Health inspection·September 12, 2019

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 medical record review, staff interview, and facility policy, the facility failed to ensure a resident's full code status was addressed in the medical record. This affected one Resident (#183) of 26 residents with full code status. The facility census was 83. Findings include: Review of Resident #183's medical record revealed an admission date of [DATE]. Diagnoses included cellulitis, muscle weakness, acute kidney failure, respiratory failure, and cardiomegaly. Review of Resident #183's active physician orders dated [DATE] revealed no order for full code or Cardiopulmonary Resuscitation (CPR) status. Further review of the resident's medical record revealed the record and care plan to be silent for advanced directives. Interview on [DATE] at 11:16 A.M. with Licensed Practical Nurse (LPN) #101 verified Resident #183's code status was not listed in the physician orders, face sheet or the resident's care plan. Review of facility policy titled Determination of Code Status dated [DATE] revealed the resident/client/representative will be informed of the need to obtain a choice regarding CPR or DNR (Do Not Resuscitate) in the event of cardiac arrest. Obtain physician's order for resident's choice of CPR or DNR. Page 1 of 23 365380 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy the facility failed to complete routine maintenance and maintain resident rooms and common areas in good repair. This failed practice affected 19 resident rooms of 35 resident rooms on the 300, 400 and 500 halls and common areas observed for repair and maintenance. The facility census was 83. Findings include: 1. During a tour with Environmental Service Director (ESD) #146 the following concerns were observed. At the time of the observations, ESD #146 verified all the findings and indicated the facility had a plan for future remodeling. a. room [ROOM NUMBER] had drywall damage to the walls in the room. The bathroom had holes and damaged drywall by the mirror where it appeared there had been a soap dispenser. There was a new soap dispenser on the opposite side of the mirror. The toilet base was stained black. b. room [ROOM NUMBER] had loose and cracked flooring in the bathroom. c. room [ROOM NUMBER] had toilet base stained black and damaged dry wall. d. room [ROOM NUMBER] had damaged drywall in the resident room. In the bathroom the flooring by the cabinet was loose and pealing up two or three inches from the floor. The floor had cracks in it and there was duct tape across the threshold. The toilet base was dirty and stained with black matter. e. room [ROOM NUMBER] had damaged drywall in the room by the bed and in the bathroom behind the toilet. There was loose flooring in the bathroom by the cabinet. f. room [ROOM NUMBER] had cracked and damaged flooring in the bathroom. g. The flooring in every resident bathroom on the 400 hall locked unit had various degrees of cracking and/or peeling. Every resident room and bathroom on the 400 hall locked unit door jams were damaged with paint chipped off, especially on the lower area of the door jams. h. The dining room had damage to the drywall with a large gouge about 18 inches long along with other areas of damage. i. In the TV room there was extensive drywall damage to three of the walls behind the recliners with multiple gouges, scratches, nicks and indentations across the entire wall behind each recliner in various sizes up to three or four inches or more. j. The archway leading to the patio doors had large areas of damage to the drywall on the corners several inches around. There was damage to the drywall by the patio door. k. There was damage to the wallpaper and walls in the corridor on both sides and the entire length of the hall with scrapes, scratches, gouges and pealing wallpaper on the lower part of the wall. 365380 Page 2 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some l. The drywall was damaged behind and around the room signs of room [ROOM NUMBER] and 409. The room number sign was attached to the wall over part of the damaged drywall. m. room [ROOM NUMBER] had drywall damage to the walls in the room. The bathroom had holes and damaged drywall by the mirror where it appeared there had been a soap dispenser. There was a new soap dispenser on the opposite side of the mirror. The toilet base was stained black n. room [ROOM NUMBER] had damaged drywall in the room and a stained, dirty toilet base. o. room [ROOM NUMBER] had duct tape across the bathroom threshold. The toilet base was dirty and stained with black matter. p. room [ROOM NUMBER] had several missing and broken floor tiles in the closet. The bathroom floor was cracked and in poor repair. The toilet base was dirty and stained with black matter. q. There was damage to the dry wall on 300 hall near the lounge. 2. Observation on 09/09/19 at 9:00 A.M. of room [ROOM NUMBER] revealed the trash can in the bathroom was overflowing onto the floor with trash and incontinence briefs. Interview on 09/09/19 at 9:30 A.M. with Licensed Practical Nurse (#121) verified the trash can in room [ROOM NUMBER] was overflowing onto the floor. Observation and interview on 09/12/19 at 11:11 A.M. with ESD #146 verified rooms [ROOM NUMBERS] had broken and damaged floor tiles in the resident rooms. Review of facility policy titled Safe Physical Environment dated 11/28/16 revealed housekeeping and maintenance services will be completed to maintain a sanitary, orderly, and comfortable interior. 365380 Page 3 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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, interview, review of Self-Reported Incidents (SRIs) and review of facility policy the facility failed to implement their policy in regard to reporting and investigating thoroughly allegations of misappropriation and abuse. This affected three Residents (#15, #30 and #75) of three reviewed for abuse. Seven SRIs were reviewed from 04/07/19 to 09/12/19. The facility census was 83. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #15 revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia, depression, psychosis, peripheral vascular disease, hypertension, anxiety and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired. Review of the nurse progress note dated 08/13/19 at 1:41 P.M. revealed Resident #15's sister called and complained regarding Resident #15 having items being thrown away by staff. The sister also indicated Resident #15 had all her bras taken. The nurse allowed the sister to vent and assured her that she would look into this matter and let the nurse manager know. The note was signed by Licensed Practical Nurse (LPN) #121. Further review of the progress notes including care conference notes from 08/13/19 to 09/10/19 revealed no other mention of the alleged misappropriation of Resident #15's items discarded by staff or of the missing bras. There was no investigation noted. There was no documentation of the facility staff looking for any missing items. Review of the facility SRIs from 08/13/19 to 09/10/19 revealed no SRI was submitted for the alleged misappropriation. Interview with LPN #121 on 09/10/19 at 10:56 A.M. verified she spoke with Resident #15's sister on 08/13/19. LPN #121 stated the sister alleged items had been thrown away by staff and that bras had been taken. LPN #121 verified she reported the concern to the Unit Manager, Registered Nurse (RN) #156 and Director of Social Services (DSS) #136. LPN #121 stated Resident #15's Power of Attorney (POA) had approved the discarding of socks with no match. Interview on 09/10/19 at 11:22 A.M. with DSS #136 verified she was aware Resident #15 had missing bras but denied knowledge of staff discarding any other items. DSS #136 stated the missing bras had been discussed during care conferences dated 03/27/19 and 06/19/19. DSS #121 reviewed the care conference notes and verified there was no documentation of the concern discussed during either meeting. DSS #136 verified Resident #15 had a POA. DSS #121 reviewed the progress notes and verified there was no documentation of the POA being made aware of the concern or of the POA giving approval to discard clothing. DSS #121 verified if notification was provided to the POA it should be charted. Interview with the Director of Nursing (DON) on 09/10/19 at 2:01 P.M. verified there was no SRI submitted in regard to the allegation of staff throwing away items or of bras being taken which belonged to Resident #15. The DON verified she was never made aware of the allegation of staff discarding resident property or of any missing bras on 08/13/19. Interview with RN #156 on 09/11/19 at 9:24 A.M. verified LPN #121 informed her of the concern that Resident #15 had no bras. RN #156 stated it was an ongoing concern and new bras had previously been purchased. RN #156 denied being informed of items being thrown away by staff as alleged on 08/13/19. 365380 Page 4 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few RN #156 stated she was only aware of a sock being discarded due to it having a hole in it and no matching sock, the POA had approved of this. RN #156 verified there was no documentation of the conversation with the POA or of any investigation of the alleged misappropriation. 2. Review of Resident #75's medical record revealed an admission date of 07/31/19. Diagnoses included Parkinson's disease, depressive disorder, altered mental status, and dementia with behavioral disturbance. Review of Resident #75' MDS dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #75's nurse's note dated 08/22/19 at 1:30 P.M. revealed the resident became agitated and threw a toy [NAME] at another resident's (#30) head. Review of Resident #75's post incident review dated 08/22/19 revealed the type of incident was an individual to individual altercation that occurred on 08/22/19 at 1:30 P.M. Physician and family were notified. The review listed the state agency was notified via the Internet. 3. Review of Resident #30's nurse's note dated 08/22/19 at 2:03 P.M. revealed another resident had thrown a toy [NAME] with a plastic bottom at the resident hitting him in the forehead. No redness or pain was noted at that time. Review of Resident #30's post incident review dated 08/22/19 revealed the type of incident was an individual to individual altercation that occurred on 08/22/19 at 1:00 P.M. Review of facility SRIs revealed the resident to resident altercation that occurred on 08/22/19 was not reported to the state agency. Interview on 09/10/19 at 1:56 P.M. with the DON verified a SRI was not completed for the resident to resident altercation that occurred between Resident #75 and Resident #30. Interview on 09/12/19 at 9:37 A.M. with LPN #181 stated Resident #75 threw a toy [NAME] at Resident #30 striking him in the head. LPN #181 stated she assessed Resident #30 for injuries and no injuries were noted. LPN #181 stated the toy [NAME] had a hard plastic part on the bottom. Review of facility policy titled Resident/Client/Participant Protection/Freedom From Abuse, Neglect and Misappropriation dated November 2016 revealed abuse must be reported immediately to the Supervisor. Statements made by the staff should be part of the investigation. Components of the protection program include screening, training, prevention, identification, investigation, protection, and reporting. 365380 Page 5 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, review of Self-Reported Incidents (SRIs) and review of the facility policy the facility failed to report alleged misappropriation and abuse. This affected three residents (#15, #30 and #75) of three reviewed for abuse. Seven SRIs were reviewed from 04/07/19 to 09/12/19. The facility census was 83. Findings include: 1. Review of the medical record for Resident #15 revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia, depression, psychosis, peripheral vascular disease, hypertension, anxiety and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired. Review of the nurse progress note dated 08/13/19 at 1:41 P.M. revealed Resident #15's sister called and complained regarding Resident #15 having items being thrown away by staff. The sister also indicated Resident #15 had all her bras taken. The nurse allowed the sister to vent and assured her that she would look into this matter and let the nurse manager know. The note was signed by Licensed Practical Nurse (LPN) #121. Further review of the progress notes including care conference notes from 08/13/19 to 09/10/19 revealed no other mention of the alleged misappropriation of Resident #15's items discarded by staff or of the missing bras. There was no investigation noted. There was no documentation of the facility staff looking for any missing items. Review of the facility SRIs from 08/13/19 to 09/10/19 revealed no SRI was submitted for the alleged misappropriation. Interview with LPN #121 on 09/10/19 at 10:56 A.M. verified she spoke with Resident #15's sister on 08/13/19. LPN #121 stated the sister alleged items had been thrown away by staff and that bras had been taken. LPN #121 verified she reported the concern to the Unit Manager, Registered Nurse (RN) #156 and Director of Social Services (DSS) #136. LPN #121 stated Resident #15's Power of Attorney (POA) had approved the discarding of socks with no match. Interview on 09/10/19 at 11:22 A.M. with DSS #136 verified she was aware Resident #15 had missing bras but denied knowledge of staff discarding any other items. DSS #136 stated the missing bras had been discussed during care conferences dated 03/27/19 and 06/19/19. DSS #121 reviewed the care conference notes and verified there was no documentation of the concern discussed during either meeting. DSS #136 verified Resident #15 had a POA. DSS #121 reviewed the progress notes and verified there was no documentation of the POA being made aware of the concern or of the POA giving approval to discard clothing. DSS #121 verified if notification was provided to the POA it should be charted. Interview with the Director of Nursing (DON) on 09/10/19 at 2:01 P.M. verified there was no SRI submitted in regard to the allegation of staff throwing away items or of bras being taken which belonged to Resident #15. The DON verified she was never made aware of the allegation of staff discarding resident property or of any missing bras on 08/13/19. Interview with RN #156 on 09/11/19 at 9:24 A.M. verified LPN #121 informed her of the concern that Resident #15 had no bras. RN #156 stated it was an ongoing concern and new bras had previously been 365380 Page 6 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few purchased. RN #156 denied being informed of items being thrown away by staff as alleged on 08/13/19. RN #156 stated she was only aware of a sock being discarded due to it having a hole in it and no matching sock, the POA had approved of this. RN #156 verified there was no documentation of the conversation with the POA or of any investigation of the alleged misappropriation. 