Health inspection·January 23, 2020

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, chronic pain, chronic kidney disease, bipolar disorder, atherosclerotic heart disease, atrial fibrillation, depression and congestive heart failure. Review of the MDS assessment, dated 12/19/19, revealed the resident was alert and oriented to person, place, and time and had minimal cognitive impairments. Residents Affected - Few Review of the facility's Self-Reported Incidents (SRI) from 10/01/19 through 01/21/20 revealed there were no SRIs filed involving Resident #8 and/or involving State Tested Nurses Aide (STNA) #408. Interview with Resident #8 on 01/21/20 at 2:34 P.M. revealed the resident had complaints of STNA #408 on night shift being rough, she cuts his conversation short and she gets rude. The resident feels she was disrespectful. She was very mean and will not respond to call lights. He requested he doesn't want her to be his STNA anymore . The resident stated that he told one of the nurses. The aide put him in chair and strapped in him too tight and it went around his private and it was very painful. Subsequent interview with Resident #8 on 01/23/20 at 10:20 A.M. revealed the STNA has been extremely rude and rough with him during care. The resident stated that he reported it to one of the aides on dayshift, and that he did not hear anything else about it after that. Interview with STNA #400 on 01/21/20 at 4:44 P.M. revealed she was hired on 10/04/19. She stated she has had residents complain about STNA #408 being rough and mean to them on three separate occasions and that she reported it to the nurse on first shift or third shift depending on when the resident informed her that STNA #408 was too rough during care. Interview with STNA #438 on 01/21/20 at 4:48 P.M. stated some residents have complained to her about an STNA being too rough when providing care. She stated the residents complain about STNA #408 and she had reported it several times. STNA #438 stated several residents have complained about it and she has reported it several times to various nurses (could not remember who it was reported it to) had complaints about an STNA being too rough. STNA #438 stated that she was not aware of the facility conducting an investigation of the situation after she reported it. STNA #438 states STNA #408 works night shift and she works day shift and the resident's complain every time she works and follows that STNA and she reports it each time. STNA #438 stated one resident stated that STNA #408 would not provide her any care and stated the STNA was too rough and the other residents frequently complain the STNA was too rough during care. Interview with STNA #426 on 01/22/20 at 1:52 P.M. revealed she has been employed for two months and she has had a few residents complain about STNA #408 being rude and rough on night shift. STNA #426 stated she reported the incidents to LPN #412 about a week ago. STNA #426 further stated Resident Page 1 of 11 366038 366038 01/23/2020 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

F 0607 #8 and Resident #187 complain about STNA #408 being mean and rough the most. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Abuse Prohibition Policy, dated 04/2019, revealed staff should report any incident or suspicion of mistreatment, neglect and abuse immediately to the Administrator and the Director of Nursing. The Administrator or designee will report to the Ohio Department of Health and required authorities per state and federal regulation. Staff should protect each resident in such a way that any reports should be provided to the direct supervisor. Residents Affected - Few Based on record review, resident and staff interviews, review of the facility's Self-Reported Incidents and review of the facility's policy, the facility failed to follow their abuse policy by not reporting resident allegations of physical abuse to administration and to the State Survey Agency, the Ohio Department of Health. This affected two of two residents reviewed for abuse (Resident #8 and #187). The facility census was 36. Findings include: 1. Review of Resident #187's medical record revealed an admission date of 01/06/20 with diagnoses including chronic kidney disease (stage three), history of transient ischemic attacks and cerebral infarction (strokes), epilepsy (seizure disorder) and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 01/15/20, revealed the resident was cognitively intact. Review of the facility's Self-Reported Incidents (SRI) from 10/01/19 through 01/21/20 revealed there were no SRIs filed involving Resident #187 and/or involving State Tested Nurses Aide (STNA) #408. Interview with Resident #187 on 01/21/20 at 2:44 P.M. revealed the resident stated STNA #408 was rough with care. She stated STNA #408 would stand behind the wheelchair when transferring her into