Health inspection·August 26, 2021

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on record review and staff interview the facility failed to refer Resident #32, with a new diagnosis of schizophrenia, for a level II Pre-admission Screening and Resident Review (PASARR). This affected one (Resident #32) of one resident reviewed for PASARR. Findings include: Review of Resident #32's medical record revealed an admission date of 03/16/17 with current diagnoses including depression, bipolar disorder, anxiety disorder, vascular dementia without behavioral disturbance and schizophrenia. Review of the 07/15/21 quarterly Minimum Data Set Assessment (MDS) revealed the resident had adequate hearing, clear speech, was sometimes understood and understands and had adequate vision and corrective lenses. The resident was moderately impaired for daily decision making. The resident had trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, moving or speaking so slowly that other people could have noticed or the opposite - being so fidgety or restless that you have been moving around a lot more than usual seven to eleven days of the review period. The resident was on insulin, antipsychotics, antianxiety, and antidepressant seven days a week. The resident had a pre-admission screen and PASARR completed on 03/15/17 and 06/16/17. Neither assessment reflected a diagnosis of Schizophrenia. The PASARR was checked no, does the individual have a documented diagnoses of dementia, Alzheimer's disease, or some other organic mental disorder. The resident's last PASARR was dated 10/12/17, after a significant change admission to a psychiatric unit. The PASARR did not include the diagnoses of vascular dementia or schizophrenia. The PASARR was checked no, does the individual have a documented diagnoses of dementia, Alzheimer's disease, or some other organic mental disorder. In the section does the individual have a diagnoses of any of the mental disorders listed below it was answered without a checkmark for Schizophrenia. Review of the resident's current diagnoses included the diagnoses of vascular dementia dated 10/19/17 and a diagnosis of schizophrenia dated 03/20/18. Interview on 08/24/21 at 10:22 A.M. with Social Service #128 verified none of the completed PASARR assessments included the diagnosis of vascular dementia and no PASARR was completed following the resident's new diagnosis of schizophrenia. SS #128 revealed prior to her becoming the facility social service designee the resident was given the new diagnoses (of schizophrenia) and no PASARR was submitted for comprehensive evaluation by the state authority to determine whether the resident had mental disorder, intellectual disability or a related condition, to determine the appropriate setting for Page 1 of 9 366218 366218 08/26/2021 Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident for recommendation as what, if any, specialized services and/or rehabilitative services the individual needed. PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has mental disorder, intellectual disability or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs. 366218 Page 2 of 9 366218 08/26/2021 Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460

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 Based on observation, record review and interview the facility failed to ensure Resident #40, who required staff assistance for activities of daily living including set up assistance with eating received adequate and timely assistance with meals. This affected one resident (#40) of two residents reviewed for activities of daily living. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed diagnoses including heart failure, rheumatoid arthritis, depression, and dementia. A care plan initiated 03/29/21 indicated Resident #40 required set up assistance for meals. The care plan indicated Resident #40 was at risk for decline with activity of daily living function. Interventions included assisting Resident #40 with activities of daily living as needed. A significant change Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 indicated Resident #40 required set up help for meals. On 08/24/21 when lunch was served, an unidentified staff member called Resident #40's name four times to wake her to eat. The staff member then left the room. At 12:02 P.M., Resident #40 had her eyes closed and she had not attempted to eat. Staff called Resident #40's name. After about two minutes staff left the room. At 12:05 P.M., Resident #40's eyes were closed. Resident #40's roommate told the surveyor, staff seldom stayed in the room to provide assistance to Resident #40 to eat. Family would feed her when present at meal time. Resident #40 continued to lay in bed with her eyes closed with no attempts