Health inspection·August 15, 2019

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents wheelchairs were kept clean. This affected one resident, Resident (#71) of two residents reviewed for environmental concerns. The facility identified 56 residents who required assistance with ambulation or assistive devices. The facility census was 93. Findings included: Review of Resident #71's medical record revealed an admission date of 06/03/19. Diagnoses included abnormalities of gait, osteoarthritis, asthma, insomnia, major depressive disorder, unsteadiness on lack of coordination, dysphagia, type II diabetes, hyperlipidemia, spinal stenosis, and osteoarthritis. Review of Resident #71's Minimum Data Set (MDS) assessment, dated 07/04/19, revealed Resident #71 was moderately cognitively impaired. Resident #71 required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. Observation on 08/12/19 at 2:12 P.M. of Resident #71's wheelchair found a build up of food crumbs, dust, and debris around the edges of Resident #71's wheelchair seat cushion. A dried piece of what appeared to be brown and white bread was wedged between the arm rest and wheel support of the wheelchair. Interview on 08/12/19 at 2:15 P.M., Resident #71 removed the dried bread from her wheelchair and reported it must have gotten in there yesterday during breakfast. Resident #71 reported it looked like the bread she had with breakfast on 08/11/19. The bread was dry and crumbled in Resident #71's hand when she pushed on it. Interview on 08/12/19 at 2:20 P.M., State Tested Nursing Assistant (STNA) #105 verified stale bread was found in Resident #71's wheelchair and Resident #71's wheelchair needed to be cleaned. STNA #105 reported all resident wheelchairs were cleaned on third shift so they had time to dry while residents were sleeping. STNA #105 reported she was not aware of when Resident #71's wheelchair was last cleaned. Observation on 08/13/19 at 8:43 A.M. found Resident #71 seated in her wheelchair in her room. Resident #71's wheelchair continued to have food crumbs, dust, and debris around the edges of the seat cushion. Interview at this time with Resident #71 revealed no one had cleaned her wheelchair. Interview on 08/13/19 at 2:02 P.M., STNA #110 revealed Resident #71 was able to make her needs Page 1 of 10 366290 366290 08/15/2019 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0584 Level of Harm - Minimal harm or potential for actual harm known but required physical assistance with transfer and mobility. STNA #110 reported Resident #71 required a wheelchair for mobility and the facility was responsible for cleaning all resident's wheelchairs and equipment. STNA #110 stated there was a schedule for when equipment to be cleaned. The schedule had wheelchairs cleaned on third shift so there was time for the wheelchair to dry overnight. STNA #110 reported there was no documentation completed related if equipment was cleaned as scheduled. Residents Affected - Few Observation on 08/13/19 at 2:12 P.M., Resident #71's wheelchair continued to have food crumbs, dust, and debris around the edges of the seat cushion. Review of the facility policy titled Wheelchair/Walker Cleaning Schedule, dated 07/26/18, revealed to clean wheelchairs on night shift per unit as scheduled. In between scheduled cleanings staff shall remove and clean visible matter from all wheelchairs and walkers on an as needed basis daily. 366290 Page 2 of 10 366290 08/15/2019 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Self-Reported Incident (SRI), medical record review, facility policy review and satff interview, the facility failed to implement the abuse policy on reporting allegations of abuse. This affected one (#9) of one residents reviewed for abuse. The faciltiy census was 93. Residents Affected - Few Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, chronic kidney disease, diabetes and hypertension. Review of the nurse progress note dated 04/15/19 at 4:28 P.M., revealed State Tested Nurse Aid (STNA) #150 reported resident called on her call light and wanted her brief changed. When the STNA's were placing the gait belt on resident, resident became upset and grabbed the STNA in her breast and also pinched her breast. Both STNA's left the room and informed the nurse and management. STNA's were instructed to continue to assist resident with two assist and gait belt. Review of SRI number 171824 revealed Resident #9 was named in the allegation of physical abuse. Review of the facility investigation of the SRI revealed on 04/14/19 at 11:30 A.M., Resident #9 reported that she was beat up on 4/13/2019 in the evening by three girls, STNA #150 who immediately reported this to the charge nurse. The investigation initiated and was submitted on 04/15/19 at 8:56 A.M. and closed on 04/16/19. Review of the staff statements revealed STNA #160 stated she assisted Resident #9 with care and transfers on 04/13/19. STNA #160 reported that approximately 8:45 Pm to 9:00 P.M., Resident #9 put on her call light. When STNA answered her call light. Resident #9 told her that three girls took her into the bathroom and beat her up. STNA #170's statement revealed on 04/13/19 at bedtime she toileted Resident #9 and gave her bedtime snack when Resident #9 mentioned that she was upset because three girls came in and hit her. Interview and review of the incident investigation with Director of Nursing (DON) on 08/14/19 at 9:46 A.M., verified the incident was reported to her on 04/14/19 at approximately 11:30 A.M. The DON verified two STNAs (#160 and #170) were aware of the incident on 04/13/19. STNA #160 was aware between 8:45 P.M. and 9:00 P.M. STNA #170 was aware on 04/13/19 at bedtime. The DON verified the alleged abuse was not reported to management by STNA #160 or #170 and the SRI was not submitted until 04/15/19 at 8:56 A.M. The DON verified the alleged abuse was not reported immediately as required and per the faciltiy policy. Review of the undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it was the facility policy to investigate all alleged violations involving abuse. