Health inspection·May 5, 2022

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on record review, facility policy and procedure review and interview the facility failed to ensure quarterly care conferences were held and included the resident. This affected one resident (#25) of three residents reviewed for care conferences. Findings include: Record review for Resident #25 revealed an admission date of 04/15/21 with diagnoses including myocardial infarction, hypertension, muscle weakness, osteoarthritis, hyperlipidemia, major depressive disorder, anxiety disorder, myasthenia gravis, dementia, complete rotator cuff tear or rupture and atherosclerotic heart disease. Review of the resident's electronic medical record revealed Minimum Data Set (MDS) 3.0 assessments were completed on 10/21/21, 11/19/21, 02/19/22, 03/24/22 and 04/05/22. Record review revealed the last documented care planning conference was held on 10/29/21. Review of the 04/05/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the Resident was cognitively intact. On 05/02/22 at 9:16 A.M. interview with Resident #25 revealed she had not had a care conference in a long time. On 05/05/22 at 8:42 A.M. interview with the Director of Nursing (DON) verified the most recent care conference for Resident #25 was held on 10/29/21. Review of the undated facility plan of care meetings policy revealed plan of care meetings would be held for each resident upon admission, quarterly and as needed. The meeting minutes would be recorded in the electronic health records during or after the plan of care meeting. Page 1 of 10 365934 365934 05/05/2022 Crestwood Ridge Skilled Nursing and Rehab 141 Willettsville Pike Hillsboro, OH 45133

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #24, who was dependent on staff for activity of daily living care, received adequate and timely assistance with routine nail care to promote proper hygiene. This affected one resident (#24) of four residents reviewed for activities of daily living (ADL) care. Residents Affected - Few Findings include: Review of Resident #24's medical record revealed an admission date of 04/21/21. Resident #24 had diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD) intervertebral disc degeneration lumbar region, restlessness and agitation, hypertension, urge incontinence, insomnia, diabetes mellitus, major depressive disorder, psychosis and COVID-19. Review of the plan of care, dated 05/10/21 revealed the resident was at risk for decline in ADL function related to Alzheimer's disease and psychosis. Interventions included encourage resident participation while performing ADL, break tasks down so that ADLs were easier for resident to perform and make adjustments to restorative program as necessary. The plan of care indicated the resident, required extensive assistance from one (staff) for personal hygiene and staff to anticipate needs and assist as needed. Review of the resident's comprehensive Minimum Data Set (MDS) assessment, dated 04/07/22 revealed the resident had clear speech, understood others, made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. The assessment revealed the resident required extensive assistance of one staff for personal hygiene, including nail care. Review of the monthly physician's orders for May 2022 failed to identify any orders related to nail care. On 05/02/22 at 10:16 A.M., observation of the resident revealed the resident had long dirty fingernails. On 05/03/22 at 9:28 A.M. observation of the resident revealed the resident's nails remained long and dirty. On 05/03/22 at 9:30 A.M. interview with the Administrator verified the resident's nails were long and dirty. Review of the facility policy titled Fingernail Care, dated 04/06 revealed the facility procedure related to the care of the residents nails (finger and toe) and equipment to provide cleanliness and to prevent the spread of infection. 365934 Page 2 of 10 365934 05/05/2022 Crestwood Ridge Skilled Nursing and Rehab 141 Willettsville Pike Hillsboro, OH 45133

