Health inspection·May 7, 2021

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure a physician ordered pressure ulcer treatment was implemented timely for Resident #6. This affected one resident (#6) of three residents reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of Resident #6's medical record revealed an admission date of 05/02/18 with diagnoses including Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum, obesity, paraplegia, peripheral vascular disease and diabetes mellitus. Review of a bi-weekly skin check dated 12/24/20 revealed the resident had a Stage IV pressure ulcer to his sacrum but no alteration to his right heel. Review of the nursing progress notes revealed the resident had a hospital stay from 12/29/20 through 01/03/21. Upon his return from the hospital on [DATE], the return skin check identified an unstageable (full thickness tissue loss in which actual depth of the ulcer is obscured by eschar (dark, dead tissue) or slough (yellow, stringy dead cells)) pressure ulcer to the right heel. Review of the wound care notes completed by Physician #225 dated 01/05/21 revealed an unstageable pressure injury wound located on the right heel that was present on re-admission to the facility, 01/03/21. There were two spots of eschar (all measured together) at 2.4 centimeters in length by 3.2 centimeters in width with an undetermined depth with 50% eschar. There was no drainage and the peri wound area appeared dry. There were no signs of infection. The note revealed to please apply skin prep, cover with an ABD pad and wrap with Kerlix. Apply treatment every Tuesday, Thursday and Saturday and as needed. Review of the wound care notes completed by Physician #225 dated 01/12/21 revealed the unstageable pressure injury wound to the right heel was assessed and remained. The area was measured and the overall wound was determined to be healing. The physician ordered to apply skin prep, cover with ABD pad and wrap with Kerlix. The order for treatment was every Tuesday, Thursday, Saturday and as needed. Review of the physician's orders revealed no physician order for the treatment of skin prep, ABD and Kerlix on Tuesday, Thursday, Saturday and as needed until 01/16/21. Review of the treatment administration record revealed no evidence the treatment was initiated until 01/16/21. Page 1 of 7 366253 366253 05/07/2021 Amberwood Manor 245 South Broadway New Philadelphia, OH 44663

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/06/21 at 12:52 P.M. interview with Registered Nurse #200 verified the facility did not implement the physician ordered pressure ulcer treatment from 01/05/21 until 01/16/21. Review of the Pressure Injury Prevention and Treatment Policy, dated 07/17/13 and revised 09/18/20 revealed residents admitted with existing pressure injuries would receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection. Pressure injuries identified will be documented and orders obtained from the provider for treatment. 366253 Page 2 of 7 366253 05/07/2021 Amberwood Manor 245 South Broadway New Philadelphia, OH 44663

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. Based on record review and staff interview, the facility failed to ensure the prescribing physician provided resident specific rationale for declining pharmacy review recommendations, acted upon pharmacy recommendations timely and/or identified missed laboratory studies. This affected three resident (#9, #14 and #24) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 07/20/20 with diagnoses that included Alzheimer's disease with dementia, anxiety, major depression and psychotic disorder. Review of the monthly pharmacy review and recommendations revealed on 02/03/21 a recommendation to attempt a gradual dose reduction of both Seroquel and Risperdal (antipsychotic medications). On 03/26/21, the physician declined the recommendation, but did not provide any resident specific rationale for declining. On 05/05/21 at 11:20 A.M. interview with Registered Nurse (RN) #200 verified the pharmacy recommendation for Resident #14 was not acted upon timely and did not include a resident specific rationale documented by the physician for why the recommendation was declined. 2. Review of Resident #24's medical record revealed an admission date of 05/13/15 with diagnoses that included Alzheimer's disease with dementia, anxiety, depression and psychosis. Review of the monthly pharmacy review and recommendations revealed on 07/10/20 recommendations to attempt a gradual dose reduction of Klonopin (antianxiety medication) and Effexor (antidepressant medication). On 07/17/20, the physician declined the recommendation, but did not provide any resident specific rationale for declining. On 05/05/21 at 11:20 A.M. interview with RN #200 verified the pharmacy recommendation for Resident #24 did not include a resident specific rationale documented by the physician for why the recommendation was declined. 3. Review of Resident #9's medical record revealed an admission date of 02/10/18 with diagnoses including asthma, hypertension and shortness of breath. Review of the physician's orders revealed an order for laboratory testing, a weekly metabolic panel (BMP) initiated 11/23/20. Review of the laboratory testing results revealed no evidence of a BMP from February 2021 through 04/14/21. Review of the pharmacy recommendations from February 2021 to April 2021 revealed no evidence the pharmacist identified the missing laboratory testing to monitor the resident's electrolytes related to the routine administration of diuretic medications. 366253 Page 3 of 7 366253 05/07/2021 Amberwood Manor 245 South Broadway New Philadelphia, OH 44663