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). All abuse incidents or allegations must be reported to the Administrator immediately. If the event that caused the allegation involves abuse it should be reported to ODH immediately but not later than two hours after the allegation is made. The Administrator will notify ODH of all alleged violations involving abuse as soon as possible but in not event later that 24 hours from the time the incident/allegation was made known to the staff member. 366290 Page 3 of 10 366290 08/15/2019 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Self-Reported Incident (SRI), medical record review,facility policy review and staff interview, the facility failed to timely report an allegation of abuse by a resident. This affected one (#9) of one residents reviewed for abuse. The faciltiy census was 93. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, chronic kidney disease, diabetes and hypertension. Review of the nurse progress note dated 04/15/19 at 4:28 P.M., revealed State Tested Nurse Aid (STNA) #150 reported resident called on her call light and wanted her brief changed. When the STNA's were placing the gait belt on resident, resident became upset and grabbed the STNA in her breast and also pinched her breast. Both STNA's left the room and informed the nurse and management. STNA's were instructed to continue to assist resident with two assist and gait belt. Review of SRI number 171824 revealed Resident #9 was named in the allegation of physical abuse. Review of the facility investigation of the SRI revealed on 04/14/19 at 11:30 A.M., Resident #9 reported that she was beat up on 4/13/2019 in the evening by three girls, STNA #150 who immediately reported this to the charge nurse. The investigation initiated and was submitted on 04/15/19 at 8:56 A.M. and closed on 04/16/19. Review of the staff statements revealed STNA #160 stated she assisted Resident #9 with care and transfers on 04/13/19. STNA #160 reported that approximately 8:45 Pm to 9:00 P.M., Resident #9 put on her call light. When STNA answered her call light. Resident #9 told her that three girls took her into the bathroom and beat her up. STNA #170's statement revealed on 04/13/19 at bedtime she toileted Resident #9 and gave her bedtime snack when Resident #9 mentioned that she was upset because three girls came in and hit her. Interview and review of the incident investigation with Director of Nursing (DON) on 08/14/19 at 9:46 A.M., verified the incident was reported to her on 04/14/19 at approximately 11:30 A.M. The DON verified two STNAs (#160 and #170) were aware of the incident on 04/13/19. STNA #160 was aware between 8:45 P.M. and 9:00 P.M. STNA #170 was aware on 04/13/19 at bedtime. The DON verified the alleged abuse was not reported to management by STNA #160 or #170 and the SRI was not submitted until 04/15/19 at 8:56 A.M. The DON verified the alleged abuse was not reported immediately as required and per the faciltiy policy. Review of the undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it was the facility policy to investigate all alleged violations involving abuse. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). All abuse incidents or allegations must be reported to the Administrator immediately. If the event that caused the allegation involves abuse it should be reported to ODH immediately but not later than two hours after the allegation is made. The Administrator will notify ODH of all alleged violations involving abuse as soon as possible but in not event later that 24 hours from the time the incident/allegation was made known to the staff member. 366290 Page 4 of 10 366290 08/15/2019 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

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 Based on medical record review, observation, facility policy review and staff interviews, the facility failed to follow the physician orders for treatment of a non-pressure skin condition. This failed practice affected one (#87) of one resident reviewed for non-pressure skin conditions. The facility census was 93. Residents Affected - Few Findings include: Review of the medical record for Resident #87 revealed an admission date of 01/02/19, with diagnoses of Parkinson's disease, dementia, repeated falls, depression, anxiety, heart disease, diabetes, hallucinations, seborrheic dermatitis and bulbous pemphigoid (a medical condition which causes blistering of the skin). Review of the nurse progress note dated 08/03/19 at 7:58 A.M., revealed Resident #87 had a new blister located below the left knee. Blister was fluid filled and resident was not showing signs of discomfort at this time. Review of the current physician orders revealed to wash