Health inspection·February 14, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, policy review and interview, the facility failed to ensure a dignified dining experience for residents that ate in the main dining room. Residents (#2, #3, #8, #11, #12, #14, #15, #16, #17, #19, #24, #28, #29, #30, #31, #33, #38, #40, #41, #43, #46, #152, #199, and #247) ate meals in the dining room sitting at three long tables. State Tested Nursing Assistants (STNA) served entrees to the residents by tickets switching from table to table with not all residents served by table. This affected all 24 residents that ate in the main dining room. Findings include: Observations during meal service for lunch in the main dining room on 02/10/19 from 11:35 A.M. through 12:50 P.M. revealed that residents were served by STNAs by tickets switching from table to table with not all residents served by table. This was verified by Registered Dietitian #148 at 12:50 P.M. Interview with Registered Dietitian on 02/10/19 at 12:50 P.M. verified that all residents should be served table to table. Review of policy entitled, The Briarwood Dining Room Meal Service, dated 11/18, revealed that each resident at a table should be served before moving to a new table. Page 1 of 16 365858 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

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 accommodate a proper fitting mattress for Resident #42. This affected one resident out of the 48 residents that were screened during Phase I of the annual survey. Residents Affected - Few Findings include: Review of Resident #42's medical record revealed an admission date of 03/31/17 and a readmission date of 01/09/18. Diagnoses included heart failure, chronic kidney disease, diabetes mellitus, hypertension, and peripheral vascular disease. An admission height was obtained on 01/09/18 of 74.0 inches. Review of Resident #42's Minimum Data Set (MDS) 3.0 assessment, dated 01/20/19, revealed the resident exhibited moderate cognitive impairment. Observation on 02/10/19 at 9:40 A.M. Resident #42 was lying in bed with his heels resting on the footboard of the bed and stated he was uncomfortable. Licensed Practical Nurse (LPN) #113 verified that Resident #42 had his heels resting on the foot board of the bed and stated that she had told them Resident #42 needed a bigger bed before. Observation on 2/11/19 at 1:21 P.M. Social Worker (SW) #143 with this surveyor observed Resident #42 lying in bed with his heels resting on the footboard of the bed. SW #143 asked Resident #42 if he wanted a bigger bed, and he stated yes. Interview on 2/11/19 at 1:47 P.M. with Executive Director (ED) revealed that the bed was the correct height, but the mattress was not, and a new mattress had been ordered. He stated that the mattress currently on Resident #42's bed was 76 inches and the new one would be 80 inches. On 2/12/19 at 12:30 P.M. interview and record review with ED revealed that an extra-large mattress was ordered and delivered on 02/11/19 at 4:08 P.M. to Resident #42's room. Interview and observation on 2/12/19 at 1:15 P.M. with Resident #42 revealed that his feet were not resting on the foot board of the bed. Resident #42 stated that he liked his new mattress. 365858 Page 2 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, interviews, policy review, and review of the wheelchair cleaning schedule, the facility failed to ensure resident care equipment was maintained in a clean and sanitary manner. This affected Resident #22 and Resident #43. The facility census was 48. Findings include: On 02/12/19 at 9:45 A.M. observation revealed dried food items on the bars and seat of a black electric wheelchair in the hallway and on Resident #43's wheelchair. On 02/12/19 at 9:45 A.M. Minimum Data Set Nurse (MDS Nurse) #154 verified a black electric wheelchair in the hallway and the wheelchair of Resident #43 had dried food on the bars and seat of the chairs. On 02/12/19 at 9:49 A.M. an interview with Licensed Practical Nurse (LPN) #113 verified dried food on the bars and seat of Resident #43's wheelchairs. On 02/12/19 at 11:07 A.M. observation of Resident #22's tube feeding equipment revealed the pole holding the tube feeding pump and the tube feeding bag with solution had a moderate amount of dried tan material (same color as the tube feeding solution infusing) on the base of the pole. On 02/12/19 at 11:19 A.M. an interview with the Director of Nursing (DON) verified dried tube feeding solution on the base of the resident's tube feeding pole. Review of the Cleaning and Disinfection of Resident - Care Items and Equipment policy, dated 07/2014, revealed that non-critical and reusable resident care equipment such as wheelchairs and tube feeding poles are to be cleaned. Review of the Wheelchair Cleaning Schedule, undated, revealed all resident wheelchairs are scheduled to be cleaned on specific days of the week based on the resident's room number. The schedule revealed the wheelchairs were to be wiped down