Health inspection·August 29, 2019

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of resident council meeting minutes, review of resident grievance/concern logs and associated forms and interview, the facility failed to adequately address resident concerns regarding call light response times. This had the potential to affect all 54 residents. Residents Affected - Some Findings include: 1. Review of the facility's Guest Satisfaction Concern/Suggestion Tracking Logs from August 2018 through August 2019 revealed three entries on the September 2018 log regarding wait time and one concern in October 2018 regarding call light response times. Starting in November 2018 the concern logs only indicated what department the concern involved. A random sample of concerns were chosen for review. Review of Resident Council Meeting Minutes dated 02/13/19 revealed 12 residents attended the meeting. The list of attendees included residents who had dementia. The minutes revealed there were no group concerns, but individual concerns regarding call light response times were addressed on social service concern forms and forwarded to the Director of Nursing (DON). The minutes did not reveal how many alert and oriented residents shared concerns regarding call light response time. Review of Resident Council Meeting Minutes dated 03/13/19 revealed 11 residents attended. The list of attendees included residents who had dementia. The minutes indicated there were no group concerns, but individual concerns on call light response times were addressed. A member of the nursing staff was present to address concerns, and social services would review call light times on individuals. The minutes did not reveal how many alert and oriented residents shared concerns regarding call light response time. A concern form dated 06/27/19 revealed Resident #46 reported it takes forever when using the call light. The concern was referred to the DON/Adm. (was not clear if Administrator or administrative staff). An in-service dated 06/27/19 signed by 13 staff members revealed there had been numerous concerns/complaints regarding call lights not being answered for more than ten minutes. The in-service indicated nurses and aides needed to be observant of the call lights. The form indicated the facility was able to audit call light response daily, and the system recorded exactly how long a call light was on. A concern form dated 07/10/19 revealed Resident #50 reported waiting 45 minutes for her call light to be answered. The concern was referred to the DON. An in-service report dated 07/10/19 was signed by 15 staff members. The in-service form indicated recent complaints and call log reports supported that staff had failed to answer residents' needs in a timely manner. All staff were required to assist in answering lights and with care if it was under the employee's scope of practice. Page 1 of 14 366378 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A concern form dated 08/09/19 revealed Resident #254 indicated he waited one hour and ten minutes for call light response that morning. His oxygen tubing had water in it and he was having difficulty breathing. The concern was referred to the DON. A response indicated all staff were educated regarding answering call lights in a timely manner. There were no in-service records attached. During confidential resident interviews conducted on 08/26/19 and 08/27/19, eight of 12 residents interviewed reported concerns regarding staffing and time it took to get call lights and requests responded to. Among the concerns reported were staff turning call lights off without addressing resident requests and not returning, not getting assistance with toilet use in a timely manner resulting in incontinence, and not receiving medication in a timely manner. Six of the residents stated they had waited greater than 30 minutes for assistance. One State Tested Nursing Assistant (STNA) who requested anonymity due to fear of retaliation stated the 200 hall had many residents who required two assists for activities of daily living. There were times when only one nursing assistant was scheduled to work the 200 hall. Due to the nursing assistant working 200 hall needing to stop and wait for assistance from another staff member, there were times residents had to wait. The STNA also reported there were times at meals when there was only one nursing assistant on the floor to deliver trays and respond to call lights and requests, making it difficult to respond to call lights/requests in a timely manner. The STNA reported there were times when showers were not able to be provided as scheduled related to staffing. On 08/29/19 at 9:31 A.M., Personal Care Attendant (PCA) #648 reported part of her job responsibilities included answering call lights. Sometimes residents' requests were of a nature she was unable to address. In those instances, PCA #648 would inform the nursing assistants. However, sometimes nursing assistants were assisting another resident and could not respond right away. Residents would put their call lights on again. On 08/29/19 at 12:52 P.M., the DON was asked for the second time about providing call light response logs and stated the facility recently switched computer systems and could not access the website to get the logs. The DON verified when reviewing grievances she did find call lights were not being responded to timely and educated staff working the day/time of the grievance but had never done full staff education. The DON indicated she only audited the call light response times for specific complaints/grievances. 