Health inspection·July 31, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to ensure a written notice including reasons for transfer/discharge was provided to the resident, resident's representative, and ombudsman prior to transfer/discharge. This affected one (#35) of three residents reviewed for hospitalization. The facility census was 46. Findings include: Review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease, major depressive disorder, chronic kidney disease stage four, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/02/19, revealed the resident had severe cognitive impairment. Review of Resident #35's nursing progress notes revealed on 06/14/19, Resident #138 noted the resident appeared to be in respiratory distress and the resident was to sent the emergency department for evaluation and treatment. She noted the daughter was notified via a telephone message with a return call requested. A progress note, dated 06/14/19 at 10:26 P.M., revealed the resident was admitted to the hospital with diagnoses including febrile illness and dyspnea. On 06/19/19 at 10:55 A.M., Resident #35 returned from the hospital. The medical records was silent for written notification to resident/representative and Ombudsman for the reason for transfer. On 07/30/19 at 5:25 P.M., interview with the Director of Nursing (DON) verified she did not have any information to confirm the resident/representative and Ombudsman were made aware of the reason for transfer. On 07/31/19 at 8:40 A.M., interview the Administrator revealed he thought that notice of transfer/discharge information only had to be provided in writing to residents/representative and the Ombudsman if it was a facility-initiated 30 day discharge notice. No additional information was provided to show that transfer/discharge information was in writing to Resident #35, her representative, and the Ombudsman. Review of the facility policy titled Discharge/Transfer revealed that facility-initiated transfers included emergency and acute care transfers because the resident's return is generally expected. The section in the policy titled notice of transfer or discharge and Ombudsman Notification: For Facility-Initiated transfer/discharge specified the facility must notify the resident and resident representative of the transfer or discharge and the reasons for the move in writing and in a language and Page 1 of 10 366439 366439 07/31/2019 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0623 Level of Harm - Minimal harm or potential for actual harm manner they under stand, and a copy of the notice of transfer or discharge is to be sent to the Ombudsman. The facility policy also specified the notice of transfer/discharge must include the reason for the transfer/discharge, the effective dated of the transfer/discharge and location of transfer/discharge. Residents Affected - Few 366439 Page 2 of 10 366439 07/31/2019 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two (#8 and #32) of 13 residents reviewed for MDS accuracy. The facility census was 46. Residents Affected - Few Findings include: 1. Review of the record for Resident #8 revealed an admission date of 11/08/17 with diagnoses which included chronic obstructive pulmonary disease and asthma. Review of hearing progress notes signed by a nurse practitioner dated 05/07/18, 10/26/18, and 04/11/19 revealed Resident #8 was evaluated and failed a whisper test (a preliminary test for assessing for hearing impairment) and would benefit from an audiology referral. Review of the MDS assessment, dated 04/19/19, revealed the resident was cognitively intact and had adequate hearing. Review of physician orders revealed an order, dated 05/21/19, that resident may be seen and treated by an audiologist. Interview with Resident #8 on 07/29/19 at 10:03 AM confirmed the resident had difficulty with hearing, that she did not wear hearing aids, and that she wanted to see an audiologist regarding her hearing loss. Interview with Registered Nurse (RN) #111 on 07/30/19 at 12:43 P.M. confirmed Resident #8's MDS assessment dated [DATE] was was coded in error regarding the resident's hearing status. 2. Review of the record for Resident #32 revealed an admission date of 05/14/19 with diagnoses which included unspecified dementia without behavioral disturbance. Review of the MDS assessment, dated 05/22/19, revealed the resident had natural teeth or teeth fragments and was not edentulous. Review of the care plan, dated 06/04/19, revealed the resident had a potential for oral/dental health problems related to being edentulous and having no lower dentures. Review of the dental progress note for Resident #32, dated 07/12/19, revealed the resident was edentulous (had no natural teeth), had upper dentures, did not have lower dentures, and was not a candidate for new lower dentures. Observation of Resident #32 on 07/29/19 at 10:15 A.M. revealed the resident was edentulous and had upper dentures in place and no lower dentures in place. Interview with RN #111 on 07/30/19 at 12:43 P.M. confirmed Resident #32 was edentulous upon admission to the facility and the MDS assessment, dated 05/22/19, was coded in error regarding the resident's dental status. 366439 Page 3 of 10 366439 07/31/2019 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of policy titled Resident Assessment, dated 12/06/16, revealed the facility expected every member of the interdisciplinary team to be knowledgeable of the Minimum Data Set 3.0 Resident Assessment Instrument Manual to ensure accurate documentation for each resident. Residents Affected - Few 366439 Page 4 of 10 366439 07/31/2019 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

