Health inspection·October 4, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interview, and policy review, the facility failed to ensure notification was made to the physician, dietician, and the resident representative of a significant weight loss. This affected two residents (#04 and #34) out of two residents reviewed for notification of change in status. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included dementia, atherosclerotic heart disease, atrial fibrillation, hypertension, chronic diastolic (congestive) heart failure, chronic kidney disease, osteoarthritis, and other intervertebral disc degeneration. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired, required extensive assistance with personal hygiene, toilet use, and dressing, required supervision with eating and had weight loss of 5 percent (%) or more in the past month and was not on a prescribed weight loss regimen. Review of the plan of care focus area revised 09/08/22 revealed Resident #04 remained at risk for nutritional decline related to diagnoses of dementia, causing a decrease in appetite, intake and weight as disease process progressed. Additionally, Resident #04 continued to need supplements to maintain weight and had significant weight loss. Interventions included Ensure clear eight ounces two times daily, have foods available whenever the resident was hungry, monitor intake per facility policy, offer bedtime snacks, provide medications per orders, honor food preferences and observe changes in weight and notify the physician. Review of the current physician orders revealed Resident #04 was ordered Ensure Clear two times daily and was on a regular, thin liquid diet. Review of the weights dated from 04/02/22 through 09/01/22 revealed Resident #04 weighed 113.8 pounds on 04/02/22, 112.4 pounds on 05/02/22, 106.4 pounds on 06/01/22, 105.8 pounds on 07/01/22, 104 pounds on 08/04/22 and 101.4 pounds on 09/01/22. Further review of Resident #04's weights dated 05/02/22 and 06/01/22 revealed a weight loss of six pounds in one month, indicating a significant weight loss of 5.34%. Additional review of Resident #04's weights dated 04/02/22 and 09/01/22 revealed a weight loss of 12.4 pounds over six months, indicating a significant weight loss of 10.90%. Review of a Dietary/Nutrition Quarterly Data Collection assessment dated [DATE] documented Resident Page 1 of 25 365380 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0580 #04 had a significant weight loss of 5.3% over one month. Level of Harm - Minimal harm or potential for actual harm Review of a Dietary/Nutrition Annual Data Collection assessment dated [DATE] documented Resident #04 had a significant weight loss over 10% over six months. Residents Affected - Few Review of the progress notes dated from 06/01/22 through 09/27/22 revealed no documentation the physician, representative, or the dietitian were notified by the facility of Resident #04's significant weight loss in June 2022 or September 2022. Interview on 09/26/22 at 1:20 P.M., of Resident #04's representative revealed the representative was not notified of Resident #04 having any weight loss. The representative denied being made aware of any weight issues. Interview on 09/28/22 at 2:13 P.M., the Director of Nursing (DON) verified Resident #04's medical record had no documentation the physician, the representative, or the dietitian was notified of the resident's significant weight loss. The DON stated she believed the dietitian may have contacted the physician and the representative and possibly had additional records to confirm notifications had been made. Interview on 09/29/22 at 8:55 A.M., of Dietary Technician (DT) #505 and Registered Dietitian (RD) #507 revealed each were contract staff. DT #505 stated she was at the facility one time weekly, while RD #507 was at the facility one time monthly. DT #505 and RD #507 verified Resident #04 had a significant weight loss noted in June 2022 and again in September 2022. Both DT #505 and RD #507 verified it was the facility's nursing staff who were responsible for physician and representative notification of a significant weight loss and neither DT #505 or RD #507 had notified Resident #4's physician or representative of the significant weight loss. Follow-up interview on 09/29/22 at 12:08 P.M., of DT #505 and RD #507 verified the facility had not contacted either of them regarding Resident #04's significant weight loss in June 2022 or September 2022 and each had become aware of the Resident's weight loss when they reviewed the facility's weight exception reports. Review of facility policy titled Notification of Changes, revised December 2016, revealed immediate notification of the resident, consult with the resident's physician and notification of the resident representative was to be done when there was a significant change in resident's physical, mental, or psychosocial status and/or a need to alter treatment/plan of care significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment). Review of facility policy titled Weight Monitoring - Nursing Services, revised May 2019, revealed the licensed nurse would notify the physician and dietitian of variances the same day the weight was taken, and document the notification on the weight record, according to the following parameters: five pound fluctuation for residents weighing less than 100 pounds, single incident or cumulative over time; three pound fluctuation for residents weighting more than 100 pounds, single incident or cumulative over time; and report weight trend changes of a least 5% in one month, 7.5% in three months, and/or 10% in six months. 2. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, and anxiety. 365380 Page 2 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #34's annual MDS assessment dated [DATE] revealed the resident was cognitively intact and required the extensive assistance of one staff for a majority of the activities of daily living. Review of Resident #34's plan of care dated 08/12/22 revealed the resident was at nutritional risk due to diagnosis of dementia, variable intakes with occasional meal refusal, fluid retention, and diuretics. Interventions included observing changes in weight and notifying physician. Review of Resident #34's weight record revealed the following: a. The resident weighed 230.2 pounds on 03/24/22 and weighed 224.2 pounds on 03/29/22, which was a six pound loss. b. The resident weighed 224.2 pounds on 04/02/22 and weighed 212.4 pounds on 04/12/22, which was an 11.8 pound loss. c. The resident weighed 217 pounds on 05/17/22 and weighed 208.6 pounds on 05/31/22, which was an 8.4 pound loss. d. The resident weighed 206 pounds on 07/06/22 and weighed 200.3 pounds on 08/05/22, which was a 5.7 pound loss. Review of Resident #34's medical record revealed no documentation the physician or dietitian were notified of any of the aforementioned weight loss. Interviews with the Dietitian #505 and the Diet Technician #507 on 09/29/22 at 9:13 A.M. verified neither staff member were notified of the weight loss which should have been identified on 08/05/22, 05/31/22, 04/12/22, and 03/29/22. Staff also verified there was no evidence the physician was notified of the weight loss. Review of facility policy titled Weight Monitoring - Nursing Services, revised May 2019 revealed the dietitian and physician would be notified the same day, anytime a resident who weighed greater than 100 pounds had a weight fluctuation of five or more pounds. 365380 Page 3 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0583 Keep residents' personal and medical records private and confidential. 