Health inspection·November 21, 2019

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure confidential medical information was maintained in a safe and secure manner. This affected one resident (#137) of one resident reviewed for privacy. Residents Affected - Few Findings include: Review of the medical record for Resident #137 revealed an admission date of 10/30/19 with diagnoses including major depressive disorder, dementia, heart disease, mass and/or lump in neck, obstructive and reflux uropathy, anemia, moderate protein-calorie malnutrition. Review of most current Minimum Data Set (MDS) 3.0 assessment, dated 11/06/19 revealed the resident exhibited cognitive impairment with a Brief Interview for Mental Status (BIMS)score of three. Interview on 11/18/19 at 10:54 A.M. with Resident #137's daughter revealed when she arrived to take her mother to a cardiologist appointment her packet of information was not available. Licensed Practical Nurse (LPN) #269 told her it was given to the family that left earlier to another appointment. Resident #137's information was printed again and she left to the appointment with her mother. Interview on 11/21/19 at 9:03 A.M. with the Director of Nursing (DON) reported being present when the information needed printed out again for Resident #137's daughter and she thought that was unusual. The DON revealed the printed information that had been printed prior had been given to another resident's family. Interview on 11/21/19 at 9:44 A.M. with Office Personnel #290 revealed she scheduled the appointments, printed out the required documents prior to the appointment, placed the information in an envelope and delivered the envelopes to the units the day before the appointment date. She reported on this date, Resident #137's envelopes was stuck to another resident's information and both packets were given to the other resident's family member. Interview on 11/21/19 12:18 P.M. LPN #269 revealed she worked the day the information was given to the wrong family. She did not realize she had given Resident 137's envelope of information to the wrong family. She discovered it was not available when she could not find it for Resident #137 and her daughter. LPN #269 left the floor to print out the required documents and while she was gone, the pharmacy tech was able to print out the information after confirmation from the DON. She stated both parties returned to the facility but did not know what happened to the documents. Review of the Notice of Privacy Practices policy, reprinted from the HIPAA Privacy Reference Manual, revealed how medical information may be used and disclosed and how you can get access to this Page 1 of 5 365800 365800 11/21/2019 Chardon Woods 12340 Bass Lake Road Chardon, OH 44024

F 0583 Level of Harm - Minimal harm or potential for actual harm information. Included were sections on: Understanding your health record and information, How we may use and disclose protected health information, Other allowable uses of your health information, Other uses if health information, Your rights regarding health information about you, Our responsibilities, Changes to this notice and Complaints. Residents Affected - Few 365800 Page 2 of 5 365800 11/21/2019 Chardon Woods 12340 Bass Lake Road Chardon, OH 44024

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 observation, record review and interview the facility failed to ensure Resident #118, who sustained significant weight loss, was cued to eat or offered a substitute during meals. This affected one resident (#118) of four residents reviewed for nutrition. Residents Affected - Few Findings include: Record review revealed Resident #118 was admitted to the facility on [DATE] with diagnoses including dementia, depression and non-infective gastroenteritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/17/19 revealed the resident was cognitively impaired and required the assistance of one staff for eating. The assessment also indicated the resident had a weight loss of 5% or more in one month and or a loss of 10% over six months. Review of the resident's care plan, dated 10/17/19 revealed the staff were to offer meal substitutes when foods were refused. Review off the physician's orders revealed the resident was ordered a regular diet, and supplements of fortified cereal (11/18/19), frozen nutritional treat twice a day (09/27/19) and a nutritional drink three times a day (07/29/19). Review of the November 2019 medication administration record (MAR) revealed the resident drank 100% of the nutritional drink, except three occurrences were she drank 50%. The supplement of a frozen treat was eaten 100% of 22 times and less than 25% 18 times. Review of the resident weights revealed the resident had a six month weight loss of 13.67% between 06/17/19 and 11/18/19 and a three month weight loss of 14.29% between 09/03/19 and 11/18/19. On 11/18/19 at 12:00 P.M. an observation of the lunch meal revealed Resident #118 pushed away the plate of cabbage, buttered noodles, ham and corn bread that had been served to her. At 12:08 P.M. the resident had eaten half the ham and a couple of forks of cabbage, approximately 10% of the total meal. At no time was the resident cued to continue eating or offered a substitute. On 11/20/19 at 8:30 A.M. observation of the breakfast meal revealed the resident refused the breakfast meal and was not offered a meal substitution. Review of the State tested nursing assistant (STNA) documentation for breakfast reflected the resident had refused the meal. Interview on 11/21/19 at 10:44 A.M. with Dietitian (RDLD) #222 revealed she monitored the intake of the supplements and revealed Resident #118 was on weekly weights. When asked if substitutes were brought down on the steam cart and made available to the residents she stated she wasn't sure if the substitutes were on the steam table. Interview on 11/21/19 at 10:50 A.M. with Dietary Manager (DM) #223 revealed staff ask the residents the day before if they want to substitute meals, and if they do, he makes sure they are on the steam table. In regards to residents who had dementia and might not know or remember if they wanted a meal substitution, he stated there were always substitutes in the kitchen and the staff only needed to 365800 Page 3 of 5 365800 11/21/2019 Chardon Woods 12340 Bass Lake Road Chardon, OH 44024