2. Review of Resident #75's medical record revealed an admission date of 07/31/19. Diagnoses included Parkinson's disease, depressive disorder, altered mental status, and dementia with behavioral disturbance. Review of Resident #75' MDS dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #75's nurse's note dated 08/22/19 at 1:30 P.M. revealed the resident became agitated and threw a toy [NAME] at another resident's (#30) head. Review of Resident #75's post incident review dated 08/22/19 revealed the type of incident was an individual to individual altercation that occurred on 08/22/19 at 1:30 P.M. Physician and family were notified. The review listed the state agency was notified via the Internet. 3. Review of Resident #30's nurse's note dated 08/22/19 at 2:03 P.M. revealed another resident had thrown a toy [NAME] with a plastic bottom at the resident hitting him in the forehead. No redness or pain was noted at that time. Review of Resident #30's post incident review dated 08/22/19 revealed the type of incident was an individual to individual altercation that occurred on 08/22/19 at 1:00 P.M. Review of facility SRIs revealed the resident to resident altercation that occurred on 08/22/19 was not reported to the state agency. Interview on 09/10/19 at 1:56 P.M. with the DON verified a SRI was not completed for the resident to resident altercation that occurred between Resident #75 and Resident #30. Interview on 09/12/19 at 9:37 A.M. with LPN #181 stated Resident #75 threw a toy [NAME] at Resident #30 striking him in the head. LPN #181 stated she assessed Resident #30 for injuries and no injuries were noted. LPN #181 stated the toy [NAME] had a hard plastic part on the bottom. Review of facility policy titled Resident/Client/Participant Protection/Freedom From Abuse, Neglect and Misappropriation dated November 2016 revealed abuse must be reported immediately to the Supervisor. Statements made by the staff should be part of the investigation. Components of the protection program include screening, training, prevention, identification, investigation, protection, and reporting. 365380 Page 7 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0610 Respond appropriately to all alleged violations. 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, interview, review of Self-Reported Incidents (SRIs) and review of the facility policy the facility failed to thouroughly investigate allegations of misappropriation and abuse. This affected three Residents (#15 #30 and #75) of three reviewed for abuse. Seven SRIs were reviewed from 04/07/19 to 09/12/19. The facility census was 83. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #15 revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia, depression, psychosis, peripheral vascular disease, hypertension, anxiety and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired. Review of the nurse progress note dated 08/13/19 at 1:41 P.M. revealed Resident #15's sister called and complained regarding Resident #15 having items being thrown away by staff. The sister also indicated Resident #15 had all her bras taken. The nurse allowed the sister to vent and assured her that she would look into this matter and let the nurse manager know. The note was signed by Licensed Practical Nurse (LPN) #121. Further review of the progress notes including care conference notes from 08/13/19 to 09/10/19 revealed no other mention of the alleged misappropriation of Resident #15's items discarded by staff or of the missing bras. There was no investigation noted. There was no documentation of the facility staff looking for any missing items. Review of the facility SRIs from 08/13/19 to 09/10/19 revealed no SRI was submitted for the alleged misappropriation. Interview with LPN #121 on 09/10/19 at 10:56 A.M. verified she spoke with Resident #15's sister on 08/13/19. LPN #121 stated the sister alleged items had been thrown away by staff and that bras had been taken. LPN #121 verified she reported the concern to the Unit Manager, Registered Nurse (RN) #156 and Director of Social Services (DSS) #136. LPN #121 stated Resident #15's Power of Attorney (POA) had approved the discarding of socks with no match. Interview on 09/10/19 at 11:22 A.M. with DSS #136 verified she was aware Resident #15 had missing bras but denied knowledge of staff discarding any other items. DSS #136 stated the missing bras had been discussed during care conferences dated 03/27/19 and 06/19/19. DSS #121 reviewed the care conference notes and verified there was no documentation of the concern discussed during either meeting. DSS #136 verified Resident #15 had a POA. DSS #121 reviewed the progress notes and verified there was no documentation of the POA being made aware of the concern or of the POA giving approval to discard clothing. DSS #121 verified if notification was provided to the POA it should be charted. Interview with the Director of Nursing (DON) on 09/10/19 at 2:01 P.M. verified there was no SRI submitted in regard to the allegation of staff throwing away items or of bras being taken which belonged to Resident #15. The DON verified she was never made aware of the allegation of staff discarding resident property or of any missing bras on 08/13/19. Interview with RN #156 on 09/11/19 at 9:24 A.M. verified LPN #121 informed her of the concern that Resident #15 had no bras. RN #156 stated it was an ongoing concern and new bras had previously been purchased. RN #156 denied being informed of items being thrown away by staff as alleged on 08/13/19. 365380 Page 8 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few RN #156 stated she was only aware of a sock being discarded due to it having a hole in it and no matching sock, the POA had approved of this. RN #156 verified there was no documentation of the conversation with the POA or of any investigation of the alleged misappropriation. 