Health inspection·December 28, 2019

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of a Self-Reported Incident (SRI) of neglect, staff interview, and review of the facility policy, the facility failed to follow their policy to protect the residents following an allegation of neglect involving two (#42 and #54) residents. The facility census was 62. Residents Affected - Few Findings include: Review of the SRI dated 12/23/19 revealed the facility reported a allegation of neglect to the Ohio Department of Health. A written statement from State Tested Nursing Assistant (STNA) #250 documented on 12/22/19 during dinner, STNA # 265 was asked to answer call lights on the 100 Hall. STNA #250 was overheard by STNA#265 telling Resident # 42 and Resident #54 I can't help you. I have my own residents to care for. The written statement noted STNA # 250 reported the incident to the nurse on duty and nothing was done. STNA #250 documented she felt STNA #265 was neglecting the residents and not providing adequate care. The SRI noted the written statement was placed under the the Director of Nursing (DON)'s door on 12/22/19. STNA #265 worked the remainder of the 2:00 P.M. to 10:00 P.M. shift and was not suspended until 12/23/19. The SRI file contained interviews with Resident #42 and #54 revealing no concerns. There were no interviews with the other residents or staff. Interview with the Administrator on 12/28/19 at 5:00 P.M. he verified he was aware of the neglect allegation on 12/22/19 however, he did not feel it was an allegation of neglect. He stated STNA #250 and #265 were friends and were having some kind of a disagreement. He verified the facility received a call on 12/23/19 of an allegation of neglect involving Resident #42 and #54, which was the same information contained in STNA #250 written document. The Administrator verified STNA #265 was not suspended until 12/23/19. Review of the facility policy titledAbuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/16, indicated under Section D-1 b indicated if the staff member was accused or suspected of abuse, neglect, exploitation, and misappropriation of resident property, the facility should remove the staff member from the facility pending the outcome of the investigation. This deficiency substantiates Complaint Number OH00109009. Page 1 of 7 366370 366370 12/28/2019 Mill Creek Nursing & Rehabilitation 900 Wedgewood Circle Galion, OH 44833

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of a Self-Reported Incident (SRI) of neglect, staff interview, and review of the facility policy, the facility failed to protect the residents following an allegation of neglect involving two (#42 and #54) residents. The facility census was 62. Residents Affected - Few Findings include: Review of the SRI dated 12/23/19 revealed the facility reported a allegation of neglect to the Ohio Department of Health. A written statement from State Tested Nursing Assistant (STNA) #250 documented on 12/22/19 during dinner, STNA # 265 was asked to answer call lights on the 100 Hall. STNA #250 was overheard by STNA#265 telling Resident # 42 and Resident #54 I can't help you. I have my own residents to care for. The written statement noted STNA # 250 reported the incident to the nurse on duty and nothing was done. STNA #250 documented she felt STNA #265 was neglecting the residents and not providing adequate care. The SRI noted the written statement was placed under the the Director of Nursing (DON)'s door on 12/22/19. STNA #265 worked the remainder of the 2:00 P.M. to 10:00 P.M. shift and was not suspended until 12/23/19. The SRI file contained interviews with Resident #42 and #54 revealing no concerns. There were no interviews with the other residents or staff. Interview with the Administrator on 12/28/19 at 5:00 P.M. he verified he was aware of the neglect allegation on 12/22/19 however, he did not feel it was an allegation of neglect. He stated STNA #250 and #265 were friends and were having some kind of a disagreement. He verified the facility received a call on 12/23/19 of an allegation of neglect involving Resident #42 and #54, which was the same information contained in STNA #250 written document. The Administrator verified STNA #265 was not suspended until 12/23/19. Review of the facility policy titledAbuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/16, indicated under Section D-1 b indicated if the staff member was accused or suspected of abuse, neglect, exploitation, and misappropriation of resident property, the facility should remove the staff member from the facility pending the outcome of the investigation. This deficiency substantiates Complaint Number OH00109009. 366370 Page 2 of 7 366370 12/28/2019 Mill Creek Nursing & Rehabilitation 900 Wedgewood Circle Galion, OH 44833

