Health inspection·June 2, 2022

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 adequate wound care for Resident #23 to prevent infection and to promote optimal healing. This affected one resident (#23) of two residents reviewed for wound care. Residents Affected - Few Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, history of COVID-19, schizoaffective disorder, osteoarthritis, severe sepsis, osteomyelitis, gout, migraines, chronic obstructive pulmonary disease, anemia, bronchospasm, kidney disease, diabetes, post traumatic stress disorder, depressive disorders and anxiety disorders. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/15/22 revealed Resident #23 had intact cognition and no pressure ulcers. Review of the May 2022 physician's orders revealed Resident #23 had an order, dated 05/26/22 to cleanse right heel with wound cleanser, pat dry, activate derma-blue with normal saline, apply to wound, cover with dry dressing, secure with an ace wrap and change every other day and as needed and an order for the antibiotic, Doxycycline hyclate 100 milligrams twice daily for redness and warmth to the right heel for seven days. Resident #23 was actively being treated for a right heel wound infection. On 06/01/22 at 10:25 A.M. Registered Nurse (RN) #31 was observed to provide wound care for Resident #23. RN #31 cut the old dressing off the resident's right foot, placed her scissors down on the clean dressing field, cleaned the right heel with a normal saline vial and wiped the wound off with a clean four by four gauze. RN #31 did not change her gloves or wash her hands between removing the old dressing and cleaning with the clean dressing. RN #31 then picked up the scissors and cleaned them off with a Microdot bleach wipe, she then proceeded to cut the derma blue dressing with the scissors while holding the derma blue dressing with her soiled gloved hand. She placed the derma blue directly on the right heel wound and wrapped with gauze wrap RN #31 never washed her hands or changed her gloves after cleaning the soiled scissors with the Microdot bleach wipe and picking up the clean derma-blue dressing and applying it to the resident's heel wound. On 06/01/22 at 10:40 A.M. interview with RN #31 verified she had not changed her gloves or washed her hands after she removed the old dressing. The RN also verified she cleaned her scissors with a bleach wipe then touched the clean dressing and applied it to the resident's right heel wound. Page 1 of 10 366231 366231 06/02/2022 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure weight loss interventions were provided as ordered by the physician for Resident #24. This affected one resident (#24) of two residents reviewed for nutrition. Residents Affected - Few Findings include: Review of the Consulting Management Fall Winter menu, signed by Dietitian #43 dated 10/08/21 revealed milk was to be served with each meal. Record review for Resident #24 revealed an admission date of 03/04/20 with diagnoses including muscle wasting and atrophy, weakness and adult failure to thrive. Review of laboratory results for Resident #24 revealed on 10/04/21 Resident #24's protein level was 6.1 (normal range was 6.0-8.3). On 01/05/22 Resident #24's protein level was 6.6. On 01/27/22 Resident #24's protein level was 5.3 and on 04/04/22 Resident #24's protein level was 5.7. Record review revealed a plan of care, dated 04/15/22 indicating Resident #24 had potential for alteration in nutrition and hydration related to underweight status, variable intake and adult failure to thrive. Interventions included to provide diet and supplements as ordered. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/16/22 revealed Resident #24 required supervision and set up help with eating. Review of Resident #24's physician orders for May 2022 and June 2022 revealed Resident #24 was to receive a regular texture, regular consistency diet with whole milk with each meal, cream soup with lunch and supper, and large portions each meal. Resident #24 was also to receive a magic cup (supplement) before meals and at bedtime four times a day. Review of the nutritional assessment, dated 04/20/22 completed by Dietitian #43 revealed Resident #24's intake was variable, 25-100% meals. Magic cup four times a day (intake 50-100% both supplements, occasional refusals or <25%). Current intake of meals alone was inadequate to meet estimated nutritional needs. Current intake of meals + nutritional supplements meets and/or exceeds estimated nutritional needs, thus weight maintenance/gain anticipated. Magic Cup four times a day equaled 160 kcal, and 36 grams of protein. Record review of Resident #24's meal ticket (used by the kitchen staff to determine what should be placed on each meal tray) revealed Resident #24 was to receive large portions, cream soup with meals, magic cup with all meals, milk and a snack. On 05/31/22 at 11:46 A.M. observation revealed lunch trays were served to residents in the dining room. Observation revealed juice and water were served on the lunch trays. No milk was present on any trays served in the dining room. On 05/31/22 at 12:15 P.M. interview with Assistant Director of Nursing/Dietary Assistant #28 confirmed she ordered all food items for the kitchen and this was the correct menu (Fall/Winter menu) used for May 2022 and June 2022. 