Health inspection·January 15, 2020

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide the residents on the Taft unit with appropriate water containers. This affected Resident #68 and Resident #316 and affected 25 of 26 other residents on the Taft unit, Residents #10, #29, #30, #33, #42, #43, #52, #61, #83, #85, #86, #88, #89, #95, #96, #104, #105, #117, #126, #135, #136, #146, #160, #162, and #420. Resident #9 received thickened liquids and was not permitted a water pitcher/cup. The facility census was 167. Residents Affected - Some Finding include: Observation on 01/12/20 from 9:58 A.M. through 11:51 A.M. revealed residents on the Taft unit did not have water pitchers or dedicated cups for water in their rooms. No individual water pitchers or large cups were noted in the common areas. A water pitcher with small clear plastic cups was at the nurse's station for residents to get water. Interview on 01/12/20 at 10:32 A.M. with Resident #68 revealed she saved used pop bottles to put water in for her room. An observation at that time revealed Resident #68 had a pop bottle with water on her over bed table. No water pitcher or water cups were noted in her room. Interview on 01/13/20 at 11:58 A.M. with Resident #316 revealed his family brought him food and a beverage from an outside restaurant. Resident #316 stated he was keeping his cup so he could put water in it to keep in his room. No water pitcher or water cups were noted in his room. Interview on 01/13/20 at 1:25 P.M. with Resident #4, during the resident council meeting, revealed all residents were not provided individual cups or water pitchers. Resident #4 stated some residents had to go to the nurse's station to ask for water. Interview on 01/14/20 at 8:38 A.M. with State Tested Nursing Assistant (STNA) #411 revealed residents had water pitchers but often left them sitting around where other residents could take them. STNA #411 stated there was a resident on the Taft unit that received thickened liquids so it was not safe for residents to leave their water pitchers or cups sitting in the common areas. STNA #411 verified Resident #9 was the only resident on the Taft unit that received thickened liquids and would not have a water pitcher or cup provided at the bedside. Interview on 01/14/20 at 8:43 A.M. with Licensed Social Worker (LSW) #200 confirmed there were not individual water pitchers for residents on the Taft unit because there were residents with orders for thickened liquids. Interview on 01/14/20 at 11:59 A.M. with the Director of Nursing (DON) revealed she was not sure Page 1 of 11 365655 365655 01/15/2020 McKinley Nursing 800 Market Avenue North Suite 1560 Canton, OH 44702

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some why there were no individual water pitchers or cups provided for residents on the Taft unit. The DON stated it could be because of residents with fluid restrictions, thickened liquids, or behaviors. Review of the policy and procedure for Serving Drinking Water, dated August 2008, revealed the purpose was to provide residents with a fresh supply of drinking water and to provide adequate fluids for the residents. The necessary equipment and supplies included a water pitcher and cup. 365655 Page 2 of 11 365655 01/15/2020 McKinley Nursing 800 Market Avenue North Suite 1560 Canton, OH 44702

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many 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 record review and interview, the facility failed to ensure Residents #78 and #167 were notified in writing the reason for the discharge in an easily understood language. This affected two (Residents #78 and #167) of four resident records reviewed for hospitalization and had the potential to affect all 168 residents residing in the facility. Findings include: 1. Review of Resident #78's medical record revealed the resident was admitted to the facility on [DATE], discharged to the hospital on [DATE] and returned to the facility on [DATE] with diagnoses including aspiration pneumonia, weakness and anemia. Review of Resident #78's Minimum Data Set (MDS) 3.0 assessment dated [DATE] confirmed the resident had a memory problem. Review of Resident #78's progress note dated 12/10/19 at 9:45 A.M. indicated the emergency technicians transported the resident to the hospital and a report was given to the resident's significant other. Resident #78's medical record did not contain evidence the resident or family was notified in writing the reason for the discharge in an easily understood language. Interview on 01/13/20 at 4:49 P.M. with Admissions Coordinator #802 confirmed the resident or family were not notified in writing the reason for the discharge to the hospital in an easily understood language. 2. Review of Resident #167's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses including anemia and depression. Review of Resident #167's progress note dated 11/18/19 at 9:19 A.M. indicated on 11/15/19 the resident was admitted to the hospital for respiratory failure. Resident #167's medical record did not contain evidence the resident or the resident's representative were notified in writing the reason for the discharge to the hospital in an easily understood language. Interview on 01/13/20 at 4:53 P.M. with Admissions Director #802 confirmed Resident #167's family were not notified in writing the reason for the discharge in an easily understood language. 365655 Page 3 of 11 365655 01/15/2020 McKinley Nursing 800 Market Avenue North Suite 1560 Canton, OH 44702

