Health inspection·January 18, 2024

F 0641 Ensure each resident receives an accurate assessment. 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, observation, and interview, the facility failed to accurately reflect residents' status on Minimum Data Set (MDS) assessments related to mental health status and oxygen use. This affected three (Residents #11, #21, and #33) of 24 residents whose assessments were reviewed. The facility census was 53. Residents Affected - Few Findings include: 1. Review of Resident #11's medical record review revealed diagnoses including schizoaffective disorder (bipolar type), psychosis, pseudobulbar affect, depression, bipolar disorder and anxiety disorder. A Preadmission Screen and Resident Review dated 07/05/22 indicated Resident #11 had no indications of serious mental illness. Resident #11 was hospitalized between 11/14/22 and 12/07/22. Review of a Preadmission Screen and Resident Review Determination (PASRR) determination revealed Resident #11 was approved for nursing facility services. The attached summary report dated 12/01/22 indicated Resident #11 was first medically hospitalized ( for increased ammonia level in the blood and diagnosed with pneumonia and metabolic encephalopathy) and when stable was transferred to the inpatient psychiatric unit. The summary indicated Resident #11 had mental health diagnoses of psychotic disorder, language disorder - cognitive communication deficit, major depressive disorder, bipolar disorder, and dependence on psychotropic medications with induced mood disorder and anxiety disorder. The summary indicated Resident #11 was hospitalized for having unreal thoughts and seeing and hearing things that were not there. Resident #11 also exhibited physical aggression. The summary indicated Resident #11 had one inpatient psychiatric hospitalization in the past two years and was receiving psychotropic medication. There were no recommendations for disability specific services. However, the summary indicated services and supports which would be needed to be provided included an Occupational Therapy evaluation, a safety plan, ongoing evaluation of the effectiveness of psychotropic medications on target symptoms, ongoing medication review by a psychiatrist or similarly-credentialed professionals, medication evaluation and monitoring by a designated physician, family involvement in care, and socialization and recreation activities to decrease isolation, improve mood and increase social interaction. Review of Resident #11's annual MDS dated [DATE] indicated Resident #11 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related conditions. During an interview on 01/18/24 at 9:48 A.M., Registered Nurse (RN) #355 verified the annual MDS dated [DATE] was marked incorrectly regarding serious mental illness. Page 1 of 6 366306 366306 01/18/2024 Valley Oaks Care Center 500 Selfridge Street East Liverpool, OH 43920

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident #21's medical record revealed diagnoses including bipolar disorder, schizoaffective disorder, brief psychotic disorder, and anxiety disorder. Resident #21 was admitted to the facility 06/19/20. Review of a facsimile (fax) dated 06/17/20 revealed the facility in which Resident #21 previously resided provided PASRR information they had available. A PASRR identification screen dated 06/22/17 indicated Resident #21 had a diagnosis of bipolar disorder and had continuously received ongoing case management from a mental health agency over two years. Due to the mental health disorder, Resident #21 had experienced functional limitations on a continuing or intermittent basis over the prior six months. Resident #21 was determined to have indications of serious mental illness. A level II determination dated 04/02/18 indicated Resident #21 was located in a nursing facility and was requesting continued placement in a nursing facility. A resident review assessment was completed on 04/01/18. Resident #21 did not have the potential to live in the community and was receiving case management. The determination indicated Resident #21 had a history of serious mental illness with diagnoses including Bipolar 1 Disorder, mixed and severe major depressive disorder. The determination indicated Resident #21 had an unspecified personality disorder by history. No specialized services were recommended. The determination indicated services recommended included ongoing medication review by a physician to assure medical conditions were appropriately treated, medication education on the value of taking medication as prescribed, and a behavior management safety plan to decrease inappropriate behaviors and ensure safety. Review of Resident #21's annual MDS dated [DATE] indicated Resident #21 was not currently considered by state II PASRR process to have a serious mental illness. On 01/16/24 at 12:47 P.M., RN #355 verified the annual MDS section A1500 was marked incorrectly as the most recent PASRR determination indicated Resident #21 did have a serious mental illness. 3. Review of medical record for Resident #33 revealed an admission date of 09/24/21. Diagnoses included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation and chronic respiratory failure. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact and did not use oxygen. Review of Resident #33's physician orders revealed an order dated 11/18/22 for oxygen two liters via nasal cannula, may titrate as needed. Review of Resident #33's care plan dated 09/25/21 revealed the resident had an impaired respiratory status related to anxiety, being a current smoker, and having shortness of breath. Interventions included oxygen as ordered by the physician. Observation on 01/16/24 at 10:35 A.M. of Resident #33's room revealed the resident was not in the room, but there was an oxygen concentrator in room. Observation on 01/17/24 at 9:42 A.M. revealed Resident #33 was in room receiving oxygen via nasal cannula. Interview on 01/18/24 at 10:02 A.M. with RN #354 confirmed the Resident #3's quarterly 12/13/23 MDS was incorrectly marked, since Resident #33 should have been marked as receiving oxygen. 366306 Page 2 of 6 366306 01/18/2024 Valley Oaks Care Center 500 Selfridge Street East Liverpool, OH 43920

