Health inspection·December 28, 2019

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 interview and record review the facility failed to notify Resident #10 of a medication change when an anti-psychotic medication was ordered and administered to him. This affected one resident (Resident #10) of three residents reviewed for notification of change in condition. The facility census was 51. Findings include: Review of the medical record for Resident #10 revealed an admission date of 06/14/18. Diagnoses included brief psychotic disorder, acute respiratory failure, diabetes, and chronic kidney disease. Review of the annual Minimum Data Set (MDS) assessment, dated 11/30/19, revealed Resident #10 had intact cognition. No behaviors were listed per the assessment. Review of a nursing note dated 11/30/19 at 4:08 P.M. written by Licensed Practical Nurse (LPN) #604 revealed Psychiatrist #702 was contacted regarding Resident #10's behaviors that included he was the Profit. Resident #10 stated he was going to buy a worker a Porsche and he was going to marry the staff as that was God's plan. The psychiatrist ordered Invega (antipsychotic) six milligram (mg) daily with a diagnosis of psychotic disorder. There was no documentation the resident was notified of the medication change or side effects of the medication in the nursing note. Review of a physician order for Resident #10 dated 11/30/19 at 4:14 P.M. revealed Primary Care Physician (PCP) #701 ordered Invega extended release tablet six mg by mouth at bedtime every day for brief psychotic disorder. Review of the Medication Administration Record (MAR) for November and December 2019 revealed Resident #10 received Invega extended release six mg by mouth that was ordered for 9:00 P.M. on 11/30/19, 12/01/19, and 12/02/19. Review of self- reported incident (SRI) with tracking number 184772 and a discovery date of 12/04/19 revealed Resident #10 felt he had been abused because he was put on a medication and was not made aware. The facility unsubstantiated the SRI. Review of an undated witness statement signed by Resident #10 revealed he was given a medication without his knowledge. He stated he felt no actual harm was done but there was a miscommunication regarding his medication. Review of a nursing note dated 12/04/19 at 1:54 P.M. written by LPN #703 revealed Psychiatrist #702 was notified of Resident #10's concern and discontinued the Invega. Resident #10 was made aware the Page 1 of 10 365991 365991 12/28/2019 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0580 medication was discontinued. Level of Harm - Minimal harm or potential for actual harm Review of Resident #10's care plan with a revision date of 12/04/19 revealed the resident was on psychotropic medications related to a brief psychotic disorder and displayed behaviors. Interventions included administer medications as ordered, monitor, document side effects and effectiveness and educate Resident #10 about risks, benefits, side effects and toxic symptoms of the medications. Residents Affected - Few Review of a witness statement dated 12/05/19 written by LPN #604 revealed Resident #10 was making delusional statements and believed he was the Profit. She called the psychiatrist and he ordered the medication Invega. She indicated she informed Resident #10 of the new order and he did not ask any questions. Review of witness statement dated 12/08/19 written by LPN #700 revealed Resident #10 approached her during the medication pass and asked what medications he was on and if he was on any new medications. She indicated she went over the medications with Resident #10. She indicated Resident #10 asked what the Invega was for and when she informed him he became angry. Review of a nursing note dated 12/09/19 at 11:49 A.M. written by LPN #604 revealed a late entry for 11/30/19 which indicated Resident #10 was informed of new medication and did not ask any questions. The nursing note did not reveal if side effects of the Invega were explained to the resident. Interview on 12/26/19 at 11:02 A.M., with Resident #10 revealed he was upset as a nurse had called the psychiatrist and received an order for Invega and never notified him of the new medication. He revealed he received a couple doses before he realized he was receiving the medication that he did not know was ordered. He revealed he had side effects of the medication that included dry mouth, dizziness, and blurred vision. He revealed he did not realize the side effects were because he was receiving a new medication that he was not notified he was ordered. He revealed he felt this was against his right as he would not have agreed to receive this medication if he was aware this medication was ordered. He said the nurse said she notified him, but she did not as he would remember that. Interview on 12/26/19 at 9:51 A.M. with LPN #604 verified notification documentation related to the Invega was not completed until a late entry was entered on 12/09/19 which was after Resident #10 reported he was not notified of his medication change. Interview on 12/28/19 at 9:02 A.M. with the Administrator and Director of Nursing revealed on 12/04/19 Resident #10 was upset and reported he was ordered a medication and was not notified of the medication and side effects of the medication. They verified LPN #604 did not document Resident #10 was notified of the medication change or side effects of the medication on 11/30/19 when the medication was ordered. Review of the facility policy titled, Notification for Changes in Condition, dated 11/30/18, revealed the purpose of the policy was for guidance for notifications to a resident, resident representative, and family for the resident. The policy revealed the facility was to notify for changes that included but not limited to significant medication changes. This deficiency substantiates Complaint Number OH00108976. 