Health inspection·September 19, 2019

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 record review and interview the facility failed to implement nutritional recommendations for a dietary supplement for Resident #9 in a timely manner. This affected one resident (#9) of four residents reviewed for nutrition. Residents Affected - Few Findings include: Medical record review revealed Resident #9 was admitted to the facility on [DATE] and a most recent re-admission on [DATE]. The resident had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, traumatic subarachnoid hemorrhage, anemia, hypertension, muscle wasting, hyperlipidemia, depression and delusional disorders. A physician order, dated 02/20/19 revealed the resident received a regular diet, regular texture with thin liquid consistency. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited mild cognitive impairment. The resident was assessed to require set up assistance with meals and able to feed herself. Review of resident's weights revealed the following weights for 2019: 09/04/2019 - 128.2 pounds (#) 07/05/2019 - 134.2 # 06/01/2019 - 136.2 # 05/31/2019 - 136.2 # 05/03/2019 - 135.6 # 04/05/2019 - 130.2 # 03/05/2019 - 129.6 # 03/01/2019 - 129.6 # 02/01/2019 - 144.4 # Page 1 of 4 366010 366010 09/19/2019 The Pinnacle Rehabilitation and Nursing Center 330 Southwest Ave Tallmadge, OH 44278

F 0692 01/03/2019 - 140.4 # Level of Harm - Minimal harm or potential for actual harm Review of the progress notes and dietary note dated 01/29/19 revealed Resident #9 was able to feed herself, had a good appetite and was consuming most of her meals and fluids. Resident #9's skin was noted to be intact but she had cellulitis noted on her upper right shoulder. The medical records stated that the resident had maintained a stable weight and no significant weight changes were noted. The documented weight was 140 # on 01/03/19 and this reflected a body mass index (BMI) at 23.4. The dietitian stated the resident continued to be in good nutrition and hydration status and remained at low risk. Residents Affected - Few Review of a dietary note dated 03/03/19 revealed Resident #9 had been recently hospitalized on [DATE] and returned on 02/20/19 secondary to an infection on the right upper arm. Resident #9 was readmitted to the facility on a regular diet with thin liquids and the resident's appetite was noted to be fair since the readmission. Resident #9 had refused some meals and would often eat in her room versus the dining room. Laboratory values were obtained and included in the dietary assessment, dated 03/03/19 and revealed the dietitian had recommended Resident #9 receive a nutritional supplement to support and better meet her nutritional needs. Dietitian #300 recommended the supplement Med +2.0, four ounces, twice a day as this would've provided an additional 480 calories and 20 grams of protein. A nursing note dated 03/05/19 revealed Resident #9 had been identified for a significant weight change of 10.2% loss as the current body weight was 129.6 #. The ideal body weight was documented at 125 # and the usual body weight was noted to be 135 # to 144 # with a BMI of 21.6 at the time. The document stated under the supplements section, recommending Med pass 2.0, 120 milliliters (ml), three times a day to provide 240 kcal and 10 g of protein per serving. The note was authored by Dietician #400. The dietary note dated 03/27/19 revealed Resident #9 had been assessed by Certified Dietary M(CDM) #475. The assessment stated Dietician #400 had agreed with the previous is dietician's recommendation for Resident #9 to receive nutritional support to better meet her needs. Med pass 2.0, four ounces, twice a day for increased protein related to her decreased appetite and increased needs related to infection and wound to the right upper arm. The dietary assessment or quarterly nutrition assessment dated [DATE] revealed the resident had a current body weight of 136 # and the BMI was at 22.7. This was within normal range. The resident remained on regular diet with regular texture, thin consistency diet. The supplements section had no dietary supplements stated. Review of the current care plan for Resident #9 revealed a focus area of altered nutrition had been initiated on 12/13/18. This document revealed Resident #9 was to receive Med pass 2.0, four ounces, twice a day related to poor intake and possible weight loss and was placed on the care plan on 03/27/19. Review of the medication administration record (MAR) and treatment administration record (TAR) for Resident #9 was completed for the period 03/01/19 through 04/30/19. Nutritional supplements would have been recorded in the TAR. These records were void of any evidence of a nutritional supplement having been provided to Resident #9. An interview was completed on 09/17/19 at 3:55 P.M. with the Administrator and Director of Nursing and no documentation was provided to evidence the facility staff had followed through with the 366010 Page 2 of 4 366010 09/19/2019 The Pinnacle Rehabilitation and Nursing Center 330 Southwest Ave Tallmadge, OH 44278

F 0692 recommendations to add nutritional supplements to the diet regimen of Resident #9. Level of Harm - Minimal harm or potential for actual harm An interview was completed on 09/19/19 at 8:50 AM with Registered Dietician, (RD) #500. During the interview the dietitian stated any nutritional supplements or recommendations made by the dietitian would have been placed in a log and presented to the physician for approval. Once approval was made these orders would be placed back in the log. The registered dietitian would verify the orders and ensure follow-through was completed upon her next visit into the facility. The registered dietitian stated she had visited the facility every Tuesday and Thursday. Residents Affected - Few 366010 Page 3 of 4 366010 09/19/2019 The Pinnacle Rehabilitation and Nursing Center 330 Southwest Ave Tallmadge, OH 44278

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 prepare, store and maintain the kitchen in a clean and sanitary manner to prevent contamination and food borne illness. This had the potential to affect all 63 of 65 residents who received meals from the dietary department (Resident #27 and #57 received nothing by mouth (NPO)). The facility census was 65. Findings include: A tour of the kitchen was conducted on 09/16/19 at 8:59 A.M. and 09/18/19 at 9:30 A.M. with the Dietary [NAME] (DC) #200 which revealed the following which were verified with the cook at the time of the observations: Observation of the kitchen revealed white plastic pipes under a two-compartment sink had a heavy build up of a brown unidentifiable substance. Heavy dust build-up was on the juice machine filters. There was a heavy buildup of a brown unidentifiable substance under a two-compartment sink. One small bowl of oatmeal was observed unwrapped and undated sitting on top of the metal plate warmer lid. One metal plate had a brown crust substance on the rim of the plate. The convection oven contained heavy amounts of burnt spillage on the bottom. The drawer containing scoop ladles had multiple food crumbs on the bottom. The ice machine contained dust build up on the vents and outside door. The steamer had dirt and food particle build up underneath of it. The walk-in cooler had a pack of cheese properly wrapped but not dated. Three large metal food storage bins were stored with free standing water. Interview with Food Service Manager (FSM) #207 on 09/18/19 at 10:30 A.M. confirmed the above findings. 366010 Page 4 of 4