366231 Page 2 of 10 366231 06/02/2022 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/31/22 at 12:25 P.M. of Resident #24's lunch tray served in his room revealed Resident #24 did not have milk, soup, magic cup or a snack on his lunch tray. On 05/31/22 at 12:28 P.M. interview with State Tested Nursing Assistant (STNA) #26 confirmed Resident #24 did not have milk, soup, magic cup or a snack on his lunch tray. STNA #26 revealed the kitchen staff were supposed to put the magic cup on the meal trays. On 05/31/22 at 1:41 P.M. interview with Dietary Assistant #34 confirmed the kitchen staff were supposed to put the magic cup on the meal tray for Resident #24. Dietary Assistant #34 revealed residents only receive milk on the breakfast trays. On 06/01/22 at 11:27 A.M. observation of the food service tray line revealed Dietary Manager #23 and Dietary Assistant #18 prepared resident meal plates with food for the lunch meal. There were two food carts. Each cart had the trays for each resident pre-made in the cart. On each tray were drink items, water and juice, silverware and the residents' food ticket which described the diet the resident was to receive. Observation revealed during the food service tray line for the lunch meal, neither Dietary Manager #23 or Dietary Assistant #18 looked at or discussed Resident #24's food items ordered prior to setting up the food to be delivered to Resident #24. Each plate served received one five and one third ounce scoop of the main entree, spaghetti. No milk was placed on any tray for any resident. On 06/01/22 at 11:50 P.M. interview with Dietary Manager #23 revealed staff did not read meal tickets because staff knew the residents well enough, they did not need to look at the ticket. On 06/01/22 at 12:19 P.M. observation with Dietary Manager #23 of Resident #24's meal tray that had been served to the resident in his room confirmed Resident #24 did not have milk, soup or a large portion served on his tray as per the physician's dietary orders. Dietary Manager #24 confirmed the kitchen was also to serve a magic cup and a snack that was additionally on the food ticket that were also not present on Resident #24's lunch tray. On 06/01/22 at 1:16 P.M. interview with Dietitian #43 confirmed she had assessed Resident #24. Dietitian #43 confirmed Resident #24 was to receive large portions for every meal. Dietitian #43 revealed large portions were a scoop and a half (instead of one scoop) for each food item. Resident #24 was also to receive milk with all meals, cream soup with lunch and dinner, and a magic cup and snack with all meals. Dietitian #24 revealed her assessments were based on Resident #24 receiving the dietary ordered items. Dietitian #43 confirmed she approved the menus for the facility and each resident was to receive milk with each meal. On 06/02/22 between 8:27 A.M. and 8:33 A.M. interview with Licensed Practical Nurse (LPN) #1 and LPN #20 revealed Resident #24's magic cup was to come from the kitchen with his meals. LPN #1 and LPN #20 then confirmed the order for the magic cup was to be given before meals. LPN #20 stated, That's just the way it's done. LPN #1 and LPN #20 revealed nursing staff did not look to see how much of the magic cup was consumed, the STNA staff would let them know how much was consumed. On 06/02/22 at 11:10 A.M. interview with Assistant Director of Nursing/Dietary Assistant #28 confirmed she also worked in the kitchen serving the tray line. Assistant Director of Nursing/Dietary Assistant #28 indicated staff, including herself did not look at the residents' meal tickets during meal service due to not having enough time. Assistant Director of Nursing/Dietary Assistant #28 revealed she ordered the food for the kitchen routinely and residents would only receive milk for breakfast 366231 Page 3 of 10 366231 06/02/2022 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0692 unless they specifically requested milk during the meal served, due to the budget. Level of Harm - Minimal harm or potential for actual harm On 06/02/22 at 2:16 P.M. interview with STNA #39 revealed the magic cup supplements were served on resident meal trays from the kitchen. STNA #39 revealed at times the kitchen does not send them and when staff floats from different areas of the facility, they