Health inspection·May 26, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #16's advance directive wishes were accurately documented and consistent throughout the medical record. This affected one resident (#16) of 16 residents whose records were reviewed for advance directives. Findings include: Review of Resident #16's medical record revealed diagnoses including dementia with behavioral disturbance, depression, and mild cognitive impairment. Review of the electronic health record revealed a code status of Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) (providers would treat resident as any other without a Do Not Resuscitate (DNR) order until the point of cardiac or respiratory arrest at which point all interventions would cease and the DNR Comfort Care (DNRCC) would be implemented). A sticker on the physical medical record indicated a DNRCC-A status but no corresponding form/order was able to be located. On 05/23/22 at 3:24 P.M., Licensed Practical Nurse (LPN) #112 was interviewed regarding the resident having no signed code status form in the medical record. LPN #112 reported she would notify the supervisor. On 05/24/22 Resident #16 was noted to have a form signed 02/13/15 in the medical record indicating her desired code status was DNRCC. The sticker was changed from DNRCCA to DNRCC. The code status in the electronic health record had been changed to DNRCC. On 05/24/22 at 1:35 P.M. interview with the Director of Nursing revealed Resident #16 used to reside in the residential care facility and had a signed DNRCC. No DNRCCA form was able to be located. Once she learned of the discrepancy in the medical record on 05/23/22 she educated Resident #16 on the difference between DNRCC and DNRCCA. Resident #16 indicated she desired a DNRCC code status and the sticker and electronic health record were changed. The signed DNRCC order from 2015 was placed in the resident's medical record. Review of the facility Advance Directives policy, revised December 2016 revealed prior to or upon admission of a resident, the social services director or designee would inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directive. Information about whether or not the resident had executed an advance directive should be displayed prominently in the medical record. The plan of care for each resident would be consistent with his or her documented treatment preferences and/or advance directive. Page 1 of 4 366341 366341 05/26/2022 Wayne County Care Center 876 S Geyers Chapel Road Wooster, OH 44691

F 0578 Level of Harm - Minimal harm or potential for actual harm Review of a paper titled Ohio's Do-Not -Resuscitate Law, provided by the facility, revealed with a DNRCC order a person received any care that eased pain and suffering but no resuscitative measures to save or sustain life from the moment the order was signed by the physician. With a DNRCC-Arrest order, a person received standard medical care that may include some components of resuscitation until he or she experienced a cardiac or respiratory arrest. Residents Affected - Few 366341 Page 2 of 4 366341 05/26/2022 Wayne County Care Center 876 S Geyers Chapel Road Wooster, OH 44691

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure timely provision of dental services for Resident #11. This affected one resident (#11) of three residents reviewed for dental services. Residents Affected - Few Findings include: Review of Resident #11's medical record revealed diagnoses including delusional disorder, psychotic disorder, depression, dementia, and Parkinson's disease. A plan of care, initiated 06/14/18 indicated Resident #11 had two dental implants and had all her own teeth. An intervention initiated 06/28/18 (revised 08/25/20) revealed staff were to assist with any dental appointments, transportation and paperwork needed as necessary. Review of a significant change Minimum Data Set (MDS) 3.0 assessment, dated 08/21/21 indicated Resident #11 had obvious or likely cavity or broken natural teeth. Review of a dental progress note and summary report, dated 01/20/22 revealed Resident #11 presented with tooth tenderness and slight puffiness at tooth #5 and a missing crown at tooth #7. Treatment planned for the next visit included extraction of tooth #5 and further evaluation of tooth #7 including radiography. No additional dental visit notes were located. On 05/25/22 at 3:13 P.M. interview with the Director of Nursing (DON) revealed the dentist provided documentation via email regarding visit notes. The DON stated once the dental notes were received, they were reviewed by social service, herself, and the MDS nurse. When a procedure was needed the dental provider sent consent forms for resident/family to consent and for the physician to give medical clearance. The DON revealed since the dentist had not sent the forms to be completed, Resident #11 was not seen by the dentist when they made their visit in February. The dental provider was notified today and the forms were provided. The facility called and obtained consent over the phone from Resident #11's grandson. The physician clearance papers had been placed in the physician's folder to be completed. On 05/25/22 at 3:18 P.M. interview with Social Service Director (SSD) #148 revealed since Resident #11's dental visit on 01/20/22 was an emergency visit the information from the dentist was emailed to the facility. SSD #148 stated once she received the paper work from the dentist she scanned the information into the record and provided a copy to the DON and MDS nurse. SSD #148 revealed she did not review the information since she was unable to contact families or residents to obtain consent for procedures. SSD #148 revealed the dental provider generally created a list of residents to be seen before each visit and she was able to add to the list. Someone must communicate to her that a resident needed dental services so she could add them to the list. If a resident had an emergency visit and needed a follow up the dental provider generally sent a consent to treat and physician clearance forms. Resident #11 was now on the list to be seen by the dentist on 05/31/22. On 05/25/22 at 3:31 P.M. interview with SSD #148 indicated she received the 01/20/22 dental notes for Resident #11 via email on 01/25/22. The next regular dental visit was on 02/07/22. SSD #148 revealed if she had been informed of the plan to extract teeth for Resident #11 she could have requested the necessary forms and added her to the list of residents to receive services on 02/07/22. 366341 Page 3 of 4 366341 05/26/2022 Wayne County Care Center 876 S Geyers Chapel Road Wooster, OH 44691

F 0791 Level of Harm - Minimal harm or potential for actual harm Review of a contract with Mobile Medical, effective on 05/26/16 revealed dental services to be provided at the facility included dental examinations and oral cancer screening, diagnostic x-ray examination, prophylaxis and denture cleaning, tooth surface restorations, simple extractions, removable prosthetic fabrication, relines and repairs. Residents Affected - Few This deficiency substantiates Complaint Number OH00132855. 366341 Page 4 of 4