Health inspection·September 1, 2022

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on record review, facility policy and procedure review and interview the facility failed to ensure all employees were checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property as required. This had the potential to affect all 114 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel file for Registered Nurse (RN) #548 revealed a hire date of 03/28/22. There was no printed evidence of RN #548 being checked against the NAR prior to or on the first day of work/hire. Review of the personnel file for RN #547 revealed a hire date of 06/13/22. There was no printed evidence of RN #547 being checked against the NAR prior to or on the first day of work/hire. Review of the personnel file for Licensed Practical Nurse (LPN) #569 revealed a hire date of 07/05/22. There was no printed evidence of LPN #569 being checked against the NAR prior to or on the first day of work/hire. On 08/31/22 at 9:05 A.M. interview with Director of Nursing (DON) and RN #578 confirmed screening/checking employees through the Ohio Nurse Aide Registry for abuse, neglect, exploitation, and misappropriation were not completed for LPN #569, RN #547, and RN #548 prior to or on the first date of hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. DON further verified the facility checked nursing assistants through the NAR but not all individuals prior to or on the first date of hire. Review of the facility policy titled Abuse and Neglect, revised 06/03/22, revealed the facility will not employ individuals who have a finding of abuse, neglect, or misappropriation of property in the State Nurse Aide Registry. Page 1 of 3 365574 365574 09/01/2022 Crandall Nursing Home 800 S 15th St Sebring, OH 44672

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, policy review and staff interview, the facility failed to ensure resident re-weights were obtained to verify accuracey of weight changes per facility policy. This affected one (Resident #101) of five residents reviewed for nutrition. The facility census was 114. Residents Affected - Few Findings included: Review of Resident #101's medical record revealed an admission date of 03/17/22 with diagnoses including end stage renal disease and hypertension. Further review of the medical record including weight recording identified on 03/26/22 the resident's weight was 280.4 pounds. The next weight recorded on 04/14/22 was 286.8 pounds, a difference of 6.4 pounds from the prior weight. On 04/28/22 the weight recorded was 293.8 pounds, a difference of seven pounds from the prior weight. On 05/07/22 the weight recorded was 279.6 pounds, a difference of 14.2 pounds from the prior weight. On 05/14/22 the weight recorded was 286.6 pounds, a difference of seven pounds from the prior weight. On 05/21/22 the weight recorded was 284.6 pounds. On 07/02/22 the weight recorded was 274.6 pounds, a difference of 10 pounds from the prior weight. On 07/16/22 the weight recorded was 289.6 pounds, a difference of 15 pounds from the prior weight. On 07/30/22 the weight recorded was 273.6 pounds, a difference of 16 pounds from the prior weight. On 08/06/22 the weight recorded was 290.0 pounds, a difference of 16.4 pounds from the prior weight. On 08/13/22 the weight recorded was 264.8 pounds, a difference of 25.2 pounds from the prior weight. On 08/20/22 the weight recorded was 266.2 pounds. On 08/27/22 the weight recorded was 259.2 pounds, a difference of seven pounds from the prior weight. Review of the facility policy Weight Policy and Procedure with an updated date of 07/13/22 indicated if the weight had a five pound variance or more, either up or down, the nurse aide would be responsible to re-weigh the resident in 24 hours. Interview with the Director of Nursing on 08/31/22 at 1:10 P.M. verified staff did not obtained re-weights for Resident #101 to confirm accuracy of weights per the facility policy. 365574 Page 2 of 3 365574 09/01/2022 Crandall Nursing Home 800 S 15th St Sebring, OH 44672

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on medical record review and staff interview the facility failed to ensure hospice records including certification, assessments and visitation notes were available to the facility staff for collaborative care and services to Resident #101. This affected one (Resident #101) of two residents reviewed for hospice services. The facility census was 114. Findings included: Review of Resident #101's medical record revealed an admission date of 03/17/22 with diagnoses including end stage renal disease and hypertension. Further review of the medical record revealed a physician's order dated 08/05/22 to admit the resident to hospice services by Southern Hospice. Further review of the medical record including paper medical chart in the nursing office found no evidence of any type of hospice certification paperwork, hospice assessments or hospice visitation notes. Interview with Unit Secretary #504 on 09/01/22 at 9:45 A.M. verified there was no evidence of any hospice certification paperwork, assessments and/or visitation notes in the resident's medical record or a separate binder located in the nursing office. 365574 Page 3 of 3