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 Based on observation, record review and interview the facility failed to comprehensively assess and monitor multiple areas of bruising for Resident #232. This affected one resident (#232) of one resident reviewed for skin conditions. Residents Affected - Few Findings include: Review of Resident #232's medical record revealed an admission date of 05/01/22 with the admitting diagnoses of chronic respiratory failure, pneumonia, hypertension, chronic obstructive pulmonary disease (COPD), heart failure, dementia and anxiety disorder. Review of the resident's admission Packet, dated 05/01/22 revealed the resident was admitted to the facility with a large bruise covering the left knee, a large bruise over the left forearm and scattered bruising over body. Further review of the medical record failed to provide an assessment for each bruise; the resident had multiple bruises to the body. Review of the plan of care, dated 05/01/22 revealed the resident was at risk for skin breakdown related to impaired mobility, underlying disease, weakness and debility related to pneumonia diagnosis. Interventions included encourage fluids, inspect skin during routine daily care, lift sheet on chair/bed for positioning, medications as ordered, pillows for positioning, pressure reduction devices as ordered, treatment as ordered and turn and reposition as ordered. Review of the resident's physician's orders failed to identify any orders to monitor the multiple bruises to the resident's body. On 05/02/22 at 10:13 A.M. observation of the resident revealed dark purple bruises to both arms. On 05/03/22 at 9:45 A.M. observation of the resident revealed the dark purple bruises remained to the resident's arms. On 05/03/22 at 12:35 P.M. interview with the Director of Nursing (DON) verified the multiple bruises to the resident's body were not assessed or monitored following the resident's admission. 365934 Page 3 of 10 365934 05/05/2022 Crestwood Ridge Skilled Nursing and Rehab 141 Willettsville Pike Hillsboro, OH 45133

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure respiratory equipment was stored properly and to prevent infection for Resident #30 and Resident #232. This affected two residents (#30 and #232) of two residents reviewed for oxygen therapy. The facility identified four residents receiving respiratory treatments. Residents Affected - Few Findings include: 1. Review of Resident #30's medical record revealed an initial admission date of 01/12/18 with the latest readmission of 02/08/22. Resident #30 had diagnoses including cholecystitis, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), severe morbid obesity, esophagitis, neurogenic bladder, dysphagia, history of COVID-19, allergic rhinitis, hypertension, diabetes mellitus, chronic kidney disease, insomnia, congestive heart failure, atrial fibrillation, osteoarthritis, hyperlipidemia, hypothyroidism, restless leg syndrome and major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/16/22 revealed the resident had clear speech, understood others, makes herself understood and had no cognitive deficit as indicated by Brief Interview for Mental Status (BIMS) score of 14. The assessment revealed the resident required extensive assistance from two staff with bed mobility, transfers and ambulating did not occur. The assessment indicated the resident had an indwelling urinary catheter. The assessment indicated the resident had obvious or likely cavity or broken natural teeth. Review of the plan of care, dated 04/27/18 revealed the resident had an alteration in oxygen exchange/perfusion related to COPD, history of COVID-19 and chronic respiratory failure. Interventions included evaluate shortness of breathe for pain and discomfort when breathing and administer medications as ordered to relieve, instruct resident in pursed lip breathing techniques, maintain head of bed elevated to prevent shortness of breath or exacerbation of COPD, nursing to monitor resident and assess for effectiveness of respiratory treatment and provide respiratory treatment as per physician orders. Review of the May 2022 physician's orders revealed an order, dated 03/10/22 for DuoNeb (aerosol) solution 0.5-2.5 milligrams (mg)/3 milliliters (ml) with the special instructions to administer one vial every four hours as needed for shortness of breath. On 05/02/22 at 11:11 A.M. observation revealed the resident's nebulizer and disposable nebulizer kit were stored on the window sill in the room without being covered. On 05/03/22 at 9:45 A.M. observation revealed the resident's nebulizer and disposable nebulizer kit remained stored on the window sill in the room without being covered. On 05/03/22 at 9:47 A.M.,interview with Licensed Practical Nurse (LPN) #107 verified the nebulizer and the disposable nebulizer kit were not stored properly to prevent infection. 2. Review of Resident #232's medical record revealed an admission date of 05/01/22 with the admitting diagnoses of chronic respiratory failure, pneumonia, hypertension, chronic obstructive pulmonary disease (COPD), heart failure, dementia and anxiety disorder. Review of the resident's admission Packet, dated 05/01/22 revealed the resident was admitted to the 365934 Page 4 of 10 365934 05/05/2022 Crestwood Ridge Skilled Nursing and Rehab 141 Willettsville Pike Hillsboro, OH 45133

