Health inspection·May 17, 2021

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident, resident representative and staff interviews, and policy review, the facility failed to invite residents and their representatives to quarterly care plan conferences and did not hold quarterly care plan conferences. This affected three (#14, #16, and #91) of three residents reviewed for comprehensive care plan conferences. The facility census was 102. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/10/18. Diagnosis included dorsalgia, fibromyalgia, hyperlipidemia, polyosteoarthritis, essential (primary) hypertension, unspecified hearing loss, personal history of transient ischemic attack and cerebral infarction without residual deficits, unspecified displaced fracture of surgical neck of left humerus, hypo-osmolality and hyponatremia, unspecified dementia without behavioral disturbance, major depressive disorder recurrent, epileptic seizures related to external causes, and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 02/17/21, revealed the resident is severely cognitively impaired. Review of Resident #14 care conference notes revealed the last documented care conference was on 09/11/19. Interview on 05/10/21 at 3:30 PM., with Resident #14's resident representative revealed they had no knowledge of recent care plan conference invites or care conferences. Interview on 05/12/21 at 10:13 A.M., with Social Worker #400 verified Resident #14's last care conference was on 09/11/19 and there was no evidence of the resident or family being invited. 2. Review of the medical record for Resident #16 revealed an admission date of 04/16/20. Diagnosis included heart failure, major depressive disorder, hypothyroidism, paroxysmal atrial fibrillation, pure hypercholesterolemia, sleep apnea, long term use of anticoagulants, long term use of oral hypoglycemic drugs, anxiety disorder, type two diabetes with diabetic chronic kidney disease, hypertensive heart and chronic kidney disease, unilateral primary osteoarthritis right knee, personal history of pneumonia, personal history of pneumonia, personal history of (healed) traumatic fracture, respiratory failure, and dependence on supplemental oxygen. Review of the most recent MDS assessment, dated 02/23/21, revealed the resident is moderately cognitively impaired. Page 1 of 13 366068 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0657 Level of Harm - Minimal harm or potential for actual harm Review of Resident #16 care conference notes revealed the last documented care conference was on 06/16/20. Interview on 05/10/21 at 11:24 A.M., with Resident #16 revealed the resident had no recent care conferences metings . Residents Affected - Few Interview on 05/12/21 at 10:13 A.M., with Social Worker #400 verified Resident #16's last care conference was on 06/16/20. Social Worker #400 reported the facility had got behind on holding care conferences. 3. Review of Resident #91 medical record revealed an admission date of 01/31/20. Diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting right dominant [NAME], hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease or end statge renal disease, type two diabetes mellitus with diabetic chronic kidney disease, major depressive disorder recurrent, encephalopathy, acquired absence of left leg below knee, personal history of pneumonia, dependence on renal dialysis, anemia, pressure ulcer of sacral region stage four, paraplegia, dysphagia, and difficulty in walking. Review of the most recent MDS assessment, dated 04/21/21, revealed the resident was cognitively intact. Review of Resident #91 care conference notes revealed the last documented care conference was on 05/05/20. Interview on 05/10/21 at 5:07 P.M., with Resident #91 revealed the resident has not had a care conference in an unknown amount of time. Resident #91 does not recall having a care conference meeting. Interview on 05/12/21 at 10:14 A.M.,with Social Worker #400 verified Resident #91's last care conference was on 05/05/20. Review of the policy titled Care Planning, reviewed 11/13/20, verified the resident's family and/or the resident's legal representative/guardian or surrogate should participate in the development of the resident's care plan and when applicable. 