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Residents #78 and #167 were provided written notification of the bed-hold policy upon discharge to the hospital. This affected two of four resident records reviewed for hospitalization and had the potential to affect any of the 168 residents residing in the facility. Findings include: 1. Review of Resident #78's medical record revealed the resident was admitted to the facility on [DATE], discharged to the hospital on [DATE] and returned to the facility on [DATE] with diagnoses including aspiration pneumonia, weakness and anemia. Review of Resident #78's Minimum Data Set (MDS) 3.0 assessment dated [DATE] confirmed the resident had a memory problem. Review of Resident #78's progress note dated 12/10/19 at 9:45 A.M. indicated the emergency technicians transported the resident to the hospital and a report was given to the resident's significant other. Resident #78's medical record did not contain evidence the resident or family were notified in writing of the bed-hold policy at the time of transfer to the hospital or within twenty-four hours as required. Interview on 01/13/20 at 4:49 P.M. with Admissions Coordinator #802 confirmed Resident #78's family was not provided the written bed-hold policy during the transfer to the hospital or within twenty-four hours as required. 2. Review of Resident #167's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses including anemia and depression. Review of Resident #167's progress note dated 11/18/19 at 9:19 A.M. indicated on 11/15/19 the resident was admitted to the hospital for respiratory failure. Resident #167's medical record did not contain evidence the resident or family were notified in writing of the bed-hold policy at the time of transfer to the hospital or within twenty-four hours as required. Interview on 01/13/20 at 4:53 P.M. with Admissions Director #802 confirmed Resident #167's or the resident's family were not notified of the bed-hold policy upon discharge to the hospital or within twenty-four hours as required. 365655 Page 4 of 11 365655 01/15/2020 McKinley Nursing 800 Market Avenue North Suite 1560 Canton, OH 44702

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to assess, monitor and treat Resident #20's left lower leg scar and wounds. This affected one out of three residents reviewed for skin issues. Residents Affected - Few Findings include: Resident #20 was admitted on [DATE] with diagnoses including heart disease, traumatic brain injury following a motor vehicle accident, schizophrenia, dementia, morbid obesity and cognitive communication deficit. An interview with Resident #20 on 01/12/20 at 10:41 A.M. indicated he had sustained an injury to his lower left leg and had developed a clot from a car accident in the past. An observation at the time of the interview revealed Resident #20's left lower leg had a large discolored scarred area (approximately 4 centimeters wide by 6 centimeters long) with two scabbed areas on each end of the scar. The scarred skin had skin that was peeling off in powdery flakes. Review of Resident #20's nursing assessments and physician assessments dated 09/01/2019 to 01/13/20 revealed no documentation or his left lower leg wounds or scar. Resident #20's clinical record had no plan of care or interventions to care for the left lower leg scar or scabbed areas/wounds. An interview with Licensed Practical Nurse (LPN) #709 on 01/13/20 at 2:20 P.M. verified there was no treatment ordered by the physician to care for Resident #20's left lower leg scar and wounds. An observation and interview with Resident #20 with LPN #709 present, at the time of the interview, verified his left lower leg scar was flaking and had two scabbed areas on each end of the scar. Resident #20 indicated the scar bothered him sometimes and he said he rubbed and scratched the area due to pain and itching. LPN #709 indicated Resident #20 had not complained to her about the scarred area and said she hadn't noticed the scar with two scabbed areas and flaking. LPN #709 agreed some kind of skin treatment needed ordered to care for these areas. An interview with the Director of Nursing on 01/13/20 at 3:30 P.M. verified the above findings. 365655 Page 5 of 11 365655 01/15/2020 McKinley Nursing 800 Market Avenue North Suite 1560 Canton, OH 44702

