Health inspection·May 10, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observations, medical record review, review of the facility policy, and staff interview, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #44) of three residents observed for medication administration. The facility identified a total of 11 residents received insulin in the facility. The facility census was 41. Residents Affected - Few Findings include: Review of Resident #44's medical record revealed an admission to the facility occurred on 12/02/21. Diagnoses included diabetes mellitus and Alzheimer's disease. Review of the current physician orders for May 2023 revealed medications including; Humalog eight units before meals, call physician if blood sugar was below 70 or above 400. Observation of Resident #44 on 05/10/23 at 7:49 A.M. revealed she received her breakfast and was eating independently. Resident #44 was observed to eat 100% of her breakfast meal on 05/10/23 at 8:08 A.M. Observation of Licensed Practical Nurse (LPN) #41 on 05/10/23 at 8:53 A.M. revealed LPN #41 gathered medications for Resident #44 including Humalog insulin pen. LPN #41 stated Resident #44's blood sugar (BS) level was 92 that morning (05/10/23) and LPN #41 obtained the BS level around 6:00 A.M. LPN #41 administered the Humalog eight units for Resident #44 at 8:57 A.M. LPN #41 confirmed Resident #44's current physician order for Humalog was to be administered before breakfast. LPN #41 confirmed she did not follow the physician order. Review of the facility's policy titled General Guidelines for Medication Administration, dated 03/01/07, revealed all medication are administered in accordance with written orders of the attending physician. Medications are administered within 60 minutes of scheduled time, except before or after meals orders, which are administered precisely as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00142307. Page 1 of 3 365118 365118 05/10/2023 Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, review of facility policy, and residents and staff interviews, the facility failed to ensure a comfortable water temperature was maintained on the orange unit of the facility. This affected seven residents (#24, #25, #28, #29, #30, #33, and #35) and had the potential to affect all 22 residents residing on the orange unit. The facility census was 41. Findings include: Interview and observation of the shower room, across from the nursing station on the orange unit was completed on 05/10/23 at 7:11 A.M. State Tested Nursing Assistant (STNA) #31 was observed in the room with a resident who she was getting ready to give a shower to. The water in the shower was running at that time and was tested with a thermometer and was noted to be 90 degrees Fahrenheit (F) and felt luke warm. STNA #31 stated the facility was having trouble with lack of hot water on the orange unit for a few weeks. STNA #31 confirmed the facility has been working on it, but it was not fixed. STNA #31 did identify the facility has a shower room on the purple unit, that does not have issues with hot water temperatures and staff can take residents there to shower. Water temperatures were obtained in the bathroom sinks in Residents #24, #28, #29, and #30's rooms on the Orange Unit on 05/10/23 between 7:22 A.M. and 7:28 A.M. The water was noted to be 90 to 92 degrees F and felt luke warm. STNA #32 confirmed the water temperatures and confirmed this has been happening off and on for the past several weeks. Observation of the orange nursing station on 05/10/23 at 7:34 A.M., revealed a nursing assistant book that contained the shower schedules. The book contained a note that revealed If there is no hot water on station two please use the station one shower room. The note was not dated. Interviews with Resident #25, #30, #33 and #35 on 05/10/23 between 10:45 A.M. and 11:10 A.M. confirmed they have been having issues with lack of hot water several times in the past month. The residents revealed they have sinks located in their rooms and the water was too cold. The residents revealed the shower room frequently does not have hot water and this was ongoing issue over the last several weeks. Interview with the Facility Plumber #500 on 05/10/23 at 9:41 A.M. confirmed he was currently working on the hot water system in the facility and was here last Friday. Facility Plumber #500 confirmed upon arriving the hot water on one side of the building was not hot enough. Facility Plumber #500 confirmed the facility recently installed a larger mixing valve as the old one was not large enough. Facility Plumber #500 stated he was at the facility to calibrate the system that day (05/20/23). Interview with Chief Operating Officer (CEO) #600 on 05/10/23 at 9:57 A.M. revealed at this time they could not locate any water temperature log checks for the month of May 2023, as the facility's maintenance director was on vacation. Review of the facility's undated bath/shower water temperature monitoring policy revealed the purpose was to establish procedures to ensure the protection of individuals from hot water while bathing/showering. Hot water used for bath hand shower shall be between 110-115 degrees F. Residents shall receive the needed supports and supervision during bathing/showering that will ensure their protection from hot water injuries. Hot water temperatures shall be in the range of 110-115 degrees F and 365118 Page 2 of 3 365118 05/10/2023 Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903

F 0921 water temperatures shall be measured and documented by maintenance. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00142307. Residents Affected - Some 365118 Page 3 of 3