Health inspection·August 12, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, medical record review, and staff interview, the facility failed to assisted residents with dining in a dignified manner. This affected three (#2, #21, and #28) of eight residents observed eating in the South dining room. The census was 77. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 11/26/19. Diagnoses included dysphagia, adjustment disorder with mixed anxiety and depressed mood, chronic kidney disease, bradycardia, and heart disease. Review of the most recent Minimum Data Set (MDS) assessment, completed 07/12/22, revealed Resident #2 was assessed as cognitively intact and required extensive one person physical assist with eating. Review of a nutritional care plan dated 12/02/19 revealed an intervention Resident #2 needed assistance with eating. 2. Review of Resident #21's medical record revealed an admission date of 07/02/15. Diagnoses included Alzheimer's disease with late onset, dementia without behavioral disturbances, dysphagia, hypothyroidism, and essential hypertension. Review of the most recent MDS assessment, completed 05/14/22, revealed Resident #21 was assessed with severely impaired cognitive skills for daily decision making and required extensive one person physical assist with eating. Review of a nutritional care plan dated 07/17/15 revealed an intervention that Resident #21 needed assistance with eating. 3. Review of Resident #28's medical record revealed an admission date of 10/01/18. Diagnoses included dementia with behavioral disturbances, diabetes mellitus type II, major depression, anxiety, and Alzheimer's disease. Review of the most recent MDS assessment, completed 05/25/22, revealed Resident #28 was assessed with severely impaired cognitive skills for daily decision making and required extensive one person physical assist with eating. Review of a nutritional care plan dated 10/03/18 revealed an intervention that Resident #28 needed assistance with eating. Page 1 of 25 366290 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 08/02/22 at 5:07 P.M. revealed State Tested Nurse Aide (STNA) #413 was feeding three residents (#2, #21, and #28) in the South dining room. Further observation revealed all three residents were seated at the same table and STNA #413 was standing feeding one of the residents. There was one empty chair at the table not being used by anyone at this time. Continual observation was made, on 08/02/22 between 5:08 P.M. and 5:25 P.M., and revealed STNA #413 stood beside one of the residents and offered a bite of food or drink, and then walked to the next resident to offer food and drink, and walked to the last resident to offer food and drink. STNA #413 moved in a clockwise fashion from resident to resident seated at the table, while standing and when walking around the table. STNA #413 offered no more than one bite of food or one drink to each resident during each turn throughout the entire observation. STNA #413 walked around the entire table and offered food and drink to each of the three residents at least five times during this observation. Observation on 08/02/22 at 5:26 P.M. revealed 14 empty chairs in the South dining not being utilized by any resident, visitor, or staff member. Interview on 08/02/22 at 5:28 P.M. with STNA #413 verified the three residents she was assisting with feeding were Resident #2, #21, and #28 and verified they all required staff assistance with eating. STNA #413 stated she started feeding all three residents around 5:00 P.M. on 08/02/22 and verified she was standing, walking, and feeding all three residents at the same time. 366290 Page 2 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on medical record review, staff interview, and review of a facility policy, the facility failed to timely notify the physician when a resident experienced a change in condition that required a new treatment. This affected one (#62) of two reviewed for changes in condition. The census was 77. Findings include: Review of Resident #62's medical record revealed an admission date of 07/01/22. Diagnoses included pressure ulcer of the sacral region, osteomyelitis, quadriplegia, diabetes mellitus type II, chronic kidney disease, acute kidney failure, anemia, and muscle weakness. Resident #62 was discharged on 07/12/22. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with intact cognition, required extensive assistance of at least two staff with bed mobility, was dependent with transfers, and no episodes of rejection of care. Resident #62 was assessed at risk for pressure ulcers and was admitted with three stage four and two unstageable (obscured full-thickness skin and tissue loss) pressure ulcers on admission. Review of a risk for skin breakdown care plan, dated 07/01/22, revealed Resident #62 was to be assessed for risk factors associated with pressure ulcer development, turn and reposition every two hours when in bed, and provide pressure reduction to the bed and chair. Review of an admission nursing assessment, dated 07/01/22, revealed Resident #62 was assessed with a suspected deep tissue injury to the right heel measuring 3.5 centimeters (cm) long by 4.0 cm wide, a suspected deep tissue injury to the right lateral ischium measuring 2.0 cm long by 2.0 cm wide, a stage four pressure ulcer to the right ischium measuring 8.5 cm long by 3.5 mc wide by 0.1 cm deep, a stage four pressure ulcer to the sacrum measuring 13.0 cm long by 8.0 cm wide by 2.0 cm deep, and a stage four pressure ulcer to the left sacrum measuring 3.5 cm long by 2.0 cm wide by 2.0 cm deep. Review of the July 2022 treatment administration record (TAR) revealed Resident #62 had the skin surrounding all wounds monitored every night shift for changes with no concerns noted and all pressure ulcers measured on 07/03/22. There was no other documentation of Resident #62 having any other wounds measured or assessed. Review of a nursing progress note dated 07/09/22 revealed a nurses aide informed the nurse there was a small amount of green fluid found in Resident #62's abdominal fold on the right side. The nurse aide showed the nurse the area, and when Resident #62's abdomen was lifted greenish-yellow fluid started coming out of a small opening in the skin. The nurse documented she continued to hold Resident #62's abdomen while it continued to drain. Review of a nursing progress note dated 07/10/22 revealed when Resident #62 was washed up there was more drainage from the small opening in Resident #62's skin. The area was cleaned and was not warm to the touch and no fever was present. There was no documentation of a physician or nurse practitioner being notified of the new wound discovered in Resident #62's abdominal fold on 07/09/22, 07/10/22, or 07/11/22. 