Health inspection·September 26, 2024

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. Based on medical record review, staff interview, family interview, and policy review, the facility failed to inform the resident and/or family regarding need to discontinue a seizure medication. This affected one (#107) of three residents reviewed for notification. The facility census was 106. Findings include: Review of Resident #107's medical record for Resident #107 revealed an admission date of 07/17/24 and a discharge date of 08/31/24. Diagnoses for Resident #107 included hypertensive urgency, urinary tract infection (UTI), schizophrenia, chronic obstructive pulmonary disease, muscle weakness, need for assistance with personal care, difficulty in walking, unsteadiness on feet, osteoarthritis, heart failure, seizures, pneumonia, vascular dementia, benign prostate hyperplasia (BPH), Alzheimer's disease, atrial fibrillation (a. fib), and seizures. Review of the Minimum Data Set (MDS) Assessment revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating Resident #107 is cognitively intact. Review of the August 2024 monthly physician orders revealed an order dated 08/01/24 at 6:45 A.M., Phenytoin Sodium (Dilantin) Extended Capsule 100 milligrams, give two capsules by mouth two times a day for anticonvulsant. Review of a discontinued physician order dated 08/25/24 at 1:33 P.M., revealed an order to discontinue the Phenytoin Sodium due to physcian recommendation and pharmacy recommendation. Interview on 09/25/24 at 12:22 P.M., with the Administrator revealed Resident #107's Dilantin (a medication that is taken to control seizure activity) was ordered to be discontinued by Physician #400 based on the recommendations that were made by the facility pharmacy. Further interview with the Administrator revealed there is no documentation stating that was notification made to Resident #107 or his family regarding the discontinuation of this medication. Interview on 09/25/24 at 12:19 P.M., via telephone, with the Director of Nursing (DON) revealed she does not recall if family was notified of the discontinuation of Resident #107's Dilantin. Interview on 09/25/24 at 1:36 P.M., via telephone, with Resident #107's daughter revealed neither she nor Resident #107 were notified when Resident #107's Dilantin was discontinued. Interview on 09/26/24 at 10:28 A.M., with Physician #400 revealed the decision to discontinue Page 1 of 3 365976 365976 09/26/2024 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0580 Resident #107's Dilantin was made based primarily on the pharmacy recommendations. Level of Harm - Minimal harm or potential for actual harm Further interview with Physician #400 revealed neither he nor any member of the facility staff discussed the discontinuation of Resident #107's Dilantin with Resident #107 or his family when the medication was discontinued. Residents Affected - Few Review of the policy titled, Notification of Changes, dated 10/02/22, revealed circumstances requiring notification include discontinuation of current treatment. This deficiency represents non-compliance investigated under Complaint Number OH00157606. 365976 Page 2 of 3 365976 09/26/2024 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of medical record, and review of policy, the facility failed to ensure infection control policies and procedures were followed for maintaining urinary catheter bags. This affected two (#50 and #87) of three residents reviewed for urinary incontinence. The facility census was 106. Residents Affected - Few Findings include: 1.) Review of Resident #50's medical record revealed an admission date of 09/11/24, with diagnoses of multiple subsegmental thrombotic pulmonary emboli without acute cor pulmonale, depressive disorder, failure to thrive, hypokalemia, muscle weakness, unsteadiness, need for assistance with personal care, obstructive and reflux uropathy, anemia, syncope and collapse, other specified disorders of the male genital organs, Vitamin D deficiency, Vitamin B12 deficiency, and Barrett's esophagus. Review of the admission Minimum Data Set (MDS) Assessment, dated 08/13/24, for Resident #50 revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating Resident #50 is cognitively intact. Observation on 09/25/24 at 11:27 A.M., revealed Resident #50 was seated in his chair and the urine collection bag for his indwelling urinary catheter was laying on the floor. Interview on 09/25/24 at 11:30 A.M., with Registered Nurse (RN) #322 verified the urine collection bag for Resident #50's indwelling urinary catheter was laying on the floor. 2.) Review of Resident #87 medical record revealed an admission date of 01/23/24 with diagnoses of atrial fibrillation (a. fib), protein-calorie malnutrition, type two diabetes mellitus (DM2), hypertension (HTN), obstructive reflux and uropathy, benign prostatic hyperplasia (BPH), and generalized muscle weakness. Review of the most recent quarterly MDS Assessment, dated 07/09/24, revealed a BIMS score of 03, indicating Resident #87 was severely cognitively impaired. Observation on 09/26/24 at 7:54 A.M., revealed Resident #87 being pushed down the hall by State Tested Nursing Assistant (STNA) #278 while seated in a manual wheelchair. Resident #87's urine collection bag for his indwelling urinary catheter was being allowed to drag the ground as he was pushed down the hall. Interview on 09/26/24 at 7:54 A.M., with Licensed Practical Nurse (LPN) #312 verified the urine collection bag for Resident #87's indwelling urinary catheter was being allowed to drag the ground while he was seated in a manual wheelchair and being pushed by STNA #278. Review of the policy titled, Catheter Care , dated 2014, revealed it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 365976 Page 3 of 3