Health inspection·June 26, 2019

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses that included seizures and congestive heart failure. The quarterly Minimum Data Set (MDS) dated [DATE], revealed under section

N0410-E Resident #7 received an anticoagulant medication. Residents Affected - Some Review of physician orders revealed Resident #7 was ordered Aspirin (antiplatelet) 325 milligrams (mg) daily. 3. Review of the medical record revealed Resident #29 was admitted on [DATE] with diagnoses that included diabetes mellitus and myocardial infarction. The 30-day MDS dated [DATE], revealed under section N0410-E Resident #29 received an anticoagulant medication. Review of physician orders revealed Resident #29 was ordered Aspirin 81 mg daily and Plavix (antiplatelet) 75 mg daily. 4. Review of the medical record revealed Resident #35 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included acute kidney failure and cerebral infarction. The significant change MDS dated [DATE], revealed under section N0410-E Resident #35 received an anticoagulant medication. Review of physician orders revealed Resident #35 was not ordered any anticoagulant or antiplatelet medication. 5. Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnosis that included cerebrovascular disease. The quarterly MDS dated [DATE], revealed under section N0410-E Resident #8 received an anticoagulant medication. Review of the physician orders revealed Resident #8 was ordered Aspirin 81 mg daily. 6. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnosis that included dementia and diabetes mellitus. The 14-day MDS dated [DATE], revealed under section N0410-E Resident #28 received an anticoagulant medication. Review of the physician orders revealed Resident #28 was ordered Aspirin 325 mg daily. Interview on 06/26/19 at 10:01 A.M. DON verified the MDS discrepancies and stated she currently Page 1 of 10 366231 366231 06/26/2019 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0641 coded the use of aspirin as an anticoagulant. Level of Harm - Potential for minimal harm Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed accurately regarding medications received for six residents (Residents #6, #7, #8, #28, #29, and #35) out of ten residents (Residents #1, #3, #4, #6, #7, #8, #14, #28, #29, and #35) reviewed. The facility census was 33. Residents Affected - Some Findings include: 1. Resident #6 was initially admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertension, and heart disease. Review of Resident #6's medical record reveals orders for medications including aspirin (antiplatelet) 81 milligrams (mg) every day initially ordered 04/20/18 and lisinopril-hydrochlorothiazide (ace-inhibitor diuretic combination) 12.5 mg every day initially ordered 03/29/18. Review of Resident #6's quarterly MDS with an assessment reference date (ARD) of 07/12/18 revealed under medications received in the past seven days, diuretic was marked as zero, although the MDS should have been marked as seven. The quarterly MDS with an ARD of 07/20/18 was also marked incorrectly with zero days of diuretic use. The quarterly MDS with an ARD of 07/26/18 was also marked incorrectly with zero days of diuretic use. The quarterly MDS with an ARD of 10/04/18 was also marked incorrectly with zero days of diuretic use. Review of the annual MDS assessment with an ARD of 04/06/19 had Resident #6 marked as having received seven days of an anticoagulant and zero days of a diuretic, the MDS should have been marked as zero days of an anticoagulant use and seven days of diuretic use. Interview with the Director of Nursing (DON) on 06/26/19 at 10:01 A.M. verified the MDS discrepancies and stated she currently codes the use of aspirin as an anticoagulant. Review of the Resident Assessment Instrument Manual, which gives directions on how to complete the MDS assessment directs providers to not code antiplatelet medications such as aspirin/extended release. 366231 Page 2 of 10 366231 06/26/2019 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #29 was invited and had scheduled care conferences. This affected one resident (#29) out of 16 residents reviewed for care conferences. The facility census was 33. Findings include: Review of the medical record revealed Resident #29 was admitted on [DATE] with diagnosis that included diabetes mellitus, anxiety, and chronic obstructive pulmonary disease. The 30-day Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was cognitively intact. Interview on 06/23/19 at 9:19 A.M. with Resident #29 revealed he had not had a care conference for a long time. Review of the medical record revealed no evidence of a care conference with Resident #29. Interview on 06/24/19 at 6:15 P.M. with Social Services #503 verified Resident #29 had not been invited to attend a care conference. Social Services #503 stated care conferences were not always scheduled and residents were not always invited to attend. Interview on 06/24/19 at 3:49 P.M. Director of Nursing verified social services should schedule care conferences with residents. 