366068 Page 2 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, medical record review, staff interviews and review of policy, the facility failed to apply orthotic devices as ordered. This affected one (#81) of three residents reviewed for limited range of motion. The facility census was 102. Findings include: Review of the medical record for Resident #81 revealed an admission date of 01/13/21 and a readmission date of 04/05/21. Diagnoses included pneumonitis due to inhalation of food and vomit; acute respiratory failure with hypoxia; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side; contracture left hand; contracture left knee; and morbid (severe) obesity due to excess calories. Review of the Modification of Annual Minimum Data Set (MDS) assessment, dated 04/12/21, revealed Resident #81 was cognitively intact; required extensive two person physical assistance with dressing; and total two person physical assistance with transfers. Review of the care plan revealed Resident #81 had a self care performance deficit related to limited range of motion left hand contracted and decreased range of motion. Interventions included a left hand carrot splint according to splint schedule located on resident's closet to maintain skin integrity. Review of current physician's orders revealed an order for Resident #81 to utilize hand carrot splint according to splint schedule located on Resident's closet to maintain skin integrity. Observations on 05/10/21 at 11:51 A.M., 05/11/21 at 11:16 A.M., 05/11/21 at 11:32 A.M., 05/12/21 at 8:34 A.M., and 05/12/21 at 1:05 P.M., of Resident #81 revealed the resident did not have the carrot splint applied on each of the observations. Observation on 05/12/21 at 1:06 P.M.,of the carrot splint schedule, located on Resident #81's closet door, revealed Resident #81 was to wear the carrot splint daily from 8:00 A.M. to 2:00 P.M. Interview on 05/12/21 at 1:08 P.M., of MDS Nurse #470 verified Resident #81 was not wearing the carrot splint and the posted schedule in the resident's room indicated Resident #81 was to wear the splint daily from 8:00 A.M. to 2:00 P.M. MDS Nurse #470 attempted to locate the carrot splint in the Resident's room. On 05/12/21 at 1:25 P.M., MDS Nurse #470 located the splint and Resident #81 was assisted with applying the splint. Interview on 05/12/21 at 1:29 P.M., of Occupational Therapist (OT) #475 verified Resident #81 was to wear the carrot splint daily from 8:00 A.M. to 2:00 P.M. Review of facility policy titled Contracture Prevention and Management, reviewed 03/23/19, revealed contracture prevention and management involves the moving of joints and/or application of orthotic devices according to an individualized plan to prevent skin breakdown and preserve skin integrity. In addition, for upper extremity orthotic (splint), follow schedule for application and remove and and always check skin. 366068 Page 3 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

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 observations, staff interviews, and medical record reviews, policy reviews, the facility failed to ensure a resident was transferred properly to prevent a fall and failed to implement fall precautions as ordered and care planned. This affected three (#81, #55, and #6) of three residents reviewed for falls. The facility census was 102. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 01/13/21 and a readmission date of 04/05/21. Diagnoses included pneumonitis due to inhalation of food and vomit; acute respiratory failure with hypoxia; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side; and morbid (severe) obesity due to excess calories. Review of the modification and annual Minimum Data Set (MDS) assessment, dated 04/12/21, revealed Resident #81 was cognitively intact, required two person physical assistance with transfers and bed mobility, had no resistance to care, and had one fall with no injury. Review of the care plan revealed Resident #81's fall interventions included mechanical lift with assist of two for transfers. Review of the Quarterly Fall Review, dated 03/21/21, revealed Resident #81 was identified as a high fall risk, was unable to stand without physical assistance, and had a witnessed fall with no injury. Review of a nursing progress note, dated 03/21/21 at 8:15 P.M., revealed Resident #81 had a witnessed fall, neurological checks initiated, upper and lower extremities range of motion was within normal limits, and no pain indicated. The progress note was silent for details related to the witnessed fall. Interview on 05/10/21 at 11:51 A.M., of Resident #81 revealed the Resident had a fall in March 2021. Resident #81 stated he was being transferred from his wheelchair to the bed by one staff member, using a hoyer lift, and was dropped. Resident #81 denied any injuries. Interview on 05/12/21 at 3:37 P.M., with Licensed Practical Nurse (LPN) #380 revealed on 03/21/21 she was watching, from Resident #81's door, Stated Tested Nurse Aide (STNA) #390 transfer Resident #81 from his wheelchair to his bed using a hoyer lift. LPN #380 verified she was not in the room assisting with the transfer. LPN #380 stated the lift began to tilt and she rushed into the room to assist. LPN #380 stated the lift tipped over and Resident #81 was lowered to the floor. LPN #380 stated the Resident was assessed and no injuries were noted. Interview on 05/13/21 at 6:25 A.M., with STNA #390 revealed she was the staff assigned to Resident #81 on 03/21/21. STNA #390 stated Resident #81 was anxious to go to bed. She was unable to locate another STNA to assist with the hoyer lift transfer and got LPN #380 to assist her. STNA #390 verified LPN #380 stood at the door of Resident #81's room while she performed the transfer from the wheelchair to bed. STNA #390 stated the lift began creaking, Resident #81 shifted his weight, and the lift began to tip. LPN #380 ran into the room at that point and assisted STNA #390 with lowering the resident to the floor. 