Health inspection·February 28, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to issue a written notice of the reasoning for transfer to the hospital to the resident and/or resident representative. This affected two (#11 and #39) of two residents reviewed for hospitalizations. The facility census was 42. Findings include: 1. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance, Alzheimer's disease, left leg pain, expressive language disorder, repeated falls, urinary tract infection and generalized abdominal pain. Review of the admission Minimum Data Set (MDS) assessment, dated 10/01/18 revealed the resident had severe cognitive impairment. Review of progress notes revealed Resident #11 was transferred to the hospital via emergency squad on 10/18/18. The progress notes indicated the resident's daughter was aware when the resident was sent to the hospital. The resident was noted return to the facility on [DATE] at 5:16 P.M. 2. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance,rheumatica, benign prostatic hyperplasia without lower urinary symptoms, type two diabetes mellitus, right knee pain, left knee pain, falls and bilateral artificial knee joints. Review of the nursing admission note dated 01/10/19 revealed Resident #39 was alert and oriented to person only. Review of the medical record revealed Resident #39 was transferred to the hospital by emergency personnel on 01/13/19. The resident had not returned to the facility as of the exit date of the survey on 02/28/19. There was no evidence in the medical records for Resident #11 and #39 that their representatives were provided written notice for the reason for transfer to the hospital. Interview on 02/26/19 at 4:00 P.M. with the Executive Director confirmed the facility did not issue a written notice of the transfer to the hospital to Resident #11 or Resident #39's representative regarding the residents' discharge to the hospital respectively on 10/18/18 and 01/13/19. Page 1 of 8 366252 366252 02/28/2019 Meadows of Leipsic 901 East Main Street Leipsic, OH 45856

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Regional Nurse #200 on 02/27/19 at 1:45 P.M. further confirmed the facility did not issue a written notice of reasoning for transfer to the hospital to the residents and/or representative. Review of the facility's policy on transfer/discharge policy, dated 11/2016, with a revision date of 3/2017, revealed when a resident was discharged or transferred from the facility, the reason for the discharge/transfer will be documented in the medical record. 366252 Page 2 of 8 366252 02/28/2019 Meadows of Leipsic 901 East Main Street Leipsic, OH 45856

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy the facility failed to provide the resident and/or representative of written notification of bed hold availability upon transfer of the resident to a hospital. This affected two residents (#11 and #39) of two residents reviewed for hospitalization. The facility census was 42. Findings include: 1. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance, Alzheimer's disease, left leg pain, expressive language disorder, repeated falls, urinary tract infection and generalized abdominal pain. Review of the admission Minimum Data Set (MDS) assessment, dated 10/01/18 revealed the resident had severe cognitive impairment. Review of progress notes revealed Resident #11 was transferred to the hospital via emergency squad on 10/18/18. The progress notes indicated the resident's daughter was aware when the resident was sent to the hospital. The resident was noted return to the facility on [DATE] at 5:16 P.M. 2. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance,rheumatica, benign prostatic hyperplasia without lower urinary symptoms, type two diabetes mellitus, right knee pain, left knee pain, falls and bilateral artificial knee joints. Review of the nursing admission note dated 01/10/19 revealed Resident #39 was alert and oriented to person only. Review of the medical record revealed Resident #39 was transferred to the hospital by emergency personnel on 01/13/19. The resident had not returned to the facility as of the exit date of the survey on 02/28/19. There was no evidence in the medical records for Resident #11 and #39 that their representatives were provided written notice of the facility's bed hold policy at the time of transfer to the hospital. Interview on 02/26/19 at 4:00 P.M. with the Executive Director confirmed the facility did not issue a written notice of the facility's bed hold policy to Resident #11 or Resident #39's representative regarding the residents' transfer to the hospital respectively on 10/18/18 and 01/13/19. Interview with Regional Nurse #200 on 02/27/19 at 1:45 P.M. further confirmed the facility did not issue a written notice of the facility's bed hold policy to the resident's and/or representative's. Review of the facility's policy on transfer/discharge policy, dated 11/2016, with a revision date of 3/2017, revealed when a resident was discharged or transferred from the facility, the reason for the discharge/transfer will be documented in the medical record. If the resident was being 366252 Page 3 of 8 366252 02/28/2019 Meadows of Leipsic 901 East Main Street Leipsic, OH 45856

F 0625 Level of Harm - Minimal harm or potential for actual harm transferred to an acute care hospital and plans to return to the facility, the bed hold policy will be reviewed with the resident and/or resident representative at time of transfer or as soon as practicable. If the transfer was emergent, the facility will attempt to reach the resident/ resident representative within 24 hours of the transfer to discuss the bed hold policy. Residents Affected - Few 366252 Page 4 of 8 366252 02/28/2019 Meadows of Leipsic 901 East Main Street Leipsic, OH 45856