do not realize the resident was supposed to receive them so they don't get them. Residents Affected - Few 366231 Page 4 of 10 366231 06/02/2022 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, record review and interview the facility failed to ensure sufficient staff to effectively carry out the functions of the food and nutrition services. This affected one sampled resident (#24) and had the potential to affect all 41 residents residing in the facility. Findings include: Record review for Resident #24 revealed an admission date of 03/04/20 with diagnoses including muscle wasting, atrophy and adult failure to thrive. Review of the physician's orders for Resident #24 for the months of May 2022 and June 2022 revealed orders for a regular texture diet with regular consistency, whole milk with each meal, cream soup with lunch and supper, large portions each meal and a magic cup (supplement) before meals and at bedtime four times a day. On 05/31/22 at 9:25 A.M. observation of the kitchen area revealed Dietary Assistant (DA) #18 was the only staff member available in the kitchen. Observation of the kitchen area revealed dirty dishes were piled in the sinks and on the counters. DA #18 verified the condition of the kitchen and indicated it was because she was the only staff member in the kitchen from 6:00 A.M. to 10:00 A.M. to cook the residents' breakfast, set up each tray to be served with food and drinks and clean and store the leftover food items. Dietary Assistant #18 revealed there were not enough staff in the kitchen to effectively complete these tasks. On 06/01/22 at 11:27 A.M. observation of the food service tray line revealed Dietary Manager #23 and Dietary Assistant #18 prepared residents' plates of food with the lunch meal. There were two food carts. Each cart had the trays for each resident prepared in the cart. On each tray were drink items, silverware and the resident's meal ticket which described the diet the resident was to receive. Observation revealed during the food service tray line for the lunch meal, neither Dietary Manager #23 or Dietary Assistant #18 looked at or discussed Resident #24's food items ordered prior to setting up the food to be delivered to Resident #24. Each plate served received one five and one third ounce scoop of the main entree, spaghetti. On 06/01/22 at 12:19 P.M. observation with Dietary Manager #23 of Resident #24's meal tray that had been served to the resident in his room revealed Resident #24 did not have milk, soup or a large portion served on his tray as per the physician's dietary order. Dietary Manager #24 revealed the kitchen was also to serve a magic cup and a snack that were additionally on the meal ticket that was also not present on Resident #24's lunch tray. On 06/02/22 at 11:05 A.M. interview with Dietary Assistant #18 and Assistant Director of Nursing/Dietary Assistant #28 revealed staff do not look at the resident's individual meal tickets. Dietary Assistant #18 stated, Oh do you want us to look at each ticket, we cant do that, we dont have time for that, I am the only one here for breakfast, I have to do everything. Dietary Assistant #18 and Dietary Assistant #28 confirmed they did not have enough time to look at resident's meal tickets during any meals when preparing the resident's trays. Record review of the Kitchen Schedule for the week of 05/29/22 through 06/04/22 confirmed one staff member was scheduled 6:00 A.M. to 10:00 A.M. and an additional staff member was scheduled at 10:00 366231 Page 5 of 10 366231 06/02/2022 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0802 A.M. for meal service of all 41 residents. Level of Harm - Minimal harm or potential for actual harm On 06/02/22 at 11:10 A.M. interview with Assistant Director of Nursing/Dietary Assistant #28 revealed she completed the dietary schedule monthly with only one staff member scheduled daily from 6:00 A.M. to 10:00 A.M. and a second member to come in to assist with lunch and dinner. Assistant Director of Nursing/Dietary Assistant #28 confirmed she also worked in the kitchen serving residents meals and indicated there were not enough staff present to read each resident's meal ticket and serve the food timely. Residents Affected - Many Record review of the facility assessment for Food and Nutrition Services, dated 03/21/22 revealed the facility must employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. 