366068 Page 4 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility policy titled Mechanical Lift, reviewed 11/13/19, revealed the purpose was to safely lift and transfer residents with the assist of two individuals. In addition, chair to bed transfers indicated the need to get help, a mechanical lift requires two people to assist. 2. Review of the medical record for Resident #55 revealed an admission date of 01/01/20 and a readmission date of 03/31/21. Diagnoses included displaced intertrochanteric fracture of right femur subsequent encounter for closed fracture with routine healing; unspecified dementia without behavioral disturbance; chronic kidney disease, stage 4 (severe); rheumatoid arthritis, unspecified; and repeated falls. Review of the quarterly MDS assessment, dated 04/07/21, revealed Resident #55 was moderately cognitively impaired. Resident #55 required extensive two person physical assistance with bed mobility, toilet use, and transfers. Resident #55 was not identified as resistive to care. Review of the Quarterly Fall Review, dated 03/03/21, revealed Resident #55 was at high risk for falls. Review of the Fall Review Assessment, dated 03/29/21, revealed Resident #55 was found in a sitting position next to her bed. Resident #55 suffered a right hip fracture. Additional review of assessments revealed a Fall Review Assessment, dated 04/04/21, and indicated Resident #55 was found laying on her back next to her bed with no injury noted. Review of current physician orders revealed Resident #55 had the following fall interventions ordered: bed against wall per resident preference; encourage nonskid footwear to promote safety; bed bolster to left side of bed; and bilateral transfer bars to bed to assist with mobility and transfer. Review of a nursing progress note dated 04/06/21 at 11:00 A.M. revealed current fall interventions included assist with transfers, bed against the wall, call light within reach, encourage non-slip footwear, fall risk assessment quarterly, gait belt for ambulation and transfers, grab bars and visual cue in room. A new intervention of bed bolsters to bed was added. Review of the fall care plan, dated 04/15/21, revealed resident was to have a bed bolster to the left side of bed for safety to identify bed boundaries, as tolerated. Observations on 05/11/21 at 7:35 A.M., on 05/11/21 at 11:19 A.M., on 05/11/21 at 1:30 P.M., on 05/12/21 at 9:25 A.M., and 05/12/21 1:40 P.M., revealed Resident #55 in bed on each of the observations. The bolster to the left side of the bed was not observed to be in place or available in Resident #55's room. Interview on 05/12/21 at 09:27 A.M., with STNA #360 verified Resident #55 did not have a bolster on the left side of the bed or one available in her room. STNA #360 stated a bolster used to be on the Resident's bed and she was not sure why she did not have one now. STNA #360 stated Resident #55 did not refuse care. Review of facility policy titled Falls - Clinical Protocol, reviewed 11/13/19, revealed based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and address risks of serious consequences of falling. 3. Review of the medical record for Resident #6 revealed an admission date of 02/21/21. Diagnoses 366068 Page 5 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease or unspecified kidney disease; type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye; unspecified dementia without behavioral disturbance; and repeated falls. Review of the quarterly MDS assessment, dated 04/30/21, revealed Resident #6 was severely cognitively impaired; did not reject care; required limited one person physical assistance with transfers; and had two or more falls since admission. Review of the care plan, dated 02/05/21, revealed Resident #6's fall risk was characterized by confusion related to dementia/Alzheimer's, impaired balance, impaired mobility, and history of falls. Interventions included call light within reach when in room, grab bar/transfer bar/handle to bed, have commonly used articles within easy reach, and non skid strips to floor next to bed every shift for safety. Review of current physician orders revealed the following orders: non skid strips to floor next to bed every shift for safety; transfer bars to bed to assist with mobility and transfers; and self locking wheelchair brakes. Review of Fall Review Assessments revealed Resident #6 had falls on 02/17/21, 02/23/21, 03/05/21, 03/12/21, and 04/18/21. Observation on 05/12/21 at 7:44 A.M., of Resident #6 revealed the Resident laying in bed, legs hanging over the side, blankets draped around his feet. The bed was against the far wall. One non-skid strip was observed under the frame of Resident #6's bed. Three non-skid strips were noted on the floor, approximately six feet away