after the resident goes to bed, if the wheelchair is dirty or has developed an odor. 365858 Page 3 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure a thorough investigation was completed for Self-Reported Incident (SRI), tracking number 162350. This affected one of two SRI's reviewed during the annual survey. The facility census was 48. Residents Affected - Few Findings revealed: Review of the facility investigation for SRI tracking number 162350 revealed only the comments and information sent to the State of Ohio on 10/14/18. There were no interviews of facility staff and residents, and no resident assessments. On 02/13/19 at 2:55 P.M. an interview with the Director of Nursing (DON) verified the lack of investigation for SRI tracking number 162350. The DON verbalized he was not employed at this facility at the time of the incident on 10/14/18 and verbalized attempts to reach the previous DON by phone were unsuccessful. The DON verbalized there was no additional information regarding the incident on 10/14/18 other than what is noted in the self-reported incident report submitted to the State of Ohio. On 02/14/19 at 11:20 A.M. Social Worker (SW) #143 verified the Weekend Manager on Duty notes for 10/14/18 revealed no investigation was completed for SRI tracking number 162350. Review of the Weekend Manager on Duty notes for 10/14/18 revealed no interviews or investigation was completed for SRI tracking number 162350. 365858 Page 4 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0641 Ensure each resident receives an accurate 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 comprehensive assessments were accurate. This finding affected four (Residents #5, Resident #21, Resident #27 and Resident #42's) of twenty-three resident records reviewed for comprehensive assessments. The facility census was 48. Residents Affected - Some Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), spastic quadriplegia, major depressive disorder, and anxiety. The record further revealed the resident took nothing by mouth. Review of Resident #5's medical record revealed the Minimum Data Set (MDS) 3.0 assessment, dated 11/09/18, revealed the resident was assessed as needing extensive assistance of one person for feeding. Further record review revealed the resident received all nutrition through a tube feeding and was totally dependent on staff for tube feedings. On 02/12/19 at 4:57 P.M. an interview with MDS Nurse #154 verified the comprehensive assessment completed on 11/09/18 did not accurately reflect Resident #5 was totally dependent on staff for tube feedings. 2. Review of Resident #21's medical record revealed the resident was admitted on [DATE] with diagnoses including atrial fibrillation, high blood pressure, diabetes, Alzheimer's disease, depression, and seizures. Review of Resident #21's MDS 3.0 comprehensive assessment, dated 12/28/18, revealed the resident was not receiving hospice services. Review of Resident's medical record revealed a physician order dated 11/28/18 indicated the resident was admitted to hospice with a life expectancy of six months or less. On 02/13/19 at 4:12 P.M. an interview with MDS Nurse #154 verified Resident #21's comprehensive assessment completed on 12/28/18 did not accurately reflect the resident was admitted to hospice services, and the resident's life expectancy was six months or less. 3. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including altered mental status, Alzheimer's disease, severe protein calorie malnutrition, and dementia. Review of Resident #27's MDS 3.0 assessment, dated 01/04/19, revealed the resident did not have a prognosis of less than six months and was not receiving hospice services. Review of Resident #27's medical record revealed a physician order from 11/02/18 for admission to hospice services for severe protein calorie malnutrition. On 12/14/19 at 8:23 A.M. an interview with MDS Nurse #154 confirmed Resident #96's comprehensive assessment completed on 01/04/19 was inaccurate, and the resident was receiving hospice services with a life expectancy of less than six months. 365858 Page 5 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Review of Resident #42's medical record revealed an admission date of 03/31/17 and a readmission date of 01/09/18. Diagnoses included heart failure, chronic kidney disease, diabetes mellitus, hypertension, and peripheral vascular disease. Review of Resident #42's MDS 3.0 assessment, dated 01/20/19, revealed the resident received injections seven-days of the seven-day assessment reference period. The assessment did not reflect that Resident #42 received injections of insulin. On 02/13/19 at 9:20 A.M. an interview with MDS Nurse #154 verified the comprehensive assessment completed on 01/20/18 did not accurately reflect Resident #42 was receiving injections of insulin. 