2. Interview on 08/27/19 at 3:30 P.M. with Resident #3, Resident #6 and Resident #9 revealed it sometimes took 45 minutes or longer for staff to answer call lights. This usually occurred on the weekend night shift (6:00 P.M. to 6:00 A.M.). The Residents reported they had expressed their concern more than once, but the call light response time continued to be too long. 366378 Page 2 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on review of the Beneficiary Notice worksheet, review of Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review forms, review of a Notice of Medicare Non-Coverage (NOMNC) form and interview, the facility failed to provide residents with the correct forms when their services were no longer covered under Medicare. This affected three (Resident #49, Resident #152 and Resident #153) of three residents reviewed for provision of beneficiary notices. The facility census was 54. Residents Affected - Some Findings include: 1. Review of the Beneficiary Notice worksheet revealed Resident #49 was discharged from Medicare A services on 08/05/19 and remained in the facility. Review of Resident #49's SNF Beneficiary Protection Notification Review form revealed Resident #49's Medicare Part A skilled services began 07/10/19. Resident #49's last covered day of Part A services was 08/05/19. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. An Advanced Beneficiary Notice (ABN) was not provided. A NOMNC was provided. On 08/07/19 at 3:58 P.M., Business Office Manager #630 verified Resident #49 was discharged from Medicare A skilled services on 08/05/19 and remained in the facility. However, Resident #49 was not provided with the required ABN notice. 2. Review of the Beneficiary Notice worksheet revealed Resident #152 was discharged from Medicare A services on 05/30/19 and remained in the facility. Review of Resident #152's SNF Beneficiary Protection Notification Review form revealed Resident #152's Medicare Part A skilled services began 03/30/19. Resident #152's last covered day of Part A services was 05/30/19. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. Resident #152 was not provided with a NOMNC or ABN notice. On 08/07/19 at 3:58 P.M., Business Office Manager #630 verified Resident #152 was discharged from Medicare A skilled services on 05/30/19 and remained in the facility. However, Resident #152 was not provided with the required beneficiary notices. 3. Review of the Beneficiary Notice worksheet revealed Resident #153 was discharged home 03/20/19. Review of Resident #153's SNF Beneficiary Protection Notification Review form revealed Resident #153's Medicare Part A skilled services began 02/01/19. Resident #153's last covered day of Part A services was 03/19/19. The form did not indicated if the services were terminated voluntarily of initiated by the facility. The form did not indicate Resident #153 was provided with a NOMNC but did indicate a ABN notice was not provided. On 08/07/19 at 3:58 P.M., Business Office Manager #630 stated Resident #153's discharge was initiated by the facility. No NOMNC was provided. 366378 Page 3 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

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 personnel files, review of the facility's criminal background check log, review of the abuse prohibition policy and interview, the facility failed to implement the abuse policy to ensure all potential employees had criminal background checks and reference checks completed upon hire. This affected one (Licensed Nursing Home Administer) of eight personnel files reviewed. This had the potential to affect all 54 residents. Residents Affected - Many Findings include: Review of the Administrator's personnel file with Business Office Manager (BOM) #630 revealed a hire date of 04/16/19. On 08/29/19 at 4:00 P.M., BOM #630 stated the Administrator had worked at the facility before in 2015 and returned on an interim basis 02/29/19. BOM #630 stated the Administrator provided a notice from the United States Department of Justice dated 11/13/18 which indicated a Federal Bureau of Investigations (FBI) background check was done and the Administrator had no prior arrest data at the FBI. The form indicated it did not preclude further criminal history at the state or local level. The notice also indicated the results were only effective for the date the submission was originally completed. BOM #630 verified the Administrator did not have a criminal background check completed on hire. When asked for reference checks, BOM #630 provided emails between the Administrator and staff of the management company. One email dated 04/06/19 indicated one person indicated it was nice having the Administrator back and informed the Administrator to let his request to become the full time Administrator be known to the