Health inspection·November 28, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure care conferences were held in a timely manner and residents or their representatives were included in their care conferences. This affected one (#105) of three residents reviewed for care planning. The facility census was 103. Findings include: Review of Resident #105's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, dementia, muscle weakness, insomnia, and muscle weakness. The resident expired in the facility on [DATE]. Review of Resident #105's Minimum Data Set (MDS) 3.0 assessments dated [DATE], [DATE], and [DATE], revealed the resident was assessed with severe cognitive impairment. Further review of Resident #105's medical record revealed the resident's daughter was his power of attorney for care and finances. Review of Resident #105's plan of care, initiated on [DATE], revealed the resident had the right to make lifestyle choices. Interventions included the resident being able to attend, participate in, and express personal preferences during his quarterly plan of care conference with the interdisciplinary team. Review of Resident #105's medical record, including social service notes, revealed Resident #105's last care conference was on [DATE]. Interview on [DATE] at 11:40 A.M. with Social Service Designee (SSD) #330 revealed all residents were supposed to have quarterly care conferences. SSD #330 verified Resident #105 had not had a care conference since [DATE]. This deficiency represents non-compliance investigated under Complaint Number OH00148139. Page 1 of 3 366477 366477 11/28/2023 Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039

F 0760 Ensure that residents are free from significant medication errors. 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, staff interview, and review of facility policy, the facility failed to ensure medications were administered as ordered resulting in a significant medication error. This affected one (#104) of three residents reviewed for medication administration. The facility census was 103. Residents Affected - Few Findings include: Review of Resident #104's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, presence of cardiac pacemaker, cerebral infarction, depression, heart disease, weakness, and shortness of breath. Review of Resident #104's plan of care, dated 11/11/22, revealed the resident had diabetes with a goal of no complications. Interventions included blood sugar to be checked as ordered and medications as ordered. Review of Resident #104's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/30/23, revealed the resident was assessed as cognitively impaired and required assistance of one staff member for a majority of the activities of daily living. Review of Resident #104's physician orders revealed on 08/10/23 the resident was ordered Humalog insulin subcutaneously (SQ) per sliding scale before meals. The sliding scale was ordered as follows: for blood glucose levels between 100 milligrams per deciliter (mg/dL) and 150 mg/dL, give five (5) units; for blood glucose levels between 151 mg/dL and 200 mg/dL, give seven (7) units; for blood glucose levels between 201 mg/dL and 250 mg/dL, give nine (9) units; for blood glucose levels between 251 mg/dL and 300 mg/dL, give 11 units; between 301 mg/dL and 350 mg/dL, give 13 unites; between 351 mg/dL and 400 mg/dL, give 15 units; and for blood glucose levels above 400 mg/dL, contact the physician. Review of Resident #104's physician orders revealed on 09/06/23 the resident was ordered Humalog 5 units SQ with meals. Review of Resident #104's blood glucose levels revealed a blood glucose level of 177 mg/dL on 09/20/23 at 4:01 P.M. Review of the September 2023 medication administration record (MAR) revealed Resident #104's Humalog sliding scale insulin before meals was scheduled to be given at 8:00 A.M., 12:00 P.M., and 4:00 P.M. daily, and Humalog 5 units with meals was scheduled to be given at 8:00 A.M., 12:00 P.M., and 5:00 P.M. Further review revealed Resident #104's blood glucose level was documented as 177 mg/dL on 09/20/23 at 4:00 P.M. Further review of the September 2023 MAR indicated Resident #104 did not receive the insulin as ordered on 09/20/23 at 4:00 P.M., and was documented that vital signs were outside of parameters. Resident #104 also did not received Humalog 5 units on 09/20/23 scheduled at 5:00 P.M. and was documented that vital signs were outside of parameters. Interview on 11/27/23 at 11:18 A.M. with Certified Nurse Practitioner (CNP) #594 revealed CNP #594 worked with the facility on an on-call basis during evening and night shifts. CNP #594 reported anytime a blood glucose level fell into the sliding scale range and was not being given the CNP and/or physician should be notified. 366477 Page 2 of 3 366477 11/28/2023 Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/28/23 6:27 A.M. with Licensed Practical Nurse (LPN) #252 revealed LPN #252 was the nurse assigned to care for Resident #104 on 09/20/23 when the resident did not receive insulin as ordered. LPN #252 reported the resident went out to dinner with her husband on 09/20/23. LPN #252 reported checking Resident #104's blood glucose level upon the resident returning., and reported the resident did not intend on eating for the rest of the day, so LPN #252 decided not to give the insulin per the physician order and sliding scale for fear of the resident's blood glucose level dropping. LPN #252 verified he did not notify anyone that the insulin was not given and stated he did not believe he needed to. LPN #252 verified Resident #104's sliding scale insulin at 4:00 P.M. and scheduled insulin at 5:00 P.M. were not given as ordered on 09/20/23. Interview on 11/28/23 at 8:03 A.M. with CNP #595 verified the CNP would have expected the insulin to be given per physician order and the sliding scale even though it was withheld per nursing judgement. Review of the facility policy titled, Medication Administration-General Guidelines, revised August 2014, revealed medications were administered in accordance with written orders of the prescriber. The policy also stated if a dose seemed excessive considering the resident's age and condition, or a medication order seemed to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification or the prescriber for clarification if necessary. The policy further stated if a dose of regularly scheduled medication was withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the administration record would be initialed and circled with an explanatory note entered on the reverse side of the record. If a vital medication was withheld, refused, or not available, the physician would be notified. Nursing would then document the notification and physician response. This deficiency represents non-compliance investigated under Complaint Number OH00147790. 366477 Page 3 of 3