Health inspection·July 3, 2019

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to complete a comprehensive assessment related to activity preferences for Resident #8. This affected one resident (Resident #8) of two residents reviewed for activities. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, seizures, tracheostomy, gastrostomy, cerebral palsy and intellectual disabilities. The Minimum Data Set (MDS) 3.0 admission assessment for Resident #8 dated 03/27/19 indicated the section for Assessment for Daily and Activity Preferences was not competed with the resident or family member. The section for Staff Assessment for Daily and Activity Preferences was also not completed. This was verified with the MDS nurse, Licensed Practical Nurse (LPN) #153 on 07/02/19 at 10:15 A.M. LPN #153 indicated the activity director was responsible for completion of those sections of the MDS assessment. Resident #8 was observed on 07/01/19 at 10:34 A.M. in bed with his eyes open. The resident did verbally respond. He was observed on 07/02/19 at 8:29 A.M. in bed with his eyes open and moving his arms around. Interview with Registered Nurse (RN) #123 on 07/02/19 at 8:41 A.M. revealed Resident #8 grabbed at things, swung his arms around and put his fingers in his throat when restless. She said the resident liked stuffed animals and holding them calmed him down. She said he did not attend activities. On 07/02/19 at 10:00 A.M. Resident #8 was observed in bed with a stuffed animal in his hand. On 07/02/19 at 10:35 A.M. interview with Activity Director #102 revealed she based the activity care plan for Resident #8 on the fact that the he was non-verbal and unable to communicate activity preferences. She said she attempted to contact the resident's guardian to complete the admission MDS activity assessment, but she did not return the call. Review of the medical record for Resident #8 revealed an activity note by Activity Director #102 dated 03/26/19. The note revealed she attempted to reach the guardian to complete the admission information and a left a message. The note indicated if there was no return call by Thursday, she would make another attempt. There was no evidence in the medical record of any additional attempts to reach the guardian. The next activity note dated 06/17/19 indicated Activity Director #102 completed a Page 1 of 13 365977 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0636 quarterly activity assessment, reviewed the activity section of the care plan and made no changes at that time. The findings were verified with Activity Director #102 on 03/28/19 at 10:38 A.M. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365977 Page 2 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Residents Affected - Some The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident did not receive injections of any type or insulin injections during the past seven days. Review of the the Medication Administration Record (MAR) for 04/19 indicated Resident #22 received Humulin N insulin (long-acting insulin)10 units subcutaneously twice day during the seven day assessment period. On 07/03/19 at 12:02 P.M. the MDS nurse, Licensed Practical Nurse (LPN) #153, verified the MDS was inaccurate. Based on record review and interview the facility failed to accurately reflect residents' status on required Minimum Data Set (MDS) 3.0 assessments. This affected four residents (Resident #4, #10, #22, and #30) of 20 residents whose MDS 3.0 assessments were reviewed. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 03/26/19. Diagnoses included chronic obstructive pulmonary disease and atherosclerotic heart disease without angina pectoris. A 30-day MDS assessment dated [DATE] indicated Resident #10 received an anti-coagulant (blood thinner) seven days during the assessment reference period (04/17/19-04/23/19). Review of the April 2019 MAR did not reveal the use of an anti-coagulant. On 07/02/19 at 8:30 A.M., Licensed Practical Nurse (LPN) #153 verified the MDS dated [DATE] was coded erroneously for anti-coagulant use. LPN #153 stated she coded Plavix, anti-platelet medication as an anti-coagulant. 