Health inspection·March 7, 2019

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the state mental health agency after resident's significant mental health change. This affected two (Resident #53 and Resident #86) of five residents reviewed for Preadmission Screening and Resident Review (PASARR). The facility census was 108. Findings Include: 1. Resident #53 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, restlessness and agitation, other hallucinations, brief psychotic disorder, other dissociative and conversion disorder, generalized anxiety disorder, major depressive disorder and dementia with Lewy bodies. Review of the Brief Interview for Mental Status (BIMS) assessment, dated 01/08/19, revealed she was severely cognitively impaired. Review of Resident #53 medical records revealed the facility added the mental health diagnoses unspecified psychosis not due to a substance or known physiological condition on 06/20/13, and brief psychotic disorder on 06/09/13. Review of Resident #53 PASARR application/form (completed on 03/09/12) revealed on Section C, titled Medical Diagnosis, she did not have have the diagnosis of dementia listed. Also, in review of Section D, titled indications of serious mental illness, it indicated she had mental health diagnoses, but the only mental health diagnoses that was listed were mood disorder and depression. In review of her current physician orders, she was currently being administered Seroquel for psychosis and delirium. In review of Resident #53 completed medical records, there was no other PASARR application/form completed after 03/09/12. Interview with Social Service Director #101 on 03/05/19 at 1:06 P.M. confirmed the above diagnoses were no listed on the most recent PASARR applications/forms for each of the residents. She stated if there was a significant change to the mental health (or other significant changes) to a resident, she would need to fill out a new PASARR and submit it to the state agency. She confirmed there was no documentation to support that the state mental health agency was notified when the significant mental health changes occurred. 2. Review of Resident #86's medical record revealed an admission date of 03/12/13 with diagnosis including psychosis and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 01/23/19, revealed a the resident was cognitively intact. Review of Resident #86's plan of care, dated 01/23/19, revealed interventions related to depression, anxiety, psychosis and side effects of medications. Page 1 of 9 366387 366387 03/07/2019 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0646 Level of Harm - Minimal harm or potential for actual harm Review of Resident #86's Preadmission Screening Resident Review (PASARR), dated 06/05/13, revealed the resident did not have a diagnosis of any mental disorder. Further review of Resident #86's medical record revealed the resident had an added diagnosis of psychosis not due to a substance or known physiological condition, on 02/15/19, which indicated a significant change. Residents Affected - Few Interview with Social Service Director #101 on 03/05/19 at 1:06 P.M. confirmed the above diagnoses were no listed on the most recent PASARR applications/forms for the resident. She stated if there was a significant change to the mental health (or other significant changes) to a resident, she would need to fill out a new PASARR and submit it to the State Agency. She confirmed there was no documentation to support that the state mental health agency was notified when the significant mental health changes occurred. 366387 Page 2 of 9 366387 03/07/2019 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

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, medical record review and staff and resident interviews, the facility failed to develop a plan of care regarding left-sided weakness for Resident #31. This affected one (Resident #31) of 22 residents reviewed for care plans. The facility census was 108. Findings included: Medical record review for Resident #31 revealed an admission date of 04/30/15 with diagnoses including cerebral infarction (CVA), narcolepsy, hyperlipidemia and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required limited assistance to extensive assistance of one staff for her activities of daily living (ADL), and only supervision for eating. Review of current physician's orders revealed Resident #31 was on a mechanical soft diet with instructions to assist the resident with set up and cutting of her food. The order had a revision date of 09/10/18. Review of the physical functional observation form, dated 12/21/18, revealed impairment to her left side. Review of Resident #31's plan of care (POC) dated 01/08/19, revealed no documentation related to care for the resident's left-sided related to her CVA, or anything related to needing assistance with her meal set-up. Observation on 03/04/19 at 10:52 A.M. of Resident #31 revealed the resident's left hand curled completely inward toward the palm and laying on the resident's lap. No splint or assistive device was observed on the resident. In an interview at the same time with Resident #31, she denied having any splint or therapy to her left hand. She also denied being able to use or open her left hand very much. Resident #31 stated she had never had therapy on her left hand. On 03/05/19 at 3:47 P.M., an interview with Physical Therapy Program Manager #400 (PT Manager) stated she had never interviewed Resident #31 for left-sided weakness. She stated she had been informed that day the survey team was asking questions concerning her left hand. PT Manager #400 denied Resident #31 had been in therapy and stated she couldn't recall if she had ever been evaluated. PT Manager #400 confirmed Resident #31 had a left-hand contracture. On 03/05/19 at 5:04 P.M., an interview with Occupational Therapist #405, stated Resident #31, after surveyor intervention, had just been assessed and found to have partial range of motion in her left by passive manipulation. He stated the resident could not manipulate her hand by herself. He also stated the resident would benefit from being in a restorative program. On 03/05/19 at 5:05 P.M., an interview with PT Manager #400, confirmed the last time Resident #31 had been evaluated was 06/2015. 