Inspection·July 11, 2019

F 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure a medication error rate of 5% (percent) or less. This finding affected two (Residents #12 and #44) of five residents observed for medication administration. A total of twenty-six medications were administered with two errors for a medication error rate of 7.6%. Residents Affected - Few Findings include: 1. Observation on 07/09/19 at 10:04 A.M. with Licensed Practical Nurse (LPN) #816 of Resident #44's medication administration revealed the resident received two units of Humulin R (Regular) insulin in the right lower arm. Review of Resident #44's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including schizophrenia and type two diabetes without complications. Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #44's physician orders revealed an order dated 06/26/19 for insulin regular human solution inject two units subcutaneously three times a day related to type two diabetes without complications before meals due at 8:00 A.M., 12:00 P.M. and 4:00 P.M. Interview on 07/09/19 at 10:13 A.M. with LPN #816 confirmed Resident #44 received the insulin following the breakfast meal and not prior to the meal as ordered by the physician. 2. Observation on 07/10/19 at 3:48 P.M. with LPN #817 administered carvedilol 12.5 mg (milligrams) to Resident #12. Review of Resident #12's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including essential hypertension, paranoid schizophrenia and gastrostomy status. Review of Resident #12's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #12's physician orders revealed an order dated 02/17/18 for carvedilol 12.5 mg give one tablet by mouth two times a day related to essential primary hypertension due 8:00 A.M. and 4:00 P.M. Interview on 07/10/19 at 3:50 P.M. with LPN #817 confirmed Resident #12's blood pressure medication should have been administered with food or during meals. Interview on 07/10/19 at 4:01 P.M. with Restorative Nurse Manager #815 confirmed Resident #12's blood pressure medication should be administered with food because the resident becomes nauseated with medications and the physician ordered the resident's medications to be administered with food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366275 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 staff interview the facility failed to ensure food was handled in a sanitary manner. This affected two of fourteen residents (Resident #18 and #21) eating in the dining room. Also the facility failed to ensure the kitchen was maintained in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 46. Findings Included: 1. Observation on 07/08/19 at 12:56 P.M. of residents being served in the dining room revealed Register Nurse (RN) #815 removed rolls from Resident 18 and Resident #21's plate, with no gloves on, and proceeded to butter the roll. The RN #815 placed the buttered roll on Resident #18 and Resident #21's plate, to be eaten. Interview on 07/08/19 at 1:13 P.M. with RN #815 verified she did touch Resident #18 and Resident #21's rolls with her hands to butter them and gave them to the resident to eat without washing her hands first. The RN #815 verified she did not know she was not allowed to touch residents food with her bare hands when assisting them with setup of meal. Interview on 07/08/19 at 1:25 P.M. with Food Service Director #820 verified that staff should not be handling any of the residents food with their bare hands. 2. Observations on 07/08/19 during the initial kitchen tour (9:01 A.M. through 9:30 A.M.) of the kitchen with Dietitian #821 revealed the kitchen floors had crumbs and dirty build up under and behind the prep tables, around sink drains and in dry storage room. Observation of the fronts and sides of appliances had dried food and greasy buildup, the mixer had white powder on it and the mixing bowl was dirty, the flour scoop was sitting on top of the flour container uncovered, loose chocolate chips were on top of canned goods in the dry storage room. Observations of the storage of pans revealed one pan put away wet and ten pans put away dirty, with dried food on them. Observation of the freezer and refrigerators revealed 16 single serving pineapple dished up in the freezer and not covered or dated and in the refrigerator there were two containers of cottage cheese and one container of gravy opened and not dated. Interview on 07/08/19 at 9:22 A.M. with Food Service Director #820 stated food is to be covered and dated when opened and should be thrown out after five days. The Food Service Director #820 verified that the kitchen was not sanitary and clean. The Food Service Director #820 verified flour scoop should be kept in a container, the dry storage area had loose chocolate chips and floor was dirty. The Food Service Director #820 verified the wet pan and dirty pans. Review of facility policy titled Food Safety and Sanitation Policy, dated 2010, revealed foods stored in the storeroom is clean, dry and cool. Review of facility policy titled General Sanitation of Kitchen, dated 2010, revealed kitchen should be kept in a clean and sanitary manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366275 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Food Storage, dated 2010 revealed leftover food is stored in covered containers or wrapped carefully and securely, each item is clearly labeled and dated before being refrigerated. Left over food is used within 3 days or discarded. Scoops are kept covered in a protected area near the container and washed and sanitized on a regular basis and plastic containers with tight fitting covers to be used for storing for broken lots of bulk foods. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366275 If continuation sheet Page 4 of 4