Health inspection·July 1, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on medical record review, observation, and staff interview, the facility failed to maintain dignity while feeding Resident #44. The facility identified two residents who were dependent on staff for feeding. The facility census was 64. Findings include: Review of the medical record of Resident #44 revealed an admission date of 01/09/13. Diagnoses included dysphagia, protein-calorie malnutrition, major depressive disorder, cognitive communication deficit, chronic obstructive pulmonary disease (COPD), anxiety disorder, and cerebral infarction (stroke). Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/15/21, revealed the resident had impaired cognition and was dependent on the assistance of one staff for feeding. Observation and interview on 06/28/21 at 11:43 A.M. revealed Resident #44 laying in bed. The right side of Resident #44's bed was against the wall and RN #139 was standing at the left side of the bed feeding Resident #44. RN #139 verified she was feeding Resident #44 while standing up and further stated she was right-handed so it was easier for her to feed the resident while standing up. Interview on 07/01/21 at 10:00 A.M. with the Director of Nursing (DON) stated the expectation was for staff to be seated when feeding residents. Page 1 of 5 366143 366143 07/01/2021 Adams County Manor 10856 State Route 41 West Union, OH 45693

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to accurately code a resident's fall status on the Minimum Data Set (MDS) assessment. This affected one (Resident #13) of 18 residents reviewed for accurate MDS assessments. The facility census was 64 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #13 revealed an admission date of 06/15/19. Diagnoses included dementia and transient cerebral ischemic attack. Review of the progress notes revealed the resident had falls on 03/04/21, 11/22/20, and 11/07/20. Review of the Minimum Data Set (MDS) assessments revealed a quarterly assessment was completed on 04/05/21, an annual assessment was completed on 02/11/21, and a quarterly assessment on 11/18/20. No additional MDS assessments were completed between 11/18/20 and 04/05/21. Subsequent review of the MDS assessments, dated 04/05/21 and 02/11/21, revealed section J1800 was negative for any falls since the prior assessment. Interview on 06/30/21 at 2:38 P.M. with Licensed Practical Nurse (LPN) #114 verified the MDS assessments for Resident #13, dated 04/05/21 and 02/11/21, were coded incorrectly and should have indicated there was a fall. 366143 Page 2 of 5 366143 07/01/2021 Adams County Manor 10856 State Route 41 West Union, OH 45693

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 record review, observations, and staff interviews, the facility failed to obtain a physician order for the use of oxygen, failed to administer oxygen as physician ordered, and failed to properly label the oxygen tubing during continuous use. This affected three residents (Resident #27, #44, and #215) of 23 residents receiving oxygen therapy. The facility census was 64. Residents Affected - Few Findings include: 1. Record review for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure and congestive heart failure. Review of the Minimum Data Set assessment, dated 05/05/21, revealed the resident was rarely/never understood. Review of the physician orders, dated 06/2021, revealed there were no orders for the use of oxygen. After surveyor intervention on 06/29/21, there was a physician order for the use of oxygen at two liters via nasal cannula. Observation of Resident #27 on 06/28/21 at 2:38 P.M. revealed the resident had oxygen tubing that was not labeled or dated during the time of use. Subsequent observation of Resident #27 on 06/29/21 at 2:35 P.M. revealed the oxygen tubing was still not labeled or dated. During this observation, Registered Nurse (RN) #212 verified the oxygen was running at three liters per minute and tubing was unlabeled or dated. The RN explained a contracted provider supplies the oxygen and they change out the tubing weekly, and they do not label or date the tubing. 2. Record review for Resident #215 on 06/29/21 at 1:58 P.M. revealed the resident was admitted to the facility on [DATE]. Diagnoses included asthma and emphysema. Review of the MDS assessment, dated 06/19/21, revealed the resident had intact cognition. Review of the physician orders, dated 06/2021, revealed there were no orders for the use of oxygen. After surveyor intervention on 06/29/21, there was a physician order for the use of oxygen at two liters via nasal cannula. Observation of Resident #215 on 06/28/21 at 3:22 P.M. revealed the resident had oxygen tubing that was not labeled or dated during the time of use. Subsequent observation of Resident #27 on 06/29/21 at 2:35 P.M. revealed the oxygen tubing still not labeled or dated. During the observation, RN #212 verified the oxygen was running at three liters per minute and the tubing was unlabeled or dated. On 06/30/21 at 2:40 P.M., an interview with the Director of Nursing (DON) on 06/30/21 at 2:40 P.M. verified Resident #27 and #215 did not have an active order for oxygen in place until it was obtained on 06/29/21. The DON verified the physician orders were for two liters, not three liters for Resident #27 and #215. 3. Review of the medical record for Resident #44 revealed an admission date of 01/09/13. Diagnoses included chronic obstructive pulmonary disease (COPD) and cerebral infarction. Review of the quarterly MDS assessment, dated 06/15/21, revealed the resident had impaired cognition. Review of the physician's orders revealed order on 08/20/20 for oxygen at two liters per minute as needed per nasal cannula six to eight per day and an order on 09/26/17 for one dose duoneb solution 366143 Page 3 of 5 366143 07/01/2021 Adams County Manor 10856 State Route 41 West Union, OH 45693

