Health inspection·February 13, 2020

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review and policy review, the facility failed to ensure all resident are assessed for self administration, prior to leaving medications with residents. This affected three of three residents (Resident #8, Resident #27 and Resident #59) observed with medication at bed side. The facility census was 87. Residents Affected - Few Findings include: 1. Record review revealed Resident #27 had been admitted to the facility on [DATE] with diagnoses including flaccid hemiplegia affecting the right dominant side, unsteady on feet, history of falling, wrist drop, right wrist weakness and other lack of coordination. The Minimum Data System (MDS) dated [DATE] included Resident #27 had adequate hearing, her speech had been clear, vision had been adequate, she had been understood and understands. Resident #27 had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact, required one person to physically assist for bed mobility, set up help only for dressing, toileting and eating. No orders were found in Resident #27 record to self-administer medications. Observation on 02/10/20 at 08:59 A.M. revealed Resident #27 had been sitting on the side of her bed with the bedside table next to her. Resident #27 had six medications sitting on bedside table which she had sorted into three separate small piles. Resident #27 stated she had just eaten breakfast and she was now taking her medication. No staff were present in the room with Resident #27. Observation on 02/10/20 at 9:05 A.M. revealed Registered Nurse (RN) #444 had been preparing other medications on the medication cart located in the hallway one door down from Resident #27's room. Observation revealed RN #444 could not visualize Resident #27 from his current location. Interview on 02/10/20 at 9:10 A.M. with RN #444 revealed Resident #27 prefers to take her medication by herself, and she did not like anyone watching her. RN #444 stated he would wait outside of her room until she took all of her medications. Interview on 02/10/20 at 9:15 A.M. with Resident #27, (RN #444 present), revealed Resident #27's statement, They always leave them for me and I take them all, I have been doing it forever. RN #444 verified he does not observe resident directly take her medication. 2. Record review revealed Resident #8 had an admission date 11/01/19 with diagnosis including gastroesophageal reflux disease, weakness, unspecified macular degeneration and glaucoma. Resident #8 had a BIMS of 12, indicating moderate cognitive impairment. Resident #8 had a care plan which included a requirement of supervision with activities of daily living (ADL), and Resident #8 may be at risk Page 1 of 8 366459 366459 02/13/2020 Brunswick Pointe Transitional Care 4355 Laurel Road Brunswick, OH 44212

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for developing complications associated with decreased ADL self performance related to a diagnoses of essential tremors, weakness and osteoarthritis in the knees. Resident #8 had a physician order for Tums tablet chewable, give two tablets by mouth every 24 hours as needed for heartburn or upset stomach. No orders were found in Resident #8 records to self-administer medications. Observation on 02/10/20 at 3:10 PM revealed a medication cup with one round tablet inside sitting on Resident #8's shelving unit. Resident #8 revealed that was his Tums in the medication cup, and it had been given to him by a nurse approximately one month ago to take when he had indigestion. Interview on 02/10/20 at 3:15 P.M. with RN #444 revealed he had not given Resident #8 Tums on 02/10/20. Interview on 02/11/20 at 10:30 A.M. with the Director of Nursing (DON) revealed the facility does not do self-administration of medication assessments. The DON confirmed she expected nurses to stay with residents until medication administration had been completed. 3. Record review revealed Resident #59 had an admission date of 01/07/20 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, muscle weakness, and shortness of breath. The MDS 3.0 assessment dated [DATE] had included a BIMS score of 14, indicating the resident was cognitively intact. The care plan dated 01/08/20 included Resident #59 had an altered health maintenance related to progressive physical and mental status of chronic obstructive pulmonary disease (COPD), respiratory failure with hypoxia, history of gastro intestinal bleed and neoplasm of skin with multiple lesions. The interventions in the care plan included for the RN or Licensed Practical Nurse (LPN) to administer aerosols as ordered. Resident #59 had a physician's order written 01/08/20 for Albuterol sulfate nebulization solution 0.083% (bronchodilator)one dose inhale orally via nebulizer every four hours for pneumonia. No orders were found in Resident #59 records to self-administer medications. Observation on 02/13/20 at 12:10 PM revealed LPN #477 filled the hand held neubulizer for Resident #59 with Albuterol sulfate nebulization solution 0.083%. After LPN #477 completed the respiratory assessment for Resident # 59, she handed Resident #59 the hand held neubulizer tubing, started the neubulizer then exited the room. Interview on 02/13/20 at 12:25 P.M. with LPN #477 confirmed she does not always stay with the residents during aerosol treatments but does stay in the hall and checks on them. Interview on 02/13/20 at 12:33 P.M. with RN #408 revealed she had administered aerosol treatments to residents during her shift, and she had not stayed with them to monitor the medication administration but stated she had checked on them after five minutes and then again after 10 minutes. Record review of the medication administration policy dated 06/21/17 under procedure revealed to administer medication and remain with the resident while medication is swallowed, never leave a medication in a residents room without orders to do so. 366459 Page 2 of 8 366459 02/13/2020 Brunswick Pointe Transitional Care 4355 Laurel Road Brunswick, OH 44212