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, staff interview, and policy review, the facility failed to provide privacy for one resident (#40) out of three reviewed for pressure ulcer care. The facility census was 73. Residents Affected - Few Findings Include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included spastic hemiplegia, epilepsy, falls, and foot drop. Review of the 08/04/22 annual minimum data set (MDS) revealed Resident #40 was cognitively intact, had no behaviors or refusals of care, required extensive assist with bed mobility, toilet use, personal hygiene and was dependent for on staff for transfers. Resident #40 was coded as not having a pressure ulcer. Observation of incontinence care provided by State Tested Nursing Assistant (STNA) #502 and #503 on 09/28/22 at 10:02 A.M. revealed Resident #40's bed was against the wall and the resident's head of the bed was facing the outside wall where the room window was located. The staff laid the resident in the bed with the assistance of a mechanical lift. The resident's pants and incontinent brief were removed and the resident was uncovered from the waist down. The room window blinds were in the open position and cars were visible driving on the road in front of the facility at a distance of approximately 200 feet away. The incontinence care was provided and the resident was re-dressed. During an interview with STNA #502 on 09/28/22 at 10:13 A.M., verified Resident #40 was provided personal care with the window blinds opened and the resident was not provided privacy during incontinence care. Review of the policy titled Activities of Daily Living (ADL) (Daily Life Functions), dated 2006 and revised in 10/2021 revealed assist residents in achieving maximum functional ability with dignity and self-esteem, to provide assistance to residents as necessary, to supervise and assess resident function in order to plan care to maintain optimum ADL function as long as possible, and to teach resident use of assistive devices to maintain optimum ADL function as long as possible. Facility ensures a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 365380 Page 4 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to develop a comprehensive plan of care to include a resident's pressure ulcer. This affected one resident (#64) out of 18 records reviewed for care plans. The facility census was 73. Findings include: Review of the medical record revealed Resident #64 was admitted on [DATE]. Diagnoses included major depressive disorder, anxiety disorder, Alzheimer's disease, vascular dementia, hypertension, interstitial pulmonary disease, Raynaud's syndrome, spinal stenosis, polyneuropathy, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was severely cognitively impaired, required extensive assistance with Activities of Daily Living (ADLs), was a risk for pressure ulcers and had one stage II pressure ulcer. Review of a Braden scale for predicting pressure sore risk dated 08/19/22 revealed Resident #64 had a score of 20, indicating the Resident was at high risk for developing pressure ulcers. Review of the current physician orders revealed a treatment to the medial right foot: cleanse area with wound wash, pat dry with gauze, apply povidine to reddened area and allow to dry before application of socks and shoes. Review of a nurses weekly wound documentation dated 09/27/22 revealed Resident #64 had a stage II pressure ulcer on the top of her right foot. The pressure ulcer was first identified on 05/31/22 and on 09/27/22 the wound measured 0.3 centimeters (cm) by 0.2 cm by 0.1 cm with no drainage, no undermining, no tunneling and no signs of infection noted. Additionally, the physician was notified due to no change to the wound in two weeks. Review of the plan of care initiated 02/25/22 revealed no focus area or interventions related to Resident #64's stage II pressure ulcer or risk for pressure ulcers. Interview on 09/28/22 at 11:24 A.M., the MDS Coordinator (MDS) #483 verified Resident #64 had a stage II pressure ulcer on the top of her right foot that was first identified on 05/31/22. MDS #483 verified Resident #64's plan of care not updated for any focus areas or interventions related to pressure ulcers or risk for skin impairment. Review of the policy titled Comprehensive Care Plan, revised June 2020, revealed the care plan would describe services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. In addition, the comprehensive care plan would have problem/strength statements, measurable goal statements, treatments, preferences, and interventions. Review of the facility policy titled Policy and Procedure for the Prevention and Treatment of Skin Breakdown, revised July 2018, revealed if a resident was admitted with, or there was a new development of a pressure ulcer, update the resident's individualized care plan for skin integrity, including appropriate risk factors, turning intervals and interventions as appropriate. 365380 Page 5 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed ensure timely revision of the care plan. This affected one resident (#40) out of one reviewed for position/mobility out of 18 care plans reviewed. The facility census was 73. Findings Include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included spastic hemiplegia, epilepsy, falls, and foot drop. Review of the 08/04/22 annual minimum data set revealed Resident #40 was cognitively intact, had no behaviors or refusals of care, required extensive assistance with bed mobility, toilet use, personal hygiene and was dependent on staff for transfers. A splint device was coded as zero days. Review of the care plans revealed Resident #40 had a care plan for his activities of daily living which included an intervention of a splint for the left hand which the resident would refuse to wear. The resident care plan had no documentation for the use of an ankle foot orthosis (AFO) to his left foot. Resident #40's current physician orders revealed no orders for the left hand splint or for an AFO to the left foot. During an interview with Licensed Practical Nurse (LPN) #413 on 09/28/22 at 1:53 P.M., verified Resident #40 wears an AFO to his left leg daily and the medical record had no documentation of the use of the AFO in the care plan and the physician orders. The LPN #413 said the care plan documented the residents use of a splint to his left hand, however the nurse stated the resident does use the splint and he used to have orders for the splint but he refused to wear the splint. Interview with the Administrator on 09/29/22 at 1:30 P.M., verified the splint for Resident #40's left hand was discontinued due to non use on 02/11/22. 365380 Page 6 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, review of the State Tested Nurse Aide (STNA) shower documentation, staff interview, and policy review, the facility failed to ensure dependent residents received showers as scheduled. This affected two residents (#64 and #66) out of three residents reviewed for activities of daily living (ADLs). The facility census was 73. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #64 was admitted on [DATE]. Diagnoses included major depressive disorder, anxiety disorder, Alzheimer's disease, vascular dementia, hypertension, interstitial pulmonary disease, Raynaud's syndrome, spinal stenosis, polyneuropathy, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was severely cognitively impaired and required extensive assistance with transfers, dressing, toilet use, personal hygiene, and physical help in bathing. Review of a plan of care focus area initiated 02/25/22 revealed Resident #64 was unable to carry out Activities of Daily Living (ADLs) care without assistance. Interventions included ADL care daily (required limited to extensive assistance with bed mobility, transfers, gait, toilet use, grooming and bathing assistance of one). Review of the State Tested Nurse Aide (STNA) shower documentation dated from 09/03/22 through 09/28/22 revealed not applicable was checked for Resident #64's showers on 09/10/22 and 09/24/22. Review of the shower schedules revealed Resident #64 was scheduled to receive showers on Wednesdays and Saturdays. Additional review verified the dates checked as not applicable on the STNA shower documentation 09/10/22 and 09/24/22 were Saturdays. Review of the nursing progress notes dated from 09/10/22 through 09/27/22 revealed no refusals of care. 2 Review of the medical record revealed Resident #66 was admitted on [DATE]. Diagnoses included Alzheimer's disease, type II diabetes, hypertension, major depressive disorder, anxiety disorder, and malignant neoplasm of large intestine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was severely cognitively impaired and required extensive assistance with personal hygiene. Review of the plan of care initiated 01/13/22 revealed Resident #66 required supervision and assistance with Activities of Daily Living (ADLS) and was at risk for decline as her disease progressed. Interventions included physical help from one staff with showers. Review of State Tested Nurse Aide (STNA) shower documentation dated from 08/31/22 through 09/28/22 revealed not applicable was checked for Resident #66's showers on 09/03/22, 09/10/22 and 09/24/22. Review of the shower schedules revealed Resident #66 was scheduled to receive showers on Wednesdays and Saturdays. Additional review verified the dates checked as not applicable on the STNA shower 365380 Page 7 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0677 documentation, 09/03/22, 09/10/22 and 09/24/22, were Saturdays. Level of Harm - Minimal harm or potential for actual harm Review of the nursing progress notes dated from 09/01/22 through 09/27/22 revealed no refusals of care. Residents Affected - Few Interview on 09/26/22 at 9:44 A.M., the STNA #482 revealed typical staffing on the secured memory care unit included two STNAs and a nurse. STNA #482 stated there were times when she was the only STNA working on the unit and the nurse was split with another hall, essentially leaving one and a half staff instead of the typical three. STNA #482 stated this occurred more on the weekends than on weekdays. STNA #482 stated when she was the only STNA on the unit, she was not able to provide showers because there were insufficient staff to provide supervision to the other residents residing on the unit. STNA #482 stated showers were not provided to Residents #64 and #66 on 09/24/22 because she was the only STNA working on the secured memory care unit, the nurse was split with another hall, and she could not leave the residents unsupervised while she was providing showers. STNA #482 confirmed the scheduled shower days for Residents #64 and #66 were Wednesdays and Saturdays. STNA #482 verified Resident #64 had not received a shower on 09/10/22 and 09/24/22 and Resident #66 had not received a shower on 09/03/22, 09/10/22 and 09/24/22. Additionally, STNA #482 verified she worked 09/10/22 and 09/24/22 and was unable to provide showers due to insufficient staffing on the secured memory care unit. Review of the facility policy titled Activities of Daily Living (ADL) (Daily Life Functions), revised October 2021, revealed the facility ensured a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 365380 Page 8 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, physician interview, review of the hospital records, and policy review, the facility failed to ensure early identification of a change in the resident's condition. This resulted in Actual Harm when Resident #41, who was taking an anticoagulant medication, experienced a moderate amount of blood in the stool during a bowel movement. A thorough assessment and immediate notification to the physician was not completed. Subsequently, approximately 33 hours later the resident was hospitalized and received three units of packed red blood cells for a critical low hemoglobin level. This affected one (Resident #41) of one resident reviewed for anticoagulant therapy. The facility census was 73. Residents Affected - Few Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, chronic obstructive pulmonary disease, aortic aneurysm without rupture and most currently post hemorrhagic anemia, and gastrointestinal hemorrhage. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #41 was cognitively intact, required supervision for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The resident received seven days of an anticoagulant medication during the review period. Review of the progress note dated 09/12/22 at 2:25 A.M. revealed the resident had a moderate amount of blood in the toilet with traces of blood in the stool. Resident #41 denied any abdominal pain. A stool sample was obtained if needed to send out to the laboratory. The writer documented they would pass on in report to notify the doctor in the morning. No other assessment of the resident was documented. Review of the progress note dated 09/13/22 at 1:18 A.M. revealed Resident #41 had emesis times one of clear liquid after taking a drink of water. The resident denied abdominal pain or further nausea. There was no other assessment of the resident documented. Review of the progress note dated 09/14/22 at 3:28 P.M. revealed a late entry note was written for 09/13/22 at 9:30 A.M. which stated the night shift reported during morning Resident #41 had more blood in the stool. When Resident #41 woke up in the morning the resident was jaundice, confused, hallucinating, and had complaints of abdominal pain. The writer of the note referenced the physician was faxed the day before on the resident condition. The physician stated the facility may send resident to the emergency room if the condition worsens. The resident was noted to be assessed by the facility nurse and the physician office was called and informed of the resident's condition. Review of the progress note dated 09/13/22 at 2:59 P.M. revealed Resident #41 was admitted to the hospital with a gastrointestinal bleed. Review of Resident #41's September 2022 medication administration record (MAR) revealed the resident had orders for Xarelto (a blood thinner) 15 milligram (mg) daily with the evening meal. The MAR revealed the resident received the Xarelto routinely including the dose on 09/12/22 after the resident had what was reported and documented as a moderate amount of blood in the stool. Review of the vital sign report revealed there was no documented blood pressure readings or pulses 365380 Page 9 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0684 obtained after Resident #41 had reported blood with her bowel movement on 09/12/22. Level of Harm - Actual harm Review of the September 2022 treatment administration record (TAR) revealed the staff were monitoring the resident every shift for side effects of anticoagulant therapy including nausea, emesis, blood in the stool and were to document number of episodes a shift. All entries were coded as zero indicating no episodes of blood in stool, nausea, or emesis including entries on 09/12/22 and 09/13/22, when the nurse progress notes documented the resident had episodes of blood in the stool. Residents Affected - Few Review of the fax communication between the facility and the physician on 09/12/22 at an undetermined