2. Review of Resident #4's medical record revealed diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, and obstructive sleep apnea. Review of the March 2019 Medication Administration Record (MAR) revealed Resident #4 received Ambien (sedative/hypnotic) 5 milligrams (mg) every night between 03/09/19 and 03/15/19) for insomnia and Buspar 10 mg twice a day for anxiety from 03/09/19 to 03/15/19. An annual MDS dated [DATE] indicated Resident #4 had not received any anti-anxiety or hypnotic medications. On 07/02/19 at 10:50 A.M., LPN #153 verified the MDS dated [DATE] was coded incorrectly because Resident #4 had received Buspar which was an anti-anxiety medication. LPN #153 stated she did not code the Ambien because it was a sedative. Ambien information was reviewed revealing it fell into classifications of sedatives and hypnotics. LPN #153 indicated she was unaware Ambien was also classified as a hypnotic. 3. Review of Resident #30's medical record revealed an admission date of 05/03/19. admission diagnoses included a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer to the sacrum. An admission nursing assessment dated [DATE] indicated Resident #30 had skin 365977 Page 3 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0641 impairment of the sacrum measuring 10.5 x 11 x 2.6 and had an indwelling catheter. Level of Harm - Minimal harm or potential for actual harm An admission MDS dated [DATE] indicated Resident #30 had an indwelling catheter and was occasionally incontinent of urine and had one Stage IV pressure ulcer which was present on admission. A Medicare 60 day MDS dated [DATE] indicated Resident #30 had an indwelling catheter and was continent of urine. The 60 day MDS indicated Resident #30 had one Stage IV pressure ulcer which was not coded as present on admission. Residents Affected - Some On 07/03/19 at 2:20 P.M., LPN #153 verified because Resident #30 had an indwelling urinary catheter during the above MDS assessments, continence status should not have been rated. LPN #153 verified the Stage IV pressure ulcer on the 06/30/19 was present on admission and was not coded correctly. 365977 Page 4 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

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 observation, record review and interview the facility failed to revise the care plan for range of motion for Resident #8. This affected one resident (Resident #8) of two residents reviewed for range of motion. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, seizures, tracheostomy, gastrostomy, cerebral palsy and intellectual disabilities. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] for Resident #8 indicated the resident was totally dependent on two or more for bed mobility. He had functional limitation impairment in range of motion of both upper extremities and no impairment of lower extremities. Resident #8 was observed in bed on 07/01/19 at 10:34 A.M. with both legs flexed at the knees. Interview with the Respiratory Therapist (RT) #163 revealed the resident was not able to move his legs very much. On 07/02/19 at 8:29 A.M. Resident #8 was observed in bed with both knees flexed. He was moving his arms and hands, but his legs were still. On 07/02/19 at 8:41 A.M. interview with Registered Nurse (RN) #123 revealed the resident kept his legs drawn up. She said she tries to straighten them out when she passes medications. She said the resident's legs do not extend all the way out because he will intentionally pull them back. On 07/02/19 at 11:35 A.M. interview with the MDS nurse, Licensed Practical Nurse (LPN) #153 revealed Resident #8 was able to straighten his legs out. On 07/02/19 at 12:05 PM interview with certified occupational therapy assistant (COTA) #164 revealed Resident #8 was screened upon admission on [DATE] and did not have any limited range of motion in his legs. She said his legs could be extended and flexed up to his functional needs. The resident was screened again on 06/17/19 and found to have some limited range of motion and range of motion (ROM) was to be provided by the floor staff. Review of the Rehabilitation Screening dated 06/17 19 indicated Floor staff ROM. Review of the current care plan for Resident #8 (initiated 05/09/19) did not indicate a revision to the care plan to reflect ROM by the floor staff. There was no documentation of the ROM completed by the floor staff in the medical record. This was verified with the Director of Nursing (DON) on 07/02/19 at 12:20 P.M. On 07/02/19 at 12:25 P.M. interview with the DON revealed when a recommendation from a therapy screen is made for the floor staff to complete ROM, it is communicated to the restorative nurse or nursing supervisor. The nurse puts the information into the point of care system for the State Tested Nurse Aides (STNAs) to complete and document when provided. The DON verified the ROM was not added to the point of care system and was not documented since recommended by therapy on 06/17/19. 