F 0695 0.5-2.5 (3.0) milligrams/3.0 milliliter solution every four hours as needed. Level of Harm - Minimal harm or potential for actual harm Review of the treatment administration record (TAR) revealed RN #139 signed off the oxygen as administered on 06/28/21 and 06/29/21. Residents Affected - Few Observations on 06/28/21 at 9:42 A.M. and 11:43 A.M, and on 06/29/21 at 3:00 P.M., and 4:08 P.M. revealed no oxygen concentrator nor oxygen tank in Resident #44's room. Observation on 06/29/21 at 3:00 P.M. revealed a nebulizer placed on Resident #44's bedside table. The tubing did not contain any date to indicate when it was last replaced. Interview on 06/29/21 at 4:08 P.M. with RN #139 verified there was no there was no date on the nebulizer tubing nor were there oxygen concentrator or tanks in Resident #44's room. The RN further stated Resident #44 had not received oxygen anytime recently. RN #139 verified the MAR had been signed off indicating the oxygen was administered when the oxygen had not been administered. 366143 Page 4 of 5 366143 07/01/2021 Adams County Manor 10856 State Route 41 West Union, OH 45693

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and staff interview, the facility failed to ensure the resident's call lights were functioning. This affected three (Resident #09, #16 and #18) of 24 residents reviewed for call lights. The facility census was 64 residents. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #09 revealed an admission date of 03/31/21. Diagnoses included dementia without behavioral disturbance, type 2 diabetes mellitus, muscle weakness, and bipolar disorder. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 06/23/21, revealed the resident had impaired cognition and required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the medical record for Resident #18 revealed an admission date of 09/17/20. Diagnoses included cerebrovascular disease, acute ischemic heart disease, dementia with behavioral disturbance, and cerebral infarction (stroke). Review of the comprehensive MDS assessment, dated 04/14/21, revealed the resident had impaired cognition, required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers and toileting. Observation on 06/28/21 at 11:28 A.M. revealed Resident #09's call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door. Observation on 06/28/21 at 11:29 A.M. revealed Resident #18's (Resident #09's roommate) call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door. Interview on 06/28/21 at 11:35 A.M. with Registered Nurse (RN) #215 verified the light did not light up outside the room of Residents #09 and #18 and did not transmit a signal to the pagers carried by the staff. 2. Review of the medical record for Resident #16 revealed an admission date of 12/07/20. Diagnoses included chronic obstructive pulmonary disease, dementia with behavioral disturbance, anxiety disorder, major depressive disorder, and non-st elevation (NSTEMI) myocardial infarction. Review of the quarterly MDS assessment revealed the resident had intact cognition and required supervision for bed mobility, transfers, and ambulation. Observation on 06/28/21 at 2:20 P.M. revealed Resident #16's call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door. Interview on 06/28/21 at 2:20 P.M. with State Tested Nursing Aide (STNA) #240 verified the light did not come on outside the door nor did not transmit a signal to the pagers carried by the staff. Further interview with STNA #240 revealed the call light cord was not plugged into the wall. 366143 Page 5 of 5