Health inspection·May 22, 2019

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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, hospital discharge summary review, review of facility Self-Reported Incidents (SRI), staff interview, and review of facility policy the facility failed to implement their abuse policy when they failed to report an injury of unknown origin and failed to report an allegation of physical abuse between two residents. This affected three (#35, #36, and #54) of four residents reviewed for abuse. The facility census was 87. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #54 admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, major depressive disorder, and muscle weakness. Resident #54 discharged to a hospital on [DATE] and was readmitted on [DATE] with a diagnosis of a fractured right tibia bone. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/08/18, revealed the resident's cognition was moderately impaired. Review of a progress note dated 02/24/19, at 7:24 A.M. and 7:25 A.M., revealed Resident #54 had increased swelling and pain in his right foot and lower leg. The physician was notified and ordered for the resident to be sent to the emergency room for an evaluation and treatment. At 12:48 P.M., documentation revealed the resident was being transferred to a different hospital. Review of the hospital Discharge summary, dated [DATE], revealed Resident #54 was transferred to this hospital, from a different hospital, on 02/25/19. The resident's principal problem was a right distal (lower end) tibia fracture. The resident underwent an intramedullary nail fixation (a procedure where a metal rod is forced into the medullary cavity of a bone) to the right tibia. Resident #54 was discharged back to the facility on [DATE]. Interview on 05/19/19 at 1:03 P.M., Resident #54 revealed he suffered a broken leg and had to have surgery to fix it. Resident #54 stated he did not know how his leg got broken. Interview on 05/20/19 at 10:21 A.M., the Director of Nursing (DON) verified on 02/24/19, Resident #54 was sent to the emergency room for increased pain and swelling in his right leg. The DON revealed hospital reports indicated the resident suffered a right distal tibia fracture and required surgery. The DON further verified the cause of the fracture was unknown. Interview on 05/20/19 at 10:23 A.M., the Administrator revealed the DON and herself were responsible for reporting all allegations of abuse, including injuries of unknown origin, to the Ohio Department of Health (ODH) by way of a SRI. The Administrator verified the cause of Resident #54's injury was unknown, and the facility should have submitted an SRI to the ODH. Page 1 of 6 365968 365968 05/22/2019 Admiral's Pointe Nursing & Rehabilitation 1920 Cleveland Rd W Huron, OH 44839

F 0607 Review of the facilities SRIs revealed the facility had not submitted an SRI since 02/05/18. Level of Harm - Minimal harm or potential for actual harm Review of a facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, defined an injury of unknown source as an injury that was not observed by any person or the source of the injury could not be explained by the resident; and the injury was suspicious because of the extent of the injury, location of the injury, the number of injuries observed at one particular point in time, or over time. The policy revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee who would ensure all alleged violations were reported timely to appropriate officials, including ODH. Residents Affected - Few 2. Medical record review revealed Resident #35 admitted to the facility on [DATE]. Diagnoses included dementia, mood disorder, depression, and anxiety. Review of Resident #35's progress notes, dated 06/05/18 at 8:00 P.M., revealed staff observed Resident #35 walk over to Resident #37 and hit her in the arm while Resident #37 sat in her wheelchair. When staff attempted to intervene, Resident #35 grabbed a hold of Resident #37's wheelchair and pushed it forward. Resident #37 admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia with behavioral disturbances, and major depressive disorder. Interview on 05/22/19 at 8:15 A.M., the Administrator revealed the she and the DON were responsible for reporting all allegations of abuse to the ODH by way of a SRI. The Administrator further revealed a physical altercation occurred on 06/05/19 between Resident #35 and Resident #37 where Resident #35 slapped Resident #37 and pushed her wheelchair with her in it. The Administrator verified the facility should have submitted a SRI to the ODH. Review of the facilities SRIs revealed the facility had not submitted an SRI since 02/05/18. Review of a facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee who would ensure all alleged violations were reported timely to appropriate officials, including ODH. 365968 Page 2 of 6 365968 05/22/2019 Admiral's Pointe Nursing & Rehabilitation 1920 Cleveland Rd W Huron, OH 44839

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility Self-Reported Incidents (SRI) staff interview, and review of facility policy the facility failed to report an injury of unknown origin for Resident #54. The facility further failed to report an allegation of physical abuse between two Residents (#35 and #57). The facility census was 87. Findings include: 1. Medical record review revealed Resident #54 admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, major depressive disorder, and muscle weakness. Resident #54 discharged to a hospital on [DATE] and was readmitted on [DATE] with a diagnosis of a fractured right tibia bone. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/08/18, revealed the resident's cognition was moderately impaired. Review of a progress note dated 02/24/19, at 7:24 A.M. and 7:25 A.M., revealed Resident #54 had increased swelling and pain in his right foot and lower leg. The physician was notified and ordered for the resident to be sent to the emergency room for an evaluation and treatment. At 12:48 P.M., documentation revealed the resident was being transferred to a different hospital. Review of the hospital Discharge summary, dated [DATE], revealed Resident #54 was transferred to this hospital, from a different hospital, on 02/25/19. The resident's principal problem was a right distal (lower end) tibia fracture. The resident underwent an intramedullary nail fixation (a procedure where a metal rod is forced into the medullary cavity of a bone) to the right tibia. Resident #54 was discharged back to the facility on [DATE]. Interview on 05/19/19 at 1:03 P.M., Resident #54 revealed he suffered a broken leg and had to have surgery to fix it. Resident #54 stated he did not know how his leg got broken. Interview on 05/20/19 at 10:21 A.M., the Director of Nursing (DON) verified on 02/24/19, Resident #54 was sent to the emergency room for increased pain and swelling in his right leg. The DON revealed hospital reports indicated the resident suffered a right distal tibia fracture and required surgery. The DON further verified the cause of the fracture was unknown. Interview on 05/20/19 at 10:23 A.M., the Administrator revealed the DON and herself were responsible for reporting all allegations of abuse, including injuries of unknown origin, to the Ohio Department of Health (ODH) by way of a SRI. The Administrator verified the cause of Resident #54's injury was unknown, and the facility should have submitted an SRI to the ODH. Review of the facilities SRIs revealed the facility had not submitted an SRI since 02/05/18. Review of a facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, defined an injury of unknown source as an injury that was not observed by any person or the source of the injury could not be explained by the resident; and the injury was suspicious because of the extent of the injury, location of the injury, the number of injuries observed at one particular point in time, or over time. The policy revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of resident property 365968 Page 3 of 6 365968 05/22/2019 Admiral's Pointe Nursing & Rehabilitation 1920 Cleveland Rd W Huron, OH 44839