bulbous pemphigoid blister to left knee with soap and water or normal saline and pat dry. Leave open to air, every shift ordered on 08/13/19. Observation on 08/15/19 at 10:19 A.M., with Licensed Practical Nurse (LPN) #220, revealed the resident had a skin lesion below his left knee approximated 2.5 centimeters round, scabbed and no drainage noted. LPN #220 commented she was not aware Resident #87 had the lesion at his left knee. As observations continued, LPN #220 did not cleanse the wound. LPN #220 applied Mupirocin Ointment 2 % to the area. Interview after the observation, with LPN #220 verified the lesion was a bulbous pemphigoid blister which had opened and was now dry and scabbed. After reviewing the physician orders LPN #220 verified the order was to wash the area with soap and water then leave it open to air. LPN #220 stated she thought the order was for Mupirocin ointment. LPN #220 stated there was no order to apply Mupirocin ointment to the left knee wound. LPN #220 verified she had not reviewed the physician orders prior to completing the wound treatment and verified she had not followed the physician order in regard to the left knee treatment. LPN #220 stated she could call the physician at this time to obtain an order to apply the Mupirocin ointment. Interview on 08/15/19 at 4:40 P.M., with LPN #400 stated there was a physician order for Mupirocin ointment and provided copies of additional information for review. Review of the physician orders revealed two orders, both dated and printed on 07/25/19. The first order was: Mupirocin Ointment 2 %. Apply to open sores to trunk topically every day shift for bulbous pemphigoid. The second order was nearly identical to the first with the addition of application of the ointment to the face. The second order was: Mupirocin Ointment 2 %. Apply to open sores to face/trunk topically every day shift for bulbous pemphigoid. Neither order included application to the knee. Additionally, LPN #400 verified LPN #220 had called the physician to obtain a new order to apply Mupirocin Ointment 2 % to the knee on 08/15/19 at 11:23 A.M., after the observation when she failed to complete the treatment per the current and active physician order which was to wash bulbous pemphigoid blister to left knee with soap and water or normal saline and pat dry. Leave open to air, every shift ordered on 08/13/19. Review of the facility policy titled Pressure Ulcer/Skin Breakdown Clinical Protocol revised March 2014 revealed the physician will authorize pertinent orders related to wound treatments, including 366290 Page 5 of 10 366290 08/15/2019 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0684 wound cleansing and debridement approaches, dressings and application of topical agents if indicated for the type of skin alteration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366290 Page 6 of 10 366290 08/15/2019 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on medical record review, pharmacist and staff interview, the facility failed to attempt two gradual dose reductions (GDR)of psychoactive medications with in the first year of implementation. This affected one (#67) of five residents reviewed for unnecessary medications. The facility identified 58 residents who receive psychoactive medications. The census was 93. Findings include: Review of Resident #67's medical record revealed an admission date of 08/01/18. Diagnoses included Alzheimer's disease, diabetes mellitus type II, major depression, unspecified psychosis, unspecified mood disorder, anxiety, congestive heart failure, and essential hypertension. Review of a physician order dated 08/01/19 revealed Resident #67 was ordered the antidepressant Zoloft 100 milligrams (mg) by mouth daily and the antidepressant Trazodone 100 mg by mouth every 24 hours as needed. Review of a physician order dated 08/02/19 revealed Resident #67 was ordered the antipsychotic medication Abilify 15 mg by mouth at bedtime. Review of monthly medication regimen reviews for Resident #67 completed on 08/07/18, 09/11/18, 10/17/18, 11/21/18, 12/18/18, 01/28/19, 02/11/19, 03/21/19, 04/29/19, 05/20/19, 06/17/19, and 07/30/19 revealed a GDR for Resident #67's Abilify was recommended on 03/21/19. No other GDR were recommended between 08/07/19 and 07/30/19. Review of a consultant pharmacist document dated 03/20/19 revealed a recommendation to decrease Resident #67's ordered Abilify to 10 mg at bedtime. The documented contained Resident #67's other orders for Trazodone and Zoloft, however, did not recommend a dose reduction of these medications. A nurse practitioner reviewed the GDR recommendation and agreed to reduce Resident #67's Abilify to 10 mg at bedtime on 03/26/19. Review of a physician order dated 03/28/19 revealed Resident #67 was ordered Abilify 10 mg by mouth at bedtime and the original order from 08/02/19 was discontinued. This order remained active as of 08/15/19. Review of the most recently completed Minimum Data Set (MDS) assessment revealed Resident #67's last GDR was on 03/28/19. Review of progress notes completed by a behavioral health practitioner on 08/17/18, 08/23/18, 09/06/18, 09/20/18, 10/11/18, 10/25/18, 11/20/18, 11/29/18, 11/30/18, 01/25/19, and 05/03/19 revealed no documentation of an attempt to reduce Resident #67's Abilify of Zoloft. GDR recommendations were made for Resident #67's Trazodone in August 2018 and May 2019, and the orders were