Health inspection·December 7, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility's catheter care protocols, the facility failed to ensure a resident's dressing to his midline catheter was changed in accordance with his physician's orders. This affected one resident (#50) of three residents reviewed for dressing changes. Residents Affected - Few Findings include: A review of Resident #50's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of sepsis (life threatening medical emergency when an infection you have triggers a chain reaction throughout your body) and Methicillin resistant staphylococcus aureus (MRSA) as the cause of a disease classified elsewhere. A review of Resident #50's physician's orders revealed he had an order to maintain a midline catheter (a long, thin, flexible tube that was inserted into a large vein in the upper arm to safely administer medication into the bloodstream) to the left upper arm every shift until the antibiotic therapy treatment was complete. There was also an order to provide midline dressing changes every seven days on day shift every Friday. The orders were initiated on 10/23/23. A review of Resident #50's treatment administration record (TAR) for November 2023 revealed the nurses were initialing the TAR to show the midline dressing was changed every seven days as ordered. There was no documentation to show the treatment had been completed on 11/24/23 (Friday). The last treatment documented as having been completed was on 11/17/23. A review of Resident #50's nurses' progress notes revealed there was no documented evidence of the resident's midline catheter dressing being changed on 11/24/23 as ordered. There was also no documentation to support why the dressing was not changed on the resident's midline catheter on his left upper arm on 11/24/23 as ordered. The progress notes did document the midline catheter had been in place until it was removed from the resident's left upper arm on 11/28/23. Findings were verified by the facility's Assistant Director of Nursing (ADON). On 12/07/23 at 9:45 A.M., an interview with the ADON confirmed there was not a treatment signed off for Resident #50's midline catheter's dressing change for 11/24/23. She acknowledged the progress notes provided no evidence of the treatment being completed as ordered nor did it provide any documentation to support why it was not performed. She verified by reviewing the nurses' progress notes that the midline catheter was not removed until 11/28/23 and the TAR's showed the last dressing change to the midline catheter was on 11/17/23. She stated the midline catheter's dressing should have been changed on 11/24/23. Page 1 of 9 366130 366130 12/07/2023 Riverside Landing Nursing and Rehabilitation 856 South Riverside Drive McConnelsville, OH 43756

F 0684 Level of Harm - Minimal harm or potential for actual harm A review of the facility's Catheter Care and Flush Protocols (undated) revealed Midlines and other long peripheral catheters greater than 3 inches should have a transparent dressing change performed every seven days and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00148488. Residents Affected - Few 366130 Page 2 of 9 366130 12/07/2023 Riverside Landing Nursing and Rehabilitation 856 South Riverside Drive McConnelsville, OH 43756

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident received treatments to her pressure ulcer consistently as ordered by the physician. This affected one resident (#47) of three residents reviewed for wound care. Residents Affected - Few Findings include: A review of Resident #47's medical record revealed she was admitted to the facility on [DATE]. She was readmitted to the facility on [DATE], after a hospitalization. Her diagnoses included a cutaneous abscess of the buttocks. She developed an Unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer could not be confirmed because it was obscured by slough or eschar) to her right buttock that was present upon her re-admission to the facility on [DATE]. The unstageable pressure ulcer revealed a Stage III pressure ulcer (full-thickness loss of skin, in which fat was visible in the ulcer and it may or may not contain slough and/ or eschar) to the right buttock after the slough/ eschar was removed. A review of Resident #47's physician's orders revealed the resident has had multiple treatment orders for the pressure ulcer to her right buttock following her re-admission to the facility depending on the stage of the pressure ulcer. The initial treatment was to wash the wound with soap and water, irrigate with wound wash, apply A&D ointment to periwound, pack with Kerlix moistened with Betadine, and cover the wound with an ABD (large abdominal pad) dressing every day. That order was in place between 08/22/23 and 08/28/23. The treatment was changed to cleansing the wound with wound cleanser, apply Dakin's (a mixture of sodium hypochlorite and boric acid diluted in water) soaked gauze and cover twice a day. That order was in place between 08/25/23 and 10/13/23. The most recent treatment ordered was to apply Zinc Oxide cream and cover with an ABD dressing every shift. That order was in place between 10/13/23 until the resident was discharged home on [DATE]. A review of Resident #47's care plans revealed she had a care plan in place for being at risk for impaired skin integrity/ pressure ulcers. The care plan indicated she was admitted the facility with an area on her right buttock. The care plan was initiated on 08/22/23 and the interventions included the need to perform treatments as ordered. A review of Resident #47's treatment administration record (TAR) for August 2023 revealed the treatment to the right buttock was not signed off as having been completed on 08/26/23 when it was ordered to be completed every morning. The TAR for September 2023 revealed treatments were not documented as having been completed on 09/05/23, 09/07/23, 09/12/23, 09/13/23, or 09/16/23. The treatment was ordered to be performed twice a day during that time and the times the nurses failed to document to show the treatment had been completed was for the morning treatment time. A review of Resident #47's nurses' progress notes revealed there was no documentation in the progress notes to indicate why the treatment was not being completed as ordered. There was no indication of the resident being out of the facility or having refused those treatments on the dates above when they were not initialed on the TAR as having been completed. Findings were verified by the Assistant Director of Nursing (ADON). 366130 Page 3 of 9 366130 12/07/2023 Riverside Landing Nursing and Rehabilitation 856 South Riverside Drive McConnelsville, OH 43756

