Health inspection·September 13, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, observations, staff interview, and review of the facility policy, the facility failed to ensure medications were stored safely and not left unattended. This affected Resident #3 and had the potential to affect nine additional facility-identified residents (#2, #5, #8, #9, #17, #19, #20, #22, and #23) residing on the second floor who were cognitively impaired and independently mobile. The facility census was 49 residents. Findings include: Review of the medical record for Resident #3 revealed an admission date of 03/01/23 with diagnoses including dementia without behavioral disturbance, chronic kidney disease (CKD), peripheral vascular disease (PVD), osteoarthritis (OA), and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively impaired and required limited assistance of one staff with activities of daily living (ADLs.) Review of the monthly physician orders for Resident #3 revealed orders dated 10/28/22 for multivitamin one tablet in the morning for constipation and Mirabegron one tablet in the morning for overactive bladder and an order dated 09/01/23 for senna one tablet in the morning for constipation. Review of the monthly physician orders for Resident #3 revealed there were no orders for resident to self-administer medications. Observations on 09/13/23 at 9:49 A.M. revealed Resident #3 and #8 were sitting next to one another in the common area and conversing. Licensed Practical Nurse (LPN) #755 was in the nurses' office working on the computer. LPN #755 was not observing Resident #3. On 09/13/23 at 9:59 A.M. revealed LPN #755 approached Resident #3 and told her she needed to take the pills from the resident if she wasn't going to take them. LPN #755 then took a plastic cup containing two pills out of the resident's hand and discarded the pills. LPN #755 then returned to the nurses' office and sat in front of the computer. Observation on 09/13/23 at 10:00 A.M. revealed State Tested Nursing Assistant (STNA) #920 approached Resident #3 and spoke to the resident and then came to nurses' office with a red tablet in her hand which she reported had been in Resident #3's hand. STNA #920 gave the pill to LPN #755 who then discarded the red tablet. Interview on 09/13/23 at 10:01 A.M. with STNA #920 confirmed she noticed Resident #3 had a red pill in her hand and when she asked the resident if she could take the pill to the nurse, the resident Page 1 of 3 366316 366316 09/13/2023 Seven Acres Senior Living at Clifton 476 Riddle Road Cincinnati, OH 45220

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some agreed. STNA #920 confirmed if she found medication unattended, she was supposed to report it to the nurse. Interview on 09/13/23 at 10:02 A.M. with LPN #755 confirmed she had given the following medications to Resident #3 on 09/13/23 at approximately 9:40 A.M. while the resident was sitting up in the common area: senna, mirabegron, and a multivitamin. LPN #755 confirmed she did not stay to ensure Resident #3 consumed the medications and she thought maybe if she gave the resident some space, she would take the medications. LPN #755 confirmed Resident #3 was cognitively impaired and did not have an order to self-administer medications. LPN #755 confirmed she typically would not leave medications unattended, but she thought it would be okay since the medications weren't narcotics. LPN #755 confirmed the red tablet retrieved by STNA #920 was a multivitamin and the cup she took from the resident at 9:59 A.M. contained senna and mirabegron. Interview on 09/13/23 at 10:30 A.M. with the Director of Nursing (DON) confirmed nurses should not leave medications unattended and should ensure medications were consumed by the resident during medication administration. On 09/13/23 at 2:30 P.M., the DON provided the survey with a facility-identified list of cognitively impaired independently mobile residents who reside on the second floor (#2, #5, #8, #9, #17, #19, #20, #22, and #23). Review of the facility's undated policy titled Administering Medications revealed medications shall be administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. This deficiency represents non-compliance investigated under Complaint Number OH00146198 and represents ongoing noncompliance from the complaint survey exited 08/23/23. 366316 Page 2 of 3 366316 09/13/2023 Seven Acres Senior Living at Clifton 476 Riddle Road Cincinnati, OH 45220

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of manufacturer's guidelines for glucometer use, the facility failed to ensure staff properly cleaned and disinfected glucometers after use. This affected Resident #45 and had the potential to affect 20 residents (#25, #26, #27, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #42, #44, #47, #48, and #49) who the facility identified to receive blood glucose monitoring utilizing the same glucometer as Resident #45. Residents Affected - Some Findings include: Review of the medical record for Resident #45 revealed an admission date of 05/24/23 with a diagnosis of diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact. Review of the physician orders dated 07/17/23 revealed an order for Resident #45 to receive insulin per sliding scale at meals based upon results of blood sugar check. Observation on 09/12/23 at 11:33 A.M. revealed Licensed Practical Nurse (LPN) #775 checked Resident #45's blood sugar using the glucometer from the third-floor medication cart. After checking the blood sugar, the nurse set the contaminated glucometer directly on top of the medication cart and continued with medication administration. Interview on 09/12/23 at 11:50 A.M. with LPN #775 confirmed the glucometer should be cleaned and disinfected with a bleach wipe immediately after use, but she didn't have time for that, and she didn't have bleach wipes on her cart. Observation 09/12/23 at 11:50 A.M. revealed LPN #775 wiped the front of the glucometer for the third-floor medication cart with an alcohol prep pad and placed the glucometer back in the cart after discussion with the surveyor. Interview on 09/12/23 at 3:41 P.M. with the Director of Nursing (DON) confirmed nurses should clean and disinfect the glucometer immediately after use with a bleach wipe. Subsequent interview on 09/13/23 at 9:10 A.M. with the DON confirmed 20 residents (#25, #26, #27, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #42, #44, #47, #48, and #49) receive blood glucose monitoring utilizing the same glucometer as Resident #45. Review of the undated manufacturer's instructions for the glucometer in use at the facility revealed the nurse should clean outside of blood glucose meter with soapy water or alcohol and should disinfect the meter with bleach wipes. The glucometer should be cleaned and disinfected between patient uses. This was an incidental finding during the course of the complaint investigation. 366316 Page 3 of 3