Health inspection·June 9, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect. This affected two (Residents #30 and #6) of two residents reviewed. The facility census was 35. Findings include: 1. Record review revealed Resident #30 was admitted on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, pseudobulbar affect (a condition that causes uncontrollable crying and or laughing that happens suddenly and or frequently), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/16/22, revealed Resident #30 was severely cognitively impaired. Resident required extensive assistance for activities of daily living. Resident #30 used a wheelchair for mobility and required extensive assistance of one person physical assist for mobility. Resident #30 required set up help of one for meals. Resident had no verbal or physical behaviors exhibited including rejection of care. Resident #30's hearing was adequate and vision moderately impaired. Resident wore corrective lenses. Review of the care plan, dated 04/14/22, revealed resident was dependent on staff for meeting emotional, intellectual, physical and social needs related to disease process, diagnosed with dementia. Interventions included all staff to converse with resident while providing care. Resident has behavior problems which included tearful bouts, fluctuating in mood related to dementia. Interventions included to explain all procedures to the resident before starting and allow resident adequate time to adjust to changes. During observation on 06/07/22 at 8:36 A.M., Resident #30 was sitting in the facility lounge, in her wheelchair, sleeping. Resident #30 had a clothing protector on. State Tested Nursing Assistant (STNA) #846 walked up behind Resident #30, quickly removed the clothing protector from behind and walked away without addressing the resident. Resident #30 startled, woke up, began holding her arms in the air crying, no, no. Licensed Practical Nurse (LPN) #822 was present during the observation, verified this was not a correct approach by STNA #846. During interview on 06/07/22 at 8:38 A.M., STNA #846 confirmed the above observation. STNA #846 stated Resident #30 would scream anyway and the best approach is to sneak up on her. During interview on 06/07/22 at 2:50 P.M., the Director of Nursing (DON) confirmed STNA 846's approach was not appropriate and stated sometimes Resident #30 does yell with hands on care. Page 1 of 6 366012 366012 06/09/2022 Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. During observation on 06/06/22 at 9:27 A.M., Resident #6 was sitting in her recliner chair in her room. The chair was elevated back in the reclined position with her feet reclined up on the foot rest. Resident #6 was attempting to reach the remote for the chair which was located on the far right side in back of the chair. Resident #6 was unable to reach the remote. State Tested Nursing Assistant (STNA) #846 and #824 was walking by Resident #6's room and overheard the conversation. STNA #846 revealed Resident #6 had to be reclined back in her recliner chair because she was a fall risk. Resident #6 again asked for the remote. STNA #846 told the resident she could not have the remote because she will set the chair up and fall. STNA #846 and #824 then left the room without offering to assist the resident to get up as she requested. During interview on 06/08/22 at 10:23 A.M., the DON stated Resident #30 would not be able to get out of the chair without assistance. 366012 Page 2 of 6 366012 06/09/2022 Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to investigate and report an injury of unknown origin. This affected one (Resident #30) of one resident reviewed. The facility census was 35. Findings include: Record review revealed Resident #30 was admitted on [DATE]. Diagnosis included unspecified dementia without behavioral disturbances, pseudobulbar affect (a condition that causes uncontrollable crying and or laughing that happens suddenly and or frequently), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was severely cognitively impaired. Resident required extensive assistance of two for bed mobility and transfers, Resident #30 used a wheelchair for mobility and required extensive assistance of one person physical assist for mobility. During interview on 06/06/22 at 9:18 A.M., Hospice Registered Nurse (RN) #847 revealed Resident #30 had bruises on both of her upper arms. Hospice Nurse RN #847 stated she observed the bruising on 06/02/22 and reported it to the Director of Nursing (DON) on that date. Hospice Nurse RN #847 revealed she was unsure how the bruising occurred. During interview on 06/06/22 at 9:48 A.M., the DON stated that Hospice had made her aware either the prior week of the bruising on Resident #30's arms. The DON stated she assessed the bruises at that time. During interview on 06/08/22 at 03:20 P.M., the DON again confirmed she was aware of the bruises to Resident #30's upper arms. DON revealed she had looked at the bruises but did not investigate how the bruises occurred, did not talk to staff about how they may have occurred and did not interview the resident or other residents regarding how they may have occurred because Resident #30 will flail