365977 Page 5 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to provide a restorative ambulation program in accordance with Resident #12's restorative plan. This affected one resident (Resident #12) of ten residents interviewed regarding activities of daily living. Residents Affected - Few Findings include: Review of Resident #12's medical record revealed diagnoses including Parkinson's disease, repeated falls, osteoarthritis, intervertebral disc degeneration in the lumbar region, and presence of a right artificial hip joint. A Restorative Ambulation Program assessment indicated Resident #12 required assistance to stand and walk with a walker. The assessment indicated Resident #12 was cooperative with the ambulation program but was unsteady and had a shaky gait. The assessment indicated Resident #12 was on a restorative ambulation program with maximum assistance of two persons and a front wheeled walker to ambulate 6-12 feet for 15 minutes for a minimum of 5-7 days per week with a goal to maintain his ability to ambulate 6-12 feet. Resident #12 needed cueing and encouragement and lots of time to complete the program with Parkinson's disease delaying his ability to take steps. Review of restorative ambulation program logs revealed between 04/18/19 and 06/04/19 the program was provided eight times and refused 12 times. Multiple entries revealed the activity did not occur or it was not applicable. A physician's progress note dated 05/01/19 indicated Resident #12 was assessed with vascular Parkinsonism. The physician indicated a plan for Resident #12 to exercise at least 30 minutes five days a week. On 07/03/19 at 11:49 A.M., Registered Nurse (RN) #121 stated she was never made aware the physician wanted Resident #12 to exercise 30 minutes per day five days a week and verified documentation did not support the restorative ambulation program was offered/delivered as planned. 365977 Page 6 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide range of motion services in a timely manner for Resident #29. This affected one resident (Resident #29) of two residents reviewed for range of motion. Findings include: Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, quadriplegia, end stage renal disease and ventilator dependence. The Minimum Data Set (MDS) 3.0 assessment for Resident #29 dated 05/02/19 indicated the resident required total dependence on two or more staff for bed mobility, transfers, bathing and dressing. He had functional limitation in range of motion (ROM) of the upper and lower extremities on both sides. Review of the Occupational Therapy (OT) evaluation dated 04/26/19 indicated OT treatment five times per week for 30 days for activities of daily living, wheelchair management, therapeutic exercise and activity and neuromuscular re-education. The treatment included passive ROM of upper extremities to assist with contracture management. OT was discontinued on 05/24/19 with a recommendation for a restorative nursing program for passive range of motion (PROM) to bilateral upper extremities to all joints and all planes and bilateral upper extremity positioning to maintain decreased edema (swelling). The care plan dated 06/26/19 indicated Resident #29 had limitation in ROM of the joints, debility and quadriplegia. Interventions included to assess ROM initially, quarterly, and as needed. To summarize participation, activity tolerance, maintenance, increase/decrease of ROM and evaluate the appropriateness of continuation of the Restorative Program quarterly and as needed Review of the restorative evaluation for Resident #29 dated 06/26/19 indicated impaired strength of all four extremities with passive range of motion (PROM) recommended. A PROM program was initiated for 30 repetitions, three times to all four extremities for 15 minutes minimum for five to seven days per week to maintain mobility. The restorative ROM program was documented in the point of care system by the State Tests Nurse Aides (STNAs) on 06/26/19, 06/28/19 and 07/02/19. On 07/01/19 at 12:02 P.M. Resident #29 was observed in bed. He was unable to move his arms and legs. He had slight movement in his hands. Interview with the resident revealed he was provided range of motion (ROM) by staff to his arms and legs, but not daily. On 07/03/19 at 12:16 PM interview with the restorative nurse, Registered Nurse (RN), #121 revealed she was unaware of the OT recommendation on 05/24/19 for PROM for Resident #29. She said she was talking with Resident #29 and when he realized she was the restorative nurse, he asked her if he could get some neck exercises. At that time she assessed him for restorative