Health inspection·April 18, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review the facility failed to ensure residents were afforded dignified dining experiences in the north dining room including receiving timely meals, adequate supplies of service ware such as silverware, plates, cups, bowls, and ordered/requested food items. This had the potential to affect the 15 residents (Residents #40, #55, #94, #3, #104, #102, #15, #67, #71, #69, #97, #41, #75, #43 and #7) who received meals from the north dining room and one of one resident reviewed for food concerns (Resident #3). Findings include: Review of the meal service times for the north dining room revealed breakfast was to be served at 8:15 A.M. and dinner at 5:15 P.M. Review of the monthly food committee meetings dated 12/26/18, 01/23/19, 02/27/19 and 03/27/19 revealed various, vague concerns but there was no evidence of any resolution to any of the concerns. Review of the care conference meeting, dated 03/27/19, revealed Resident #3 and family had concerns that were not written out and were very vague. Further review revealed there was no evidence of the facility addressing the concerns. Review of the communication from Social Service Designee (SSD) # 117 to Dietary Manager (DM) #118 and the Administrator, dated 04/04/19, revealed Resident #3 and his family expressed concerns of running out of dinning supplies during meals including this weekend when plastic was utilized, chicken was served in a coffee cup not on a plate and the main course was served in a salad bowl. Review of further communication revealed there was no evidence the concern was investigated or anything was put into place to ensure this did not re-occur. Review of the policy regarding stocking north dining room levels revealed to keep six bowls and nine cups in the cabinets. No other service ware was listed. Further review of the, updated 04/17/19, stocking north dining room revealed 10 sets of silverware and 10 plates. On 04/15/19 at 12:45 P.M., interview with Resident #3's family revealed concerns with meals being delivered late. Breakfast was to be delivered at 8:00 A.M. but frequently he did not receive his breakfast until 9:00 A.M. and he had to sit in the dining room for over an hour waiting on the food. The frequently run out of plates, silverware and they forget to serve bread a lot when it's on the menu. She verified she brought up these concerns in the last care conference 03/27/19 but nothing has been done to correct any of the concerns. Page 1 of 16 365317 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 04/15/19 at 5:14 P.M., the north dining room meal was observed being delivered to the dining room. At 5:35 P.M., the cook ran out of plates with two residents left to serve including Resident #3. After obtaining more plates from the kitchen Resident #3 received his meal at 5:41 P.M. Residents #40, #55, #94, #3, #104, #102, #15, #67, #71, #69, #97, #41, #75, #43 and #7 received meals from the north dining room. On 04/15/19 at 6:15 P.M., interview with State Tested Nurse Aide (STNA) #119 revealed this happened frequently including meals late, running out of plates, bowls, cups and/or silverware. On 04/15/19 at 6:17 P.M., interview with Licensed Practical Nurse (LPN) # 120 verified the north dining room occasionally ran out of serving ware before all the residents were served their meals. On 04/15/19 at 6:25 P.M., interview with Registered Dietitian (RD) #121 verified he had been aware of the above concerns since November, 2018, an in-service had been completed for the dietary staff but the concerns were ongoing. He verified they ran out of plates during the dinner meal this evening. On 04/16/19 at 4:20 P.M., interview with Dietary Manager (DM) # 118 verified she was aware of the concerns residents had with running out of serving ware. DM #118 indicated she was aware of the concerns with meals being delivered late but indicated they left the kitchen on time and did not monitor meal delivered. DM #118 verified there were concerns identified on the above food committee meetings and verified there was no evidence of addressing the concerns. On 04/16/19 at 6:04 P.M., observation of the north dining room with Corporate Administrator (CA) #107 and DM #118 revealed there was only silverware stored in the cabinets no other type of service ware. On 04/16/19 at 6:05 P.M., interview with CA #107 and DM #118 verified the concerns of no plates or other service ware in the north dining room. DM #118 indicated there was a minimum amount of each service ware to remain in the dining room and verified it was not met. 365317 Page 2 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure resident's code status were clearly and/or easily identified. This affected two of two residents reviewed for accuracy of code status (Residents #57 and #71). Findings include: 1. Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease required hemodialysis, atrial fibrillation and respiratory failure. On admission the resident had an order for a full code. The resident was admitted to the hospital 10/30/17 and Do Not Resuscitate Comfort Care Arrest (DNR CCA) paperwork was signed. When the resident returned to the facility on [DATE] an order for a full code was written. Review of the physician's order dated 10/29/18 revealed to change from full code to DNR CCA. Review of the occupational therapy evaluation dated 02/21/19 revealed the resident was a full code status. Review of the quarterly minimum data set (MDS) 3.0 dated 02/27/19 revealed the resident was cognitively intact. Review of the resident's current order, initiated 09/05/17, indicated the resident was to wear a yellow bracelet on his wrist at all times, monitor placement every shift. The yellow bracelet was an indication the resident was a full code. Review of the treatment administration record (TAR) for April, 2019 indicated daily the resident had the yellow bracelet on his wrist. Review of the hemodialysis center treatment sheet dated 04/17/19 revealed the resident was a full code. On 04/15/19 at 12:25 P.M. and 4:30 P.M., the resident was observed without a yellow bracelet on his wrist. On 04/15/19 at 4:31 P.M., interview with the resident revealed he did not have a yellow bracelet on his wrist and was not sure the meaning of it. On 04/16/19 at 11:52 A.M., 3:10 P.M. and 4:06 P.M., the resident was observed without a yellow bracelet on his wrist. On 04/17/19 at 11:20 A.M., interview with Corporate Administrator (CA) #107 verified the current order for the resident to wear a yellow bracelet on his wrist was indicative of the resident being a full code. CA #107 revealed all residents in the facility determined to be full code were to have a yellow bracelet on their wrist. On 04/17/19 at 12:25 P.M., the resident was observed without a yellow bracelet on his wrist. 365317 Page 3 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0578 Level of Harm - Minimal harm or potential for actual harm On 04/17/19 at 12:35 P.M., interview with Licensed Practical Nurse (LPN) #108 verified she had her aide go around and check all the residents this afternoon to ensure the yellow bracelets were on the wrists of all residents who were ordered them indicating they were a full code. LPN #108 verified the resident did not have on a yellow bracelet despite being signed off as in place on the TAR daily for April, 2019 as well as having an order for the yellow bracelet. Residents Affected - Few On 04/17/19 at 2:40 P.M., the resident was observed without a yellow bracelet on his wrist. On 04/17/19 at 3:30 P.M., interview with Corporate Administrator (CA) #107 and the Director of Nursing (DON) verified the orders were contradicting because he had a current order for the yellow bracelet, which was checked off daily on the April 2019 TAR as in place by the nurses, and at the same time the resident had a DNR CCA order. The DON verified the resident did not have on a yellow bracelet as ordered. On 04/17/19 at 5:30 P.M., the resident was observed without a yellow bracelet on his wrist. 2. Record review revealed Resident #71 was admitted to the facility on [DATE] with diagnoses which included Huntington's disease. Review of the quarterly MDS 3.0 dated 03/03/19 revealed the resident was cognitively intact. Review of the order dated 11/21/18 revealed the resident had a full code status. Review of the order dated 11/21/18 revealed the resident was to wear the yellow bracelet to the left wrist at all times an monitor placement every shift. Further review of the TAR for 04/15/19, 04/16/19 and 04/17/19 indicated the yellow bracelet was in place every shift. On 04/15/19 at 12:30 P.M. and 5:30 P.M., the resident was observed without a yellow bracelet on either wrist. On 04/16/19 at 12:30 P.M. and 5:30 P.M., the resident was observed without a yellow bracelet on either wrist. On 04/17/19 at 12:30 P.M., the resident was observed with a yellow bracelet on his left wrist. On 04/17/19 at 12:35 P.M., interview with LPN #108 verified she had her aide go around and check all the residents this afternoon to ensure the yellow bracelet were on the wrists of all residents who were ordered them indicating they were a full code. LPN #108 verified the resident did not have on a yellow bracelet in place as ordered even though the resident was a full code. On 04/18/19 at 9:25 A.M., interview with the resident revealed the yellow bracelet was to be worn to save my life. He verified it had been off for about a week and it comes off at times while he is in therapy. The resident verified the yellow bracelet was replaced yesterday afternoon. Review of the advanced directives procedure, not dated, revealed to ensure the residents advanced directives were documented accurately in the medical record to allow for accurate verification at the time when the directive would be implemented. The code status would be reviewed at least quarterly and upon re-admission after a hospital stay. 365317 Page 4 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident was comprehensively assessed, care planned and had a physicians order for the use of a seatbelt while in his electric wheelchair. This affected one of one residents reviewed for restraints (Resident #57). Residents Affected - Few Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease that required hemodialysis, atrial fibrillation and respiratory failure. The resident was morbidly obese and required the use of an electric wheelchair for mobility. Review of the occupational therapy evaluation dated 02/21/19 revealed the resident was referred to