Health inspection·April 11, 2019

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. 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, resident fund account review, staff interview and policy review, the facility failed to return funds from a resident personal funds account for a discharged resident. This affected one (#75) of six residents reviewed for resident fund accounts. The facility census was 76. Residents Affected - Few Findings include: Medical record review revealed Resident #75 admitted to the facility on [DATE], diagnoses included Alzheimer's disease, dementia, and hypertension. Further review revealed the resident discharged from the facility on 12/28/18. Review of a facility resident trust account balance ledger, dated 04/11/19, revealed the facility had a personal funds account for Resident #75 with a balance of $1,855.04. Interview on 04/11/19 at 9:07 A.M., Business Office Manager (BOM) #220 revealed she was responsible for managing he residents personal funds accounts. BOM #220 revealed when a resident discharged from the facility, the facility was to return any monies left in their account to the resident, or responsible party, within 30 days. BOM #220 verified Resident #75 discharged from the facility on 12/28/18. BOM #75 further verified the facility did not return Resident #75's balance of $1,855.04. Review of a facility policy titled, Resident Personal Fund, most recent revision date 01/18/18, revealed the facility was to release resident funds upon death or discharge within 30 days of the death or discharge. Page 1 of 8 365997 365997 04/11/2019 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy, the facility failed to develop a comprehensive plan of care for a resident with a vision deficit who required glasses. This affected one (#19) out of 18 residents reviewed for care plans. The facility census was 76. Findings include: Medical record review revealed Resident #19 admitted to the facility on [DATE]. Diagnoses included hyperlipidemia, low back pain, and urinary tract disorder. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/20/18, revealed the resident was alert and oriented. Further review revealed the resident was able to see adequately with glasses. Review of the most recent plan of care for Resident #19 did not indicate the resident had a vision impairment and wore glasses. Interview on 04/11/19 at 9:38 A.M. Registered Nurse (RN) #230 revealed she was responsible for completing the MDS assessments and creating and/or updating resident's plan of care. RN #230 verified she did not develop a plan of care regarding the resident's vision deficit and use of glasses. Review of the facility policy dated 2004 titled Nursing Standard of Practice; Subject: Care Plan Process revealed the interdisciplinary team directs care planning toward attaining and maintaining the highest optimal physical, psychosocial, functional status including advanced directives, and signs the approved plan of care. 365997 Page 2 of 8 365997 04/11/2019 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

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 medical record review, observation, staff and resident interview, and review of facility policy, the facility failed to ensure residents care plan were updated and revised when changes occurred. This affected one (#22) of 18 reviewed for care planning. The facility census was 76. Findings include: Review of Resident #22's medical record revealed an admission date of 12/09/17. Diagnoses included intracerebral hemorrhage, hypertension, hypokalemia, Alzheimer's disease, and neuromuscular dysfunction of the bladder. Review of Resident #22's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five indicating Resident #22 was severely cognitively impaired. Resident #22 required supervision for bed mobility, transfer, walking, locomotion, eating, and personal hygiene. Resident #22 was independent with toilet use. Resident #22 required limited assistance with dressing. Resident #22 had delusions and verbal behavioral symptoms directed toward others during the review period. Review of Resident #22's care plan revised 02/27/19 revealed supports and interventions for activities, risk for elopement, risk for falls, self-care deficit, mood behavior problems, cognitive loss, risk for falls, risk for skin breakdown, potential for pain, hypertension, risk for adverse side effects of antianxiety medication use, and potential for weight loss. The care plan was silent to supports or interventions for the use of antipsychotic medications. Review of Resident #22's physician orders revealed an order dated 01/09/19 for Zyprexa 2.5 milligrams (mg) by mouth at bedtime related to Alzheimer's disease with late onset. An interview was attempted on 04/10/19 at 2:37 P.M. with Resident #22. Resident #22 was pleasantly confused and unable to be interviewed. Resident #22 was clean, dressed, and alert. Resident #22 showed no signed of behaviors or side effects from medications. Interview on 04/10/19 at 2:45 P.M. with Licensed Practical Nurse (LPN) #200 revealed Resident #22's took Zyprexa at bedtime for Alzheimer's disease. LPN #200 stated she was not aware of any other diagnosis to support the use of this antipsychotic. Interview on 04/11/19 at 9:20 A.M. with LPN #210 verified Resident #22 was receiving Zyprexa 2.5 mg at bedtime for a diagnosis of Alzheimer's disease with late onset and there was no other diagnosis to support the use of an antipsychotic. LPN #210 also verified Resident #22's revised care plan did not include a support for use of an antipsychotic. Review of the facility policy titled, Resident Directed Care Planning Policy and Procedure, dated 11/22/16 revealed a comprehensive care plan must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 365997 Page 3 of 8 365997 04/11/2019 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0692 Provide enough food/fluids to maintain a resident's health. 