Health inspection·July 25, 2019

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. Based on medical record review, observations, resident and staff interviews and review of facility policy the facility failed to ensure all residents were treated with dignity. This affected one (#17) of 27 residents observed during initial pool. The facility census was 76. Findings Include: Review of the medical record for Resident #17 revealed an admission date of 8/17/16 with diagnoses including depression, psoriasis, dementia and Multiple Sclerosis. Review of the Plan of Care dated 02/02/19 for skin integrity related to psoriasis and redness under bilateral breast revealed no intervention to wear a hospital gown due to skin integrity. Observation on 07/22/19 at 2:04 P.M. of Resident #17 revealed resident sitting in her wheelchair with a hospital gown on. Interview on 07/22/19 at 2:05 P.M. with Resident #17 revealed she would like to wear clothes but the staff did not put clothes on her. Observation on 07/23/19 at 3:14 P.M. of Resident #17 revealed the resident in bed with a hospital gown on. Resident #17 was interviewed at the time of the observation and stated she would like to wear clothes but she did not have any pants. Interview on 07/23/19 at 3:38 P.M. with State Tested Nurse's Assistant (STNA) #190 revealed Resident #17 wears a gown during the day because of a skin condition. STNA #190 verified Resident #17 was wearing a gown and was unable to say the last time Resident #17 wore any clothes. STNA #190 verified that Resident #17 did not have any skin issues at this time. Interview on 07/23/19 at 3:43 P.M. with Licensed Practical Nurse (LPN) #143 verified Resident #17 would wear a hospital gown due to Psoriasis and yeast under breast. LPN #143 verified Resident #17 had no skin issues at this time and there were no orders indicating Resident #17 had to wear a hospital gown all the time. Review of the facility policy for, Resident Rights, dated 02/17/17 revealed staff will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. Page 1 of 5 366194 366194 07/25/2019 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, and review of facility policy and procedure, the facility failed to complete thorough fall investigations and complete/initiate new fall interventions. This affected one Resident (#22) out of one resident reviewed for falls. The census was 76. Findings include: Review of Resident #22's medical record revealed an admission date of 06/29/16. Diagnoses included healed hip fracture, high blood pressure, atrial fibrillation, cerebral infarction, chronic obstructive pulmonary disease, congestive heart failure (CHF), and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent for bathing. Further review of the MDS revealed the resident had intact cognition. Review of the residents care plan, dated 02/22/17, revealed she was at risk for falls related to a decline health with decreased mobility. Interventions included call light in reach, non-skid socks or shoes when out of bed, keep walkway free of clutter, non-skid strips to floor by bed, and provide a safe environment. Review of care plan, dated 05/01/19, revealed the resident had an alteration with self-ambulation. Interventions included to ambulate to/from activities or unit hall one or more times a day with her front wheeled walker and gait belt as tolerated. Review of a care plan, dated 02/22/17, revealed the resident had an activities of daily living (ADL)/self care deficit related to a decline in health with decreased mobility interventions included to assist with bathing. Review of Resident #22's fall risk assessments revealed the following: On 08/22/18 she was a high risk for falls; on 09/24/18, 09/26/18, 11/19/18, 02/18/19, and 03/05/19 she was a low/medium risk for falls; on 03/20/19, 04/22/19, and 05/09/19 she was a high risk for falls. Review of Resident #22's fall investigations and review of the facility fall logs revealed the following: On 08/21/18, the resident fell out of her wheelchair while attempting to pick up a puzzle piece off the floor. The residents new intervention was education to ask for assistance, but there was no documented evidence of what interventions were in place at the time of the fall. On 09/24/18, the resident was found in her room on the floor with a pillow under her hip. The residents new intervention was education to ask for assistance, but there was no documented evidence of what interventions were in place at the time of the fall. On 03/04/19 the resident was found on the floor of her room and she stated she slid out of bed. The residents new intervention was non-skid socks, but there was no documented evidence of what interventions were in place at the time of the fall. On 05/08/19 the resident fell in the shower. The residents new intervention was to be in the restorative program, but there was no documented evidence of what interventions were in place at the time of the fall. Review of nurses notes from 08/21/18 through 05/08/19 revealed no documented evidence of what interventions were in place at the time of each fall. Review of the Restorative Rehabilitation Program Recommendations, dated 04/30/19, revealed Resident #22 was to have staff assistance with ambulation daily or more to/from activities, or ambulate in the hall with staff with a gait belt and front wheel walker due to the resident being a fall risk. Review of the May 2019 through July 2019 restorative notes revealed the above restorative program was not completed on the following dates: 05/11/19, 05/12/19, 05/15/19, 05/18/19, 05/27/19, 05/30/19, 366194 Page 2 of 5 366194 07/25/2019 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