365991 Page 2 of 10 365991 12/28/2019 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview the facility failed to ensure comfortable sound levels were maintained on the A wing. This had the potential to affect all 28 residents on the A wing (Residents #1, #2, #5, #7, #8, #9, #10, #13, #14, #15, #17, #18, #21, #22, #23, #24, #27, #28, #29, #32, #34, #35, #36, #39, #43, #44, #45 and #50). The facility census was 51. Finding Include: Observation on 12/26/19 at 11:02 P.M. revealed the call light control center at the A-wing nurse's station was sounding as if a call light was on. However, no call lights were activated for any resident room. Observation on 12/26/19 at 12:20 P.M revealed Resident #36 making a phone call at the nurse's station holding the phone with one hand and covering her ear with the other in order to hear the phone conversation as the call light control center continued to sound. Observations on 12/26/19 at 12:39 P.M., 2:48 P.M., and 4:51 P.M. revealed the call light buzzer/ alarm was still going off at the nursing station. Observations on 12/27/19 at 8:36 A.M., 12:18 P.M., and 3:37 P.M. revealed the call light buzzer/ alarm was still going off at nursing station. Interview on 12/27/19 at 12:23 P.M. with Resident #36 and Resident #15 revealed they found the noise emanating from the nurse's station annoying but had learned to block it out. Both stated the did not remember when it did not make that noise. Sometimes it stopped for a day, but then returned. Interview on 12/27/19 at 3:17 P.M. with the administrator and the Director of Nursing (DON) regarding the buzzer/alarm revealed the DON had questioned the noise when she first started a few weeks before and was told there was a problem regarding the repairs. The administrator revealed the facility had had someone out to repair the call light station on the A-wing several times, but they had not been able to locate the problem. The repair company was coming in again that evening. Observation on 12/28/19 at 7:36 A.M. revealed the buzzer/ alarm continued to sound at the A-wing nurse's station. On 12/28/19 at 9:19 A.M. the administrator stated she had called the corporate office on 12/27/19 after the repair person again could not locate and fix the call light buzzer/alarm. They were arranging for a specialist to come out. Review of the facility census revealed Residents #1, #2, #5, #7, #8, #9, #10, #13, #14, #15, #17, #18, #21, #22, #23, #24, #27, #28, #29, #32, #34, #35, #36, #39, #43, #44, #45 and #50 resided on the A wing. 365991 Page 3 of 10 365991 12/28/2019 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

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 record review and interview the facility failed to ensure all appropriate staff participated in the development of Resident #7's care plan. This affected one of 18 residents whose care plans were reviewed. The facility census was 51. Findings included: Record review was conducted on Resident #7 who was admitted to the facility on [DATE] with diagnoses including cerebral palsy, schizoaffective disorder, intellectual disability and generalized anxiety. The Minimum Data Set assessment dated [DATE] indicated she had cognitive impairment and needed extensive assistance by staff for all activities of daily living including bed mobility, transfers, toileting, hygiene, eating and dressing. Observation and interview on 12/26/19 at 11:34 A.M. revealed Resident #7 laying in her bed. She was alert and oriented with garbled speech which was difficult to understand. She shared she had no concerns about her care and was dependent on the nursing staff for all of her care needs. Interview on 12/27/19 at 8:07 A.M. with Resident #7's family member revealed Resident #7 had a long history of being in facilities due to physical limitations and psychological problems. He said he had no concerns with her care and she had a close relationship with some of the nurses and aides. Review of the facility document titled Care Plan Meeting, dated 06/25/19, for Resident #7 revealed those who signed for attendance at the meeting included Licensed Practical Nurse (LPN) #605, Dietary Manager (DM) #900 and Activity Director (AD) #901. Review of the facility Progress Note dated 10/03/19 authored by Social Services Director (SSD) #903 revealed the care team met with the resident; however, the note did not indicate which team members were at the meeting. Interview on 12/27/19 at 12:23 P.M. with State Tested Nursing Assistant (STNA) #906 revealed she had