Health inspection·November 18, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, staff interview, and policy review, the facility failed to ensure residents were treated with dignity and respect while being provided assistance with eating in the dining room. This affected four (#22, #7, #19, and #36) of four residents observed receiving assistance with eating in the memory care dining room. The census was 74. Findings include: Observation on 11/15/21 at 12:05 P.M. of the afternoon meal service in the memory care dining room revealed state tested nurse aide (STNA) #260 was providing assistance with eating for Resident #22 and Resident #7 and STNA #270 was at another table, providing assistance with eating for Resident #19 and Resident #36. The observation revealed STNA #260 and STNA #270 were having a personal conversation with each other rather than interacting with the residents. The personal conversation between the two STNA's continued until the STNA's had finished assisting the residents with eating. Interview on 11/15/21 at 12:17 P.M. with STNA #270 verified STNA #270 was having a personal conversation with STNA #260 while providing Resident #19 and Resident #36 assistance eating. Interview on 11/15/21 at 12:19 P.M. with STNA #260 verified STNA #260 was having a personal conversation with STNA #270 while providing Resident #22 and Resident #7 assistance with eating. Review of a policy titled, Assistance with Meals undated, revealed facility staff will serve residents trays and will help residents who require assistance with eating. Residents who can not feed themselves will be fed with attention to safety, comfort, and dignity. The policy revealed keep interactions with other staff to a minimum while assisting a resident with meals. Page 1 of 3 366189 366189 11/18/2021 Vancrest of Delphos 1425 East Fifth Street Delphos, OH 45833

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 medical record review, observation, and staff interview, the facility failed to revise a resident's care plan. This affected one (#65) of three residents reviewed for accidents. The census was 74. Findings include: Review of the medical record for Resident #65 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia with behavioral disturbances, cognitive communication deficit, and unsteadiness on feet. Review of a quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #65 required extensive assistance of two people for transfers, walking in room, and locomotion on unit. Resident #65 was assessed as having one fall since admission or prior assessment. Review of a care plan dated 02/05/21, revealed Resident #65 was at risk for falls with the potential for injury related balance deficit, cognitive deficits, weakness, a history of falls, forgets to use safety devices, verbalizes dizziness, unable to transfer without assistance, impulsive, poor safety awareness, and dementia with behavioral disturbance. Interventions included anti-roll back device to wheelchair. Review of a physician order dated 03/15/21, revealed anti-roll backs to the wheelchair due to Resident #65's attempts at unassisted transfers. Observation on 11/17/21 at approximately 9:00 AM. of Resident #65 revealed the resident was sitting up in the wheelchair in the dining room. Observation of the wheelchair revealed there was no anti-roll back device on the resident wheelchair. Interview on 11/17/21 at 9:18 A.M. with registered nurse (RN) #290 verified Resident #65 had a physicians order for anti-roll back devices on the residents wheel chair. RN #280 further verified the anti-roll back device on the residents wheelchair was a care planned fall interventions. Observation completed during the interview with RN #290 verified there was no anti-roll back device on Resident #65's wheel chair. Interview on 11/17/21 at 10:10 A.M. with the director of maintenance revealed an anti-roll back device would not fit on the high back wheelchair for Resident #65 because of the way the chair was put together. Interview on 11/17/21 at 10:15 A.M. with the director of nursing (DON) revealed Resident #65 was switched to a high back wheelchair for comfort and positioning. The DON further revealed the anti-roll back device order should have been discontinued and the care plan updated when the resident was provided the high back wheel chair. 366189 Page 2 of 3 366189 11/18/2021 Vancrest of Delphos 1425 East Fifth Street Delphos, OH 45833

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medication administration observation, medical record review, staff interview, and manufacturer's instructions review, the facility failed to ensure insulin was administered as ordered by the physician and as instructed by the manufacturer resulting in a significant medication error. This affected one (#10) of one resident observed for insulin administration. The census was 74. Residents Affected - Few Findings include: Observation on 11/16/21 at 7:06 A.M. of licensed practical nurse (LPN) #280 preparing and administering insulin for Resident #10 revealed the basaglar kwikpen in the medication cart did not contain enough insulin for the nurse to administer the entire scheduled dose. LPN #280 went to the storage room, obtained another basaglar kwikpen, and returned to the medication cart. The observation revealed LPN #280 turned the dose knob on one kwikpen to seven units and turned the dose knob on the other kwikpen to 51 units. Continued observation revealed the nurse administered Resident #10 basaglar seven units and basaglar 51 units. The observation revealed LPN #280 did not prime either of the kwikpens prior to injecting the basaglar insulin. Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses includes diabetes mellitus type two, heart disease, and hypothyroidism. Review of a physician order dated 11/10/21, revealed Resident #10 was to be administered basaglar (insulin) kwikpen solution pen injector 100 units/milliliter (ml), inject 60 units subcutaneously one time a day related to diabetes mellitus type two. Interview on 11/16/21 at 7:08 A.M. with LPN #280 verified the basaglar insulin dose administered to Resident #10 was seven units from one kwikpen and 51 units from the other kwikpen which was not the correct dose of insulin. LPN #280 further verified the basaglar kwikpens were not primed prior to insulin administration. Review of basaglar kwikpen packaging instructions revealed the pen was to be primed (to remove the air from the needle and cartridge that may collect during normal use) before injection. It is important to prime your pen before each injection so that it will work correctly. To prime your pen- turn the dose knob to select two units. Hold your pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Continuing to hold the pen with needle pointing up push the dose knob in until it stops and zero is seen in the dose window, hold the knob in and count to five slowly. 366189 Page 3 of 3