2. Review of Resident #75's medical record revealed an admission date of 07/31/19. Diagnoses included Parkinson's disease, depressive disorder, altered mental status, and dementia with behavioral disturbance. Review of Resident #75' MDS dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #75's nurse's note dated 08/22/19 at 1:30 P.M. revealed the resident became agitated and threw a toy [NAME] at another resident's (#30) head. Review of Resident #75's post incident review dated 08/22/19 revealed the type of incident was an individual to individual altercation that occurred on 08/22/19 at 1:30 P.M. Physician and family were notified. The review listed the state agency was notified via the Internet. 3. Review of Resident #30's nurse's note dated 08/22/19 at 2:03 P.M. revealed another resident had thrown a toy [NAME] with a plastic bottom at the resident hitting him in the forehead. No redness or pain was noted at that time. Review of Resident #30's post incident review dated 08/22/19 revealed the type of incident was an individual to individual altercation that occurred on 08/22/19 at 1:00 P.M. Review of facility SRIs revealed the resident to resident altercation that occurred on 08/22/19 was not reported to the state agency. Interview on 09/10/19 at 1:56 P.M. with the DON verified a SRI was not completed for the resident to resident altercation that occurred between Resident #75 and Resident #30. Interview on 09/12/19 at 9:37 A.M. with LPN #181 stated Resident #75 threw a toy [NAME] at Resident #30 striking him in the head. LPN #181 stated she assessed Resident #30 for injuries and no injuries were noted. LPN #181 stated the toy [NAME] had a hard plastic part on the bottom. Review of facility policy titled Resident/Client/Participant Protection/Freedom From Abuse, Neglect and Misappropriation dated November 2016 revealed abuse must be reported immediately to the Supervisor. Statements made by the staff should be part of the investigation. Components of the protection program include screening, training, prevention, identification, investigation, protection, and reporting. 365380 Page 9 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and policy review the facility failed to provided notification of discharges to the residents and residents' representative upon discharge to the hospital. This affected two Residents (#62 and #85) of two reviewed for discharge notice. The facility census was 83. Findings include: 1. Review of the medical record for Resident #62 revealed he was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, hypertension, chronic kidney disease, osteoarthritis, dementia, anemia and left femur fracture. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #62 was severely mentally impaired. Review of the nurse progress notes dated 08/29/19 revealed Resident #62 was discharged to the hospital for left hip pain. Tthere was no documentation in the medical record of Resident #62, or his representative being given notification of the discharge to the hospital. Review of the transfer/discharge information also revealed Resident #62 was discharged to the hospital for left hip pain on 08/29/19. There was no signature on the form indicating the information was given to Resident #62 or his representative upon discharge. Interview with Director of Social Services #136 on 09/12/19 at 8:57 A.M. verified Resident #62 was sent to the hospital on [DATE] for left hip pain. DSS #136 verified the written notification of discharge was never given to the Resident #62 or his representative. 2. Review of the medical record for Resident #85 revealed he was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, hypertension, dementia, pneumonia, debility related to cardiorespiratory condition, anxiety and depression. Review of the nurse progress notes revealed Resident #85 was discharged to the hospital for psychiatric treatment on 08/07/19. There was no documentation in the medical record of Resident #85, or his representative being given notification of the discharge to the hospital. Review of the transfer/discharge information also revealed Resident #85 was discharged to the hospital for psychiatric treatment on 08/07/19. There was no signature on the form indicating the information was given to Resident #85 or his representative upon discharge. Interview with Director of Social Services #136 on 09/12/19 at 8:57 A.M. verified Resident #85 was sent to the hospital on [DATE] for psychiatric treatment. DSS #136 verified the written notification of discharge was never given to the Resident #85 or his representative. Review of the facility policy titled Explanation of Residents Transfer and Discharge Regulations dated November 2015 revealed the facility may give less than 30 days notice of transfer or discharge if an emergency arises in which the safety to individuals in the facility is endangered or when an emergency arises in which the resident's urgent medical needs necessitate a more immediate transfer or 365380 Page 10 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0623 Level of Harm - Minimal harm or potential for actual harm discharge. If it is necessary to pursue the 30-day notice, the notice will outline why it is being given. The policy did not include information regarding the requirement to immediately provide discharge notification to the resident and representative in writing, including where the resident was being discharged to and the reason for the discharge. Residents Affected - Few 365380 Page 11 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

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 staff interview, the facility failed to refer a resident who was newly diagnosed with mental illness to the appropriate state-designated authority for a Level II Pre-admission Screening and Resident Review, (PASARR) evaluation. This affected one Resident (#80) of one reviewed for PASARR screening. The facility census was 83. Findings include: Review of the medical record for Resident #80 revealed she was admitted to the facility on [DATE] with diagnoses of degenerative disease of the nervous system, hypertension, anemia, anorexia, delusional disorder and unspecified psychosis dated 04/11/16. New diagnoses since admission included depression (02/20/19), Obsessive-Compulsive Disorder (OCD) (03/15/17) and history of mental and behavior disorders (08/22/19). Further review of the medical record revealed the Area Agency on Aging Review Results dated 04/08/16 revealed Resident #80 was reviewed for Pre-admission Screening (PAS) for a different facility. There was no PAS completed for Resident #80 by the current facility. The PAS determination was marked Not Applicable and was signed by a PAS reviewer. There was no PASRR completed for Resident #80. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #80 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Review of the Counseling Source Contact Notes revealed Resident #80 was seen for individual therapy 09/06/19 and 09/09/19. Interview with the Director of Nursing (DON) on 09/11/19 at 12:57 P.M. stated there was no other PASRR documentation completed for Resident #80. Interview with Director of Social Services (DSS) #136 on 09/11/19 at 2:12 P.M. Resident #80 did not have a PASRR Level 2 evaluation completed as the PAS screening indicated it was not applicable. DSS #136 verified Resident #80 was admitted to the facility on [DATE] with diagnoses of delusional disorder and unspecified psychosis. DSS #136 stated she assumed the diagnoses had been included in the PAS assessment completed on 04/08/16 but she could not verify they were included. DSS #136 verified there was no PASRR completed for Resident #80. Additionally, DSS #136 verified there was no PASRR completed for Resident #80 when she had new diagnosis since admission including depression on 02/20/19, OCD on 03/15/17 or history of mental and behavior disorders on 08/22/19. DSS #136 verified the facility should submit another PASRR for the new diagnosis of mental illness. 