Health inspection·May 12, 2022

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, resident interview, staff interview and policy review, the facility failed to ensure fall prevention interventions were in place for a resident who had a history of falls and was also known to be a fall risk as per the resident's plan of care. This affected one (Resident #42) of two residents reviewed for falls. The facility census was 44. Findings included: A review of Resident #42's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of falls, syncope and collapse (fainting), lack of coordination, muscle wasting and atrophy, history of seizures, essential tremors, morbid obesity, adult onset diabetes mellitus, hypertension, congestive heart failure and dementia. A review of Resident #42's physician's orders revealed she had an order that she could be up in a recliner or chair as tolerated. The only fall prevention intervention included as part of the physician's orders was for the use of a fall mat to the side of her bed while the resident was in bed. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate vision with the use of corrective lenses. She did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. She required an extensive assist of two for transfers and ambulation. A review of Resident #42's care plans revealed she had a care plan in place for being at risk for falls and fall related injuries related to abnormalities of her gait and mobility, history of a stroke, weakness, osteoarthritis, dementia, history of falls, poor safety awareness, medications, and diabetes mellitus. Her interventions included assisting the resident with a wheelchair or walker for mobility as needed and the use of Dycem (non-slip material used to prevent sliding out of a chair) to the seat of her wheelchair when up. That intervention had been in place since 01/18/22. On 05/10/22 at 10:20 A.M., an observation of Resident #42 noted her to be sitting up in her wheelchair in her room reading a book. She was noted to be sitting on a cushion while up in her wheelchair. An interview with the resident, at the time of the observation, revealed she did not have Dycem under her while in her wheelchair as per her fall prevention interventions. Dycem was found folded over and on top of another cushion that was sitting on top of her nightstand. She reported the Dycem was in her wheelchair when she was up yesterday but, was not placed in her wheelchair when they got her up earlier that day. Page 1 of 5 366249 366249 05/12/2022 Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/10/22 at 10:22 A.M., State Tested Nursing Assistant (STNA) #300 was asked to verify if Resident #42's Dycem was under her while she was sitting up in her wheelchair. She assisted the resident to a standing position and did not find the Dycem on top of her cushion or below the cushion the resident was sitting on. She acknowledged the Dycem was still on top of another cushion sitting on top of the resident's nightstand. She was asked how the nursing staff knew what fall prevention interventions were to be in place for each resident. She stated they got that information in report and also had a form on their STNA clipboard titled Resident Device List. She checked the Resident Device List for Resident #42 and reported Resident #42 was not identified as having the use of Dycem to her wheelchair. There was a box to check, if the resident had non-slip material in her seat, but that box was left unchecked. A review of the facility's Managing Falls and Fall Risk policy, revised March 2018, revealed the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. 366249 Page 2 of 5 366249 05/12/2022 Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695

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 and staff interview the facility pharmacist failed to identify medications ordered for a short time period included stop dates for administration. This affected one (Resident #11) of five reviewed for medications. The facility census was 44. Findings included: Review of Resident #11's medical record revealed an admission date of [DATE] with admission diagnoses that included schizoaffective disorder, bipolar disorder and anxiety. Review of the monthly physician's orders for medications revealed on [DATE], Resident #11 was prescribed the use of hydroxyzine (anti-anxiety medication) 50 milligrams (mg) every six hours as needed for 14 days for anxiety and agitation. Review of the Medication Administration Record (MAR) revealed no stop date was entered for the medication and was continued beyond the 14 days as ordered on [DATE]. The medication should have had an end date of [DATE]. Further review of the MAR revealed the last time the medication was administered was on [DATE], 30 days after the stop date. Review of the monthly pharmacy review and recommendations revealed monthly review completed on [DATE], [DATE] and [DATE]. The pharmacist did not identify and address the lack of stop date for the medication. Interview with the Director of Nursing on [DATE] at 3:00 P.M. verified the hydroxyzine was an active and current medication order on the MAR and should have ended after the 14 days expired as ordered by the physician on [DATE]. 366249 Page 3 of 5 366249 05/12/2022 Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to follow medication orders and discontinue an anti-anxiety medication as ordered by the prescriber. This affected one (Resident #11) of five reviewed for medications. The facility census was 44. Findings included: Review of Resident #11's medical record revealed an admission date of [DATE] with admission diagnoses that include schizoaffective disorder, bipolar disorder and anxiety. Review of the monthly physician's orders for medications revealed on [DATE], Resident #11 was prescribed the use of hydroxyzine (anti-anxiety medication) 50 milligrams (mg) every six hours as needed for 14 days for anxiety and agitation. Review of the Medication Administration Record (MAR) revealed no stop date was entered for the medication and was continued beyond the 14 days as ordered on [DATE]. The medication should have an end date of [DATE]. Further review of the MAR revealed the last time the medication was administered was on [DATE], 30 days after the stop date. Interview with the Director of Nursing on [DATE] at 3:00 P.M. verified the hydroxyzine was an active and current medication order on the MAR and should have ended after the 14 days expired as ordered by the physician on [DATE]. 366249 Page 4 of 5 366249 05/12/2022 Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and staff interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 5.1% and included two medication errors of 39 observed medication administration opportunities. This affected two residents (#38 and #95) of three residents observed during medication administration. Residents Affected - Few Findings included: 1. On 05/10/22 at 8:00 A.M. observation of medication administration with Registered Nurse (RN) #143 revealed medications administered to Resident #95. The observation revealed Vitamin B12 was not administered as ordered at the time of administration. Review of Resident #95's medical record revealed an admission date of 04/28/22 with diagnoses that included dementia and anemia. Review of the physician's medication orders revealed vitamin B12 (vitamin supplement) 500 micrograms (mcg) two tablets every day. Review of the Medication Administration Record (MAR) indicated vitamin B12 was to be administered every day at 8:00 A.M. On 05/11/22 at 9:00 A.M. interview with the Director of Nursing verified vitamin B12 was not administered to Resident #95 as ordered by the physician. 2. On 05/11/22 at 8:25 A.M. observation of medication administration with Licensed Practical Nurse (LPN) #151 revealed medications administered to Resident #38. The observation revealed omeprazole was not administered at the time of administration. Review of Resident #38's medical record revealed an admission date of 06/13/17 with diagnoses that included congestive heart failure, diabetes mellitus, Alzheimer's disease and gastroesophageal reflux disease (GERD). Review of the physician's medication orders revealed omeprazole (proton-pump inhibitor, medication for GERD) 20 milligrams (mg) every day for heartburn. Review of the MAR indicated omeprazole was to be administered every day at 8:00 A.M. On 05/11/22 at 8:55 A.M. interview with LPN #151 verified omeprazole not administered to Resident #38 as ordered by the physician. 366249 Page 5 of 5