F 0609 Level of Harm - Minimal harm or potential for actual harm and all injuries of unknown source must be reported immediately to the Administrator or designee who would ensure all alleged violations were reported timely to appropriate officials, including ODH. 2. Medical record review revealed Resident #35 admitted to the facility on [DATE]. Diagnoses included dementia, mood disorder, depression, and anxiety. Residents Affected - Few Review of Resident #35's progress notes, dated 06/05/18 at 8:00 P.M., revealed staff observed Resident #35 walk over to Resident #37 and hit her in the arm while Resident #37 sat in her wheelchair. When staff attempted to intervene, Resident #35 grabbed a hold of Resident #37's wheelchair and pushed it forward. Resident #37 admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia with behavioral disturbances, and major depressive disorder. Interview on 05/22/19 at 8:15 A.M., the Administrator revealed the she and the DON were responsible for reporting all allegations of abuse to the ODH by way of a SRI. The Administrator further revealed a physical altercation occurred on 06/05/19 between Resident #35 and Resident #37 where Resident #35 slapped Resident #37 and pushed her wheelchair with her in it. The Administrator verified the facility should have submitted a SRI to the ODH. Review of the facilities SRIs revealed the facility had not submitted an SRI since 02/05/18. Review of a facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee who would ensure all alleged violations were reported timely to appropriate officials, including ODH. 365968 Page 4 of 6 365968 05/22/2019 Admiral's Pointe Nursing & Rehabilitation 1920 Cleveland Rd W Huron, OH 44839

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital discharge summary review and staff interview, the facility failed to ensure resident's care plans were revised when a resident had a change in condition. This affected one Resident (#54) of five residents reviewed for care plans. The facility census was 87. Findings include: Medical record review revealed Resident #54 admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, major depressive disorder, and muscle weakness. Resident #54 discharged to a hospital on [DATE] and was readmitted on [DATE] with a diagnosis of a fractured right tibia bone. Review of the comprehensive Minimum Data Sets assessment, dated 05/08/18, revealed the resident's cognition was moderately impaired. Review of a progress note dated 02/24/19, at 7:24 A.M. and 7:25 A.M., revealed Resident #54 had increased swelling and pain in his right foot and lower leg. The physician was notified and ordered for the resident to be sent to the emergency room for an evaluation and treatment. At 12:48 P.M., documentation revealed the resident was being transferred to a different hospital. Review of the hospital Discharge summary, dated [DATE], revealed Resident #54 was transferred to this hospital, from a different hospital, on 02/25/19. The resident's principal problem was a right distal (lower end) tibia fracture. The resident underwent an intramedullary nail fixation (a procedure where a metal rod is forced into the medullary cavity of a bone) to the right tibia. Resident #54 was discharged back to the facility on [DATE]. Review of Resident #54's plan of care revealed no evidence the care plan was revised to address the resident's fractured leg. Interview on 05/21/19 at 7:37 A.M., Registered Nurse (RN) #300 revealed she was responsible for updating resident's care plans. RN #300 further revealed changes in a resident's condition, including fractures, were supposed to be care planned to address any special needs and/or complications the resident was at risk for related to the change. RN #300 verified she did not revise Resident #54's care plan to address the resident's fractured leg. 365968 Page 5 of 6 365968 05/22/2019 Admiral's Pointe Nursing & Rehabilitation 1920 Cleveland Rd W Huron, OH 44839

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 on medical record review, observation, staff interview, and policy review the facility failed to follow a physician order for oxygen therapy. This affected one Resident (#7) of one reviewed for oxygen therapy. The facility census was 87. Residents Affected - Few Findings include: Medical record review revealed Resident #7 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), and arteriosclerotic heart disease. Review of physician order dated 02/14/19 revealed the resident was to receive two liters of oxygen per minute, via a nasal cannula, continuously. Observation on 05/19/19 at 10:58 A.M., 2:18 P.M., and 5:17 P.M., revealed the resident's oxygen concentrator was set to deliver one and a half liters of oxygen per minute. An observation on 05/20/19 at 12:30 P.M., revealed the concentrator was set to deliver three and a half liters of oxygen per minute. Interview on 05/20/19 at 12:36 P.M., Licensed Practical Nurse (LPN) #200 confirmed Resident #7's oxygen concentrator was delivering three and a half liters of oxygen per minute. LPN #200 further confirmed Resident #7's physician order was for the resident to receive two liters of oxygen continuous. Review of facility policy titled, Respiratory: Oxygen Per Concentrator, revision date 04/2009, revealed oxygen will be used to correct hypoxic conditions so that residents were adequately oxygenated and to increase comfort and breathing efficiency for resident's with chronic lung disease. 365968 Page 6 of 6