the chair and grab her by the back of her pants and move her over and it was too rough. She stated her left side was weak from the stroke and she typically needed support under her left arm during transfers and STNA #408 would not assist her. Resident #187 stated that STNA #408 had a harsh tone and mean attitude toward her and she had previously told other STNAs and nurses she no longer wanted STNA #408 to take care of her. Interview with STNA #400 on 01/21/20 at 4:44 P.M. confirmed Resident #187 had complained about STNA #408 being rough and mean to her. STNA #400 stated she had been notified of rough care provided by STNA #408 by several residents and she had reported it to the nurse on three separate occasions. STNA #400 was unable to provide the names of the nurses she had reported it to. Interview with STNA #438 on 01/21/20 at 4:48 P.M. verified the residents have complained to her about STNA #408 being too rough when providing care and she had reported it several times to the nurses. STNA #438 stated several residents have complained about it and she had reported it several times to various nurses (could not remember who it was reported it to). STNA #438 stated STNA #408 worked night shift and she worked day shift and each time she followed STNA #408, residents had complained STNA #408 was too rough with care and was mean. STNA also stated Resident #187 complained STNA #408 would refuse to give her care and the resident had to ask for assistance from the STNA that was assigned to the other hallway. Interview with STNA #426 on 01/22/20 at 1:52 P.M. revealed she had heard a few residents complain about STNA #408 being rude and rough on night shift. STNA #426 stated she reported the incidents to Licensed Practical Nurse (LPN) #412 about a week ago. STNA #426 further stated Resident #8 and 366038 Page 2 of 11 366038 01/23/2020 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

F 0607 Resident #187 complained about STNA #408 being mean and rough. Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator and Director of Nursing (DON) on 01/23/20 at 10:21 A.M. revealed no knowledge of the resident's complaints regarding STNA #438 and there were no previous incidents regarding STNA #438 filed. Residents Affected - Few Interview with the [NAME] President of Operations #442 on 01/23/20 at 10:45 A.M. revealed allegations of mistreatment and mean were handled as incidents of abuse and would require that any staff member report allegations or incidents to the DON or Administrator immediately. 366038 Page 3 of 11 366038 01/23/2020 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, chronic pain, chronic kidney disease, bipolar disorder, atherosclerotic heart disease, atrial fibrillation, depression and congestive heart failure. Review of the MDS assessment, dated 12/19/19, revealed the resident was alert and oriented to person, place, and time and had minimal cognitive impairments. Review of the facility's Self-Reported Incidents (SRI) from 10/01/19 through 01/21/20 revealed there were no SRIs filed involving Resident #8 and/or involving State Tested Nurses Aide (STNA) #408. Interview with Resident #8 on 01/21/20 at 2:34 P.M. revealed the resident had complaints of STNA #408 on night shift being rough, she cuts his conversation short and she gets rude. The resident feels she was disrespectful. She was very mean and will not respond to call lights. He requested he doesn't want her to be his STNA anymore . The resident stated that he told one of the nurses. The aide put him in chair and strapped in him too tight and it went around his private and it was very painful. Subsequent interview with Resident #8 on 01/23/20 at 10:20 A.M. revealed the STNA has been extremely rude and rough with him during care. The resident stated that he reported it to one of the aides on dayshift, and that he did not hear anything else about it after that. Interview with STNA #400 on 01/21/20 at 4:44 P.M. revealed she was hired on 10/04/19. She stated she has had residents complain about STNA #408 being rough and mean to them on three separate occasions and that she reported it to the nurse on first shift or third shift depending on when the resident informed her that STNA #408 was too rough during care. Interview with STNA #438 on 01/21/20 at 4:48 P.M. stated some residents have complained to her about an STNA being too rough when providing care. She stated the residents complain about STNA #408 and she had reported it several times. STNA #438 stated several residents have complained about it and she has reported it several times to various nurses (could not remember who it was reported it to) had complaints about an STNA being too rough. STNA #438 stated that she was not aware of the facility conducting an investigation of the situation after she reported it. STNA #438 states STNA #408 works night shift and she