F 0695 facility with oxygen at two liters per minute via nasal cannula. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care dated 05/02/22 revealed the resident had an alteration in cardiac function related to cardiovascular disease, hypertension, heart failure and atherosclerosis. Interventions included administer medications as ordered, administer oxygen as ordered, encourage rest periods as needed, monitor lung sounds and report abnormal findings to physician and monitor vitals and report abnormal to physician. Residents Affected - Few Review of the monthly physician's orders for May 2022 revealed an order, dated 05/01/22 for oxygen at two liters per minute per nasal cannula to keep oxygen saturation rate above 90% every shift and an order, dated 05/02/22 for Ipratropium-Albuterol (aerosol) Solution 0.5-2.5 milligrams (mg)/3 milliliters (ml) with the special instructions to inhale contents of one vial every four hours for shortness of breath. On 05/02/22 at 10:13 A.M. observation revealed the resident's nebulizer machine and disposable nebulizer kit were laying on the resident's dresser without being covered. On 05/03/22 at 9:45 A.M. observation revealed the resident's nebulizer machine and disposable nebulizer kit remained laying on the dresser without being covered. On 05/03/22 at 9:48 A.M. interview with LPN #107 verified the nebulizer and the disposable nebulizer kit were not stored properly to prevent infection. 365934 Page 5 of 10 365934 05/05/2022 Crestwood Ridge Skilled Nursing and Rehab 141 Willettsville Pike Hillsboro, OH 45133

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Based on record review and interview the facility failed to ensure recommendations from a psychiatric consult were implemented timely for Resident #24, who had diagnoses of major depressive disorder and psychosis. This affected one resident (#24) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #24's medical record revealed an admission date of 04/21/21 with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD), intervertebral disc degeneration lumbar region, restlessness and agitation, hypertension, urge incontinence, insomnia, diabetes mellitus, major depressive disorder, psychosis and COVID-19. Review of the resident's physician medication orders, revealed an order dated 08/13/21 for Depakote Sprinkles delayed release 125 milligrams (mg) with the special instructions to administer four capsules by mouth twice a day. Review of a psychiatric consult, dated 03/09/22 revealed a recommendation was made to increase the Depakote Sprinkles delayed release to 500 mg by mouth twice a day and add 250 mg by mouth at 2:00 P.M. Further review revealed Physician #127 hand wrote a note, please add Depakote 250 mg by mouth at 2:00 P.M. and keep other medications, no changes. Review of the medical record failed to provide evidence the Depakote 250 mg by mouth daily at 2:00 P.M. was implemented. Review of the resident's comprehensive Minimum Data Set (MDS) assessment, dated 04/07/22 revealed the resident had clear speech, understood others, made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. On 05/04/22 at 9:56 A.M. interview with the Director of Nursing (DON) verified the physician orders were not implemented as written following the psychiatric consult on 03/09/22. 365934 Page 6 of 10 365934 05/05/2022 Crestwood Ridge Skilled Nursing and Rehab 141 Willettsville Pike Hillsboro, OH 45133