366387 Page 3 of 9 366387 03/07/2019 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0656 On 03/06/19 at 5:51 P.M., an interview with Corporate Registered Nurse #201 and the Director of Nursing both confirmed Resident #31 had not been care planned for left-side weakness or meal set-up. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366387 Page 4 of 9 366387 03/07/2019 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, staff interview, and facility policy review, the facility failed to revise the resident's care plan. This affected one (Resident #13) of 22 resident care plans reviewed. Also, the facility failed to conduct quarterly care conference meetings for residents. This affected three (Resident #47, #49, and #69) of three residents reviewed for care conference meeting reviews. The facility census was 108. Findings Include: 1. Record review for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cognitive communication deficit, unspecified dementia without behavioral disturbances, delirium due to known physiological condition and anxiety disorder. Review of his Brief Interview for Mental Status (BIMS) assessment score, dated 02/21/19, revealed he was severely cognitively impaired. Review of his electronic progress notes, dated 01/02/19, revealed the resident was receiving one-on-one supervision due to two successful attempts of elopement. Review of the plan of care under the problem area of at risk for injury related to elopement and wandering, dated 03/07/19, revealed the interventions listed in the plan of care were assessing the risk factors quarterly and as needed, redirect as needed, and applying a wanderguard. There was no intervention related to one-on-one supervision. Interview with Corporate Nurse #201 on 03/07/19 at 9:40 A.M. confirmed there was not a current intervention to Resident #13 wandering/elopement plan of care regarding one-on-one supervision. The Corporate Nurse confirmed the resident remained on one-on-one supervision. 3. Review of medical record revealed Resident #47 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included paraplegia, multiple sclerosis, type two diabetes, hypertension, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/28/18, revealed the resident had intact cognition. Review of Interdepartmental (IDT) Advance and Careplan Conference Sheet revealed a care conference was held for Resident #47 on 03/23/18; the resident's wife and daughter were present. Review of IDT Plan of Care Review Summary revealed a care conference was held on 01/02/19; the resident's wife was in attendance. No other care conference notes were found within the electronic nor the paper chart. 4. Review of medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included hypertension, type two diabetes mellitus, generalized anxiety disorder, chronic obstructive pulmonary disease, and rheumatoid arthritis. Review of the quarterly MDS assessment, dated 01/09/19, revealed the resident had no cognitive impairment. 366387 Page 5 of 9 366387 03/07/2019 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A request for documentation of care conferences from 03/2018 thru 03/06/19 resulted in one care conference note dated 01/28/19. Review of Interdepartmental (IDT) Plan of Care Review Summary revealed a care conference was held on 01/28/19; the resident was in attendance and had no issues nor concerns. No other care conference notes were found within the electronic medical record nor the hard copy medical record. Interview on 03/06/19 at 12:35 P.M. with Corporate Nurse (CN) #201 and Social Service Professional (SSP) #101 revealed facility protocol for care conferences included holding care conferences upon admission, annually, quarterly, for a significant change and upon resident request. They confirmed Resident #47 only had two care conferences in the last year and one care conference in the last year for Resident #49. SSP #101 stated the SSP had attempted different methods of contacting families for care conferences including telephone and United States postal service but had not yet identified an effective method to schedule care conferences. Interview on 03/06/19 at 12:40 P.M. with CN #201 confirmed there was no evidence the facility attempted to arrange quarterly care conferences for Resident #47 nor for Resident #49. Review of Resident/Resident Representative Care Conference policy, revised on 05/09/18, revealed the resident and/or resident representative would be informed of the facility's care conference protocols and be offered an initial care conference meeting. The projected schedule of care conferences for the year would be given. Residents and/or resident representatives could request a care conference at any time. At routine intervals the resident and/or resident representative would be given the opportunity to have a care conference. Quarterly reminders of care conferences would be given during Resident Council. 