therapy to instruct the resident on the use of the new electric wheelchair. There was no mention of a seatbelt with the wheelchair. Further review of the therapy re-evaluation from 04/12/19 through 05/10/19 revealed the resident needed additional education on use of the electric wheelchair because he have having difficulty maneuvering through doorways and running into objects. There was no mention of the seatbelt for the wheelchair. Review of the quarterly minimum data set (MDS) 3.0 dated 02/27/19 revealed the resident was cognitively intact and did not have a trunk restraint and his wheelchair did not prevent him from rising. Further review of the care plan revealed there was no evidence the resident used a seatbelt in his electric wheelchair. Review of the current monthly physician orders for April, 2019 revealed there was no evidence the resident used the seatbelt while in his electric wheelchair. Further review revealed there were no assessments to determine if the seatbelt was a restraint and there were no care plans for instruction for use of the seatbelt. On 04/15/19 at 12:25 P.M. and 4:30 P.M., the resident was observed in his electric wheelchair with the custom seatbelt secured around his waist. On 04/15/19 at 4:31 P.M., interview with the resident revealed he had worn the seatbelt that came with the wheelchair since he got the electric wheelchair in February, 2019. On 04/16/19 at 11:52 A.M., 3:10 P.M. and 4:06 P.M., the resident was observed in his electric wheelchair with the seatbelt securely around his waist. On 04/17/19 at 11:20 A.M., interview with Corporate Administrator #107 verified there was no order, no assessment, no care plan and no documentation in the medical record related to the use of the seatbelt since the resident had the electric wheelchair in February, 2019. The seatbelt was custom with the wheelchair. On 04/17/19 at 12:25 P.M., 2:40 P.M. and 5:30 P.M., the resident was observed in his electric wheelchair with the seatbelt securely around his waist. 365317 Page 5 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to re-evaluate a resident via a Pre-admission Screening and Resident Review (PASARR) after being newly diagnosed with psychosis. This affected one (Resident #6) of one resident reviewed for PASARR assessments. Findings include: A record review of the medical record of Resident #6 revealed he was admitted on [DATE] with diagnoses of delusional disorders, hallucinations, bipolar disorder, psychosis and mild cognitive impairment. His diagnosis of bipolar disorder was entered on 12/29/16 and diagnosis of unspecified psychosis entered on 05/21/18. Record review of the PASARR assessment dated [DATE] revealed there were no indications of serious mental illness. There were no other PASARR assessments completed since 06/28/16. The care plan of Resident #6 dated 07/05/18 revealed this resident had psychotic symptoms and staff were to monitor his behaviors. He had the potential for altered behavior patterns, disruptive interactions, disruptive verbal behaviors, resistance to care, violence and anger, agitation, anxiety and hallucinations. A record review of behavior documentation for Resident #6 from 02/18/19 to 04/18/19 revealed he had experienced fixations in wanting cough syrup, hallucinations and delusions regarding mice, cats and other things in his room and bed. Behaviors were documented on 02/19/19, 02/21, 02/22, 02/28, 03/03, 03/04, 03/13, 03/14, 03/19, 03/23, 03/24, 03/28 and 04/11. An interview on 04/18/19 at 10:46 A.M. with the Administrator revealed they did not conduct another PASARR review since the onset of new mental health diagnoses for Resident #6 and they did not contact any appropriate mental health authority for such assessments. An interview on 04/18/19 at 1:12 P.M. with Licensed Practical Nurse (LPN) #106 revealed she had witnessed Resident #6 hallucinating and having delusions. 365317 Page 6 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

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 observation, interview and record review the facility failed to ensure a comprehensive care conference for a resident to ensure all concerns were addressed. This affected one of one residents reviewed for care conferences (Resident #3). Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Traumatic Brain Injury and Cerebral Vascular Accident with right sided hemiparesis. Review of the care conference meeting, dated 03/27/19, revealed Resident #3 and family had concerns with dietary and nursing that were not written out and were very vague. Review of the sign in sheet revealed there were only three staff involved in the meeting including Social Service Designee (SSD) #117, activities aid (AA) #122 and wound nurse, Licensed Practical Nurse, (LPN ) #123. Further review revealed there was no evidence of the facility addressing the concerns. Review of the communication from Social Service Designee (SSD) # 117 to Dietary Manager (DM) #118 and the Administrator, dated 04/04/19, revealed Resident #3 and his family expressed concerns of running out of dining supplies during meals including this weekend when plastic was utilized, chicken was served in a coffee cup not on a plate and the main course was served in a salad bowl. Review of further communication revealed