use of O2. During observations made on 12/16/18 at 4:22 P.M., and 12/17/18 at 8:56 A.M., Resident #21 was observed lying in bed with O2 being administered per nasal cannula at 2 liters per minute. Review of Resident #21's COPD care plan revealed staff would monitor vital signs, skin color, pulse oximetry (SATS), airway functioning and degree of restlessness which may indicate hypoxia. Review of vitals recorded for Resident #21 revealed O2 SATS had not been recorded since 12/04/18. During an interview 12/17/18 at 2:57 P.M., with Licensed Practical Nurse (LPN) #100 confirmed there was no an active order for O2 administration in Resident #21's electronic medical record. The Director of Nursing (DON) confirmed in an interview on 12/18/18 at 10:20 A.M., that Resident #21 did not have an active order for O2 when it was being administered on 12/16/18 and 12/17/18. The DON confirmed in a second interview on 12/18/18 at 11:15 A.M., that Resident #21's O2 SATS were not documented since 12/04/18. The DON also confirmed one of Resident #21's COPD care plan interventions listed was to monitor vitals, such as pulse oximetry (SATS). 365894 Page 3 of 5 365894 12/19/2018 MCV Health Care Facilities, Inc 411 Western Row Road Mason, OH 45040

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, medical record review, staff interview, and review of the facility's medication storage policy, the facility failed to secure a resident's medications. This affected two residents (#44 and #49) of two reviewed for unsecured medications. The facility census 66. Findings include: During a tour of the 400 hallway on 12/16/18 at 4:28 P.M., medications were observed unattended on top of a medication cart. A single pink/orange oblong shaped tablet was observed in a medication cup, as well as a white powder in a plastic cup with a plastic spoon inside. A nurse was observed approximately two doors down at another medication cart. This nurse exited the hallway at 4:29 P.M., and entered a resident's room. At 4:31 P.M., a State Tested Nursing Assistant (STNA) #27 approached the medication cart, noticed the tablet in the cup on top of the medication cart. The STNA picked up the cup with the tablet inside and was going to throw the medication away when the surveyor intervened and asked the STNA to get the nurse who was responsible for the medication cart. At 4:36 P.M., Licensed Practical Nurse (LPN) #34 confirmed STNA #27 had told her of the medication that was left on top of the medication cart. LPN #34 confirmed the medications were left unattended on top of the medication cart. On 12/17/18 at 7:23 A.M., LPN #34 identified the tablet left attended on top of the medication cart was Memantine hydrochloride (dementia medication) and confirmed it belonged to Resident #44. On 12/18/18 at 6:16 P.M., LPN #34 identified the white powder left unattended on the medication cart as Miralax (laxative) and confirmed it belonged to Resident #49. Review of Resident #44's medical record revealed the resident had a current order for Memantine hydrochloride. Review of Resident #49's medical record revealed the resident had a current order for Miralax. Review of the facility's undated policy titled, Storage of Medications, revealed that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 365894 Page 4 of 5 365894 12/19/2018 MCV Health Care Facilities, Inc 411 Western Row Road Mason, OH 45040

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and review of peritoneal dialysis policy, the facility failed to accurately document dialysis medications used in the peritoneal dialysis solution. This affected one resident (#13) of one reviewed for dialysis. The facility census was 66. Findings include: Review of medical record review of Resident #13, revealed an admission date of 09/17/18. Diagnosis included end stage renal dialysis (ESRD), congestive heart failure (CHF), atrial fibrillation (A-Fib), and aphasia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 was cognitively intact. Review of Resident #13's physician's orders dated 12/08/18, revealed orders for heparin (blood thinner) sodium 1,000 units per liter to be added to peritoneal dialysis (PD) solution nightly of 12 liters for a total of 12,000 units of heparin nightly. Review of Resident #13's physician's orders dated 12/11/18, revealed orders for heparin sodium 1,000 units per milliliter (mL). Inject 6,000 units of Heparin as an anticoagulant in to one 6,000 mL of PD solution bag nightly. Review of physician's orders dated 12/12/18, revealed Resident #13 was to receive one green 2.5 % 6,000 milliliter (mL) bag of PD solution if weight was over 200 pounds. Resident #13 was to receive one yellow 1.5 % bag of 6,000 mL bag of PD solution if weight was below 200 pounds. Review of Medication Administration Record (MAR) for December 2018 from 12/11/18 to 12/17/18, revealed both orders of heparin administrations were being documented as given for a total of 18,000 units of heparin in 18,000 ml of peritoneal solution. On 12/18/18 at 3:50 P.M., during an interview with Resident #13, he verified he was only getting one 6,000 mL bag of PD solution nightly. On 12/18/18 at 4:00 P.M., interview with Licensed Practical Nurse (LPN) # 32, revealed she verified both orders for heparin (6,000 and 12,000 unites) were active and being documented as being administered from 12/11/18 through 12/17/18. On 12/18/18 at 4:45 P.M., interview with LPN #195, verified she normally worked night shift and was very familiar with Resident #13's peritoneal dialysis procedures. LPN #195 verified she checked the resident's weight to verify which bag of PD solution to administer. LPN #195 verified she injected 6,000 units of heparin in one bag of 6,000 mL bag of PD solution nightly. LPN #195 also verified she wasn't aware that she was signing off on the two different orders. Review of an undated facility policy titled, Peritoneal Dialysis, revealed nurses were to review all existing orders and instruction for care pertaining to the resident's dialysis. Nurses were also to verify, dialysate solution/concentration, medications to be added, number of exchanges and infusion, swell and drain times, monitoring parameters and laboratory orders. 365894 Page 5 of 5