Health inspection·June 27, 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 review of facility beneficiary notices and staff interview, the facility failed to ensure Medicare beneficiaries received the appropriate notices informing them of their rights when discharged from skilled services. This affected two (Resident #53 and #91) of three residents reviewed for beneficiary notices. The facility census was 112. Residents Affected - Few Findings include: 1. Review of Resident #53's skilled nursing facility beneficiary protection notification form revealed her last covered day of skilled service under Medicare Part A was on 05/02/19. The resident remained in the facility after being discharged from skilled services. Review of the resident's beneficiary notices revealed she did not receive the skilled nursing facility advanced beneficiary notice (SNF ABN) form as required. Interview with the Director of Nursing (DON) on 06/25/19 at 5:55 P.M. verified Resident #53 did not receive a SNF ABN form completed as required. 2. Review of Resident #91's skilled nursing facility beneficiary protection notification form revealed her last covered day of skilled service under Medicare Part A was on 06/20/19. The resident remained in the facility after being discharged from skilled services. Review of the resident's beneficiary notices revealed she did not receive the SNF ABN form as required. Interview with the DON on 06/25/19 at 5:55 P.M., verified Resident #91 did not receive a SNF ABN form completed as required. She stated the facility implemented a plan of action with monitoring on 06/25/19. Page 1 of 8 365963 365963 06/27/2019 Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830

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 and staff interview, the facility failed to ensure a resident, resident's representative, and the ombudsman were notified in writing when a resident was transferred to the hospital. This affected one (Resident #103) of one residents reviewed for hospitalization. The facility census was 112. Findings include: Review of Resident #103's medical record revealed an admission date of 09/25/18. She was transferred to the hospital on [DATE]. Medical diagnoses included candidal cystitis and urethritis, sepsis, osteomyelitis of vertebra, hypertension, end stage renal disease, acute and subacute infective endocarditis, diabetes mellitus, iron deficiency anemia, spinal stenosis, and chronic obstructive pulmonary disease. Continued review of the resident's medical record revealed no indication the resident, the resident's representative, or the ombudsman were notified in writing of the reason for the resident's transfer to the hospital. Interview with the Director of Nursing (DON) on 06/26/19 at 12:23 P.M., verified the facility did not notify the resident, the resident's representative, or the ombudsman in writing of the reason for transfer when she was transferred to the hospital. She stated the facility did not currently have a policy as they were not aware of this requirement. 365963 Page 2 of 8 365963 06/27/2019 Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830

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 record review, and staff interview the facility failed to ensure all treatments were completed as ordered. This affected two residents, (Resident #10 and Resident #92) out of five residents reviewed for treatments. The current census is 112. Residents Affected - Few Findings include: 1. Record review of Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #10 include abnormal findings in the lung field, infection of the skin, non-pressure ulcer of the left lower leg, chronic kidney disease, diabetes, edema, and normal pressure hydrocephalus. Review of Resident #10's care plans dated 09/08/15 revealed a focus for impaired skin integrity due to cellulitis and abscess of legs. Interventions for the focus include treatments per order. Review of Resident #10's quarterly Minimum Data Set, (MDS), dated [DATE] revealed the resident had impaired cognition. Per the assessment the resident was documented as having an unhealed, unstageable pressure ulcer and received non-surgical dressing, ointments, and medications as treatment. Further review of Resident #10's medical record revealed the resident had a non-pressure ulcer on her left lower leg. Per the record the resident was being seen by the facility's Wound Nurse Practitioner for care and treatment of the wound. Review of physician orders for Resident #10 revealed on 03/12/19 the resident was ordered to have the left anterior shin cleansed with normal saline, apply Medihoney to wound bed, calcium alginate dressing, and to be covered with foam dressing daily and as needed, the order was discontinued on 05/27/19. On 05/30/19, the resident was ordered to have the left anterior shin washed with normal saline, apply Vashe moistened fluffed gauze to wound, lightly pack and cover with ABD pad twice a day and as needed, the order was discontinued of 06/10/19. On 06/10/19, the resident was ordered to have the wound cleansed with normal saline on the left anterior shin skin wound, pack the wound with Vashe moistened fluffed gauze. Please avoid putting gauze on good, intact skin, cover with ABD pad and Kerlix twice a day and as needed. There were no orders for the dressing change from 05/27/19 to 05/30/19. Review of Resident #10's Treatment Administration Record, (TAR), dated 05/2019 revealed no documentation of the treatment to the left anterior shin completed on 05/11, 05/12, 