F 0686 Level of Harm - Minimal harm or potential for actual harm On 12/07/23 at 9:35 A.M., an interview with the ADON confirmed they did not have any documented evidence of treatments being provided to Resident #47's right buttock as ordered for the six dates listed above. She acknowledged the progress notes did not indicate any refusals by the resident on those dates or any other explanation as to why the treatments were not completed as ordered. She also acknowledged if a treatment was not documented as having been done then it was not done. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00148488. 366130 Page 4 of 9 366130 12/07/2023 Riverside Landing Nursing and Rehabilitation 856 South Riverside Drive McConnelsville, OH 43756

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented to prevent avoidable falls. This affected one resident (#25) of three residents reviewed for falls. Findings include: A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included toxic encephalopathy, hypertension, transient ischemic attacks, seizure disorder, atrial fibrillation, abnormalities of gait and mobility, unsteadiness on his feet, muscle weakness, insomnia, and disorientation. A review of Resident #25's fall risk assessment dated [DATE] revealed the resident was at risk for falls related to impaired decision making, needing assistance with activities of daily living (adl's), unsteady gait, use of assistive devices for mobility, and bladder incontinence. A review of Resident #25's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he did not have any communication issues and his cognition was moderately impaired. He was not known to display any behaviors nor was he known to reject care. He required an extensive assist of two for transfers and toilet use. He required an extensive assist of one for locomotion on and off the unit. Ambulation in his room and the hall only occurred once or twice during that assessment period, but he required the assist of one when that activity occurred. He was known to have balance issues and required staff assistance to stabilize. A walker and a wheelchair were marked as mobility devices used. He was indicated to have had one fall since his admission that was without injury. A review of Resident #25's care plans revealed he was at risk for falls and potential injury related to impaired cognition. His care plan reflected he had a slip out of his recliner occurring on 09/01/23 while trying to go to the restroom. He was indicated to have sustained another fall on 09/06/23 when he attempted to go to the bathroom unassisted. He slipped out of his recliner again on 09/11/23 when he was trying to go to bed and tipped over his recliner on 12/01/23 when he was sitting on his knees on the seat of the recliner leaning against the back of the recliner causing it to tip. Interventions on the care plan indicated the recliner had been removed from his room on 12/04/23 as a fall prevention intervention. A review of Resident #25's physician's orders revealed he had the use of a low bed with the bed against the wall and mat on the floor while in bed. The low bed was ordered on 08/28/23. The use of a low bed was not on the resident's at risk for falls care plan. A review of Resident #25's nurses' progress notes revealed he had a fall on 09/06/23 at 10:49 A.M. He was found sitting on his buttocks at the end of the bed. He reported he was returning to his wheelchair after using the bathroom when the fall occurred. He had his call light in but did not wait for staff to respond to provide assistance before trying to transfer himself. The new intervention added in response for that fall was for the resident to be up in a populated area when in his chair. Further review of Resident #25's nurses' progress notes revealed he had subsequent falls on 09/11/23, 10/20/23, 10/26/23, 11/27/23, and 12/01/23. All five falls occurred in the resident's room while 366130 Page 5 of 9 366130 12/07/2023 Riverside Landing Nursing and Rehabilitation 856 South Riverside Drive McConnelsville, OH 43756