366231 Page 6 of 10 366231 06/02/2022 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure food items were served at an appetizing and palatable temperature for all residents. This affected four residents (#14, #3, #17 and #24) and had the potential to affect all 41 residents residing in the facility. Residents Affected - Many Findings include: Review of the Resident Council Meeting Minutes, dated 01/06/22 revealed resident concerns with dietary which included concerns of cold food. On 05/31/22 at 9:52 A.M. interview with Resident #17 revealed breakfast was cold every morning and lunch was not good either. On 05/31/22 at 10:49 A.M. interview with Resident #3 revealed dietary concerns including the food was always cold, never warm when served. On 05/31/22 at 11:25 A.M. interview with Resident #14 revealed concerns his food was often served cold. On 06/01/22 at 12:15 P.M. interview with Resident #24 revealed concerns at times the food served was cold. On 06/01/22 at 12:08 P.M. observation of the lunch meal revealed the meal consisted of spaghetti with hamburger meat sauce, peas and a breadstick. A test tray completed with Dietary Assistant #18 revealed the spaghetti with hamburger meat sauce was 61 degrees Fahrenheit (F) and the peas were 43.3 degrees F. The taste of the spaghetti was slightly warm to cool, the peas were cold and the breadstick was cool to touch. Dietary Assistant #18 confirmed the temperatures of the food. On 06/02/22 11:10 A.M. interview with Assistant Director of Nursing/Dietary Assistant #28 revealed neither the food carts or plates the resident's food items were served on for each meal had warming elements to keep the food warm. There were two food carts to deliver the food and one of the two did not have a cover. Both carts were filled before serving the food to the residents. On 06/02/22 at 11:40 A.M. interview with Administrator revealed he was new to position and unaware of any concerns with the food temperatures. Record review of the facility undated policy titled, Cooking Temperatures, What is the Danger Zone revealed bacteria need warm, moist conditions to multiply in food. Foods must be held either below 41 degrees or above 135 degrees to reduce forborne illness. 366231 Page 7 of 10 366231 06/02/2022 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, facility policy and procedure review and interview the facility failed to ensure food items were prepared and distributed under sanitary conditions to prevent contamination and/or food borne illness. This had the potential to affect all 41 residents residing in the facility. Findings include: On 06/01/22 at 11:42 A.M. observation of the tray line service for the lunch meal revealed Dietary Manager #23 had tested the temperatures of the of the food items on the steam table. Dietary Manager #23 had disposable gloves on both hands. After completing the food temperatures, Dietary Manager #23 dropped the alcohol wipe including the wrap the wipe came in on the floor. Dietary Manager #23 reached down and picked the wipe and covering off the floor, walked over to the trash can, removed the lid to the trash can and threw the wipe and covering away. Dietary Manager #23 then walked back to the tray line, picked up bread sticks with the hand he removed the trash can lid up with (no utensils were used) and placed the bread sticks on the plates to be served to the residents. Dietary Manager #23 then began plating the spaghetti with meat sauce on the plates when the surveyor intervened related to the observed kitchen sanitation concern. On 06/01/22 at 11:47 A.M. interview with Dietary Manager #23 confirmed after he picked up the trash from the floor, he picked up the lid to the trash can, threw away the trash, then returned to the tray line and picked up and plated the bread sticks with his same gloved hands to be served to the residents. Dietary Manager #23 confirmed he then then began plating the spaghetti and did not wash his hands or change his gloves before picking up the bread sticks or plating the spaghetti. Record review of the facility undated policy titled, Food Handling Guidelines revealed cross contamination precautions included hands should be scrubbed following facility policy between food preparation, tasks, etc. 366231 Page 8 of 10 366231 06/02/2022 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility infection control logs, facility policy and procedure review and staff interview the facility failed to implement an effective antibiotic stewardship program to ensure antibiotics were not used unless residents' met the criteria to treat an infection. This affected one resident (#23) of two residents reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, history of COVID-19, schizoaffective disorder, osteoarthritis, severe sepsis, osteomyelitis, gout, migraines, chronic obstructive pulmonary disease, anemia, bronchospasm, kidney disease, diabetes, post traumatic stress disorder, depressive disorders and anxiety disorder. Review of the nursing note, dated 01/18/22 at 11:40 A.M. revealed wound rounds were done and Resident #23 had erythema (redness) and warmth noted at the peri-wound to the right heel. A new order was received from the physician. Review