Health inspection·April 3, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, record review, and review of the facility policy, the facility failed to ensure dependent residents were turned and repositioned every two hours per plan of care. This affected one (Resident #11) of four residents reviewed for turning and repositioning. The facility census was 57. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed an admission date of 01/10/18 with diagnoses of psychosis, epilepsy, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #11 had impaired cognition and required extensive assistance of two people for bed mobility. Review of the care plan initiated 04/03/20 for Resident #11 revealed she required staff assistance to complete activities of daily life (ADL) tasks completely. Interventions included turning and repositioning every two hours. Observation on 03/29/23 at 5:24 A.M. revealed Licensed Practical Nurse (LPN) #202 in the room with Resident #11 waiting for State Tested Nurse Aide (STNA) #101. Interview on 03/29/23 at 5:24 A.M. with STNA #101 revealed she was the only aide in the facility, along with two LPNs. STNA #101 revealed Resident #11 required two staff to assist with repositioning and incontinence care. STNA #101 stated she previously provided care for Resident #11 at approximately 1:00 A.M. Review of the Point of Care (POC) History on 03/29/23 at 1:02 P.M. for Resident #11 revealed the resident was turned and repositioned on 03/29/23 at 12:44 A.M. No additional entries for care were entered in the POC at the time of review. Observation 04/03/23 at 5:20 A.M. revealed LPN #201 and LPN #207 conducting checks and repositioning rounds for Resident #11. A concurrent interview with LPN #201 revealed Resident #11 was last checked and repositioned at 1:00 A.M. LPN #207 revealed residents were checked and changed twice during the eight-hour shift, usually every three to four hours. Interview on 04/03/23 at 1:00 P.M. with the Director of Nursing confirmed the care plan for Resident #11 revealed she should be turned and repositioned every two hours. Review of the facility policy titled Turning and Repositioning, reviewed 12/31/22, revealed Page 1 of 6 366452 366452 04/03/2023 Lakes of Sylvania, The 5351 Mitchaw Road Sylvania, OH 43560

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents requiring assistance to reposition while in bed should be assisted with turning and repositioning as needed to maintain skin integrity, decrease pain and maintain proper body alignment. Further review revealed turning and reposition was a standard of practice that will be performed in accordance with the resident's care plan. This represents non-compliance investigated under Master Complaint Number OH00141638 and Complaint Number OH00141225. 366452 Page 2 of 6 366452 04/03/2023 Lakes of Sylvania, The 5351 Mitchaw Road Sylvania, OH 43560

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, staff interview, review of facility schedules, and record review, the facility failed to ensure adequate staff was available to timely administer medications and timely turn and reposition dependent residents. This affected two (#11 and #13) of five residents reviewed for timely care and treatment. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 01/10/18 with diagnoses of psychosis, epilepsy, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #11 had impaired cognition and required extensive assistance of two people for bed mobility. Review of the current care plan for Resident #11 revealed she required staff assistance to complete activities of daily life (ADL) tasks completely. Interventions included turning and repositioning very two hours. Observation on 03/29/23 at 5:24 A.M. revealed Licensed Practical Nurse (LPN) #202 in the room with Resident #11 waiting for State Tested Nurse Aide (STNA) #101. Interview on 03/29/23 at 5:24 A.M. with STNA #101 revealed she was the only aide in the facility, along with two LPNs. STNA #101 stated she was responsible for two halls for a total of approximately 44 residents. STNA #101 revealed Resident #11 required two staff to assist with repositioning and incontinence care. Observation at that time revealed LPN #202 in the room with Resident #11 waiting for STNA #101. STNA #101 revealed she previously provided care for Resident #11 at approximately 1:00 A.M. Interview on 03/29/23 at 5:36 A.M., LPN #202 stated two STNAs called off for third shift. Interview on 03/29/23 at 11:55 A.M. with Scheduler #301 confirmed two aides called off the previous night for third shift. Review of the staff schedule for third shift on 03/28/23 revealed one STNA called off for the shift, and another staff left the shift at 2:00 A.M. on 03/29/23. Further review revealed two nurses and one STNA were the only staff during third shift between 2:00 A.M. and 6:00 A.M. Review of the Point of Care (POC) History on 03/29/23 at 1:02 P.M. for Resident #11 revealed was turned and repositioned on 03/29/23 at 12:44 A.M. No additional entries for care were entered in the POC at the time of review. 2. Review of the medical record for Resident #13 revealed an admission date of 07/15/19 with diagnoses of Parkinson's disease and dementia. Review of the comprehensive MDS assessment, dated 01/13/23, revealed Resident #13 had intact cognition. 366452 Page 3 of 6 366452 04/03/2023 Lakes of Sylvania, The 5351 Mitchaw Road Sylvania, OH 43560