works day shift and the resident's complain every time she works and follows that STNA and she reports it each time. STNA #438 stated that one resident stated that STNA #408 would not provide her any care and stated the STNA was too rough and the other residents frequently complain the STNA was too rough during care. Interview with STNA #426 on 01/22/20 at 1:52 P.M. revealed she has been employed for two months and she has had a few residents complain about STNA #408 being rude and rough on night shift. STNA #426 stated she reported the incidents to LPN #412 about a week ago. STNA #426 further stated Resident #8 and Resident #187 complain about STNA #408 being mean and rough the most. Review of the facility's Abuse Prohibition Policy, dated 04/2019, revealed staff should report any incident or suspicion of mistreatment, neglect and abuse immediately to the Administrator and the Director of Nursing. The Administrator or designee will report to the Ohio Department of Health and required authorities per state and federal regulation. Staff should protect each resident in such a way that any reports should be provided to the direct supervisor. 366038 Page 4 of 11 366038 01/23/2020 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

F 0609 Level of Harm - Minimal harm or potential for actual harm Based on record review, resident and staff interviews, review of the facility's Self-Reported Incidents and review of the facility's policy, the facility failed to timely report the resident's allegations of physical abuse to administration and to the State Survey Agency, the Ohio Department of Health. This affected two of two residents reviewed for abuse (Resident #8 and #187). The facility census was 36. Residents Affected - Few Findings include: 1. Review of Resident #187's medical record revealed an admission date of 01/06/20 with diagnoses including chronic kidney disease (stage three), history of transient ischemic attacks and cerebral infarction (strokes), epilepsy (seizure disorder) and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 01/15/20, revealed the resident was cognitively intact. The resident required the extensive assistance of two people for bed mobility, transfer, dressing, toileting and hygiene needs and the resident did not have any behaviors of rejecting care. Review of the facility's Self-Reported Incidents (SRI) from 10/01/19 through 01/21/20 revealed there were no SRIs filed involving Resident #187 and/or involving State Tested Nurses Aide (STNA) #408. Interview with Resident #187 on 01/21/20 at 2:44 P.M. revealed the resident stated STNA #408 was rough with care. She stated STNA #408 would stand behind the wheelchair when transferring her into the chair and grab her by the back of her pants and move her over and it was too rough. She stated her left side was weak from the stroke and she typically needed support under her left arm during transfers and STNA #408 would not assist her. Resident #187 stated that STNA #408 had a harsh tone and mean attitude toward her and she had previously told other STNAs and nurses she no longer wanted STNA #408 to take care of her. Interview with STNA #400 on 01/21/20 at 4:44 P.M. confirmed Resident #187 had complained about STNA #408 being rough and mean to her. STNA #400 stated she had been notified of rough care provided by STNA #408 by several residents and she had reported it to the nurse on three separate occasions. STNA #400 was unable to provide the names of the nurses she had reported it to. Interview with STNA #438 on 01/21/20 at 4:48 P.M. verified the residents have complained to her about STNA #408 being too rough when providing care and she had reported it several times to the nurses. STNA #438 stated several residents have complained about it and she had reported it several times to various nurses (could not remember who it was reported it to). STNA #438 stated STNA #408 worked night shift and she worked day shift and each time she followed STNA #408, residents had complained STNA #408 was too rough with care and was mean. STNA also stated Resident #187 complained STNA #408 would refuse to give her care and the resident had to ask for assistance from the STNA that was assigned to the other hallway. Interview with STNA #426 on 01/22/20 at 1:52 P.M. revealed she had heard a few residents complain about STNA #408 being rude and rough on night shift. STNA #426 stated she reported the incidents to Licensed Practical Nurse (LPN) #412 about a week ago. STNA #426 further stated Resident #8 and Resident #187 complained about STNA #408 being mean and rough. Interview with the Administrator and Director of Nursing (DON) on 01/23/20 at 10:21 A.M. revealed no knowledge of resident complaints regarding STNA #438 and there were no previous incidents 366038 Page 5 of 11 366038 01/23/2020 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few regarding STNA #438 filed. The Administrator and DON stated they did not have a disciplinary record available for review of STNA #438 and there was not a 90 day evaluation available for review of STNA #438. The Administrator stated she would suspend STNA #438 immediately while conducting the investigation and submit a self-reporting incident immediately. Interview with the [NAME] President of Operations #442 on 01/23/20 at 10:45 A.M. revealed allegations of mistreatment and mean were handled as incidents of abuse and would require that any staff member report allegations or incidents to the DON or Administrator immediately. 