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. 3. Record review for Resident #2 revealed an admission date of 05/14/21 with diagnoses including chronic obstructive pulmonary disease, hypertension, chronic kidney disease, heart failure, type one diabetes mellitus, glaucoma, respiratory failure, atrial fibrillation, hyperlipidemia, localized edema, major depressive disorder, hypothyroidism, thrombocytopenia, essential tremor, obesity, chronic duodenal ulcer, lymphedema and pneumonia. Review of a pharmacy monthly review, dated 01/13/22 revealed a recommendation to change the frequency of the eye drop medication, Timolol Maleate 0.5% (used to treat increased pressure in the eye) solution from once a day to twice a day. The physician did not address the recommendation until 03/07/22 and declined the recommendation. Review of a pharmacy monthly review, dated 01/13/22 revealed a recommendation to include an apical pulse reading and hold parameters if pulse was less than 60 related to the administration of Digoxin (a cardiac medication). The physician did not address the recommendation until 03/07/22 and agreed with the recommendation. Review of a pharmacy monthly review, dated 01/13/22 revealed a recommendation to evaluate the use of and consider a dose reduction for the antidepressant medication, Cymbalta. The physician did not address the recommendation until 03/07/22 and declined the recommendation. On 05/05/22 at 10:37 A.M. interview with the DON verified the 01/13/22 pharmacy recommendations for Resident #2 were not reviewed timely by the physician. On 05/05/22 at 12:27 P.M. interview with the DON revealed she was unable to find a policy giving the timeframe when pharmacy recommendations should be addressed by the physician. However, the DON revealed her expectations were for them to be addressed by the physician within 30 days of the pharmacist review. Based on medical record review and interview the facility failed to ensure pharmacy recommendations were addressed timely for Resident #2, Resident #22 and Resident #24. This affected three residents (#2, #22 and #24) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #24's medical record revealed an admission date of 04/21/21 with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD) intervertebral disc degeneration lumbar region, restlessness and agitation, hypertension, urge incontinence, insomnia, diabetes mellitus, major depressive disorder, psychosis and COVID-19. Review of a pharmacy recommendation, dated 01/13/22 revealed the pharmacist recommended a gradual dose reduction (GDR) for the resident's Tagament. The physician did not address the recommendation until 03/07/22. The physician agreed and decreased the Tagament to 400 milligrams once a day. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/07/22 revealed the resident had clear speech, understood others, made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. The assessment 365934 Page 7 of 10 365934 05/05/2022 Crestwood Ridge Skilled Nursing and Rehab 141 Willettsville Pike Hillsboro, OH 45133

F 0756 indicated the resident received antipsychotic and antidepressant medications. Level of Harm - Minimal harm or potential for actual harm Record review revealed the resident received the antipsychotic medications on a routine basis, no dose reduction was attempted and the physician documented the gradual dose reduction (GDR) was contraindicated. Residents Affected - Few Review of the current monthly physician's orders for May 2022 revealed an order, dated 03/09/22 for Tagament 400 mg by mouth twice daily for behaviors. Review of the resident's plan of care failed to identify a plan addressing the resident's behaviors. On 05/03/22 at 3:21 P.M. interview with the Director of Nursing (DON) verified the physician had not addressed the pharmacy recommendation from 01/13/22 in a timely manner. On 05/05/22 at 12:27 P.M. interview with the DON revealed she was unable to find a policy giving the timeframe when pharmacy recommendations should be addressed by the physician. However, the DON revealed her expectations were for them to be addressed by the physician within 30 days of the pharmacist review. 2. Review of Resident #22's medical record revealed an admission date of 03/25/22 with diagnoses including myocardial infarction, angina pectoris, atrial fibrillation, congestive heart failure, generalized muscle weakness, cerebrovascular accident (CVA) with left sided hemiplegia, dysphagia, speech disturbances, constipation, hypertension, hyperlipidemia, atrial flutter and protein-calorie malnutrition. Review of a pharmacy recommendation, dated 03/31/22 revealed the pharmacist recommended to add administration parameters for the medication Digoxin, add a stop date to the medication Ativan (an anti-anxiety medication), Restoril (sleep aide used to treat insomnia), Diflucan and Nystatin Solution. Further review revealed the physician did not address the recommendations until 05/02/22. Review of the resident's comprehensive MDS 3.0 assessment, dated 04/01/22 revealed the resident had clear speech, usually understood others, usually made herself understood and had a severe cognitive deficit as indicated by a BIMS score of three. On 05/04/22 at 2:31 P.M. interview with the DON verified the resident's 03/31/22 pharmacy recommendations were not addressed in a timely manner. On 05/05/22 at 12:27 P.M. interview with the DON revealed she was unable to find a policy giving the timeframe when pharmacy recommendations should be addressed by the physician. However, the DON revealed her expectations were for them to be addressed by the physician within 30 days of the pharmacist review. 365934 Page 8 of 10 365934 05/05/2022 Crestwood Ridge Skilled Nursing and Rehab 141 Willettsville Pike Hillsboro, OH 45133