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 review of a facility policy, the facility failed to evaluate a resident and notify the physician and/or dietician of a severe weight loss of 6.98 percent (%) in one month. This affected one (#36) of two residents reviewed for nutrition. The facility census was 76. Residents Affected - Few Findings included: Medical record review revealed Resident #36 admitted to the facility on [DATE] with diagnoses including dementia, weight loss, and major depressive disorder. Review of the Minimum Data Set (MD'S) revealed the resident's cognition was severely impaired. Review of Resident #36's weights revealed on 03/06/19 the resident weighed 143.2 pounds. On 04/06/19 the resident weighed 133.2 pounds which revealed a 6.98% weight loss (ten pounds) in 30 days. There was a lack of evidence the physician and/or dietician was notified regarding the severe weight loss. Additionally, there was no evaluation of Resident #36 following the weight loss until the date of the survey. Interview on 04/10/19 at 3:09 P.M., the Director of Nursing verified the facility did not notify the physician or the dietician of the resident's 6.98% weight loss (10 pounds) in 30 days. The DON also confirmed Resident #36 was not re-evaluated following the weight loss. Review of a facility policy titled, Weight Change Policy, most recent revision date 03/2018, revealed if a resident weighed greater than 100 pounds, the facility were to notify the physician and dietician of any weight gain or loss of five pounds or more. 365997 Page 4 of 8 365997 04/11/2019 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

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** 2. Review of Resident #54's medical record revealed an admission date of 05/05/17. Diagnosis included dementia with behavioral disturbances, anxiety, congestive heart failure and diabetes mellitus. Review of Resident #17's quarterly MDS dated [DATE] revealed the resident had no behaviors. Review of Resident #54's annual MDS dated [DATE] revealed the resident had a high cognitive function. The resident required supervision in bed mobility, transfers, dressing and eating. Review of Resident #17's most recent care plan revealed the resident had mood/behavior problems related to anxiety and depression. The care plan documented Xanax (antianxiety) was ordered. Review of Resident #17's medical record revealed a physician's order dated 11/12/16 for Seroquel (antipsychotic) to be administered by mouth every evening related to dementia with behavioral disturbances. Further review of Resident #54's medical record revealed a physician's order dated 03/01/19 for Alprazolam (antianxiety) 0.25 milligram tablet to be given one time every 12 hours as needed for anxiety. The end date was indefinite. Interview was completed with LPN #210 on 04/11/19 at 9:25 A.M. The LPN verified that Resident #17 diagnosis for Seroquel was dementia with behavioral disturbances. LPN #210 further verified Resident #54 failed to be reevaluated by the physician every 14 days with a new as needed Ativan order written. Review of the Medscape dosage and indication information for the Zyprexa. The review revealed Zyprexa was able to be used for residents who were diagnosed with schizophrenia or bi-polar related agitation. Delusional disorders and dementia with behavioral disturbances were not listed as supported diagnoses. Review of the facility policy titled, Antipsychotic/Psychotropic Drugs reviewed 03/03/17 revealed antipsychotic and psychotropic drug therapy shall be used only when it was necessary to treat a specific condition. These conditions include schizophrenia, schizo-affective disorder, delusional disorder, psychotic mood disorders, acute psychotic episodes, brief reactive psychosis, schizophreniform disorder, atypical psychosis, Tourette's disorder, Huntington's disease and organic mental syndrome. Further review of the policy revealed the document was silent to the time frame limitations for PRN antianxiety medications and the need for reason for continuation. Based on medical record review, observation, staff and resident interview, review of medication information from Medscape and review of facility policy, the facility failed to ensure residents had appropriate diagnosis to support the use of antipsychotic medications. Additionally, the facility failed to ensure residents who received anti-anxiety medications as needed (PRN) did not have the medication in place for greater than fourteen days without a stop date or a reason for continuation. This affected two residents (#22, and #54) of five residents reviewed for unnecessary medications. The facility identified eleven residents who received anti-psychotic medications and nine residents who received anti-anxiety medications. The facility census was 76. 