time verified the physician was notified Resident #41 had an episode of moderate bleeding with a bowel movement and there was blood in the stool. The fax documentation had a reply from the physician questioning if the resident was on an anticoagulant, ordered a complete blood count (CBC), wanted to know the characteristics of the stool such as hard or if the resident had hemorrhoids. The fax documented to send the resident to the Emergency Department (ED) if the resident condition worsened or if there was worsening blood in the stool. There was no evidence in the medical record the facility completed the orders attached to the 09/12/22 faxed physician notification of completion of the laboratory test of a CBC, informing the physician if the resident had hard stools or hemorrhoids, and to verify if the resident was taking an anticoagulant. Review of the hospital gastroenterology consult note dated 09/16/22 revealed Resident #41 presented to the emergency department on 09/13/22 where she reported she had not felt well. Per reports Resident #41 had some black stool and a report of bright red blood earlier in the week. She was on Xarelto, and her last dose was reported as 09/13/22. No additional information could be obtained from her due to her mental status. She presented to the ED with a hemoglobin of 4.7 grams per deciliter (g/dL) and received three units of packed red blood cells. (A critical low hemoglobin level is a value of less than 5.0 g/dL which can lead to heart failure and death. A normal hemoglobin level is 11.9 g/dL to 15.11 g/dL.). Review of the resident discharge summary from the hospital dated 09/16/22 revealed Resident #41 had orders for a CBC and Basic Metabolic Panel (BMP) on 09/19/22. There was no evidence in the medical record these laboratory tests were performed. Interview with Licensed Practical Nurse (LPN) #501 on 09/28/22 at 7:55 A.M., verified if a resident was on an anticoagulant and the resident had signs of active bleeding, she would not give the medication and would call the physician, and inform them of her findings and follow any orders the physician would provide. Interview with LPN #413 on 09/29/22 at 8:35 P.M., verified the residents on anticoagulants are monitored for abnormal bleeding and bruising. The LPN stated if a resident on an anticoagulant had bleeding, she would contact the physician and report the condition of the resident and would get instructions from the physician regarding any immediate orders such as holding the anticoagulant medication and on-going monitoring. Interview with the Director of Nursing (DON) on 09/28/22 at 2:39 P.M. verified the facility documented on 09/12/22 at 2:25 A.M. Resident #41 had a moderate amount of blood in the toilet and blood visible in the resident stool and left the physician notification for the day shift staff to complete. The DON verified with a moderate amount of blood visible she would expect the physician notification 365380 Page 10 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0684 to occur right away and not wait until the next shift. Level of Harm - Actual harm Interview with Physician #700 on 09/28/22 at 4:43 P.M., verified he would not necessarily expect to be notified of blood in a resident's stool if the amount was small and the resident was known to have hemorrhoids, which he was not made aware in this case. The physician assumed the facility staff probably took Resident 41's vital signs and the vital signs were stable, and they decided to notify me in the morning. The physician verified Resident #41's hemoglobin was low when she was in the ED, and she received blood products to raise her hemoglobin. Residents Affected - Few A follow-up interview with the DON on 09/29/22 at 11:56 A.M., verified the physician ordered Resident #41 to have a CBC when he was notified of the blood in Resident #41's stool on 09/12/22 and it was not completed. The DON verified the documentation of the resident having blood in the stool had not included vital signs for the resident, and the medical record had no other documented vital signs/assessment when the resident had experienced blood in the stool. Interview with the Administrator and the DON on 09/29/22 at 10:09 A.M., verified the CBC and BMP ordered for Resident #41 on 09/19/22 was not completed as ordered. A follow-up interview on 09/29/22 at 1:28 P.M., with the Administrator verified there was no documentation in Resident#41's medical record indicating the physician was notified the resident was on a blood thinner when the fax notification related to blood with a bowel movement requested to know additional information. The Administrator verified the medical record had no documentation the 09/12/22 CBC laboratory test being completed as ordered by the physician. Review of the policy titled Notification of Change, dated 2006 last revised in 12/2016 revealed when there is a need to alter treatment significantly immediate notification of the resident will occur. There will also be consultation with the resident's physician and the resident's representative if consistent his/her authority. Definition: Need to alter treatment significantly includes the following: a need to change a current treatment, discontinuing a current treatment or commencing a new treatment. Procedure: Immediate notification of the resident; consult with the resident's physician; notification of the resident representative is to be done in the following situations: - A significant change in the resident's physical, mental or psychosocial status including a deterioration in the health, mental, cognition, medication change, or psychosocial status in either life-threatening conditions, or clinical complications. - A need to alter treatment/plan of care significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form or treatment). 365380 Page 11 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included dementia, atherosclerotic heart disease, atrial fibrillation, hypertension, chronic diastolic (congestive) heart failure, chronic kidney disease, osteoarthritis, and other intervertebral disc degeneration. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired, required extensive assistance with transfers, personal hygiene, toilet use, and dressing, and had one fall with no major injury. Review of the plan of care focus area revised 06/28/22 revealed Resident #04 was at risk for falls related to side effects of medication, unsteady gait, decreased balance and medical conditions. Interventions included electric bed in functional position, indicated by tape on the wall. Review of a fall investigation dated 06/01/22 revealed Resident #04 was found on the floor beside her bed, noting the resident was getting up to go to the bathroom. Review of an interdisciplinary team (IDT) note on the investigation dated 06/02/22 revealed interventions included reviewing the tape on the wall, add skid strips to the bathroom floor, therapy evaluation and therapy to review functional height of the resident's bed. Review of a Morse Fall Scale Data Collection assessment dated [DATE] revealed Resident #04 scored 51, indicating the resident was at high risk for falls. Observation on 09/28/22 at 3:25 P.M. of Resident #4's room revealed no tape was on the wall indicating the functional position of the resident's bed. Interview on 09/28/22 at 3:28 P.M., the State Tested Nurse Aide (STNA) #430 verified there was no tape placement on Resident #04's room wall to indicate the functional position of the resident's bed. STNA #430 stated she did not even know what that meant and had not previously heard of the intervention being included in