366290 Page 3 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a nursing progress note dated 07/12/22 revealed the wound care physician was notified about the condition of Resident #62's wounds. Review of a nurse practitioner visit note, dated 07/12/22, revealed Resident #62's wound vacuum was in place and functioning with no concerns. The nurse practitioner noted a new wound in the right abdominal fold measuring approximately 2.0 cm long by 2.0 cm wide with a small amount of serosanguinous (thin and watery) fluid noted. Resident #62 voiced no complaints of pain or discomfort at that time. Review of a nursing progress note dated 07/12/22 revealed Resident #62 received orders to be sent to the hospital for evaluation and treatment and did not return to the facility. Review of hospital documents dated 07/12/22 revealed Resident #62 was admitted to the hospital in fair condition. Resident #62 was well known to the hospital having been seen there for the past eight years for treatment and evaluation of her sacral pressure wounds. Resident #62 underwent surgery for pressure wound debriedment (removal of dead or damaged tissue) and was started on antibiotics. Resident #62 was also noted to have a small wound and erythema (redness) with a skin breakdown under the abdominal pannus (excess skin and fat that hangs over the pubic region) on the right. There were no treatments or further assessments completed on Resident #62's wound under the abdominal pannus. Interview on 08/03/22 at 1:41 P.M. with Licensed Practical Nurse (LPN) #391 stated she was the nurse that was working when Resident #62's wound in her abdominal wound was discovered. LPN #391 stated the wound was in Resident #62 abdominal fold and when pressure was applied yellowish-green fluid came out. LPN #391 stated the wound was about half the size of an eraser on a pencil and stated she notified the nurse practitioner (Nurse Practitioner #500) about the wound but could not remember if she documented the notification in the medical record. LPN #391 stated there was a calendar book that nurses sometimes used to document in, but the book could not be found. LPN #391 stated she could not remember if the nurse practitioner gave any orders to treat the wound, but stated she placed gauze over the wound. LPN #391 stated she could not remember if she documented the wound treatment in the medical record. Interview on 08/03/22 at 10:34 A.M. with Nurse Practitioner (NP) #500 stated she was not notified of Resident #62's abdominal wound the first time she knew about Resident #62's abdominal wound was on 07/12/22 when she physically assessed Resident #62 and it was observed. NP #500 stated the wound was approximately 2.0 cm long by 2.0 cm wide and stated she did not order any treatments for the wound because there were other issues with Resident #62's condition that required immediate attention. NP #500 stated Resident #62 needed to be seen for evaluation of her pressure ulcers and was sent to the hospital. Review of a facility policy titled Review of the Notification of Changes, dated 03/30/22, revealed the facility must inform the resident, consult with the resident's physician and or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification included a need to alter treatment, this may include a new treatment or discontinuation of a current treatment, and a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status. This may include life-threatening conditions or clinical complications. Review of a facility policy titled Wound Treatment Management, dated 11/24/21, revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of 366290 Page 4 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0580 Level of Harm - Minimal harm or potential for actual harm dressing, and frequency of dressing changes. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, of the assigned licensed nurse in the absence of the treatment nurse. This deficiency substantiated Complaint Number OH000134422. Residents Affected - Few 366290 Page 5 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, staff interview, and resident interview, the facility failed to ensure residents were assessed for the appropriate use of a restraint and free from use of an unnecessary restraint. This affected one (#53) of six residents reviewed for falls. The facility census was 77. Residents Affected - Few Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, delirium, and overactive bladder. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #53 had mild cognitive impairment and exhibited no physical, verbal or wandering behaviors. Review of fall risk assessments dated 05/24/22, 07/06/22, and 08/06/22 revealed Resident #53 was at moderate risk for falls. Review of the care plan for Resident #53 revealed the risk for falls due to Resident #53's decreased safety awareness. Interventions for Resident #53 included the use of a chair alarm when resident in chair and a bed alarm when Resident #53 was in bed. Review of restrictive device consent, signed 05/28/22, revealed Resident #53 was to use a bed alarm when in bed and a chair alarm when in any chair. The consent was signed by family after the resident had a fall which required a hospital assessment during which a urinary tract infection was identified. Review of the social service notes dated 05/30/22 revealed Resident #53 mentioned she felt she had lost her independence because of the chair and bed alarms. Review of the physician orders dated 06/29/22 revealed an order for an alarm to the chair and to the bed to alert staff of unassisted attempts to rise per self due to resident unable realize own limitations secondary to dementia. The record contained no assessment for the use of the bed and chair alarm. Interview with Resident #53 on 08/01/22 at 2:35 P.M. revealed Resident #53 felt she had lost independence due to the use of the chair and bed alarms. Observation on 08/02/22 at 9:06 A.M. Resident #53 ambulated to the bathroom with a wheeled walker and the chair alarm was sounding. Two staff responded immediately. Observation on 08/03/22 at 8:52 A.M. revealed Resident #53 was in her room sitting in the recliner with the chair alarm in place. At 1:51 P.M. Resident #53 standing with the walker in hand in front of the recliner with the chair alarm sounding. Staff in hallway outside of the room responded. Observations on 08/04/22 at 8:50 A.M., 12:07 P.M., and 4:08 P.M. revealed Resident #53 was her room 366290 Page 6 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0604 sitting in the recliner with the chair alarm in place. Level of Harm - Minimal harm or potential for actual harm Interview with the State Tested Nursing Assistant (STNA) #431 on 08/04/22 at 8:50 A.M. revealed knowledge that Resident #53 did not like the chair alarm and did not want the alarms for either the bed or chair. Residents Affected - Few Interview on 08/04/22 at 1:53 A.M. with Social Work #376 revealed the family for Resident #53 requested the use of the alarms due Resident #53's increased falls. Social Worker #376 stated Resident #53 was not afraid of the alarm and continues to get up without the assistance of staff. Interview on 08/04/22 at 3:50 P.M. with the Director of Nursing revealed no specific resident evaluations are completed either initially or ongoing for the use of bed alarms or chair alarms. If the family requests the use of an alarm the facility will place one on the resident. Review of the policy titled Restraint Free Environment, dated 10/12/21, revealed residents are to be treated with respect and dignity, which included the right to be free of any physical restraint imposed for the purpose of discipline or staff convenience and not required to treat the resident's medical symptoms. A physician's order alone is not sufficient to warrant the use of a physical restraint and the facility is responsible for the appropriateness of the determination to use a restraint. 