Health inspection·September 27, 2024

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, staff interviews and policy review, the facility failed to ensure the administration of as needed medication was documented in the resident's medical record. Additionally, the facility failed to document care and services related to incontinent care and application of durable medical equipment as ordered. This affected three (#15, #45 and #18) of three residents reviewed for medical record accuracy. The facility census was 42. Findings include: 1. Medical record review for Resident #45 revealed an admission on [DATE] and a discharge to the hospital on [DATE]. Diagnoses include congestive obstructive pulmonary disease, chronic respiratory failure with hypoxia, sleep apnea, atrial fibrillation, anxiety disorder, obesity, and fracture of right fibula. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #45 revealed an intact cognition. Resident #45 required moderate assistance with eating, dependent for toileting, max assistance for bed mobility, transfers not attempted. Resident was incontinent of bladder and continent of bowel. Resident was coded as receiving a non-evasive mechanical ventilator during the assessment period. Review of the plan of care for Resident #45 dated 06/08/24 revealed an alteration in Bladder Elimination/Potential for incontinence related to diuretic use. Interventions include administration of medications as ordered, assist with toileting needs and incontinence care on routine rounds and resident requests, provide assistance as needed with toileting hygiene and skin care, assist with wearing and changing incontinent garments, check and changed on routines rounds as needed or requested. Review of the electronic health record State Tested Nursing Assistant (STNA) documentation for incontinent care was silent for any staff documentation indicating the care and services were provided. Interview on 09/26/24 at 9:58 A.M. with the Director of Nursing (DON) verified the task was not triggered for the STNA's to document and she was unable to locate any other documentation related to incontinent care being provided for Resident #45 per plan of care and it should have been documented. Review of the facility policy titled Incontinence- Clinical Protocol, dated 12/08/23 states as appropriate, based on assessment of the causes of incontinence the staff will provide scheduled toileting or prompted voiding. Page 1 of 3 366302 366302 09/27/2024 Aventura at Shiloh Springs 3500 Shiloh Springs Road Trotwood, OH 45426

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Medical record review for Resident #18 revealed an admission on [DATE] with diagnoses including but not limited to kidney failure, acute chronic respiratory failure, congestive obstructive pulmonary disease (COPD), morbid obesity, chronic bronchitis, seizures, asthma, anxiety, depression, sleep apnea, and candidiasis. Review of the quarterly MDS assessment dated [DATE] for Resident #18 revealed an intact cognition. Resident #18 required supervision for eating, and totally dependent on staff for bed mobility, transfers, and toileting. Review of the plan of care for Resident #18 dated 11/18/23 and revised on 06/24/24 revealed resident has altered respiratory status/difficulty breathing related to COPD, chronic respiratory failure with hypoxia, chronic bronchitis, asthma, shortness of breath, anxiety, obstructive sleep apnea with use of BiPap at bedtime. Interventions included will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern and will have no complications related to shortness of breath. Review of the active physician's order for Resident #18 revealed an orders indicating it was okay to use the BiPap from home dated 01/30/24 and an order for oxygen-may wear BiPap full face mask setting 16/5 humidification while sleeping toe times a day for sleep apnea. Review of the treatment administration record for Resident #18 was silent for any documentation related to the application of the mask for Resident #18 at bedtime. Interview on 09/26/24 at 10:37 A.M. with the DON verified the treatment administration record (TAR) was silent for application of the bi-pap device for Resident #18. Additionally, the DON verified Resident #18 had physician orders and when she returned from the hospital they were not added to the electronic health record as orders and should have been. Review of the facility's policy titled CPAP/BiPap Support dated 03/2015 revealed under documentation following should be in the residents medical record, general assessment including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status prior to procedure, time CPAP was started and the duration of therapy, mode and settings for the CPAP/BiPap, oxygen concentration and flow and how the resident tolerated the procedure. 3. Medical record review for Resident #15 revealed an admission on [DATE] with diagnosis including not but limited to chronic embolism and thrombosis of deep vein lower, Arnold Chiari Syndrome without spina bifida or hydrocephalus, hypertension, lymphedema, osteoarthritis, insomnia, dermatitis, sleep apnea, bariatric surgery, and asthma. Review of the admission MDS assessment dated [DATE] for Resident#15 revealed resident has an intact cognition. Resident #15 required supervision for eating, supervision for toileting, maximal assistance for bed mobility and transfers was not attempted. Resident #15 is incontinent of bowel and bladder. Resident #15 weighs 394 pounds. Review of the plan of care dated 09/09/24 for Resident #15 revealed resident has potential for pain: related to arthritis, Arnold Chiari Syndrome, history of lymphedema, and decrease in mobility. Interventions include Resident and/or responsible party in treatment plan, update as indicated by change in condition/treatment, Medications as ordered, observe for effectiveness/side effects, update physician as needed regarding effectiveness or need for order change. Assess resident for location, 366302 Page 2 of 3 366302 09/27/2024 Aventura at Shiloh Springs 3500 Shiloh Springs Road Trotwood, OH 45426

F 0842 Level of Harm - Minimal harm or potential for actual harm onset, origin, intensity of, and precipitating factors to pain. Utilize pain scale = 0 or 1-10 (mild, moderate, severe). Observe for pain that may interfere with ability to perform self-care, attempt to increase comfort through nonpharmacological means, i.e., repositioning, quiet environment, guided imagery, music therapy, gentle massage, etc and observe for side effects of narcotic pain medication, sedation, constipation, confusion, respiratory depression. Residents Affected - Few Review of the active physician's orders for Resident #15 revealed an order dated oxycodone oral tablet 5 milligrams one tablet by mouth dated one every eight hours as needed for severe pain dated 09/24/24 at 12:45 P.M. and Tylenol 325 mg two tablets every six hours for pain. Review of the discontinued physicians' orders for Resident #15 revealed an order for Norco tablet 5-325 my one table every eight hours as needed for moderate pain discontinued on 09/24/24. Review of the Medication Administration Record (MAR) for Resident #15 revealed was silent for any Tylenol being administered since 09/21/24. Interview on 09/25/24 with Licensed Practical Nurse (LPN) #28 verified she administered Tylenol to Resident #15 last evening when the resident was asked if she had any pain. Resident #15 stated that her pain was a two or three on a pain scale of 1-10. Interview on 09/26/24 at 7:51 A.M. with LPN #81 verified she administered Tylenol on 09/23/24 at 4:34 P.M. when Resident #15 complained about pain. Additionally, LPN #81 stated Resident #15 stated the pain was at a three or four. Interview on 09/26/24 at :37 A.M. with DON verified the Resident #15 did not have any Tylenol recorded on the MAR since 09/21/24 and the nurses that stated they administered the pain medication would be coming into the facility and making a late entry regarding the administration of the medication. Additionally, the DON verified Resident #15 did not have a order independent of the pain medication for pain monitoring every shift and had added that to Resident #15's medication profile on 09/25/24. Review of the facility policy titled Charting and Documentation, dated 08/24 stated the following information is to be documented in the medical record, observations, medication administration, treatment or services, changes in condition and events, accidents involving the resident. This deficiency represents non-compliance investigated under Complaint Numbers OH00157965, OH00157841 and OH00157354. 366302 Page 3 of 3