Health inspection·May 18, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, staff interview and review of the Resident Assessment Instrument (RAI) 3.0, the facility failed to complete admission Minimum Data Set (MDS) assessments within the required timeframe. This affected four (#208, #209, #212 and #55) out of the four residents reviewed for timely completion of admission MDS assessments. The facility census was 53. Findings include: 1. Review of the medical record for Resident #212 revealed an admission date of 04/13/23 with medical diagnoses of hypotension, atrial fibrillation, status post left hip fracture, and chronic obstructive pulmonary disease. Review of the medical record for Resident #212 revealed an admission nursing assessment dated [DATE] which indicated Resident #212 was cognitively intact and required extensive assist with bed mobility, transfers, toileting, and dressing. Review of the medical record revealed an admission MDS had not been completed. 2. Review of the medical record for Resident #209 revealed an admission date of 04/14/23 with medical diagnoses of altered mental status, acute respiratory failure with hypoxia, dementia, and peripheral vascular disease. Review of the medical record for Resident #209 revealed an admission nursing assessment, dated 04/14/23, which indicated Resident #209 was alert to person only and required extensive assistance with bed mobility, transfers, dressing, and toileting. Review of the medical record for Resident #209 revealed an admission MDS had not been completed. 3. Review of the medical record for Resident #208 revealed an admission date of 05/02/23 with medical diagnoses of arthritis, hyperlipidemia, anxiety, depression, and anemia. Review of the medical record for Resident #208 revealed an admission nursing assessment, dated 05/02/23, which indicated Resident #208 was cognitively intact and required extensive assist for bed mobility, transfers, dressing and toileting. Review of the medical record for Resident #208 revealed an admission MDS had not been completed. Page 1 of 3 366444 366444 05/18/2023 Vancrest of Ada 600 West North Avenue Ada, OH 45810

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Review of the medical record for Resident #55 revealed an admission date of 04/21/23 with medical diagnoses of cardiac arrest, atrial fibrillation, congestive heart failure, diabetes mellitus, and hypertension. Review of the medical record for Resident #55 revealed an admission nursing assessment, dated 04/21/23, indicated Resident #55 was cognitively intact with long term memory loss and required extensive assistance with bed mobility, transfers, toileting and bathing. Review of the medical record for Resident #55 revealed an admission MDS had not been completed. Interview on 05/16/23 with the Director of Nursing (DON) confirmed admission MDS assessments were not completed for Residents #208, #209, #212, and #55. DON stated the facility was training a new MDS nurse and the facility was behind in completing admission MDS assessments timely. Review of the RAI manual revealed an admission comprehensive MDS must be completed on the 14th day of the resident's admission to the facility. 366444 Page 2 of 3 366444 05/18/2023 Vancrest of Ada 600 West North Avenue Ada, OH 45810

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, observation, staff interview and review of facility of policy, the facility failed to provide care for a resident's intravenous access. This affected one (#15) of one residents reviewed in the sample for IV access. The census was 53. Residents Affected - Few Findings include: Review of Resident #15's medical record revealed an admission dated of 03/24/22. Diagnoses listed included hypertension, major depressive disorder, chronic obstructive pulmonary, type two diabetes mellitus, hyperlipidemia, hypothyroidism, hemiplegia, and hemiparesis. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was cognitively intact with brief interview for mental status score (BIMS) of 14 and required extensive assistance for personal hygiene. Review of physician orders revealed an order dated 05/02/23 for may place peripherally inserted central catheter (PICC). Further review of Resident #15's medical record revealed no documentation of her PICC line dressing being changed or being assessed. Observation on 05/16/23 at 2:24 P.M. revealed a PICC line dressing located in Resident #15's right upper arm was dated 05/02/23. During an interview on 05/17/23 at 9:17 A.M. the Director of Nursing (DON) confirmed Resident #15's PICC line dressing had not been changed since the insertion date of 05/02/23. The DON also confirmed the was not any documentation of Resident #15 PICC line being assessed since 05/02/23. Review of the facility's undated policy titled Intravenous Therapy-Preventing Catheter-Related Infections revealed catheter sites should be assessed visually or by palpitation on a daily basis. If residents have any of the following symptoms, remove the dressing the dressing and thoroughly examine the site. Symptoms included tenderness and the insertion site, fever without obvious source, and other signs and symptoms suggesting local or bloodstream infection (BSI). Transparent dressing on short term central venous catheter (CVC) devices should be changed every three to seven days. 366444 Page 3 of 3