processed for the recommendations on 08/17/18 and 05/05/19. Review of physician progress notes dated between 08/01/18 and 08/15/19 revealed no documentation of an attempt to GDR Resident #67's psychoactive medications. Interview on 08/15/19 at 11:48 A.M. with Registered Nurse (RN) #300 verified there was no documentation in Resident #67's medical record for any GDR of her Zoloft with an order date of 08/01/19, and 366290 Page 7 of 10 366290 08/15/2019 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few only one GDR of her Abilify with an original order date of 08/02/19, and a GDR on 03/28/19, within the first year of Resident #67 being ordered both medications. Telephone interview on 08/15/19 at approximately 1:30 P.M. with Pharmacist #500 stated when conducting GDR recommendations he was under the impression if one psychoactive medication was recommended for a GDR it covered all psychoactive medications that particular resident was ordered, and there was no need to address each psychoactive medication individually. Pharmacist #500 also stated he was under the impression when a GDR was accepted and the medication was ordered with a different dose, the calendar year was reset to the new date of the new order. 366290 Page 8 of 10 366290 08/15/2019 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, medical record review, review of facility policy and staff interview, the facility failed to ensure residents who required mechanically altered diets received the proper nutrition. This affected the two residents (#28 and #78) of two residents the facility identified as receiving pureed diets. The facility census was 93. Findings Include: Observation on 08/13/19 at 8:52 A.M., of the kitchen found the dietary staff were preparing cold sub sandwiches as was indicated on the regular lunch menu. Observation on 08/13/19 at 8:56 A.M., of the kitchen found Dietary Staff (DS) #201 completing the pureed lunch meals. Coinciding interview with DS #201 revealed the facility currently had two residents who received a pureed diet, Resident #28 and #78. DS #201 was observed following the recipe to puree two sub sandwiches. DS #201 added two portions of buns, two portions of ham and turkey, and two portions of cheese into a clear glass blender. DS #201 added 1/4 cup water and pork broth per serving to soften the sub components to puree properly. After the subs were pureed properly, DS #201 was observed following the recipe and portioned two four ounce servings (two #8 scoops) into two separate containers. DS #201 held up the blender and a good sized portion of the pureed sub sandwich was noted to still be in the blender. Interview on 08/13/19 at 9:04 A.M. with DS #201 verified she had a lot of the pureed food left over. Observation of the blender found 12 ounces of pureed food remained in the blender. DS #201 discarded the left over pureed food, covered, dated, labeled, and stored the two portions of pureed subs. Interview on 08/13/19 at 3:38 P.M. with Dietician #250 revealed the calculations for the portion size was incorrect for the pureed sub sandwich. Dietician #250 verified the scoop size did not provide the same nutrition as the regular sub sandwich. Dietician #250 stated the pureed food should have been divided into two equal portions. Review of Resident #28's medical record revealed an admission date of 04/20/19. Diagnoses included stroke and Alzheimer's disease. Review of Resident #28's physician orders revealed an order dated 10/04/18 for Resident #28 to receive a regular diet, pureed texture and thin consistency. Review of Resident #78's medical record revealed an admission date of 12/25/17. Diagnoses included dysphagia and Alzheimer's disease. Review of Resident #78's physician orders revealed an order dated 10/04/18 for Resident #78 to receive a regular diet, pureed texture, and nectar thick consistency. Review of the facility policy titled, Texture and Consistency- Modified Diets, revised 2017 revealed the food and nutrition services department were responsible for preparing and serving the diet texture and fluid consistency as ordered. Care was to be taken to serve the foods and fluids as ordered on the consistency altered diets. 366290 Page 9 of 10 366290 08/15/2019 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility and the staff interview, the facility failed to ensure outdoor garbage dumpster areas were kept in a safe and sanitary manner. This had the potential to affect 93 of 93 facility residents. The facility census was 93. Residents Affected - Many Findings include: Observation on 08/12/19 at 9:39 A.M. of the outside garbage storage area revealed a large puddle of liquid on the ground around the dumpster. The liquid had a strong, foul, odor that smelled like decomposing garbage. A nine volt battery, used disposable latex gloves, pieces of plastic, and other unidentifiable debris were observed in the liquid. Interview on 08/12/19 at 9:44 A.M. with Dietary Manager (DM) #210 verified the area around the outdoor garbage dumpster had not been cleaned. DM #210 reported it was the maintenance staff's responsibility to ensure the area was kept clean. Review of the facility policy titled, Garbage/Recycling Area Cleaning Schedule dated 08/14/18 revealed the facility would maintain a clean waste environment in the facility's receiving/loading dock area where the garbage dumpster/compactor is located. 366290 Page 10 of 10