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/05/21 at 12:52 P.M. interview with RN #200 verified the pharmacist did not identify physician ordered laboratory testing for medication monitoring was not completed as ordered. RN #200 revealed this was part of the monthly pharmacy review and should have been identified. In addition, review of the pharmacy recommendation, dated 01/08/21 revealed Resident #9 takes a medication containing an inhaled corticosteroid, Symbicort with recommendations to rinse the mouth with water after use. Do not swallow. Record review revealed no response to this recommendation. Review of the pharmacy recommendation, dated 04/09/21 again recommended the resident rinse mouth with water after use. Do not swallow. The recommendation was not addressed until 05/04/21 when the physician ordered to rinse the mouth after and do not swallow. Record review revealed Resident #9 had a physician order for Symbicort aerosol 160-mcg/ACT two puffs twice a day for asthma. On 05/05/21 at 12:49 P.M. interview with RN #200 verified the pharmacy recommendation was not addressed timely in January 2021 or April 2021. RN #200 revealed once she saw it had not been addressed, the physician was immediately contacted. 366253 Page 4 of 7 366253 05/07/2021 Amberwood Manor 245 South Broadway New Philadelphia, OH 44663

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure Resident #9, who received routine diuretic medication had laboratory testing completed as ordered to monitor for the effectiveness and correct dosage of the medication and to monitor the resident's potassium level. This affected one resident (#9) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Review of Resident #9's medical record revealed an admission date of 02/10/18 with diagnoses including asthma, hypertension and shortness of breath. Review of the physician's medication orders revealed an order, dated 11/20/20 for Torsemide (a diuretic) 20 milligrams give two tablets daily for edema. On 01/21/21 an order was obtained for Metolazone (a diuretic) five mg once a day. Both medications have the potential to cause electrolyte imbalances. Review of the physician's orders revealed an order for laboratory testing, including a weekly metabolic panel (BMP), initiated 11/23/20. Review of the laboratory testing results revealed no BMP had been completed from February 2021 through 04/14/21. On 04/16/21 the resident was started on Potassium 20 milliequivalents once a day after the resident's BMP on 04/14/21 identified the resident's potassium level was low (a complication of routine diuretic use). On 05/05/21 at 12:49 P.M. interview with Registered Nurse #200 verified the laboratory testing (BMP) had not been completed as ordered for Resident #9 from February 2021 until 04/14/21 to ensure the resident's electrolytes were being monitored related to the administration of diuretic medication. 366253 Page 5 of 7 366253 05/07/2021 Amberwood Manor 245 South Broadway New Philadelphia, OH 44663

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. Based on record review and staff interview the facility failed to appropriately monitor Resident #14 who received psychotropic medications for resident specific behaviors. This affected one resident (#14) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #14's medical record revealed an admission date of 07/20/20 with diagnoses that included Alzheimer's disease with dementia, anxiety, major depression and psychotic disorder. Review of the physician medication orders revealed an order for Seroquel (antipsychotic medication) 25 milligrams (mg) in the morning and 50 mg at night and Remeron (antidepressant medication) 7.5 mg every night. Review of the plan of care for Resident #14 revealed care plans in place for antipsychotic and antidepressant therapy. The antidepressant care plan interventions included monitor for suicidal ideations and medication side effects. However, no specific resident behaviors were identified. The antipsychotic therapy care plan interventions included monitor and report target behavior symptoms but were not identified specific to the resident. Further review of the medical record revealed no evidence of any resident specific behaviors identified or being monitored. On 05/05/21 at 11:20 A.M. interview with Registered Nurse (RN) #200 verified there were no resident specific behaviors identified or monitored for Resident #14 related to the psychoactive medications the resident was prescribed. 366253 Page 6 of 7 366253 05/07/2021 Amberwood Manor 245 South Broadway New Philadelphia, OH 44663

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review, menu review, diet card review and interview the facility failed to ensure Resident #9 was provided a diet as ordered. This affected one resident (#9) of 12 residents who received meals on the south wing meal cart. The facility census was 31. Findings include: Review of Resident #9's medical record revealed a physician order dated 03/09/21 for double protein (for each meal). Review of the 05/05/21 lunch menu revealed the planned menu included three ounces of savory pork roast, pork gravy, au gratin potatoes, braised cabbage and mud pie On 05/05/21 at 11:53 A.M. Dietary Supervisor (DS) #105 was observed to plate Resident #9's lunch meal which consisted of one slice of savory pork roast with gravy, au gratin potatoes, cabbage, mud pie and bread with butter. Review of the resident's meal card/tray ticket revealed the resident was to receive double protein with meals. On 05/05/21 at 11:56 A.M. DS #105 informed Dietary [NAME] (DC) #128 the trays were ready to be taken to the floor and DC #128 began to push the trays from the steam table area. The surveyor asked DS #105 to please check Resident #9's tray with her ticket to ensure she would receive the correct diet as indicated on her meal ticket. DS #105 pulled the resident's tray and reviewed the ticket and verified the resident did not have a double protein as indicated on the ticket. DS #105 placed a second slice of pork roast on the resident's plate and the trays were sent out to the unit. On 05/05/21 at 12:55 P.M. interview with Resident #9 revealed she received two slices of pork roast on her lunch tray this date. The resident stated she did not always receive double portions of protein with her meals. 366253 Page 7 of 7