from Resident #6's bed. Interviews on 05/12/21 at 8:03 A.M., with STNA #350 and #355 revealed Resident #6 required assistance with transfers and had a history of falls. STNAs #350 and #355 verified non-skid strips were not in place next to Resident #6's bed. STNA #350 stated the Resident's bed used to be in the middle of the room, which was why there were non-skid strips located approximately six feet from the location of the Resident's bed. Interview on 05/12/21 at 8:51 A.M. of the Director of Nursing (DON) verified there was only one non-skid strip located next to Resident #6's bed and stated she would be adding additional strips. The DON stated the resident's bed was moved against the wall at the request of family. Review of facility policy titled Falls - Clinical Protocol, reviewed 11/13/19, revealed based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and address risks of serious consequences of falling. 366068 Page 6 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, staffing schedule review and review of policy, the facility failed to ensure tube feeding care was provided and documented as ordered. This affected one (#73) of one resident reviewed for tube feeding. The facility identified five residents with tube feeding. The facility census was 102. Findings Include: Review of Resident #73's medical record revealed an admission date of 03/25/21. Diagnoses included chronic respiratory failure, chronic kidney disease, persistent vegetative state, dysphagia, convulsions, tracheostomy, heart failure, aphasia, and contracture. Review of Resident #73's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was in a persistent vegetative state. Resident #73 was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Resident #73 had a tracheostomy care and suctioning at the time of the review. Review of Resident #73's care plan revised 04/08/21 revealed supports and interventions for inability to make needs known and tube feeding to maintain nutritional status. Review of Resident #73's physician's orders and Treatment Administration Record (TAR) revealed an order dated 08/23/18 and discontinued 03/23/21 for Resident #73's gastrointestinal (g-tube) to be flushed with 200 milliliters (ml) of water four times a day. Flushing was not documented as being completed as ordered on 03/05/21 at 4:00 P.M. or 8:00 P.M. Review of a physician's order dated 03/25/21, to check Resident #73 for residual every shift. If less than 100 cubic centimeters (cc)/ml hold tube feeding for one hour, recheck residual and notify physician. Every shift for tolerance of enteral feeding. Tube feeding monitoring was not documented as being completed as ordered on the evening shift on 03/05/21, 03/22/21, 03/31/21, 04/16/21, 04/20/21, or 05/09/21. Review of a physician's order dated 03/31/21, for Resident #73 to be administered 200 ml of free water four times a day. The free water was not documented as being administered as ordered at 9:00 P.M. on 04/11/21, 04/16/21, 04/19/21, 04/20/21, 04/22/21, 05/09/21 or at 5:00 P.M. on 04/16/21, 04/20/21, or 05/09/21. Interview on 05/11/21 at 2:36 P.M., with Licensed Practical Nurse (LPN) #465 revealed Resident #73 was in a completely vegetative state. Resident #73 required total assistance for all his tube feeding nutritional needs. LPN #465 reported the nursing staff was responsible for providing and documenting all tube feeding and tube feeding related care. LPN #465 reported the nursing staff was required to document all care and treatment in the electronic medical record when care was provided. Interview on 05/13/21 at 8:38 A.M., with the Director of Nursing (DON) verified Resident #73's tube feeding related care was not documented as being provided as ordered on the previous dates listed. Interview on 05/13/21 at 12:22 P.M., with the DON revealed she was able to identify the two nurses 366068 Page 7 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who failed to document in Resident #73's medical record. The DON stated she called them and they told her it was done. The DON was unable to find any supporting documentation or nurse's notes indicating the care was actually provided. The DON provided a list of dates she had written down and indicated the staff were educated on documentation of care provided. Review of the provided paper found dates of 03/05/21, 03/13/21, 03/17/21, 03/20/21, 04/11/21, 04/16/21, 04/19/21, 04/20/21, and 05/09/21, listed with the DON signing the bottom indicating the information was received and provided via phone call. However, no shift information was provided nor was there any indication as to what hallway the nursing staff were assigned to. Interview on 05/13/21 at 5:17 P.M., with Licensed Practical Nurse (LPN) #415 revealed LPN #415 had worked with Resident #73 but was unable to recall what shift she covered or what days she worked with Resident #73 in March 2021. LPN #415 reported there were two to three nurses which covered first shift, two nurses that covered second shift and two nurses