worked at the facility for several years and was not asked to attend plan of care meetings for residents nor asked for input from staff holding the plan of care meetings. Interview on 12/27/19 at 12:29 P.M. with STNA #905 revealed she had worked at the facility for many years and did not attended plan of care meetings for any resident nor was she asked for any input regarding a resident for plan of care meetings. Interview on 12/27/19 at 1:36 P.M. with SSD #903 revealed she had started at the facility in August 2019. She said STNAs nor Registered Nurses (RN) attended the plan of care meetings. Those in regular attendance from the facility included herself, LPN #605, DM #900 and AD #901. She verified STNAs or RNs did not attend Resident #7's meetings on 06/25/19 according to the meeting document and staff signatures nor on 10/03/19 which was a meeting she personally held. An interview on 12/27/19 at 3:17 P.M. with the Administrator revealed the corporate office wanted the facility to have an RN at the plan of care meetings and the DON could fill that role but that had not been implemented. The Administrator had no comment regarding the lack of STNA attendance or 365991 Page 4 of 10 365991 12/28/2019 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0657 input. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365991 Page 5 of 10 365991 12/28/2019 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

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 observation, interviews and record reviews the facility failed to routinely monitor Resident #11's blood glucose levels and complete timely assessments to prevent critically high blood glucose levels. This affected one of five residents reviewed for unnecessary medications. The facility census was 51. Residents Affected - Few Findings included: Record review for Resident #11 revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified convulsions, repeated falls, type two diabetes mellitus with polyneuropathy, major depression, multiple sclerosis, heart failure and weakness. The Minimum Data Set assessment dated [DATE] revealed Resident #11 was cognitively impaired, required the assistance of two staff for bed mobility, transfers, toileting, hygiene, dressing and had two falls without injury since being admitted to the facility. The plan of care with an initial date of 01/12/19 revealed the resident had nutritional problems related to diabetes mellitus with interventions including diet and monitoring lab work. He was non-compliant with diabetic diet restrictions liking candy and sugary snacks with the intervention of monitoring for signs of hyperglycemia including thirst and increased appetite. Review of hospital discharge papers dated 01/11/19 and facility physician orders from 01/11/19 to 12/19/19 revealed the resident had been on sliding scale insulin ( insulin given in response to elevated blood glucose testing ) and it was not continued at the facility upon admission. There were no orders at the time of admission for routine blood glucose monitoring. A physician order written 05/03/19 included a basic metabolic panel (chemistry panel that includes blood glucose level) every month. The diet order dated 01/11/19 was for consistent carbohydrate. Metformin HCL 500 milligrams (mg) (anti diabetic medication) by mouth once a day was ordered 01/11/19. On 12/02/19 Metformin HCL was increased to 500 mg twice a day and Tradjenta (anti diabetic medication) five mg by mouth in the morning. On 12/16/19 an order was written for Farxiga (oral diabetic medication that helps to control blood sugar levels) five mg by mouth in the morning and Humalog insulin per sliding scale glucose. On 12/19/19 Insulin Detemir solution inject 10 units at bedtime for diabetes was ordered. Review of facility documents titled Lab Results Report revealed the following: 10/28/19 fasting blood glucose (FBG) 192 11/04/19 FBG 247 11/07/19 Hemoglobin A1C ( a blood test used to determine an average FBG over several months ) was 8.4 (normal range being 4.1-6.1) 12/02/19 FBG 542 12/17/19 FBG 226 and Hemoglobin A1C 13.7 with the mean (average ) glucose of 346. Review of the Medication Administration Record (MAR) dated 11/01/19 to 11/30/19 revealed Resident #11 was compliant with his medications. On 11/08/19, 11/09/19 and 11/10/19 at 6:00 A.M. the blood sugars were as follows: 365991 Page 6 of 10 365991 12/28/2019 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0684 11/08/19 - 231 Level of Harm - Minimal harm or potential for actual harm 11/09/19 - 305 11/10/19 - 248. There were no other checks listed on the MAR for the month of November 2019. Residents Affected - Few Review of the Progress Notes dated 11/01/19 to 12/01/19 revealed an entry on 11/10/19 at 3:56 P.M. by Licensed Practical Nurse (LPN) #700 who wrote resident's blood sugar 344. Review of all entries following that note revealed there was no evidence the physician or Certified Registered Nurse Practioner (CRNP) #911 were informed of the blood sugar of 344 nor any explanation why LPN #700 had checked the blood glucose. Review of the facility document titled Physician Notification for Change in Condition Reporting, dated 08/01/16, revealed