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of a physician order dated 08/17/21 revealed Resident #13 was to receive the medication for Parkinson's disease carbidopa-levodopa 25-100 milligrams (mg) 2.5 tablets three times daily with specifications to provide the first dose prior to 6:00 A.M. Doses were scheduled at 5:00 A.M., 10:00 A.M. and 2:00 P.M. Review of an additional physician order dated 08/17/21 revealed Resident #13 received carbidopa-levodopa 25-100 mg, one tablet three times daily, with specifications to provide the first dose prior to 6:00 A.M. Doses were scheduled at 5:00 A.M., 10:00 A.M. and 2:00 P.M. Review of the Medication Administration Record (MAR) for 03/02/23 revealed Resident #13 received both doses of carbidopa-levodopa scheduled for 10:00 A.M. at 11:58 A.M. The documented reason for the late dose was Resident care. Review of the MAR for 03/23/23 revealed Resident #13 received both doses of carbidopa-levodopa scheduled for 10:00 A.M., at 11:47 A.M. The documented reason for the late dose was Patient care. Observation on 03/29/23 at 10:07 A.M. revealed Medication Technician (MT) #102 was still passing morning medications after 10:00 A.M. Interview at the time of the observation MT #102 revealed all morning medications should be passed by 10:00 A.M. MT #102 stated she was still passing morning medications after 10:00 A.M. because she had helped the STNA provide care to residents on the hall, including mechanical lifts requiring two staff to operate. Interview on 03/29/23 at 10:08 A.M. with Registered Nurse (RN) #203 revealed she was still passing morning medications. RN #203 confirmed the doses were late because she assisted the STNAs with resident care and assisted in passing meal trays, which included repositioning residents so they could eat breakfast. Observation on 03/29/23 at 10:29 A.M. revealed LPN #205 passing medications to residents. Interview at that time with LPN #205 revealed she was late passing morning medications because she was assigned to assist staff on another hall. She assisted residents with breakfast and assisted the STNA with mechanical lifts. This represents non-compliance investigated under Master Complaint Number OH00141638 and Complaint Number OH00141225. 366452 Page 4 of 6 366452 04/03/2023 Lakes of Sylvania, The 5351 Mitchaw Road Sylvania, OH 43560

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, staff interview, review of prescribing information website, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected two (#11 and #13) of three residents reviewed for medication administration. The facility census was 57. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 01/10/18 with diagnoses of psychosis, epilepsy, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #11 had impaired cognition. Review of a physician order dated 12/30/22 revealed Resident #11 received levothyroxine tablet 50 micrograms (mcg) one tablet daily by mouth for hypothyroidism. Review of the Medication Administration Record (MAR) for March 2023 revealed Resident #11 received levothyroxine after breakfast on 03/02/23 at 11:17 A.M., on 03/03/23 at 11:19 A.M., on 03/04/23 at 11:02 A.M., on 03/05/23 at 10:00 A.M., on 03/16/23 at 11:00 A.M., and on 03/19/23 at 10:32 A.M. Review of the meal intake for Resident #11 revealed she consumed breakfast on 03/02/23, 03/03/23, 03/04/23, 03/05/23, 03/16/23, and 03/19/23. Review of the prescribing guidelines at https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021402s024s028lbl.pdf for levothyroxine (generic for Synthroid) reveal it should be administered once daily, preferably on an empty stomach, one-half to one hour before breakfast. Interview on 03/29/23 at 8:42 A.M. with State Tested Nurse Aide (STNA) #105 revealed breakfast was served between 7:00 A.M. and 9:00 A.M. Interview on 03/29/23 at approximately 1:00 P.M. with the Administrator confirmed the documentation in the MAR for Resident #11 revealed levothyroxine was provided after the scheduled breakfast time on 03/02/23, 03/03/23, 03/04/23, 03/05/23, 03/16/23, and 03/19/23. Interviews on 03/29/23 at 2:25 P.M. with STNA #106, Medication Technician (MT) #102, and Registered Nurse (RN) #203 confirmed Resident #11 ate breakfast daily. Continued interview with RN #203 confirmed late levothyroxine medication administration was a concern as it should be given before breakfast. 2. Review of the medical record for Resident #13 revealed an admission date of 07/15/19 with diagnoses of Parkinson's disease and dementia. Review of the comprehensive MDS assessment, dated 01/13/23, revealed Resident #13 had intact cognition. Review of a physician order dated 08/17/21 revealed Resident #13 was to receive the medication for Parkinson's disease carbidopa-levodopa 25-100 milligrams (mg) 2.5 tablets three times daily with 366452 Page 5 of 6 366452 04/03/2023 Lakes of Sylvania, The 5351 Mitchaw Road Sylvania, OH 43560

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few specifications to provide the first dose prior to 6:00 A.M. Doses were scheduled at 5:00 A.M., 10:00 A.M. and 2:00 P.M. Review of an additional physician order dated 08/17/21 revealed Resident #13 received carbidopa-levodopa 25-100 mg, one tablet three times daily, with specifications to provide the first dose prior to 6:00 A.M. Doses were scheduled at 5:00 A.M., 10:00 A.M. and 2:00 P.M. Review of the MAR for 03/01/23 revealed Resident #13 received both doses of carbidopa-levodopa, scheduled for 5:00 A.M., at 6:35 A.M. Review of the MAR for 03/02/23 revealed Resident #13 received both doses of carbidopa-levodopa, scheduled for 10:00 A.M., at 11:58 A.M. Review of the MAR for 03/23/23 revealed Resident #13 received both doses of carbidopa-levodopa, scheduled for 10:00 A.M., at 11:47 A.M. Interview on 03/29/23 at approximately 1:00 P.M. with the Administrator confirmed the documentation in the MAR for Resident #13 revealed the carbidopa-levodopa was not given as ordered on 03/01/23, 03/02/23, and 03/23/23. Review of the policy titled Medication Administration, dated November 2018, revealed medications are to be administered in accordance with written orders, and are to be administered within 60 minutes of the scheduled time, except before with or after meal orders which are administered based on mealtimes. This is an incidental citation of non-compliance discovered during the complaint investigation. 366452 Page 6 of 6