F 0689 he had been up in his wheelchair or recliner. Level of Harm - Minimal harm or potential for actual harm On 12/05/23 at 10:34 A.M., an observation of Resident #25 noted him to be lying in bed with his eyes closed. His bed was not observed to be in it's lowest position as it was approximately a couple of feet off the floor. The right side of the bed was against the wall and there was a mat on the floor to the left of the bed. His bed had an air mattress on it. Residents Affected - Few On 12/05/23 at 10:40 A.M., an interview with State Tested Nursing Assistant (STNA) #75 revealed he had worked at the facility for two months now. He commonly worked on Resident #25's hall and felt he was familiar the resident. He confirmed the resident was a fall risk and was asked what fall prevention interventions were in place for the resident. He reported the use of a fall mat on the floor by his bed and use of Dycem to his wheelchair. He did not mention the use of a low bed as a fall prevention intervention despite it being included in the physician's orders. On 12/05/23 at 10:47 A.M., an interview with Registered Nurse (RN) #100 revealed Resident #25 was a fall risk and had been known to fall while in the facility. She was not sure how often he had fallen but stated the falls were related to him not asking for assistance. She was asked what fall prevention interventions were in place for the resident to prevent falls from occurring. She mentioned he had the use of a fall mat. She was not aware that the use of a low bed was a fall prevention intervention for the resident. She had only been working the floor for the past two to three days now. She verified the resident's bed was not in it's lowest position as ordered. She was noted to re-enter the resident's room at 11:01 A.M. and lowered the resident's bed to its lowest position. She had provided education to STNA #75, who was in the room assisting the resident back from the bathroom, that the bed must be in a low position. On 12/05/23 at 11:15 A.M., a follow up interview with STNA #75 revealed he was not aware of the use of a low bed as a fall prevention intervention for Resident #25. He was asked how they knew what fall prevention interventions were in place for each resident. He stated he assumed they had some sort of sheet with all that information on it, but was new to the facility and mainly went by what he picked up on while caring for the residents. He thought the residents' care needs might be on a [NAME] (care plan accessible to the aides on the computer), but was not real familiar with the facility's processes yet. He confirmed RN #100 informed him Resident #25 should be in a low bed when lying in bed. On 12/05/23 at 1:50 P.M., an interview with the Assistant Director of Nursing (ADON) confirmed Resident #25 has had multiple falls that had occurred in his room while up in a chair, after his fall on 09/06/23. She verified they added a fall prevention intervention following the fall on 09/06/23 for the resident to be placed in a populated area when up in his chair for added supervision. She could not explain why he had several falls in his room when up in his chair, after they had put the need for him to be in populated areas when in his chair as a fall prevention intervention from a previous fall. She then stated she believed that intervention had been resolved due to the resident's wife leaving him back in his room unattended without staff being aware. She was asked to provide evidence of when that fall prevention intervention was resolved. She provided a copy of the resident's at risk for falls care plan that showed the need to keep him in a populated area when up in his chair had not been resolved until 12/04/23. She again acknowledged he had numerous falls while up in a chair in his room unattended/ unsupervised while that fall prevention intervention was still in place. She also acknowledged the resident was observed to be in a bed that was not in its lowest position. She confirmed that was still an active fall prevention intervention and should have been included in his fall risk care plan (not just the physician's orders) as the information that was included in the 366130 Page 6 of 9 366130 12/07/2023 Riverside Landing Nursing and Rehabilitation 856 South Riverside Drive McConnelsville, OH 43756

F 0689 fall risk care plan was what was carried over on the aides' [NAME]. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Fall Management policy (undated) revealed the facility would identify each resident who was at risk for falls and would develop a plan of care and implement interventions to manage falls. A care plan was to be implemented upon admission for residents who were identified as at risk for falls with interventions to attempt to prevent further incident. The care plan would be updated routinely and with significant change in the resident's condition. Residents Affected - Few A review of the facility's policy on Falls Program (undated) revealed the purpose of the falls program was to determine and monitor those residents that were at risk for falls and increase awareness of the staff to attempt in the prevention of falls. The interdisciplinary team (IDT) would review occurrences and the implemented immediate interventions daily and implement additional interventions, as needed. The plan of care would be updated at that time. This deficiency represents non-compliance investigated under Master Complaint Number OH00148808, Complaint Number OH00148769, and Complaint Number OH00148488. 366130 Page 7 of 9 366130 12/07/2023 Riverside Landing Nursing and Rehabilitation 856 South Riverside Drive McConnelsville, OH 43756

