Health inspection·February 27, 2020

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, review of Resident Council meeting minutes, staff interview, resident interview, and a resident group interview, the facility failed to address resident concerns regarding call lights being turned off by staff and needs not being met. This affected thirteen residents (#2, #5, #12, #21, #22 #26, #31, #33, #34, #47, #50, #57, and #60) who attended Resident Council during the months of December 2019, January 2020, and February 2020 and one resident (#23) whose light was turned off twice without care. This had the potential to affect all 59 residents in the facility. Findings include: Review of Resident Council minutes from 12/20/19, 01/17/20, and 02/19/20 revealed residents had a concern of call lights being turned off and staff not coming back. Thirteen residents (#2, #5, #12, #21, #22 #26, #31, #33, #34, #47, #50, #57, and #60) were in attendance over the three months. Observation on 02/24/20 at 8:58 A.M. revealed Resident #23's call light was activated. State Tested Nurse Aide (STNA) #400 was observed to exit the resident's room and the call light was turned off. Interview on 02/24/20 at 9:14 A.M. to 9:22 A.M. with Resident #23 revealed staff do not answer call lights quickly and will turn off the call light without providing care. Resident #23 verified he pressed his call light, staff came in, stated they were busy, and would return. Resident #23 verified staff had not returned. Observation on 02/24/20 at 9:22 A.M. revealed Resident #23 initiated the call light again. STNA #401 entered the room, turned off the call light, and stated she was finishing up with another resident, and would return. Observation at 02/24/20 at 9:43 A.M. revealed STNA #401 entered Resident #23's room and shut the door to provide care. Resident waited from 8:58 A.M. to 9:43 A.M. to receive personal care and the call light was turned off twice during this timeframe. On 02/25/20 at 10:30 A.M. in a group interview with seven current residents (#5, #12, #21, #22, #47, #57, #60) revealed the residents have reported staff for turning call lights off and not returning to assist with resident concerns. They stated this had been reported at the December 2019, January 2020, and February 2020 Resident Council meetings and no resolution has occurred. Interview on 02/26/20 at 2:06 PM with Activities Director #403 verified residents' concern regarding call lights being turned off without care continues to be remain unresolved. Page 1 of 7 366060 366060 02/27/2020 Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617

F 0585 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Quality Assistance Procedure, dated July 2018, verified the facility will consider the views of a resident or family group and act upon the assistance request and recommendations of such groups concerning issues of resident care and life in the facility. Residents Affected - Some 366060 Page 2 of 7 366060 02/27/2020 Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, medical record review, review of list of supervised smoking residents, staff interview, and review facility policy, the facility failed to ensure residents who required supervision with smoking were not in possession of cigarettes and lighters. This affected one (#23) of one residents reviewed for smoking at the facility. The census was 59. Findings include: Review of Resident #23's medical record revealed an admission date of 04/23/19. Diagnoses included encephalopathy, hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side, antisocial personality disorder, major depressive disorder, schizoaffective disorder bipolar type, hypertension, hyperlipidemia, heart failure, and diabetes type 2. Review of the last Minimum Data Set (MDS) assessment, dated 01/02/20, revealed Resident #23 was cognitively intact. Review of the care plan revealed Resident #23 was a supervised smoker. Review of list of residents who smoke provided by the facility revealed Resident #23 was a supervised smoking resident. Interview on 02/24/20 at 10:08 A.M. with Resident #23 revealed the resident maintains cigarettes and lighter in his personal possession. Observation on 02/24/20 at 10:19 A.M. revealed Resident #23 to be in possession of cigarettes and a lighter without supervision. Interview on 02/24/20 at 10:19 A.M. with Licensed Practical Nurse (LPN) # 402 verified Resident #23 was a supervised smoker. LPN #402 did not know if Resident #23 possessed cigarettes and lighter or not. Review of facility policy titled Smoking Policy, dated July 2017, verified residents with smoking privileges shall not be permitted to retain types of smoking articles, to include lighter, matches, etc. either on his or her person or within his/her living or sleep area. 366060 Page 3 of 7 366060 02/27/2020 Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, review of a daily medication refrigerator temperature log, and review of manufacturers' storage recommendations, the facility failed to store medication requiring refrigeration at the proper temperature in accordance with manufacturer recommendations. This had the potential to affect seven residents (#10, #17, #33, #47, #48, #50, and #61) identified by the facility as having orders for medications being stored in the refrigerator. The census was 59. Findings include: Observation on 02/27/20 at 9:42 A.M., revealed the medication refrigerator located in the Subacute East Unit medication room had an internal temperature of 30 degrees Fahrenheit (F). Resident medication found to be stored in the refrigerator included six unopened Humalog insulin pens, three unopened Lantus insulin pens, 10 unopened Novolog insulin pens, two unopened Basaglar insulin pens, three unopened Levemier insulin pens, and an unopened vial of Novolog insulin. Review of February 2020 daily medication refrigerator temperatures located in the Subacute East Unit medication room revealed an internal temperature of 28 degrees F on 02/02/20, 02/04/20, 02/06/20 through 02/09/20, 02/15/20, 02/23/20, and 02/24/20; an internal temperature of 30 degrees F on 02/01/20, 02/03/20, 02/05/20, 02/16/20 through 02/18/20, 02/20/20, 02/22/20, 02/25/20, and 02/26/20; an internal temperature of 31 degrees F on 02/11/20 and 02/14/20; an internal temperature of 32 degrees F on 02/12/20 and 02/13/20; and an internal temperature of 34 degrees F on 02/21/20. Review of the manufacturer's recommendations, dated 2015, for storage of unused Basaglar insulin revealed not in-use (unopened) pens should be refrigerated at a temperature between 36 degrees F and 46 degrees F. Review of the manufacturer's recommendations, dated 2007, for storage of Humalog insulin pens revealed unopened Humalog should be stored in a refrigerator between 36 degrees F and 46 degrees F, but not in the freezer. Review of the manufacturer's recommendations, dated 2007, for storage of Lantus insulin pens revealed unopened Lantus should be stored in a refrigerator between 36 degrees F and 46 degrees F. Review of the manufacturer's recommendations, dated 2005, for storage of Levemier insulin revealed unused insulin should be stored between 36 degrees F and 46 degrees F. Review of the manufacturer's recommendations, dated February 2015, for storage of Novolog insulin revealed unused insulin should be stored in a refrigerator between 36 degrees F and 46 degrees F. Interview on 02/27/20 at 9:48 A.M. at Licensed Practical Nurse (LPN) #594 verified the refrigerated medications were stored at temperatures below the manufacturers' recommendations. LPN #594 also stated it was the third shift nurses' responsibility to check and record the temperature, and verified the documentation on the February 2020 refrigerator log revealed multiple entries below 36 degrees F. The facility identified seven residents (#10, #17, #33, #47, #48, #50, and #61) with physician 366060 Page 4 of 7 366060 02/27/2020 Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617

