Health inspection·February 6, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff interview, and policy review, the facility failed to administer medications as ordered. This affected four (#2, #3, #17, and #25) out of the four residents reviewed for medication administered as ordered. The facility census was 66. Findings included: 1. Review of the medical record for Resident #2 revealed an admission date of 04/16/21 with medical diagnoses of cerebral infarction with right hemiparesis, dementia, depression, and anxiety. Review of the medical record for Resident #2 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #2 had moderate cognitive impairment and required substantial staff assistance with bathing, bed mobility, and transfers, and was independent with eating. Review of the medical record for Resident #s revealed physician orders dated 03/07/22 for ferrous sulfate 325 milligram (mg) one tablet by mouth two times per day, 12/03/19 for Dilantin 100 mg one capsule by mouth three times per day, 10/30/19 for fish oil 1200 mg one capsule by mouth three times per day, 09/12/21 for atorvastatin 10 mg one tablet by mouth daily, 10/30/19 for Zoloft 50 mg take one and one half tablet daily, 10/30/19 for protonix 40 mg on tablet by mouth daily, and 01/07/23 for Nuedexta 20-10 mg one capsule by mouth two times per day. Review of the medical record for Resident #2 revealed the Medication Administration Records (MAR) for January 2024 which did not contain documentation to support the following medications were administered: ferrous sulfate 325 milligram (mg) one tablet by mouth on 01/08/24 and 01/22/24, Dilantin 100 mg one tablet by mouth on 01/08/24, 01/21/24, and 01/22/24, fish oil 1200 mg one tablet by mouth on 01/22/24, atorvastatin 10 mg one tablet by mouth on 01/08/24, Zoloft 50 mg one tablet by mouth on 01/08/24, and protonix 40 mg one tablet by mouth on 01/08/24. Further review of the medical record for Resident #2 revealed the February 2023 MAR which did not contain documentation to support Resident #2's Nuedexta 20-20 mg one capsule by mouth on 02/05/24. 2. Review of the medical record for Resident #3 revealed an admission date of 11/03/22 with medical diagnoses of chronic obstructive pulmonary disease (COPD), psychotic disorder with delusions, dementia, anxiety, and gastric esophageal reflux disease (GERD). Review of the medical record for Resident #3 revealed a quarterly MDS, dated [DATE], which indicated Resident #3 had severely impaired cognition and was independent with toileting, bed mobility, transfers and required supervision with bathing. Page 1 of 5 366235 366235 02/06/2024 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the medical record for Resident #3 revealed physician orders dated 10/24/23 for Buspar 10 mg one tablet by mouth three times per day, 11/03/22 for Advair disc 500/50 use one puff daily, 01/10/24 for Namenda 10 mg one tablet by mouth every evening, and Zoloft 125 mg one tablet by mouth every evening. Review of the medical record for Resident #3 revealed the January 2024 MAR did not contain documentation to support the following medications were administered as ordered: Namenda 10 mg tablet by mouth on 01/17/24 and 01/30/24, Zoloft 125 mg one tablet by mouth on 01/17/24, Advair disc one puff on 01/17/24, and Buspar 10 mg one tablet by mouth on 01/08/24. 3. Review of the medical record for Resident #17 revealed an admission date of 06/06/15 with medical diagnoses of cerebral infarction with left hemiparesis, chronic pain syndrome, diabetes mellitus, and depression. Review of the medical record for Resident #17 revealed a quarterly MDS, dated [DATE], which indicated Resident #17 was cognitively intact and required substantial staff assistance with toilet hygiene, bathing, and bed mobility. Review of the medical record for Resident #17 revealed physician orders dated 06/06/15 for metoprolol 25 mg by mouth one tablet two times per day, 09/04/18 for simvastatin 20 mg one tablet by mouth daily, 06/06/15 Novolog insulin to be administered per sliding scale instructions of blood sugar levels of 0-139 none, 140-189 one unit, 190-239 three units, 240-289 five units, 290-339 seven units, 340-389 nine units, readings less than 70 or greater than 389 facility to call physician for orders. Review of the medical record for Resident #17 revealed the January 2024 MAR which did not contain documentation to support the following medications were administered as ordered: metoprolol 25 mg one tablet by mouth on 01/04/24, simvastatin 20 mg one tablet by mouth on 01/14/24, and Novolog insulin per sliding scale on 01/20/24, 01/17/24, and 01/18/24. 4. Review of the medical record for Resident #25 revealed an admission date of 01/25/24 with medical diagnoses of right femur fracture, diabetes mellitus, hypertension, hypothyroidism, and depression. Review of the medical record for Resident #25 revealed an admission nursing screener completed 01/25/24 which indicated Resident #25 was alert and oriented to person, place, and time and required extensive staff assistance with bed mobility, transfers, and toileting. Review of the medical record for Resident #25 revealed physician orders dated 01/25/24 for glipizide 10 mg one tablet by mouth two times per day, Levemir eight units inject subcutaneous (SQ) daily, Actos 30 mg one tablet by mouth daily, ranolazine 500 mg one tablet by mouth two times per day, senna 8.6 mg two tablets by mouth daily, Synthroid 125 micrograms one tablet by mouth daily, and acetaminophen 325 mg two tablets by mouth four times per day. Review of the medical record for Resident #25 revealed the January 2024 MAR did not contain documentation to support the following medications were administered as ordered: glipizide 10 mg on tablet by mouth on 01/31/24, Levemir inject eight units SQ daily on 01/30/24, Actos 30 mg one tablet by mouth on 01/30/24, ranolazine 500 mg one tablet by mouth on 01/30/24, senna 8.6 mg two tablets by mouth on 01/30/24, Synthroid 125 micrograms one tablet by mouth on 01/31/24, and acetaminophen 325 mg two tablets by mouth on 01/30/24. 