365380 Page 12 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 staff interview, the facility failed to follow up on a Pre-admission Screening and Resident Review (PASARR) determination. This affected one Resident (#80) of one reviewed for PASARR screening. The facility census was 83. Residents Affected - Few Findings include: Review of the medical record for Resident #80 revealed she was admitted to the facility on [DATE] with diagnoses of degenerative disease of the nervous system, hypertension, anemia, anorexia, delusional disorder and unspecified psychosis dated 04/11/16. New diagnoses since admission included depression (02/20/19), Obsessive-Compulsive Disorder (OCD) (03/15/17) and history of mental and behavior disorders (08/22/19). Further review of the medical record revealed the Area Agency on Aging Review Results dated 04/08/16 revealed Resident #80 was reviewed for Pre-admission Screening (PAS) for a different facility. There was no PAS completed for Resident #80 by the current facility. The PAS determination was marked Not Applicable and was signed by a PAS reviewer. There was no PASRR completed for Resident #80. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #80 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Review of the Counseling Source Contact Notes revealed Resident #80 was seen for individual therapy 09/06/19 and 09/09/19. Interview with the Director of Nursing (DON) on 09/11/19 at 12:57 P.M. stated there was no other PASRR documentation completed for Resident #80. Interview with Director of Social Services (DSS) #136 on 09/11/19 at 2:12 P.M. verified Resident #80 did not have a PASRR Level 2 evaluation completed as the PAS screening indicated it was not applicable. DSS #136 verified Resident #80 was admitted to the facility on [DATE] with diagnoses of delusional disorder and unspecified psychosis. DSS #136 stated she assumed the diagnoses had been included in the PAS assessment completed on 04/08/16 but she could not verify they were included. DSS #136 verified there was no PASRR completed for Resident #80. DSS #136 denied having a policy in regard to PASRR. 365380 Page 13 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0679 Provide activities to meet all resident's needs. 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, observation, interview, review of the locked unit Activities Calendar and review of the facility policy the facility failed to provide scheduled and structured activities. This directly affected one Resident (#80) of one reviewed for activities. This had the potential to affect 13 Residents (#15, #30, #33, #53 #62, #67, #68, #73, #75, #79, #80, #133 and #134) who resided on the locked dementia unit. The facility census was 83. Residents Affected - Few Findings include: Review of the medical record for Resident #80 revealed she was admitted to the facility on [DATE] with diagnoses of degenerative disease of the nervous system, hypertension, anemia, anorexia, delusional disorder, unspecified psychosis, depression, Obsessive-Compulsive disorder (OCD) and history of mental and behavior disorders. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #80 was cognitively intact. Review of the Plan of Care (POC) revealed Resident #80 had a focus for activities and therapeutic recreation. The goal was for Resident #80 to attend one or two activities a day. Interventions included she enjoyed being around animals such as cats. She enjoyed arranging her stuffed animals in her room. Resident #80 enjoyed being outdoors. Staff and volunteers will make sure she gets outside when it is nice. Music is an interest and she preferred 50's and 60's music. Resident #80 enjoyed social events. Staff will invite her to attend parties or social events. Religious services are an interest. Staff will invite Resident #80 to religious services. Staff will invite Resident #80 to BINGO and accompany her to community room and be sure she is with staff/volunteer before leaving her. Staff will invite Resident #80 to Bible study. Staff will provide one-on-one. Another focus revealed Resident #80 had some difficulty with communicated her needs. The goal was for staff to help Resident #80 with meeting social needs by talking with her. Intervention was to encourage socialization. Resident #80 was very verbal and enjoyed talking with others. Another focus was Obsessive-Compulsive Disorder with a goal for Resident #80 to regain a sense of control and pleasure in life. Interventions included one-on-one visits as needed. A focus for Resident #80 included behaviors related to dementia, depression, OCD, delusions and other medical problems. The goals included for Resident #80 to comply with care routine and remain free of injury. Interventions included to provide diversional activities for Resident #80. Observation on 09/09/19 from 9:30 A.M. to 11:45 P.M. and from 1:15 P.M. to 4:00 P.M. revealed no structured activities being provided on the locked dementia unit. Resident #80 was not seen participating in any activity. Resident #80 was seen sitting by the patio doors alone. There were several residents observed sitting, some of them sleeping in the TV room. No staff were present with the residents. Interview with Resident #80 on 09/09/19 at 2:04 P.M., she stated there was nothing to do. There were never any activities because the facility didn't have enough staff to do activities. Resident #80 stated they were supposed to have BINGO on Monday at 1:00 P.M., but they didn't have it today because they didn't have help. Resident #80 stated she would enjoy going outside but could not go outside because there was no staff to take her. Resident #80 was sitting alone by the patio doors. 