365858 Page 6 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interviews and record reviews, the facility failed to ensure care plans reflected resident needs regarding medications and diagnoses. This affected four (Resident #28, Resident #32, Resident #34, and Resident #38) of twenty-three resident records reviewed. The facility census was 48. Findings include: 1. Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure, osteoporosis, chronic kidney disease, obesity, sleep apnea, repeated falls, diabetes, atrial fibrillation, high blood pressure, and major depressive disorder. Review of Resident #28's physician orders and medication administration records revealed the resident received Novolog, Levemir, and Humalog (insulin's) in addition to Eliquis (an anticoagulant) and Hydrochlorothiazide (a diuretic). Review of Resident #28's care plan revealed no focus areas, goals, or interventions for the anticoagulant, diuretic, and insulin medications the resident was receiving. On 02/13/19 at 2:30 P.M. an interview with the Director of Nursing (DON) confirmed Resident #28's care plan did not reflect the insulin, anticoagulant, and diuretic medications the resident was receiving. 2. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, dementia with behavioral disturbances, chronic obstructive pulmonary disease, depression, and fluid retention. Review of Resident #32's physician orders and medication administration records revealed the resident received Aripiprazole (an antipsychotic), Lexapro (an antidepressant), Eliquis (an anticoagulant), and Lasix (a diuretic). Review of Resident #32's intermediate care plan dated 12/24/18 (from the paper record) revealed no focus areas, goals, or interventions for dementia with behaviors, anticoagulant medication, antipsychotic medication, diuretic medication, or antidepressant medication. Review of Resident #32's electronic record revealed the care plan had no focus areas, goals, or interventions for diuretic medications or dementia with behaviors. On 02/14/19 at 10:38 A.M. MDS Nurse #154 verified the intermediate care plan and electronic care plan did not reflect the resident's diagnosis of dementia with behaviors and medications administered. 3. Review of Resident #34's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses of anxiety, atrial fibrillation, peripheral vascular disease, major depressive disorder, high blood pressure, and diabetes. 365858 Page 7 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #34's physician orders and medication administration record revealed the resident received insulin, Buspirone for anxiety, Trazodone for depression, Lasix (a diuretic) and Tramadol (an opioid pain medication). Review of Resident #34's electronic record revealed the care plan had no focus areas, goals, or interventions for insulin, antianxiety medication, antidepressant medication, diuretic medication, and pain medication. On 02/13/19 at 4:15 P.M. an interview with the DON verified the resident's care plan did not reflect the insulin, antianxiety, antidepressant, diuretic, and pain medications the resident was receiving. 4. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dysphagia, high blood pressure, dementia, peripheral vascular disease, and major depressive disorder. Review of Resident #38's physician orders and medication administration record revealed the resident received Buspirone (an antianxiety medication), Paroxetine and Mirtazapine (antidepressants), and Lasix (a diuretic). Review of Resident #38's care plan revealed no focus areas, goals, or interventions for antianxiety medication, antidepressant medication, and diuretic medications the resident was receiving. On 02/13/19 at 4:11 P.M. an interview with the DON verified the resident's care plan did not reflect the antianxiety, antidepressant, and diuretic medications the resident was receiving. 365858 Page 8 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on record review and interview, the facility failed to properly transfer a resident resulting in a fall with fracture. This affected one (Resident #21) of five residents reviewed for falls. The facility census was 48. Residents Affected - Few Findings Include: Review of the medical record revealed Resident #21 was admitted to this facility on 06/16/18. His admitting diagnoses included presence of cardiac pacemaker, history of falling, paroxysmal atrial fibrillation, hypertension, and Alzheimer's disease. Review of the Fall Risk Assessment, dated 06/16/18, revealed the resident was a high risk for falls. Review of the resident's care plan, dated 06/18/18, revealed the resident was at risk for falls related to impaired mobility, unsteady gait, and history of falls. An intervention dated 06/18/18 stated the resident should be transferred with the use of a gait belt and assist of one. Review of the nurse's note dated 07/31/18 at 8:10 P.M. revealed an unknown state tested nursing assistant (STNA) #900 was getting the resident out of his chair. She stood him up with the walker and no gait belt. She needed help from another STNA to get him cleaned up, so she stepped away from the resident and stepped to the