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident receiving Coumadin (an anticoagulant) had Prothrombin (PT)/ International Normalized Ratio (INR) levels monitored consistently as ordered by the physician. This affected one resident (#25) of three residents reviewed for unnecessary medications. Residents Affected - Few Findings include: A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation (an irregular heart rhythm that commonly caused poor blood flow). He was hospitalized between 10/08/23 and 10/12/23. A review of Resident #25's physician's orders revealed he was receiving Coumadin 1 milligrams (mg) by mouth (po) once a day at bedtime. The Coumadin dosage had been ordered since 12/01/23. Prior dosages included 8 mg po daily (08/25/23- 09/11/23), 9 mg po daily (09/11/23- 10/04/23), and 10 mg po daily (10/04/23- 12/01/23). His physician's orders also included the need to obtain a PT/ INR (blood test that determined the time it took for the blood to clot) every week on Thursdays (08/28/23- 11/27/23). A review of Resident #25's lab reports for PT/ INR's drawn since the order originated on 08/28/23 revealed there was no evidence of the resident's PT/ INR being consistently monitored as ordered. There were no lab reports for a PT/ INR that should have been collected on 09/14/23, 09/21/23, 09/28/23, 10/26/23, or on 11/02/23. Findings were verified by the facility's Administrator. She stated she would check to see if there was any evidence of the lab test being performed as ordered. A review of Resident #25's nurses' progress notes revealed there was no documentation to explain why the resident's PT/ INR was not collected on the dates mentioned above. There was no documentation of the lab test being refused or the resident was out of the facility or unavailable for the PT/ INR to be done. On 12/04/23 at 2:40 P.M., a follow up interview with the Administrator revealed she was not able to find any evidence of a PT/ INR being completed for the resident on the dates mentioned above (09/14/23, 09/21/23, 09/28/23, 10/26/23, or 11/02/23). She could not explain why the PT/ INR's were not completed on those dates when there was an order to check them weekly. She stated any lab report they had would be in the electronic medical record (EMR) or under the lab/ diagnostics tab in the hard chart of the resident's medical record. If it was not found there then it had not been completed. This deficiency is cited as an incidental finding to Master Complaint Number OH00148808. 366130 Page 8 of 9 366130 12/07/2023 Riverside Landing Nursing and Rehabilitation 856 South Riverside Drive McConnelsville, OH 43756

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's physician was notified of laboratory test results timely after they were obtained. This affected one resident (#25) of three residents reviewed. Findings include: A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation (an irregular heart rhythm that commonly caused poor blood flow). He was hospitalized between 10/08/23 and 10/12/23. A review of Resident #25's physician's orders revealed he was receiving Coumadin 1 milligrams (mg) by mouth (po) once a day at bedtime. That Coumadin dosage had been ordered since 12/01/23. Prior dosages included 8 mg po daily (08/25/23- 09/11/23), 9 mg po daily (09/11/23- 10/04/23), and 10 mg po daily (10/04/23- 12/01/23). A physician order dated 11/28/23 revealed an order was received to repeat a PT/ INR due to a clinically high INR of 6.4 (therapeutic INR was between 2.0 and 3.0). A review of Resident #25's laboratory tests results for a PT/ INR collected on 11/28/23 at 12:58 A.M. revealed the resident's PT was high at 67.5 (therapeutic range for someone receiving anticoagulant therapy was between 14.7 to 24.4, which was 1.5 to 2 times the normal range of 9.8 to 12.2) and his INR was critically high at 6.4. The results were reported to the facility on [DATE]. The lab report documented the physician was notified at 7:50 P.M. and a new order was received to hold the resident's Coumadin and to repeat the PT/ INR stat (immediately). Another lab report for a PT/ INR showed that the resident's PT/ INR was rechecked on 11/29/23 at 12:40 A.M. His PT remained high at 61.5 and his INR remained critically high at 5.8. The lab report was not marked to reflect the physician was made aware of the resident's repeat PT/ INR levels that were ordered stat. A review of Resident #25's progress notes revealed his first PT/ INR was documented as having been drawn on 11/28/23 at 1:45 A.M. The progress notes revealed those lab results were reported to the physician on 11/28/23 at 7:50 P.M. and orders were received to hold the Coumadin and to repeat the PT/ INR stat. A nurse's progress note indicated the stat lab was ordered for a PT/ INR on 11/28/23 at 8:00 P.M. The progress notes did not document the repeat PT/ INR being obtained as ordered stat. There was no further mention of the PT/ INR that had been ordered to be repeated stat until a nurse's note dated 11/30/23 at 6:16 A.M. that indicated the resident's INR was 5.8 and the results were reported to an advanced level provider from an on call service (MedOne) the facility used on 11/30/23 at 6:16 A.M. Findings were verified by the facility's Administrator. On 12/04/23 at 2:40 P.M., an interview with the facility's Administrator revealed they were not able to find any documented evidence to show Resident #25's physician was made aware of his repeat PT/ INR levels that were ordered stat following his elevated PT/ INR levels on 11/28/23 until 11/30/23 at 6:16 A.M. She confirmed the lab report indicated the repeat PT/INR ordered stat was collected on 11/29/23 at 12:40 A.M. and the results showed they were reported on 11/29/23 (time no specified). She acknowledged the notification of the physician was not timely as it was the next day when the notification occurred (approximately 30 hours after the PT/INR was collected). This deficiency is cited as an incidental finding to Master Complaint Number OH00148808. 366130 Page 9 of 9