Health inspection·September 26, 2019

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed as required. This affected three residents (#3, #11 and #12)of 14 residents whose medical records were reviewed for completion of assessments. Findings include: On [DATE] beginning at 4:30 P.M., Minimum Data Set (MDS) 3.0 assessment completion and submission information was reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350. The following findings were noted related to the completion of annual MDS 3.0 assessments: 1. Review of Resident #3's Assessment Lookup Information revealed a comprehensive MDS 3.0 assessment was scheduled with an Assessment Reference Date (ARD) of [DATE]. The log indicated the MDS was not completed. MDS Coordinator #350 verified Resident #3 had an annual MDS assessment with a ARD of [DATE] which had not been completed. 2. Review of Resident #11's Assessment Lookup information revealed a comprehensive MDS 3.0 assessment was scheduled with an ARD of [DATE]. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #11 had a MDS with a ARD of [DATE] which was not completed. 3. Review of Resident #12's Assessment Lookup Information revealed a comprehensive MDS 3.0 assessment was scheduled with an ARD of [DATE]. The log indicated data entry had not been completed. MDS Coordinator #350 revealed Resident #12 had expired on [DATE]. Resident #12 had an annual MDS assessment with a ARD date of [DATE] that had never been completed. Page 1 of 5 365574 365574 09/26/2019 Crandall Nursing Home 800 S 15th St Sebring, OH 44672

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to conduct quarterly Minimum Data Set (MDS) 3.0 assessments in a timely manner. This affected four residents (#9, #10, #13 and #15) of 14 residents whose medical records were reviewed for completion of assessments. Residents Affected - Some Findings include: On 09/24/19 beginning at 4:30 P.M., Minimum Data Set (MDS) 3.0 assessment completion and submission information was reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350. The following findings were noted regarding quarterly MDS 3.0 assessments: 1. Review of Resident #9's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment was scheduled with an Assessment Reference Date (ARD) of 07/23/19. The log indicated the MDS was not completed. MDS Coordinator #350 verified Resident #9 had a quarterly MDS assessment with an ARD of 07/23/19 which had not been completed. 2. Review of Resident #10's Assessment Lookup information revealed a quarterly MDS 3.0 assessment was scheduled with an ARD of 07/29/19. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #10 had a MDS with a ARD of 07/29/19 which was not completed. 3. Review of Resident #13's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment was scheduled with an ARD of 07/31/19. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #13's quarterly MDS with an ARD of 07/31/19 had not been completed. 4. Review of Resident #15's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment with an ARD of 08/18/19 had not been completed. MDS Coordinator #350 verified Resident #15's quarterly MDS with an ARD of 08/18/19 was not completed. 365574 Page 2 of 5 365574 09/26/2019 Crandall Nursing Home 800 S 15th St Sebring, OH 44672

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 interview the facility failed to ensure resident Minimum Data Set (MDS) 3.0 assessments were transmitted in the required time frames. This affected seven residents (#1, #2, #4, #5, #6, #7, and #8) of 14 residents reviewed for submission of assessments. Residents Affected - Some Findings include: On 09/24/19 beginning at 4:30 P.M., submission of Minimum Data Set (MDS) 3.0 assessments were reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350 with the following concerns identified regarding submission of assessment data: 1. Review of Assessment Lookup logs for Resident #1 indicated there was a quarterly MDS 3.0 assessment dated [DATE]. The log indicated data entry was completed 07/26/19 but the assessment had not been submitted. MDS Coordinator #350 verified Resident #1 had a MDS with an ARD of 07/05/19 which was completed 07/26/19 but had not been submitted. 2. Review of Assessment Lookup logs for Resident #2 indicated there was an annual MDS 3.0 assessment with an ARD of 07/06/19. The log indicated data entry was completed 08/02/19. The assessment had not been submitted. MDS Coordinator #350 verified Resident #2 had a MDS with an ARD of 07/06/19 which was not completed until 08/02/19 and which had not been submitted yet. 3. Review of Assessment Lookup logs for Resident #4 indicated there was a significant change MDS 3.0 assessment with an ARD of 07/03/19. The log indicated a data entry complete date of 08/02/19. The assessment had not been submitted. MDS Coordinator #350 verified Resident #4 had a MDS with an ARD of 07/03/19 which was marked as complete 08/02/19 but not submitted yet. 4. Review of Assessment Lookup logs for Resident #5 revealed there was a quarterly MDS 3.0 assessment with an ARD of 07/04/19. The log indicated a data entry date of 09/15/19. The assessment was not submitted until 09/20/19. MDS Coordinator #350 verified Resident #5 had a MDS with an ARD of 07/04/19 which was completed late (09/15/19) and submitted late (09/20/19). 5. Review of Assessment Lookup Information for Resident #6 revealed there was a comprehensive annual MDS 3.0 assessment with an ARD of 08/10/19. Data entry was completed 09/23/19 but had not been submitted. MDS Coordinator #350 verified Resident #6 had a MDS with an ARD of 08/10/19 which was marked as completed 09/23/19 but which had not been submitted yet. 365574 Page 3 of 5 365574 09/26/2019 Crandall Nursing Home 800 S 15th St Sebring, OH 44672

F 0640 Level of Harm - Minimal harm or potential for actual harm 6. Review of Assessment Lookup information for Resident #7 revealed there was a quarterly MDS 3.0 assessment dated [DATE]. The assessment was not submitted until 09/20/19. MDS Coordinator #350 verified Resident #7 had a MDS with an Assessment Reference Date of 07/05/19. The MDS was not completed until 09/13/19 and was not submitted until 9/20/19. Residents Affected - Some 7. Review of Assessment Lookup information for Resident #8 revealed there was a quarterly MDS 3.0 assessment with an ARD of 07/10/19. The log indicated data entry was not completed until 09/22/19 and not been submitted. MDS Coordinator #350 verified Resident #8 had a MDS with a ARD of 07/10/19 which was not completed until 09/22/19 so it was done late and not yet submitted. 365574 Page 4 of 5 365574 09/26/2019 Crandall Nursing Home 800 S 15th St Sebring, OH 44672

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on record review and interview the facility failed to ensure quarterly quality assurance (QA) meetings were attended by a physician and the administrator, owner or board member. This had the potential to affect all 165 residents residing in the facility. Residents Affected - Many Findings include: Review of quarterly sign in sheets for the QA meetings held in 10/11/18 and 01/10/19 revealed no evidence of physician attendance. The January 2019 sign in sheet did not contain the signature of the administrator, owner or board member. On 09/26/19 at 6:05 P.M., QA nurse #360 verified the Administrator was a member of the QA committee but did not attend the quarterly meeting on 01/10/19. There was no physician attendance during quarterly QA meetings held 10/11/18 and 01/10/19. 365574 Page 5 of 5