365380 Page 14 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Licensed Practical Nurse (LPN) #101 on 09/09/19 at 1:41 P.M. verified BINGO had not been provided on the locked unit as scheduled at 1:30 P.M. Observation on 09/10/19 at 2:40 P.M. Resident #80 was outside in the courtyard with staff. She was not seen participating in any other activities and no structured or scheduled activities were observed being provided on the locked unit on 09/10/19. Observation on 09/11/19 at 10:37 A.M. revealed Resident #80 was observed one-on-one with staff for less than five minutes. At 1:21 P.M. Resident #80 was outside with two other residents. One resident's daughter was on the patio with the residents and having a snack with her mother. Resident #80 was seated alone and did not have any snack or anyone interacting with her. At 3:45 P.M. Resident #80 was again seen sitting alone in the lounge near the patio doors. There was no music on, or any other form of entertainment or distraction provided. No structured or scheduled activities were observed being provided on the locked unit on 09/11/19. Interview with State Tested Nurse Aid (STNA) #155 on 09/11/19 at 1:25 P.M. stated unit staff and activities staff both provide activities. STNA #155 verified there was no staff on the patio with the residents, only a daughter to one of the residents was outside with the residents. Interview with 09/11/19 at 3:36 P.M. with STNA #255 stated the STNAs are in charge of providing activities on the locked unit. STNA #255 reviewed the Activity Calendar and stated the identified 9:00 A.M. activity (Good news and weather) was to turn the news on the TV. STNA #255 stated she was not sure if the 9:00 A.M. activity had been provided. STNA #255 verified she did not follow the activity calendar and stated it was just a suggestion. STNA #255 stated she was usually busy with resident care and she did not usually do the activities. The activities she provided included talking with the residents during care. STNA #255 verified on 09/11/19 the 9:30 A.M. Fitness and Fun was not done, the 10:30 A.M. Memory Magic not done, the 1:00 P.M. Craft time was not done, the 2:00 P.M. Snack and chat activity was not done and the 3:00 P.M. Name That Tune was not done. STNA # 255 acknowledged cards games were scheduled at 4:00 P.M. STNA #255 observed that two residents with a visitor were currently in the dining room playing cards. STNA #255 verified the staff were not providing the activity and it involved the visitor and two residents the visitor was visiting STNA #255 verified she had not provided any activities for any of the residents throughout the day of 09/11/19. She stated she had been providing resident care and did not do any of the listed activities. STNA #255 stated there was only one other STNA working on the unit with her on 09/11/19 and she left the provision of activities to the other STNA. STNA #255 stated residents can participate in activities provided in the main area of the facility however that required someone to escort the resident to the activity off the unit. STNA #255 verified she did not escort any residents off the unit and someone else normally did that, such as activity staff or volunteers. Interview with Life Enrichment Assistant (LEA) #166 on 09/11/19 at 3:47 P.M. stated the STNAs provided the activities on the locked unit. Residents can also attend main facility activities but must be escorted to the activities. LEA #166 stated activities staff also provide activities but one of the activities staff had recently resigned. Interview with Activity Director (AD) #126 on 09/11/19 at 3:52 P.M. stated once a week in the evenings the activities staff provide activities on the locked unit. Activity staff provided movie and popcorn activity in the evening on 09/09/19. The STNAs on the unit provide all the other activities. Interview on 09/12/19 at 9:43 A.M. with STNA #155 verified only one resident went to an activity 365380 Page 15 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few off the unit on 09/11/19. STNA #155 verified she had worked on the locked unit on 09/11/19 for only two hours from 12:00 P.M. to 2:00 P.M. She verified there was an activity calendar for the locked unit, but it was only used as a guide. The STNAs try to offer activities when they have time. STNA #155 verified she did not provide any activities for the residents while she was here on 09/11/19. Interview with LPN #181 on 09/12/19 at 9:49 A.M. verified the locked unit staff are expected to provide activities for the residents however there was normally only one STNA on the unit and they do not usually have a nurse assigned to the unit. The nurses from the 300 hall and 500 hall cover the nursing responsibilities on the locked unit as well as their unit assignments. LPN #181 verified she worked the locked unit on 09/11/19 but was gone with a resident for an appointment from 10:30 A.M. to 12:30 P.M. and she did not provide any activities. LPN #181 stated activities are hit and miss. LPN #181 stated the residents need more stimulation. Interview with AD #126 on 09/12/19 at 10:06 A.M. she verified Resident #80 did not attend activities off the unit on a daily basis. Interview with Registered Nurse (RN) #156 on 09/12/19 at 1:07 P.M. denied having documentation of activities provided on the locked unit, however stated staff track any distress observed during care on the 400 Distress Tracking Form. The documentation was related to an effort to decrease stress and behaviors and not actually intended to track activities, however, RN #156 stated the form did include interventions provided for Resident #80 related to observations of distress. RN #156 stated the 400 Distress Tracking Form was documentation of activities provided or Resident #80. RN #156 stated the frontline staff provide activities for the locked unit. RN #156 stated the Activities Calendar was just a suggestion and verified activities on the locked unit were not provided as scheduled on the calendar. There were no scheduled activities. RN #156 stated the residents have structured activities available off the unit. RN #156 stated staff on the locked unit provide activities when the majority of the residents are available and again stated there was no specific calendar because every day is different. RN #156 stated if we sing and dance in the hall way, that was an activity. When asked if she considered staff singing and dancing in the hall while providing care was an activity for the residents. RN #156 verified it was and stated yes, she wound consider that an activity. Review of Resident #80's All Activity Attendance record from 08/28/19 to 09/10/19 revealed she was not offered nor attended any main facility activities on seven of the 14 days. Resident #80 attended one main facility activity on two of 14 days. Three days indicated activities was offered and refused. Two days of 14 days Resident #80 attended main facility activities. Review of the 400 Distress Tracking Form from 09/03/19 to 09/12/19 revealed Resident #80 Activities Attended/Performed included Hospice, outside sitting, chat or chatting, TV, phone and friend visit. BINGO was the only scheduled, structured activity documented on 09/09/19. Per LPN #101 verification, BINGO was not provided on the locked unit on 09/09/19. Per the All Activity Attendance record, Resident #80 refused BINGO on 09/09/19. Review of the Activates Calendar for 09/09/19 revealed BINGO was scheduled at 1:30 P.M. Review of the Activates Calendar for 09/11/19 revealed: 9:00 A.M. Good News and Weather 9:30 A.M. Fitness and Fun 365380 Page 16 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0679 10:30 A.M. Memory Magic Level of Harm - Minimal harm or potential for actual harm 1:00 P.M. Craft Time 2:00 P.M. Snack and Chat Residents Affected - Few 3:00 P.M. Name That Tune 4:00 P.M. Care Games 7:30 P.M. Jeopardy Further review of the Activities Calendar for September 2019 revealed each day had similar activities listed. Other listed items included hobby talk, discuss and recall, News on TV, movie and popcorn, puzzles and matching, hangman word game and YouTube Videos. Review of the facility policy titled Introduction to Memory Support Activities dated January 2016 revealed the memory support program recognizes that all persons have physical, social, emotional, intellectual, occupational and spiritual needs. The facility memory support program will meet the needs of persons with dementia a safe nurturing environment. Memory support program engage residents in cognitive, physical and psychosocial activities. Memory support programs endorse therapeutic programming as a mode of treatment. Therapeutic programming, both groups and one-on-one, is scheduled on a daily basis. 