Health inspection·December 16, 2021

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #186 revealed the resident was admitted [DATE] after a fall with injury at home. Resident #186 had diagnoses that included dementia, anxiety disorder, major depressive disorder, and fracture of the right femur. Residents Affected - Few Review of the admission Minimum Data Set (MDS) 3.0 assessment for Resident #186, dated 12/01/21, revealed the resident had a moderate degree of cognitive impairment. The assessment indicated Resident #186 required assistance of one for walking in the room and toileting, and assistance of two staff, for transfers. The assessment further indicated Resident #186 was not steady and was only able to stabilize with staff assistance when moving from a seated to standing position, and during surface-to-surface transfers. Review of the care plan for Resident #186 revealed it identified a risk for falls with a goal to be free from injury from a fall. Interventions included placement of the call light within the resident's reach. Observation on 12/15/21 at 4:08 P.M. revealed Resident #186 was sitting in a chair next to the bed. The call light cord was wrapped around the bed's grab bar, on the opposite side of the bed. During this observation, Resident #186 confirmed she was unable to reach the call light. Interview on 12/15/21 at 4:20 P.M. with State Tested Nursing Assistant (STNA) #270 confirmed Resident #186's call light was out of the resident's reach. The aide further confirmed Resident #186 was at a high risk for falls. Based on observation, resident and staff interview, and medical record review, the facility failed to ensure a resident's call light was accessible. This affected two Resident's (#186 and #229) of 24 sampled residents. The facility census was 83. Findings include: 1. Review of the medical record revealed Resident #229 was admitted on [DATE]. Diagnoses include atherosclerotic heart disease of native coronary artery without angina pectoris, essential (primary) hypertension, alcohol dependence, spinal stenosis lumbar region without neurogenic claudication, other intervertebral disc degeneration dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, anxiety disorder, polyneuropathy, hyperlipidemia, insomnia, vitamin B12 deficiency anemia, and encounter for palliative care. Page 1 of 6 365968 365968 12/16/2021 Admiral's Pointe Nursing & Rehabilitation 1920 Cleveland Rd W Huron, OH 44839

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Minimum Data Set (MDS) assessment, dated 12/03/21 revealed the resident was moderately cognitively impaired. Resident #229 required extensive one person assistance with bed mobility, transfers, and locomotion on unit. Review of the care plan, initiated 11/28/21, revealed Resident #229 is at risk for falls and interventions included keeping the call light within reach, encouraged and reminded to ask for assistance. Review of the fall investigation, dated 12/11/21, revealed Resident #229 had a fall allegedly attempting to transfer from the chair. At the time of the incident, the call light was in hand and not on. Observation on 12/13/21 at 10:50 A.M. and 12:37 P.M. revealed Resident #229 in bed and the call light out of reach laying on the floor near the wall and side table. Interview on 12/13/21 at 12:37 P.M. with State Tested Nursing Assistant #300 verified Resident #229's call light was out of reach. 365968 Page 2 of 6 365968 12/16/2021 Admiral's Pointe Nursing & Rehabilitation 1920 Cleveland Rd W Huron, OH 44839

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, staff interview, and facility policy the facility failed to properly monitor and record blood glucose levels and failed to notify the physician of blood glucose levels and use of emergency medication. This affected one (Resident #67) of seven residents reviewed for unnecessary medication. The facility census was 83. Residents Affected - Few Findings include: Review of the medical record for Resident #67 revealed an initial admission date of 04/12/17 and re-entry on 11/12/21. Diagnoses included acute kidney failure, unspecified protein calorie malnutrition, type two diabetes mellitus with diabetic chronic kidney disease, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, difficulty in walking, hyperlipidemia, other lack of coordination, unsteadiness on feet, heart failure, hypothyroidism, chronic kidney disease stage 3, other specified anxiety disorders, unspecified osteoarthritis, vitamin B12 deficiency anemia due to intrinsic factor deficiency, hypokalemia, urinary tract infection, and encounter for surgical after following surgery on digestive system. Review of the Minimum Data Set (MDS), dated [DATE], revealed the resident is cognitively intact. The assessment also revealed Resident #67 received insulin. Review of the Blood Sugar Summary, dated 12/08/21 at 6:50 A.M., revealed Resident #67 blood glucose was 45 milligrams per deciliter (mg/dL). The medical record was silent of any additional blood glucose records on 12/08/21 and 12/09/21. Review of physician note, dated 12/08/21, revealed Resident #67 was seen for a follow-up skilled visit. Staff had reported Resident #67 had symptomatic hypoglycemia and required glucagon twice. Review of the Blood Sugar Summary, dated 12/10/21 at 3:41 A.M., revealed Resident #67's blood sugar glucose was 40 mg/dL. The record was silent for record of blood sugar until 8:49 P.M. with a blood sugar level of 156 mg/dL. Review of Resident #67's Medical Administration Record (MAR), dated December 2021, revealed Glucagon Emergency Kit 1 MG (milligram) was administered on 12/08/21, 12/10/21, and 12/14/21. Review of Resident #67's progress notes, dated 12/10/21, were silent of information of low blood glucose, justification for use of emergency medication, and physician notification. Interview on 12/15/21 at 12:15 P.M. with Registered Nurse (RN) verified blood glucose below 70 mg/dL should be reported the physician. Interview on 12/15/21 at 3:30 P.M. with the Director of Nursing (DON) verified no documentation of monitoring and documenting blood glucose levels on 12/08/21 and 12/10/21 after administration of Glucagon Emergency Kit 1 MG. The DON verified there was no notification to the physician on 12/10/21 of the low blood glucose or use of the Glucagon Emergency Kit. Interview on 12/15/21 at 3:44 P.M. with the Assistant Director of Nursing (ADON) #240 verified on 12/08/21 providing care to Resident #67 and reported the blood glucose level was 45 mg/dL. ADON #240 365968 Page 3 of 6 365968 12/16/2021 Admiral's Pointe Nursing & Rehabilitation 1920 Cleveland Rd W Huron, OH 44839

