Health inspection·September 7, 2022

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, review of Facility Reported Incidents (FRI), record review and facility policy review, the facility failed to timely report an allegation of abuse for one resident (Resident #207). This affected one (Resident #207) of one residents reviewed for abuse. The facility census was 54. Findings Include: Review of the medical record for Resident #207 revealed an admission date on 08/06/22 and a discharge date on 08/30/22. Medical diagnoses included stable burst fracture of third lumbar vertebra, morbid obesity, depression, unsteadiness on feet, muscle weakness, unspecified abnormalities of gait and mobility, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #207 had mildly impaired cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #207 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), including bed mobility. Review of the physician orders dated August 2022 revealed Resident #207 had an order dated 08/09/22 to encourage and/or assist to turn and reposition as tolerated every shift. Review of the plan of care dated 08/06/22 revealed Resident #207 experienced an alteration in mood and/or behavior that included yelling, screaming, refusing care, feeling bad about herself or feeling like a failure, feeling tired or having little energy, poor appetite, overeating, and often refused to get out of bed. Interventions included allow resident to vent, validate feelings as needed, attempt to identify what triggered behavior, find a staff member with a good rapport with the individual, and administer medications as ordered by the physician. Review of progress notes dated 08/29/22 revealed there was no documentation of any reported allegations of abuse. Interview on 08/29/22 at 2:16 P.M. with Resident #207 revealed an aide or nurse over the weekend was not very friendly toward her and refused to reposition her when the resident requested to be moved in the bed. Resident #207 stated she felt mistreated by the staff person over the weekend. Resident #207 described the staff person involved as an African American, heavyset female. Resident #207 stated she reported the incident this morning (08/29/22) to State Tested Nurse Aide (STNA) #100. Resident #207 stated she had not received any follow up from the staff since reporting the incident this morning. Page 1 of 7 366374 366374 09/07/2022 Trueman Pointe Care Center 4660 Trueman Blvd Hilliard, OH 43026

F 0609 Review of Facility Reported Incidents (FRIs) revealed there was no report of the allegation on 08/29/22. Level of Harm - Minimal harm or potential for actual harm Interview on 08/31/22 at 10:33 A.M. with STNA #100 revealed the aide had worked at the facility for three years and worked on Resident #207's unit Monday through Friday during the day. STNA #100 confirmed Resident #207 informed her she did not feel the staff over the weekend treated her very nicely. STNA #100 confirmed Resident #207 reported the incident to her first thing in the morning on 08/29/22. STNA #100 stated Resident #207 reported the aide over the weekend was a little rough and didn't clean her up very well. STNA #100 stated she told Resident #207 that the aide's behavior was unacceptable and that the resident should definitely report the incident to the Administrator. STNA #100 stated she was pretty sure she also reported the incident to the Assistant Director of Nursing (ADON)/Unit Manager (UM) #60 within an hour of Resident #207 reporting it to her. Residents Affected - Few Interview on 08/31/22 at 10:50 A.M. with UM #60 revealed she had been the UM on Resident #207's unit for a couple of weeks. UM #60 stated she had been in and out of the facility over the weekend and had not received any negative reports about the weekend staff from any of the residents. UM #60 stated she did not recall STNA #100 reporting any allegations of abuse or negative interactions that involved Resident #207 on 08/29/22. Interview on 08/31/22 at 4:42 P.M. with the Director of Nursing (DON) confirmed a FRI was just opened today (two days after the allegation had been reported to staff) once the administrative staff had been made aware of the allegation. Review of the facility policy, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed the policy stated, all incident and allegations of abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property and all injuries of an unknown source must be reported immediately to the Administrator or designee. 366374 Page 2 of 7 366374 09/07/2022 Trueman Pointe Care Center 4660 Trueman Blvd Hilliard, OH 43026