to feed herself. At 12:26 P.M. Activity Assistant #155 arrived at the doorway and spoke to Resident #40's roommate. Resident #40 remained in bed with her eyes closed, the lunch tray in front of her and the food untouched. Continuous observations of Resident #40 between 12:05 P.M. and 12:52 P.M. revealed no staff arrived to provide assistance or to attempt to ensure Resident #40 remained awake long enough to eat. During an interview on 08/24/21 at 12:52 P.M., State Tested Nursing Assistant (STNA) #139 reported Resident #40 was dependent for many of her activities of daily living. STNA #139 revealed staff were constantly waking Resident #40 to eat. STNA #139 indicated staff needed to start feeding Resident #40 but felt the resident needed a nutritionist to evaluate her. STNA #139 was observed of the above observations in which staff were only observed entering the room once after lunch was served to awake Resident #40. STNA #139 did not deny the accuracy of the observations. After the interview, STNA #139 walked down the hall without intervening to provide assistance or encourage meal intake for Resident #40. On 08/25/21 at 1:34 P.M. interview with Rehab Tech #148 verified Resident #40 fell asleep a lot. Rehab Tech #148 indicated Resident #40 had to be awakened frequently during meals and she would place utensils in Resident #40's hand to encourage intake. Rehab Tech #148 revealed she did not stay in the room to try to keep Resident #40 awake and encourage intake or provide assistance because Resident #40 was physically able to feed herself and she was not on the list of residents who needed fed. On 08/25/21 at 3:05 P.M. interview with Licensed Practical Nurse (LPN) #164 revealed Resident #40 had several admissions and had not had a good appetite. LPN #164 acknowledged Resident #40 slept a lot. LPN #140 was informed of the observations of Resident #40 sleeping during meals without staff 366218 Page 3 of 9 366218 08/26/2021 Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460

F 0677 intervention. LPN #140 revealed residents did not have to be on a list to be fed for staff to offer assistance or stay in the room to ensure the resident stayed awake for meals. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366218 Page 4 of 9 366218 08/26/2021 Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide a comprehensive and individualized activity program to meet the total care needs of Resident #40. This affected one resident (#40) of three residents reviewed for activities. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed diagnoses including heart failure, rheumatoid arthritis, depression, and dementia. An admission care plan dated 01/07/21 revealed a goal for Resident #40 to attend/participate in activities of interest. Interventions included evaluating the time awake and readiness for activity, providing a calendar of activities, and providing supplies for activities as needed. A significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #40 was able to understand others and had adequate vision without the use of corrective lenses. The assessment indicated it was somewhat important for Resident #40 to have reading material, listen to music she liked, be around animals such as pets, keep up with the news, do things with groups of people, do favorite activities, go outside to get fresh air when weather was good, and participate in religious services or practices. The primary respondent for activity preferences was Resident #40. The assessment indicated Resident #40 required extensive assistance for transfers and locomotion on the unit. Observations of Resident #40 on 08/23/21 at 10:57 A.M., 11:59 A.M., 12:02 P.M., 12:53 P.M. 1:25 P.M. and 2:18 P.M., on 08/24/21 at 8:53 A.M., 11:17 A.M., between 12:05 P.M. and 12:52 P.M. and at 1:50 P.M. and on 08/25/21 at 8:18 A.M., 9:15 A.M., 11:10 A.M. and 2:40 P.M. revealed no activities being offered or provided for Resident #40. There was no television or radio/music player in the room except the roommate's television which was out of view of Resident #40. On 08/24/21 at 2:39 P.M. interview with Activity Assistant (AA) #155 revealed Resident #40 had been spending more time in bed. AA #155 revealed prior to that, Resident #40 would participate in socials, go to court chat and green thumb activities and watch television in the common area. On 08/25/21 at 1:34 P.M., Rehab Tech #148 was interviewed regarding activities she had observed Resident #40 be provided and/or participated in. Rehab Tech #148 revealed Resident #40 probably received one to one visits but she was unsure how often. Rehab Tech #148 verified she had not heard any music playing but added Resident #40 would probably benefit from having music to listen to. On 08/25/21 at 3:15 P.M., activity participation