366290 Page 7 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of facility policies, the facility failed to ensure residents with hearing impairments were assisted with placement of hearing aides as care planned and as ordered. This affected one (#25) of one residents reviewed for vision and hearing. The facility identified 23 residents in the facility with hearing aides. The census was 77. Residents Affected - Few Findings include: Review of Resident #25's medical record revealed an admission date of 03/06/20. Findings included Alzheimer's disease with late onset, orthostatic hypotension, diabetes mellitus type II, dementia without behavioral disturbances, major depression, anxiety, and atrial fibrillation. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was assessed with severely impaired cognitive skills for daily decision making, was assessed with minimal hearing difficulty, and wore hearing aids. Review of the Care Area Assessment (CAA) Summary for communication revealed Resident #25 had minimum hearing difficulty and staff were to assist with hearing aids, adjust the tone, and repeat as needed. The facility indicated Resident #25's communication deficits would be care planned. Review of the most recently completed MDS assessment dated [DATE] revealed Resident #25 continued to be assessed with severely impaired cognitive skills for daily decision making, was assessed with minimal hearing difficulty, and wore hearing aids. Review of a care plan dated 03/19/20 revealed Resident #25 was alert with clear speech, and minimal hearing difficulty with hearing aids. Review of an intervention dated 03/19/20 revealed Resident #25 had bilateral hearing aids available and in use. Review of a physician order dated 07/28/21 revealed Resident #25 was to have her hearing aids put in her ears before breakfast and removed at night. Resident #25's hearing aids were to be stored in the nurse's cart. Review of the August 2022 medication administration record (MAR) revealed Resident #25's hearing aids were documented as not placed in her ears on 08/01/22 and 08/02/22. Observation on 08/01/22 between 9:00 A.M. and 2:30 P.M. revealed Resident #25 did not have her hearing aids in her ears throughout the day. Observation on 08/02/22 at 12:38 P.M., at 1:40 P.M., at 3:00 P.M., and at 5:08 P.M. revealed Resident #25 did not have hearing aids in her ears. Observation on 08/03/22 at 7:58 A.M. revealed Resident #25 sitting in her reclining chair in her bedroom eating breakfast. Resident #25 did not have her hearing aids in her ears at this time. Subsequent observations on 08/03/22 at 8:59 A.M. and at 9:48 A.M. revealed Resident #25 continued to not have her hearing aids in her ears. Interview on 08/03/22 at 10:34 A.M. with Licensed Practical Nurse (LPN) #417 verified she was the 366290 Page 8 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0676 Level of Harm - Minimal harm or potential for actual harm nurse providing care to Resident #25 on 08/03/22 and verified Resident #25's hearing aids were kept in the medication cart. Observation on 08/03/22 at 10:35 A.M., with LPN #417, revealed both of Resident #25's hearing aids were inside of a case and stored in the medication cart at that time. Residents Affected - Few Interview on 08/03/22 at 10:35 A.M. with LPN #417 verified Resident #25 did not have her hearing aids in her ears and stated she thought Resident #25's family did not want her to have her hearing aids in unless they said to put them in, but could not identify where or when she discovered that information. Observation on 08/03/22 at 11:27 A.M. revealed Resident #25 remained with no hearing aids in her ears. Review of a facility policy titled Activities of Daily Living (ADLs), revised 11/22/21, revealed based on the resident's comprehensive assessment and consistent with the resident's needs and choices, the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for all ADLs including using speech, language, or other functional communication systems. Review of a facility policy titled Care and Use of Hearing Aids, revised 03/29/22, revealed it is the practice of the facility to assist residents in using their hearing aides, and to provide care to the hearing aides to ensure they are clean and protected from loss and breakage when not being worn. 366290 Page 9 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

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, medical record review, staff interview, review of State Tested Nurse Aide (STNA) bowel tracking documentation and review of facility policy, the facility failed to ensure residents who were dependent for care received assistance with nail care. This affected one (#177) of two residents reviewed for activities of daily living (ADLs). The facility census was 77. Residents Affected - Few Findings include: Review of the medical record for Resident #177 revealed an admission date of 07/23/22. Diagnoses included cerebral infarction, myocardial infarction, aphasia, multiple fractures of ribs, fracture of nasal bones, chronic obstructive pulmonary disease (COPD), hypertension, and retention of urine. Review of the Minimum Data Set (MDS) assessment, dated 07/29/22, revealed Resident #177 had short and long term memory problems, was severely cognitively impaired, and required extensive assistance with bed mobility, dressing, and personal hygiene. Additionally, Resident #177 was occasionally incontinent of bowel. Review of the plan of care, initiated 07/23/22, revealed Resident #177 had a potential/actual deficit with activities of daily living (ADLs). Interventions included allow ample time for participation, assist with ADLs as current needs required, encourage Resident #177 to participate in ADLs, encourage rest periods as needed, and monitor for changes in functional ADL ability. Review of STNA documentation from 07/24/22 through 08/04/22 revealed Resident #177 had bowel movements on 07/26/22, 07/30/22, 07/31/22 and 08/04/22. Review of a nursing progress note dated 07/31/22 revealed Resident #177 had a bowel movement and smeared feces over self and bed. Observation on 08/01/22 at 1:34 P.M. of Resident #177 revealed a dark substance was present under the Resident's left hand fingernails. Additional observations on 08/02/22 at 8:03 A.M. and 8:49 A.M. revealed Resident #177 had a dark substance was present his left hand fingernails. Interview on 08/02/22 at 9:00 A.M. of Licensed Practical Nurse (LPN) #417 verified Resident #177 had a dark substance was present under his left hand fingernails. Interview on 08/02/22 at 9:06 A.M., STNA #418 confirmed Resident #177 had a dark substance under his left hand fingernails. STNA #418 stated Resident #177 was incontinent of bowel and would remove the brief and get feces on his hands. STNA #418 stated she believed Resident #177 had feces under his left hand fingernails and she planned to clean them today. STNA #418 stated Resident #177 did not have a bowel movement yet today on her shift, which began at 6:00 A.M. STNA #418 confirmed resident's bowel movements were documented and tracked in the electronic medical record with the Resident's last documented bowel movement being 07/31/22. Additional observations on 08/02/22 at 10:36 A.M. and 12:07 P.M. of Resident #177 revealed the dark substance was remained under his left hand fingernails. 