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** Based on observation, record review and interview the facility failed to ensure Resident #47's and Resident #78's pressure ulcer treatments were provided as ordered by the physician. This affected two out of three residents reviewed for pressure ulcers. Residents Affected - Few Findings include: 1. Resident #47 was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral vascular accident (stroke)affecting the non-dominant side, respiratory disease, heart disease, Alzheimer's disease, schizophrenia, anxiety and depression. Review of Resident #47's wound assessment dated [DATE] indicated a stage III pressure ulcer (a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to underlying fascia and presents as a deep crater with or without tunneling or undermining of adjacent tissue) on the left heel measuring 0.5 centimeters (cm) long by 2.0 cm wide and 0.2 cm deep. The wound assessment dated [DATE] indicated a stage III pressure ulcer was present on his/her coccyx area and measured 0.4 centimeters (cm) long by 0.1 cm wide and 0.2 cm deep. A review of Resident #47's physician orders dated 01/01/20 to 01/31/20 revealed an order dated 01/08/20 for a wound treatment to the left heel and coccyx pressure ulcers. The physician orders directed nursing staff to cleanse the left heel ulcer with wound cleanser and apply skin prep spray and cover with Tegaderm foam adhesive dressing daily and as needed. The other treatment was to cleanse the coccyx ulcer with wound cleanser and apply Medi-honey and cover with foam Tegaderm adhesive dressing once a day. An observation on 01/15/20 at 10:58 A.M. of Resident #47's incontinence care, performed by State Tested Nursing Assistant (STNA) #401 and STNA #609, revealed no dressing covering the coccyx ulcer and the left heel dressing was dated 01/13/20. STNA #401 and STNA #609 verified these observations. Review of Resident #47's treatment administration record (TAR) from 01/01/20 to 01/31/20, with the Assistant Director of Nursing (ADON), revealed Resident #47's left heel and coccyx pressure ulcer treatments were not signed as completed by nursing staff on 01/14/20. 2. Review of Resident #78's medical record revealed an admission to the facility on [DATE] with diagnoses including aspiration pneumonia, weakness and anemia. Review of Resident #78's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had a memory impairment. Review of Resident #78's physician orders revealed an order dated 01/02/20 for nursing staff to cleanse the coccyx pressure ulcer with wound cleanser, apply a nickel-thick amount of Santyl ointment (a debriding agent) and cover with Calcium Alginate (absorbent agent) and a foam dressing daily and as needed. Observation on 01/13/20 at 3:07 P.M. with Licensed Practical Nurse (LPN) #803 revealed the resident was turned to complete the pressure ulcer care. There was no dressing to Resident #78's coccyx pressure ulcer. Resident #78 was observed lying on a sheet saturated with urine. There was no dressing observed in the bed or on the floor. 365655 Page 6 of 11 365655 01/15/2020 McKinley Nursing 800 Market Avenue North Suite 1560 Canton, OH 44702

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/13/20 at 3:15 P.M. with LPN #803 confirmed Resident #78's wound care dressing was not in place at the time of the observation and he was unable to determine how long the resident had been lying on the urine soaked sheets without a dressing to cover the coccyx pressure ulcer. LPN #803 confirmed there was no dressing in the bed or on the floor at the time of the observation. Interview on 01/14/20 at 10:30 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON) #804 confirmed she was not informed by care staff that Resident #78's wound care dressing had been removed or come off. RN/ADON #804 indicated she was unaware of how long Resident #78 lay in the urine soiled bedding with no dressing on his coccyx ulcer. 365655 Page 7 of 11 365655 01/15/2020 McKinley Nursing 800 Market Avenue North Suite 1560 Canton, OH 44702

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure all state tested nurse aides (STNAs) completed twelve hours of in-service education annually. This affected one of three STNA's reviewed who had been employed greater than one year. This had the potential to affect all 28 residents residing on the Taft unit, Residents #9, #10, #29, #30, #33, #42, #43, #52, #61, #68, #83, #85, #86, #88, #89, #95, #96, #104, #105, #117, #126, #135, #136, #146, #160, #162, #316 and #420. The facility census was 167. Residents Affected - Some Findings include: Review of the personnel record for STNA #407 revealed a hire date of 04/08/16. There was no documentation found to indicate STNA #407 had received at least 12 hours of continuing education for the last annual period of 04/08/18 through 04/08/19 as required. On 01/15/20 at 1:35 P.M., interview with the Human Resource (HR) Director confirmed STNA #407 did not have any paper documenting of continuing education in the personnel file for the review period. The HR Director said staff also uses the computer based education program called Relias to complete continuing education. Review of the completed education on the Relias program for STNA #407 revealed no education was completed for the review period. This was verified at that time with the HR director. STNA #407 was assigned to work on the Taft unit which had 28 residents, Residents #9, #10, #29, #30, #33, #42, #43, #52, #61, #68, #83, #85, #86, #88, #89, #95, #96, #104, #105, #117, #126, #135, #136, #146, #160, #162, #316 and #420. 365655 Page 8 of 11 365655 01/15/2020 McKinley Nursing 800 Market Avenue North Suite 1560 Canton, OH 44702