of the physician's orders revealed Resident #23 had an order, dated 01/18/22 for the antibiotic, Cephalexin 500 milligrams (mg) twice daily for seven days for a wound infection. Review of the McGeer's Criteria, dated 01/18/22 revealed Resident #23 had a skin infection with redness and serous drainage. The criteria indicated the resident must have four of the following: fever greater than 100.4 Fahrenheit, heat, redness, swelling, pain or tenderness or serous drainage. The resident did not meet the criteria for antibiotic therapy. Review of the facility's infection control log, dated 01/18/22 revealed Resident #23 had wound infection which was treated with Cephalexin 500 mg with no culture done. Review of the physician's orders revealed Resident #23 had an order, dated 02/10/22 for the antibiotic, Doxycycline hyclate 100 mg twice daily for 10 days for a wound infection. Review of the facility's infection control log, dated 02/10/22 revealed Resident #23 had a skin infection which was treated with Doxycycline 100 mg with no culture done. Review of the McGeer's Criteria dated 02/10/22 revealed Resident #23 had a skin infection with heat, redness, and serous drainage. The criteria indicated the resident must have four of the following: fever greater than 100.4 Fahrenheit, heat, redness, swelling, pain or tenderness or serous drainage. The resident did not meet the criteria for antibiotic therapy. Review of the physician's orders revealed Resident #23 had an order, dated 03/03/22 for the antibiotic, Doxycycline hyclate 100 mg twice daily for 10 days for a wound infection. Review of the McGeer's Criteria dated 03/03/22 revealed Resident #23 had a skin infection with heat and redness. The criteria indicated the resident must have four of the following: fever greater than 100.4 Fahrenheit, heat, redness, swelling, pain or tenderness or serous drainage. The resident did not meet the criteria for antibiotic therapy. 366231 Page 9 of 10 366231 06/02/2022 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0881 Level of Harm - Minimal harm or potential for actual harm Review of the facility's infection control log, dated 03/23/22 revealed Resident #23 had a wound infection which was treated with Doxycycline 100 mg with no culture done. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/15/22 revealed Resident #23 had intact cognition and no pressure ulcers. Residents Affected - Few Review of the May 2022 physician's orders revealed Resident #23 had an order dated 05/26/22 for Doxycycline hyclate 100 mg twice daily for redness and warmth to the right heel for seven days. Resident #23 had was actively being treated for a right heel wound infection. Review of the nursing note, dated 05/26/2022 at 6:57 P.M. revealed a new order was received from the physician to start the resident on the antibiotic, Doxycycline 100 mg by mouth twice daily for redness and warmth to right heel. Review of the McGeer's Criteria dated 05/27/22 revealed Resident #23 had a skin infection with heat, redness, and serous drainage. The criteria indicated the resident must have four of the following: fever greater than 100.4 Fahrenheit, heat, redness, swelling, pain or tenderness or serous drainage. The resident did not meet the criteria for antibiotic therapy. Review of the facility's infection control log, dated 05/27/22 revealed Resident #23 had a wound infection which was treated with Doxycycline 100 mg with no culture done. Review of the laboratory results from 01/01/22 to 05/30/22 revealed no documentation or orders for a wound culture of the resident's right heel. On 06/02/22 at 9:19 A.M. interview with the Director of Nursing (DON) revealed all the wound/skin infections for Resident #23 were related to his right heel. The DON revealed there were never any cultures done of the resident's heel because the wound physician never ordered any. She stated she never asked him why he had not ordered any wound cultures. On 06/02/22 at 11:10 A.M. interview Physician #17 revealed the resident was prescribed a round of Doxycycline for cellulitis of the foot but the resident had chronic osteomyelitis and had responded well previously to Doxycycline. The physician indicated he had previously followed the resident up until August of 2021 and just started to follow him again in the last 6-8 weeks. He stated he had not ordered an wound culture, however if he had not seen a response to the Doxycycline this time he would order blood cultures but he had not done so previously. Review of the facility policy titled Antibiotic Stewardship, revised 08/2019 revealed the policy was to maintain an Antibiotic Stewardship Program (ASP) with the mission of promoting the appropriate use of antibiotic to treat infections and reduce possible adverse events associated with antibiotic use. 366231 Page 10 of 10