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 and interview the facility failed to ensure the comprehensive assessment were accurate for Resident's #15, and #69. This affected two of 25 (Residents #9, #11, #15, #16, #17, #22, #26, #27, #29, #31, #40, #43, #46, #51, #54, #67, #69, #75, #76, #86, #88, #89, #90, #338 and #342) comprehensive assessments reviewed. Residents Affected - Few Findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, depression and psychosis. The quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had cognitive impairment. Observation of the resident 02/10/2020 at 10:00 A.M. revealed the resident was in her room in bed on her back. The head of the bed was at 30 degrees. The resident appeared thin, emaciated, with her skeletal frame visible. The resident had a carton of chocolate supplement in front of her on the over bed table. Interview with the resident during the time of the observation revealed the resident was getting tired of the chocolate milk shake supplement. Surveyor asked if they had given her anything else besides the milk shake. She stated yes, that it was a milky supplement, but she didn't like it. The resident record indicated the resident had physician orders for a regular diet with mechanical soft texture and thin liquids. Nutritional supplements of a Magic Cup and Might Shake were also ordered. On 11/08/19 the 62 inch resident weighed 92.6 pounds. Review of the quarterly comprehensive assessment dated [DATE] under the heading of nutritional status stated a loss of 5% or more in the last month or loss of 10% or more in last 6 months was due to a physician prescribed weight-loss regimen. Interview on 02/13/2020 at 2:42 P.M. with MDS Nurse #463 revealed the nutritional status in the comprehensive assessment dated [DATE] was an error. The assessment erroneously indicated the 92.6 pound resident was on a physician prescribed weight-loss regimen. 2. Record review revealed Resident #69 had an admission date of 02/15/19. On 12/18/19 a significant change in status MDS had been completed for Resident #69 to include a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Diagnosis for Resident #69 included dementia in other diseases classified elsewhere with behavioral disturbances. Observation on 02/11/20 at 10:05 A.M. revealed Resident #69 laying in bed, awake, talkative, answers simple yes or no questions appropriately. Resident #69 had been unable to answer complex questions. Interview on 02/11/20 at 05:10 P.M. with Licensed Practical Nurse (LPN) #465 revealed Resident #69 had been alert and oriented to person only. 366459 Page 3 of 8 366459 02/13/2020 Brunswick Pointe Transitional Care 4355 Laurel Road Brunswick, OH 44212

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/11/20 at 05:16 P.M. with State Tested Nursing Assistant (STNA) #451 revealed when Resident #69 was admitted , she could remember her name. Resident #69 no longer was able to recognize her or remember her name. Interview on 02/11/20 at 5:22 P.M. with MDS Registered Nurse (RN) #463 revealed she had submitted the significant change MDS on 12/18/20, MDS RN #463 revealed she had not completed the BIMS, and the BIMS had been completed for the MDS submitted 12/18/20 by the Social Worker Designee. MDS Registered Nurse (RN) #463 confirmed the BIMS score submitted on 12/18/19 for Resident #69 had been inaccurate. Interview on 02/11/20 at 5:34 P.M. with Social Worker Designee #455 revealed she had not input the BIMS score for Resident #69 completed for the significant change MDS until 12/20/20. Social Worker Designee #455 confirmed the BIMS score for Resident #69 submitted 12/18/20 had been inaccurate. 366459 Page 4 of 8 366459 02/13/2020 Brunswick Pointe Transitional Care 4355 Laurel Road Brunswick, OH 44212