there was no evidence the concern was investigated or anything was put into place to ensure this did not re-occur. On 04/15/19 at 12:45 P.M., interview with Resident #3's family revealed concerns with meals being delivered late. Breakfast was to be delivered at 8:00 A.M. but frequently he does not receive his breakfast until 9:00 A.M. and he has to sit in the dining room for over an hour waiting on the food. The frequently run out of plates, silverware, they forget to bring bread/rolls a lot when its on the menu and don't have all the alternative meal items available. She verified she brought up these concerns many times to different staff, including the last care conference 03/27/19, but nothing has been done to correct any of the concerns. On 04/15/19 at 5:14 P.M., the north dining room meal was observed being delivered to the dining room. At 5:35 P.M., the cook ran out of plates with two residents left to serve including Resident #3. After obtaining more plates from the kitchen Resident #3 received his meal at 5:41 P.M. On 04/18/19 at 12:00 P.M., interview with SSD #117 verified there was no evidence of addressing the concerns in the 04/04/19 communication with DM #118 and the Administrator. She verified the 03/27/19 care conference summary did not address the specific concerns the resident and family had just that they would be addressed. She verified there was no evidence of an interdisciplinary team to collaborate for the care conference and verified there was no dietary representation despite the family having ongoing concerns with dietary. On 04/18/19 at 12:15 P.M., interview with Corporate Administrator #107 verified the quality assurance staff had identified concerns with care conference meetings at the facility and were working on correctly the concerns. 365317 Page 7 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/18/19 at 11:25 A.M., interview with SSD #117 revealed she was in charge of scheduling the care conferences which were held on Wednesdays and the staff that were available attended but she did not ensure a comprehensive interdisciplinary approach to the meetings. SSD #117 verified only three staff attended the 03/27/19 care conference for Resident #3 (AA #122, wound nurse, LPN #123, and herself). She verified there was no evidence any direct care staff or dietary staff were involved or had input related to the meeting. SSD #117 verified the summary was very vague and did not indicate specific concerns because she did not feel comfortable writing the specific information. She verified the family addressed multiple dietary concerns during the meeting but there was no evidence of specifics or evidence the concerns were addressed. SSD #117 verified LPN #123 handled the nursing concern and she did not recall what it entailed. On 04/18/19 at 1:45 P.M., interview with LPN #123 revealed the nursing concern related to the care conference 3/27/19 was related to the resident having a leg bag on without an order and the resident did not want the leg bag. 365317 Page 8 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident had a comprehensive bladder program in place when the resident needed assistance of staff for toileting to ensure the resident was able to maintain as much continence as possible. This affected one of one residents reviewed for bladder incontinence (Resident #12). Findings include: Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease requiring continuous oxygen and respiratory failure with hypoxia. Review of the three day tracker revealed it was only completed one day on 07/06/18 which indicated the resident was continent of bladder. Further review revealed no comprehensive assessment or care plan were completed and implemented. Review of the admission minimum data set (MDS) 3.0 dated 07/11/18 revealed the resident was cognitively intact but needed extensive assistance of two staff for activities of daily living (ADL) including transferring and toileting. No toileting trial was initiated nor was the resident on a toileting program. The resident was occasionally incontinent of urine. Further review revealed there was no care plan related to the resident's urinary incontinence. Review of the quarterly MDS 3.0 dated 01/07/19 revealed the resident was cognitively intact but needed extensive assistance of one staff for transfers and toileting. The resident was not trialed on a toileting program nor was the resident currently on a toileting program. The resident was occasionally incontinent of urine. Further review revealed there was no care plan related to the resident's urinary incontinence. Review of the continence assessment dated [DATE] revealed the resident was occasionally incontinent of urine and needed staff assistance for toileting. The resident had confusion with long term memory loss. No trial of a toileting program was attempted. The plan was to reduce the number of incontinence episodes and scheduled voiding program. Further review revealed there was no three day tracker completed, no toileting program implemented and no care plan initiated. Review of the hospital records revealed the resident was admitted on [DATE] due to low oxygen levels, was diagnosed with aortic stenosis and returned to the facility on [DATE]. On 04/16/19 at 11:46 A.M., 3:06 P.M. and 4:06 P.M., the resident was observed in bed with oxygen in place via nasal cannula. The resident was not interviewable. On 04/17/19 at 10:01 A.M., the resident was observed in bed with oxygen in place via nasal cannula. The resident was not interviewable. On 04/18/19 at 9:20 A.M., the resident was observed in bed with oxygen in place via nasal cannula. The resident was not interviewable. 