Health inspection·May 30, 2019

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to develop a baseline care plan for newly admitted residents. This affected one (Resident #28) of two residents reviewed for baseline care plans. The facility identified ten newly admitted residents. The facility census was 43. Findings include: Review of Resident #28's medical record revealed an admission date of 04/03/19. Diagnoses included chronic obstructive pulmonary disease, cerebral infarction, dysphagia, lack of coordination, type II diabetes, anxiety disorder, major depressive disorder, hypertension, osteoarthritis, anemia, hyperlipidemia, and Wernicke's encephalopathy. Review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #28 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #28 required limited assistance with walking and supervision with eating and locomotion. Resident #28 displayed no behaviors during the review period. Review of Resident #28's care plan, revised 05/13/19, revealed a single support with interventions for nutritional risk. No supports or interventions were found for psychotropic medication use or diagnoses of anxiety or depression. Review of Resident #28's assessments revealed no baseline care plan was completed. Interview on 05/29/19 at 2:22 P.M. with MDS Nurse #210 verified Resident #28 did not have a baseline care plan completed and there was only one support for nutrition in the revised care plan. Review of the facility policy titled Care Plans- Preliminary, revised August 200, revealed a preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four hours of admission. Page 1 of 5 365885 365885 05/30/2019 Concord Care and Rehabilitation Center 620 W Strub Rd Sandusky, OH 44870

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on medical record review, staff interview and policy review, the facility failed to develop and implement a comprehensive care plan for residents who smoked, experienced pain and used psychotropic medications. This affected two (Residents #33 and #41) of 14 care plans reviewed. The facility census was 43. Findings include: 1. Review of Resident #33's medical record revealed an admission date of 04/11/19. Diagnoses included symbolic dysfunctions, hypertension, lack of coordination, osteoarthritis, major depressive disorder, anxiety disorder, nicotine dependence, fracture of upper end of tibia subsequent encounter for closed fracture, and encounter for surgical aftercare. Review of Resident #33's Minimum Data Set (MDS) assessment, dated 05/09/19, revealed the resident was cognitively intact. Resident #33 required supervision of staff for set up only for bed mobility, transfer, walking, locomotion, eating, toilet use and personal hygiene. Resident #33 displayed no behaviors during the review period. Resident #33 received as needed (PRN) pain medications and non-medication interventions for pain. Resident #33 reported frequent moderate pain at the time of the review. Review of Resident #33's care plan, updated 04/24/19, revealed supports and interventions for mood problems, and risk for nutritional problems. No supports or interventions were noted for smoking or pain. Resident #33's printed care plan was requested on 05/29/19 at 9:30 A.M. Interview on 05/29/19 at 1:12 P.M. with the Director of Nursing (DON) and MDS Nurse #210 verified Resident #33's care plan had not been revised or updated to include supports and interventions for smoking or pain. 2. Review of Resident #41's medical record revealed an admission date of 04/22/19. Diagnoses included metabolic encephalopathy, cerebral infarction, lack of coordination, altered mental status, dysphagia, aphasia, post traumatic seizures, acute kidney failure, abnormal blood chemistry, anxiety disorder, dysarthria and anarthria, psychosis, legal blindness, restlessness and agitation, dementia, chronic obstructive pulmonary disease, convulsion, and vascular dementia. Review of Resident #41's MDS assessment, dated 05/10/19, revealed the resident was rarely or never understood and had short term and long term memory problems. Resident #41 was not able to recall the current season, location of his room, names or faces of staff or that he was in a nursing home. Resident #41 had delusions during the review period. Resident #41 displayed behavioral symptoms not directed toward others daily during the review period. Review of Resident #41's care plan, updated 04/24/19, revealed supports and interventions for risk for nutritional problems, activities, impaired cognitive function, dementia, and behaviors. No supports or interventions were noted for psychotropic medication use. Interview on 05/29/19 at 1:12 P.M. with the Director of Nursing (DON) and MDS Nurse #210 verified Resident #41's care plan had not been revised or updated to include supports and interventions for psychotropic medication use. 365885 Page 2 of 5 365885 05/30/2019 Concord Care and Rehabilitation Center 620 W Strub Rd Sandusky, OH 44870