services and began the PROM program to all extremities on 06/26/19. She said therapy usually sends a slip with the recommendation to her and she then develops a restorative program. On 07/03/19 at 1:45 PM interview with Certified Occupational Therapist Assistant (COTA) #164 and RN 365977 Page 7 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0688 Level of Harm - Minimal harm or potential for actual harm #121 was conducted. COTA #164 indicated Resident #29 was ill during the time of the recommendation. It was verified the recommendation on 05/24/19 was not addressed at the time to indicate the resident was ill and the recommendation was not revisited by the restorative nurse until a month later when Resident #29 requested neck exercises. Residents Affected - Few 365977 Page 8 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

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. Based on observation, record review and interview the facility failed to check placement of a gastrostomy tube prior to the administration of medication for Resident #22. This affected one resident (Resident #22) of one resident observed for the administration of medications per gastrostomy tube of six residents observed during the medication administration. Findings include: On 07/02/19 at 7:50 A.M. medication administration was observed with Licensed Practical Nurse (LPN) #128. LPN #128 prepared medications for administration per gastrostomy tube (tube placed directly into the stomach for administration of nutrition and medications) for Resident #22. LPN #128 crushed a tablet of Oxycodone-acetaminophen (a narcotic pain medication)10-325 milligrams (mg) and mixed it with a small amount of water in a medication cup. She administered approximately 30 milliliters (ml) of water per the resident's gastrostomy tube via gravity per syringe. She then administered the narcotic pain medication mixture via gravity per syringe, followed by a water flush. LPN #128 did not check the gastrostomy tube for proper placement prior to the administration of the medication. This was verified with LPN #128 on 07/02/19 at 8:02 A.M. LPN #128 indicated she should have checked the placement of the tube prior to administration of the medication. Review of the facility's undated policy and procedure for the administration of medications through an enteral tube revealed to check placement of the gastrostomy tube by aspirating prior to the administration of medications. 365977 Page 9 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, policy review and interview the facility failed to administer oxygen in accordance with physician orders for Resident #10. This affected one resident (Resident #10) of 15 residents screened for oxygen use. The facility identified 15 residents with oxygen orders. Residents Affected - Few Findings include: Review of Resident #10's medical record revealed an admission date of 03/26/19. Diagnoses included chronic obstructive pulmonary disease (COPD) and atherosclerotic heart disease. Resident #10 had a physician order dated 03/27/19 for oxygen to be delivered at three liters per nasal cannula as necessary for COPD. A care plan indicated Resident #10 required continuous oxygen therapy related to respiratory illness. On 07/01/19 at 11:00 A.M., Resident #10 was observed lying in bed with the head of his bed elevated. An oxygen concentrator placed between the foot of the bed and the chair was operating with a setting at two liters per minute (LPM). The tubing from the concentrator was observed going under the covers but there was no oxygen on Resident #10. When Resident #10 was asked if he wore oxygen, he touched his face near his nares and stated he was supposed to have a tube. On 07/01/19 at 11:04 A.M., Licensed Practical Nurse (LPN) #143 stated Resident #10's oxygen was ordered on an as necessary basis and he sometimes removed it. On 07/02/19 at 8:19 A.M., 9:54 A.M., and 11:29 A.M. , Resident #10 was observed lying in bed with his nasal cannula in place and oxygen set at two liters per minute (lpm). On 07/02/19 at 11:46 A.M., upon request, Licensed Practical Nurse (LPN) #154 assessed Resident #10's oxygen saturation with a pulse oximeter. Resident #10's oxygen saturation level was 88% with oxygen at two lpm. LPN #154 verified Resident #10's oxygen concentrator was set at two lpm and increased it to three lpm. LPN #154 also instructed Resident #10 to cough a couple times. The oxygen saturation level rose to 92%. After the oxygen was set on three lpm for less than one minute, Resident #10's oxygen saturation increased to 98%. Review