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few verified not calling the doctor after utilization of the emergency medication. ADON #240 verified on 12/08/21 the physician assessed the resident during rounds and verified not calling the physician to provide an update until 12/14/21. Review of facility policy, Change in Condition, revised April 2013, verified the unit supervisor or charge nurse will notify the resident, physician, and guardian/interested family member of changes or situations requiring notification. 365968 Page 4 of 6 365968 12/16/2021 Admiral's Pointe Nursing & Rehabilitation 1920 Cleveland Rd W Huron, OH 44839

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and facility policy review ,the facility failed to ensure an extended release medication was administered properly. This affected one Resident (#03) of one resident observed for administration of potassium chloride extended release tablet. The facility census was 83. Residents Affected - Few FINDINGS INCLUDED: Review of Resident #03's medical record revealed an admission date of 03/17/21. Diagnoses included hypokalemia, schizophrenia and diabetes mellitus. Review of Resident #03's medical record revealed a physician's order dated 02/23/21 for Potassium Chloride ER tablet extended release 20 milliequivalent (mEq) tablet. Directions were to administer one tablet by mouth one time a day for supplementation related to hypokalemia. Observation of medication administration on 12/15/21 at 8:14 A.M. revealed Licensed Practical Nurse (LPN) #210 prepared Resident #03's medication for administration. Further observation revealed LPN #200 pulled a potassium chloride extended release tablet and placed the tablet in a plastic bag stating she would crush the tablet due to Resident #03 having issues swallowing the large tablet. Interview with LPN #210 on 12/15/21 at 8:15 A.M. verified she was attempting to crush the potassium chloride extended release tablet to place in applesauce. Review of the Institute for Safe Medication Practices located at http://www.ismp.org/tools/DoNotCrush.pdf revealed Klor-Con (potassium) should not be crushed. Review of the facility policy titled Medication Administration dated 06/21/17 revealed for tablets that appear on the Do Not Crush List, check with the pharmacist regarding a suitable alternative, and obtain a new order from prescriber, if appropriate, prior to crushing. 365968 Page 5 of 6 365968 12/16/2021 Admiral's Pointe Nursing & Rehabilitation 1920 Cleveland Rd W Huron, OH 44839

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 review of the lunch meal menu, resident and staff interview, and observation, the facility failed to ensure appropriate meals were served at an appetizing temperature. This had the potential to affect all residents in the facility except Resident #31 who the facility identified as receiving no food from the kitchen. The facility census was 83. Residents Affected - Many Findings include: Interview on 12/13/21 with Resident #34, #39, and #67 revealed the meals from the kitchen are cold. Review of the lunch menu for 10/27/21 revealed the main entrée hot foods included ham, au gratin potatoes, and carrots that were substituted for a mixed vegetable. Observation on 12/14/21 at 2:01 P.M. of the test tray revealed meal tempting of the hot foods. The ham tempted at 98 degrees Fahrenheit. The potatoes tempted at 110 degrees Fahrenheit. The cooked mixed vegetables tempted at 104 degrees Fahrenheit. The ham was barely warm to the touch. Interview on 12/14/21 at 2:02 P.M. with the Director of Nursing (DON) verified the meal was not tempting to a preferred temperature. Observation on 12/14/21 at 2:04 P.M. of the lunch meal revealed the ham and vegetables were not at a palatable temperature and the potatoes were minimally acceptable. Interview on 12/14/21 at 2:15 P.M. with Resident #34 verified the lunch meal was not a palatable temperature. 365968 Page 6 of 6