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical records, staff interview, and review of the facility policy, the facility failed to revise care plans with new diagnoses and treatments for two (#59 and #32) of 16 residents reviewed for care plans. The census was 62. Findings include: 1. Review of Resident #59's medical record revealed she admitted to the facility 06/15/18. Diagnoses included encephalopathy, cerebral infarction, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 11/08/19, revealed Resident #59 had a severe cognitive impairment and required extensive assistance from staff for activities of daily living. Review of a nursing progress note dated 11/25/19 revealed Resident #59 was difficult to arouse, would not verbally respond to sternal rub and had frequent twitching of her arms noted. Her physician was notified of her change of condition and she was sent to the emergency room for evaluation and treatment. Review of a nursing note dated 11/27/19 revealed Resident #59 re-admitted to the facility with a primary diagnoses of seizures. Review of hospital documentation titled Continuity of Care, dated 11/27/19, revealed Resident #59 had a new onset of seizures on 11/25/19. Review of Resident #59's current care plan revealed no care plan had been developed for the resident's onset of seizures upon return from the hospital on [DATE]. Interview on 12/28/19 at 12:09 P.M., with MDS Registered Nurse (MDS RN) #28 confirmed Resident #59 returned to the facility 11/27/19 with a new diagnosis of seizures. MDS RN #28 confirmed a care plan had not been developed for Resident #59's new condition of seizures. Review of a facility policy titled Documentation: Care Plan, last revised July 2006, revealed the interdisciplinary team (IDT) would develop, maintain, and modify the nursing component of the plan of care. The policy revealed the care plan was reviewed and revised at least quarterly with the MDS, and on an as needed basis as changes occurred in the resident's regimen. 2. Resident #32 was admitted to the facility on [DATE]. Diagnoses included age related osteoporosis, major depressive disorder, restless leg disorder, hypothyroidism, gastrointestinal reflux disease, and hypertension. Review of the admission MDS assessment, dated 07/31/19, revealed Resident # 32 had no cognitive deficits. She required extensive assistance of two staff for mobility activities of daily living (ADL) and toileting. The assessment indicated she was occasionally incontinent of bladder and always continent of bowel with no toileting plan. Review of a Certified Nurse Practitioner (CNP) progress note, dated 10/26/19, documented the 366370 Page 3 of 7 366370 12/28/2019 Mill Creek Nursing & Rehabilitation 900 Wedgewood Circle Galion, OH 44833

F 0656 resident had urinary retention. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS assessment, dated 10/31/19, revealed the resident was frequently incontinent of bladder and occasionally incontinent of bowel with no toileting plan. Residents Affected - Few Review of the December 2019 monthly physician orders revealed an order to straight catheterize the resident for urinary retention if she did not void for eight hours and alert the physician. The order was initiated on 09/17/19. Review of the plan of care, updated 10/31/19, revealed the resident had an alteration in elimination related to occasional bladder incontinence. The care plan did not identify the resident was to be straight catheterized if unable to void for eight hours. Interview on 12/28/19 at 1:00 P.M., RN #120 and Cooperate RN #113 verified the plan of care did not address urinary retention with the need for intermittent catheterization. 366370 Page 4 of 7 366370 12/28/2019 Mill Creek Nursing & Rehabilitation 900 Wedgewood Circle Galion, OH 44833

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, resident interview, and staff interview, the facility failed to follow the physician order for the administration of an anti-diarrheal medication and failed to follow up with the physician when loose stools continued for one (#36) out of 16 residents reviewed during the survey. The census was 62. Residents Affected - Few Finding include: Review of Resident #36's medical record revealed she admitted to the facility [DATE]. Diagnoses included moderate protein-calorie malnutrition, dysphagia, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #36 had a moderate cognitive impairment and required limited assistance with toilet use. Review of a physician's progress note dated [DATE] revealed Resident #36 stated she was having more frequent stools but not frank diarrhea. Review of Resident #36's bowel documentation revealed loose stools occurred twice on [DATE], on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] twice, [DATE], and [DATE]. Review of Resident #36's Medication Administration Record (MAR) for [DATE] revealed an order dated [DATE] for loperamide 2 milligrams, one or two tablets every six hours as needed for diarrhea for a total of seven days. The MAR revealed the medication was only administered once on [DATE]. Review of the medical record revealed the physician had not been notified of the continued loose stools of Resident #36. Interview on [DATE] at 11:20 A.M., Resident #36 stated she had loose bowels since she admitted . She revealed the had briefly given her something for the diarrhea but that she was no longer receiving anything to help. She stated she used a commode to remain continent with her loose bowels. She stated she was still having loose bowels. Interview on [DATE] at 1:39 P.M., State Tested Nurse Aide (STNA) #65 stated Resident #36 had loose bowels. She stated if she noticed loose stools she would document it in the medical record and inform the nurse. Interview on [DATE] at 1:41 P.M., Registered Nurse (RN) #51 confirmed Resident #36 had been prescribed a seven day order on [DATE] for loperamide for diarrhea as needed for seven days, ending on [DATE]. RN #51 confirmed Resident #36 only received her as needed anti-diarrheal once, on [DATE], but had documented loose stools [DATE], [DATE], and [DATE] without the medication being administered. She confirmed Resident #36 continued having documented loose stools once her anti-diarrheal order had expired and there was no evidence the physician had been notified for further intervention for Resident #36's loose stools. 366370 Page 5 of 7 366370 12/28/2019 Mill Creek Nursing & Rehabilitation 900 Wedgewood Circle Galion, OH 44833