365317 Page 9 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/18/19 at 10:00 A.M., interview with State Tested Nurse Aide (STNA) #109 revealed the resident's individual needs were listed on the [NAME] which she pulled out of her pocket. She verified there was no instructions what to do for this resident for toileting needs. She stated the resident had episodes of incontinence but had gotten worse a couple weeks prior to her going out to the hospital on [DATE]. She stated prior to the hospitalization two staff transferred her to the bedside commode whenever the resident requested, by activating her call light, but now she is just a check and change. She was not ever on any type of toileting program. STNA #109 verified the resident would come and go with the ability to be interviewable. On 04/18/19 at 12:20 P.M., interview with Corporate Administrator #107 verified the facility did not have a comprehensive plan for the resident, there were no three day trackers completed according to the protocol to complete a comprehensive assessment to better determine the residents toileting needs. There was no care plan for toileting and/or incontinence. The resident was never trialed on a toileting program and currently did not have any documentation of any plan. Review of the protocol related to assessment of bladder (incontinence), revised October 2014, revealed to identify individuals with reversible and irreversible causes of incontinence and to institute the appropriate interventions to meet the needs of the resident. A resident who is incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. 1. Complete a continence assessment within seven days of admission or readmission, then quarterly and whenever there is a change in continence status. 2. If the initial continence assessment identifies the resident as incontinent, a three day voiding pattern assessment would be initiated. 3. If continence assessment identifies the resident as incontinent the facility would initiate appropriate interventions to help maintain dryness. 4. Based on information contained in voiding pattern and in-depth assessments along with input from the resident, family and interdisciplinary team, a care plan would be developed and implemented to meet the needs of the resident. 5. The care plan would be reviewed quarterly and as needed. Changes would be made based on on-going assessments and changes in physical and/or cognitive status. 365317 Page 10 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to provide timely and effective pain management for Resident #60's continued pain following a fall. This affected one (Resident #60) of three residents reviewed for falls. The facility census was 102 residents. Residents Affected - Few Findings include: Review of Resident #60's medical record revealed an admission date of 03/30/18 with diagnoses that included dementia and unsteadiness on feet. An annual Minimum Data Set 3.0 (MDS) assessment revealed Resident #60 had severely impaired cognition and required extensive assist with transfers and ambulation. The resident had a physician's order dated 03/30/18 for acetaminophen 650 milligrams (mg) every four hours for pain as needed (PRN). Review of the medication administration record (MAR) since January, 2019 indicated Resident #60 used the PRN acetaminophen one time prior to 02/07/19. Review of the progress notes revealed on 02/07/19 at 8:00 A.M. Resident #60 was found on the floor next to her bed by staff members. The resident complained of pain to the shoulder at that time. The physician was notified of the fall with no new orders received. Further review of the medical record including the MAR revealed Resident #60 was administered PRN acetaminophen 650 milligrams (mg) 14 times following the fall on 02/07/19. On 02/13/19 at 8:00 P.M. the nurse practitioner was notified of continued pain concern to the left shoulder. At this time, the nurse practitioner ordered x-rays of the left shoulder. Review of the x-ray results revealed the x-ray was completed on 02/13/19 at 8:55 P.M. and results were reported at 9:22 P.M. on 02/13/19. The x-ray indicated a fracture to the left distal clavicle (collar bone). An additional progress note dated 02/14/19 at 7:58 A.M. indicated x-ray results were received at 12:00 A.M. and primary care physician was notified and no new orders were received. On 02/14/19 at 11:45 A.M. Resident #60 was evaluated by the nurse practitioner. Exam revealed the resident was status post fall on 02/07/19 and continued pain to the left shoulder clavicle area. Further exam revealed the resident had acetaminophen use with poor pain control. Bruising was noted to the left shoulder clavicle area. At this time the nurse practitioner ordered the use of hydrocodone/acetaminophen (narcotic analgesic medication) twice daily and every six hours as needed for pain. The nurse practitioner also ordered the use of a left arm sling and referred the resident to an orthopedist on 02/15/19. Interview with the Director of Nursing on 04/17/19 at 1:10 P.M. verified Resident #60 suffered a fall during a self-transfer on 02/07/19; the resident was administered PRN acetaminophen 14 times after the fall, indicating the resident's continued poor pain management, prior to the nurse practitioner being notified of continued pain concerns on 02/13/19. The DON verified it wasn't until this point that an x-ray was ordered, and a left clavicle fracture was found. The DON further verified staff members should have notified the physician or nurse practitioner of the resident's continued pain prior to 02/13/19. 