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, staff interview, observation and review of a facility policy, the facility failed to ensure accurate and timely revision of a resident's care plan. This affected one (Resident #16) of fifteen residents reviewed for care plan revision. The facility census was 42. Findings include: Review of Resident #16's medical record revealed an admission date of 08/14/18. The resident was discharged on 12/24/18 and returned on 12/27/18. Medical diagnoses included displaced fracture of base of neck of left femur, dementia with behaviors, pain left hip, repeated falls, visual hallucinations, altered mental status and cognitive communication deficit. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe impairment in cognition. The resident required extensive assistance with two plus staff for bed mobility, transfers, toilet use, and locomotion. Review of the resident's care plan created 08/24/18, with the last revision date of 02/25/19, revealed the resident was at risk for falling. On 08/29/18, an intervention was implemented for a defined perimeter mattress (DPM) to help the resident identify the edges of the bed. Review of the resident's nursing admission assessment observation and data collection form dated 12/27/18 revealed the resident was at risk for falls and required interventions of a wheelchair and a low bed. DPM was not indicated at that time. Observation of Resident #16 resting in bed on 02/25/19 at 9:47 A.M. and 11:48 A.M., 02/26/19 at 12:49 P.M., and on 02/27/19 at 10:37 A.M. revealed he had a regular mattress. Interview with the Director of Nursing on 02/27/19 at 4:10 P.M. verified the resident's current fall care plan included an intervention of a DPM dated 08/29/18. She stated the DPM should have been discontinued when the resident returned to the facility on [DATE] per the nursing admission assessment. She verified the care plan was not revised to reflect the current interventions for the resident. Review of a facility policy titled Comprehensive Care Plan Guideline, effective 05/22/18, revealed the comprehensive care plan should be reviewed no less than quarterly with the completion of the Omnibus Budget Reconciliation Act (OBRA) assessment, and revised to reflect changes in the resident's condition as they occur. If a resident is readmitted to the campus, the previous care plan will be reviewed and updated to meet the resident's current needs. If a previous care plan is no longer needed, it will be resolved from the active care plans. 366252 Page 5 of 8 366252 02/28/2019 Meadows of Leipsic 901 East Main Street Leipsic, OH 45856

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's Legionella policy and staff interview, the facility failed to develop a facility water risk assessment for Legionella. This had the potential to affect all 42 residents residing in the facility. Residents Affected - Many Findings include: Review of an undated facility document titled Legionella and Other Opportunistic Pathogens revealed the Director of Plant Operations (DPO) will maintain documentation that describes the facility's water system. A risk assessment of water system components will be conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The risk assessment will be completed by facility leadership and the infection preventionist with collaboration from other facility team members such as maintenance employees, safety officers, risk and quality management staff, and the Director of Nursing. Based on the risk assessment, control measures will be established to address potential hazards. Further review of the facility Legionella documentation revealed the facility did not complete a risk assessment of water system components. Interview with the Administrator on 02/28/19 at 3:32 P.M. verified the facility had not completed a risk assessment of the water system to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. 366252 Page 6 of 8 366252 02/28/2019 Meadows of Leipsic 901 East Main Street Leipsic, OH 45856

F 0881 Implement a program that monitors antibiotic use. 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, review of the facility infection control log, staff interview, and review of a facility policy, the facility failed to ensure the antibiotic stewardship program was implemented when a resident did not have adequate indication for antibiotic usage. This affected one (Resident #11) of seven residents reviewed during the antibiotic stewardship program review. The had the potential to affect all 42 residents residing in the facility. Residents Affected - Many Findings include: Review of Resident #11's medical record revealed the resident was admitted [DATE]. Medical diagnoses included dementia, Alzheimer's disease and urinary tract infection. Continued review of the resident's medical record revealed the resident was diagnosed with a urinary tract infection on 10/12/18 with the organism identified as Escherichia coli (E. coli). The resident was treated with Cefuroxime (antibiotic) until 10/20/18. On 11/29/18, the resident was diagnosed with a urinary tract infection with the organism identified as Enterococcus faecalis (e. faecalis). The resident was treated with ciprofloxacin (antibiotic) until 12/04/18. Further review of the resident's medical record revealed an entry dated 10/17/18 indicating the resident's daughter was requesting a prophylactic antibiotic. She stated if the facility medical director would not order the prophylactic antibiotic, she would switch to a different physician. Continued review revealed no evidence the resident or resident's family was educated regarding the use of prophylactic antibiotics. The resident remained on prophylactic Cephalexin. Review of a pharmacy recommendation dated 01/14/19 revealed the pharmacist requested additional information regarding the use of Cephalexin for Resident #11. The recommendation indicated the use of antibiotics should be limited to confirmed or suspected bacterial infection based on the presence of symptoms. Prophylactic use of any antibiotic was discouraged due to risk of side effects and bacterial resistance. If the current therapy was to be continued, please document the reasoning below, and that the risks versus benefits have been considered. On 01/21/19, the physician responded due to recurrent urinary tract infections, risks/benefits reviewed. Review of a facility fax to the physician dated 02/20/19 revealed the Director of Nursing (DON) stated the resident was still on Cephalexin 250 milligrams (mg.) daily since 12/14/18. The resident's chest x-ray dated 12/14/18 was negative. Resident was asymptomatic of respiratory concerns. Centers for Medicare & Medicaid Services (CMS) guidelines for long term care facility for antibiotic use requires positive lab cultures or positive chest x-ray. She asked if the facility could discontinue Cephalexin. Then stated if you would like to continue prophylactic use of Cephalexin please provide diagnosis for prophylactic use. The physician responded it was not for her lungs. She has been on it long term for prophylaxis. Interview with the DON on 02/28/19 at 12:35 P.M. verified Resident #11 was on a prophylactic antibiotic for a urinary tract infection. She verified there was no clinical indication for the use of the Cephalexin long term. She verified there was no documentation indicating Resident #11's family was educated regarding the use of prophylactic antibiotics. She stated the facility medical director would not order the prophylactic antibiotic, so the resident's family obtained a different physician. 366252 Page 7 of 8 366252 02/28/2019 Meadows of Leipsic 901 East Main Street Leipsic, OH 45856

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the January facility infection control log revealed Resident #11 received Cephalexin (antibiotic medication) 250 milligrams (mg.) orally once daily since 12/14/18. The infection type and organism were listed as not applicable (N/A). The antibiotic was identified as a prophylactic antibiotic and the end date was listed as indefinite. Review of a facility policy titled Antibiotic Stewardship effective 11/10/17 revealed the purpose of the policy was to optimize the treatment of infections by ensuring residents who require an antibiotic, are prescribed the appropriate antibiotic. Reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. 366252 Page 8 of 8