365380 Page 17 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on medical record review, interview and facility policy review, the facility failed to complete weekly assessments of pressure wounds. This affected one Resident (#15) of one reviewed for pressure wounds. The facility identified four residents in the facility with pressure wounds. The facility census was 83. Findings include: Review of the medical record for Resident #15 revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia, depression, psychosis, peripheral vascular disease, hypertension, anxiety and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was severely cognitively impaired. Review of the nurse progress note dated 08/08/19 at 11:20 A.M. revealed Resident #15 had a new open area on her inner right buttock. The area measured 0.5 centimeters (cm) x 0.2 cm x 0.1 cm and a full assessment was completed. A note indicated will measure the area weekly. Review of the physician orders dated 08/08/19 revealed weekly wound documentation for the wound on the right buttock. Review of the Nurses Weekly Wound documentation dated 08/15/19 at 11:00 A.M. revealed the Stage 2 pressure wound was identified as #1. The wound was first noted on 08/08/19 on the right buttock. A complete assessment was included. There were no other assessments of the Stage 2 pressure wound #1 until the Nurses Weekly Wound Documentation dated 09/05/19 at 1:38 P.M. The assessment was that the Stage 2 pressure wound #1 on the right buttocks was healed. Further review revealed a second Stage 2 pressure wound was identified as #3, first noted on 08/08/19 on the right buttock but with no assessment completed until 08/22/19 at 11:57 A.M. The next assessment of wound #3 was dated 08/29/19. There was no further weekly wound assessments completed for Stage 2 pressure wound #3 from 08/29/19 to 09/10/19. Interview on 09/10/19 at 10:56 A.M. with Licensed Practical Nurse (LPN) #121 verified Resident #15 had an area on her buttock which appeared to be a scratch. LPN #121 verified there was still an order for a weekly wound assessment in the physician orders. The physician did not want any treatment, just verified off-loading was still being done. The only order in place from the physician was to off-load the buttock. LPN #121 verified assessments were completed weekly and the wound was last assessed on 09/05/19. Interview with Director of Nursing (DON) on 09/10/19 at 3:07 P.M. verified the wound documentation was indicative of two separate wounds identified as Wound #1 and Wound #3. The DON verified there was no weekly documentation for the two wounds as noted above. Interview with Registered Nurse (RN) #116 on 09/10/19 at 4:10 P.M. verified the facility identified two wounds and verified there was no documentation of assessments completed for Wound #1 on 365380 Page 18 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 08/22/19 or 08/29/19. RN #116 verified there was documentation of an assessment for Wound # 3 on 08/15/19 or after 08/29/19. Review of the facility policy titled Policy and Procedure for the Prevention and Treatment of Skin Breakdown dated 2018 revealed for a resident with pressure wounds, initiate Weekly Wound Documentation Progress Sheet which will include the type of wound, location, date, stage, length width ad depth and full assessment of the wound. The Weekly Wound Documentation Progress Sheet should only have one wound per form. 365380 Page 19 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0791 Provide or obtain dental services for each resident. 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, and staff and family interviews the facility failed to ensure resident's received dental services. This affected two Residents (#41 and #73) of three reviewed for dental services. The facility census was 83. Residents Affected - Few Findings include: 1. Review of Resident #41's medical record revealed an admission date of 10/16/12. Diagnoses included legal blindness, anxiety disorder, and anemia. Review of Resident #41's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Review of Resident #41's ancillary services form revealed the resident's brother signed on 11/11/18 for the resident to receive dental services. Further review of Resident #41's medical record revealed no documentation of the resident being visited by a dentist. Interview on 09/09/19 at 2:34 P.M. with Resident #41 stated he wanted to be seen by the dentist and have his teeth cleaned. The resident stated he had not been seen by a dentist. Interview on 09/12/19 at 8:21 A.M. with Director of Social Services #136 stated she was unable to provide documentation that Resident #41 had been visited by a dentist. Telephone interview on 09/12/19 at 10:00 A.M. with Resident #41's sister in-law (emergency contact) stated she had signed a paper indicating they wanted the resident to have dental services. The resident's sister in-law stated she would never decline medical care for the resident. 2. Review of Resident #73's medical record revealed an admission date of 08/20/18. Diagnoses included anemia, hypertension, diabetes, dementia, hemiplegia, anxiety, and depression. Review of Resident #73's MDS dated [DATE] revealed the resident had intact cognition. Review of Resident #73's ancillary services form revealed the resident's Power of Attorney (POA) signed on 08/20/18 for the resident to receive dental services. Interview on 09/09/19 at 1:41 P.M. with Resident #73 revealed the resident had missing front teeth and had requested to see a dentist. Telephone interview on 09/11/19 at 5:20 P.M. with Resident #73's son and POA stated he had told the facility he wanted his mother seen by a dentist and believed he had signed a form for her to receive services. Interview on 09/12/19 at 10:32 A.M. with Director of Social Services #136 stated she was unable to provide documentation that Resident #73 had been visited by a dentist. 