records and the most recent activity assessment (on the MDS) were reviewed with Activity Director #128. Activity Director #128 was informed of the above observations of Resident #40 with no activity stimulation except for a family visit and no evidence of activities of interest being provided over three days of observations. Activity logs revealed daily active participation in viewing television/radio was documented. When it was discussed that Resident #40 did not have a television or radio in her room and that with the privacy curtain pulled between Resident #40 and her roommate's bed it would not be possible for Resident #40 to view her roommate's television, Activity Director #128 revealed she thought Resident #40 had a television in her room. Activity Director #128 was accompanied to Resident #40's room and verified Resident #40 did not have a television/radio and would not be able to view her roommate's. Activity Director #128 was 366218 Page 5 of 9 366218 08/26/2021 Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interviewed regarding how Resident #40's interest in having reading material was addressed. Activity Director #128 indicated she was uncertain if Resident #40 could see to read but acknowledged books on tape could be offered. Activity Director #128 verified the assessment indicated it was somewhat important for Resident #40 to listen to music she liked and to keep up with the news but no plans were in place to provide a means to do so unless current events were brought up during one on one visits. Activity Director #128 indicated Resident #40 loved animals and she used to have a cat. Activity Director #128 did not know what happened to the cat or if it would be an option for the family to take the cat in to visit if they still had it. Review of activity participation logs revealed one pet visit (04/11/21) and Activity Director #128 verified the facility just had a pet parade on 08/24/21. Activity Director #128 verified she had access to get books on tapes, music, and possibly a television to help meet Resident #40's stated interests. On 08/26/21 at 8:03 A.M. interview with [NAME] President of Operations (VPO) #108 revealed Resident #40's activity preference was reassessed the evening of 08/25/21 and her interests were pretty much the same. Resident #40 was provided a television and music player at that time. On 08/26/21 at 10:12 A.M. interview with Licensed Practical Nurse (LPN) #137 verified there had been no comprehensive activity care plan developed for Resident #40. The admission care plan had not been updated to reflect areas of interest or additional interventions to ensure areas of activity interests were met. 366218 Page 6 of 9 366218 08/26/2021 Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460

F 0760 Ensure that residents are free from significant medication errors. 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 ensure Resident #191 was free of a significant medication error. Resident #191, who had a critical potassium level (low potassium) did not receive Potassium medication as ordered resulting in a significant medication error for the resident. This affected one resident (#191) of nine residents observed for medication administration. Residents Affected - Few Findings include: Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, atrial fibrillation and a cardiac pacemaker. The 08/22/21 admission orders included an order for Klor-Con Tablet Extended Release (Potassium Chloride ER) 30 milliequivalent (mEq) by mouth once a day for hypokalemia (low potassium level). The first dose was scheduled for 8:00 P.M. on 08/23/21. The resident's potassium level was 5.0 mEq/L on 08/18/21. On 08/23/21 at 3:15 A.M. a potassium level was drawn. A critical potassium level of 2.8 mEq/L, normal 3.5-5.3 mEq/L, was reported at 3:23 P.M. A fax was sent at 3:50 P.M. to the physician. A return fax included a note written with orders indicating a call to increase the potassium to twice a day and give orange juice and bananas. Review of the Medication Administration Record revealed the once a day potassium was discontinued at 5:17 P.M. before the 08/23/21 8:00 P.M. dose was administered. The potassium was rewritten to be administered twice a day on rising and in the afternoon. The first dose was scheduled to be administered the afternoon of 08/24/21. Review of the Medication Administration Record on 08/24/21 at 12:19 P.M. revealed no potassium had been administered to the resident by the facility since the critical potassium level was reported the day prior. Interview on 08/24/21 at 12:38 P.M. with [NAME] President of Operations #108 and Registered Nurse (RN) #132 verified the resident should of been administered potassium the day prior and the morning of 08/24/21 for the 2.8 mEq/L critical potassium level. RN #132 revealed when the new order for potassium twice a day was entered into the computer system it defaulted to be administered for the first time the next afternoon. RN #132 indicated the order should have been manually changed to administer the first dose the day of the order entry. The resident should have received doses of the potassium by the time of the interview. 