366231 Page 3 of 10 366231 06/26/2019 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure Resident #28 was positioned properly in a wheelchair. This affected one resident (#28) out of one reviewed for positioning. Facility census was 33. Residents Affected - Few Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnosis that included dementia, diabetes mellitus, and difficulty walking. The 14-day Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had impaired cognition and required limited assistance of one for bed mobility, transfers, and locomotion. Observation on 06/23/19 at 11:52 A.M. revealed Resident #28 was sitting in a wheelchair in the common area. No foot pedals were observed on the wheelchair and Resident #28's feet were dangling approximately one to two inches above the floor. Observation on 06/24/18 at 10:56 A.M. revealed Resident #28 was sitting in a wheelchair in the common area. No foot pedals were observed on the wheelchair and Resident #28's feet were dangling approximately one to two inches above the floor. Observation on 06/24/19 at 5:26 P.M. revealed staff was pushing Resident #28 to the dining room. No foot pedals were observed on the wheelchair and Resident #28's feet were dangling approximately one to two inches above the floor. Observation on 06/25/19 at 11:17 A.M. revealed Resident #28 was sitting in a wheelchair in the common area with feet dangling approximately one to two inches above the floor. Interview on 06/25/19 at 11:19 A.M. Licensed Practical Nurse (LPN) #506 verified there were no foot pedals on Resident #28's wheelchair and the resident's feet were dangling and not touching the floor. Interview on 06/25/19 at 11:31 A.M. with Director of Nursing verified Resident #28's feet were not touching the floor and the resident needed foot pedals or a different wheelchair. 366231 Page 4 of 10 366231 06/26/2019 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

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, observation, and interview, the facility failed to ensure Resident #30 used adaptive equipment (smoking apron) properly. This affected one resident (#30) out of six residents that required supervision and adaptive equipment. The facility also failed to ensure cigarettes were discarded in an appropriate container. This had the potential to affect the 12 residents that smoke out of the 33 residents. Facility census was 33. Findings include: 1. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnosis that included Alzheimer's and flexion deformity of right wrist. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #30 had cognitive impairment. Review of the plan of care revealed Resident #30 was at risk for injury related to smoking. An intervention was in place was for Resident #30 to wear a smoking apron (used to protect from accidental cigarette burns) while smoking. The quarterly smoking assessment date 05/24/19 revealed Resident #30 required supervision while smoking. Observation on 06/24/19 at 10:59 A.M. revealed Resident #30 was sitting in a chair in the smoking area. Resident #30 was wearing a smoking apron but the apron did not cover the top of the resident's legs. Interview on 06/24/19 at 11:03 A.M. Laundry #601 verified there were no ashtrays, fire blanket (used to extinguish small fires), or fire extinguisher in the resident smoking area. Observation on 06/24/19 at 4:03 P.M. revealed Resident #30 was sitting in a chair in the smoking area. Resident #30 was wearing a smoking apron but the apron did not cover the top of the residents right leg. Observation on 06/24/19 at 4:07 P.M. revealed Resident #30 was sitting in a chair in the smoking area. Resident #30 was wearing a smoking apron but the apron was between his legs exposing the top of both lets. Observation on 06/25/19 at 11:00 A.M. revealed Resident #30 was sitting in a chair in the smoking area. Resident #30 was wearing a smoking apron but the top of resident left leg was uncovered. Interview on 06/25/19 at 11:00 A.M. with Activities #600 verified Resident #30 did not like to wear the smoking apron and did not keep the apron over the top of his legs. Activities #600 also verified there were no ashtrays or fire blanket in the resident smoking area. 2. During the kitchen tour completed on 06/23/19 at 8:57 A.M., facility staff and surveyor had to exit the building out the exit near room [ROOM NUMBER]. Observed immediately outside of the exit door, underneath an overhang was a flower planter sitting on the ground with dirt and no plants. Observed on top of the dirt was approximately 20 to 25 smoked cigarette butts. The flower planter with the cigarette butts was verified with the Director of Nursing (DON) and Maintenance Director (MD) #502 on 06/23/19 at 9:39 A.M. The DON stated staff enter the facility through this door and also verified smoking should not be either so close to the building or have cigarette butts placed in the flower 366231 Page 5 of 10 366231 06/26/2019 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0689 planter. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366231 Page 6 of 10 366231 06/26/2019 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

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 facility failed to ensure food was stored under safe techniques and the kitchen was maintained and arranged to avoid unsanitary conditions. This had the potential to affect all 33 residents in the facility who receive food from the kitchen. The facility census was 33. Findings include: During the initial kitchen tour with Dietary Manager (DM) #504 on 06/23/19 from 8:57 A.M. to 9:31 A.M. observations were made of two reach-in refrigerators, a small freezer, and a large walk-in freezer. Observed in the reach-in refrigerators were the following items, all undated: a bag of Swiss cheese slices, twelve glasses of milk, five cups of sliced peaches, two pieces of black forest cake, a bag of bologna slices, a container of a rice mixture, a large container of chili, and a lunch tray from 06/20/19. Also observed in the reach-in refrigerators was an open, undated bag of American cheese slices. Observed in the small freezer were the following items, all undated: a bag of green beans, a bag of meatballs, a bag of waffles, a bag of riblets, two bags of Salisbury steaks, a bag of corn dogs, eight bags of turkey slices, seventeen cups of ice cream, two hams, and two bags of salami slices. Also observed in the small freezer were the following items, all undated and opened: a bag of biscuits, a bag of chicken breasts, a bag of chicken chunks, a bag of bread sticks, a bag of fish, a bag of pierogies, a bag of Caribbean blend vegetables, and a bag of garlic bread. Observed in the large walk-in freezer were open boxes of frozen broccoli with a cup