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to follow physician's orders to intermittent catheterize a resident if there was no urine output for an eight hour period for one (#32) of one resident reviewed for urinary catheterization. The facility identified one resident as requiring intermittent catheterization. The facility census was 62. Findings include: Resident #32 was admitted to the facility on [DATE]. Diagnoses included age related osteoporosis, major depressive disorder, restless leg disorder, hypothyroidism, gastrointestinal reflux disease, and hypertension. Review of the admission Minimum Data Set (MDS) assessment, dated 07/31/19, revealed the resident had no cognitive deficits. She required extensive assistance of two staff for mobility activities of daily living (ADL) and toileting. The assessment indicated she was occasionally incontinent of bladder and always continent of bowel with no toileting plan. Review of a Certified Nurse Practitioner progress note dated 10/26/19 documented the resident had urinary retention. Review of the quarterly MDS assessment darted 10/31/19 revealed the resident was frequently incontinent of bladder and occasionally incontinent of bowel with no toileting plan. Review of the December 2019 monthly physician orders revealed an order to straight catheterize the resident for urinary retention if she did not void for eight hours and alert the physician. The order was initiated on 09/17/19. Review of State Tested Nursing (STNA) documentation for bowel and bladder elimination revealed on 12/16/19 Resident #32 was continent of urine at 1:19 P.M. and 11:23 P.M. with no other evidence of urinary output documented. On 12/17/19 the resident was continent of urine at 10:29 A.M. and 10:09 P.M. with no other evidence of urinary output documented. On 12/18/19 the resident was continent of urine at 1:26 P.M. and 10:00 P.M. with no other evidence of urinary output documented. On 12/19/19 the resident was continent of urine at 12.56 A.M. and incontinent of urine 11:43 AM and 11:29 P.M. with no other evidence of urinary output documented. On 12/20/19 the resident was continent of urine at 12:55 A.M. and incontinent of urine at 11:23 P.M. with no other evidence of urinary output documented. On 12/21/19 the resident was continent of urine at 12:04 AM, at 1:25 P.M. the resident did not void, and at 11:12 P.M. was continent of urine with no other evidence of urinary output documented. On 12/22/19 the resident was continent of urine at 1:22 PM and 11:12 P.M. with no other evidence of urinary output documented. On 12/23/19 the resident was incontinent of urine at 9:11 A.M. and continent of urine at 11:59 P.M. with no other evidence of urinary output documented. On 12/24/19 the resident was continent of urine at 1:29 P.M. and 7:43 P.M. with no other evidence of urinary output documented. On 12/25/19 the resident was incontinent of urine at 1:46 P.M. and at 7:09 P.M. was continent of urine with no other evidence of urinary output documented. On 12/26/19 the resident was continent of urine 2:40 A.M., 11:27 A.M. and 11:41 P.M. with no other evidence of urinary output documented. There was no evidence Resident #36 was catheterized when she went greater than eight hours without 366370 Page 6 of 7 366370 12/28/2019 Mill Creek Nursing & Rehabilitation 900 Wedgewood Circle Galion, OH 44833

F 0690 voiding. Level of Harm - Minimal harm or potential for actual harm Interview on 12/28/19 at 1:30 P.M., Registered Nurse (RN) #120 verified Resident #32 had a physician order was to catheterize the resident if she did not void every eight hours. She stated the information found in the STNA Tasks section of the electronic record possibly did not track all the resident's episodes of urinating. The nurses relied on the the STNAs to verbally tell them at the end of their shift if the resident did not void. Residents Affected - Few 366370 Page 7 of 7