that covered third shift on Resident #73's hallway. LPN #415 was not able to say if care was provided for the missing documentation on second shift in March. Interview on 05/17/21 at 7:06 A.M., with LPN #460 revealed LPN #415 typically worked second shift, which was 3:00 P.M. to 11:00 P.M. and worked with one other nurse, who covered Resident #73's hallway. LPN #460 reported she provided respiratory care for Resident #73 on 05/09/21 and verified it was not documented as required. LPN #460 reported there were two nurse who worked on second shift and was not able to say if care was provided for the missing documentation on second and third shift in March 2021, or April 2021. Review of the staffing schedule for 03/05/21, 03/13/21, 03/17/21, 03/20/21, 04/11/21, 04/16/21, 04/19/21, 04/20/21, and 05/09/21 revealed two nurses were on the schedule for second shift on Resident #73's hallway. The staffing schedule did not indicate which nurse was assigned to Resident #73's care specifically. Review of the policy titled, Enteral Tube Feeding- Bolus and Continuous, dated 11/13/19 revealed the nursing staff was to check the physician's order. Staff were to administer tube feeding and document the care and treatment provided. 366068 Page 8 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 interviews, staffing schedule review and review of the facility policy, the facility failed to ensure tracheostomy care was provided and documented as ordered on second shift. This affected one (#73) of one resident reviewed for tracheostomy care. The facility identified two residents with tracheotomies. The facility census was 102. Residents Affected - Few Findings include: Review of Resident #73's medical record revealed an admission date of 03/25/21. Diagnoses included chronic respiratory failure, chronic kidney disease, persistent vegetative state, dysphagia, convulsions, tracheostomy, heart failure, aphasia, and contracture. Review of Resident #73's Minimum Data Set (MDS) dated [DATE] revealed Resident #73 was in a persistent vegetative state. Resident #73 was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Resident #73 had a tracheostomy care and suctioning at the time of the review. Resident #73 received respiratory therapy seven days during the review period. Review of Resident #73's care plan revised 04/08/21 revealed supports and interventions for inability to make needs known and ineffective breathing patterns. Interventions for ineffective breathing patters included administer medications and respiratory treatments as ordered, and tracheostomy care per physician order. Review of Resident #73's physician's orders and Treatment Administration Record (TAR) revealed an order dated 07/25/18 and discontinued 03/23/21 for tracheostomy care to be completed twice daily and as needed every day and evening shift. Tracheostomy care was not documented as completed as ordered on the evening shift on 03/13/21, 03/17/21, or 03/20/21. Review of physician's order dated 07/26/18 and discontinued 03/23/21 for cool mist collar at 21% to tracheostomy to keep oxygen levels greater than 90% every shift to tracheostomy status. The cool mist collar was not applied as ordered on 03/13/21, 03/17/21, or 03/20/21. Review of physician's order dated 07/25/18 and discontinued 03/23/21 to fill Resident #73's bubble humidifier with distilled water every shift. The humidifier was not filled as ordered on 03/13/21, 03/17/21, or 03/20/21. Review of physician's order dated 03/26/21 for tracheostomy care to be completed twice a day and as needed every day and evening shift. Tracheostomy care was not documented as completed as ordered on 05/09/21 on the evening shift. Review of physician's order dated 03/26/21 for tracheostomy care to be completed twice daily and as needed every day and evening shift. Tracheostomy care was not completed as ordered on 04/16/21, 04/20/21, 05/09/21. Interview on 05/11/21 at 2:36 P.M., with Licensed Practical Nurse (LPN) #465 revealed Resident #73 was in a completely vegetative state. Resident #73 required total assistance for all his tracheostomy care. LPN #465 reported the respiratory therapist provided all tracheostomy care during the day 366068 Page 9 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift during the week. The nursing staff was responsible for providing and documenting tracheostomy care when the respiratory therapist was not in the facility. LPN #465 reported the nursing staff was required to document all care and treatment in the electronic medical record when care was provided. Interview on 05/12/21 at 1:10 P.M., with Respiratory Therapist (RT) #455 revealed RT #455 worked Monday through Friday on first shift. RT #455 reported all resident respiratory care and treatments were to be completed by the nursing staff during second and third shifts during the week and on all shifts on the weekends when the respiratory therapist was not working. RT #455 reported all care and treatment completed was documented in the electronic medical