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. Based on observation, record review, review of facility policy and staff interviews, the facility failed to revise care plans with fall interventions and specific medical devices in use. This affected two (#21 and #33) of thirteen residents reviewed for care planning. The facility census was 46. Findings include: 1. Review of Resident #21's medical record revealed an admit date of 10/08/18 with diagnosis including dementia, osteoarthritis, neuropathy, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 04/19/19, indicated the resident had moderate cognitive impairment, no behaviors or rejections of care, and extensive assist of two for all activities of daily living. Review of the fall care plan, dated 10/18/18, included to utilize a stand pivot disc with two staff for transfers. The care plan was silent for a revision to the use of foot pedals on the wheelchair. Review of a progress note, dated 06/20/19 at 8:42 P.M.,. revealed a nurse responded to a 9-1-1 page and found Resident #21 lying on her back and state tested nurse assistant (STNA) reporting while she was pushing the resident in her chair, she dropped her feet down and fell forward out of her chair. No complaints of pain or injury indicated. Review of a progress note, dated 06/20/19 at 10:14 A.M., indicated the interdisciplinary meeting review was held and revealed a fall occurred on 06/20/19 when a staff member was pushing Resident #21 in her wheelchair. While being pushed, she put her feet down and fell forward out of chair. The note also stated the new intervention will be to place foot pedals on the wheelchair while in use for safety. Review of Resident #21's care card revealed it was not updated to reflect wheelchair with foot rests and to assist with transfers of two staff using a stand pivot disc. Observation on 07/29/19 at 12:42 P.M. of Resident #21 sitting in her wheelchair in a common area revealed her wearing hard soled shoes and had no foot pedals on her chair. Interview on 07/30/19 at 11:27 A.M. with STNA #103 and #121 both reported they were unaware of any wheelchair pedals indicated for Resident #21 and confirmed her wheelchair did not have foot pedals in place at that time. STNA #103 reported the care cards were reviewed by STNAs before each shift for any care changes. She confirmed the care card for Resident #21 had no mention of foot pedals and voiced she was unsure who would update the cards. Interview with the Director of Nursing on 07/30/19 at 11:36 A.M. confirmed the care card did not include the updates and deferred to Assistant Licensed Nursing Home Administer since she was their supervisor. Interview on 07/30/19 at 11:42 A.M. with Assistant Nursing Home Administrator #171 stated the care cards were to be updated by the therapist who make the recommendations and verified the care plan and care card was silent to stand pivot disc and wheelchair pedals when pushed in wheelchair. 366439 Page 5 of 10 366439 07/31/2019 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident #33's medical record revealed an admit date of 06/06/19 with diagnoses of chronic kidney disease, major depressive disorder, anemia, convulsion, pulmonary fibrosis, emphysema, and malignant cancer of bladder. Review of the Minimum Data Set (MDS) assessment, dated 06/17/19, revealed the resident had intact cognition, no behaviors or rejections of care, and limited assist required for all activities of daily living. Review of the care plan, dated 06/06/19, revealed a focus of catheter with interventions that failed to identify the type or size of a catheter. Another intervention indicated to change the catheter but failed to identify frequency. A separate focus on the care plan identified potential for dental problems and the intervention failed to specify if the resident had natural teeth, missing teeth, dentures, or was edentulous. A nutritional screen dated 06/10/19 revealed Resident #33 wore upper denture, partial lower denture and both fit well. Interview on 07/31/19 at 9:44 A.M. with facility MDS Registered Nurse #111 stated the care plan should have been completed to indicate Residents #33's catheter type, size, and his dental status. Review of the facility policy titled Care Planning Procedure, dated 12/06/16, indicated each care plan problem will be resident centered and have specific interventions. 366439 Page 6 of 10 366439 07/31/2019 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure that residents received treatment for hearing loss. This affected one (Resident #8) of two residents reviewed for communication and sensory concerns. The facility census was 46. Residents Affected - Few Findings include: Review of the record for Resident #8 revealed an admission date of 11/08/17 with diagnoses which included chronic obstructive pulmonary disease and asthma. Review of the Minimum Data Set (MDS) assessment, dated 04/19/19, revealed the resident was cognitively intact, had adequate hearing and did not wear hearing aids. Review of hearing progress notes signed by a nurse practitioner dated 05/07/18, 10/26/18, and 04/11/19 revealed Resident #8 was evaluated and failed a whisper test (a preliminary test for assessing for hearing impairment) and would benefit from an audiology referral. Review of physician orders for Resident #8 revealed an order, dated 05/21/19, that resident may be seen and treated by an audiologist. Interview with Resident #8 on 07/29/19 at 10:03 AM confirmed the resident had difficulty with hearing, that she did not wear hearing aids, and that she wanted to see an audiologist regarding her hearing loss. Interview with the Director of Nursing (DON) on 07/29/19 at 4:55 P.M. confirmed that the facility had not followed up on the nurse practitioner's recommendations made on 05/07/18, 10/26/18, and 04/11/19 regarding Resident #8 failing the whisper test, and that the resident had not been examined by an audiologist during her stay at the facility. 366439 Page 7 of 10 366439 07/31/2019 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