appropriate staff. An email dated 04/17/19 congratulated the Administrator. BOM #630 stated she considered the emails a reference. Review of the facility's Criminal Background Check Log indicated the Administrator applied on 02/28/19 and was hired 02/28/19. The log indicated fingerprint records were submitted to the Bureau of Criminal Investigation/Federal Bureau of Investigations on 02/18/15 with results received 03/18/15. On 08/29/19 at 4:00 P.M., BOM #630 revealed the information was placed on the log when the Administrator returned to work on an interim basis but again verified no new criminal background check was conducted. Review of the facility's Abuse Prohibition policy (dated April 2019) revealed as part of the screening process, at a minimum, the facility would check the applicant's references from prior employers and conduct a criminal background check in accordance with Ohio law. 366378 Page 4 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete comprehensive resident assessments a minimum of every 12 months. This affected two (Residents #1 and #10) of four residents reviewed for resident assessments. The facility census was 54. Findings include: 1. Review of Resident #1's medical record revealed diagnoses including Alzheimer's disease and depression. Resident #1 had a 14-day Minimum Data Set (MDS) 3.0 assessment dated [DATE]. Resident #1 had an annual MDS with an assessment reference date (ARD) of 07/19/19 which was still in progress. On 08/29/19 at 2:50 P.M., MDS Coordinator #643 verified Resident #1's annual MDS with an ARD of 07/19/19 had not been completed. MDS Coordinator #643 stated the annual MDS should have been submitted 08/12/19. 2. Review of Resident #10's medical record revealed diagnoses including stroke, chronic respiratory failure, anemia, hypertension and severe contractures. Resident #10 had a significant change MDS with an ARD of 08/14/18. An annual MDS with an ARD of 08/05/19 was still in progress. On 08/29/19 at 2:50 P.M., MDS Coordinator #643 verified Resident #10's annual MDS with an ARD of 08/05/19 was not completed in a timely manner, stating it was due 08/19/19. 366378 Page 5 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and interview, the facility failed to complete quarterly Minimum Data Set (MDS) assessments a minimum of every three months. This affected one (Resident #9) of four residents reviewed for MDS assessments. Residents Affected - Few Findings include: Review of Resident #9's medical record revealed diagnoses including anxiety, hypertension, depression, chronic kidney disease, and hyperlipidemia. Resident #9's most recent completed MDS had an assessment reference date (ARD) of 04/29/19. A quarterly MDS with an ARD of 07/30/19 was still in progress. On 08/29/19 at 2:50 P.M., MDS Coordinator #643 verified Resident #9's quarterly MDS with an ARD of 07/30/19 had not been completed in a timely manner. The MDS should have been submitted 08/13/19. 366378 Page 6 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and interview, the facility failed to transmit a Minimum Data Set (MDS) assessment in a timely manner. This affected one (Resident #3) of four residents whose resident assessments were reviewed. Residents Affected - Few Findings include: Review of Resident #3's medical record revealed diagnoses including hypertension, thyroid disorder, osteoporosis and anxiety disorder. Resident #3's quarterly MDS completed 04/25/19 was submitted 06/08/19. On 08/29/19 at 3:20 P.M. MDS Coordinator #643 stated Resident #3's quarterly MDS with an assessment reference date (ARD) date of 04/11/19 was not completed timely and not accepted until 06/08/19. 366378 Page 7 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

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 observation, interview and record review, the facility failed to adequately care plan and monitor behavior for Resident #21. This affected one of one resident reviewed for behavior. Findings include: Review of the medical record revealed Resident #21 was admitted on [DATE] with diagnoses including gastrointestinal hemorrhage, atrial fibrillation, mitral valve disorder and chronic obstructive pulmonary disease (COPD). A diagnosis of metabolic encephalopathy as added on [DATE] when Resident #21 was sent to the emergency room for delusions and paranoia for psychiatric evaluation. Review of the Elopement Risk assessment dated [DATE] revealed the resident had a history of elopement behavior. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact with verbal behaviors towards others, wandering, was on oxygen therapy, required supervision only for most activities of daily living, used a wheelchair and wore a WanderGuard (a device that alerts staff when a resident is trying to exit the facility) due to wandering behavior. Review of the physician progress note dated [DATE] revealed Resident #21 was yelling that some man placed a bomb in his room. The physician wrote this was a major change where he was delirious and completely confused, calling everybody liars and all against him. Review of the progress note of [DATE] revealed Resident #21 had a cigarette lighter and was flicking it in the proximity of residents on oxygen. Resident #21 was not using oxygen at the time. When staff asked the resident for the lighter, the resident threatened to hurt and burn staff. The resident proceeded to attempt to burn a nurse's arm and shirt before throwing the lighter. The resident stated he had more lighters in his room. A search of Resident #21's room yielded $330 cash, $340 in unscratched lottery tickets, scissors, 75 Ibuprofen tablets and seven prescription narcotic tablets (marked IP 115). The physician and the resident's son were notified and in agreement to send the resident to the hospital for geriatric psychiatry. Review of the progress note of [DATE] revealed Resident #21 was placed on one to one (1:1) staffing, cursed at and attempted to hit staff, wandered across the hall to another resident's bathroom, sat on the toilet, continued to curse and yell and threatening to [NAME] feces from the toilet at staff. The physician was contacted and ordered 1 milligram (mg) of Haldol (an antipsychotic medication) intramuscularly, and transfer to the hospital for a psychiatric evaluation. Review of the hospital discharge paperwork dated [DATE] revealed the reason for the admission was a gastrointestinal bleed and congestive heart failure. There was no mention of any psychiatric evaluation or treatment. Review of care plan dated [DATE] revealed care areas for poor decision making and refusal of care related to anxiety, cognitive impairment, alteration in mood related to depression and requiring antidepressant to manage (added [DATE]) and alteration in mood and behavior related to metabolic encephalopathy and COPD as evidenced by delusional thinking (added [DATE]). 366378 Page 8 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the psychiatric progress notes from [DATE] to [DATE] revealed Resident #21 was seen for depression and anxiety at the facility. Review of physician's progress notes from [DATE] and [DATE] revealed Resident #21 reported a number of hallucinations including the handles of the drawers in his room turning into snakes, and his wife (deceased ) disappearing into the wall. Observations of Resident #21 on [DATE] at 9:25 A.M. and 1:26 P.M., [DATE] at 1:28 P.M. and [DATE] at 8:50 A.M. revealed the resident appeared calm but confused, rummaging in his room and wandering. No verbal or physical behaviors were observed. Interview with Resident #21 on [DATE] at 1:28 P.M. revealed the resident was missing his wallet and thought his roommate had taken it. Interview on [DATE] at 9:10 A.M. with State Tested Nursing Aide (STNA) #672 revealed the resident was usually delusional, with repetitive themes. Interview on [DATE] at 12:55 P.M. with Registered Nurse (RN) #700 revealed after Resident #21 exhibited delusional behavior in April of 2019 and was sent to the hospital , the resident was diagnosed with metabolic encephalopathy which the RN and the physician attributed as the cause of his delusions, hallucinations and aggressive behavior. The RN stated it was not determined how Resident #21 obtained the lighter, pills and scissors. It was thought the resident got them when he left the facility with his son. The RN was not aware of the resident leaving the facility after the lighter incident, and there were no further searches of the resident's room. Interview on [DATE] 1:20 PM with the Director of Nursing (DON) verified Resident #21's care plan was silent to the behaviors of [DATE] and [DATE]. The care plan did not adequately address Resident #21's behaviors, including baseline behaviors and safety concerns. Interview on [DATE] 1:35 P.M. with Resident #21's son revealed Resident #21 likely got the pills, lighter and scissors when the son took him to his old house. The son stated the items may have been in the pockets of jackets brought to the facility from the home. The son stated he had taken Resident #21 out of the facility a couple times since the incident. Due to Resident #21's weakened condition, the resident did not leave the son's car. They would go for a ride, and the son would stop and get some lottery scratch offs while the resident waited in the car. The son was confident that Resident #21 could not have received any additional lighters or potentially harmful items. Review of the sign out log for Resident #21 verified the resident left the faciity on [DATE] and [DATE] with his son. 366378 Page 9 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

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 and interview, the facility failed to implement a resident's bowel protocol. This affected one (Resident #23) of five residents whose records were reviewed for medication use. Residents Affected - Few Findings include: Review of Resident #23's medical record revealed diagnoses including Alzheimer's disease, depression, and abnormalities of gait and mobility. A plan of care initiated 07/08/15 indicated Resident #23 had chronic constipation with hard stools and frequent refusals of routine constipation medications and bowel protocol placing Resident #23 at risk for impaction and injury related to constipation. Interventions included administering medications as ordered and implementing the bowel program as indicated. Physician's orders dated 05/06/19 revealed 30 milliliters (ml) of Milk of Magnesia (MOM), laxative, was to be administered as needed for constipation if Resident #23 had no bowel movement for three days, a 10 milligram (mg) Bisacodyl-evac suppository, laxative, as needed for constipation for no results eight hours following MOM administration, and one enema as needed for constipation for no result eight hours following the suppository. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 required extensive assistance with toilet use. Review of bowel movement (BM) records and Medication Administration Records (MAR) from 06/01/19 through 08/27/19 revealed the following: No BM was recorded 06/06/19 to 06/10/19. The June 2019 MAR revealed no initiation of Resident #23's bowel protocol during that time frame. No BM was recorded 06/14/19 to 06/17/19. The June 2019 MAR revealed no initiation of Resident #23's bowel protocol during that time frame. No BM was recorded 06/28/19 to 07/04/19. The June 2019 and July 2019 MAR revealed no initiation of Resident #23's bowel protocol. A progress note dated 07/01/19 at 6:31 P.M. indicated Resident #23 refused MOM. There were no further documented attempts to initiate the bowel protocol. On 08/28/19 at 11:32 A.M., Corporate Registered Nurse (RN) #700 provided a form titled Bowel Protocol and Monitoring Tool dated June 2010 which indicated Resident #23 received MOM and had a BM. RN #700 verified the bowel protocol should have been initiated after three full days with no BM on 06/09/19. On 08/29/19 at 9:13 A.M., Corporate RN #700 verified Resident #23's physician orders regarding her bowel protocol when she had no BM in three days were not implemented consistently. 366378 Page 10 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, and interview, the facility failed to administer nutritional formula through a feeding tube in a manner to prevent microbial growth. This affected one (Resident #10) of one resident reviewed for feeding tubes. The facility identified three residents receiving tube feedings. Findings include: Review of Resident #10's medical record revealed diagnoses including cachexia (loss of weight, muscle atrophy, fatigue, weakness and significant loss of appetite in someone who is not actively trying to lose weight), aphasia (inability to comprehend or formulate language because of damage to specific brain regions) following a stroke, chronic respiratory failure, anemia, and severe contractures. Resident #10 had physician orders for nothing by mouth. A physician order dated 07/11/19 revealed Resident #10 was to receive Jevity 1.5 (supplement) via a feeding tube at 60 milliliters per hour (ml/hr) with 75 milliliters (ml) of water flush every hour. On 08/26/19 at 9:41 A.M., Resident #10 was observed with a tube feeding pole beside her bed. The pole had a kangaroo bag (bag in which tube feed formula is placed for administration) with approximately 800 ml of formula. The bag had two dates written on it, one was dated 8/25 (no year) and the other was dated 8/26. The label indicated Resident #10 was receiving Jevity 1.5 at 60 ml/hr. The tube feed pump was set at 60 ml/hr with a flush of 75 ml of water every hour. At 4:25 P.M., the kangaroo bag contained approximately 500 ml of formula. On 08/27/19 at 8:20 A.M., Resident #10's kangaroo bag was labeled Jevity (not 1.5) and was dated 08/27/19 at 1:00 A.M. Approximately 800 ml of formula was in the bag. At 11:54 A.M., approximately 600 ml of formula remained in the bag. At 2:20 P.M. between 400 and 500 ml of formula remained in the bag. On 08/28/19 at 9:11 A.M., Resident #10's kangaroo bag was labeled Jevity 1.5 and was dated 08/27/19 at 10:00 P.M. There was between 700 and 800 ml of formula in the bag. On 08/28/19 at 9:21 A.M., Registered Nurse (RN) #702, an agency nurse, stated he had not added any formula to the kangaroo bag since his shift began. RN #702 stated if he had to add formula he would indicate what was added and the time on the bag. RN #702 stated the kangaroo bags were only good for 24 hours. RN #702 stated if he had to add formula it would be no more than two briks (carton) so it lasted about eight hours. On 8/28/19 at 9:39 A.M., Licensed Practical Nurse (LPN) #606 provided a brik of Jevity 1.5 which contained 237 ml of formula stating it was what was used to fill Resident #10's kangaroo bag. LPN #606 verified the manufacturer was [NAME] labs. LPN #606 verified the bag hanging indicated it was hung at 10:00 P.M. on 08/27/19 and had between 700 and 800 ml of formula remaining in it. Concerns were shared with LPN #606 regarding the amount of time the formula was hanging. At 9:50 A.M., LPN #606 provided a ready to hang bag of Jevity 1.5 stating she had been incorrect and hospice provided the tube feed in the ready to hang canisters but did not provide the spikes to access it so the canisters were opened and poured into the kangaroo bags. 366378 Page 11 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/28/19 at 9:55 A.M., [NAME] Company Representative #710 verified when pouring the tube feed formula from its original container into another container (such as a kangaroo bag) it should hang no greater than eight to twelve hours as long as clean technique was used during the preparation. On 08/28/19 at 10:15 A.M. the information obtained for [NAME] Company Representative #710 was shared with LPN #606. LPN #606 stated she had a call out to the night shift nurse to see if she added any extra formula to the bag prior to leaving and forgot to mark the bag. LPN #606 reported she received a call back during the conversation. After speaking to the night shift nurse, no additional information was provided. Review of the facility's policy, Enteral Tube Feeding via Continuous Pump (revised November 2018), revealed the policy referred to facility procedures for hang times and administration set changes. When requested, no additional policies regarding hang times were provided. 