365317 Page 11 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure coordination of care for a resident who received hemodialysis from an outside facility. This affected one of one residents reviewed for dialysis (Resident #57) and affected four of four residents on fluid restrictions (Resident's #96, #2, #10 and #57) . Residents Affected - Few Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease requiring hemodialysis (HD). The resident had physician ordered medications to be given daily in the morning as well as a physician's order to monitor fluid intake. Review of the quarterly minimum data set (MDS) 3.0 dated 02/27/19 revealed the resident was cognitively intact. a) Review of the facility's Intake and Output Recoding Tool Guidelines, revised May 2014, revealed measurements of fluid would be initiated with a physicians order. Review of the physicians order dated 08/13/18 revealed the resident was to be on an 1800 cubic centimeter (cc) fluid restriction daily. Further review of the February, March and April, 2019 treatment administration record (TAR) revealed there was a daily check mark but no fluid amounts. Further review of the medical record revealed there was no evidence the facility was measuring the resident's fluid intakes. Review of the nutrition progress note dated 01/31/19 revealed the resident was on a fluid restriction and the resident had weight gains but there was no evidence of addressing the weight/fluid gains, ensuring the fluid restriction was being followed or communication with the renal registered dietitian (RD). The plan was to monitor with no change in care. Review of the quarterly minimum data set (MDS) 3.0 dated 02/27/19 revealed the resident was cognitively intact and received dialysis outside of the facility. Review of the nutrition progress note dated 02/27/19 revealed the resident continued with significant weight fluctuations due to fluid shifts with fluid restriction in place. The plan was to monitor with no change in care. Review of the nutrition progress note dated 03/22/19 revealed the resident was on a fluid restriction and the resident continued with significant weight gains due to fluid shifts. There was no follow up or communication with the renal registered dietitian (RD). The plan was to monitor with no change in care. Review of the daily treatment sheets for April, 2019, provided by the dialysis center, revealed the resident was having significant weight gains between treatments and at times the resident was not able to tolerate removing all the total fluid goal. The sheets included pre and post weights, fluid gains, dry weight goal, blood work completed and nursing assessments. On 04/15/19 at 12:25 P.M., the resident was observed eating and had two large thermos's (24 ounces 365317 Page 12 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0698 each) of liquid, an eight ounce cup of water and a 12 ounce cup of coffee which he had drank out of each. Level of Harm - Minimal harm or potential for actual harm On 04/17/19 at 12:25 P.M., the resident was observed eating and had two large thermos's (24 ounces each) of liquid, an eight ounce cup of water and a 12 ounce cup of coffee which he had drank out of each. Residents Affected - Few On 04/17/19 at 12:26 P.M., interview with the resident revealed he was told to watch his fluid intake but was not sure how much fluid he was limited to nor how much fluid was currently on his lunch tray. b) Review of the current orders revealed the resident went to HD on Monday, Wednesdays and Fridays every week at 5:30 A.M. The resident was ordered the following medications daily after breakfast: Breo Ellipta Aerosol inhalation (a medication used to treat chronic obstructive pulmonary disease), Lexapro (an antidepressant), Reno Caps (water soluble vitamins for people on HD), Cholestyramine (a medication for high cholesterol) and Prostat (a high protein liquid supplement). The resident was ordered calcium acetate (a medication used to prevent high blood phosphate levels for people on HD) before breakfast. The resident was ordered Neurontin (a medication to help with pain from neuropathy) at 9:00 A.M. The resident had a physician's order dated 10/28/18 for Do Not Resuscitate Comfort Care Arrest (DNR CCA). Review of the treatment sheet dated 04/17/19 from HD revealed the resident was a Full Code. Review of the corresponding medication administration records (MAR) for February, March and April, 2019 revealed the resident did not receive the above ordered daily medications on HD days (three days a week). Further review revealed there was no evidence