366290 Page 10 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0677 Observation on 08/02/22 at 2:39 P. M. revealed Resident #177's fingernails had been cleaned. Level of Harm - Minimal harm or potential for actual harm Observation on 08/04/22 at 8:37 A.M. of Resident #177 revealed a dark substance was present under the resident's left hand fingernails. Residents Affected - Few Interview on 08/04/22 at 10:23 A.M., STNA # 390 revealed Resident #177 had a bowel movement that morning and the resident stuck his hand in the feces. STNA #390 stated he cleaned Resident #177 up after the bowel movement but did not clean his fingernails. Additional observations on 08/04/22 at 10:25 A.M., 11:19 A.M. and 1:07 P.M. revealed Resident #177 continued to have debris under his left hand fingernails. Follow up interview on 08/04/22 at 1:07 P.M., STNA #390 confirmed Resident #177 only had one bowel movement that day which was earlier in the morning. Interview on 08/04/22 at 2:45 P.M., STNA #424 verified Resident #177 had debris under his left hand fingernails. STNA #424 stated she would take care of cleaning the Resident's fingernails. Review of facility policy titled Activities of Daily Living (ADLs), dated 11/22/21, revealed a resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 366290 Page 11 of 25 366290 08/12/2022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility polices, the facility failed to ensure wounds were assessed and treated in a timely manner and failed to ensure compression garments were applied as ordered. This affected one (#62) of one residents reviewed for non-pressure skin impairments and one (#52) of one residents reviewed for edema. The facility identified three residents in the facility with non-pressure skin impairments. The census was 77. Residents Affected - Few Findings include: 1. Review of Resident #62's medical record revealed an admission date of 07/01/22. Diagnoses included pressure ulcer of the sacral region, osteomyelitis, quadriplegia, diabetes mellitus type II, chronic kidney disease, acute kidney failure, anemia, and muscle weakness. Resident #62 was discharged on 07/12/22. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with intact cognition, required extensive two-plus persons assistance with bed mobility, was totally dependent with transfers, and no episodes of rejection of care. Resident #62 was assessed at risk for pressure ulcers and was admitted with three stage four and two unstageable (obscured full-thickness skin and tissue loss) pressure ulcers on admission. Review of a risk for skin breakdown care plan dated 07/01/22 revealed Resident #62 was to be assessed for risk factors associated with pressure ulcer development, turn and reposition every two hours when in bed, and provide pressure reduction to the bed and chair. Review of an admission nursing assessment dated [DATE] revealed Resident #62 was assessed with a suspected deep tissue injury to the right heel measuring 3.5 centimeters (cm) long by 4.0 cm wide, a suspected deep tissue injury to the right lateral ischium measuring 2.0 cm long by 2.0 cm wide, a stage four pressure ulcer to the right ischium measuring 8.5 cm long by 3.5 mc wide by 0.1 cm deep, a stage four pressure ulcer to the sacrum measuring 13.0 cm long by 8.0 cm wide by 2.0 cm deep, and a stage four pressure ulcer to the left sacrum measuring 3.5 cm long by 2.0 cm wide by 2.0 cm deep. Review of the July 2022 treatment administration record (TAR) revealed Resident #62 had the skin surrounding all wounds monitored every night shift for changes with no concerns noted and all pressure ulcers measured on 07/03/22. There was no other documentation of Resident #62 having any other wounds measured or assessed. Review of a nursing progress note dated 07/09/22 revealed a nurses aide informed the nurse there was a small amount of green fluid found in Resident #62's abdominal fold on the right side. The nurse aide showed the nurse the area, and when Resident #62's abdomen was lifted greenish-yellow fluid started coming out of a small opening in the skin. The nurse documented she continued to hold Resident #62's abdomen while it continued to drain. Review of a nursing progress note dated 07/10/22 revealed when Resident #62 was washed up there was more drainage from the small opening in Resident #62's skin. The area was cleaned and was not warm to the touch and no fever was present. There was no assessment of the new wound discovered in Resident #62's abdominal fold on 07/09/22, 366290 Page 12 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0684 07/10/22, or 07/11/22. Level of Harm - Minimal harm or potential for actual harm Review of a nursing progress note dated 07/12/22 revealed the wound care physician was notified about the condition of Resident #62's wounds. Residents Affected - Few Review of a nurse practitioner visit note dated 07/12/22 revealed the nurse practitioner noted a new wound in the right abdominal fold measuring approximately 2.0 cm long by 2.0 cm wide with a small amount of serosanguinous (thin and watery) fluid noted. Resident #62 voiced no complaints of pain or discomfort at that time. Review of a nursing progress note dated 07/12/22 revealed Resident #62 received orders to be sent to the hospital for evaluation and treatment and did not return to the facility. Review of hospital documents dated 07/12/22 revealed Resident #62 was admitted to the hospital in fair condition. Resident #62 was well known to the hospital having been seen there for the past eight years for treatment and evaluation of her sacral pressure wounds. Resident #62 underwent surgery for pressure wound debriedment (removal of dead or damaged tissue) and was started on antibiotics. Resident #62 was also noted to have a small wound and erythema (redness) with a skin breakdown under the abdominal pannus (excess skin and fat that hangs over the pubic region) on the right. There were no treatments or further assessments completed on Resident #62's wound under the abdominal pannus. Interview on 08/03/22 at 1:41 P.M. with Licensed Practical Nurse (LPN) #391 stated she was the nurse that was working when Resident #62's wound in her abdominal wound was discovered. LPN #391 stated the wound was in Resident #62 abdominal fold and when pressure was applied yellowish-green fluid came out. LPN #391 stated the wound was about half the size of an eraser on a pencil and stated she notified the nurse practitioner (Nurse Practitioner #500) about the wound but could not remember if she documented the notification in the medical record. LPN #391 stated there was a calendar book that nurses sometimes used to document in, but the book could not be found. LPN #391 stated she could not remember if the nurse practitioner gave any orders to treat the wound, but stated she placed gauze over the wound. LPN #391 stated she could not remember if she documented the wound treatment in the medical record. Interview on 08/03/22 at 10:34 A.M. with Nurse Practitioner (NP) #500 stated she was not notified of Resident #62's abdominal wound and did not order any treatments for the wound. NP #500 stated the first time she knew about Resident #62's abdominal wound was on 07/12/22 when she physically assessed Resident #62 and it was observed. NP #500 stated the wound was approximately 2.0 cm long by 2.0 cm wide and stated she did not order any treatments for the wound because there were other issues with Resident #62's condition that required immediate attention. NP #500 stated Resident #62 needed to be seen for evaluation of her pressure ulcers and was sent to the hospital. Review of a facility policy titled Documentation of Wound Treatments, dated 11/24/21, revealed wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. Review of a facility policy titled Wound Treatment Management, dated 11/24/21, revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, of the assigned licensed nurse in the absence of the treatment nurse. 