2. Review of Resident #69's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple-sclerosis, schizophrenia and early-onset cerebellar ataxia. Review of Resident #69's Minimum Data Set (MDS) assessment, dated 01/21/19, revealed the resident had a severe cognitive deficit. Review of Resident #69's plan of care dated 01/21/19 revealed preferences for daily life and person-centered care would be reviewed quarterly and as needed with Resident and/or responsible party. Further review of the resident's medical record revealed the resident's representative only attended one care conference meeting on 06/14/18. There was no evidence the representative was invited to attend the care conferences held on 08/28/18, 10/22/18 or 01/21/19. Interview on 03/04/19 at 12:25 P.M. with Resident #69's mother revealed talking to an unnamed staff in June of 2018. The staff stated her son should have been having quarterly care plan meetings four times a year. Resident's mother stated she has attended only one care conference since her son was admitted . Resident #69's mother denied having been invited or notified of any care conference, other than the 06/14/18 care conference. Interview on 03/05/19 at 12:15 P.M. with Social Service (SS) #101 provided progress notes which confirmed participation of family in a care conference on 06/14/18. SS #101 could not provide any additional documentation to confirm participation or having provided information to the family relative to Resident #69's care conferences that occurred on 08/28/18, 10/22/18 or 01/21/19. 366387 Page 6 of 9 366387 03/07/2019 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/06/19 at 12:35 P.M. with Corporate Nurse (CN) #201 and SS #101 revealed facility protocol for care conferences included admission, annually, quarterly, a significant change and upon resident request. SS #101 stated she has attempted different methods of contacting families for care conferences including telephone and United States postal mail however has not found an effective method at this time. Interview on 03/06/19 at 12:40 P.M. with CN #201 confirmed there was no evidence that the facility attempted to arrange quarterly care conferences for Resident #69 and/or Resident #69's family. Review of the facility policy titled, Resident/Resident Representative Care Conference, dated 05/09/18, revealed the facility's responsibility to inform resident and resident's representative of projected schedule for quarterly care conferences for the year. 366387 Page 7 of 9 366387 03/07/2019 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to sign the Controlled Drug Receipt/Record/Disposition form after giving controlled substances. The facility also failed to document in the Medication Administration Record (MAR) following administration of a controlled substance. This affected two residents (Resident #42 and #59) of two residents reviewed for administration of controlled substances. The facility census was 108. Findings include 1. Review of medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, disease of the spinal cord, shoulder pain, and hypertension. Review of the Minimum Data Set (MDS) quarterly assessment, dated 01/01/19, revealed the resident had no cognitive impairment. The resident received opioid medication and antianxiety medication on all seven days of the look back period. Observation on 03/06/19 at 8:15 A.M. revealed Assistant Director of Nursing (ADON) #121 administered Lyrica (pain medication) 30 milligrams (mg.) and Morphine Extended Release (narcotic pain medication) 30 mg. to Resident #42. The ADON signed the medication on the Medication Administration Record (MAR) and then proceeded to go to the next room to administer medications. The ADON did not signed out the controlled substance on the Controlled Drug/Receipt/Record/Disposition form. Interview on 03/06/19 at 9:00 A.M. with ADON #121 revealed the policy was to sign out the controlled substance on the Controlled Drug Receipt/Record/Disposition form after administering the medication. The ADON verified the controlled substances had not been signed out. ADON #121 immediately proceeded to sign the medications on the Controlled Drug Receipt/Record/Disposition form. 2. Review of medical record revealed Resident #59 was admitted to the facility on [DATE]. Diagnoses included traumatic brain injury, post traumatic stress disorder and chronic kidney disease. Review of the annual Minimum Data Set (MDS) assessment, dated 01/13/19, revealed the resident had no cognitive impairment. Resident #59 received opioid medication on all seven days of the look back period. Observation on 03/06/19 at 11:57 A.M. revealed Registered Nurse (RN) #112 signed out Oxycodone (narcotic pain medication) 10 mg. on the Controlled Drug Receipt/Record/Disposition form for Resident #59. The RN proceeded to administer the medication. The RN did not document on the resident's MAR this medication was administered. Review on 03/07/19 of the MAR for Resident #59 revealed Oxycodone had not been documented as administered on 03/06/19 at 11:57 A.M. Interview on 03/07/19 at 8:32 A.M. with ADON #117 verified the medication had not been documented as administered. ADON #117 stated the RN would be notified to come to the facility to document the administration of Oxycodone on 03/06/19. 366387 Page 8 of 9 366387 03/07/2019 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and staff interview, the facility failed to provide an accurate diagnosis for a psychotropic medication. This affected one (Resident #86) of five residents reviewed for unnecessary medications. The facility census was 108. Findings include: Review of Resident #86's medical record revealed an admission date of 03/12/13 with diagnoses including cerebrovascular disease, psychosis and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 01/23/19, revealed the resident was cognitively intact. There was no diagnosis of seizure disorder or epilepsy. Review of Certified Nurse Practitioner (CNP) #301 order, dated 03/06/19, revealed Depakote 500 milligrams (mg.) by mouth at bedtime for anticonvulsant. Review of Medication Administration Record (MAR), dated 03/06/19, revealed Depakote 500 mg. by mouth at bedtime for anticonvulsant. Review of Resident #86's plan of care, dated 01/23/19, revealed no interventions related to a seizure disorder or epilepsy. Review of Resident #86's Certified Nurse Practitioner (CNP) #301 note, dated 03/06/19, did not identify any reference to a seizure disorder. Interview on 03/07/19 at 8:10 A.M. with Corporate Nurse (CN) #201 and Director of Nursing (DON) confirmed Resident #86 does not have a seizure disorder and confirmed Depakote did not have an appropriate diagnosis for Resident #86. 366387 Page 9 of 9