F 0760 Ensure that residents are free from significant medication errors. 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, and resident interview, the facility failed to administer one resident (Resident #23) Lantus insulin as ordered upon admission. This affected one (Resident #23) of six residents reviewed for medication administration. The facility census was 54. Residents Affected - Few Findings Include: Review of the medical record for Resident #23 revealed an admission date on 06/17/22. Medical diagnoses included displaced bicondylar fracture of right tibia (lower leg), Type II Diabetes Mellitus without complications, major depressive disorder-recurrent, stage three chronic kidney disease, and congestive heart failure (CHF). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #23 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #23 received daily insulin injections. Review of the Medication Administration Record (MAR) for June 2022 revealed Resident #23 had an order for Lantus Solostar 100 unit per milliliter (mL) Solution pen-injector with instructions to inject 25 units subcutaneously at bedtime for diabetes mellitus. The order had a start date on 06/18/22 at 7:00 P.M. Resident #23 also had an order for Insulin Glargine Solution (generic for Lantus insulin) 100 units/mL with instructions to inject 25 units subcutaneously one time a day for diabetes with a start and end date on 06/18/22. Resident #23 received a one time dose on 06/18/22 of Insulin Glargine Solution. However, Resident #23 did not receive Lantus insulin until 06/20/22. Resident #23 was not administered any insulin on 06/19/22 as ordered. Review of the admission Assessment & Baseline Care Plan dated 06/17/22 revealed diabetes was not marked as a part of Resident #23's medical history. Vital signs did not include a blood sugar reading and the vital signs documented were dated 01/05/22 and 01/07/22 (five months prior to admission). An admitting weight was not completed. The weight included on the assessment was dated 12/22/21 (six months prior to admission). Review of blood sugar readings dated from admission on [DATE] revealed Resident #23 did not receive a blood sugar check until 06/20/22 at 8:48 P.M. The reading was 201 mg/dL. Review of the progress notes dated from 06/17/22 to current revealed there was no admission note for Resident #23. There were not any progress notes related to the missed dose of Lantus insulin. Review of the plan of care dated 06/18/22 revealed Resident #23 was at risk for hypoglycemia and hyperglycemia episodes related to insulin dependent diabetes mellitus. Interventions included insulin as ordered and monitor blood sugar levels as ordered and as needed for symptoms of hypoglycemia or hyperglycemia. Review of the list of medications stored in the facility's EDK box revealed Lantus insulin was a medication listed as being stored in the facility's EDK box. Interview on 08/29/22 at 1:55 P.M. with Resident #23 revealed he did not receive medications, 366374 Page 3 of 7 366374 09/07/2022 Trueman Pointe Care Center 4660 Trueman Blvd Hilliard, OH 43026

F 0760 including insulin, for approximately two days after being admitted to the facility in June 2022. Level of Harm - Minimal harm or potential for actual harm Interview on 08/31/22 at 5:56 P.M. with the Director of Nursing (DON) and the Administrator confirmed Resident #23 did not receive Lantus insulin injection on 06/19/22 as ordered. Residents Affected - Few A facility policy related to following physician orders for a new admission was requested during the survey period but a policy was not provided. 366374 Page 4 of 7 366374 09/07/2022 Trueman Pointe Care Center 4660 Trueman Blvd Hilliard, OH 43026

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interviews, the facility failed to provide timely physician ordered laboratory services for two of six residents (Resident #29 and Resident #37) reviewed for medications. The facility census is 54. Residents Affected - Few Findings include: 1. Review of Resident #29's medical record identified admission to the facility occurred on 12/29/21, with diagnoses including; downs syndrome, constipation and vascular disease. Resident #29 was observed to be verbal and able to make her needs known. Resident #29 was noted with a urinary catheter on 08/10/22. Review of Resident #29's progress notes identified on 08/10/22 at 8:57 P.M. confusion was noted and increased behaviors with staff. The staff called the physician whom ordered a UA C&S (urinalysis/culture/sensitivity). The notes identified on 08/11/22 the staff collected the urine sample which was ready for the laboratory to pick up. The progress notes dated 08/12/22 at 8:14 A.M. identified the specimen was collected incomplete and will attempt to collect again. The progress notes identified on 08/13/22 Resident #29 increased confusion persists and the facility is awaiting the urinalysis results. The progress notes identified Resident #29 went to a urology appointment on 08/17/22, with a new order to remove the urinary catheter. The notes identified on 08/18/22 Resident #29 identified I want this marble out. The notes confirmed the urinary catheter was removed on 08/18/22. Review of the record identified no evidence what occurred with the urine sample and or results from the 08/12/22 urinalysis. Interview with the facility Director of Nursing (DON) on 08/30/22 at 2:21 P.M. confirmed there was an order on 08/10/22 for a urinalysis for Resident #29. The interview revealed the laboratory called the facility on 08/17/22 and informed them the urine sample, from 08/12/22 was contaminated and was not able to be processed. The interview identified on 08/18/22 another sampled was collected from Resident #29 and was submitted to the laboratory. The interview identified the laboratory then called and identified that sample had spilled. The interview confirmed the facility did not recollect the sample until 08/22/22. The interview confirmed the results were returned to the facility on [DATE] at which time Resident #29 was diagnosis with a urinary tract infection and was placed on two different antibiotics. The interview confirmed the original order for the urinalysis test was on 08/10/22 and this was not completed and returned for Resident #29, treatment until 08/26/22 (16 days later). 2. Resident #37 was admitted to the facility 09/11/19 with diagnoses that include but are not limited to paraplegia, morbid obesity, metabolic encephalopathy, panic disorder, vascular dementia, depression, anemia, and insomnia. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] confirmed the resident was cognitively intact, had no delusions, or hallucinations but did have daily rejection of care. The resident required assist for bed mobility, dressing, toileting, hygiene. and was dependent on staff for transfers. 366374 Page 5 of 7 366374 09/07/2022 Trueman Pointe Care Center 4660 Trueman Blvd Hilliard, OH 43026