F 0692 call the kitchen. He stated substitutes were not automatically placed on the steam cart. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365800 Page 4 of 5 365800 11/21/2019 Chardon Woods 12340 Bass Lake Road Chardon, OH 44024

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 observation and interview the facility failed to ensure the kitchenette on the G unit was maintained in a clean and sanitary manner and in good repair to prevent contamination and/or food borne illness. This had the potential to affect 30 residents (#3, #9, #10, #12, #22, #25, #30, #35, #37, #38, #39, #40, #50, #67, #69, #70, #73, #76, #77, #78, #79, #80, #85, #88, #92, #94, #113, #114, #118 and #123) of 142 residents residing in the facility. Findings include: During a kitchen tour on 11/20/19 at 9:24 A.M. two kitchenette were observed on the G unit. The left side which contained higher room numbers had a toaster with loose debris and water mark type stains, the outside of the microwave had smears of food residue on the top and sides The counter tops in both kitchenettes were stained with multiple round brown and red stains and the finish on the top of the counter had worn away leaving an unclean surface. In addition, a refrigerator with a broken off door handle that left behind sharp broken hard plastic was also observed. The dish washing and storage area contained an ice machine with a clogged drain in the spill reservoir leaving 1/4th of an inch of standing water beneath the ice shoot. There was a side by side freezer which [NAME] #207 stated hadn't worked since June of 2018. The refrigerator on right side read 46 degrees on the outside thermometer, but, there wasn't a thermometer on the inside. The above concerns were verified with State tested nursing assistant (STNA) #370, STNA #356 and [NAME] #207 at the time of the observation. On 11/21/19 at 8:42 A.M. the observation of the right side refrigerator revealed there still was no thermometer inside the refrigerator and the outside thermometer again read 46 degrees. The refrigerator was noted to be running loudly with a slight knocking noise. A pool of standing water was observed on the bottom of the refrigerator with two cases of canned soda sitting in the standing water. [NAME] #210 verified the temperature and standing water . He stated the refrigerator was defrosting and that was why it made that loud rattling noise. During an interview on 11/21/19 at 10:50 A.M. Dietary Manager (DM) #223 revealed he would check the refrigerator to ensure a thermometer had been placed inside and to check on the standing water. At 11:12 P.M. DM #223 revealed he had placed a thermometer in the refrigerator and it had also read 46 degrees indicating the supplements and perishable food inside were not stored at the proper temperature and had been disposed of. He stated the refrigerator had malfunctioned. The facility identified 30 residents, Resident #3, #9, #10, #12, #22, #25, #30, #35, #37, #38, #39, #40, #50, #67, #69, #70, #73, #76, #77, #78, #79, #80, #85, #88, #92, #94, #113, #114, #118 and #123 who resided on the G unit. 365800 Page 5 of 5