365997 Page 5 of 8 365997 04/11/2019 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0758 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of Resident #22's medical record revealed an admission date of 12/09/17. Diagnoses included intracerebral hemorrhage, hypertension, hypokalemia, Alzheimer's disease, and neuromuscular dysfunction of the bladder. Residents Affected - Few Review of Resident #22's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five indicating Resident #22 was severely cognitively impaired. Resident #22 required supervision for bed mobility, transfer, walking, locomotion, eating, and personal hygiene. Resident #22 was independent with toilet use. Resident #22 required limited assistance with dressing. Resident #22 had delusions and verbal behavioral symptoms directed toward others during the review period. Review of Resident #22's care plan revised 02/08/19 revealed supports and interventions for activities, risk for elopement, risk for falls, self-care deficit, mood behavior problems, cognitive loss, risk for falls, risk for skin breakdown, potential for pain, hypertension, risk for adverse side effects of antianxiety medication use, and potential for weight loss. The care plan was silent to supports or interventions for use of antipsychotic medications. Review of Resident #22's physician orders revealed an order dated 01/09/19 for Zyprexa 2.5 milligrams (mg) by mouth at bedtime related to Alzheimer's disease with late onset. Review of Resident #22's psychiatric follow up notes dated 01/09/19 revealed the psychiatrist recommended starting Zyprexa 2.5 mg at bedtime for Alzheimer's with behaviors. Review of Resident #22's psychiatric follow up notes dated 04/10/19 revealed the psychiatrist added the diagnoses of delusional disorder and dementia with behaviors to Resident #22's diagnoses list. Further review of Resident #22's physician orders revealed an order dated 04/04/19 for Ativan 0.5 milligrams (mg) one tablet by mouth every 12 hours as needed for increased agitation. No specific end date was indicated on the order. The end date was noted as indefinite. An interview was conducted on 04/10/19 at 2:37 P.M. with Resident #22. Resident #22 was pleasantly confused and unable to be interviewed. Resident #22 was observed to be clean, dressed, and alert. Resident #22 showed no signed of behaviors or side effects from medications. Interview on 04/10/19 at 2:45 P.M. with Licensed Practical Nurse (LPN) #200 revealed Resident #22 took Zyprexa at bedtime for Alzheimer's disease. LPN #200 stated she was not aware of any other diagnosis to support the use of this antipsychotic. LPN #220 further revealed Resident #22's PRN Ativan was discontinued last month but was brought back last week due to Resident #22 getting upset and agitated over the use of the bathroom. Interview on 04/11/19 at 9:20 A.M. with LPN #210 verified Resident #22 was receiving Zyprexa 2.5 mg at bedtime for a diagnosis of Alzheimer's disease with late onset and there was no other diagnosis to support the use of an antipsychotic. LPN #210 also verified Resident #22's revised care plan did not include a support for use of an antipsychotic. LPN #210 verified Resident #22 was prescribed and had been receiving Ativan 0.5 milligram (mg) with no end date and no indicated reason for continuation. 365997 Page 6 of 8 365997 04/11/2019 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0758 Level of Harm - Minimal harm or potential for actual harm Interview on 04/11/19 at 10:35 A.M. with LPN #210 verified Resident #22 did not have a diagnosis to support the use of an antipsychotic in January 2019 when Resident #22 was first prescribed Zyprexa and the diagnoses of delusional disorders and dementia with behavioral disturbances were added yesterday 04/10/19 to support the use. Residents Affected - Few 365997 Page 7 of 8 365997 04/11/2019 Parkvue Health Care Center 3800 Boardwalk Blvd 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 medical record review, observation, staff interview, review of facility policy and procedures, the facility failed to ensure a resident who was positive with Influenza B wore personal protective equipment (PPE) when exiting their room. This had the potential to affect 13 residents (#23, #48, #62, #66, #67, #73, #224, #225, #226, #227, #228, #229, #230) residing in the 100 neighborhood. The facility census was 76. Residents Affected - Some Findings include: Medical record review for Resident #23 with an admission date of 03/07/16 with diagnose including dementia with behavioral disturbance, anxiety disorder, and hyperlipidemia. Review of the physician orders dated 04/07/19 revealed Tamiflu capsule 75 (mg) milligrams by mouth every 12 hours for Influenza B for five days. In addition, Resident #23 to be on droplet precautions. Review of the Treatment Administration record (TAR) dated 04/09/19 revealed Droplet precautions every shift. Observation on 04/09/19 at 12:26 P.M. revealed Resident #23 has PPE's outside of his/her room with a sign reading to see the nurse before entering. In addition, Resident #23 was outside of his/her room without a mask while sitting in wheelchair in the 100 area. This was verified with Registered Nurse (RN) #250 and the Director of Nursing (DON). The facility confirmed this had the potential to affect 13 residents (#23, #48, #62, #66, #67, #73, #224, #225, #226, #227, #228, #229, #230) residing in the 100 neighborhood who could then be exposed to the Influenza B virus. Review of facility policy titled Isolation, undated, revealed droplet precautions refer to the actions designed to reduce/prevent the transmission of pathogen spread through close respiratory or mucous membrane contact with respiratory secretions. 365997 Page 8 of 8