the physician was notified of the facility not following the physicians orders for the medications. On 04/17/19 at 12:26 P.M., interview with the resident revealed he did not get all his ordered medications on days he went to dialysis. c) Review of the medical record including electronic and hard chart revealed there was no evidence where the resident went for HD, there were no HD run sheets with weekly laboratory values, pre and post HD weights, recommendations, report cards or any evidence the facility was monitoring and coordinating the care with the HD center. On 04/17/19 at 11:20 A.M., interview with Corporate Administrator (CA) #107 and Director of Nursing (DON) verified the facility did not measure any residents fluid intakes when ordered a fluid restriction by the physician. The DON verified there were currently four residents (Resident's #96, #2, #10 and #57) with physician ordered fluid restrictions. The DON verified Resident #57's medications were not given three days a week (on HD days) despite being ordered daily because the resident was not at the facility at the time the medications were to be given. The DON verified there was no evidence the physician was notified of the orders not being followed nor did the facility address the concern nor assess the best times medications should be administered for best absorption for the resident on HD. The DON verified Resident #57's HD code status was not accurate with the current physicians order of DNR CCA. CA #107 verified there was no evidence the RD completed comprehensive assessments for Resident #57 including ensuring the fluid restriction was monitored, pre and post dialysis weights were monitored, weekly laboratory values were reviewed, medications were given as ordered and given at appropriate times for best absorption nor were adjustments made as needed to ensure the 365317 Page 13 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident received the high protein supplement as ordered to sustain adequate visceral protein stores which are essential for residents on HD. The DON verified there was no evidence the facility had a plan in place to effectively coordinate the residents care with the HD center. Review of the dialysis policy, reviewed July 2013, revealed to ensure the resident receiving dialysis treatment receives safe and appropriate treatment related to dialysis care by: 1. developing a plan of care which addresses the following: alteration in fluid volume, potential for bleeding, monitoring of the access site, potential for infection, alteration in nutrition and alteration in skin integrity. 2. The facility dietitian is responsible to monitor the dietary needs of the resident and to maintain regular communication with the dialysis center's dietitian. 3. The licensed nursing stiff will notify the physician, family and dialysis center of any abnormal findings and document in the medical record these findings and notifications. 4. The nursing staff would ensure information sharing between the facility and dialysis center was maintained. 365317 Page 14 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure the operation of the kitchen was maintained in a sanitary manner related to the dish machine, cleaning of the thermometers and monitoring appropriate food temperatures prior to service in the north dining room. This had the potential to affect the 102 residents who received meals from the facility and the 15 residents (Residents #40, #55, #94, #3, #104, #102, #15, #67, #71, #69, #97, #41, #75, #43 and #7) who received meals from the north dining room. Findings included: 1. Review of the dish washer temperature/sanitation logs policy, not dated, revealed the logs would be maintained for wash/rinse temperatures daily. Test strips for chlorine would be used weekly for testing of the final rinse sanitation level for low temperature dish machines. The required chlorine levels were 50 parts per million (ppm). Review of the in-service dated 11/27/18 revealed the staff were educated on dish machine soap and reading the temperature (not the chemical levels). Further review of the sign in revealed dietary aids (DA) #110, #111 and #112 attended the in-service. On 04/15/19 during the initial tour at 9:40 A.M. revealed there were three DA's #110, #111 and #112 operating the dish machine. While the dish machine was in use three water temperature gauges were observed. Multiple racks were observed going through the dish machine. The wash gauge read 120 degrees and the rinse gauge varied between 130 and 135 degrees. On 04/15/19 at 9:45 A.M., interviews with DA #110, #111 and #112 revealed they did not know if the dish machine was a high or low temperature machine nor if the machine required chemicals for cleaning. Then DA #111 said there is a log where we put the water temperatures. Review of the April, 2019 dish machine log revealed temperatures recorded above 160 degrees for wash and above 180 degrees for rinse. Also hanging from the log was a baggy with chemical strips and written on the baggy was take internal temperature of the dish machine every Tuesday and record. On 04/15/19 at 9:40 A.M., interview with the dietary manager (DM) indicated the dish machine was a low temperature with chemicals for sanitation. The dietary manager stated