record. RT #455 reported Resident #73 was in a permanent vegetative state and was unable to make his needs known. Resident #73 was totally dependent on staff for all tracheostomy care. Interview on 05/13/21 at 8:38 A.M., with the Director of Nursing (DON) verified Resident #73's tracheostomy care was not documented as being provided as ordered on 03/13/21, 03/17/21, 03/20/21, 04/16/21, 04/20/21, and 05/09/21. Interview on 05/13/21 at 12:22 P.M., with the DON revealed she was able to identify the two nurses who failed to document in Resident #73's medical record. The DON stated she called them and they told her it was done. The DON was unable to find any supporting documentation or nurses notes indicating the care was actually provided. The DON provided a list of dates she had written down and indicated the staff were educated on documentation of care provided. Review of the provided paper found dates of 03/05/21, 03/13/21, 03/17/21, 03/20/21, 04/11/21, 04/16/21, 04/19/21, 04/20/21, and 05/09/21 listed with the DON signing the bottom indicating the information was received and provided via phone call. However, no shift information was provided nor what hallway the nursing staff were assigned to. Interview on 05/13/21 at 5:17 P.M., with Licensed Practical Nurse (LPN) #415 revealed LPN #415 had worked with Resident #73 but was unable to recall what shift she covered or what days she worked with Resident #73 in March 2021. LPN #415 reported there were two to three nurses which covered first shift, two nurses that covered second shift and two nurses that covered third shift on Resident #73's hallway. LPN #415 was not able to say if care was provided for the missing documentation on second shift in March. Interview on 05/17/21 at 7:06 A.M., with LPN #460 revealed LPN #415 typically worked second shift, which was 3:00 P.M. to 11:00 P.M. and worked with one other nurse and covered Resident #73's hallway. LPN #460 reported she provided respiratory care for Resident #73 on 05/09/21 and verified it was not documented as required. LPN #460 reported there were two nurse who worked on second shift and was not able to say if care was provided for the missing documentation on second and third shift in March 2021, or April 2021. Review of the staffing schedule for 03/05/21, 03/13/21, 03/17/21, 03/20/21, 04/11/21, 04/16/21, 04/19/21, 04/20/21, and 05/09/21 revealed two nurses were on the schedule for second shift on Resident #73's hallway. The staffing schedule did not indicate which nurse was assigned to Resident #73's care specifically. Review of the policy titled, Tracheostomy Care, dated 11/13/19, revealed tracheostomy care was to be provided at least twice daily, as needed, or as ordered. Staff were to document care and treatment in the electronic medical record. 366068 Page 10 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, dialysis center staff and facility staff interviews, medical record review, and review of facility policy, the facility failed to accurately assess a resident dialysis Central Venous Catheter (CVC). This affected one (#52) of one resident reviewed for dialysis treatment. The facility identified 12 residents receiving dialysis treatment. The facility census was 102. Residents Affected - Few Findings include: Review of the medical record for Resident #52 revealed an admission date of 04/03/21. Diagnoses included sepsis, arthritis, end stage renal disease, long term use of insulin, morbid obesity, and heart disease. Review of the admission Minimum Data Set (MDS) assessment for Resident #52, dated 04/09/21, revealed a Brief Interview for Mental Status (BIMs) score of 14, indicating the resident was cognitively intact. Additionally, the assessment indicated the resident received dialysis treatment. Review of the hospital admission paperwork dated 04/03/21 revealed the resident was admitted to the facility with a double lumen hemodialysis catheter in his right chest. Review of the most recent physician orders for Resident #52 revealed the resident was to receive hemodialysis on Monday, Tuesday, Thursday, and Fridays. Review of the dialysis communication handoff form for Resident #52, dated 05/06/21, revealed the resident was assessed prior to leaving for dialysis. Licensed Practical Nurse (LPN) #415's signature was written at the bottom of the assessment. The dialysis communication form revealed a section for the assessment of the dialysis access site prior to leaving for dialysis. The location and type of access device was not present on the assessment. The documentation of the condition of the dialysis access device revealed a bruit and thrill were present, with no signs of infection. Observation on 05/10/21 at 11:10 A.M., of Resident #52 revealed he had a dialysis central venous catheter (CVC) in his right upper chest. Interview with Resident #52, at the time of the observation, confirmed the CVC in his upper chest is used for dialysis treatments. Resident #52 stated there had been no complications with the CVC that he was