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Comprehensive Assessment and the Care Delivery Process, revised December 2016, revealed monitoring results and adjusting interventions included periodically reviewing progress and adjusting interventions. Residents Affected - Few 365885 Page 3 of 5 365885 05/30/2019 Concord Care and Rehabilitation Center 620 W Strub Rd Sandusky, OH 44870

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, staff interview, review of manufacturer's instructions and policy review, the facility failed to ensure the dishwashing machine maintained the proper chemical sanitizing level to sanitize dishes; and failed to store foods in a safe and sanitary manner. This had the potential to affect all residents who received food from the kitchen. The facility identified all 43 residents received food from the kitchen. The facility census was 43. Findings include: Observation on 05/28/19 at 8:48 A.M. of the low temperature dishwasher revealed the sanitization level test strip showed no sanitizer was found in the rinse cycle of the dishwasher. The bottle of sanitizer connected below the dishwasher was empty. Interview on 05/28/19 at 8:50 A.M. with Dietary Staff #101 verified the sanitizer bottle was empty and the test strip was white which indicated no sanitizer was present in the rinse cycle of the dishwasher. Interview on 05/28/19 at 8:52 A.M. with Dietary Staff #101 revealed no rinse sanitizer solution was available to replace the empty bottle. Dietary Staff #101 reported all the dishes would be washed or rewashed in the three sink system to ensure sanitation. Dietary Staff #101 was not able to say how long the dishwasher sanitizing solution had been empty. The dishwasher stick log posted on the wall revealed the most recent test strip was completed on 05/07/19 and the sanitation level was appropriate at 50 parts per million of chlorine. Observation on 05/28/19 at 9:00 A.M. of the kitchen revealed a four pound jar of concord grape jelly, partially used, and being stored at room temperature in the preparation area. Visible on the label was refrigerate after opening. In addition, a dented can of mandarin oranges which had it's seal compromised was found in the walk-in cooler in line to be used. Interview on 05/28/19 at 9:01 A.M. With Dietary Staff #101 verified the grape jelly was kept at room temperature and should have been kept in the refrigerator. Dietary Staff #101 also verified the can of mandarin oranges was dented with the seal compromised. Dietary Staff #101 reported the dented can should have been removed from use and set aside to be returned to the supplier for credit. Observation on 05/28/19 at 11:05 A.M. of the kitchen revealed the rinse cycle sanitation solution was replaced. Coinciding interview with Dietary Manager #200 revealed the new bottle was added and the previous dishes were washed in the three sink system. Dietary Manager #200 tested the rinse solution and found the test strip was still clear indicating there was no rinse sanitizing solution running through the dishwasher. Dietary Manager #200 verified there was no sanitizing solution running through the dishwasher. Dietary Manager #200 stated she would inform maintenance for assistance with repairing the dishwashing machine. Interview on 05/28/19 at 11:40 A.M. with Dietary Manager #200 revealed maintenance looked at the dishwasher and the rinse sanitizing solution needed to be primed after it was replaced. Coinciding observation of the test strip revealed the test strip turned purple indicating the sanitizing solution was up to the proper level of 50 ppm. 365885 Page 4 of 5 365885 05/30/2019 Concord Care and Rehabilitation Center 620 W Strub Rd Sandusky, OH 44870

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 05/29/19 at 12:15 P.M. with Dietary Manager #200 revealed there was no facility policy for checking the dishwasher sanitation levels. Dietary Manager #200 revealed they followed the manufactures instructions for proper sanitation. Review of the manufacturer's instructions for the American Dish Service Upright Dishwashers revealed all machines required detergent and sanitizer for proper operation. Sanitizer should be 6% solution of sodium hypochlorite. The initial setting was five cubic centimeter (cc) and this was to be checked regularly with a chlorine test kit. Free chlorine in the final rinse was to be 50 ppm or more. Review of the facility policy titled Food Storage, dated 2017, revealed refrigerated foods should be stored upon delivery and careful rotation procedures should be followed. 365885 Page 5 of 5