05/16, 05/17, 05/21, 05/25, 05/26, 05/27/19. Per the TAR dated 06/2019 there was no documentation for the left anterior shin treatment completed on 06/03/19 P.M., on 06/04/19 A.M., on 06/05/19 A.M., 06/07/19 A.M., 6/08/19 A.M. and P.M., 06/09/19 A.M., 06/18/19 A.M., 06/19/19 A.M. and P.M., 06/21/19 A.M., 06/22/19 A.M. and P.M., 06/23/19 A.M., and 06/26/19 P.M. treatments were not documented as completed. Review of Resident #10's progress notes dated from 05/2019 to 06/2019 revealed no corresponding progress notes for the missing documentation noted on the TARs. Interview on 06/26/19 at 9:26 A.M., with Licensed Practical Nurse, (LPN), #550 verified the missing documentation in Resident #10's MARs and TARs. 365963 Page 3 of 8 365963 06/27/2019 Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/ 26/19 at 4:30 P.M. with the Director of Nursing, (DON), verified there was missing documentation in Resident #10's MARs and TARs and no documentation in the progress notes for the dates missed on the MARs and TARs. 2. Record review for Resident #92 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #92 include unspecified dementia, diabetes, hypertension, weakness, Parkinson's disease, muscle weakness, and Alzheimer's disease. Review of Resident #92's care plans dated 08/24/18 revealed a focus for impaired physical mobility. Interventions for the focus include up to geri-chair for comfort and out of room mobility, Review of Resident #92' physician orders revealed on 08/24/18 the resident was ordered to have her feet elevated by a pillow while in bed and in the resident's geri-chair. On 10/03/18, the physician ordered for a soft palm cone splint to wear during the day except for meals. Review of Resident #92's quarterly MDS assessment dated [DATE] revealed the resident has intact cognition and was an extensive assist with all Activities of Daily Living, (ADL). Observation and interview on 06/24/19 at 10:03 A.M., revealed Resident #92 was sitting in the geri-chair in the resident's room. Resident #92 stated she was supposed to have her feet elevated while sitting in her chair. Interview on 06/27/19 at 9:30 A.M., with Resident #92 revealed the resident stated her feet were again not elevated on a pillow while she was sitting in her chair. Resident #92 also verified she did not have her hand cone in her hand during the observation. Interview on 06/27/19 at 10:00 A.M. with Registered Nurse, (RN), #540 revealed she was the nurse unit manager for Resident #92's unit. RN #540 verified Resident #92's feet were not elevated on a pillow and the resident did not have her hand cone per the physician's order. 365963 Page 4 of 8 365963 06/27/2019 Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, record review, and staff interview, the facility failed to ensure the proper care and treatment was completed for resident's with tube feedings. This affected one (Resident #41) of one resident reviewed for tube feedings. The current census was 112. Findings include: Record review of Resident #41 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #41 included hypertension, hemiplegia, aphasia, dysphagia, diabetes, convulsions, apraxia, and cerebral vascular accident. Review of Resident #41's physician orders revealed on 03/06/19 an order to check placement and residual of the feeding tube five times a day, to check the placement and residual with each feed five times a day, and to cleanse the peg tube site with normal saline and apply gauze to the site twice a day. Review of Resident #41's care plan dated 03/07/19 revealed a focus feed tube was in place. Interventions included to check tube placement per order and dressing changes per order. Review of Resident #41's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and was documented as having a feeding tube. Observation on 06/25/19 at 3:45 P.M., of LPN #500 administering a tube feeding to Resident #41 revealed the nurse did not check the residual or placement prior to administered a flush of the tube. LPN #500 was observed taking a paper towel, wetting it with tap water, and cleansing the peg tube site after administering the tube feeding. Interview on 06/25/19 at 3:55 P.M., with LPN #500 verified the nurse did not check the resident's tube residual or check the placement of the tube prior to administering the flush and the tube feeding. LPN #500 verified it was facility policy to check the placement and residual of the tube prior to administering medications and tube feedings. LPN #500 verified she did not use gauze or normal saline to cleanse the peg site per physician order. Review of the facility policy titled, Medication Administration, dated 02/2019 revealed the facility staff was to check patency and placement of tube feeding prior to administering medication. 