366290 Page 13 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, hypertension, hypothyroid, aphasia, vitamin D deficiency, weakness, transient ischemic attack, and a cerebral infarct. Review of the MDS assessment dated [DATE] revealed Resident #52 was cognitively intact and required extensive assistance with dressing. Review of physician orders revealed orders dated 12/15/21 for amlodipine besylate 10 milligram (mg), one tablet daily and 12/01/21 for monthly weights. An order dated 03/07/22 revealed the nurse was to measure Resident #52 for knee high compression stockings and the compression stockings were to be applied in the morning and removed at bedtime. An order written on 06/20/22 for Lasix 20 mg once daily for bilateral lower extremity edema. Review of progress note dated 07/19/22 revealed chronic bilateral lower extremity edema with left lower extremity greater than the right lower extremity. Observations on 08/02/22 at 9:13 A.M., 08/03/22 at 8:29 A.M. and on 08/04/22 at 12:48 P.M. revealed swelling and edema to Resident #52's bilateral lower extremities with the edema to the left lower extremity greater than the edema to the right lower extremity. Compression stockings were not observed in place. Interview on 08/03/22 at 2:16 PM with State Tested Nursing Assistant (STNA) #431 revealed Resident #52 was not wearing compression stockings. STNA #431 stated she was unaware Resident #52 was to wear compression stocking and added Resident #52 does not have compression stockings. Interview on 08/03/22 at 2:20 P.M. with Registered Nurse (RN) #443 verified Resident #52 did have an order for compression stockings. RN #443 was unsure if Resident #52 had been wearing the compression stockings. RN #443 stated she measured and ordered the compression stockings. Review of facility policy titled Physician Orders dated 11/22/2, revealed the physician must provide written or verbal orders for the residents' immediate care and needs. The orders allow staff to provide essential care to the resident and provide information to maintain or improve the resident's functional status. This deficiency substantiates Complaint Number OH00134422. 366290 Page 14 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

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 medical record review, staff interview, and review of a facility policy, the facility failed timely assess pressure ulcers. This affected one (#62) of six residents reviewed for pressure ulcers. The facility identified 10 residents in the facility with pressure ulcers. The census was 77. Residents Affected - Few Findings include: Review of Resident #62's medical record revealed an admission date of 07/01/22. Diagnoses included pressure ulcer of the sacral region, osteomyelitis, quadriplegia, diabetes mellitus type II, chronic kidney disease, acute kidney failure, anemia, and muscle weakness. Resident #62 was discharged on 07/12/22. Review of hospital documents dated 05/20/22, prior to Resident #62's admission to the facility, revealed Resident #62 was admitted with chronic osteomyelitis due to uncontrolled diabetes mellitus, had multiple extensive pressure ulcers with necrotizing fascitis (flesh-eating infection), and three separate infectious organisms discovered in her wounds. Resident #62's wound infections were treated with two antibiotics and consideration was made for a surgical consultation. Resident #62's wounds initially got better but then deteriorated rapidly to a necrotizing state. Review of a wound progress note dated 06/27/22 revealed Resident #62 had a stage three (full-thickness skin loss) pressure ulcer to the right heel which measured 3.0 centimeters (cm) long by 4.0 cm wide with no depth and 75 percent (%) to 100% of the wound covered with eschar (dead tissue); a stage four (full-thickness skin and tissue loss) to the right ischium (on the curvature of the posterior pelvic bone) measuring 9.0 cm long by 2.5 cm wide by 0.1 cm deep; and a stage four pressure ulcer to the coccyx (bone structure at the base of the spine) measuring 8.5 cm long by 14.5 cm wide by 1.0 cm deep. Review of a physician note dated 06/29/22 revealed Resident #62 would be discharged to a nursing facility within the next 24 to 48 hours and Resident #62 had arranged follow up with care with a plastic surgeon to look at the sacral and ischial wounds. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with intact cognition, required extensive assistance of two staff for bed mobility, was dependent with transfers, and no episodes of rejection of care. Resident #62 was assessed at risk for pressure ulcers and was admitted with three stage four and two unstageable (obscured full-thickness skin and tissue loss) pressure ulcers on admission. Resident #62 had interventions with pressure reduction to the bed and chair, turning and repositioning, pressure ulcer care, and application of non-surgical dressings. Review of the Care Area Assessment (CAA) Summary for pressure ulcer and injury revealed Resident #62 was able to voice needs and required extensive assistance with bed mobility to reduce friction. Resident #62's skin was observed with care and weekly skin checks completed. Staff provided treatments and monitored for changes as needed. Review of a care plan dated 07/01/22 revealed Resident #62 had actual skin breakdown with pressure ulcers on admission. Care plan interventions included provide treatments as ordered and monitor for changes, observe skin daily with care, and weekly wound management. Review of an assessment used to predict pressure ulcer development dated 07/01/22 revealed Resident #62 was assessed at moderate risk. Review of an admission nursing assessment dated [DATE] revealed Resident #62 was assessed with a 366290 Page 15 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0686 Level of Harm - Minimal harm or potential for actual harm suspected deep tissue injury to the right heel measuring 3.5 cm long by 4.0 cm wide, a suspected deep tissue injury to the right lateral ischium measuring 2.0 cm long by 2.0 cm wide, a stage four pressure ulcer to the right ischium measuring 8.5 cm long by 3.5 mc wide by 0.1 cm deep, a stage four pressure ulcer to the sacrum measuring 13.0 cm long by 8.0 cm wide by 2.0 cm deep, and a stage four pressure ulcer to the left sacrum measuring 3.5 cm long by 2.0 cm wide by 2.0 cm deep. Residents Affected - Few Review of the July 2022 treatment administration record (TAR) revealed Resident #62 had the skin surrounding all wounds monitored every night shift for changes with no concerns