366235 Page 2 of 5 366235 02/06/2024 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/05/24 at 3:10 P.M. with Director of Nursing (DON) confirmed the medical records for Residents #2, #3, #17, and #25 did not contain documentation to support the residents received their medications as ordered in January and February 2024. Review of the facility policy titled Medication Administration stated all medications must be administered in accordance with the written orders of the attending physician. This deficiency represents non-compliance investigated under Complaint Number OH00150230. 366235 Page 3 of 5 366235 02/06/2024 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record reviews, and policy review, the facility failed to ensure medications were administered as ordered resulting in two medication errors out of 33 opportunities or six percent (%) medication error rate. This affected two (#2 and #17) out of the three residents observed for medication administration. The facility census was 66. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #17 revealed an admission date of 06/06/15 with medical diagnoses of cerebral infarction with left hemiparesis, chronic pain syndrome, diabetes mellitus, and depression. Review of the medical record for Resident #17 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #17 was cognitively intact and required substantial staff assistance with toilet hygiene, bathing, and bed mobility. Review of the medical record for Resident #17 revealed a physician order dated 07/24/18 for lisinopril 20 milligram (mg) one tablet by mouth daily for blood pressure. Observation with interview on 02/05/24 at 9:10 A.M. of Licensed Practical Nurse (LPN) #117 administering medications to Resident #17 revealed the Lisinopril 20 mg one tablet was not administered as ordered. LPN #117 confirmed the Lisinopril was not in the medication cart and was not administered to Resident #17 was ordered. 2. Review of the medical record for Resident #2 revealed an admission date of 04/16/21 with medical diagnoses of cerebral infarction with right hemiparesis, dementia, depression, and anxiety. Review of the medical record for Resident #2 revealed a quarterly MDS, dated [DATE], which indicated Resident #2 had moderate cognitive impairment and required substantial staff assistance with bathing, bed mobility, and transfers, and was independent with eating. Review of the medical record for Resident #2 revealed a physician order dated 01/07/23 for Nuedexta (administered for neurological conditions) 20-10 mg one capsule by mouth two times per day. Observation with interview on 02/05/24 at 9:22 A.M. of LPN #117 administering medications to Resident #2 revealed the Nuedexta 20-10 mg capsule was not administered as ordered. LPN #117 confirmed the Nuedexta was not in the medication cart and the medication was not administered to Resident #2 as ordered. Interview on 02/05/24 at 1:05 P.M. with Director of Nursing (DON) stated all medications are to be reordered from the pharmacy when there is a week supply left so that the facility has medications in stock to administer to all residents. Review of the facility policy titled, Medication Administration, stated medications must be administered in accordance with the written orders of the attending physician. This deficiency represents non-compliance investigated under Complaint Number OH00150230. 366235 Page 4 of 5 366235 02/06/2024 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0880 Provide and implement an infection prevention and control program. 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, observation, staff interviews, and policy review, the facility failed to follow infection control guidelines when performing incontinence care. This affected one (#53) out of three residents reviewed for incontinence care. The facility census was 66. Residents Affected - Few Findings included: Review of the medical record for Resident #53 revealed an admission date of 12/02/16 with medical diagnoses of Alzheimer's disease, macular degeneration, peripheral vascular disease, and anxiety. Review of the medical record for Resident #53 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #53 had severe cognitive impairment and was dependent for toilet hygiene, bed mobility, transfers, eating, and bathing. The MDS indicated Resident #53 was always incontinent of bladder and bowel. Observation on 02/06/24 at 12:51 P.M. revealed Registered Nursing (RN) #108 and Stated Tested Nursing Assistant (STNA) #106 completed incontinence care for Resident #53. The observation revealed STNA #106 cleansed Resident #53 peri area with cleansing wipes and then proceeded to cleanse Resident #53's buttocks. As STNA #106 was cleaning Resident #53 stool was noted on the cleansing wipes. STNA #106 properly disposed of soiled cleansing wipes and soiled depends. STNA #106 proceeded to apply barrier cream to Resident #53's buttocks and then applied a clean depends. The observation revealed STNA #106 did not remove her gloves or perform hand hygiene after she performed incontinence care for Resident #53 or prior to the application of the barrier cream and clean depends. Interview on 02/06/24 at 1:26 P.M. with STNA #106 confirmed she did not perform hand hygiene or change gloves after completing incontinence care for Resident #53 and prior to application of barrier cream and clean depends. Interview on 02/06/24 at 2:32 P.M. with Infection Control Nurse #157 confirmed during incontinence care, staff are to remove soiled gloves, wash hands, and then apply clean gloves prior to application of barrier creams and clean depends. Review of the policy titled, Infection Control, dated 03/19/21, stated the facility believed good, basic hygiene was the most powerful weapon against infection, particularly with respect to hand washing. The policy stated all staff members should wash their hands after handling any body fluids or soiled items. This deficiency represents non-compliance investigated under Complaint Number OH00150806. 366235 Page 5 of 5