366378 Page 12 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 Medscape website review, the facility failed to ensure Resident #4's laboratory results were addressed timely. This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. Residents Affected - Few Findings include: Review of a medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, syncope and collapse, muscle weakness, gout, dementia, diabetes, hypertension and tremor. Review of the 14-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had severely impaired cognition and received an anticoagulant. Review of a physician's order dated 06/14/19 revealed Resident #4 had an order for 7.5 milligrams of Coumadin (anticoagulant) for atrial fibrillation and an order dated 06/12/19 for a laboratory test, protime (PT) and International Normalized Ratio (INR) to be done every Monday and Thursday. Review of the Anticoagulation Record for Resident #4 revealed the resident had a PT and INR completed on 07/04/19 with results of: PT of 19.3 and an INR 1.8. The physician was not notified until 07/05/19 and ordered an extra one milligram only with the residents usual dose of 7.5 milligrams. Review of a physician's order dated 07/05/19 revealed an order for one milligram of Coumadin one time daily for a low INR, give in addition to the scheduled Coumadin. Review of laboratory results dated [DATE] revealed Resident #4 had a PT of 19.3 and a INR of 1.8 with a hand written order by the nurse practitioner to give an extra one milligram of Coumadin today then resume as ordered and continue PT and INR's as ordered. Review of the website Medscape revealed the INR target range for atrial fibrillation was 2.0-3.0. An interview on 08/29/19 at 3:25 P.M. Corporate Registered Nurse #700 verified the Coumadin order should have been addressed on 07/04/19. 366378 Page 13 of 14 366378 08/29/2019 Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413

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 observation, medical record review, Infection Control Log review and staff interview, the facility failed to administer eye drops to in a sanitary manner and failed to maintain a comprehensive Infection Control Log indicating the pathogens for residents who had urinary tract infections. This affected one resident (Resident #7) of seven observed for medication administration and five residents (Resident #32, Resident #152, Resident #17, Resident #31 and Resident #257) with urinary tract infections but had the potential to affected all 54 residents in the facility. Residents Affected - Many Findings include: 1. An observation of an eye drop administration on 08/27/19 at 11:26 A.M. Registered Nurse (RN) #601 administered eye drops to Resident #7. RN #601 placed the cap for the residents artificial tears directly on the bedside stand, the open end touching the table with no barrier. An interview at this time with RN #601 verified she should not have place the eye drop cap directly on the bedside stand without a barrier. 2. Review of the Infection Control log dated June 2019 revealed Resident #32 had a urinary tract infection (UTI) with an onset date of 06/06/19 with no pathogen listed. Review of the laboratory test dated 06/05/19 revealed Resident #32 had escherichia coli in her urine. 3. Review of the Infection Control log dated June 2019 revealed Resident #152 had a UTI with an onset date of 06/07/19 with no pathogen listed. Review of the laboratory test dated 06/10/19 revealed Resident #152 had Klebsiella pneumoniae in her urine. 4. Review of the Infection Control Log dated June 2019 revealed Resident #17 had a UTI with an onset dated of 06/07/19 with no pathogen listed. Review of the laboratory test dated 06/10/19 revealed Resident #17 had escherichia coli in her urine. 5. Review of the Infection Control Log revealed Resident #31 had a UTI with an onset date of 06/12/19 with no pathogen listed. Review of the laboratory test dated 06/10/19 revealed Resident #31 had escherichia coli in her urine. 6. Review of the Infection Control Log for August 2019 revealed Resident #257 was admitted on [DATE] with a UTI. There was no pathogen documented on the log. Review of the laboratory report dated 08/09/19 indicated a [NAME] species was the pathogen. An interview on 8/29/19 at 5:07 P.M. the Director of Nursing verified the Infection Control Log was incomplete and had not been updated with the pathogen and therefore would not identify pattern or trend in the facility. 366378 Page 14 of 14