the staff were educated in November, 2018 because it was a problem they were not monitoring the dish machine correctly. Review of the in-service revealed they were educated on recording temperatures, there was no mention of using the chemical test strips. The DM verified the April, 2019 dish machine temperature log was inaccurate and the water temperatures did not get that high. The DM verified the baggy said to take internal temperature of the dish machine every Tuesday and record and there was no evidence this was completed. The DM was questioned since the dish machine sanitized the dishes with chemicals why were the chemical levels not checked and the DM could not answer. The DM verified the facility had no documented instructions or visual instructions on how to use the chemical strips for testing the dish machine and there was no evidence the staff were trained on using the chemical strips for testing just on recording water temperature. On 04/16/19 at 5:53 P.M., DA #116 was observed operating the dish machine. Interview revealed she was to check the temperatures which should be between 120 and 140 degrees. She denied checking any 365317 Page 15 of 16 365317 04/18/2019 Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many chemical levels nor did she know she was supposed to check for chemical levels. Review of the dish machine log revealed it only had entries to check twice daily, not before each use and there was only the morning entry for 04/16/19. DA #116 verified she had not entered temperatures yet despite already washing dishes. On 04/16/19 at 5:56 P.M., interview with the DM and Corporate Administrator (CA) #107, with [NAME] #114 and RD #115 present, verified the dish machine had not been checked for chemical levels and verified the above concerns. On 04/17/19 at 5:05 P.M., interview with RD #115 and the Administrator verified the facility did not have any documentation on instructions for staff on how to test the dish machine for proper sanitation levels. 2. Review of the food temperatures on trayline guide, revised March 2013, revealed the temperatures of all cold and hot foods would be taken during preparation prior to serving to ensure safety of all food served. Taking temperatures: wipe the thermometer stem with alcohol wipes prior to and after taking the temperatures of each food. Record the temperatures in the temperature record log sheet. On 04/16/19 at 5:00 P.M., the surveyor entered the kitchen and observed a full pan of cheesy ham and potato casserole on top of the pans that were sunk in the well of the steam table. DA #13 was serving from this pan. At 5:05 P.M., DA #113 brought the half used pan to [NAME] #114 and set it on her cart to take to the north dining room (where the foods were served from a steam table). [NAME] #114 proceeded to remove other pans from the warmer and place on her cart. [NAME] #114 began taking the temperatures of the hot food items. She removed the thermometer from its sleeve and placed it in the beef barley soup without cleaning it with an alcohol wipe, she removed the thermometer, ripped open the top of the alcohol wipe packet, placed the stem (which only fit about half way in the packet), twirled it around and removed the stem, she then placed the thermometer stem in they cheesy ham and potato casserole after obtaining the temperature removed it, opened another packet containing an alcohol wipe, did not remove the wipe but placed half of the stem inside the packet. She verified this was how she always cleaned the thermometer stem between temperatures. She then placed the thermometer stem back into the beef barley soup (after re-heated), a white milky substance was observed in the soup and around the plastic covering the pan. She verified this and verified only about half of the stem entered the alcohol packet when cleaning because it was too long and verified there was still remnants from the cheesy ham and potato casserole on the stem to the top of the thermometer gauge. Yet she continued to clean the stem the same way after each food she obtained temperatures from. This was verified by the registered dietitian (RD) #115 who observed the above. [NAME] #114 did not record any of the food temperatures either during or after completing the temperatures. She verified she never recorded the temperatures and verified she did not retake the temperatures when the food was taken to the north dining room and placed in the steam table prior to service. Review of the directions for use of the individual packet of alcohol wipes revealed to remove the wipe from the packet before use. This was verified by RD #115 at the time of the finding. The hot food then left the kitchen and no cold food temperatures were taken. On 04/16/19 at 5:56 P.M., interview with the DM and CA #107 verified the above concerns. The DM revealed milk and juices were kept in the refrigerator in the north dining room and the dietary staff did not check the beverage temperatures prior to service because the nurse aids were responsible for passing the beverages. No one was assigned to check the cold beverage temperatures. The DM verified there were no records of documenting the north dining room food temperatures prior to service for any meal for either hot of cold foods. 365317 Page 16 of 16