F 0761 orders for medications being stored in the Subacute East Unit medication refrigerator. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 366060 Page 5 of 7 366060 02/27/2020 Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617

F 0772 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. **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 obtain laboratory tests as ordered by the physician and at the appropriate times to monitor therapuetic drug levels for one (#48) of one resident reviewed for intravenous antibiotic therapy. The facility census was 59. Findings include; Review of the medical record revealed Resident #48 admitted to the facility on [DATE]. Diagnoses included type 1 diabetes mellitus, vascular dementia with behavioral disturbance, benign prostatic hyperplasia, epilepsy, major depression, peripheral vascular disease, hypertension, atrial fibrillation, osteomyelitis, acute kidney failure, and history of transient cerebral attack. Review of the physician orders dated 02/04/20 revealed an order for the antibiotic Vancomycin 1250 milligrams (mg) to be administered intravenously (IV) every day shift for osteomylitis with the pharmacy to dose. Review of the February 2020 Medication Administration Record (MAR) revealed a physician order dated 02/12/20 for the pharmacy to dose a trough level for Vancomycin in the morning. This was signed off as being completed daily. The Vancomycin was documented as administered at 9:00 A.M. daily. Review of laboratory blood testing noted a Vancomycin trough level obtained on 02/13/20 at 6:33 A.M. There was no evidence of any further Vancomycin trough level obtained until 02/16/20 at 8:40 A.M. The next trough level was not obtained until 02/20/20 at 8:20 A.M. No further trough levels were in the record. Interview on 02/25/20 at 2:30 P.M. with Registered Nurse (RN) #300 revealed the laboratory had just obtained a trough. Review of the laboratory tests revealed on 02/25/20 at 4:00 P.M. a trough level was recorded in the medical record drawn at 2:00 P.M. Review of the facility policy titled Therapeutic Drug Monitoring, dated 11/01/19, revealed a Vancomycin trough draw should be drawn 15-30 minutes prior to the next dose or with the morning pick ups if the if the antibiotic was administered between 7:00 A.M. and 12:00 P.M. Interview with the Administrator on 02/26/20 at 12:55 P.M. verified the Vancomycin trough level's are drawn 15-30 minutes prior to the next dose or with the morning pick ups if the if the antibiotic was administered between 7:00 A.M. and 12:00 P.M. 366060 Page 6 of 7 366060 02/27/2020 Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, and staff interview, the facility failed to wear clean gloves during medication administration for one (#45) resident. This had the potential to affect all 59 residents in the facility. Residents Affected - Few Findings include: Review of Resident #45's medical record revealed an admission date of 12/31/19. Diagnoses included dysthymic disorder, chronic diastolic heart failure, obstructive sleep apnea, type 2 diabetes mellitus without complications, hypertension, major depressive disorder, hyperlipidemia, chronic kidney disease, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment, dated 01/08/20, revealed the resident was cognitively intact. Observation on 02/24/20 at 11:20 A.M. revealed Licensed Practical Nurse (LPN) #402 entered Resident #45's room for medication administration, which included an injection. LPN #402 dropped one disposable glove on the resident's floor, picked up the glove off the floor, and put it on. LPN #402 then administered medication, including an injection. Interview on 02/24/20 at 11:22 A.M. with LPN #402 verified the disposable of glove was dropped on the resident's floor and was worn during medication administration. 366060 Page 7 of 7