Health inspection·May 24, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - 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 Resident #28 was provided prompt and necessary medical treatment following an unwitnessed fall with serious injury. Residents Affected - Few Actual Harm occurred on 05/02/23 when Resident #28, who was severely cognitively impaired, did not receive timely treatment and services following a fall. The resident complained of pain (initially beginning on 05/02/23 at 12:00 P.M.) and continued to complain of pain in the right hip throughout 05/03/23. The resident had limited weight bearing and a decrease in range of motion (ROM) to the right lower extremity (RLE). The resident was not transferred to the hospital until 05/03/23 at 4:04 P.M. where he was treated for a fractured right femur. This affected one resident (#28) of three residents reviewed for falls. Findings include: Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, difficulty in walking, convulsions, hearing loss, tricuspid valve disorder, major depressive disorder, and anxiety. The resident resided in the secured dementia care unit. Review of the plan of care, dated 06/27/22, revealed Resident #28 was at risk for falls related to dementia, difficulty walking, hypertension, advanced age, and medications. Interventions included to ensure the call light was within reach and to encourage the resident to use it for assistance, and to encourage and assist as needed to reapply appropriate footwear. Further review of the plan of care, dated 07/11/22, revealed the resident had pain related to generalized discomfort. Interventions included to evaluate the effectiveness of pain interventions, to review for compliance, alleviation of symptoms, and to notify the physician if interventions were unsuccessful or if current complaint is a significant change from resident's past experience. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/25/23, revealed the resident had severely impaired cognition with no behaviors or rejection of care. The resident required extensive, one-person physical assistance for bed mobility, and supervision of one-person for walking in his room, transfers, dressing, personal hygiene, and toileting. The assessment indicated there were no falls since admission or the prior assessment. Review of a nursing progress note, authored by Licensed Practical Nurse (LPN) #195, dated 05/02/23 at 10:20 A.M., revealed staff reported they heard a loud sound and entered the room and observed the resident standing from the floor with his briefcase full of art supplies which had tipped over and Page 1 of 6 366285 366285 05/24/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0684 Level of Harm - Actual harm Residents Affected - Few spilled on the floor. Both arms were bleeding and the resident rubbed the right side of his head. Nurse Practitioner (NP) #300 was in the facility and assessed the resident. The resident denied pain and moved all extremities. There were skin tears noted to the right elbow and the left arm, steri-strips were applied. The resident was able to bear his own weight and neurological checks were within normal limits. The resident stated he got out of bed to walk over to the dresser, and became dizzy after standing up, and lost his balance. Orthostatic blood pressure monitoring was ordered for three days. Review of a nursing progress note, dated 05/02/23 at 12:00 P.M., revealed the resident complained of right hip discomfort. The DON and NP were notified and an order was received for an x-ray of the right hip and pelvis. Review of a nursing progress note, dated 05/02/23 at 2:31 P.M., revealed resident was wincing and yelling out while moving in bed. The resident stated he was not in enough pain to do something about it quite yet. The note indicated staff would continue to monitor. Review of the nursing progress note, dated 05/02/23 at 3:45 P.M., revealed staff reported the resident yelled out and when entering the room, resident was sitting on the floor, on the left side of his floor. The resident was wearing gripper socks and the call light was within reach. The note indicated the resident was moving all extremities without difficulty. Blood pressure was 146/80, temperature 98.1, pulse 76, and respirations were 22. The resident was assisted to a wheelchair for safety and brought out of the room to the dayroom for closer monitoring. The DON updated the NP and the resident's wife. Neurological checks were completed. The note also reflected an x-ray of the right hip/pelvis was negative earlier today. Review of a facility Fall Investigation, dated 05/02/23 at 3:45 P.M., revealed staff heard yelling and entered the room and found Resident #28 sitting on the floor beside the left side of bed. The resident stated he was getting out of bed from taking a nap and his legs gave out and he sat on floor. The fall investigation indicated the risk factors were impaired cognition, gait disturbance, functional loss, and unassisted transfer. The fall investigation indicated the resident refused his medications and the staff's last involvement with the resident was at 3:00 P.M. when an x-ray was obtained and at 3:15 P.M. when the resident used a urinal. A weekly review by the falls committee/administration, dated 05/03/23, indicated the cause was accurately identified. Further review of the fall investigation revealed that it did not include the name/names of the staff who observed the resident on the floor following the fall. Review of the nursing progress note, dated 05/02/23 at 4:41 P.M., revealed Resident #28 complained of right hip pain and received Tylenol 650 milligrams (mg). Review of a nursing progress note, dated 05/03/23 at 2:31 A.M., revealed the resident complained of pain in the right hip and stated, it only hurts when I move it and would not move the right leg without assistance. Review of a nursing progress note, dated 05/03/23 at 3:03 A.M., revealed the resident refused to have blood drawn for labs. Review of a nursing progress note, dated 05/03/23 at 8:21 A.M. revealed the resident refused medications, despite education and encouragement with multiple attempts. 