Health inspection·August 22, 2019

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on resident interview, observation, and staff interview, the facility failed to place the recent survey results in an accessible place for resident and visitors to review without asking for staff assistance. This had the potential to affect all 25 residents residing in the facility. Residents Affected - Many Findings include: On 08/20/19 at 3:37 P.M., interview with eight residents (#9, #10, #14, #15, #17, #18, #19 and #25) attending the Resident Council Meeting did not know where the state survey results were located in the facility. Resident #14 stated he would have to ask the nurse where the survey results were if he wanted to read them. Observation of the common areas on 08/20/19 at 3:50 P.M. revealed there was no survey results or any information indicating where the results were located. Interview with Licensed Practical Nurse (LPN) #120 on 08/20/19 at 3:51 P.M. stated he did not know where the inspection reports were. Interview with Activity Director #13 on 08/20/19 at 3:55 P.M. stated the inspection results were kept in a blue binder at the nurses station. Observation at this time revealed the survey results were found behind the nurses station on a rack with the medical records. Interview with LPN #120 on 08/20/19 at 3:57 P.M. verified the residents and visitors would have to ask the nurse to review the inspection results. Interview with Corporate Nurse #150 on 08/20/19 at 4:00 P.M. verified the survey results were on the medical record rack behind the nurses station not accessible to residents and visitors. Page 1 of 7 366002 366002 08/22/2019 Crestline Rehabilitation and Nursing Center 327 West Main Street Crestline, OH 44827

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 medical record review, staff interview and review of facility protocol, the facility failed to provide appropriate treatment according to the bowel protocol for a resident. This affected one (Resident #18) of one resident reviewed for constipation. The facility census was 25. Residents Affected - Few Findings include: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] with diagnoses including severe intellectual disabilities, major depressive disorder and insomnia . Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/03/19, revealed the resident had severe cognitive impairments. She required total assistance of one person for toilet use. She was always incontinent of bowel and bladder. Review of the plan of care, last updated 07/08/19, revealed Resident #18 had bowel incontinence due to immobility, severe intellectual disabilities and a history of constipation. The interventions included checking the resident frequently and assisting with personal hygiene as needed and provide perineum care after each incontinent episode. There were no interventions mentioned in the plan of care regarding the resident's constipation. Review of the nursing progress notes, dated 08/07/19 at 6:00 P.M., revealed an state tested nursing assistant (STNA) came and informed the nurse that the resident was in the bed laying on her left side and could not have a bowel movement. The nurse manually dis-impacted a large amount of hard stool rectally using one digit. No blood was noted. The nurses progress notes were silent to physician notification of the manual removal of hard stool. Interview with License Practical Nurse (LPN) #100 on 08/21/19 at 2:00 P.M. stated the facility's bowel protocol was to give Milk of Magnesia (MOM) if the resident not had a bowel movement in three days, then wait 24 hours. If the MOM was not effective the the nurse was to give the resident a suppository and wait 12 hours . If the suppository was ineffective, the nurse was to give an enema. She verified the nurses were not to manually remove the stool . She verified if the resident was having constipation and was using MOM and suppositories, the physician should be notified. Review of the facility's undated Bowel Movement Protocol, signed by the Medical Director , stated if no bowel movement in three days start MOM and wait 24 hour. If MOM was ineffective give a suppository and wait 12 hours. If the suppository was ineffective give an enema. Document the interventions in the progress note, reason for administration and update the doctor of each interventions. This is an example of continued non-compliance from the survey dated 08/04/19. 366002 Page 2 of 7 366002 08/22/2019 Crestline Rehabilitation and Nursing Center 327 West Main Street Crestline, OH 44827

