Health inspection·October 24, 2019

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #57 was assessed quarterly for the use of alarming devices. This affected one (Resident #57) of six residents reviewed for restraints. Residents Affected - Few Findings include: Resident #57 was admitted on [DATE] with diagnoses including hydrocephalus, epilepsy, anxiety disorder, unspecified dementia with behavioral disturbance, lack of coordination, and a history of traumatic brain injury. Resident #57's physician orders dated 12/29/16 revealed he was ordered a personal alarm while in bed to alert staff of transfers and on 04/11/18 he was ordered a motion sensor alarm to alert staff of unassisted transfers. Resident #57's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had short and long term memory problems. The Restraint section of the MDS indicated a bed alarm and motion sensor alarm were used daily. Review of Resident #57's medical record revealed no evidence the resident was assessed quarterly for the use of a motion alarm or personal alarm. Observation on 10/22/19 at 3:55 P.M. revealed Resident #57 was lying in a low positioned bed, with a personal alarm clipped to his shirt and a motion sensor alarm on a floor mat next to his bed. Interview on 10/23/19 at 9:49 A.M. with the Assistant Director of Nursing (ADON) revealed the facility assessed residents for alarm use quarterly. Interview on 10/23/19 at 10:06 A.M. with the ADON revealed residents were assessed to determine need for a reduction or discontinuation of alarms. The ADON confirmed there was no evidence Resident #57 had been assessed quarterly for the use of the personal or motion sensor alarms. Review of the facility policy, titled Restraint Use, dated 06/20/15, revealed the facility creates and maintains an environment that fosters minimal use of restraints. The interdisciplinary team regularly evaluates restraint reduction for each resident and a restraint assessment shall be used for initial and ongoing assessments. Page 1 of 4 366024 366024 10/24/2019 Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654

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** Based on medical record review and staff interview the facility failed to ensure comprehensive assessments were accurate regarding prognosis for Resident #56 and falls for Resident #57. This affected two (Residents #56 and #57) of 26 reviewed for plans of care. The facility census was 108. Residents Affected - Few Finding include: 1. Resident #56 was admitted to the facility on [DATE] with diagnoses including dementia, acute embolism and thrombosis, diabetes, hypokalemia, hypertension, dysphagia, right bundle block, hyperlipidemia, absence of kidney, Alzheimer's disease, syncope and collapse, cataract, insomnia, anxiety disorder, major depressive disorder, macular degeneration, acute myocardial infarction, and intervertebral disc degeneration. Review of the October 2019 Physicians orders revealed Resident #56 had an order dated 12/07/18 to be discharged from hospice services due to a prognosis of greater than six months. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 03/16/19 revealed Resident #56 had a life expectancy of less than six months. Review of the quarterly MDS 3.0 dated 05/16/19 revealed Resident #56 had a life expectancy of less than six months. Review of the quarterly MDS 3.0 dated 08/16/19 revealed Resident #56 had a life expectancy of less than six months. On 10/24/19 at 9:01 A.M. Licensed Practical Nurse (LPN) #213 verified section J of the MDS assessments dated 03/16/19, 05/18/19 and 08/18/19 were coded incorrectly to indicate the resident had a prognosis of less than six months. 2. Resident #57 was admitted on [DATE] with diagnoses including hydrocephalus, epilepsy, anxiety disorder, unspecified dementia with behavioral disturbance, lack of coordination, and a history of traumatic brain injury. Resident #57's quarterly MDS assessment dated [DATE] revealed no falls were identified in his fall history since his last MDS dated [DATE]. Review of Resident #57's medical record from 05/22/19 through 08/22/19 revealed the resident had one fall on 07/30/19 that resulted in a small laceration and hematoma to his forehead. On 10/23/19 at 7:34 A.M. LPN #202 confirmed Resident #57's MDS dated [DATE] was inaccurately coded, and should have been coded one fall with an injury that was not major. 366024 Page 2 of 4 366024 10/24/2019 Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654