door, approximately four feet away, to call for another STNA. Resident #21 lost his balance and fell to the floor. He landed laying on his back, beside his chair with his head resting on his trash can. The nurse stated she was walking down the hall and she was asked to come into the resident's room. The resident was lying on the floor beside his recliner chair with his head resting on his trash can. There were two STNAs in the room at that time. When the resident was asked if he was in any pain, he said that his right ribs hurt. He also stated that the rib pain did not hurt when he breathes but hurt when he moved. Resident #21 also sustained a bruise on the posterior portion of his elbow that partly extended up the back of his arm. Resident #21 had a superficial abrasion to the posterior portion of his neck. When the nurse asked STNA #900 what happened, she stated that she stood him up out of his chair with his walker and she stepped to the door for a moment to call for the other STNA to come and help her. The resident lost his balance and fell to the floor. The physician was notified of the fall. On 08/01/18 at 10:36 A.M. a chest x-ray was obtained for the resident's continued complaint of right rib pain. The results of the x-ray showed that the resident sustained a right sixth and seventh rib fracture. Review of the resident's progress notes dated 07/31/18 to 08/02/18 indicated the resident would yell out in pain during turning and repositioning. On 08/02/18, Clinical Nurse Practitioner (CNP) was emailed for resident's increase of pain. The resident rated his pain a 10 out of 10 (10 being the worst) that was unrelieved by Percocet (a narcotic pain medication) 5 milligrams (mg). A new order was received to increase his from Percocet 5/325 mg every six hours as needed to Percocet to 10/325 mg every four hours as needed for pain. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/05/18, prior to the fall revealed the resident had severe cognitive impairment. He required extensive assistance of two staff for toilet 365858 Page 9 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0689 use and transfers. He was non-ambulatory. Level of Harm - Minimal harm or potential for actual harm Interview with Physical Therapist (PT) #604 on 02/12/18 at 4:30 P.M. revealed at the time of the resident's fall on 07/31/18, the resident was being seen by physical therapy. He stated that as of 07/30/18 the resident required contact guard assist with transfers, contact guard assist is described as staff required to have one or two hands on the resident's body but provides no other assistance. The contact was made to help with balance. Residents Affected - Few Interview with Director of Nursing (DON) #200 on 02/13/18 at 10:30 A.M. revealed that he was not there at the time of the fall but verified the nursing documentation of the fall. DON #200 stated that he would contact former DON #201 to see if she was able to give additional information regarding this fall. DON #201 did email current DON #200 and verified STNA #900 did not use a gait belt during the transfer and left the resident unattended to walk to the door to call for assistance resulting in a fall with injury for Resident #21. 365858 Page 10 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on record review and interview, the facility failed to ensure urinary catheter changes were completed per the physician's order. This affected one resident (Resident #35) out of one resident reviewed for urinary catheters. The facility census was 48. Findings Include: Review of the medical record revealed Resident #35 was admitted to this facility on 01/06/18. His admitting diagnoses included obstructive sleep apnea, neurogenic bladder, cardiac pacemaker, quadriplegia, and stage IV pressure ulcers on the left and right buttocks (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/10/19, the resident was alert and oriented with no cognitive impairment. Functionally, he required extensive assistance for most of his activities of daily living. The bowel and bladder section of this MDS showed that the resident did have an indwelling urinary catheter. Review of the physician's orders revealed on 07/12/18 the physician ordered a 16 French Coude (type of catheter) to gravity drainage daily. The physician also ordered the catheter change needed to be done by the urologist or at the hospital, and call the physician for orders. The resident's Treatment Administration Record (TAR) also showed the same order with no documentation showing that this was completed as ordered. Further review of the urologist's record showed that on 11/13/18, the resident was seen by urology and the catheter was changed. Attached to this record was an additional order from the Certified Nurse Practitioner (CNP) dated 11/13/18 which stated the foley catheter changes were to be done by the facility using a 16 French Coude catheter every four weeks and as needed. This order was not listed on the physician orders or on the TAR. Interview