Health inspection·May 30, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to maintain a drainage bag for an indwelling urinary catheter in a manner to ensure the dignity of one (#285) out of three residents reviewed for personal privacy. The census was 48. Findings include: Review of Resident #285's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, enterocolitis due to clostridium difficile, sepsis, and chronic kidney disease. Observation of Resident #285 on 05/28/19 at 8:50 A.M. and 3:43 P.M., on 05/29/19 at 10:20 A.M., 11:50 A.M.,1:09 P.M., and 2:23 P.M., and on 05/30/19 at 8:50 A.M. revealed the resident was in his room lying in bed. Resident #285's catheter bag was attached to the bed frame facing the open door and without a cover. Interview on 5/30/19 at 8:50 A.M., with the Director of Nursing verified the observation of Resident #285's catheter bag being in view of the hallway and not covered. Page 1 of 6 366342 366342 05/30/2019 St Mary of the Woods 35755 Detroit Road Avon, OH 44011

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop an initial baseline plan of care for one (#288) of 12 residents reviewed for initial baseline plans of care. The facility census was 48. Findings include: Review of Resident #288's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to thrombosis of left anterior cerebral artery, Antiphospholipid Syndrome (a disorder in which the immune system mistakenly attacks normal proteins in the blood. It causes blood clots, can cause organ damage and death), epilepsy, thrombocytopenia, chronic kidney disease, stage 3, bipolar disorder, and vascular dementia without behavioral disturbance. The record contained no evidence Resident #288 had an Initial Baseline Plan of Care developed until 05/29/19. Interview with the Director of Nursing (DON) on 05/29/19 at 10:20 A.M. verified she could not find any documented evidence the facility developed a baseline plan of care for Resident #288. 366342 Page 2 of 6 366342 05/30/2019 St Mary of the Woods 35755 Detroit Road Avon, OH 44011

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, family interview, staff interview and record review, the facility failed to provide assistance with activities of daily living of bathing, hygiene, and opening food packets for one (#291) of 12 residents reviewed for showers. The facility identified 48 residents who required staff assistance or were dependent for bathing and 26 residents who required assistance or were dependent for eating. The facility census was 48. Residents Affected - Few Findings include: Review of Resident # 291 medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, pneumonitis, ischemic cardiomyopathy, chronic stage 4 kidney disease, and type 2 diabetes mellitus. Review of Resident # 291's plan of care, dated 05/22/19, revealed the resident had limited ability to perform his activities of daily living, including bathing, hygiene, and eating. The goal was for the resident to be well-groomed and dressed appropriately with proper hygiene maintained. Interventions included to provide assistance with activities of daily living. Observation on 05/28/19 at 12:20 P.M. revealed Resident #291's fingernails were soiled, his teeth were not brushed, and his hair was combed but not clean. On 05/29/19 at 10:50 A.M., 1:09 P.M. and 4:50 P.M., Resident #291 was observed seated in a recliner chair with dry, cracked, lips, his teeth not brushed, his fingernails remained dirty, and his hair was greasy and uncombed. Interview on 05/29/19 at 4:50 P.M. the Director of Nursing verified the unkempt appearance of Resident #291. Additionally, interview with Resident #291's family member on 05/28/19 at 11:00 A.M. revealed Resident #291 had vision problems. Since admission the staff have brought in his meal trays, opened up the silverware, and expected the resident to feed himself. Staff do not open packets for him and he has trouble getting the food items open. Resident #291's family member stated he has stayed with the resident to make sure he eats and receives care. Observation on 05/28/19 at 12:20 P.M. of Resident #291's lunch meal revealed the resident was in bed with his lunch tray setting on the bedside table out of reach and to his left side. The tray contained two small packets of peanut butter and three packets of saltine crackers. No other food items were on the tray. The peanut butter and crackers had not been opened and the silverware was out of the resident's reach. Interview at the time of the observation on 05/28/19 at 12:20 P.M., Resident #291 it was his choice to have the peanut butter and crackers and not the full lunch meal. He stated he was hungry, could not see the food packets and could not open the packets. Resident Interview on 05/28/19 at 12:30 P.M., Registered Nurse (RN) #509 verified the observation of Resident #291 and his food packages. 366342 Page 3 of 6 366342 05/30/2019 St Mary of the Woods 35755 Detroit Road Avon, OH 44011

