Health inspection·December 22, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure Resident #60's fall interventions were in place to help prevent falls. This affected one Resident (#60) out of one Resident reviewed for accidents. The facility census was 57. Findings include: Review of Resident #60's medical record revealed an admission date of 11/23/22. Diagnoses included psychotic disorder with delusions, delusional disorders, cognitive communication deficit, difficulty in walking, and weakness. Review of Resident #60's admission Minimum Data Set 3.0 assessment, dated 11/30/22, revealed the resident had impaired cognition and needed physical extensive assistance of two persons for bed mobility, transfers, and walking. Review of Resident #60's initial fall risk evaluation, dated 11/30/22, revealed the resident had a moderate risk for falls. Review of Resident #60's 48-hour admission care plan, dated 11/23/22, revealed the resident was at risk for falls. Interventions included place call bell within reach and keep the bed in the lowest position. Observation on 12/19/22 at 10:52 A.M. Resident #60 was observed lying in bed. Her call light was out of reach, positioned at the bottom of her bed between the wall and her bed. Observation on 12/21/22 at 2:25 P.M. Resident #60 was lying in bed asleep. Her bed was in a high position. Her call light was out of reach, positioned at the bottom of her bed between the wall and her bed. Interview and observation on 12/21/22 at 2:35 P.M. with Licensed Practical Nurse #813 confirmed Resident #60's bed was in a high position, and her call light was out of reach. Interview on 12/21/22 at 3:03 P.M. with the Director of Nursing confirmed that Resident #60's fall interventions of bed in low position and call light within reach were not in place for Resident #60. Page 1 of 4 366104 366104 12/22/2022 Salem North Healthcare Center 250 Continental Drive Salem, OH 44460

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on medical record review, observation and staff interview, the facility failed to follow physician's orders for tube feed formula infusion time and proper labeling of tube feed formula. This affected one Res(Resident #18) of one Resident reviewed for tube feedings. The facility census was 57. Findings include: Review of Resident #18's medical record revealed an admission date of 03/05/21 with diagnoses including Alzheimer's disease with dementia, adult failure to thrive, cerebrovascular accident and percutaneous endoscopic gastrostomy tube. Further review of the medical record revealed a physician's order on 12/22/21 to label feeding tube formula with resident name, date and time and nurse's initials. A physician's order on 12/07/22 indicated Resident #18 was to receive Jevity 1.2 (nutritional supplement formula) at 65 milliliters per hour (ml/h) per feeding tube for 18 hours from 5:00 P.M. to 9:00 A.M. and disconnect resident from feeding tube at 9:00 A.M. every day. Observation of Resident #18 on 12/19/22 at 11:16 A.M. revealed a tube feeding pole, tube feed pump and bag of tube feed formula. The bag of tube feed formula had no evidence of a label indicating the type of formula, the date and time opened or a nurses signature. Additional observation of Resident #18 on 12/20/22 at 12:50 P.M. revealed tube feeding infusing and no evidence of a label on the tube feed formula indicating type of formula, date and time prepared and nurse signature. Interview with Registered Nurse (RN) #814 on 12/20/22 at 12:53 P.M. verified Resident #18's tube feed formula was still infusing and should be disconnected at 9:00 A.M. as per physicians orders. RN #814 also verified the tube feeding container was not labeled with the type of formula, date and time of preparation and nurse signature as per physician's order. 366104 Page 2 of 4 366104 12/22/2022 Salem North Healthcare Center 250 Continental Drive Salem, OH 44460

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 maintain sanitary conditions during observations of meal preparations . This affected all residents except for Resident #18 and Resident #21 who do not receive food prepared in the kitchen. The facility census was 57. Findings include: Observation on 12/20/22 at 11:55 A.M. of [NAME] #809 preparing to purée Swedish meatballs. She placed the meatballs into the RoboCoup blender which was setting on the sink counter. The sink was observed to have water and food particles present. [NAME] #809 used a large spatula to stir the meatballs and laid it directly on the sink counter. She then continued to purée the meatballs, stop the blender, sir the meatballs with the same spatula and then laid it directly on the counter. [NAME] #809 then used the spatula to scoop the meatballs into a tray on the steam table. [NAME] #809 then scooped noodles into a clean RoboCoup blender. Some of the noodles were observed protruding from the top. She used an unwashed and ungloved hand to push the noodles into the blender. She then blended the noodles, grabbed a new spatula, stirred the noodles, and sat the spatula down on counter. She repeated this two more times. At 12:10 P.M. She began to check the temperature of each food item. She began by putting the thermometer into the meatballs. After obtaining the temperature she walked the thermometer to the sink and dipped it into a prefilled bucket of sanitizer solution and then again in another prefilled bucket of water with a visible rag at the bottom. [NAME] #809 tapped the thermometer on the inside of the sink to remove the excess water and then checked the temperature of the noodles. She completed this same process after checking each food item (beets, mixed vegetables, hamburgers, gravy, pureed meatballs, and pureed beets). Interview on 12/20/22 at 12:37 P.M. Corporate Dietitian #810 confirmed proper sanitation practices were not in place during meal preparation. 366104 Page 3 of 4 366104 12/22/2022 Salem North Healthcare Center 250 Continental Drive Salem, OH 44460

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure laboratory testing was obtained prior to initiating antibiotic therapy for a resident with a possible infection. This affected one (Resident #32) of five residents reviewed for infections. The facility census was 57. Residents Affected - Few Findings include: Review of Resident #32's medical record revealed an admission date of 09/23/22 with admission diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus and hypertension. Further review of the medical record including physician's orders revealed on 09/30/22 Resident #32 was initiated on Cipro (antibiotic) 500 milligrams (mg) twice daily until 10/05/22 for bacteremia (infection). Review of the Antibiotic Assessment completed on 09/30/22 indicated Resident #32 had pain with urination, a urinalysis was positive for infection and the resident was initiated on Cipro for a urinary tract infection (UTI). The antibiotic assessment indicated the resident met criteria for antibiotic use for a UTI. Review of the resident's laboratory results found no evidence of a urinalysis obtained or located within the medical record. Interview with the Director of Nursing on 12/21/22 at 9:10 A.M. revealed the resident was receiving hospice services upon admission and a hospice nurse ordered the antibiotic and advised the facility the urinalysis was positive for infection. Additional interview at 2:15 P.M. with the DON verified there was no evidence obtained by the facility there was a urinalysis completed for the resident as indicated in the antibiotic assessment. 366104 Page 4 of 4