any glucose reading over 300 would be reported to the physician. Review of the Progress Notes dated 12/16/19 at 1:31 P.M. authored by Registered Nurse (RN) #601 revealed RN #601 contacted CRNP #911 for Resident #11's blood sugar reading HI times two attempts. CRNP #911 gave a new order for 15 units of Novolin R insulin, recheck in one hour then two hours and start sliding scale insulin coverage. RN #601 charted the son and doctor were notified. Review of the Progress Notes dated 12/16/19 at 6:00 P.M. authored by LPN #707 revealed Resident #11's blood sugar read HI so a new order was obtained from CRNP #911 to give 15 units Humulin R insulin. Review of the December 2019 MAR revealed on 12/16/19, 14 units of insulin were administered for a blood glucose of 342. Review of the Dietary Nutrition Reviews completed by the Registered Dietitian (RD) revealed the last Dietary Nutrition Review was dated 10/01/19. There were no other assessments or notes from the RD in the medical record regarding Resident #11's elevated blood glucose levels. Observation on 12/26/19 from 11:56 A.M. to 12:34 P.M. revealed Resident #11 being wheeled by staff to the dining room for lunch. He was alert with some confusion and was able to express his wants verbally to the staff. He was wheel chair dependent and appeared to have some weakness in his lower and upper extremities as he tried to reposition his chair closer to the dining table. He was able to feed himself after complete meal and beverage set up by the staff. He consumed 100% of his meal. Interview on 12/26/19 at 4:34 P.M. with Resident #11's son revealed he was in the facility to visit his father on or around 12/16/19 or 12/17/19 and upon greeting his father noticed he could barely talk because his mouth was so dry. Throughout the visit he noticed his father kept saying he was thirsty and kept drinking more and more water during the visit. He said he spoke with the nurses on duty ( he did not recall the nurses name ) who told him they were not checking his father's blood sugar levels. The son said he requested the nurse check the blood sugar and when the nurse checked it was so high the glucometer just read HI. He said he knew his dad's sugar was high because he was not talking normally and appeared to be very weak and thirsty. He said he reported his concerns to the administrator because he was so upset seeing his dad in that condition. Interview on 12/28/19 at 11:57 P.M. with CRNP #911 via telephone revealed she was assigned to the facility effective 11/01/19 but was on vacation the first week of November 2019. She added it was 365991 Page 7 of 10 365991 12/28/2019 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few probably the second or third week of November 2019 before she physically saw Resident #11. She said she was first notified of his blood sugar issues in December 2019 when the nurse at the facility could not get a reading other than HI on the glucometer so CRNP #911 ordered a lab draw and discovered the blood sugar was over 500 so she started him on insulin and additional oral medication. CRNP #911 revealed she discovered he had eaten a whole tray of cookies and other sweets in the month of December which caused the high blood sugars. She said she did educate the resident but it was his right to eat what he wanted so she covered the high blood sugars with insulin. Interview and record review on 12/28/19 at 12:11 P.M. with the Director of Nursing (DON) verified there were only three blood glucose checks on the MAR during the month of November 2019 and there was nothing in the progress notes to indicate LPN #700 notified the physician of the blood glucose of 344 per the 11/10/19 progress note authored by LPN #700 at 3:56 P.M. At 1:54 P.M. on 12/28/19 the DON brought the surveyor a loose piece of paper that was not part of the medical record. On the paper was a hand printed note dated 11/11/19 authored by Physician #701. The DON said Physician #701 had just faxed it to the facility as evidence he was aware of the resident's high blood glucose in November 2019. The print on the paper explained he was aware Resident #11 had high glucose on 11/08/19 to 11/10/19 and was noncompliant with diet and medications. He listed his plan was to encourage diet compliance, continue Metformin, education for two to three weeks and repeat labs. Interview and record review on 12/28/19 at 2:41 P.M. with the DON verified the RD's last nutritional assessment of Resident #11 was on 10/01/19. Interview on 12/28/19 at 4:55 P.M. with the administrator revealed Resident #11's son did express concerns over his father's high blood sugar and Resident #11 eating candy bars from other residents. The administrator reported she had moved Resident #11 to a private room about a week ago, since Resident #11 had been taking candy from his room mate. 365991 Page 8 of 10 365991 12/28/2019 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure Resident #35's urinary catheter tubing and drainage bag was not laying on the floor and failed to ensure staff followed appropriate hand washing practices during and after wound care. This affected one resident (Resident #35) out of one resident reviewed for catheter