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure preadmission screening and record review assessments were resubmitted after a new major mental illness diagnosis was added for Resident #43. This affected one (Resident #43) of four residents reviewed for preadmission screening and resident review. The facility census was 53. Findings include: Review of Resident #43's medical record revealed an admission date of 04/12/23 with diagnoses that included chronic obstructive pulmonary disease, hyperlipidemia, major depression and anxiety. A Preadmission Screening and Resident Review (PASARR) completed on 04/11/23 indicated Resident #43 had only anxiety. Upon admission to the facility, Resident #43 was prescribed Navane (antipsychotic medication) five milligrams (mg) twice daily which the resident was on long term prior to admission. Further review of the medical record, including psychiatrist evaluations, revealed the Navane was gradually reduced and discontinued on 06/06/23. Review of Resident #43's progress notes indicated the resident had a new onset of paranoid behaviors and was transferred and admitted directly to a geriatric in-patient psychiatric unit on 06/13/23. On 06/27/23 Resident #43 was readmitted to the facility with a new diagnosis of paranoid schizophrenia added. Review of hospital records revealed Resident #43 had a prior history of mental illness including schizophrenia with Navane use. On 06/22/24 the geriatric in-patient psychiatric hospital resubmitted a PASARR which indicated major depression with psychotic features. No evidence of schizophrenia was noted. No evidence of any new PASARR was submitted by the facility after readmission on [DATE] despite the new mental illness diagnosis of schizophrenia. On 01/17/24 at 10:48 A.M., interview with the Administrator verified no PASARR assessment was submitted following readmission with the identified new diagnosis of schizophrenia for Resident #43. 366306 Page 3 of 6 366306 01/18/2024 Valley Oaks Care Center 500 Selfridge Street East Liverpool, OH 43920

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and facility policy, the facility failed to ensure oxygen tubing was changed weekly for Residents #33 and #51. This affected two residents (#33 and #51) of four residents reviewed for respiratory care. The facility census was 53. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #33 revealed an admission date of 09/24/21. Diagnoses included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation and chronic respiratory failure. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact. Review of Resident #33's physician orders revealed an order dated 11/18/22 for oxygen two liters via nasal cannula, may titrate as needed. Review of Resident #33's care plan dated 09/25/21 revealed the resident had an impaired respiratory status related to anxiety, being a current smoker, and having shortness of breath. Interventions included oxygen as ordered by the physician. Observation and interview on 01/16/24 at 10:37 A.M. with Respiratory Therapist (RT) #354 revealed Resident #33 oxygen tubing was dated 12/20. RT #354 confirmed, at the time of observation, the tubing had a date of 12/20 and the tubing should be changed weekly. RT #354 stated it was his first day on the job, and he was getting ready to change it out. Interview on 01/16/24 at 10:38 A.M. with Resident #33 confirmed the oxygen tubing was not changed weekly, but it was usually changed every other week. 2. Review of the medical record for Resident #51 revealed an admission date of 11/27/23. Diagnoses included unspecified diastolic (congestive) heart failure and chronic obstructive pulmonary disease (COPD) with (acute) exacerbation. Review of the 11/30/23 admission Minimum Data Set (MDS) revealed Resident #51 was cognitively intact and used oxygen. Review of Resident #51's physician orders revealed an order dated 11/28/23 to change oxygen tubing and set up every night shift every Tuesday and an order dated 01/17/24 for three liters oxygen via nasal cannula as needed, may titrate as needed. Review of care plan dated 11/29/23 revealed Resident #51 had impaired respiratory status related to congestive heart failure (CHF) and COPD with emphysema. Interventions included provide oxygen as needed when the resident exhibits signs/symptoms of difficulty breathing (short of breath, cyanosis, and low oxygen saturation levels). Observation and interview on 1/16/24 at 10:27 A.M. with Respiratory Therapist (RT) #354 revealed Resident #51's oxygen tubing was dated 12/20. RT #354 confirmed, at the time of observation, the 366306 Page 4 of 6 366306 01/18/2024 Valley Oaks Care Center 500 Selfridge Street East Liverpool, OH 43920

F 0695 Level of Harm - Minimal harm or potential for actual harm tubing had a date of 12/20 and the tubing should be changed weekly. RT #354 stated it was his first day on the job, and he was getting ready to change it out. Interview on 1/17/24 at 10:29 A.M. with Resident #51 confirmed his oxygen tubing was not changed out weekly. Residents Affected - Few Review of facility policy Departmental (Respiratory Therapy), revised November 2011 revealed oxygen tubing should be changed every seven days and dated. 366306 Page 5 of 6 366306 01/18/2024 Valley Oaks Care Center 500 Selfridge Street East Liverpool, OH 43920

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 interview, food committee meeting minutes and facility menu review, the facility failed to provide a menu which offered a variety of items served at the breakfast meal. This had the potential to affect 52 residents who received meals from the kitchen. The facility identified Resident #13 as receiving nothing by mouth. The facility census was 53. Findings include: Review of facility food committee meeting minutes dated 07/31/23 revealed concern related to repeating menu items was noted. Review of the facility's fall 2023-24 four-week (28 day) menu revealed scrambled eggs were served 14 out of 28 days. For week three, scrambled eggs were served five days (Sunday, Monday, Tuesday, Thursday, and Saturday) out of seven days and three days in a row between the end of week four and the beginning of week one (week four Saturday, week one Sunday, and week one Monday). Interview on 01/17/24 at 11:56 A.M. with the Dietary Supervisor revealed she did have residents complain to her there was too much repetition of some items on the menu. Interview on 01/17/24 at 1:14 P.M. with the Registered Dietitian confirmed, upon review of the menus, there was a lot of scrambled eggs, but scrambled eggs were a cheap option. She stated the menus came pre-made, but she had the option to adjust the menu. Interview on 01/17/24 at 3:24 P.M. with Resident #38 revealed there were too many scrambled eggs on the menu. 366306 Page 6 of 6