Health inspection·April 13, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, guardian interview, and policy review, the facility failed to notify a resident's representative when new orders were received. This affected one (Resident #23) reviewed for change in condition. The facility census was 35. Findings include: Medical record review for Resident #23 revealed an admission date of 05/22/17 with diagnoses including dementia without behaviors, chronic obstructive pulmonary disease, malnutrition. emphysema, acute cystitis without hematuria, metabolic encephalopathy, weight loss, bladder dysfunction, hypothyroidism, hyperlipidemia, schizoaffective disorder, major depressive disorder, anorexia, obsessive compulsive disorder, delusional disorders, essential tremor, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] with for Resident #23 revealed intact cognition. Resident #23 required limited assistance for bed mobility, extensive assistance for transfers, limited assistance for eating and extensive assist for toileting. Resident #23 was assessed with no coughing or difficulty swallowing during the look back period. Resident #23 was on a mechanically altered therapeutic diet. Review of the plan of care for Resident #23 dated 04/11/23 revealed the resident was at malnutrition/dehydration risk due to cognitive deficits, mood problems, history of weight loss, dysphagia (difficulty swallowing), and medical problems. Interventions included medications as ordered, diet per physician's order: pureed with thin consistency liquids, speech therapy as ordered, and monitor and record oral intake. Review of the progress notes dated 04/07/23 at 6:16 P.M. revealed Resident #23 coughing with food/liquid and having difficulty swallowing. A nursing measure, downgraded to pureed diet with referral to speech therapy (ST). Review of the speech therapy notes for Resident #23 dated 04/11/23 revealed new onset of increased signs and symptoms of dysphagia and coughing/choking during oral intake, indicating the need for speech therapy to access and evaluate oral function. Resident #23 choked on peaches per verbal report from state tested nursing assistant. The resident was downgraded to puree diet until an evaluation completed. Resident #23 presented with mild dysphagia with decreased oral motor strength and function resulting in increased mastication (chewing) time and decreased bolus (round mass of food) formation. Resident #23 with inconsistent swallow onset increased risk for aspiration. Page 1 of 6 365970 365970 04/13/2023 Union City Care Center 907 East Central Street Union City, OH 45390

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/12/23 10:27 A.M. with Therapy Director #40 stated Resident #23 was evaluated on 04/11/23 for speech therapy services. Resident #23 will be seeing the speech therapist for a couple of weeks. Interview on 04/12/23 at 11:17 A.M. with the Assistant Director of Nursing (ADON) verified Resident #23 received new orders on 04/07/23 for a diet downgrade and speech therapy. The ADON did not notify the guardian of the new orders related to the coughing spell resulting in a change in diet levels, and stated she should have. Review of facility policy titled, Change of Condition or Status, dated 2/2018 revealed the facility shall promptly notify the resident, attending physician, and resident representative of changes in the residents medical condition or status. 365970 Page 2 of 6 365970 04/13/2023 Union City Care Center 907 East Central Street Union City, OH 45390

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 and staff interview, the facility failed to ensure a resident was free from unnecessary medications when the facility failed to follow through with pharmacy and physician recommendations to decrease a medication dosage. This affected one (Resident #21) of six residents reviewed for unnecessary medications. The facility's census was 35. Residents Affected - Few Findings include: Medical record review for Resident #21 revealed an admission date of 06/06/19 with diagnoses including chronic kidney disease, morbid obesity, congestive heart failure, hypertension, anemia, alcohol induced dementia, malnutrition, osteoarthritis, noncompliance with medical treatment, schizophrenia, major depressive disorder, bariatric surgery status, anxiety, insomnia, repeated falls, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition. Resident #21 required extensive assistance for bed mobility from two staff members, extensive assistance for transfers and toileting with one staff member, and supervision for eating. Resident #21 received medication from the following classifications during the assessment period: antipsychotic, antidepressant, anticoagulant, and narcotics. Review of Resident #21's plan of care revealed the resident required use of anti-coagulant medication due to history of deep vein thrombosis (blood clots) and cardiovascular disorder. Review of Resident #21's physician orders revealed an order dated 07/23/19 for Eliquis (anti-coagulant) Tablet, give 5 milligrams (mg) by mouth every day and evening shift related to acute embolism and thrombosis, discontinued on 01/18/23. Additional review revealed an order dated 01/25/23 for Eliquis Tablet 2.5 mg, give 1 tablet by mouth every day and evening shift for prophylaxis, discontinued on 01/30/23. Review of the pharmacy recommendation dated 01/13/23 revealed a recommendation was made to the physician to decrease the milligrams of Eliquis to 2.5 mg for prophylaxis two times a day. The physician agreed with the reduction and gave orders to decrease the dose on 01/16/23. Review of the Medication Administration Record (MAR) for January 2023 revealed the new recommended dose of Eliquis 2.5 mg was not initiated until 01/25/23 (nine days after the physician gave orders). Interview on 04/11/23 at 5:27 P.M. the Director of Nursing (DON) verified the recommended 2.5 mg dose of Eliquis was ordered 01/16/23, and was not initiated until 01/25/23, and stated she did not have an answer as to why the medication was not reduced as ordered. 365970 Page 3 of 6 365970 04/13/2023 Union City Care Center 907 East Central Street Union City, OH 45390