aware of. Interview on 05/12/21 at 11:36 A.M., with LPN #415 confirmed she had taken care of Resident #52 on occasion. LPN #415 revealed that residents receiving hemodialysis are sent to dialysis with a dialysis communication form that includes documented vitals signs and assessment of the residents dialysis access device. LPN #415 stated staff must complete this assessment before sending any resident to dialysis. LPN #415 confirmed that Resident #52 had a CVC in his upper chest that she assessed while caring for him. LPN #415 confirmed that on 05/06/21, she assessed the residents' CVC for a bruit and a thrill and documented her assessment on the communication form. LPN #415 stated she felt for the vibration above the residents CVC insertion site where his veins are. LPN #415 verified she assessed all dialysis access devices for a bruit and thrill and was unaware that those assessment pieces were specific to a fistula. Interview on 05/12/21 at 11:44 A.M., with LPN #480 revealed he had cared for Resident #52 366068 Page 11 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few frequently. LPN #480 confirmed that Resident #52 did not have a fistula, and had a CVC in his chest that is used for hemodialysis. LPN #480 stated that the CVC in the resident's chest is assessed for signs and symptoms of infection and the integrity of the dressing prior to being sent to dialysis. LPN #480 confirmed that it would not be possible to assess for a bruit or thrill unless the person had a fistula. LPN #480 stated he documents the assessment piece of a bruit and thrill are not applicable on Resident #52's dialysis communication form. Interview on 05/17/21 at 2:30 P.M., with Hemodialysis Registered Nurse (HDRN) #485 revealed she cares for Resident #52 when he comes to dialysis. HDRN #485 confirmed the resident has a CVC in his upper chest that is called a Perma Cath. HDRN #485 confirmed that Resident #52 does not have a fistula. HDRN #485 further confirmed the resident's CVC in his chest should not be assessed for a bruit or thrill as that assessment piece only applies to a fistula. Review of the facility policy titled Hemodialysis/Dialysis dated 11/13/21, revealed hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of the device. Additionally, the policy stated that care involves the primary goal of preventing infection and maintaining patentcy of the catheter. 366068 Page 12 of 13 366068 05/17/2021 Orchard Villa 2841 Munding Drive Oregon, OH 43616

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of policy, the facility failed to ensure a pharmacist accurately reviewed a resident's medication regimen. This affected one (#43) of five reviewed for unnecessary medications. The census was 102. Findings include: Review of Resident #43's medical record revealed an original admission date of 11/20/19 and a most recent admission date of 08/30/20. Diagnoses included respiratory failure, toxic encephalopathy, major depression, anemia, fibromyalgia, anxiety disorder, and unspecified dementia without behavioral disturbances. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had short and long-term memory problems. Review of a physician's order dated 08/30/20 revealed Resident #43 was ordered the antidepressant Trazodone 50 milligrams (mg) and to give one and one-half tablets to equal 75 mg daily. Review of a medication regimen review (MRR) dated 10/23/20 revealed the pharmacist reviewed Resident #43's Trazodone as 150 mg every night with a recommendation to attempt a dose reduction as clinically indicated. A Nurse Practitioner #100 response was given on 10/27/20 and agreed to a dose reduction and decreased Resident #43's Trazodone to 100 mg every night. Review of Resident #43's physician orders for Trazodone revealed she was never ordered or was administered doses of 150 mg or 100 mg as indicated on the October 2020 (MRR). Review of Resident #43's physician orders revealed she was ordered and received doses of Trazodone 50 mg or 75 mg every night through 05/17/21 as ordered. Interview on 05/13/21 at 2:21 P.M., with Director of Nursing (DON) #1 verified Resident #43 was never ordered Trazodone 100 mg or 150 mg and the pharmacist inaccurately reviewed Resident #43's medication regimen. DON #1 verified the inaccurate review of the Trazodone 150 mg on 10/23/20 caused the nurse practitioner to incorrectly recommend a dose reduction of 100 mg on 10/27/20. Review of an undated written statement from the facility Pharmacist #200 revealed on 10/23/20, Resident #43 was receiving Trazodone 75 mg every night and she incorrectly reviewed the medication as 150 mg on the 10/23/20 MRR. Review of the policy titled, Medication Records Reviews, last reviewed 11/13/19, revealed the consultant pharmacist will perform a medication regimen review monthly. As part of the review the consultant pharmacist will determine if the resident is receiving the correct medications as ordered and identify medication errors, including those related to documentation. 366068 Page 13 of 13