Resident #04's care planned fall interventions. Interview on 09/28/22 at 3:32 P.M., the Minimum Data Set MDS Coordinator #483 verified Resident #04's plan of care included a fall intervention for the resident's bed to be aligned with tape placed on the wall as assessed by therapy as the functional position to reduce the fall risk for Resident #04. MDS #483 stated Resident #04 was in a review period and the plan of care would be updated if the intervention was no longer necessary. Interview on 09/29/22 at 8:30 A.M., the Occupational Therapist (OT) #600 revealed the facility contracted with her company for therapy services. The OT #600 stated her company began providing therapy services the end of June 2022. OT #600 stated Resident #04 had not been evaluated or treated by therapy since they took over and they had no previous records of therapy services and was unaware of any recommendation from the IDT for therapy to evaluate and review the functional height position of Resident #04's bed following a fall on 06/01/22. The OT #600 stated it was likely medical records had information on any previously provided therapy. Interview on 09/29/22 at 3:17 P.M., the Administrator revealed the facility had no evidence of the therapy evaluation or therapy review of the functional height of Resident #04's bed following her 365380 Page 12 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fall on 06/01/22, as recommended by the IDT on 06/02/22. The Administrator stated the facility had a new contracted therapy department as of the end of June 2022 and the previous therapy departments notes did not exist or the facility was unable to obtain the notes. Review of the facility policy titled Fall Risk Data Collection and Protocol, undated revealed preventative measures would be taken to decrease the number of falls whenever possible, and appropriate interventions/precautions would be implemented for residents at risk for falls. Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure planned fall interventions were implemented. This affected two residents (#04 and #37) out of four resident reviewed for falls. The facility census was 73. Findings include: 1. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, hypertension, long-term use of insulin, obstructive sleep apnea, unspecified psychosis, bipolar disorder, anxiety, and depression. Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident required extensive assistance of one staff for bed mobility, dressing, eating, toilet use, and personal hygiene. Review of Resident #37's fall risk assessments dated 03/22/20, 06/21/20, 09/05/20, 11/30/20, 02/27/21, 05/30/21, 08/29/21, 08/30/21, 11/29/21, 11/30/21, 02/26/22, 05/29/22, 07/16/22, 07/30/22, and 08/01/22, revealed the resident was at high risk for falls. Review of Resident #37's plan of care dated 08/12/22 revealed the resident was at risk for falls due to diagnoses of bipolar, diabetes, hypertension, other health issues, received psychotropic medication, fluctuating cognition, mood and behaviors, incontinence, and progressive visual deficit. Interventions included gripper socks on when in bed or up, keep the room well-lit and clutter free, monitoring while on the toilet, right sided grab bar, and a perimeter mattress with cut-outs to bed. Further review of Resident #37's plan of care revealed the perimeter mattress with cut-outs to bed was implemented on 10/18/19. Review of Resident #37's physician orders for September 2022, identified an order dated 12/01/14 for gripper socks at bedtime. Review of Resident #37's medical record revealed the resident fell from her bed on 11/25/19, 12/03/19, 01/08/21, and 03/09/22 and there was no positioning device in place at the time of each fall. Observations on 09/26/22 at approximately 10:00 A.M., on 09/27/22 at approximately 8:00 A.M., and on 09/27/22 at 12:28 P.M. revealed Resident #37 had a regular mattress and no perimeter mattress or perimeter mattress with cut-outs was in place. Interview on 09/27/22 at 12:32 P.M. with Licensed Practical Nurse (LPN) #454 verified Resident #37 had a regular mattress and should have had a perimeter mattress with cut-outs in place according to the plan of care. LPN #454 reported she did not recall the resident ever having a perimeter mattress in place and staff used a body pillow instead. 365380 Page 13 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0689 Level of Harm - Minimal harm or potential for actual harm Observation on 09/29/22 at 7:47 A.M. revealed Resident #37 was lying in bed with no gripper-socks on her feet. Interview on 09/29/22 with LPN #600 verified Resident #37 was supposed to have gripper-socks on when in bed and was not wearing any. Residents Affected - Few Review of the facility policy titled Fall Risk Data Collection and Protocol not dated revealed preventative measures would be taken to decrease the number of falls whenever possible, and appropriate interventions/precautions would be implemented for residents at risk for falls. 365380 Page 14 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medial record review, staff interview and review of facility policy, the facility failed to ensure weights were monitored per facility policy and failed to track meal intakes as care planned. This affected one (#4) of two residents reviewed for nutrition. In addition, the facility failed to ensure weights were obtained per physician order. This affected one (#34) of two residents reviewed for nutrition. The facility census was 73. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included dementia, atherosclerotic heart disease, atrial fibrillation, hypertension, chronic diastolic (congestive) heart failure, chronic kidney disease, osteoarthritis, and other intervertebral disc degeneration. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired, required extensive assistance with personal hygiene, toilet use, and dressing, required supervision with eating and had weight loss of 5 percent (%) or more in the past month and was not on a prescribed weight loss regimen. Review of the plan of care focus area revised 09/08/22 revealed Resident #04 remained at risk for nutritional decline related to diagnoses of dementia, causing a decrease in appetite, intake and weight as disease process progressed. Additionally, Resident #04 continued to need supplements to maintain weight and had significant weight loss. Interventions included Ensure clear eight ounces two times daily, have foods available whenever the resident was hungry, monitor intake per facility policy, offer bedtime snacks, provide medications per orders, honor food preferences and observe changes in weight and notify the physician. Review of the current physician orders revealed Resident #04 was ordered Ensure Clear two times daily and was on a regular, thin liquid diet. Review of the weights dated from 04/02/22 through 09/01/22 revealed Resident #04 weighed 113.8 pounds on 04/02/22, 112.4 pounds on 05/02/22, 106.4 pounds on 06/01/22, 105.8 pounds on 07/01/22, 104 pounds on 08/04/22 and 101.4 pounds on 09/01/22. Further review of Resident #04's weights dated 05/02/22 and 06/01/22 revealed a weight loss of six pounds in one month, indicating a significant weight loss of 5.34%. Additional review of Resident #04's weights dated 04/02/22 and 09/01/22 revealed a weight loss of 12.4 pounds over six months, indicating a significant weight loss of 10.90%. Review of a Dietary/Nutrition Quarterly Data Collection assessment dated [DATE] documented Resident #04 had a significant weight loss of 5.3% over one month. Review of a Dietary/Nutrition Annual Data Collection assessment dated [DATE] documented Resident #04 had a significant weight loss over 10% over six months. Observation on 09/29/22 at 8:24 A.M. of STNA #415 weighing Resident #04 revealed Resident #04's weight was 104.4 pounds. Interview on 09/28/22 at 2:13 P.M., the Director of Nursing (DON) verified Resident #04's medical 365380 Page 15 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few record had no documentation for increased weight monitoring following a significant weight loss. Additionally, the DON said each meal intake should be documented in a resident's electronic medical record (EMR) and consistent meal tracking was not completed for Resident #04, as care planned. Interview on 09/29/22 at 8:55 A.M., the Dietary Technician (DT) #505 and the Registered Dietitian (RD) #507 revealed each were contract staff. The DT #505 stated she was at the facility one time weekly, while RD #507 was at the facility one time monthly. The DT #505 and the RD #507 verified Resident #04 had a significant weight loss noted in June 2022 and September 2022. The DT #505 stated in the past a weekly weight would have been implemented to more closely monitor residents who had weight loss but she was unsure if this was the current practice of the facility. The DT #505 stated she would anticipate Resident #04's weight loss due to age and natural disease progression. The RD #507 stated the monthly weight lists were reviewed for weight loss. If a significant weight loss was noted they would look at adding supplements and making any diet changes. For Resident #04, a supplement was added, and her diet liberalized to encourage meal consumption. In addition, RD #507 stated some weight fluctuations were expected due to Resident #04 being prescribed a diuretic. Both the DT #505 and the RD #507 verified they relied on accurate meal intakes being documented in the resident's EMR to assist with making accurate assessments and recommendations. The DT #505 and the RD #507 verified Resident #04's significant weight loss would be an adverse trend and increased monitoring of the resident's weight was not completed per facility policy. Review of facility policy titled Weight Monitoring - Nursing Services, revised May 2019 revealed the timing of weights included weekly for the first four weeks of admission and monthly thereafter unless an adverse trend was identified. Residents would be weighted weekly or more often based upon ongoing assessment of nutritional intake, fluid retention, and other medical factors. 2. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, and anxiety. Review of Resident #34's annual MDS assessment dated [DATE] revealed the resident was cognitively intact and required the extensive assistance of one staff for a majority of the activities of daily living. Review of the physician's order dated 05/03/22 revealed Resident #34 should be weighed weekly, every day shift, every Tuesday. Review of Resident #34's weight record revealed Resident #34 was not weighed per physician order on 05/03/22, 05/10/22, 05/24/22, 06/07/22, 06/14/22, 06/21/22, 06/28/22, 07/05/22, 07/12/22, 07/19/22, 07/26/22, 08/02/22, 08/09/22, and 09/06/22. Interviews with the RD #505 and the DT #507 on 09/29/22 at 9:13 A.M., verified Resident #34's weight was not obtained per physician order on 05/03/22, 05/10/22, 05/24/22, 06/07/22, 06/14/22, 06/21/22, 06/28/22, 07/05/22, 07/12/22, 07/19/22, 07/26/22, 08/02/22, 08/09/22, or 09/06/22. Review of facility policy titled Weight Monitoring - Nursing Services, revised May 2019 revealed the facility would monitor residents' weights from the time of admission. 365380 Page 16 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, and staff interview, the facility failed to ensure oxygen was applied per physician order. This affected one resident (#33) of two residents reviewed for respiratory care. The facility census was 73. Residents Affected - Few Findings include: Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included displaced segmental fracture of shaft of humerus, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, Parkinson's disease, depression, and muscle weakness. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired. The resident required extensive assistance of one staff for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. The resident used oxygen. Review of Resident #33's physician orders for September 2022 identified orders for oxygen at three liters per minute via nasal cannula, every shift, and oxygen at two liters per minute as needed per nasal cannula. Review of Resident #33's plan of care dated 08/19/22 revealed the resident had complications related to respiratory diagnoses, abnormal lung sounds, and shortness of breath related to COPD and respiratory failure, and was at risk for complications. Interventions included assisting resident with activities that cause shortness of breath, encouraging fluid intake, monitoring and observing for episodes of shortness of breath, and routine oxygen per order. Observation on 09/26/22 at 10:05 A.M. revealed Resident #33's oxygen concentrator was running at 2.5 liters per minute but Resident #33 was not wearing her nasal cannula. Observation on 09/27/22 at 7:55 A.M. revealed Resident #33 was in bed and was wearing her nasal cannula with oxygen running at 2.5 liters per minute. Observation on 09/27/22 at 12:45 P.M. revealed Resident #33 was sitting in a recliner, her oxygen concentrator was off and the nasal cannula and tubing was on the floor in her room. Observation on 09/27/22 at 1:11 P.M. revealed Resident #33 was not wearing her oxygen and the oxygen tubing/nasal cannula were on the floor. Interview on 09/27/22 at 1:20 P.M., with Agency Licensed Practical Nurse (LPN) #708 revealed the Agency LPN #708 was assigned to care for Resident #33 for the day shift on 09/27/22 and was unsure of whether Resident #33's oxygen was supposed to be continuous or as needed. Agency LPN #708 reported a physician's order would normally say continuous or as needed, but she was unsure since the order said every shift. Agency LPN #708 reported sometimes Resident #33 was wearing oxygen and sometimes she was not. Agency LPN #708 verified Resident #33's oxygen/nasal cannula should not have been on the floor and replaced the resident's tubing. Observation on 09/29/22 at 7:54 A.M. revealed Resident #33 was in bed, was not wearing her nasal cannula, and her oxygen concentrator was off. Interviews at the time of observation with State Tested 365380 Page 17 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse Aide (STNA) #428 and STNA #800 verified Resident #33 was supposed to be wearing her oxygen at all times. Staff reported they were unsure of how long Resident #33's oxygen had been off. When prompted, STNA #428 checked Resident #33's oxygen level, which was at 96 percent on room air. Interview on 09/29/22 at 2:15 P.M. with the Assistant Director of Nursing (ADON) #469 verified Resident #33 was supposed to receive continuous oxygen via nasal cannula at three liters per minute. 365380 Page 18 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the staff schedules, and review of the facility unit staffing guidelines, the facility failed to ensure sufficient staff on the secured memory care unit to provide resident care. This directly affected two residents (#64 and #66) and had the potential to affect all 12 residents (#09, #12, #13, #19, #23, #54, #55, #59, #60, #63, #64 and #66) out of 12 residents residing on the secured memory care unit. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #64 was admitted on [DATE]. Diagnoses included major depressive disorder, anxiety disorder, Alzheimer's disease, vascular dementia, hypertension, interstitial pulmonary disease, Raynaud's syndrome, spinal stenosis, polyneuropathy, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was severely cognitively impaired and required extensive assistance with transfers, dressing, toilet use, personal hygiene, and physical help in bathing. Review of a plan of care focus area initiated 02/25/22 revealed Resident #64 was unable to carry out Activities of Daily Living (ADLs) care without assistance. Interventions included ADL care daily (required limited to extensive assistance with bed mobility, transfers, gait, toilet use, grooming and bathing assistance of one). Review of the State Tested Nurse Aide (STNA) shower documentation from 09/03/22 through 09/28/22 revealed not applicable was checked for Resident #64's showers on 09/10/22 and 09/24/22. Review of the shower schedules revealed Resident #64 was scheduled to receive showers on Wednesdays and Saturdays. 2. Review of the medical record revealed Resident #66 was admitted on [DATE]. Diagnoses included Alzheimer's disease, type II diabetes, hypertension, major depressive disorder, anxiety disorder, and malignant neoplasm of large intestine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was severely cognitively impaired and required extensive assistance with personal hygiene. Review of the plan of care initiated 01/13/22 revealed Resident #66 required supervision and assistance with Activities of Daily Living (ADLS) and was at risk for decline as her disease progressed. Interventions included physical help from one staff with showers. Review of the State Tested Nurse Aide (STNA) shower documentation from 08/31/22 through 09/28/22 revealed not applicable was checked for Resident #66's showers on 09/03/22, 09/10/22 and 09/24/22. Interview on 09/26/22 at 9:44 A.M., the STNA #482 revealed the secured memory care unit typically had two STNAs and one nurse assigned to work the unit. However, there were times those staffing levels were not met and residents did not receive the care needed. STNA #482 stated on 09/24/22, she was the only STNA assigned to the unit and the nurse was split between the secured memory care unit and 365380 Page 19 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the 600 hall. STNA #482 stated she was unable to provide showers to Residents #64 and #66 because there was insufficient staff available to provide supervision to the other residents on the unit while she was providing resident care in the shower room. Interview on 09/28/22 at 3:38 P.M., the Administrator verified the facility was under the 2.50 hour direct care state licensure staffing requirement on 09/24/22, noting the facility was at 2.48 hours. The Administrator stated the facility had two agency staff call off that day. The Administrator confirmed the typical staffing for first shift on the secured memory care unit would have been two STNAs and one nurse. The Administrator verified on 09/24/22 there was only one STNA and a nurse split with the 600 hall. The Administrator confirmed the secured memory care unit was short staffed on 09/24/22. The Administrator was unaware resident care had not been provided and stated he would follow up to ensure residents received scheduled showers. Review of the staff schedule for 09/24/22 revealed there was one State Tested Nurse Aide (STNA) and a nurse, who was split with the 600 hall, assigned to the secured memory care unit on first shift on 09/24/22. Review of the staffing tool from 09/20/22 through 09/26/22 revealed the facility's daily direct care staffing on 09/24/22 was below the 2.50-hour requirement for state licensure. Review of the facility unit staffing guidelines revealed the secured memory care unit first shift staffing included two STNAs and one licensed nurse. 365380 Page 20 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to timely act on pharmacy recommendations. This affected two residents (#28 and #03) out of eight residents reviewed for unnecessary medications. The facility census was 73. Findings Include: Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, schizoaffective disorder, chronic kidney disease, and diabetes mellitus type two. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #28 was cognitively intact, had behaviors directed toward others four to six days of the review period, required extensive assistance with dressing, limited assist with toilet use and bed mobility and supervision with transfers, eating, and personal hygiene. Resident #28 had seven days of injections: insulin, an antipsychotic, an antidepressant, an antianxiety, a diuretic and an opioid medication. The last gradual dose reduction was attempted on 12/28/21 and the physician documented a gradual dose reduction (GDR) was contraindicated for the resident. Review of the pharmacy recommendation for Resident #28 dated 11/22/21 revealed to consider discontinuing the use of Benadryl (antihistamine) and Zofran (antiemetic) due to the lack of use, stating the medications have not been used in the last 90 days. The recommendation was accepted and implemented on 01/11/22. Interview with the Director of Nursing (DON) on 09/28/22 at 4:26 P.M., verified the pharmacy recommendation was not acted on timely for the discontinuation of the Benadryl and Zofran used in the resident's care. 2. Review of Resident #03 medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included narcolepsy with cataplexy, diabetes type two, atrial fibrillation and hypertension. Review of the quarterly MDS dated [DATE] revealed Resident #03 was cognitively intact, had no behaviors, had narcolepsy with cataplexy coded as a current diagnosis. Review of Resident #03's pharmacy recommendation dated on 02/25/22 requested to reevaluate Sucralfate (an antacid medication) use as Sucralfate may reduce the effectiveness of other medications and require adjustments to the administration schedule. The recommendation was addressed on 04/06/22 when the medication was discontinued. Review of Resident #03's medication administration record revealed the Sucralfate was discontinued after the morning dose on 04/06/22. Interview on 09/28/22 at 4:25 P.M., with the DON verified the pharmacy recommendation was not acted on timely when the Resident's Sucralfate continued to be administered until 04/06/22 when it was recommended to discontinue the medication on 02/25/22. 365380 Page 21 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview, and policy review, the facility failed to ensure foods kept in the refrigerator and freezer on the memory care unit were properly stored, labeled, and dated. This had the potential to affect 12 residents (#09, #12, #13, #19, #23, #54, #55, #59, #60, #63, #64 and #66) out of 12 residents residing on the secured memory care unit. The facility census was 73. Findings include: Observation on 09/26/22 at 9:54 A.M. of the kitchen area on the memory care unit revealed a reach in refrigerator and freezer combination. The refrigerator compartment revealed a container of applesauce dated 08/30/22, an undated and unlabeled package of luncheon meat in a plastic bag, an undated and unlabeled half-full pitcher of juice, a red cup with a lid containing an unknown liquid, undated and unlabeled, and a loosely covered bowel of butter with toast crumbs noted on the butter, undated and unlabeled. Additional observations revealed the refrigerator grates had food particles and dirt build-up and a sticky substance was spilled on the inside of the refrigerator. Continued observations of the freezer revealed three slices of loosely covered pie, with the sides of each of the slices