366038 Page 6 of 11 366038 01/23/2020 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify a resident in writing of the reason for a transfer and send a copy to the Office of the State Long-Term Care Ombudsman. This affected one (Resident #14) of two residents reviewed for hospitalization. The facility census was 36. Findings include: Record review of Resident #14 revealed an admission date of 07/25/17. Diagnoses included heart failure and artery disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/24/19, revealed the resident was cognitively intact. Review of a progress note, dated 12/13/19 at 5:53 P.M., revealed Resident #14 was having wheezing and shortness of breath and resident was sent to the hospital. Resident #14 was transferred to the hospital on [DATE] with an admitting diagnosis of urinary tract infection and dehydration. There was no evidence of a written reason for transfer sheet given to the resident or the Office of the State Long-Term Care Ombudsman was notified of the transfer. Interview with [NAME] President of Operations #200 on 01/23/20 at 1:08 P.M. verified the facility did not give Resident #14 a written reason for transfer sheet or notify the Office of the State Long-Term Care Ombudsman of the transfer to the hospital on [DATE]. 366038 Page 7 of 11 366038 01/23/2020 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify a resident in writing of the remaining bed hold days at the time of transfer to the hospital. This affected one (Resident #14) of two resident reviewed for hospitalization. The facility census was 36. Findings include: Record review of Resident #14 revealed an admission date of 07/25/17. Diagnoses included heart failure and artery disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/24/19, revealed the resident was cognitively intact. Review of a progress note, dated 12/13/19 at 5:53 P.M., revealed Resident #14 was having wheezing and shortness of breath and resident was sent to the hospital. Resident #14 was transferred to the hospital on [DATE] with an admitting diagnosis of urinary tract infection and dehydration. There was no evidence of a written number of bed hold days remaining being given to Resident #14. Interview with [NAME] President of Operations #200 on 01/23/20 at 1:08 P.M. verified the facility did not give Resident #14 written information on the number of bed hold days remaining when she was discharged on 12/13/19. 366038 Page 8 of 11 366038 01/23/2020 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on record review, resident and staff interviews and review of the facility's policy, the facility failed to provide showers/baths on scheduled shower days to Resident #187. This affected one (#187) of two residents reviewed for activity of daily living (ADL) assistance. The facility identified 35 residents who require assistance from staff for bathing. The facility census was 36. Residents Affected - Few Findings include: Review of Resident #187's medical record revealed an admission date of 01/06/20. Diagnoses included chronic kidney disease (stage three), history of transient ischemic attacks and cerebral infarction (strokes), epilepsy (seizure disorder), acute pulmonary edema,and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 01/15/20, revealed the resident was cognitively intact The MDS further revealed the resident required the extensive assistance of two people for dressing and hygiene needs. The resident did not have a behavior of rejecting care. Review of the facility's shower schedule revealed Resident #187 was to receive showers on Tuesday and Friday. Review of Resident #187's shower sheets, from 01/06/20 through 01/21/20, revealed only three shower sheets were available for review. This was out of the five scheduled shower opportunities per the shower schedule . The shower sheet, dated 01/07/20, revealed the resident refused a shower and was not signed by the State Tested Nurses Aid (STNA) or nurse. The shower sheet, dated 01/17/20, revealed the resident received a shower and was signed by the STNA and Registered Nurse (RN). The shower sheet, dated 01/21/20, revealed the resident refused a shower and was not signed by the STNA but the Licensed Practical Nurse (LPN) signed