care and one resident (Resident #22) out of one resident reviewed for wound care. Residents Affected - Few Findings include: 1. Review of medical record for Resident #35 revealed an admission date of 09/27/19 and diagnoses included urosepsis, acute kidney failure, neuromuscular dysfunction of the bladder, and dementia. Review of the care plan dated 10/09/19 revealed Resident #35 had an indwelling urinary catheter due to neurogenic bladder and urinary retention. Interventions included check tubing for kinks each shift. Review of December 2019 physician orders revealed Resident #35 was being treated with antibiotics for urosepsis (infection in the urinary tract system). The antibiotics included Doxycycline 100 milligram (mg) give one capsule by mouth two times a day and Amoxicillin 500 mg give two capsules by mouth three times a day. In addition, the resident had an order for a Foley (urinary) catheter to continuous drainage. Observation on 12/26/19 at 11:24 A.M. revealed Resident #35 was in a low bed and his catheter tubing and catheter drainage bag was touching the floor. Observation on 12/28/19 at 7:43 A.M. revealed Resident #35 was in a low bed and his catheter tubing and drainage bag was laying on the floor. Interview on 12/28/19 at 7:45 A.M. with Minimum Data Set (MDS)/ Licensed Practical Nurse (LPN) #605 verified Resident #35's tubing and catheter drainage bag was laying on the floor. Interview on 12/28/19 at 9:14 A.M. with the Director of Nursing revealed the Foley catheter tubing and/or drainage bag should not have been on the floor and verified Resident #35 was currently being treated with antibiotic therapy for the treatment of urosepsis. Review of facility policy titled, Catheter Care dated 05/01/17 revealed staff were check to ensure the urinary drainage collection bag was not on the floor, draining properly, and secured allowing for no reflux of urine back to the bladder. 2. Review of medical record for Resident #22 revealed an admission date of 10/11/19 and diagnoses of paraplegia, pressure ulcer of left buttock, schizoaffective disorder, and hypertension. Review of Resident #22's care plan dated 10/24/19 revealed Resident #22 was admitted with a pressure ulcer to his left gluteal fold and was at risk for the potential of more pressure ulcers due to incontinence, immobility, and non-compliance with wound care and preventative skin care as he refused to be turned and repositioned. The care plan indicated on 11/18/19 Resident #22 developed a venous ulcer to his left lower leg as he refused compression stockings. Interventions included administer treatments as ordered and monitor for effectiveness. Review of current physician orders for December 2019 revealed Resident #22 had an order to cleanse 365991 Page 9 of 10 365991 12/28/2019 Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his left lower leg wound with normal saline solution/ Dakin's solution, then apply Xeroform (non stick petrolatum based gauze) and border gauze dressing daily as resident allows. Review of skin assessment titled, Skin Grid Non- Pressure for Resident #22's left lower leg dated 12/20/19 revealed he had a venous ulcer that originated on 11/21/19 and his wound measured a length of three centimeters, width of five centimeters and a depth of 0.6 centimeters. Observation of dressing change on 12/28/19 at 10:27 A.M. to Resident #22's left lower leg revealed Infection Control/ Registered Nurse (RN) #704 washed her hands and applied gloves prior to starting the dressing change. She removed the old dressing to Resident #22's left lower leg, then washed her hands and applied a new pair of gloves. She cleansed Resident #22's left lower leg wound per order and then proceeded to apply the Xeroform to the wound without washing her hands. She then covered the wound with border gauze per order. She then removed her gloves, walked out of the room and began pushing the treatment cart. She did not wash her hands after the completion of the dressing change. Interview on 12/28/19 at 10:35 A.M. with Infection Control/ RN #704 verified she did not wash her hands after she cleansed Resident #22's wound and before she applied Xeroform and she verified she did not wash her hands after she removed her gloves prior to exiting the room after completing the dressing change. Interview on 12/28/19 at 11:05 A.M. with the administrator revealed Infection Control/ RN #704 should have washed her hands after cleansing Resident #22's wound and after she completed Resident #22's dressing change. Review of the facility policy titled, Standard Precautions dated 10/31/18 revealed practicing hand hygiene was a simple but effective way to prevent the spread of infections by breaking the chain of infection. The policy revealed proper cleaning of hands prevented the spread of germs including those that were resistant to antibiotics and becoming resistant to antibiotics. Hand hygiene was to be completed after contact with blood, body fluids or excretion, mucous membranes, non-intact skin or wound dressings, when hands moved from a contaminated body site to a clean body site during resident care, after removal of gloves, and care between residents. 365991 Page 10 of 10