with MDS Nurse #154, on 02/13/19 at 3:30 P.M. revealed that she could only provide paperwork showing that the catheter was changed in the physician's office on 11/13/18. When asked about changing the resident's catheter every four weeks per the order, she stated that they do not change the catheters according to their policy. They would change the catheter as needed. She further stated that the resident does not get his catheter changed at the facility but at the physician's office. Interview with the Director of Nursing (DON) on 02/13/19 at 4:00 P.M. revealed that he was unaware of the order from the CNP to change the foley catheter at the facility. When asked what was the most recent order from the urologist, he was unable to accurately state which order was valid. Interview with Medical Aide (MA) #800 at the urologist's office on 02/14/18 at 10:55 A.M. revealed that the most recent order for this resident was the order written on 11/13/18. MA #800 further stated that the CNP did document in her notes on that day that she talked to the DON at the facility to inform him the catheter changes were now to be done by the facility. She also wrote in her note that the DON verified that the facility did have Coude catheters. Further interview with the DON on 02/14/19 at 11:15 A.M. revealed that he did not remember the CNP 365858 Page 11 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0690 Level of Harm - Minimal harm or potential for actual harm telling him that the facility would now assume catheter changes. He stated he did remember telling her that the facility did have Coude catheters in stock. Further review of the TAR showed no documentation for the months of December 2018 and January 2019 that the catheter was changed per the physician's orders. Residents Affected - Few 365858 Page 12 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, interview and policy review, the facility failed to ensure a licensed pharmacist did monthly pharmacy reviews for the month of January 2019. This had the potential to affect all 48 residents in the facility. Findings include: Review of Residents #28, #32, #33, #34, #35, and #38 records revealed no monthly pharmacy reviews were completed for the month of January 2019. Interview on 02/12/19 at 1:41 P.M. the Director of Nursing (DON) revealed the facility changed pharmacies 01/01/19. The DON verbalized he had called the pharmacy requesting a consulting pharmacist to come to the facility. The DON verified the facility has not had a consulting pharmacist review resident medications since 01/01/19. Telephone interview on 02/12/19 at 2:20 P.M. with Chief Executive Officer (CEO) for the facilities pharmacy revealed that a pharmacist resigned, and a consultant pharmacist was not sent to the facility in January 2019. He verified that the monthly medication review for January 2019 was not completed and would send someone to come out to do the monthly reviews. An interview on 2/13/19 at 2:46 P.M. with Consulting Pharmacist #701 revealed that she got her assignment with the facility at the beginning of February 2019. A review of the policy entitled Consultant Pharmacist Provider Requirements revealed that a pharmacist will establish a system whereby the consultant pharmacist observations and recommendations regarding customer's drug therapy are communicated to those with authority in an appropriate and timely fashion. 365858 Page 13 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

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, policy review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 45 out of 48 residents who ate meals in the facility's kitchen. Three residents (Residents #4, #5, and #22) received enteral nutrition and did not receive meals from the kitchen. Findings include: Observations during the initial tour of the kitchen on 02/10/19 from 8:14 A.M. through 8:30 A.M. revealed one case of nectar thickened dairy drink, one container of nectar apple juice, one case of honey tea and one case of Styrofoam containers on the floor in the dry storeroom. Two bakers' racks were dirty with dried food, one rack had fruit pies on sheet trays for the upcoming meal and the other had a sheet tray with sliced apples portioned in dessert cups, five salads with diced chicken, and one plain salad. Storage bins of sugar and rice had food splatter on the outside. The side of the six burner stove had grease running down the side. The table the steamer was placed had dried food and crumbs on it. The microwave had food splatter inside. The walls had splatter on them, and the drain board where clean dishes come out of the dish washing machine had food residue and black streaks on it. This was verified on 02/10/19 with [NAME] #166 at 8:30 A.M. Interview with Registered Dietitian on 02/11/19 at 6:21 A.M. verified the observations above and he said the kitchen could be cleaner, and she does sanitation inspections monthly. Review of sanitation policy entitled Dietetic Services Standards of Practice- Basic Sanitation Rules revealed that sanitary conditions will be maintained to prevent contamination of food. 365858 Page 14 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