the shower sheet. There wasn't any other shower sheets to show the resident was offered a shower on other days then her scheduled shower days. Interview with Resident #187 on 01/21/20 at 2:44 P.M. revealed the resident stated she had only had one shower since her admission date on 01/06/20 and that she had not been offered any other showers. Resident #187 stated she had to ask several times when her shower days were and she was just told they were scheduled for Tuesdays and Fridays. Resident #187 stated she had been told on different occasions there was not enough STNAs working to provide her with a shower. Interview with the Director of Nursing on 01/23/20 at 3:00 P.M. confirmed the facility only had three of the five shower sheets for Resident #187 and verified refused was noted on the 01/21/20 shower sheet. The DON verified there were no other shower sheets to show the staff offered her a shower on other days of the week. Subsequent interview with Resident #187 on 01/23/20 at 3:15 P.M. revealed the resident stated she did not refuse a shower on 01/21/20 and she was not offered a shower that day. Resident #187 stated again she had only received one shower since her admission date and it was several days ago. Review of the facility's policy titled Quality of Life- Resident Self Determination and Participation, dated December 2016, revealed each resident is allowed to choose schedules that are consistent with his or her interest including daily routine such as sleeping and walking, eating, exercise, bathing schedules, personal care needs (bathing, grooming styles, and dress). 366038 Page 9 of 11 366038 01/23/2020 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

F 0677 Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy titled Resident Rights revealed the resident had the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that comprise necessity and appropriate care consistent with the program for which the resident contracted. Residents Affected - Few 366038 Page 10 of 11 366038 01/23/2020 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

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. Based on record review, staff interview and review of the drug label, the facility failed to ensure a proper diagnoses for the use of a psychotropic medication and failed to document behavior monitoring in relation to the use of a psychoactive medication use in Resident #3. This affected one (#3) of five residents reviewed for unnecessary medications. The facility identified all 36 residents were on psychoactive medications. The facility census was 36. Findings include: Review of Resident #3's medical record revealed an admission date of 12/31/19. Diagnoses included Parkinson's Disease, dementia without behavioral disturbance and seizures. Review of the Minimum Data Set assessment, dated 01/07/20, revealed the resident was severely cognitively impaired. Review of the physician orders revealed an order, undated, to administer Seroquel 25 milligrams (mg.) by mouth two times a day for the diagnoses of Parkinson's Dementia. (Seroquel is an antipsychotic medication used to treat mental and mood conditions). Review of the nursing progress notes, dated 01/20/20 at 3:54 P.M., revealed a new order was received to begin Seroquel 25 mg. by mouth two times a day for Parkinson's dementia and a progress note dated 01/21/20 revealed the resident received the first dose of Seroquel 25 mg by mouth at bedtime. Review of the Medication Administration Record (MAR), dated January 2020, revealed the resident was administered Seroquel 25 mg. for Parkinson's Dementia one time on 01/20/20, two times on 01/21/20, and two times on 01/22/20. Review of the care plan, dated 01/21/20, revealed the resident had potential for adverse side effects of psychotropic medication use and interventions to monitor/record any abnormal behavior/moods and to notify the physician. Review of the behavior monitoring log, dated January 2020, revealed the resident had no behaviors monitored as the forms were blank. Interview with the Director of Nursing (DON) on 01/22/20 at 6:10 P.M. revealed the facility had not been completing behavior logs or documenting behaviors on Resident #3. Subsequent interview with the DON on 01/23/20 at 10:06 A.M. confirmed Parkinson's Dementia was not an approved diagnosis for the use of Seroquel. Review of the Federal Drug Administration drug label for Seroquel, dated 1997, revealed a warning that use of the medication in elderly patients with dementia-related psychosis placed the patient at an increased level of risk for death and Seroquel was not approved for elderly patients with dementia-related psychosis. The drug label further revealed the medication is an atypical antipsychotic indicated for the treatment of schizophrenia and bipolar disorder manic and depressive episodes. 366038 Page 11 of 11