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. **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 was free from unnecessary psychotropic medications when a resident received duplicate medication therapy. This affected one (Resident #27) of six residents reviewed for unnecessary medications. The facility's census was 35. Findings include: Review of medical record for Resident #27 revealed an admission date of 08/20/20. Diagnoses included schizoaffective disorder, noncompliance with medication and medical treatment, extrapyramidal movement disorder, depression, hypertension, bipolar with manic severe with psychotic features, schizophrenia, chronic viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had a Brief Interview Mental Status (BIMS) score of 14, indicating intact cognition. She required extensive one person assistance for dressing and toileting, limited assistance for bed mobility and personal hygiene, and was independent for transfers and eating. Further review of the medical record revealed Resident #27 was prescribed the medication, Depakote, to treat bipolar disorder. Review of the care plan revealed the resident had multiple complicating diagnoses and was at risk for anxiety and depression, which require medications to control. Interventions included administer medications as ordered, psychiatric services as ordered, and monitor mental status. Review of Resident #27's March 2023 medication orders revealed an order for Depakote Sprinkles (prescribed for bipolar disorder) 125 milligrams (mg), two capsules by mouth two times a day (8:00 A.M. and 8:00 P.M.) with a start date of 03/06/23 for five days. The second order was for Depakote Sprinkles 125 mg, one capsule at bedtime with a start date of 03/09/23. A third order for Depakote Sprinkles 125 mg, give two capsules at bedtime for five days with a start date of 03/11/23. Further review of the medical record revealed no indication facility staff communicated with the physician about the duplicate Depakote orders. Interview on 04/13/23 at 10:52 A.M. with the Director of Nursing (DON) revealed the physician had been titrating (changes to medication doses to achieve the best clinical response) Resident #27's Depakote during the month of March 2023 and verified the facility had not clarified the concurrent Depakote orders and she was unaware of the multiple Depakote orders until the survey. A request for a policy related to medication administration was made during the survey and was not provided for review. 365970 Page 4 of 6 365970 04/13/2023 Union City Care Center 907 East Central Street Union City, OH 45390

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews, and policy review, the facility failed to properly thaw hamburger meat, failed to ensure dishwasher temperatures achieved proper temperatures, and failed to ensure the sanitizer was working and tested properly. This had the ability to affect all residents at the facility. The facility census was 35. Findings include: 1. Observation on 04/10/23 at 8:37 A.M. revealed an approximately four inch (in) by (x) 24 in packaged tube of hamburger meat lying directly on the bottom of the first compartment of the three compartment sink. The packaged meat was submerged in approximately two inches of cool water, further observation revealed approximately one inch of the burger felt thawed and the middle remained hard. Interview on 04/10/23 at 8:49 A.M. with Dietary Staff (DS) #49 revealed she had put the hamburger in cool water in the sink to thaw at 6:45 A.M. DS #49 verified the water was not running, the burger was not fully submerged and approximately one inch of the perimeter was thawed. Review of the facility policy, Preventing Foodborne Illness-Food Handling Policy, last revised 02/18, revealed frozen foods will not be thawed at room temperature and one of the thawing processes was to submerge the item in cold running water (70 degrees) or below. 2. Observation on 04/10/23 at 8:40 A.M. revealed the dishwasher wash cycle temperature was 133 degrees and the rinse cycle was 170 degrees. The documentation on the dishwasher stated, wash cycle 150 degrees and rinse cycle 180 degrees. This was verified by Dietary Manager #27 at the time of the observation. Review of the dishwasher log for March 2023 revealed temperatures for the wash cycle were documented under 150 degrees at least once a day on 03/01/23, 03/10/23, 03/11/23 and 03/12/23. The rinse cycle temperatures were documented as less than 180 degrees at least once a day on 03/01/23 through 03/12/23. There was no documentation of temperatures after 03/12/23 until April 2023. Review of the April 2023 dishwasher log revealed temperatures for the wash cycle were documented under 150 degrees at least once a day on 04/01/23, 04/02/23, 04/05/23 through 04/10/23. The rinse cycle temperatures were documented as less than 180 degrees at least once a day from 04/01/23 through 04/10/23. Interview on 04/10/23 at 8:40 A.M. with DM #27 revealed temperatures had been documented outside of the parameters and additionally stated she failed to double check temperatures recorded from 03/13/23 through 03/31/23. She stated maintenance was aware of the temperature issue and they were awaiting a part for repair. Review of the facility's dishwasher policy, last revised 02/18, revealed the was solution temperature should be 150 degrees and the hot water sanitation rinse temperature should be 180 degrees for the current dishwasher at the facility. Observation on 04/10/23 at 9:12 A.M. of the three-compartment sink revealed the third compartment was not filled. Interview with DS #49 revealed the compartment did not hold water and she used the 365970 Page 5 of 6 365970 04/13/2023 Union City Care Center 907 East Central Street Union City, OH 45390

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hose supplying the sanitizer to rinse the dishes. She proceeded to turn on the sanitation hose in order to use the test strip to verify proper sanitation. There was no reaction with the strip. Upon inspection of the hose, it was discovered the bucket under the sink containing the sanitizer did contain solution. The hose went from the bucket between the wall and the sink, it continued up and was attached to the top of the sink and ran down to the left and into the third compartment. The pink solution could be seen filling the entire circumference of the hose from the bucket running along the top of the sink, then there was an approximately 12-inch area with minimal solution and then back to it filling the entire circumference of the hose. DS #49 moved the sink from the wall where the hose was noted to be kinked and restarted the solution. The hose filled entirely with the pink solution for approximately two minutes, before a void was noted again in the same area as previously observed. A second testing with the strip again revealed no reaction. DS #49 verified the sanitation was not working or testing properly and the supplying company would be contacted. Review of the facility's infection control logs for March and April 2023 revealed no foodborne illnesses. 365970 Page 6 of 6