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow physicians orders to decrease the dosage of an antianxiety and antipsychotic medication resulting in an unobserved medication errors for Resident #1 and #5. This affected two (#1 and #5) of six residents reviewed for unnecessary medications. The facility census was 25. Findings include: 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbances, delirium and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/08/19, the resident has short and long term memory loss. There was no psychosis, rejection of care, behaviors or psychotic diagnoses documented on the MDS. Review of the plan of care, dated 03/12/19, stated the resident uses psychotropic medications Risperdal (antipsychotic) due to diagnosis of dementia/delirium. The interventions include monitoring, documenting and reporting adverse reactions of the medications. Monitor and record occurrence of target behavior symptoms such as being uncooperative or aggressiveness with care. Review of the physician telephone order, dated 07/26/19, revealed an order to decrease Risperdal to 0.25 mg. twice a day. Review of the August 2019 monthly summary of physician orders revealed an order stating Risperdal 0.5 milligrams (mg.) give 0.25 mg. by mouth in the morning related to unspecified dementia with behavioral disturbances and delirium due to known physiological condition, 0.5 mg. in the morning and 0.25 mg. at bedtime. Review of the Medication Administration Record (MAR) dated August 2019 revealed the resident received Risperdal 0.5 mg in the morning and 0.25 mg at bedtime from 08/01/19 through 08/21/19. Interview with Licensed Practical Nurse (LPN) #100 on 08/21/19 at 1:40 P.M. stated the physicians order for Risperdal was unclear if the resident was to receive 0.25 mg. or 0.5 mg in the morning. She stated she does not give the morning Risperdal because it was given at 6:00 A.M. by the night nurse. LPN #100 pulled the Risperdal medication cards from the medication cart containing a card for Risperdal 0.5 mg (rust color pill) with a label stating to administer Risperdal 0.5 mg. tablet every morning. She removed a second card containing Risperdal 0.25 mg. (yellow tablet) stating to administer 0.25 mg at bedtime. LPN #100 verified both medication cards were being used. She verified based on the medication cards and the unclear order she felt the resident was receiving Risperdal 0.5 mg. in the morning and 0.25 mg. at bedtime. 2. Record review for Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia and anxiety. Review of the annual Minimum Data Set (MDS) assessment, dated 04/12/19, revealed the resident had severe cognitive deficit. The resident did no exhibit any behaviors during the assessment reference 366002 Page 3 of 7 366002 08/22/2019 Crestline Rehabilitation and Nursing Center 327 West Main Street Crestline, OH 44827

F 0755 period. Level of Harm - Minimal harm or potential for actual harm Review of the pharmacy recommendation Note to Attending Physician / Prescriber, dated 06/16/19, revealed the resident was currently receiving Xanax 0.125 mg. in the morning and 25 mg. at bedtime. The pharmacy recommendation was to decrease the dosage of Xanax . On 07/03/19, the physician agreed with the recommendation to decrease the dose of Xanax. He wrote to decrease Xanax to 0.125 mg. twice a day. Residents Affected - Few Review of the Medication Administration Record (MAR), dated 07/2019, revealed the resident has received Xanax 0.125 mg. everyday at 9:00 A.M. and Xanax .25 mg everyday at 8:00 P.M. The MAR, 08/2019, revealed the resident had received Xanax 0.125 mg everyday at 9:00 A.M. and Xanax .25 mg everyday at 8:00 P.M. from 08/01/19 through 08/19/19. Review of the August 2019 monthly summary physician orders revealed an order for Xanax (anti-anxiety) 0.125 mg. in the morning and Xanax 0.25 mg. at bedtime with a start date of 12/21/18 for general anxiety. On 08/20/19 at 2:45 P.M., an interview with the Director of Nursing verified the Xanax dosage was not decreased as ordered by the physician on 07/03/19. 366002 Page 4 of 7 366002 08/22/2019 Crestline Rehabilitation and Nursing Center 327 West Main Street Crestline, OH 44827