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #51 revealed admission date of 12/27/19 with diagnosis including diabetics mellitus type II. Residents Affected - Few Review of the comprehensive MDS 3.0 assessment, dated 01/02/20, revealed the resident had intact cognition. The resident was insulin dependent. Review of the physician's orders for 02/2020 revealed Humalog (insulin) solution 100 unit/ milliliters per sliding scale before meals and at bed time for diabetics mellitus. Review of the Medication Administration Record (MAR) dated 02/12/20 revealed Resident #51 required seven units of Humalog which was given at 9:00 A.M. Interview with Resident #51 at 02/12/20 at 8:09 A.M. revealed she had not had her sugar checked. Observation at 8:25 A.M. of Resident #51's breakfast was served and the nurse, RN #439 was in the hall by the residents room. At 8:28 A.M. Resident #51 stated her blood sugar had not been checked, she told the aide and she was going to tell the nurse. At 8:29 A.M. RN #439 went into the room to check the blood sugar. Observation at 8:46 A.M. revealed Resident #51 finished breakfast, and RN #439 had not been back to her room to give her insulin. Observation at 9:00 A.M. of RN #439 entering Resident #51's room with insulin in hand. Interview on 02/12/20 at 9:37 A.M. with Resident #51 stated she received her insulin coverage about 10 to 15 minutes after she ate. Interview on 02/12/20 at 4:00 P.M. with RN #439 verified he checked Resident #51 blood sugar after the resident received her breakfast tray, and she did require insulin coverage. RN #439 verified he did not give Resident #51's insulin, prior to Resident #51 eating. RN #439 verified he gave Resident #51's insulin coverage after she had completed her breakfast and not as ordered. Interview on 02/12/20 at 4:22 P.M. with the Director of Nursing (DON) verified Humalog should be given prior to meals and as ordered. Based of observation, interviews and record review, the facility failed to administer medication per physician's orders. This affected one (Resident #16) of six residents observed during medication administration pass and one (Resident #51) of one resident randomly observed. Findings include: 1. Record review revealed Resident #16 had an admission date of 12/09/18 with diagnoses including included muscle weakness, unsteady on feet, type II diabetes and gastro-esophageal reflux. Resident #16 also had a history of constipation. The Minimum Data Assessment (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS revealed Resident #16 also required supervision/set-up help only with eating. Resident #16 had a care plan dated 02/12/20 which revealed Resident #16 had been at risk for constipation related to decreased mobility. An intervention to reduce the risk for constipation was to administer medication per physician's orders. Resident #16 had a care plan dated 02/21/18 which revealed Resident #16 was at risk for hypo/hyperglycemia (low or high blood sugar). An 366459 Page 5 of 8 366459 02/13/2020 Brunswick Pointe Transitional Care 4355 Laurel Road Brunswick, OH 44212