365380 Page 20 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, review of pureed recipes and review of nutrition risk tracking the facility failed to ensure foods were prepared for maximum nutrition and at the appropriate consistency for pureed diets. This had the potential to affect three Residents (#18, #29, #77) who the facility identified as receiving pureed diets. The facility census was 83. Findings include: Observation on 09/10/19 at 9:00 A.M. of [NAME] #310 pureeing turkey and broccoli revealed the following concerns. [NAME] #310 revealed there were only three Residents (#18, #29, #77) who received pureed diets; however, she prepared enough for four residents. [NAME] #310 revealed she prepared recipes #133 (Broccoli Pureed Thick) and #146 (Turkey Pot Roast Pureed Thick). [NAME] #310 revealed she prepared 24 ounce of meat and one whole bag of broccoli for the four servings. [NAME] #310 poured the turkey from a baking dish into the blender. [NAME] #310 added one scoop of thickener from a can and poured in an unmeasured amount of hot water from a coffee carafe. Cook #310 poured the turkey into a warming pan. The appearance of the turkey was very thin and watery. [NAME] #310 revealed she cleaned the blender and continued. Observation of [NAME] #310 pureeing the broccoli revealed she poured in the cooked broccoli and what looked like a butter sauce. [NAME] #310 put in one scoop of thickener from a can. [NAME] #310 poured the pureed broccoli into a warming pan. The appearance of the broccoli was very thin and watery. Interview on 09/10/19 at 9:10 A.M. with [NAME] #310 verified the turkey and the broccoli were thin and watery. [NAME] #310 revealed she believed it would be the correct consistency after sitting in the steaming table from 9:10 A.M. until lunch time. [NAME] #310 revealed recipes #133 and #146 she followed were for 25 servings. [NAME] #310 verified she was not following the recipe, she did not use broth as the recipe required, and she did not measure the water substituted for the broth. [NAME] #310 verified she believed a scoop was one tablespoon. [NAME] #310 verified she did not know what equivalence one scoop of thickener should be to make four servings with the bag of broccoli or the 24 ounces of meat. [NAME] #310 further verified she had always eyeballed the amounts and the consistency of the foods she pureed and she didn't follow the recipe. Review of Qualified Recipe #146 Turkey Pot Roast Pureed Thick revealed the recipe was for a minimum of 25 servings. For the correct consistency and nutrition the ingredients and measurements were as follows. The recipe #146 would need four pounds and 11 ounces of turkey, one and 1/4 quarts of hot water, one and 2/3 tablespoon of chicken base and 1/2 cup of food thickener, and two tablespoons of food thickener. The recipe #146 further revealed chicken base and water would make the broth. Review of Qualified Recipe #133 Broccoli Pureed Thick revealed the recipe was for a minimum of 25 servings. For the correct consistency and nutrition the recipe would consist of three quarts and 1/2 cup of broccoli. Additional ingredients were one and 1/4 teaspoon of food thickener, 1/2 cup of margarine, and two tablespoon of margarine. Review of the Nutrition Risk Tracking for Autumnwood Care Center 2019 revealed all three Residents (#18, #29, #77) on a pureed diet were being monitored for weight loss. 365380 Page 21 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

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, staff interview, and review of facility policy the facility failed to ensure food was dated appropriately. This had the potential to affect all 83 residents who received meals from the facility kitchen. The facility census was 83. Findings include: Observation on 09/09/19 during the initial tour of the kitchen between 8:25 A.M. and 9:10 A.M. revealed the following concerns: Seven opened and undated items were observed in the dry kitchen storage. A 32 ounce bag of dry mashed potatoes was not dated and closed with a twisty tie. A 32 ounce bag of navy beans was not dated and closed with a twisty tie. A half empty 16 ounce bottle of Kitchen Bouquet browning sauce was not dated when opened. A one gallon bottle of Worcestershire that was two thirds full was not dated when opened and had an expiration date of 09/28/19 (the bottle of Worcestershire was not expired as of yet). A half empty one gallon bottle of white vinegar was not dated. A one gallon bottle of Karo syrup was not dated. A one gallon bottle of maple syrup was not dated. Interview on 09/09/19 at the time of the observation with the Dietary Manager (DM) #300 verified the above findings. DM #300 indicated the facility policy was to date the items as she gathered the items and revealed she would dispose of them promptly. Review of the facility policy and procedure titled Food Storage and dated 2019 revealed food should be dated and dried foods should be stored in plastic containers with tight lids. 365380 Page 22 of 23 365380 09/12/2019 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews and review of facility policy the facility failed to maintain appropriate infection control practices to prevent food borne illness when taking food temperatures and preparing food. This directly affected Residents (#3, #67, #76, #79 and #80) who ordered a grilled cheese sandwich. This had the potential to affect all 83 residents. The census was 83. Residents Affected - Many Findings include: 1. Observation on 09/10/19 at 10:50 A.M. of [NAME] #310 taking food temperatures revealed appropriate food temperatures of eight hot food items. However, [NAME] #310 was observed using only two probe wipes to sanitize in between the eight food items. [NAME] #310 used ungloved hands and reused each wipe four times. Each time [NAME] #310 reused a probe wipe she would lay the used probe wipe on the bare counter. Interview on 09/10/19 at 10:58 A.M. with [NAME] #310 verified she was using a contaminated probe wipe to disinfect the probe in between hot food items. [NAME] #310 further verified she always uses only two probe wipes to temp all the foods. Interview on 09/11/19 at 1:25 P.M. with Dietary Manager (DM) #310 verified all residents residing in the facility ate lunch on 09/10/19 unless they decided not to come down to eat. DM #310 further verified a new probe wipe was to be used each time a food temperature was measured. Review of the Policy and Procedure Manual titled Food Temperatures revealed the thermometer probe is to be cleaned and disinfected after each food measured. 2. Observation on 09/10/19 between 11:00 A.M. and 11:25 A.M. [NAME] #310 made five grilled cheese sandwiches. Each time [NAME] #310 would use the same spatula that had been laying on the bare counter to retrieve the grilled cheese sandwich out of the panini press and placed them on a plate. Interview on 09/10/19 at 11:25 A.M. with [NAME] #310 verified she had laid the spatula on a contaminated bare counter after each use of the spatula for the five grilled cheese sandwiches. After the [NAME] #310 verified the spatula was contaminated, she pulled out a new spatula and laid it on a clean plate. Interview on 09/11/19 at 1:30 P.M. with DM #300 verified the first five grilled cheese sandwiches that were served on 09/10/19 for lunch was for Residents (#3, #67, #76, #79, and #80). 365380 Page 23 of 23