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. Based on interview and record review, the facility failed to ensure bowel and bladder tracking was consistently documented for Resident # 5 and Resident #197. This affected two residents reviewed for incontinence. The facility census was 48. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 07/30/18. Diagnoses included constipation, dysphagia, anxiety disorder, major depressive disorder, insomnia, encounter for attention to gastrostomy, cognitive communication deficit, and spastic quadriplegic cerebral palsy. Review of Resident #5's Minimum Data Set (MDS) 3.0 assessment, dated 11/09/18, revealed the resident was rarely understood and required extensive assistance with Activities of Daily Living (ADL). Resident #5 was always incontinent of bowel and bladder. Review of the bowel and bladder tracking revealed Resident #5 did not have a bowel movement for five days from 02/08/19 to 02/12/19. The Director of Nursing (DON) verified the lack of documented evidence of a bowel movement. Observation and interview on 2/13/19 at 1:15 P.M. with Resident #5 revealed that she has had daily bowel movements. Resident #5 pointed on a communication board as the Director of Nursing (DON) asked her yes or no questions. 2. Review of the medical record for Resident #197 revealed an admission date of 02/06/19. Diagnoses included dementia with behavioral disturbance, insomnia, hallucinations, peripheral vascular disease, dysphagia, and dementia with Lewy bodies. Review of Resident #197's baseline care plan dated 02/06/19 revealed that the resident required extensive assistance of one person for most ADL. Observation on 02/10/19 at 9:30 A.M. revealed that Resident #197 had an odor of urine. On 02/10/19 at 9:51 A.M. State Tested Nursing Assistant (STNA) #182 stated she took Resident #197 to the toilet at 7:30 A.M. STNA #182 verified that Resident #197 was on two-hour checks. Record review of physician's order and a comprehensive care plan, initiated on 02/08/19, revealed that Resident #197 was on two hour checks due to incontinence. Review of the bowel and bladder tracking revealed Resident #197 did not have bladder tracking for four days from 02/08/19 to 02/12/19. Interview on 02/12/19 at 3:00 P.M., MDS Nurse #154 brought copies of Resident #197 's bowel and bladder tracking. MDS Nurse #154 stated that she got the bowel and bladder tracking from the electronic medical record. This surveyor showed MDS Nurse #154 the screen shot that was taken on 02/11/19 at 12:15 P.M. which did not include the documentation she provided. MDS Nurse #154 stated that she called all the STNAs and asked about Resident #197's bowel and bladder tracking, and she added the information. Review of the STNA Job Description revealed that STNA's were required to document as assigned. 365858 Page 15 of 16 365858 02/14/2019 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure proper hand hygiene protocol was maintained during dressing changes of pressure ulcers. This affected one resident (Resident #35) out of five residents reviewed for pressure ulcers. There was a total of eight residents in the facility who received dressing changes. The facility census was 48. Residents Affected - Few Findings Include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. His admitting diagnoses included obstructive sleep apnea, neurogenic bladder, cardiac pacemaker, quadriplegia, and stage IV pressure ulcers on the left and right buttocks (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/10/19, the resident was alert and oriented with no cognitive impairment. Functionally, he required extensive assistance for most of his activities of daily living. This MDS also revealed the resident was at risk for pressure ulcers, and he had two stage IV pressure ulcers on his buttocks. Review of the physician orders dated 12/2018, revealed an order for cleanse both wounds with normal saline, pat dry, then apply anasept gel (an antimicrobial skin and wound gel) and pack with alginate (an absorbent dressing), then cover with a foam dressing every night shift. Observation of a dressing change on 02/14/19 at 11:00 A.M. by Registered Nurse (RN) #142, she washed her hands and put on clean gloves and proceeded to lift the resident's skin with her left hand and clean both the left and right buttocks wounds. She then discarded the dirty pad used to clean and dry the wounds, and then proceeded to apply new dressings to the wounds. She did not remove her gloves used to the clean the wounds, wash her hands and apply clean gloves to dress the wound. Interview with RN #142 at 02/14/19 at 11:45 A.M. verified that she did not remove her dirty gloves from cleaning the wound, wash her hands or apply a clean set of gloves before dressing the wound. 365858 Page 16 of 16