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, observation and staff interview, the facility failed to have a specific diagnoses or documented condition for the use of an antipsychotic medication for a resident. This affected one (Resident #1) of six residents reviewed for unnecessary medications. The facility identified seven residents as receiving antipsychotic medication. The facility census was 25. Findings include: Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbances, delirium and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/08/19, revealed the resident had short and long term memory loss. No psychosis, rejection of care, behaviors or psychotic diagnoses were documented on the MDS. Review of the plan of care, dated 03/12/19, stated the resident used psychotropic medication Risperdal (antipsychotic) due to diagnosis of dementia/delirium. The interventions included monitoring, documenting and reporting adverse reactions of the medications. Monitor and record occurrence of target behavior symptoms, uncooperative or aggressiveness with care. Review of the August 2019 monthly physician orders revealed the resident was receiving Risperdal 0.5 milligrams (mg.) in A.M. and 0.25 mg. at bedtime related to unspecified dementia without behavioral disturbances and delirium due to known physiological condition. Review of the August 2019 Medication Administration Record revealed the resident was not having any behaviors. Observation of the Resident #1 on 08/19/19, 08/20/19 and 08/21/19 between 8:30 A.M. and 5:00 P.M. revealed the resident was non-verbal with her eyes closed most of the time expect during meals. Interview with Licensed Practical Nurse (LPN) #100 on 08/21/19 at 2:00 P.M. stated the resident does not have any behaviors that she was aware of. Interview with State Tested Nursing Assistant (STNA) #200 on 08/21/19 at 2:15 P.M. stated the resident does not have any behaviors or rejection of care. Interview with STNA #210 on 08/21/19 at 2:30 P.M. stated the resident does not have any behaviors or rejection of care. Interview with the Director of Nursing on 08/21/19 at 3:30 P.M. verified he did not know what the diagnosis or condition was which warranted the use of an antipsychotic for Resident #1. He did not know the physiological condition associated with the resident's diagnosis of delirium. 366002 Page 5 of 7 366002 08/22/2019 Crestline Rehabilitation and Nursing Center 327 West Main Street Crestline, OH 44827

F 0881 Implement a program that monitors antibiotic use. 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, facility policy review and staff interview, the facility failed to implement antibiotic stewardship protocols for Resident #1 and #24 receiving long term use of prophylactic antibiotics. This affected two (#1 and #24) of six residents reviewed for unnecessary medication. The facility census was 25. Residents Affected - Few Findings include: 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/08/19, revealed the resident has short and long term memory loss. Review of the plan of care, last revised on 06/07/19, stated Resident #1 has a history of frequent urinary tract infections with long term use of antibiotics. The goal was for the resident to be free of urinary tract infections. The interventions included giving the antibiotic as ordered to prevent urinary tract infections and monitor any change. Review of the monthly physician orders for August 2019 revealed an order for Macrodantin (antibiotic) 50 milligrams (mg.) one tablet daily for Vitamin B deficiency. The start date for the Macrodantin was 02/26/19 with no stop date. Interview with the Director of Nursing (DON) verified on 08/21/19 at 2:30 P.M. the Macrodantin was being used as a prophylaxis to prevent urinary tract infection. Interview with the Medical Director #175 on 08/21/19 at 3:00 P.M. stated he does not like to use prophylaxis antibiotics. He stated he would rather use probiotics and cranberry juice for the prevention of urinary tract infections. He verified Macrodantin was not used for Vitamin B deficiency. Interview with DON on 08/21/19 at 3:30 P.M. stated the pharmacy reviews all of the resident's medications and makes recommendations to the physician to discontinue or decrease the dose of medication. He verified there was no recommendations from the pharmacist to the doctor concerning the use of the prophylactic antibiotic for Resident #1. He verified there was no documentation regarding the long term use of Macrodantin as a prophylactic antibiotic for Resident #1. 2. Record review for Resident #24 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/09/19, revealed the resident has short and long term memory deficits. She does not have any genitourinary diagnoses or infections documented in Section I of the MDS. The MDS stated she was received antibiotics three days of the seven day assessment period. Review of the plan of care, last revision date 02/14/19, stated the resident was incontinent of bladder due to immobility, cerebral vascular accident, and history of a urinary tract infection. The interventions included to provide perineum care after each incontinence episode and check and change the resident frequently. Review of the laboratory results found in the medical record revealed no laboratory results indicating the resident has had a urinary tract infection in the past year. 366002 Page 6 of 7 366002 08/22/2019 Crestline Rehabilitation and Nursing Center 327 West Main Street Crestline, OH 44827

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the August 2019 monthly physicians orders revealed an order for Bactrim (antibiotic) 400-80 mg. one tablet every Monday, Wednesday and Friday for a history of urinary tract infections. The start date for the Bactrim was 03/22/19 with no end date. Interview with the Director of Nursing on 08/21/19 at 3:15 P.M. stated the pharmacist had reviewed the use of the prophylactic antibiotic with him but did not want to request the antibiotic be discontinued because of the resident's age. He verified there was no documentation regarding the continued use of the long term antibiotic for the resident. He verified the facility policy for antibiotic stewardship does not address the long term use of antibiotics for prophylaxis. Review of the facility's policy titled Antibiotic Stewardship, last revised 12/2016, revealed the policy did not address the use of long term prophylactic antibiotic use. 366002 Page 7 of 7