noted. Resident #62's pressure ulcers were assessed on 07/03/22 and were as followed: Resident #62's deep tissue injury to the right heel measured 3.8 cm long by 3.5 cm wide by 0.1 cm depth; Resident #62's deep tissue injury to the right lateral ischium measured 2.0 cm long by 2.0 cm wide by 0.2 cm deep; Resident #62's stage four pressure ulcer to the left ischium measured 3.5 cm long by 2.2 cm wide by 0.5 cm deep; Resident #62's stage four pressure ulcer to the right ischium measured 7.5 cm long by 3.5 cm wide by 2.0 cm deep; and Resident #62's stage four pressure ulcer to the sacrum measured 13.0 cm long by 9.0 cm wide by 4.0 cm deep. Review of the July 2022 TAR revealed Resident #62's deep tissue injury to the right heel was assessed on 07/10/22 and measured 3.5 cm long by 3.0 cm wide with no depth; however, none of Resident #62's other pressure ulcers were assessed or measured on 07/10/22. Review of nursing progress notes and assessments dated between 07/04/22 and 07/12/22 revealed no documentation of Resident #62's wounds on her right lateral ischium, left ischium, right ischium, and sacrum assessed or measured after 07/03/22. Review of a nursing progress note dated 07/11/22 revealed Resident #62's wound vacuum change and reapplication were held for day shift. The nursing note indicated with the complexity level it was felt it would take two staff to manage it appropriately and the unit manager was notified. Review of a nursing progress note dated 07/11/22 revealed Resident #62's wound vacuum was changed with the canister noted to have brownish-red drainage and a foul odor. The pressure ulcers were observed to be beefy red with increased necrotic tissue to the wound perimeter. There were no measurements obtained of these wounds and the wounds were not staged. The wound vacuum was applied and sealed with no leaks. Review of a nursing progress note dated 07/12/22 revealed the wound care physician was notified about the condition of Resident #62's wounds. Review of a nursing progress note dated 07/12/22 revealed Resident #62 received orders to be sent to the hospital for evaluation and treatment and did not return to the facility. Review of hospital documents dated 07/12/22 revealed Resident #62 underwent surgical debridement of the pressure ulcers on her left and right ischium and sacrum to remove necrotic tissue. Resident #62's wounds were not significantly bigger and did not change stages. Interview on 08/04/22 at 4:55 P.M. with Director of Nursing (DON) verified Resident #62's wounds were assessed in the facility on 07/01/22, on admission, and on 07/03/22. DON stated Resident #62's wounds were scheduled to be assessed on 07/10/22; however, the wound vacuum was in place and the wounds could not be observed. DON verified Resident #62's wound vacuum was changed on 07/11/22 and verified Resident #62's wounds wound have been visible and able to be assessed at that time but the 366290 Page 16 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility did not assess them. DON verified Resident #62's pressure ulcers on her right lateral ischium, left ischium, right ischium, and sacrum were not assessed after 07/10/22 as Resident #62 was sent to the hospital on [DATE]. Review of a facility policy titled, Documentation of Wound Treatments, dated 11/24/21, revealed wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. This deficiency substantiates Complaint Number OH00134422. 366290 Page 17 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

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 observation, medical record review, staff interview and review of facility policy, the facility failed to ensure fall interventions were implemented as care planned. This affected one (#13) of six residents reviewed for falls. The facility census was 77. Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included Alzheimer's disease, history of falling, major depressive disorder, orthostatic hypotension, osteoporosis, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was severely cognitively impaired, required extensive assistance with bed mobility, transfers, and locomotion, and had two or more falls. Review of the plan of care, revised 10/29/20, revealed Resident #13 was at risk for falls. Interventions included assist resident getting in and out of bed, a scoop mattress to bed to define bed parameters, and keep wheelchair at bedside while in bed for safety. Review of the Fall Risk Assessment, dated 06/10/22, revealed Resident #13 was at moderate risk for falls. Review of a physician order, dated 02/01/22, revealed a scoop mattress to bed to define bed parameters due to resident's decreased awareness of own physical limitations. Observation on 08/01/22 at 3:01 P.M. revealed Resident #13 in bed. Resident #13 did not have a scoop mattress on the bed and the wheelchair was located on the wall opposite the Resident's bed, in front of the window. Observation on 08/02/22 at 7:30 A.M. revealed Resident #13 in bed. Resident #13 did not have a scoop mattress on the bed and the wheelchair was located on the wall opposite the Resident's bed, in front of the window. Interview on 08/02/22 at 11:18 A.M. with State Tested Nurse Aide (STNA) #434 confirmed Resident #13 did not have a scoop mattress to the bed. Additionally, STNA #434 stated it was not typical for Resident #13's wheelchair to be left at bedside when the Resident was in bed. STNA #434 was unaware of the fall interventions for Resident #13 to have a scoop mattress or for her wheelchair to be placed bedside when Resident #13 was in bed. STNA #434 stated Resident #13 did attempt to get up on her own sometimes and had a history of falls at the facility. STNA #434 confirmed Resident #13 was dependent on staff for all care, including safe transfers. Observation on 08/03/22 at 8:08 A.M. revealed Resident #13 in bed. Resident #13 did not have a scoop mattress and her wheelchair was located on the wall opposite her bed, in front of the window. Review of facility policy titled Fall Prevention Program, revised 06/23/22, revealed each resident's risk factors and environmental hazards would be evaluated when developing the resident's 366290 Page 18 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0689 comprehensive plan of care and staff were to be aware of interventions in the electronic medical record and plan of care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366290 Page 19 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure physician ordered fluid restrictions were followed and failed to ensure appropriate mechanisms were used to alert staff to residents on fluids restrictions per the policy. This affected one (#45) of one residents reviewed for hydration. The census was 77. Residents Affected - Few Findings include: Review of Resident #45's medical record revealed an admission date of 09/20/20. Diagnoses included Alzheimer's disease with late onset, epilepsy, dementia without behavioral disturbances, hypo-osmolality and hyponatremia, syndrome of inappropriate secretion of antidiuretic hormone, flaccid neuropathic bladder, hallucinations, anxiety, congestive heart failure, and aphasia. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was assessed with moderately impaired cognitive skills for daily decision making and required supervision for eating. Review of Resident #45's most recently completed basic metabolic panel (a laboratory test that measures electrolyte balance) revealed Resident #45's sodium and potassium levels were within normal range. Review of a nutrition care plan dated 10/05/21 revealed Resident #45 had an intervention for no water pitcher at the bedside. Review of a consulting dietician recommendation document dated 07/07/22 revealed Resident #45 was ordered a regular diet with small portions and a fluid restriction consisting of no water pitcher at the bedside. Review of a physician order dated 07/12/22 revealed Resident #45 was ordered a fluid restriction with no water pitcher at the bedside. There was no physician order to monitor Resident #45's fluid intake. Review of a dietary communication form dated 07/1/522 revealed Resident #45 was to have no water pitcher at the bedside. Review of nurse aide documentation dated between 07/10/22 and 08/08/22 revealed only one fluid intake documented on 07/10/22 and revealed Resident #45 had 20 milliliters of fluid intake. Observation on 08/02/22 at 3:10 P.M. and 5:11 P.M. revealed Resident #45 sitting in her reclining chair in her bedroom with a large white Styrofoam cup sitting on the bedside table, with fluid in the cup, to the right of Resident #45 within her reach. There was no signage to identify Resident #45 was on a fluid restriction outside or inside the room. Observation on 08/03/22 at 7:22 A.M. revealed Resident #45 was up sitting in her reclining chair eating breakfast. There was a large white Styrofoam cup on the bedside table near her food tray that contained fluids with the date of 08/03/22 written on the outside of the cup. Resident #45 was eating and drinking independently. Subsequent observations on 08/03/22 at 9:03 A.M. and 9:48 A.M. revealed 366290 Page 20 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #45 remained in her reclining chair with a large white Styrofoam cup with fluid inside with her reach on the beside table. There remained no signage indicating Resident #45 was on a fluid restriction outside or inside the room. Interview on 08/03/22 at 7:48 A.M. with Resident #45 stated she was not aware she was on a fluid restriction and when asked what she drank from when she was thirsty, Resident #45 lifted her large white Styrofoam cup full of fluid. Interview on 08/03/22 at 10:02 A.M. with State Tested Nurse Aide (STNA) #456 stated residents received large white Styrofoam cups as their water pitchers and the third shift staff were responsible for getting the residents new cups every day and filling them with fresh ice water. STNA #456 stated each Styrofoam cup could hold 20 ounces of water. Observation on 08/03/22 at 10:25 A.M., with STNA #456, verified Resident #45 had a large white Styrofoam cup within her reach that contained fluid and no signage identifying Resident #45 was on a fluid restriction. Interview on 08/03/22 at 10:25 A.M. with STNA #456 stated she was not aware Resident #45 was on a fluid restriction and was not to have a water pitcher at the bedside. A telephone interview was completed on 08/08/22 at 8:49 A.M. with Dietician #550 who verified Resident #45 was ordered to have no water pitcher at the bedside. Dietician #550 stated Resident #45 had a history of low sodium levels and as a first line of intervention to prevent low sodium, he ordered the fluid restriction for no water at the bedside. Dietician #550 stated Resident #45 was moderately to severely cognitively impaired and was physically capable of drinking independently, and by having no water pitcher at the bedside, it eliminated the readily available source of water for Resident #45 to drink. Review of a a facility policy titled Hydration, last revised 08/03/22, revealed the resident's goals and preferences regarding hydration will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Signage will be placed in individual resident rooms alerting staff to resident specific needs, such as thickened liquids, no water at bedside, etc. 366290 Page 21 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

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 observation, staff interview, review of visitor screening logs, review of resident vaccination status, and review of facility policy, the facility failed to ensure proper infection control practices and procedures were followed for visitor screening and source control to prevent the spread of COVID-19 with the potential to affect 13 (#1, #6, #11, #13, #15, #17, #24, #29, #31, #50, #58, #67 and #76) of 13 residents in the Special Care Unit (memory care). Additionally, the facility failed to ensure clean linen was transported in a sanitary manner with the potential to affect 10 (#40, #70, #177, #178, #179, #180, #182, #183, #184 and #187) of 10 residents on the rehabilitation unit. Lastly, the facility failed to ensure sanitary conditions for one Resident (#61) of three residents reviewed who had a catheter. The facility census was 77. Residents Affected - Some Findings include: 1. Interview on 08/01/22 at 8:00 A.M. of the Administrator revealed the facility was in COVID-19 outbreak status until 08/07/22. Observation on 08/02/22 at 11:33 A.M. of the Special Care Unit dining room revealed Resident #11 sitting at a table with three visitors, a male, a female and a toddler who was sitting on Resident #11's lap. The male visitor had his facemask hanging from his left ear, the female visitor had her facemask below her chin, and the toddler was unmasked. Each visitors' mouth and nose were exposed. Resident #6 approached the table and sat with Resident #11 and the three visitors. Both residents and all visitors were within arms reach of each other. Neither Resident #11 or Resident #6 were wearing facemasks. Additional observation revealed Residents #1, #13, #17, #24 and #50 were also sitting in the dining room, unmasked, and at adjacent tables from Resident #11, Resident #6 and the three visitors. Review of the facility resident COVID-19 vaccination list revealed Resident #11 was not vaccinated for COVID-19 and Resident #6 was not up-to-date with COVID-19 vaccinations. Review of the facility COVID-19 kiosk screening log, dated 08/02/22, revealed Resident #11's three visitors did not screen for signs and symptoms of COVID-19 prior to visiting the Special Care Unit on 08/02/22. Interview on 08/02/22 at 11:35 A.M. with State Tested Nurse Aide (STNA) #434 confirmed visitors were to wear facemasks during visits and were to social distance to potentially limit transmission of COVID-19 to residents. STNA #434 stated the visitors were family of Resident #11. STNA #434 verified the visitors were not properly wearing facemasks to cover their mouth and nose and Residents #1, #6, #11, #13, #17, #24 and #50 were in the dining room with the visitors, in close proximity, and the residents were also unmasked. STNA #434 stated she had asked the family many times to put their facemasks on correctly but they refused and she was not sure what else she could do about it. Interview on 08/02/22 at 12:20 P.M. with the Administrator confirmed visitors were expected to wear facemasks, especially in common areas of the facility. If visitors refused to wear the proper personal protective equipment (PPE) staff were expected to contact someone in administration