her arms and she probably hit something or she was fighting staff during a shower or transfer. She told staff to be more careful. She stated she did not document the areas, measure the areas, or notify the resident's representative. She did not do an SRI or any investigation. During observation on 06/08/22 at 3:24 P.M., Resident #30 had a large faded bruise to the right and left upper arm. During interview on 06/09/22 at 9:21 A.M., Licensed Practical Nurse (LPN) #837 revealed she was first aware of the bruises on 06/06/22. LPN #837 confirmed she did not assess, document or notify the family of the bruises because it was near the end of her shift. LPN #837 measured the bruise on Resident #30's right upper arm and it was five centimeters (cm) by five and one half cm. The bruise was faded purple brown in color. The left arm bruise measured three and a half cm by two and a half cm and light purple in color. There was an additional bruise on the right wrist that measured four cm by three cm and light purple in color. LPN #837 confirmed she was not aware how the bruises occurred. Record review of the progress notes from 03/01/22 through 06/09/22 revealed no documentation regarding bruising on residents body. 366012 Page 3 of 6 366012 06/09/2022 Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of facility Self Reported Incidents (SRI) revealed no reports for Resident #30 having injuries of unknown origin. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated 10/27/17, revealed its the facilities policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of a residents property including injuries of an unknown source. 366012 Page 4 of 6 366012 06/09/2022 Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to perform incontinence care on a resident. This affected one (Resident #30) of one resident reviewed for incontinence care. The facility census was 35. Residents Affected - Few Findings include: Record review revealed Resident #30 was admitted on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was severely cognitively impaired. Resident #30 was occasionally incontinent of urine and frequently incontinent of bowel and required total dependence of one for toilet use. Review of the care plan dated 04/14/22 revealed Resident #30 had mixed bladder incontinence related to dementia. Interventions included to toilet every two hours and as required for incontinence. Wash, rinse and dry perineum after incontinent episode. Ruing observation on 06/07/22 at 9:15 A.M., State Tested Nursing Assistant (STNA) #846 and #824 stood Resident #30 up to a standing position from her wheel chair and removed Resident #30's incontinence brief, which was soiled with urine. Without performing incontinent care, STNA #846 placed a clean incontinence brief on Resident #30 and returned her to the wheelchair. During interview at the time of the observation, STNA 846 and #824 verified they did not perform incontinence care. STNA #846 stated she would perform care when she put the resident to bed later. Review of the facility policy titled, Perineal Care, dated October 2010 revealed the purpose of the procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents skin condition. 366012 Page 5 of 6 366012 06/09/2022 Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813

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, interview and policy review, the failed to ensure a resident refrigerator was clean and that food items were labeled and dated. This had the potential to affect all 35 residents residing at the facility. Findings include: During observation on 06/06/22 at 4:35 P.M. , the refrigerator located in the medication storage room was full of undated and unlabeled food items. The refrigerator had a foul odor. The Director of Nursing (DON), present during the observation, stated the refrigerator held resident food items. Food items include a prepared meal with the store print enjoy by 5/25/22 with no name; a Tupperware bowl and lid with a white liquid that had no name and no date; a plastic bag of bagels that was stuck to the refrigerator shelf that had no name and no date; a half stick of butter that was unwrapped with no name and no date; deli lunch meat that appeared slimy and was dated 5/26/22 with no name; a plastic bag of cobbler undated and with no name; a plastic bag of ham dated 05/13/22 with no name; a plastic bag of cooked bacon, undated with no name; a piece of ham dated 05/07/22 with no name; a container of potato salad, undated with no name; a container of cottage cheese with a use by date of 01/01/22 and no name; and a chicken sandwich with no name and no date. The back of the refrigerator had approximately one and a half inches of ice build up from top to bottom. There were undated drinks with no names and the shelves had fluid spills that had dried and were sticky. The DON verified the above findings at the time of the observation. Review of the policy titled Refrigerators and Freezers, dated December 2014, revealed the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. All food shall be appropriately dated . Use by dates will be completed with expiration dates on all prepared food in refrigerators. 366012 Page 6 of 6