of the facility's undated Oxygen Administration policy indicated under step 10 that the proper flow of oxygen was to be administered On 07/02/19 at 3:50 P.M., LPN #153 verified Resident #10 had an order for oxygen to be administered on an as needed basis but the care plan indicated it was continuous. LPN #153 stated the care plan was written that way because Resident #10 wore the oxygen all the time. 365977 Page 10 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to monitor laboratory tests in accordance with physician orders to ensure the adequate use of medications at the prescribed dose for Resident #4. This affected one resident (Resident #4) of five residents reviewed for medication use. Residents Affected - Few Findings include: Review of Resident #4's medical record included diagnoses including chronic obstructive pulmonary disease, atherosclerotic heart disease, congestive heart failure, type 1 diabetes mellitus, and anemia. Resident #4's medication regimen included Metformin 1000 milligrams (mg) twice a day, 80 units of Basaglar insulin twice a day, 40 mg of Lasix every day and 40 milliequivalents (mEq) Potassium chloride every day. Resident #4 had a basal metabolic panel (BMP- blood test that gives doctors information about the blood glucose level, levels of electrolytes like sodium and potassium, and how well the kidneys are working) and a complete blood count (CBC-a blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia) drawn 04/25/19. The physician wrote a notation on the bottom of the laboratory results to re-check the laboratory tests on 06/10/19. On 05/07/19, a CBC was obtained. On 05/09/19, an order was written to obtain a BMP and CBC on 05/23/19. There were no laboratory results for 05/23/19. On 06/01/19, and order was written for a CBC and comprehensive metabolic panel (CMP - monitors electrolytes and blood glucose levels) to be drawn 06/10/19. The CBC was obtained on 06/10/19 but there were no results for a CMP. During an interview on 07/02/19 between 1:25 P.M. and 1:45 P.M., the Director of Nursing stated Resident #4 had a CBC and BMP drawn 04/25/19 and the physician ordered the tests be re-checked 06/10/19. The DON stated the CBC was probably re-checked 05/07/19 due to an order for a weekly CBC that had not been discontinued. The DON verified the BMP and CBC ordered to be drawn on 05/23/19 was not obtained. On 06/01/19, an order was written for a CBC and CMP to be drawn 06/10/19. The CMP was not obtained. 365977 Page 11 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure a physician attended Quality Assurance committee meetings. This had the potential to affect all 42 residents. Residents Affected - Many Findings include: Review of the facility's undated Quality Assurance (QA) Management Policy and Procedure indicated QA meetings were scheduled for the last Thursday of the month following each calendar quarter. Per the policy, members of the committee included the medical director. The chairperson was responsible for verifying attendance of the outside committee members. Monthly medical director reports were to be reviewed at the quarterly meeting. Review of attendance sign in sheets for the QA committee meetings held 07/26/18, 10/25/18, 01/31/19, and 04/25/19 revealed no physician signature at any of the meetings. On 07/03/19 at 1:07 P.M., the Director of Nursing (DON) revealed the medical director was the physician on the QA committee. The DON indicated the medical director did not attend QA meetings but did complete medical director reports. The DON indicated meetings were held on Thursdays and the Medical Director did not visit the facility on Thursdays. 365977 Page 12 of 13 365977 07/03/2019 Circle of Care 1985 East Pershing Street Salem, OH 44460

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to implement a comprehensive and effective Legionella prevention program including water testing per the facility's plan. This had the potential to affect all 42 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility's Legionella Environmental Assessment Form, dated 05/18/18 revealed it included a water management plan. The plan indicated the facility monitored incoming water parameters by testing the water temperatures on the 4th floor for hot water to reach 105-115 degrees within five minutes. Record review revealed there was no evidence the water testing was completed as per the plan on the 4th floor. On 07/03/19 at 4:10 P.M. interview with Maintenance Director #119 verified water testing was not being completed per the facility Legionella plan. 365977 Page 13 of 13