for assistance. Interview on 08/04/22 at 10:31 A.M. with the Administrator and Director of Nursing (DON) verified 366290 Page 22 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on 08/02/22 Resident #11's three visitors were not screened for COVID-19 signs and symptoms on the facility kiosk prior to visiting the Special Care Unit. The Administrator stated the visitors may have screened in through the connected assisted living entrance, which was a paper screening. Follow-up interview on 08/04/22 at 11:38 A.M. with the Administrator revealed a family member of Resident #11 screened for signs and symptoms of COVID-19 through the assisted living entrance. The paper screening document was dated 08/01/22 and 08/02/22. Each specific visitor entry was undated, including the date Resident #11's family member screened for signs and symptoms of COVID-19. Review of the facility assisted living paper COVID-19 screening log, dated 08/01/22 and 08/02/22 revealed Resident #11's three visitors in the facility on 08/02/22 did not screen for signs and symptoms of COVID-19 prior to visiting the Special Care Unit on 08/02/22. Interview on 08/04/22 at 11:40 A.M. with STNA #434 confirmed Resident #11's family member who screened for signs and symptoms of COVID-19 on the assisted living paper screening log dated 08/01/22 and 08/02/22 was not one of the three visitors observed visiting on the Special Care Unit on 08/02/22. STNA #434 identified the family member on the screening form to be Resident #11's daughter, who had visited at a different time. STNA #434 confirmed Resident #11's visitors on 08/02/22 were the Resident's son, granddaughter and great granddaughter. STNA #434 verified their names were not on the assisted living paper screening log. Follow up interview on 08/04/22 at 11:41 A.M. with the Administrator verified the facility had no evidence Resident #11's family, who were observed not practicing COVID-19 source control on 08/02/22, were screened by the facility for signs and symptoms of COVID-19. Review of facility policy titled COVID-19 Visitors-Vendors-Others, revised 06/22/22, revealed all individuals and personnel must be screened for COVID-19 each time they enter the facility. In addition to the screening questions, visitors were to wear masks before entering the facility or have the necessary PPE on. Unvaccinated residents, where possible, should wear a face covering during the visit. Staff will observe the visitors to ensure correct donning of PPE and appropriate hand hygiene. Additionally, visitations will not be allowed for those visitors who refuse to wear a face covering, whether visiting a vaccinated or unvaccinated resident, and all visitors are to facilitate social distancing. 2. Observation on 08/02/22 at 8:08 A.M. of the rehabilitation unit revealed a three tier cart sitting in the hall outside of Resident #180 and #183's rooms. Both Resident doors were closed, a PPE cart was placed outside of each door and signs were hanging on the room doors identifying Resident #180 and #183 were on transmission based precautions. Further observation revealed there were 14 folded personal clothing items on the top shelf of the uncovered cart. Continued observations on 08/02/22 at 8:22 A.M., 8:48 A.M. and 8:57 A.M. revealed the three tiered cart remained in the hall outside of Resident #180 and #183's rooms, with the personal clothing items on the top shelf, uncovered. Interview on 08/02/22 at 8:57 A.M. with Licensed Practical Nurse (LPN) #417 verified the uncovered cart located in the hall outside of Resident #180 and #183's rooms had uncovered resident personal clothing on the top shelf of the cart. LPN #417 stated the personal clothing was waiting to be delivered to residents. LPN #417 confirmed Residents #180 and #183 were on transmission based precautions due to being on COVID-19 quarantine. 366290 Page 23 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Additional observation on 08/02/22 at 9:06 A.M. revealed the three tier cart remained in the hall outside of Resident #180 and #183's room, with uncovered personal clothing on the top shelf. Interview on 08/02/22 with State Tested Nurse Aide (STNA) #418 verified the cart had clean, uncovered, resident personal clothing on the top shelf. STNA #418 stated some of the clothing was labeled and other items were unlabeled so she would have to figure out who they belonged to. STNA #418 stated she did not know why the uncovered cart with clean clothing was left in the hall. STNA #418 moved the cart into the clean linen closet. Review of facility policy titled Handling Clean Linen, dated 05/31/22, revealed clean linens must be transported by methods that ensure cleanliness and protect from dust and soil during loading, transport and unloading. Guidelines for the storage of clean linen included clean linen shall be delivered to resident care units on covered linen carts with covers down. The facility identified 10 residents (#40, #70, #177, #178, #179, #180, #182, #183, #184 and #187) on the rehabilitation unit. 3. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, pneumonia, hypertension, atrial fibrillation, and urinary retention. Review of the Minimum Data Set 3.0 assessment, dated 07/18/22, revealed Resident #61 had mild cognitive impairment and required extensive assistance with toilet use and personal hygiene. Resident #61 was continent of bowel and bladder and had a urinary tract infection in the last thirty days. Review of physician orders revealed an order written on 07/01/22 for the antibiotic cephalexin 500 milligrams (mg), one tablet, twice daily for seven days. Review of urine culture dated 07/06/22 revealed evidence of a urinary tract infection with pseudomonas greater than 100,000 colony forming units per milliliter (CFU/ml). Review of physician orders dated 07/14/22 included the antibiotic amoxicillin 200 mg, one tablet twice a day for seven days. Additional orders written on 07/14/22 included catheter irrigation as needed for occlusion, catheter drainage bag to be changed weekly and the tubing changed weekly every Wednesday night, catheter leg bag when Resident #61 was up, and catheter care every shift. Observation on 08/02/22 at 2:13 P.M. revealed the catheter bag folded onto itself resting on the floor next to the right side of the bed. Interview on 08/02/22 at 2:23 P.M. with STNA #551 verified the catheter bag for Resident #61 was touching the floor. STNA #551 further added catheter bags are not to be on the floor. STNA #551 readjusted the catheter bag to ensure the catheter bag no longer sat on the floor. Observation on 08/03/22 at 2:05 P.M. revealed Resident #61's catheter bag hanging off the handle of the recliner, resting on the floor. Interview on 08/03/22 at 2:08 P.M. with STNA #390 verified Resident #61's catheter bag was resting on the floor and further verified the catheter bag should not touching the floor. STNA #390 repositioned the catheter drainage bag to prevent it from touching the floor. 366290 Page 24 of 25 366290 08/12/2022 Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Catheter Care, dated 03/08/21, revealed residents with catheters should receive appropriate catheter care and further stated catheter drainage bags should be always covered when in use. Residents Affected - Some 366290 Page 25 of 25