Health inspection·March 23, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident's tube feeding was administered at the rate ordered by the physician. This affected one (Resident #117) of one reviewed for tube feeding. The facility identified one resident who received tube feeding. The facility census was 18. Findings include: Review of Resident #117's medical record revealed an admission date of 03/14/23. Diagnoses included esophageal cancer, clostridium difficile (C-Diff), and anxiety disorder. Review of Resident #117's care plan revised 03/15/23 revealed supports and interventions for Resident #117 altered mental status, self-care deficit, and enteral feeding. Interventions for tube feeding included checking for residual, flush the gastric-tube with 30 cubic centimeters of water before and after each medication and keep the head of the bed at least 30 degrees. Review of Resident #117's physician orders dated 03/15/23 revealed an order for Isosource 1.5 at 80 milliliters (ml) per hour per day through the feeding tube. Start the tube feed running at 2:00 P.M. and turn off at 8:00 A.M. Observation on 03/21/23 at 1:55 P.M. of Registered Nurse (RN) #406 revealed RN #406 preparing to administer/connect Resident #117 continuous feed tube feeding. RN #406 reviewed the order in the electronic medical record. The order read Resident #117 was to be connected to his continuous tube feed for 18 hours, from 2:00 P.M. to 8:00 A.M., running at a rate of 80 ml per hour. Coinciding interview with RN #406 revealed due to Resident #117 having excessive residual over the weekend, the rate was reduced to 65 ml per hour. RN #406 verified that was not the active order in the electronic medical record. Observation on 03/21/23 at 2:04 P.M. revealed RN #406 programmed the tube feeding flow, primed the continuous tube feed machine and connected the device to Resident #117 feeding tube. RN #406 verified Resident #117's tube feeding was set and running at 65 ml per hour with a 60 ml flush every eight hours. Interview on 03/21/23 at 3:10 P.M. with the Administrator verified there was no order for the flow rate of Resident #117's tube feeding to be changed. The Administrator stated Resident #117's tube feed rate should not have been changed without an updated order. Interview on 03/22/23 at 9:26 A.M. with the Director of Nursing (DON) verified Resident #117's tube Page 1 of 4 366358 366358 03/23/2023 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feeding was to be running at 80 ml per hour and not the 65 ml per hour it was set at yesterday. The DON stated Resident #117 had some excess residual over the weekend and verified RN #406 reduced the feeding amount without an order. Review of the facility policy titled External Tube Medication Administration, revised 06/21/17, revealed the staff was to check medication administration record for order. 366358 Page 2 of 4 366358 03/23/2023 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on review of Quality Assurance (QA) meeting attendance records, staff interview and policy review, the facility failed to ensure required staff members were in attendance at the quarterly QA meetings. This had the potential to affect all 18 residing in the facility. Residents Affected - Many Findings include: Review of the quarterly Quality Assurance (QA) meeting attendance records for the first quarter meeting held 03/15/22 and the second quarter meeting held on 06/15/22 revealed the meeting was attended by the Medical Director, Administrator, Director of Nursing/Infection Prevention Officer and the Social Worker. Further review revealed one of the required two additional staff members was not in attendance. Review of the quarterly (QA) meeting attendance record for the first quarter meeting held on 01/25/23 revealed the meeting was attended by the Administrator, Medical Director, Director of Nursing and the Certified Occupational Therapy Assistance. Further review revealed one of the required two additional staff members was also not in attendance. Interview on 03/23/23 at 8:28 A.M. with the Administrator verified the required staff were not in attendance at the QA meetings on 03/15/22, 06/15/22, and 01/25/23. Review of the facility policy titled Quality Assurance ad Performance Improvement Policy, dated 08/15/17, revealed the QA committee would include the Medical Director, Administrator, Infection Control and Prevention Officer, Director of Nursing, and at least two other care partners. 366358 Page 3 of 4 366358 03/23/2023 Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident who was on contact isolation had proper signage posted and personal protective equipment available. This affected one (Resident #117) of one resident reviewed for transmission based precautions and had the potential to affect the other seven residents (#2, #12, #14, #118, #119, #120, and #121) who resided in the home. The facility census was 18. Residents Affected - Some Findings include: Review of Resident #117's medical record revealed an admission date of 03/14/23. Diagnoses included esophageal cancer and clostridium difficile (C-Diff). Review of Resident #117's care plan revised 03/15/23 revealed supports and interventions for Resident #117 having a microbial infection related to being admitted with C-Diff. Interventions included isolation as ordered, educate on disease management, educate on infection control precautions, and on contact precautions with required hand washing, gloves, mask, and eye protection. Review of Resident #117's physician orders revealed an order dated 03/15/23 for Resident #117 to be on contact isolation for a diagnosis of C-Diff. Resident #117 was to receive all meals, medication, nursing care, activities of daily living and therapy in his room while on isolation. Two times a day/every shift staff were to wear appropriate PPE for Resident #117's direct care. Observation on 03/20/23 at 10:11 A.M. of Resident #117's room revealed no signage and no available personal protective equipment (PPE) or PPE cart indicating Resident #117 was on isolation in or around Resident #117's room entrance. Subsequent observation on 03/20/23 at 2:03 P.M. revealed there continued to be no signage indicating Resident #117 was on isolation and no personal protective equipment cart was available. Interview on 03/20/23 at 2:04 P.M. with State Tested Nursing Assistant (STNA) #414 verified there was no signs or PPE cart available for Resident #117. STNA #414 was not aware Resident #117 was on isolation. STNA #414 reported there should be signs posted to see the nurse before entering the room along with PPE in a cart and red barrels inside the room for disposal of used items. Interview on 03/20/23 at 2:22 P.M. with the Director of Nursing (DON) verified Resident #117 was admitted to the facility last week and was on contact isolation for C-Diff. The DON reported the nurse over the weekend mistakenly thought it was colonized and removed the signs and PPE. The DON verified the PPE and signage should not have been taken down and there was still an active order in place. Interview on 03/21/23 at 9:58 A.M. with Registered Nurse (RN) #406 verified she had been the nurse who completed Resident #117's intake and did not put up signs or put out PPE. RN #406 stated she was under the impression Resident #117's C-Diff was colonized but verified she should have posted the signs and put the PPE cart out because there was still an active order for contact isolation. Review of the facility policy titled Isolation Precautions Process, revised 08/01/22, revealed contact precautions were required when the possibility of the spread of infection was by person to person. The use of personal protective equipment (PPE) including a gown and gloves upon entering the resident's room is required. Prior to leaving the room, the PPE was to be removed and hand washing was to occur. 366358 Page 4 of 4