sitting in the broccoli and a vegetable medley, and an open, undated bag of tarts. Also observed in the large walk-in freezer was an extremely large amount of the frozen vegetable medley all over the freezer floor. Additional observations during the kitchen tour on 06/23/19 from 8:57 A.M. to 9:31 A.M. included a storage bin of sugar with a cup laying inside the bin on top of the sugar, the floor on the pantry appeared to be dirty and was sticky, there was one stand alone white fan oscillating over the food preparation area, and the trash can for the hand sink was at the level of the hand sink, placed immediately in front of the hand sink to where the individual had to lean over the trash can to wash their hands, and the trash can did not have a lid. Staff interview with DM #504 on 06/23/19 at 9:25 A.M. revealed knowledge staff were to label and date food items when putting in the refrigerator or freezer and also bags are supposed to be sealed or closed when used and dated when opened. DM #504 also stated the vegetable medley in the freezer must have spilled and had not been cleaned up, verified staff knew not to leave cups in the food items when used as scoops, and stated the trash can lid had accidentally been thrown away the previous week. DM #504 verified all findings found during the kitchen tour. A second observation was made of the large walk-in freezer with DM #519 on 06/25/19 at 11:38 A.M. and revealed open boxes of Caribbean blend vegetables, broccoli, cauliflower, and peas. DM #519 verified the open boxes of vegetables and securely tied all bags. Review of undated facility policy titled, Dietary: Food Storage, revealed the policy did not address the need for dating or the duration foods could be kept in either a refrigerator or freezer. The 366231 Page 7 of 10 366231 06/26/2019 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0812 policy stated food storage areas shall be clean at all times. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 366231 Page 8 of 10 366231 06/26/2019 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and policy review, the facility failed to ensure food brought in for residents was handled to ensure safe storage and consumption. This had the potential to affect all 33 residents in the facility who receive food from the kitchen. The facility census was 33. Residents Affected - Many Findings include: During the initial kitchen tour with Dietary Manager (DM) #504 on 06/23/19 from 8:57 A.M. to 9:31 A.M. observations were made of two reach-in refrigerators, a small freezer, and a large walk-in freezer. Observed in the reach-in refrigerators the following undated and unlabeled item was identified, a container of a rice mixture. Observed in the small freezer the following undated and unlabeled item was identified, a container of ice cream. DM #504 verified the presence of the two items and also verified they were neither labeled or dated. DM #504 also stated these two items were brought in by a resident who liked to order food from area restaurants. DM #504 on 06/23/19 at 9:25 A.M. stated the facility is not to store food items brought in by residents, families, or restaurants in the facility kitchen. Review of undated facility policy titled, Dietary: Foods Brought by Family Members stated non-perishable food permitted to be retained in the resident's room must be stored in plastic containers with tight-fitting lids, dated, except fresh fruit. Food may be stored for no more than five days in a refrigerator or daily if no refrigeration. Perishable foods must be thrown out at that time. The policy also stated the facility does provide a refrigerator for resident food in a central location. The policy does not state if the food can or cannot be stored in the facility kitchen. 366231 Page 9 of 10 366231 06/26/2019 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and the dressing policy and procedure, the facility failed to maintain acceptable infection control standards during a dressing change for Resident #4. This affected one resident (#4) out of one resident reviewed for a dressing change. Facility census was 33. Residents Affected - Few Findings include: Review of medical record revealed Resident #4 was admitted on [DATE] with diagnosis that included but not limited below the left knee amputation, osteomyelitis, sepsis, and diabetes mellitus. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact. Review of the physician orders for Resident #4 revealed the resident's right heel was to be cleansed with normal saline and patted dry. Calcium alginate Ag (silver), a sterile antimicrobial fiber-structure alginate with high absorbency, was to be applied and then covered with a foam dressing. The dressing was to be changed daily and as needed. An observation was made on 06/24/19 at 9:55 A.M. of Registered Nurse (RN) #500 changing the dressing to Resident #4's right heel. RN #500 entered the residents room and laid the supplies on the resident's bedside table. RN #500 washed and dried her hands and applied three pairs of gloves. RN #500 removed the resident's sock and the dressing to the right heel. RN #500 removed one pair of gloves. RN #500 cleansed the resident right heel with normal saline and removed the second pair of gloves. RN #500 applied the calcium alginate Ag and foam dressing. RN #500 removed the last pair of gloves and washed her hands. Review of the dressing, dry/clean policy and procedure dated 12/01/18 revealed the bedside stand was to be cleaned to establish a clean field. The policy and procedure also revealed the bedside table was to be cleaned after the treatment was completed. Interview on 06/24/19 at 11:09 A.M. RN #500 verified she had applied three pairs of gloves at the beginning of the dressing changed, had not washed her hands during the procedure, and did not clean the bedside table before or after supplies were placed on the bedside table. 366231 Page 10 of 10