366218 Page 7 of 9 366218 08/26/2021 Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, facility policy and procedure review and interview the facility failed to ensure all food items were held at a safe holding temperature and at point of service to prevent potential food borne illness. This had the potential to affect 30 residents who received meals from the kitchen and excluded Resident #26, #13 and #19 who received nothing by mouth (NPO) and Resident #15, #8, #34, #10 and #36 who received an alternative meal item during the 08/25/21 evening meal. The facility census was 38. Findings include: On 08/25/21 at 4:46 P.M. observation of tray line service for the evening meal with Dietary Supervisor #132 was completed. At 5:25 P.M. the temperature of the food items were obtained which included potato salad that was 55 degrees Fahrenheit (F). Dietary Manager (DM) #105 then re-tested the potato salad with a second thermometer because she thought the first thermometer was not calibrated correctly. The potato salad was 53 degrees F. DM #105 then tested the potato salad directly from the line tray in both a plastic bowl and then on a Styrofoam plate because DM #105 revealed she thought the plastic bowl temperature might have been heated and brought up the temperature of the potato salad. The potato salad in both the plastic bowl and the Styrofoam plate when re-tested were 52 degrees F. Interview on 08/25/21 at 5:35 P.M. with DM #105 confirmed the temperature of the potato salad was not below 52 degrees F despite the multiple testings. The facility identified 30 residents who would received the potato salad with their meal on this date. Of the total 38 residents residing in the facility, Resident #26, #13 and #19 received nothing by mouth (NPO) and Resident #15, #8, #34, #10 and #36 received an alternative meal item to the potato salad during the 08/25/21 evening meal and were therefore not affected. Review of the facility policy titled Food Preparation and Service, revised 04/2019 revealed proper hot and cold temperatures were to be maintained during food service. Cold food items should be held at 41 degrees F or below. 366218 Page 8 of 9 366218 08/26/2021 Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to maintain an adequate infection control program to ensure all housekeeping staff were knowledgeable regarding disinfectant products to use to prevent the spread of infection. This had the potential to affect all 38 residents residing in the facility. Residents Affected - Many Findings include: On 08/25/21 at 1:27 P.M. Housekeeper #107 was observed providing housekeeping services. An interview Housekeeper #107 at the time of the observation revealed Clean by Peroxy was the disinfectant the facility used. Housekeeper #107 revealed she had no idea if Clean by Peroxy required a certain contact time to be effective in disinfecting surfaces. The label did not indicate if the product was effective in disinfecting surfaces, what microorganisms it was effective against or if there was a required contact time. Housekeeper #107 revealed this was the only disinfectant product used, even if a resident had a Clostridium difficile infection. There were no residents who had clostridium difficile at the time of the survey. Housekeeper #107 revealed she had received two days of orientation and she had worked at the facility four days. On 08/25/21 at 1:30 P.M. a request was made to [NAME] President of Operations (VPO) #108 for information regarding the facility disinfectant. VPO #108 revealed Housekeeper #107 was new to the position but acknowledged she was working independently and should be knowledgeable about the products and how to use them. On 08/25/21 at 4:25 P.M. VPO #108 provided product information on Diffense disinfecting cleaner and indicated this was the product staff were supposed to use if there was a resident with Clostridium difficile. Otherwise, the facility general disinfectant (Super HDQ) was to be used which was effective against the coronavirus. VPO #108 indicated the facility did also use Clean by Peroxy as an all-purpose cleaner. On 08/26/21 at 8:10 A.M. review of the product information provided for the Clean by Peroxy revealed it was an all purpose hydrogen peroxide cleaner. The information did not indicate what, if any microorganisms, the product killed or prohibited the growth of. 366218 Page 9 of 9