365963 Page 5 of 8 365963 06/27/2019 Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, puree recipes, list of residents who received a puree diet and policy and procedures, the facility failed ensure puree menu items were prepared in a manner to conserve the nutritional value. This affected five Residents (#47, #67, #69, #73 and #108) of five resident who received a puree diet in a facility census of 112. Residents Affected - Some Findings include: On 6/26/19 at 10:02 A.M. until 10:22 A.M., [NAME] #200 was observed preparing puree menu items. The first item prepared was stuffing. She was observed preparing a little over five servings of dressing. As she was pureeing the dressing she added approximately a little over two cups of water to reach the desired puree consistency. She then prepared the pork with gravy as a listed menu item for this day. She was observed preparing the five serving of pork chops with five slice of bread. She then added approximately two cups of water and an unmeasured amount of thickener to reach the appropriate puree consistency. On 06/26/19 at 10:22 A.M., interview with [NAME] #200 verified she was not aware of any recipes to follow for preparing puree meal items. She then verified it was her regular practice to use water and thickener at times to obtain the desired constancy of the pureed menu items. On 06/26/19 at 11:32 A.M., interview with Dietary Director (DD) #300 verified the puree recipes for dressing and pork chops did not call to use water or thickener to ensure the appropriate puree consistency. Review of undated pureed diet list provided by the facility documented Residents (#47, #67, #69, #73 and #108) received puree diets during the annual survey. Review of recipe for pureed dressing undated documented to prepare measure amount of dressing to be pureed from the regular menu item, add chicken broth and process until smooth in texture. Further review documented to use two and half cups of low sodium chicken broth for five servings of dressing. Review of recipe for pureed pork chops undated documented to prepare pork chops as directed, measure amount of meat needed as documented on the regular recipe, add hot broth or gravy until smooth consistency, add one slice of bread per portion and process until mixed. Further review documented to use two and half cups of no salt chicken base or low salt gravy for five servings of the pork chops. Review of policy and procedure for puree food preparation dated 2018 documented it was the policy of the facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor and attractive appearance. 365963 Page 6 of 8 365963 06/27/2019 Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's legionnaires prevention documentation and staff interview, the facility failed to implement a legionella control plan with identified control measures and documentation. This had the potential to affect all the residents residing in the facility. The census was 112. Residents Affected - Many Findings include: Review of a facility policy titled Water Management Plan dated 02/25/18 revealed the facility would conduct a hazard analysis of the water systems and determine which ones present a significant risk of Legionella growth and transmission. Further review revealed the facility would establish control locations where Legionella control measures could be applied. The facility would then establish and implement control measure with performance limits, monitoring, and corrective action. The facility would establish and implement documentation of control measures. Further review of the facility legionnaires documentation revealed no facility assessment which determined specific risk areas for Legionella. The facility had implemented daily tasks, monthly tasks, and yearly tasks to control Legionella, however the documentation of these control measures was incomplete. Interview with Plant Operations Director #700 on 06/27/19 at 2:54 P.M., stated the facility does not have a flowsheet indicating what areas of concern should be monitored. He verified they have not implemented and monitored all of control measure per their plan. 365963 Page 7 of 8 365963 06/27/2019 Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830

F 0881 Implement a program that monitors antibiotic use. 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, staff interview, and review of a facility policy, the facility failed to ensure an appropriate indication for a resident's antibiotic use. This affected one (Resident #103) of five residents reviewed for unnecessary medications. The facility identified one resident on antibiotic medication. The facility census was 112. Residents Affected - Few Findings include: Review of Resident #101's medical record revealed an admission date of 03/25/19. Medical diagnoses included generalized muscle weakness, insomnia, delusional disorder, cardiac arrhythmia, hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, cognitive communication deficit, cerebral infarction, and low back pain. Review of the resident's minimum data set assessment dated [DATE] revealed she had moderately impaired cognition. Review of the resident's physician's orders revealed she was started on keflex (antibiotic) 250 milligrams (mgs) three times daily for seven days for a urinary tract infection (UTI) on 06/24/19. Continued review of the resident's medical record revealed she received the keflex from an emergency room visit on 06/24/19. Review of the hospital documentation revealed a urinary culture was in progress. Review of the resident's laboratory record revealed no evidence of results of the urinary culture. Interview with Licensed Practical Nurse (LPN) Unit Manager #520 on 06/27/19 at 11:14 A.M., verified the resident was receiving an antibiotic for a UTI and her urinary culture results had not been obtained by the facility. After speaking with the surveyor, LPN Unit Manager #520 called to obtain the results of the urine culture, which was negative on 06/25/19. Review of a facility policy titled Antibiotic Stewardship Program Policy dated 05/18 revealed at 72 hours after empiric antibiotic initiation or first dose in the facility resident will be reassessed for consideration of antibiotic need, duration, and selection of antibiotic. 365963 Page 8 of 8