Health inspection·September 12, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, and interview, the facility failed to ensure timely physician notification of signs of a urinary tract infection for Resident #38. This affected one of 23 residents whose medical records were reviewed. Findings include: Review of Resident #38's medical record revealed diagnoses including diabetes mellitus and cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was able to make herself understood. Resident #38 was assessed as being alert, oriented and cognitively intact. Resident #38 was frequently incontinent of bowel and bladder and required extensive assistance from staff for toilet use. On 09/09/19 at 2:15 P.M., Resident #38 was observed approaching Licensed Practical Nurse (LPN) #672 stating she was urinating every half hour and that it hurt. LPN #672 stated she would have to tell somebody and would probably need to get a urine sample. Resident #38 stated she doubted it. Record review revealed no evidence of physician notification on 09/09/19. A nursing note dated 09/10/2019 at 11:14 A.M. written by LPN #639 revealed Resident #38 complained of pain and burning with urination. The note indicated an attempt was made to obtain a urine sample through a straight catheterization with a scant amount of discharge obtained. Resident #38's physician was notified and an order was received to start antibiotic treatment with Cefuroxime. On 09/12/19 at 11:52 A.M., LPN #672 was interviewed by phone. LPN #672 stated she reported Resident #38's symptoms to LPN #639 who followed-up on the health concern. LPN #672 verified she did not report Resident #38's symptoms to the physician on 09/09/19. On 09/12/19 at 12:00 P.M., LPN #639 stated LPN #672 reported Resident #38's symptoms to her the morning of 09/10/19. Resident #38 had a standing order to obtain a urine sample via clean catch or straight catheterization which she attempted to do but the attempt was unsuccessful. LPN #639 stated she contacted Resident #38's physicians regarding the signs of a urinary tract infection on 09/10/19. On 09/12/19 at 12:18 P.M., the Director of Nursing (DON) stated if residents complained of symptoms of a urinary tract infection, the physician should be notified the same day. Review of the facility's policy, Change in the Resident's Condition or Status, updated November 2016, revealed a significant change in condition was identified as a condition which would not normally Page 1 of 4 366027 366027 09/12/2019 Altercare of Hartville Ctr For 1420 Smith Kramer Road Hartville, OH 44632

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacted more than one area of the resident's health status and required interdisciplinary review and/or revision of the plan of care. Immediately was determined to be as soon as practicable after the resident had been adequately assessed, necessary emergent care or treatment was rendered and the resident's safety had been secured. The policy noted leaving an oral/telephone message with someone other than the physician, the on-call physician, or the medical director or sending a fax did not constitute notification. The nurses were to immediately notify the resident, consult with the resident's attending physician, on call physician, nurse practitioner, physician assistant or clinical nurse specialist and notify the resident's authorized representative or interested family member when there was a significant change in the resident's physical, mental or psychosocial status, a need to alter the resident's medical treatment significantly or commence a new form of treatment Review of the facility's Antibiotic Stewardship Program (not dated) revealed when staff suspected a resident had an infection, the nurse was to perform and document an assessment of the resident using the established and accepted Loeb assessment protocols to determine if the resident's status met minimum criteria for initiating antimicrobial's prior to calling the physician. When a nurse contacted a physician/prescriber to communicate a resident's change in condition due to a suspected infection, the medical record was reviewed and the nurse was responsible for communicating the results of the written resident Loeb assessment, description of the signs and symptoms, and onset of the signs and symptoms. 366027 Page 2 of 4 366027 09/12/2019 Altercare of Hartville Ctr For 1420 Smith Kramer Road Hartville, OH 44632

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure state tested nursing assistants (STNAs) received annual education regarding dementia and care of the cognitively impaired. This had the potential to affect 61 residents (Residents #1, #3, #4, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20, #22, #23, #24, #25, #27, #29, #30, #32, #33, #35, #36, #37, #38, #41, #42, #44, #48, #50, #51, #52, #54, #55, #56, #58, #59, #60, #61, #63, #64, #66, #67, #68, #69, #70, #71, #76, #77, #78, #81, #83, #89, #90, #291, #292, #293, #294, #295 and #296) of 84 residents who were assessed to be cognitively impaired or who had diagnoses of dementia or Alzheimer's disease. Findings include: On 09/12/19 at 9:30 A.M., the Administrator was interviewed regarding the facility's education/ ongoing training program. The Administrator stated the corporate office provided a list of training that was to be completed by staff on a monthly basis. Corporate staff then tracked who/what percentage of employees completed the training and provided a list to the facility. The Administrator stated all staff training had been completed. Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) manual revealed residents with a Brief Interview for Mental Status (BIMS) score of 8-12 were determined to be moderately cognitively impaired and residents with a score of 0-7 were determined to be severely cognitively impaired. Review of the facility's dementia training provided by the facility revealed training conducted between 07/01/18 and 09/10/19 had training opportunities related to for care of the cognitively impaired, handling aggressive behaviors, and providing high quality dementia care. On 09/12/19 at 11:09 A.M., the Administrator was informed the following resident aides and STNAs did not have evidence of dementia training since 07/01/18: STNA #602, STNA #623, STNA #611, STNA #608, STNA #620, STNA #647, Aide #675, and Aide #677. The Administrator stated it was up to her and the Human Resource department to ensure staff received the training identified as needed by the corporate office. The Administrator stated she would see what additional information she could find. On 09/12/19 at 2:20 P.M. the Administrator provided the following additional certificates of completion: STNA #602 had no evidence of training provided. STNA #623 had no evidence of training provided. STNA #611 had a certificate of completion for Interacting with Residents dated 01/30/15, a certificate of completion for Interacting with Residents dated 12/25/15, and a certificate of completion for Handling Aggressive Behaviors dated 03/29/16. STNA #608 had a certificate of completion for Care of the Cognitively Impaired dated 06/15/18. 366027 Page 3 of 4 366027 09/12/2019 Altercare of Hartville Ctr For 1420 Smith Kramer Road Hartville, OH 44632

F 0947 STNA #647 had a certificate of completion for Care of the Cognitively Impaired dated 02/28/17. Level of Harm - Minimal harm or potential for actual harm Aide #675 had no evidence of training provided. Residents Affected - Some Aide #677 had a certificate of completion for Alzheimer's/Dementia Managing Challenging Behaviors dated 03/29/13. STNA #620 had a certificate of completion for Care of the Cognitively Impaired dated 03/30/18. The Administrator verified all of the aids and STNAs did not have evidence of annual training regarding dementia and care of the cognitively impaired residents as required. Review of the Facility assessment dated [DATE] (and reviewed 10/31/18) revealed nursing assistants were to receive core training regarding dementia management training and care of the cognitively impaired. The facility identified 61 residents (Residents #1, #3, #4, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20, #22, #23, #24, #25, #27, #29, #30, #32, #33, #35, #36, #37, #38, #41, #42, #44, #48, #50, #51, #52, #54, #55, #56, #58, #59, #60, #61, #63, #64, #66, #67, #68, #69, #70, #71, #76, #77, #78, #81, #83, #89, #90, #291, #292, #293, #294, #295 and #296) of 84 residents who were assessed to be cognitively impaired or who had diagnoses of dementia or Alzheimer's disease. 366027 Page 4 of 4