F 0689 06/05/19, 06/06/19, 06/07/19, 06/14/19, 06/20/19, 07/04/19, 07/16/19, and 07/24/19. Level of Harm - Minimal harm or potential for actual harm An interview on 07/25/19 at 11:30 A.M. with Resident #22 revealed staff did walk with her for the restorative program. She further stated the object of the program was to get her out of her wheelchair and back to using a walker, so she was afraid she would decline if they didn't provide her assistance with the program. Residents Affected - Few Multiple interviews on 07/24/19 at 1:29 P.M. through 07/25/19 at 11:39 A.M. with the Director of Nursing (DON) confirmed the fall investigations were not completed since they did not indicate what interventions were in place at the time of each fall. The DON further confirmed the absence of documentation of the completed restorative program tasks, that the restorative program was put into place prior to the fall on 05/08/19, and that the restorative program was not a new intervention. In regards to the 02/22/17 care plan, the DON stated that assist with bathing, could mean anything from independent to any type of actual staff assistance. She stated the aides should be documenting what kind of assistance they were providing at each shower for Resident #22, but she was unable to provide documentation of what amount of assistance she was actually being provided at each shower. Review of the policy titled, Fall Management, dated 03/08/17, revealed all falls were to be documented in the residents record including objective and factual statements regarding circumstances at the time of the fall. 366194 Page 3 of 5 366194 07/25/2019 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, review of medication insert and review of facility policy the facility failed to ensure multi-vial tuberculosis solution was dated when opened. This had the potential to affect 17 Residents (#46, #54, #58, #59, #63, #73, #174, #175, #176, #224, #225, #226, #228, #227, #274, #275 and #276) who the facility identified as being admitted after 04/25/19 and receiving a Tuberculin Purified Protein Derivative (Tuberculin PPD) upon admission. The facility census was 76. Findings include: 1. Observation on 07/24/19 at 9:08 A.M. of the Medication storage room on the 200 Hall revealed one opened vial of Tuberculin PPD solution in the refrigerator with a delivery date of 04/25/19. There was no date on the vial to indicate when it was opened. Interview on 07/24/19 at 9:10 A.M. with Licensed Practical Nurse (LPN)#157 verified the Tuberculin PPD solution had a delivery date of 04/25/19 and had not been dated when it was opened. LPN #157 was unable to determine how long the Tuberculin PPD solution had been opened. LPN #157 verified that the Tuberculin PPD solution was to be discarded 30-days after being opened and the date it was open should of been placed on the vial. 2. Observation on 07/24/19 at 9:57 A.M. of the Medication storage room on the 100-Hall revealed two opened vials of Tuberculin PPD solution in the refrigerator with a delivery date of 05/30/19. There was no date on the vials to indicate when they were opened. Interview on 07/24/19 at 10:00 A.M. with Registered Nurse (RN) #206 verified the Tuberculin PPD solution had a delivery date of 05/30/19 and neither vial had not been dated when they were opened. RN #206 was unable to determine how long the Tuberculin PPD solution had been opened. RN #206 verified that the Tuberculin PPD solution is to be discarded 30-days after being opened and the date it was open should of been placed on the vial. Review of the medication insert for Tuberculin PPD solution revealed vials in use more that 30-days should be discarded due to possible oxidation and degradation, which may affect potency. Review of the facility policy entitled Medication Storage, dated 04/01/13 revealed medications are monitored for appropriate label with the appropriate expiration date. The facility identified 17 Residents (#46, #54, #58, #59, #63, #73, #174, #175, #176, #224, #225, #226, #228, #227, #274, #275 and #276) who were admitted after 04/25/19 and who had received a Tuberculin PPD upon admission. 366194 Page 4 of 5 366194 07/25/2019 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

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, and facility policy review, the facility failed to ensure scoop handles were not stored in the flour container and proper hand hygiene practices were followed in the kitchen. This had the potential to affect all 75 residents who received meals from the kitchen. The facility identified one Resident (#65 ) as not receiving food from the facility. The census was 76. Findings include: Observation of the flour container on 07/22/19 at 8:32 A.M. revealed a scoop was laying in the flour container with the scoop handle touching the flour. Observation on 07/24/19 at 10:39 A.M. revealed Prep [NAME] (PC) #132 opened the refrigerator door with their gloved hand, grabbed a food container out of the refrigerator with the same gloved hand, then used the same unclean gloved hand to grab the eating side of a fork, knife, and spoon and place it on a residents tray. Observation on 07/24/19 at 10:50 A.M. revealed PC #132 used their gloved hand to grab a label gun, then with the same unclean gloved hand, PC #132 grabbed the inside of two bowls which were then filled with pudding and placed on a residents tray by Dietary Manager (DM) #133. Interview with DM #133 on 07/22/19 at 8:32 A.M. verified the scoop was laying in the flour container with the handle touching the flour. Interview with DM #133 on 07/24/19 at 10:51 A.M. revealed the refrigerator door handles were cleaned once per day prior to breakfast service and the label gun was cleaned once per week. During the interview with DM #133 on 07/24/19 at 10:51 A.M., DM #133 verified PC #132 used a gloved hand to grab the label gun then used the same unclean gloved hand to touch the inside of two bowls which were then filled with pudding and placed on a residents tray. Interview with PC #132 on 07/24/19 at 11:17 A.M. verified PC #132 used a gloved hand to open the refrigerator door and grab a food container out of the refrigerator then used the same unclean gloved hand to grab the eating side of a fork, knife, and spoon and place it on a residents tray. Review of the policy titled Infection Control Practices last revised June 2016 revealed food will be stored in a safe manner and protected from contamination in all areas of the operation. Review of the policy titled Hand Washing dated 01/22/17 revealed staff must wash their hands after handling contaminated items. 366194 Page 5 of 5