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of resident medication orders revealed the resident had an order for Primidone 50 milligrams (mg) three times daily which was ordered on 07/22/21 for tremors. Review of the pharmacy recommendation written on 08/18/22 revealed the recommendation requested the provider to consider a Primidone level to ensure non-toxic levels of the medication, as the resident had received Primidone 50 mg three times daily. The physician reviewed the recommendation and ordered a Primidone level with the next laboratory day dated 08/22/22. Review of the laboratory rejected report provided by the facility revealed the resident had a Primidone level obtained on 08/23/22. The report revealed the specimen was rejected as the specimen was not placed in the correct collection tube. Review of the laboratory requisition form dated 08/25/22 revealed Resident #37 had a Primidone level re-drawn. During an interview with the Director of Nursing (DON) on 09/01/22 at 10:41 A.M. it was confirmed on 08/23/22 the resident had a Primidone laboratory test collected, however the test was initially placed in the wrong tube for laboratory processing by the laboratory employee who drew the resident's blood. The laboratory test was recollected on 08/25/22 and the facility was told the laboratory test had to be sent to a reference laboratory for processing. The DON revealed on 08/30/22 at 4:14 P.M. the facility was informed by the laboratory the Primidone level was pending and could take up to 15 days to complete. The DON revealed the laboratory called the facility back on 08/30/22 at 5:08 P.M. and stated the laboratory cannot use the sample they had collected for Resident #37 on 08/25/22 there was no explanation provided for why the laboratory specimen was unusable. The laboratory stated to the facility they were sending another phlebotomist to draw another specimen and test would be completed stat. The facility stated they were in contact with the laboratory on 09/01/22 and the Primidone level is still pending. The DON indicated the laboratory could not tell the facility the time frame it would take to complete the Primidone serum level to be completed. 366374 Page 6 of 7 366374 09/07/2022 Trueman Pointe Care Center 4660 Trueman Blvd Hilliard, OH 43026

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 observations, medical record reviews, facilities isolation guidelines and infection control policies and staff interviews, the facility failed to ensure one of two residents (Resident #29) identified with an infection, was placed into contact isolation as required. The facility census was 54. Residents Affected - Few Findings include: Review of Resident #29's medical records identified admission to the facility occurred on 12/29/21. Resident #29 had medical diagnoses including; downs syndrome, constipation and vascular disease. Review of Resident #29's urinalysis results dated 08/26/22 identified positive results that evidenced two different bacteria (klebsiella pneumoniae and entercoccus Faecalis) were growing. The report also identified resistance markers included; ESBL (extended spectrum [NAME]-lactamase) which is a multi-drug resistant and can not be killed by many of the antibiotics available. Observation of Resident #29 and her room occurred on 08/29/22 at 11:08 A.M. and 08/30/22 at 7:52 A.M. Resident #29's room identified no evidence of any isolation precautions were in place (no signage on door and no equipment outside the door). Review of Resident #29 urinalysis results occurred with the facility Director of Nursing (DON) on 08/30/22 at 2:21 P.M. The review of the results confirmed the bacteria was positive for ESBL producing. The interview confirmed Resident #29 should be placed in contact isolation throughout her antibiotic treatment regimen. Review of physician orders for Resident #29 confirmed the facility placed Resident #29 into contact isolation on 08/30/22, which is to continue through 09/02/22, following the interview with the DON. Review of the facility standard and transmission-based precautions policy, dated 11/28/17 identified specifies the different types of precautions, including when and how isolation should be used for a resident. The policy identified contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiological important microorganisms, which are spread by direct or indirect contact with the resident or the residents environment. Transmission-based precautions will be maintain as long as necessary to prevent the transmission of infection (while the risk of transmission of the infectious agent persists or for the duration of the illness). However should be the least restrictive possible and for the shortest amount of time. Review of the CDC guidelines, isolation precautions, provided from the facility regarding ESBL's infectionsThe recommendation identified Contact precautions. The MDRO judged by the infection control program, based on local, state and regional or national recommendations to be of clinical and epidemiologic significance. Contact Precautions recommended in setting with evidence of on-going transmission, acute care setting with increased transmission or wound that cannot be contained by dressing. 366374 Page 7 of 7