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of Nursing Handbook guidance and interview the facility failed to ensure the cardiac medication, Digoxin was only administered to Resident #22 when necessary and administered with adequate/proper monitoring. This affected one resident (#22) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings Include: Review of Resident #22's medical record revealed an admission date of 03/25/22 with diagnoses including myocardial infarction, angina pectoris, atrial fibrillation, congestive heart failure, generalized muscle weakness, CVA with left sided hemiplegia, dysphagia, speech disturbances, constipation, hypertension, hyperlipidemia, atrial flutter, GERD and protein-calorie malnutrition. Review of a pharmacy recommendation, dated 03/31/22 revealed the pharmacist recommended to add administration parameters to hold for the medication Digoxin if the resident's apical pulse was less than 60 beats per minute (BPM). Further review revealed the physician did not address the recommendation unit 05/02/22. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/01/22 revealed the resident had clear speech, usually understood others, usually made herself understood and had a severe cognitive deficit as indicated by a BIMS score of three. Review of the plan of care, dated 04/08/22 revealed the resident had an alteration in cardiac function related to angina, arrhythmia, cardiovascular disease, congestive heart failure, edema and hypertension. Interventions included to administer medications as ordered, monitor for side effects and notify the physician of any abnormal findings. Review of the March 2022 medication administration record (MAR) revealed the resident was administered the medication Digoxin 125 micrograms (mcg) without an apical pulse being obtained on 03/26/22, 03/28/22, 03/30/22 and 03/31/22. Review of the April 2022 MAR revealed the resident was administered the medication Digoxin 125 mcg when the resident's pulse was less than 60 BPM on 04/03/22, 04/04/22, 04/11/22, 04/16/22, 04/20/22 and 04/31/22. Review of the physician's orders revealed an order, dated 05/02/22 for Digoxin 125 micrograms (mcg) by mouth daily with the special instructions to hold if apical pulse was less than 60 BPM. On 05/04/22 at 2:31 P.M. interview with the Director of Nursing (DON) verified the resident was administered the medication, Digoxin 125 mcg during March and April 2022 without checking the apical pulse and when the resident's apical pulse was below 60 BPM on the dates noted above. Review of the Nursing Drug Handbook, 2021, published 05/03/20 revealed an apical pulse should be obtained for one full minute prior to the administration of the medication Digoxin. Additionally, the medication should be held for an apical pulse of less than 60 BPM. 365934 Page 9 of 10 365934 05/05/2022 Crestwood Ridge Skilled Nursing and Rehab 141 Willettsville Pike Hillsboro, OH 45133

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review, facility policy and procedure review and interview the facility failed to ensure adequate justification and ineffective non-pharmacological interventions prior to the administration of psychoactive medications for Resident #24. This affected one resident (#24) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #24's medical record revealed an admission date of 04/21/21 with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD) intervertebral disc degeneration lumbar region, restlessness and agitation, hypertension, urge incontinence, insomnia, diabetes mellitus, major depressive disorder, psychosis and COVID-19. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/07/22 revealed the resident had clear speech, understood others, made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. The assessment indicated the resident received anti-psychotic and anti-depressant medications. Review of the resident's physician's orders revealed an order, dated 05/01/22 for the anti-psychotic medication, Haldol 1 milligram (mg) by mouth for one dose for aggressive behaviors and the antihistamine medication, Hydroxyzine 25 mg by mouth for one dose for anxiety. Review of a nursing progress note, dated 05/01/22 at 3:00 P.M. revealed a new order was received for one dose of Hydroxyzine 25 mg for anxiety. Review of a nursing progress note, dated 05/01/22 at 5:44 P.M. revealed the resident was eating food from another resident's plate, when staff tried to redirect the resident he raised his hand to strike staff, staff were able to move out of the way. The resident was relocated to another table and given another tray. The resident also sat in chair next to the nurse's station. The physician was notified and a new order was given for Haldol 2.5 mg by mouth for one dose. On 05/03/22 at 12:19 P.M. interview with the Director of Nursing (DON) verified the Haldol 2.5 mg and the Hydroxyzine 25 mg were administered to the resident on 05/01/22 without adequate justification for use. Review of the facility policy titled Dose Reduction, dated 02/24/14 revealed residents were to be functioning at the highest level possible on the lowest dose of medication. Residents who utilized antipsychotic medications would receive gradual dose reductions and behavioral interventions unless clinically contraindicated. 365934 Page 10 of 10