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** 2. Resident #56 was admitted to the facility on [DATE] with diagnoses of dementia, acute embolism and thrombosis, diabetes, hypokalemia, hypertension, dysphagia, right bundle block, hyperlipidemia, absence of kidney, Alzheimer's disease, syncope and collapse, cataract, insomnia, anxiety disorder, major depression disorder, macular degeneration, acute myocardial infarction, and intervertebral disc degeneration. Review of the plan of care dated 05/23/14 revealed no plan of care that addressed the use of a pommel cushion for Resident #56. Observation on 10/21/19 at 8:50 A.M., on 10/22/19 at 9:01 A.M., and on 10/23/19 at 10:07 A.M. revealed Resident #56 was seated in a tilt and space wheelchair with a permanently affixed pommel cushion. On 10/24/19 at 9:01 A.M. Licensed Practical Nurse #213 verified The lack of a care plan to address the use of a pommel cushion for Resident #56. Based on observation, record review, and interview the facility failed to ensure two residents (Residents #56 and #79) had care plans in place to address the use of positioning devices. This affected two of 25 residents reviewed for care plans. The facility census was 108. Findings include: 1. Resident #79 was admitted to the facility on [DATE] with diagnoses including vascular dementia, major depressive disorder, and inflammatory disease of the prostate. Review of Resident #79's care plans dated 01/02/19 did not reveal any care plan which addressed the use of a pommel cushion (a cushion used to prevent sliding or forward movement) only a care plan which stated Resident #79 slid down in his wheelchair with interventions for therapy to evaluate and treat. Review of Resident #79's Restraint-Enabler Decision Tree dated 09/12/19 revealed the pommel cushion did not restrict any movement, assisted in the improvement of Resident #79's functional status, and provided optimal positioning and safety while in the wheelchair. Observations of Resident #79 on 10/21/19 at 3:31 P.M., on 10/22/19 at 11:09 A.M., on 10/23/19 at 8:30 A.M. and 11:00 A.M., and on 10/24/19 at 8:00 A.M. revealed Resident #79 had a pommel cushion in place. Registered Nurse (RN) #104 verified on 10/21/19 at 3:31 P.M. Resident #79 had a pommel cushion to his wheel chair. On 10/24/19 at 8:27 A.M. RN #104 verified Resident #79's care plans did not address the use of a pommel cushion. 366024 Page 3 of 4 366024 10/24/2019 Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure CPAP (continuous positive airway pressure) equipment for Resident #81 was cleaned regularly to reduce the risk for infection. This affected one (Resident #81) of one resident reviewed for the use of a CPAP machine. The facility census was 108. Residents Affected - Few Findings include: Resident #81 was admitted on [DATE] with diagnoses including obstructive sleep apnea. Review of physician's orders dated 09/18/19 revealed she was to utilize a CPAP machine at 14 centimeters of water and to be set at two liters of oxygen during sleep. Interview on 10/21/19 at 2:37 P.M. with Resident #81 revealed she had asked the aides and nurses to clean her CPAP equipment regularly but she had never seen them clean it nor did they tell her they cleaned it. She cleaned it monthly with vinegar according to the manufacturer guidelines when she was at home. Resident #81 stated she could tell the mask had not even been wiped. Observation on 10/22/19 at 2:19 P.M. of Resident #81's CPAP machine and equipment revealed the hose was on the floor and the mask surface had smudges and small bits of debris on it. This was verified at the time of observation by Licensed Practical Nurse (LPN) #173. Interview on 10/22/19 at 2:21 P.M. with LPN #173 revealed CPAP equipment should be cleaned by staff and signed off on the (Treatment Administration Record TAR) after every use. LPN #173 verified staff were not cleaning the resident's CPAP equipment. Review of the policy dated 01/26/06 and revised on 09/14/18 regarding Respiratory Equipment Cleaning and Disinfecting revealed the facility must maintain respiratory equipment in a manner that would prevent the spread of disease and infections. For CPAP machines the external surfaces should be cleaned as needed, the mask cleaned weekly or as needed, the circuit and the filter should be changed per manufacturer's guidelines and the non-disposable filter changed monthly or as needed. 366024 Page 4 of 4