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. Based on record review and staff interview, the facility failed to administer a resident's medication as ordered by the physician. This affected one (#5) of thirteen residents reviewed in the final sample. The facility identified all 46 residents receive medications administered by the facility nurses. Findings include: Review of Resident #5's medical record revealed an admit date of 11/09/17 with diagnoses included dementia, hypertension and heart disease. Review of the Minimum Data Set (MDS) assessment, dated 07/05/19, indicated the resident had impaired cognition with behaviors. Review of the physician orders for July 2019 revealed an order, dated 07/23/19, for Clonidine (antihypertensive medication) 0.1 milligrams to be administered as needed for a systolic blood pressure greater than 160, not to exceed twice per day. Review of the Medication Administration Record (MAR) for July 2019 revealed results of blood pressure measurements five times per day. The MAR revealed from 06/23/19 to 06/29/19 sixteen blood pressures exceeded 160 systolic: on 07/23/19 at 10 A.M. 170/88; at 2 P.M. 165/74, at 6:00 P.M. 184/126; on 07/24/19 at 10 A.M. 189/115, at 2:00 P.M. 170/80; on 07/26/19 at 10:00 A.M. at 167/99, 2:00 P.M. 167/99, at 6:00 P.M. 193/130, at 10:00 P.M. 192/117; on 07/27/19 at 6:00 A.M. 163/84, at 2:00 P.M. 218/110, at 6:00 P.M. 249/127; on 07/28/19 at 6:00 P.M. 164/101, at 10:00 P.M. 182/90; on 07/29/19 at 2:00 P.M. 170/98, at 6:00 P.M. 217/121. Further review of the MAR revealed the Clonidine was only administered to the resident six of the 16 times the resident's systolic blood pressure was greater than 160. The resident received Clonidine on 07/23/19 at 5:20 P.M., on 07/24/19 at 4:13 P.M., on 07/26/19 at 11:30 P.M., on 07/27/19 at 1:54 P.M. and on 07/29/19 at 6:12 P.M. Interview with the Director of Nursing on 07/31/19 at 11:48 A.M. confirmed the Clonidine medication had not been administered per physician orders 10 times from 07/23/19 through 07/29/19. 366439 Page 8 of 10 366439 07/31/2019 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview, the facility failed to discard expired medications, failed to date medications when open to ensure efficacy, and failed to secure controlled medications. This had the potential to affect all residents of the facility. The facility census was 44. Findings include: 1. Review of Resident #43's medication administration record (MAR) revealed Latanoprost eye drops (treats glaucoma) to be administered one drop in each eye twice daily. During a medication storage tour on 07/31/19 at 12:42 P.M. with Registered Nurse (RN) #150 revealed Latanoprost eye drop container in Resident #43's bin. The container was in a clear plastic bag displaying a handwritten date of 06/01/19 that indicated - dispose of after 42 days. RN #150 confirmed the expired date and was unable to locate any other Latanoprost supply for Resident #43. Interview with the Director of Nursing (DON) on 07/31/19 at 11:30 A.M. stated the expired Latanoprost was the only supply available for Resident #43, it was a current order, and the pharmacy was delivering a new supply today. 2. Tour of the medication cart on 300 and 400 house on 07/29/19 from 8:10 A.M. to 9:15 A.M. revealed an undated open vial of Aplisol (injectable solution to test for Tuberculosis) solution in a medication refrigerator in 400 House; an open vial of Aplisol solution with a date of 03/?? (illegible), two vials of Pneumovax with an expiration date of 05/2019, and insulin vial for a resident discharged in March of 2019 in the 300 House medication refrigerator. Interview with the DON on 07/29/19 at 8:47 A.M. confirmed the undated open vial of Aplisol, the vial of Aplisol with a 03/illegible date, and the expired Pneumovax, insulin for a resident discharged in March 2019 and removed the expired medications. She also verified the Aplisol in House 400, stating her corporate support staff had advised her to keep the solution since there was a nation-wide shortage. On 07/31/19 at 11:30 A.M., the DON verified all facility residents were able to receive the Aplisol solution. Review of package insert for the Aplisol solution indicated vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the facility policy titled Medication Storage, dated 06/21/19, indicated outdated medications are immediately removed from stock. 3. Observation of a medication cart sitting near room [ROOM NUMBER] on 07/29/19 at 8:08 A.M. revealed it was unlocked. This finding was verified by State Tested Nurse Assistants (STNA) #102 and #126 who took no action. Interview with Registered Nurse (RN) #130 at 8:20 A.M. confirmed the medication cart was unlocked, the controlled medications box was in an unlocked drawer and locked the cart. 366439 Page 9 of 10 366439 07/31/2019 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0761 Review of facility policy titled Medication Storage, dated 06/21/19, indicated controlled medications are stored in a separate, permanently affixed area and are under double lock. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 366439 Page 10 of 10