366285 Page 2 of 6 366285 05/24/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0684 Level of Harm - Actual harm Residents Affected - Few Review of a nursing progress note, dated 05/03/23 at 8:31 A.M., revealed the resident was lying in bed with the head of bed elevated to approximately 45 degrees. The resident was overheard talking to himself in the room stating at 9:00 o'clock, the doctor is going to fix my hip. Pain medication offered and refused. Encouragement and education provided. Resident stated he cannot get up due to the amount of pain in his right hip. Review of a nursing progress note, dated 05/03/23 at 8:35 A.M., revealed the resident refused to move from his current position to obtain orthostatic blood pressure (BP). BP obtained from a sitting position and was 156/64. Review of nursing progress note, dated 05/03/23, at 10:17 A.M., revealed yesterday (05/02/23), about one hour after second fall, the resident verbalized that he needed to use the bathroom to urinate and pointed that he wanted to go to the bathroom. The resident stood with two assist and used handrail to pull himself up in bathroom, however, before he could sit down on toilet, he was incontinent of urine. Peri-care was provided and the resident was assisted back to wheelchair and brought up to the day room to be closely monitored as he tried to stand up unassisted several times. Call light was within reach and urinal was provided as transferring to the toilet was difficult due to the weakness of legs. Today, the resident was still having pain to the right hip and staff reported the resident would not get out of bed due to pain, however, he was refusing Tylenol. The DON updated medical provider and received an order to repeat the x-ray of the right hip and obtain an x-ray of the left hip. Review of an Occupational Therapy (OT) evaluation and plan of treatment assessment, dated 05/03/23 at 11:23 A.M., revealed the resident resided in the dementia unit with two recent falls within 24 to 48-hour period with injuries of a skin tear and a head contusion. X-rays thus far had been negative of the pelvic and right hip. OT provided a wheelchair after the first fall. After the second fall, the resident was lying next to his bed and after the first fall, he was near the dresser. At the end of the evaluation and treatment, therapy recommended doing another x-ray as the resident was having pain and was non-weight bearing during transfers and mobility. The DON stated they were ordering more x-rays. Review of a Physical Therapy (PT) evaluation and plan of treatment assessment, dated 05/03/23 at 2:22 P.M., revealed the reason for referral due to new onset of decrease in functional mobility, decrease in strength, resident resides in the dementia unit, with two recent falls within 24 to 48-hour period. Right hip pain, skin tear to upper extremities, and head contusion. Pelvic and right hip x-rays both negative. Nursing reported additional x-rays were being ordered due to second fall and resident continuing to complain of pain and limited right, lower extremity weight bearing. Review of a nursing progress note, dated 05/03/23 at 3:07 P.M., revealed the resident had pain located in the right hip and was refusing to move, stating that he was in too much pain. Pain medication was offered numerous times, but the resident refused. Review of a nursing progress note, dated 05/03/23 at 3:48 P.M., revealed x-ray results received and order received from NP to send the resident to the emergency room. Review of a nursing progress note, dated 05/03/23 at 4:07 P.M., revealed 911 in facility and exited with the resident via stretcher at 4:04 P.M. Review of the x-ray report, dated 05/03/23, revealed the resident had limited ROM for positioning. 366285 Page 3 of 6 366285 05/24/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0684 The result revealed an acute fracture through the proximal right femur. Level of Harm - Actual harm Review of an Emergency Department After Visit Summary, dated 05/03/23, revealed the diagnosis was an accidental fall resulting in a closed, displaced subtrochanteric fracture of the right femur, leukocytosis, and hyponatremia. The resident was referred to orthopedics for a visit as soon as possible, or within three days. The resident was to remain non-weight bearing for the next several months. Hydrocodone-Acetaminophen 5-325 mg was ordered for severe pain. Residents Affected - Few During interview on 05/24/23 at 1:34 P.M., OT #34 revealed she walked into Resident #28's room and there were four to five other staff members present. Resident #28 was lying flat on his back, near his bed. OT #34 suggested placing a pillow under the resident's head for support. The resident was assisted up from the floor and placed into a wheelchair. OT #34 stated that she anticipated the resident would be sent to the emergency room and suspected a fracture because he was yelling out and appeared to be in excruciating pain and was completely non-weight bearing on the right leg. During interview on 05/24/23 at 1:57 P.M., NP #300 revealed she was not notified of Resident #28's ongoing hip pain, refusal of medications and lab work, or his decreased range of motion following his second fall on 05/02/23. NP #300 