F 0759 Level of Harm - Minimal harm or potential for actual harm intervention was to give insulin as ordered. Physician orders included Humalog Kwikpen solution (insulin) 200 units per milliliter, inject eight units subcutaneously with meals for diabetes mellitus, Lantus Solostar solution (insulin) pen injector 100 units per milliliter, inject 14 units subcutaneously one time a day for diabetes mellitus, due at rise and Glucolax powder (laxative) give 17 grams by mouth one time a day for constipation (mix in liquid) due at rise. Residents Affected - Few Observation on 02/12/20 at 8:13 A.M. of the medication administration (due at rise pass) with Registered Nurse (RN) #439 revealed 10 tablets of medication had been given to Resident #16 by mouth and Humalog quik pen 8 units had been injected subcutaneously. Record review of the physician orders for medications due at rise revealed Lantus Solostar solution pen injector 100 units per milliliter, inject 14 units subcutaneously one time a day for diabetes mellitus, due at rise and Glucolax powder give 17 grams by mouth one time a day for constipation (mix in liquid) also ordered at rise had not been given during the observed medication administration. Review of the medication administration record revealed the RN #439 signed off in the medication administration record indicating he had administered the medications Lantus and Glucolax powder as ordered. Interview on 02/12/20 at 8:50 A.M. with RN #439 confirmed he did not give any further medications to Resident #16 after completing the observed medication pass with Resident #16. Interview on 02/12/20 at 9:00 A.M. with Resident #16 confirmed RN #439 did not return and administer any medications after the observed medication pass. Record review of the administration history report (which documents the exact minute the medication was signed for in the computer as given) revealed RN #439 signed for the Lantus injection and the Glucolax powder as given at 8:14 A.M., the time which had been during the observed medication administration. 366459 Page 6 of 8 366459 02/13/2020 Brunswick Pointe Transitional Care 4355 Laurel Road Brunswick, OH 44212

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, interview and policy review, revealed the facility failed to ensure resident safety by leaving the medication cart unlocked, unattended and out of visual range of nursing staff. This had the potential to affect 12 residents (Residents #36, #78, #46, #16, #2, #342, #1, #13, #59, #51, #340 and #67) who were independently ambulatory or independently mobile in a wheelchair of 17 residents that resided on the 200 hall. Findings include: Observation on 02/12/20 at 8:00 A.M. of medication administration revealed Registered Nurse (RN) #439 prepared medications from the medication cart located in the hallway for Resident #389. RN #439 then took the medications into Resident #389's room and approached Resident #389. RN #439 did not lock the medication cart to secure the medications inside prior to leaving the medication cart unattended. Interview on 02/12/20 at 8:02 AM with RN #439, after being directed back to the med cart, confirmed he had left the medication cart unlocked and unattended. Observation on 02/12/20 at 8:13 A.M. of medication administration revealed RN #439 prepared medications from the medication cart located in the hallway for Resident #16. RN #439 then took the medications into Resident #16's room and approached Resident #16. RN #439 did not lock the medication cart to secure the medications inside prior to leaving the medication cart unattended. Interview on 02/12/20 at 8:13 AM with RN #439, after being directed back to the med cart, confirmed he had left the medication cart unlocked and unattended. Record review of the medication administration policy, dated 06/21/17, revealed the cart should remain unlocked only when the nurse or authorized individual is physically present at the cart. 366459 Page 7 of 8 366459 02/13/2020 Brunswick Pointe Transitional Care 4355 Laurel Road Brunswick, OH 44212

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and policy review, the facility failed to ensure infection control measures were followed to prevent cross contamination. This affected one (Resident #16) of two residents observed during medication injections. The facility census was 87. Residents Affected - Few Findings include: Record review revealed Resident #16 had an admission date of 01/29/19 with diagnoses including muscle weakness and type II diabetes. The Minimum Data Set (MDS) 3.0 assessment completed 02/04/20 revealed Resident #16 had moderate cognitive impairment. Physician orders for Resident #16 included Humalog Kwikpen solution (insulin) inject eight units subcutaneously with meals for diabetes mellitus. Observation of medication administration on 02/12/20 at 8:15 A.M. revealed Registered Nurse (RN) #439 administered an insulin injection to Resident #16 without applying gloves. Interview on 02/12/20 at 8:20 A.M. with RN #439 confirmed gloves were not worn during an insulin injection given to Resident #16. RN #439 stated, I never wear gloves when I give insulin. Interview on 02/12/20 at 11:40 A.M. with the Director of Nursing (DON) confirmed staff were to wear gloves when giving injections of medications to any resident. Record review of the infection control policy, dated 10/18/01, confirmed staff were to wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. 366459 Page 8 of 8