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure insulin vials were dated when opened. This affected one Resident (#110) out of five residents reviewed for insulin storage on the [NAME] unit. The facility census was 167. Findings include: Review of the medical record revealed Resident #110 was admitted on [DATE] with diagnoses including diabetes mellitus. Review of physician orders for January 2020 revealed Resident #110 was ordered Levemir (insulin) 26 units, injected subcutaneously (SQ), at bedtime, Novolog (insulin) 25 units SQ in the morning, 13 units SQ in the afternoon, and 16 units SQ in the evening. Observation on 01/15/20 at 11:06 A.M. of the medication cart on the [NAME] unit revealed open vials of Levemir and Novolog insulin for Resident #110. There were no dates on these insulin vials to indicate the date they were opened. Interview on 01/15/20 at 11:06 A.M. with Registered Nurse #600 verified Resident #110's Levemir and Novolog insulin vials were open and undated. This concern was verified with the nurse. Review of the pharmacy list of expiration dates for insulin revealed Levemir insulin expires 42 days after the vial was opened and Novolog insulin expires 28 days after the vial was opened. 365655 Page 9 of 11 365655 01/15/2020 McKinley Nursing 800 Market Avenue North Suite 1560 Canton, OH 44702

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 and interview the facility failed to maintain the kitchen in a sanitary manner. This affected 166 of 167 residents residing in the facility. Resident #78 was identified as ordered nothing by mouth to eat or drink. Findings include: Observation of the kitchen was conducted during the initial tour on 01/12/20 from 8:30 A.M. to 9:00 A.M. with Dietary Manager #102. The following concerns were observed and verified with Dietary Manager #102 at that time: 1. There was a soiled cleaning cloth hanging on the side of a plastic storage container. Inside the storage container were clean scoops and a zip-lock bag of saltine crackers. The Dietary Manager #102 indicated the container was for resident snacks and verified the soiled cloth should not be there. 2. There was a steel pan with slices of bread covered with plastic wrap which was not dated. Dietary Manger #102 indicated they were drying the bread for bread crumbs but verified the bread should have been dated. 3. There was a drain in front of the ovens with a steel cover which was visibly dirty underneath with food debris and leaves. 4. There were no lids on either of the two trash cans. 5. There was a plastic tub with the clean steel steam table lids in it. The tub was littered with food debris and small pieces of paper. There was a trash can without a lid right beside this shelf. Dietary Manger #102 indicated he did not know why the trash can was placed right beside the clean steam table pans and lids. 6. There was a four tier black cart, two gray three tier carts (one had the cartons of milk on it being served to the residents) and a small three tier steel cart. All of the carts were soiled with dried liquid spills and food debris. 7. There were two gray meal tray transportation carts and one steel meal tray transportation cart. They had visible dirt with dried food and dried liquid spills on the inside and outside. 8. In the salad refrigerator, there was one plastic container of sliced black olives and one plastic container of sliced onions covered with plastic wrap. They were not dated when opened/cut. 9. There was a five pound container of cottage cheese with the expiration date 01/05/20 in the walk-in refrigerator. 10. There was a pack of hot dog buns on the bread rack with green mold observed on the buns. 11. There was an old used tea bag laying on the the dish rack where the clean dishes are stored after they come out of the dish washer. 365655 Page 10 of 11 365655 01/15/2020 McKinley Nursing 800 Market Avenue North Suite 1560 Canton, OH 44702

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 observation, record review and interview, the facility failed to ensure Resident #110's medical record included documentation the resident was provided wine per the physician order. This finding affected one (Resident #110) of thirty-five resident records reviewed for documentation. Findings include: Review of Resident #110's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, diabetes and anxiety. Review of Resident #110's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited moderate cognitive impairment. Review of Resident #110's physician order dated 05/13/19 indicated the resident may have a glass of wine with dinner once a day as needed and the family was to provide the wine. Review of Resident #110's medication administration record (MAR) from 01/01/20 to 01/15/20 did not reveal evidence the resident received the wine. Interview on 01/12/20 at 12:39 P.M. with Resident #110 indicated she should have wine every night after dinner and sometimes she did not receive the wine. Observation of the medication storage room on 01/15/20 at 10:18 A.M. with Registered Nurse (RN) #801 revealed 13 bottles of Sutter Home Sweet Riesling California Wine, single serve size bottles, 187 milliliters each, which is just over six ounces each. Interview on 01/15/20 at 10:28 A.M. with Resident #110's guardian confirmed she delivered 16 bottles of wine to the facility on [DATE]. Although 16 bottles of wine were delivered on 01/10/20, there were only 13 bottles of wine remaining and there was no documentation to indicate wine was provided to Resident #110 in January 2020. Interview on 01/15/20 at 10:40 A.M. with the Director of Nursing (DON) confirmed the facility staff should be charting on the MAR when Resident #110 received the wine. She said nursing staff had been providing the resident the wine upon request and confirmed the resident's medical record did not reflect the resident's actual wine consumption. 365655 Page 11 of 11