stated she was not notified of the resident's continued complaints of right hip pain until 05/03/22, and at that time ordered another x-ray. During interview on 05/24/23 at 2:24 P.M., LPN #206 revealed she was Resident #28's nurse on 05/02/23. LPN #206 stated she heard someone call for the nurse and she responded and observed Resident #28 sitting next to his bed and she helped him up and placed him back into the bed. LPN #206 revealed she obtained vital signs and neurological checks which were within normal limits. LPN #206 confirmed the resident complained of pain, however, she didn't do a gait assessment or range of motion assessment because the first x-ray was still pending. LPN #206 confirmed that she did not notify the physician or NP of Resident #28's second fall because she assumed the DON did so. During interview on 05/24/23 at 5:10 P.M., LPN/CCC #195 confirmed she did not witness either of Resident #28's falls on 05/02/23, however, she completed the fall investigation and nursing progress notes regarding both falls. During interview on 05/24/23 at 5:15 P.M., the DON confirmed the NP should have been notified of the resident's continued complaints of pain and decreased range of motion following the second fall on 05/02/23. The DON confirmed she was informed of the resident's complaints of pain and decreased range of motion during morning report on 05/03/23 and notified NP #300, who then ordered another pelvic and hip x-ray for Resident #28. Review of the facility's policy titled, Fall Policy, revision date of 04/20/21, revealed it was the policy of the facility to assure proper review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls. Assessment for fall risk would be updated quarterly or as needed. A fall assessment would be completed by a nurse as soon as possible after a fall with findings documented in the medical record. Appropriate medical care would be provided as needed, including emergency transport to the emergency room if indicated. This deficiency represents non-compliance investigated under Complaint Number OH00142701. 366285 Page 4 of 6 366285 05/24/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

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, policy review, and interview, the facility failed to ensure fall risk assessments were completed at least quarterly for Resident #28. This affected one resident (#28) of three residents reviewed for falls. The facility census was 72. Findings include: Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, difficulty in walking, convulsions, hearing loss, tricuspid valve disorder, major depressive disorder, and anxiety. The resident resided in the secured dementia care unit. Review of the plan of care, dated 06/27/22, revealed Resident #28 was at risk for falls related to dementia, difficulty walking, hypertension, advanced age, and mediations. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/25/23, revealed the resident had severely impaired cognition with no behaviors or rejection of care. The resident required extensive, one-person physical assistance for bed mobility, and supervision for walking in the room transfers, dressing, personal hygiene, and toileting. Review of Resident #28's medical record revealed a fall risk assessment was completed on 09/27/22. Further review revealed there was not another fall risk assessment completed again until 05/02/23, following the resident's fall with injury. Interview on 05/24/23 at 10:39 A.M., the DON confirmed Resident #28's fall risk assessment was not completed quarterly per the facility's policy. Review of the facility's policy titled, Fall Policy, revision date of 04/20/21, revealed it was the policy of the facility to assure proper review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls. Assessment for fall risk would be updated quarterly and as needed. This deficiency is an incidental finding to Complaint Number OH00142701. 366285 Page 5 of 6 366285 05/24/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure Resident #28's medical record was accurate related to nurse practitioner (NP) progress notes. This affected one resident (#28) of three residents whose medical records were reviewed for falls. The facility census was 72. Findings include: Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, difficulty in walking, convulsions, hearing loss, tricuspid valve disorder, major depressive disorder, and anxiety. The resident resided in the secured dementia care unit. Review of the resident's medical record revealed the resident sustained a fall on 05/02/23 at 10:20 P.M. and the NP was in the facility and saw the resident at that time. The resident sustained a second fall on 05/02/23 at 3:45 P.M. Review of the NP progress note, revealed a note, dated 05/02/23 at 1:01 A.M. This was identified to be an incorrect time stamp. Review of a second NP progress note, revealed a note, dated 05/03/23 at 1:01 A.M This was identified to be an incorrect time stamp. During interview on 05/25/23 at 10:59 A.M., Corporate Registered Nurse (RN) #204 confirmed the NP progress notes, dated 05/02/23 and 05/03/23, were incorrectly time stamped at 1:01 A.M. Corporate RN #204 further confirmed all of the nurse practitioner progress notes defaulted to the 1:01 A.M. time and the facility would need to follow-up concerning this issue as it was not accurate to reflect the time of the note or care provided. During interview on 05/25/23 at 12:09 P.M., the Director of Nursing (DON) confirmed the NP progress notes related to Resident #28's falls, dated 05/02/23 and 05/03/23, were incorrectly time stamped at 1:01 A.M. This deficiency is an incidental finding to Complaint Number OH00142701. 366285 Page 6 of 6