Health inspection·November 8, 2022

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 properly submit Minimum Data Set (MDS) 3.0 assessments in the required timeframes. This affected two residents (#64 and #113) of 14 sampled residents reviewed during the annual survey. Residents Affected - Few Findings include: 1. Record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, dysphagia, epistaxis, atrial fibrillation, chronic obstructive pulmonary disease, and thrombocytopenia. Review of nursing and physician assessments, completed on 10/16/22 revealed the resident had no cognitive impairments and was able to make her needs known at all times. Review of the Minimum Data Set Entry Assessment, dated 10/16/22 which noted the current status was export ready on 11/07/22. A five-day Medicare admission Assessment, initiated on 10/21/22 revealed a current status of in progress. On 11/07/22 at 3:45 P.M. interview with MDS Nurse #200 verified both MDS assessments were past the required submittal dates. MDS Nurse #200 revealed she had not yet had a chance to complete them. 2. Record review revealed Resident #113 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, Parkinson's disease, major depressive disorder and anxiety disorder. Review of the entry MDS 3.0 assessment, dated 10/13/22 revealed the assessment had been completed on 10/19/22 but had not been exported as of 11/07/22, 19 days after it had been completed. Review of the five day MDS 3.0 assessment, dated 10/19/22 revealed the assessment was still in progress and had not been completed, 19 days after it had been opened. Review of the admission MDS assessment, dated 10/19/22 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 (out of 15). The resident was assessed to require limited assistance from two staff members for bed mobility and extensive assistance from two staff members for transfers and toileting. On 11/07/22 at 3:35 P.M. interview with MDS Nurse #200 verified the assessments had not been completed and submitted in the required timeframes. Page 1 of 3 366470 366470 11/08/2022 Wesley Woods at New Albany 4588 Wesley Woods Blvd New Albany, OH 43054

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure as needed (PRN) psychotropic medication orders were limited to 14 days (or less). This affected three residents (#5, #7 and #112) of four residents reviewed for PRN psychoactive medication use/unnecessary medication use. Findings include: 1. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, heart failure and anxiety. Review of the active physician's orders revealed an order, dated 06/30/22 for the anti-anxiety mediation, Ativan 0.5 milligram (mg) every four hours as needed (PRN) for anxiety or agitation. This order did not contain a stop date. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/24/22 revealed the resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 07 (out of 15). The assessment revealed the resident required extensive assistance from two staff members for bed mobility and toileting and limited assistance from one staff member for transfers. On 11/08/22 at 2:00 P.M. interview with MDS Nurse #200 verified the resident's current order for PRN Ativan was active and did not have a stop date. The PRN medication order had been in place longer than 14 days. 2. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, constipation, hypertensive heart disease, chronic pain syndrome and insomnia. Review of the active physician's orders, revealed an order, dated 07/15/22 for Ativan one mg solution every four hours as needed (PRN) for anxiety or agitation. This order did not contain a stop date. Review of the quarterly MDS 3.0 assessment, dated 07/27/22 revealed the resident had severely impaired cognition evidenced by a BIMS assessment score of 00 (out of 15). The resident was assessed to require extensive assistance from two staff members for bed mobility and was dependent upon two staff members for transfers and toileting. On 11/08/22 at 2:00 P.M. interview with MDS Nurse #200 verified the resident's current order for PRN Ativan was active and did not have a stop date. The PRN medication order had been in place longer than 14 days. 3. Record review revealed Resident #112 was admitted to the facility on [DATE] with diagnoses including encephalopathy, retention of urine, urinary tract infection, hyperlipidemia, restless leg syndrome, gastroesophageal reflux disease without esophagitis, edema, insomnia, gout, diabetes mellitus due to underlying condition with diabetic neuropathy, hypokalemia, acute respiratory failure with 366470 Page 2 of 3 366470 11/08/2022 Wesley Woods at New Albany 4588 Wesley Woods Blvd New Albany, OH 43054

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hypoxia, morbid obesity, epilepsy, hypokalemia, unspecified open wound of the left leg, acute respiratory failure with hypoxia, morbid obesity, chronic kidney disease, major depressive disorder, chronic obstructive pulmonary disease, chronic diastolic heart failure, chronic atrial fibrillation, hypertension, and obstructive sleep apnea. Review of the active physician's orders revealed an order, dated 06/30/22 for Ativan 0.5 mg every four hours as needed (PRN) for anxiety or agitation. This order did not contain a stop date. Review of the quarterly MDS 3.0 assessment, dated 09/11/22 revealed the resident had mildly impaired cognition evidenced by a BIMS assessment score of 11 (out of 15). The resident was assessed to require (staff) supervision for bed mobility, transfers, and eating and extensive assistance from one staff member for toileting. On 11/08/22 at 2:00 P.M. interview with MDS Nurse #200 verified the resident's current order for PRN Ativan was active and did not have a stop date. The PRN medication order had been in place longer than 14 days. 366470 Page 3 of 3