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure pain medication were available and administered timely for one (#187) of two residents reviewed for pain. The facility identified 27 residents who required pain management. The facility census was 48 residents. Residents Affected - Few Findings include: Review of the medical record revealed Resident #187 was admitted to the facility on [DATE]. Diagnoses included status post bilateral knee replacement surgery, critical illness polyneuropathy, complex regional pain syndrome, osteoarthritis, obesity and depression. Review of the baseline care plan included improving pain and ambulation. Review of the nurses' note dated 05/25/19 at 2:40 P.M. revealed Resident #187 arrived to the facility status post bilateral knee replacement surgery and was three days post-operation. Review of the May 2019 Medication Administration Record (MAR) revealed upon admission [DATE] Resident #187 was prescribed Lyrica (for nerve and muscle pain) 200 milligrams (mg) by mouth three times a day starting. The 2:00 P.M. and 10:00 P.M. doses for 05/25/19 were not administered with the notation, drug/item not available; all three doses on 05/26/19 were marked as not administered and not available; and the 6:00 A.M. dose on 05/27/19 was marked as not administered and not available. Review of a prescription for Lyrica, dated 05/28/19, was noted to not have been faxed to the pharmacy until 05/30/19. Review of the May 2019 MAR also revealed an order dated 05/25/19 for the narcotic pain medication oxycodone 5 mg, administer 10 mg ,or one to two tablets, every four hours as needed for pain. The MAR revealed no oxycodone was administered until 05/26/19 at 5:54 A.M. Review of a fax of a prescription dated 05/23/19 for oxycodone was noted to be received by the facility on 05/24/19. Interview on 05/28/19 at 10:13 A.M., Resident #187 revealed she was admitted to the facility on [DATE] at 1:30 P.M. and did not receive her oxycodone until nearly 6:00 A.M. on 05/26/19. The facility had to obtain the medicine from the pharmacy. Resident #187 shared she had been at the facility previously and had trouble with her pain medications at that time as well. Interview on 05/30/19 at 4:17 P.M., Licensed Practical Nurse (LPN) #506 revealed when a new resident came into the facility, the prescriptions needed to be sent as quickly as possible so the pharmacy could fill the orders. LPN #506 nurses can obtain an authorization to pull medication from the facility's contingency box and the process would not have taken more than several hours. Interview on 05/30/19 at 4:57 P.M. and 5:24 P.M., the Assistant Director of Nursing (ADON) confirmed the oxycodone script was received by the facility on 05/24/19 and verified the medication should have been filled timely. 366342 Page 4 of 6 366342 05/30/2019 St Mary of the Woods 35755 Detroit Road Avon, OH 44011

F 0697 Review of the facility's policy titled Medication Pass, revised May 2019, revealed all new medication orders were to be started after the next regular medication delivery time unless ordered now. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366342 Page 5 of 6 366342 05/30/2019 St Mary of the Woods 35755 Detroit Road Avon, OH 44011

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, visitor interview, and review of facility policy, the facility failed to ensure information signage was properly posted on the door of a room with contact isolation and failed to ensure visitors were educated on the need for precautions when visiting one (#285) three residents on contact isolation precautions. The facility census was 48. Residents Affected - Few Findings include: Review of Resident #285 medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, enterocolitis due to clostridium difficile, sepsis, chronic kidney disease, severe protein-calorie malnutrition, and atherosclerotic heart disease. Resident #285 was on contact isolation for clostridium difficile (C-Diff). Review of Resident #285's Initial Base Line Plan of Care dated 05/20/19, revealed the resident was on isolation for clostridium difficile, (C-Diff). Interventions included gown, gloves and handwashing. Observation of Resident #285 on 05/28/19 at 8:50 A.M. revealed the resident was in his room in bed with the call light within reach. The educational precautionary signage alerting the public of a potential for precautions was posted on the inside of the door and when the door was closed was not visible to warn visitors from entering the room. Interview with Licensed Practical Nurse (LP) #511 on 05/28/19 at 8:50 A.M. verified the lack of signage on the door for Resident #285. An additional observation on 05/28/19 at 1:50 P.M. revealed the two visitors were seated talking with Resident #285 in his room. Neither visitor had a gowns on. From the doorway the surveyor asked if the visitors were aware the resident was on isolation. Both visitors stated the saw the sign, but no one told them what the needed to do. Both visitors stated the nurse came in and did not say anything to them about putting on gowns. Interview on 05/28/19 at 1:57 P.M. the Administrator verified Resident #285 was on isolation and required to have his visitors wear gowns. The Administrator verified the visitors required additional education to find to nurse for guidance when a resident was on isolation. Interview with the Director of Nursing (DON) on 05/28/19 at 2:00 P.M. verified Resident #285 was on contact isolation which included all visitors and staff to wear gowns while visiting the resident. Review of the facility policy titled Isolation- Categories of transmission-Based Precaution, dated 12/20/15, revealed Contact- Based Precaution are for resident who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically pathogens, which require additional control measures to effectively prevent transmission. Wear a disposable gown upon entering the Contact Precaution room. Gown is to be donned prior to entering resident's room and removed prior to exiting. 366342 Page 6 of 6