exposed, undated and unlabeled, and a plastic container with an opened bag of broccoli, carrots and cauliflower mix, undated. Additionally, there was dirt and food particle build-up on the shelves of the freezer door. Interview on 09/26/22 at 10:05 A.M., the State Tested Nurse Aide (STNA) #612 verified the refrigerator and the freezer in the kitchen of the memory care unit was used to store food for the residents residing on the unit. STNA #612 verified the above findings. STNA #612 stated she assumed it was the responsibility of the staff on the unit to clean the refrigerator but she was agency staff so she was not completely sure. Observation on 09/29/22 at 11:40 A.M. of the freezer in the kitchen on the secured memory care unit revealed two loosely wrapped, undated and unlabeled pieces of pie, with the sides of the slices of pie exposed. Additionally, the dirt and food particle build up remained in the refrigerator and the freezer. Interview on 09/29/22 at 11:40 A.M., the STNA #482 verified the above findings. STNA #482 stated she was unsure how long the pie had been in the freezer. STNA #482 stated the third shift staff were supposed to clean the refrigerator one time weekly. Review of the facility policy titled Food Storage, undated revealed all refrigerator and freezer units should be kept clean and in good working condition at all times, all foods should be covered, labeled, dated, and checked to assure that foods will be consumed by their safe use by dates or discarded. Additionally, leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated. Leftover food must be used within seven days or discarded. 365380 Page 22 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure access and availability of therapy records in a resident's medical record. This affected one resident (#04) out of one resident reviewed for therapy services. The facility census was 73. Findings include: Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included dementia, atherosclerotic heart disease, atrial fibrillation, hypertension, chronic diastolic (congestive) heart failure, chronic kidney disease, osteoarthritis, and other intervertebral disc degeneration. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired, required extensive assistance with transfers, personal hygiene, toilet use, and dressing, and had one fall with no major injury. Review of the plan of care focus area revised 06/28/22 revealed Resident #04 was at risk for falls related to side effects of medication, unsteady gait, decreased balance and medical conditions. Interventions included electric bed in functional position, indicated by tape on the wall. Review of a fall investigation dated 06/01/22 revealed Resident #04 was found on the floor beside her bed, noting the resident was getting up to go to the bathroom. Review of an interdisciplinary team (IDT) note on the investigation dated 06/02/22 revealed interventions included reviewing the tape on the wall, add skid strips to the bathroom floor, therapy evaluation and therapy to review functional height of the resident's bed. Review of a Morse Fall Scale Data Collection assessment dated [DATE] revealed Resident #04 scored 51, indicating the resident was at high risk for falls. Observation on 09/28/22 at 3:25 P.M. of Resident #4's room revealed no tape was on the wall indicating the functional position of the resident's bed. Interview on 09/28/22 at 3:28 P.M., the State Tested Nurse Aide (STNA) #430 verified there was no tape placement on Resident #04's room wall to indicate the functional position of the resident's bed. STNA #430 stated she did not even know what that meant and had not previously heard of the intervention being included in Resident #04's care planned fall interventions. Interview on 09/28/22 at 3:32 P.M., the Minimum Data Set MDS Coordinator #483 verified Resident #04's plan of care included a fall intervention for the resident's bed to be aligned with tape placed on the wall as assessed by therapy as the functional position to reduce the fall risk for Resident #04. MDS #483 stated Resident #04 was in a review period and the plan of care would be updated if the intervention was no longer necessary. Interview on 09/29/22 at 8:30 A.M., the Occupational Therapist (OT) #600 revealed the facility contracted with her company for therapy services. The OT #600 stated her company began providing therapy services the end of June 2022. OT #600 stated Resident #04 had not been evaluated or treated by 365380 Page 23 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few therapy since they took over and they had no previous records of therapy services and was unaware of any recommendation from the IDT for therapy to evaluate and review the functional height position of Resident #04's bed following a fall on 06/01/22. The OT #600 stated it was likely medical records had information on any previously provided therapy. Interview on 09/29/22 at 3:17 P.M., the Administrator revealed the facility had no evidence of the therapy evaluation or therapy review of the functional height of Resident #04's bed following her fall on 06/01/22, as recommended by the IDT on 06/02/22. The Administrator stated the facility had a new contracted therapy department as of the end of June 2022 and the previous therapy departments notes did not exist or the facility was unable to obtain the notes. 365380 Page 24 of 25 365380 10/04/2022 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview, the facility failed to ensure resident rooms and common areas were kept in good repair. This had the potential to affect all 73 residents of the facility. The facility census was 73. Findings include: 1. Observation on 09/26/22 at 9:41 A.M. of Resident #64's room revealed an area, approximately two inches in diameter, on the wall near the call light box of exposed, unpainted, drywall; two areas, one on each side of the window, approximately three inches long and a half inch wide of exposed, unpainted drywall; and a quarter size and two dime size areas of exposed, unpainted drywall on the wall near the thermostat. Interview on 09/26/22 at 9:44 A.M., the State Tested Nurse Aide (STNA) #482 verified the above findings. STNA #482 stated all staff were able to complete work orders for maintenance. STNA #482 was uncertain if a work order had been completed for the damage to Resident #64's room walls. 2 Observation on 09/29/22 at 8:36 A.M. of the sunroom, located on the 200 hall, revealed a ceiling crack, approximately 10 feet long, along with exposed and crumbling drywall running from the entrance of the sunroom to a vent located near the smoke detector; a ceiling crack, approximately six feet long, running from the entrance to the cold air return vent; and various other areas of cracked and peeling paint. Interview on 09/29/22 at 10:58 A.M., the Maintenance Director (MD) #419 revealed the facility utilized an electronic work order system and all staff were able to submit work orders when needed repairs were identified. MD #419 verified the condition of the sunroom ceiling, stating it was water damage caused by leaking pipes and the roof. The MD #419 stated he had been able to repair the water leaks but had not been able to repair the damage the water leaks caused. The MD #419 stated he had a maintenance assistant but he was primarily responsible for all the building repairs. The MD #419 verified all the facility residents were able to use the sunroom, if desired. Additionally, MD #419 verified the wall damage in Resident #64's room. The MD #419 stated he was unaware of the needed repairs and denied a work order had been submitted. 365380 Page 25 of 25