Health inspection·May 10, 2019

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to maintain accurate assessments on all residents. This affected two (Resident #68 and #74) of three residents reviewed to for resident assessments. The facility census was 95. Residents Affected - Few Findings Included: 1. Review of medical records for Resident #68 revealed an admission date of 06/15/17 with diagnoses including limitation of activities, schizophrenia, amputation and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/18, revealed the resident had impaired cognition. He had a physical restraint in the chair indicating the chair prevented rising. Observation on 05/01/19 at 9:00 A.M. of Resident #68 revealed no restraint was in use on the wheelchair. Interview on 05/01/19 at 9:05 A.M. with Resident #68, he stated he does not have a seatbelt or alarm on his wheelchair preventing him from getting up. 2. Review of medical record for Resident #74 revealed admission dated 06/12/18 with diagnoses including age related physical disability, difficulty walking and history of falls. Review of the quarterly MDS 3.0 assessment, dated 04/10/19, revealed the resident had impaired cognition. He had a physical restraint of bed rails. Observation on 04/30/19 at 9:14 A.M. of Resident #74 revealed bilateral half side rails on the bed. Resident #74 was able to grab the side rail to assist with repositioning. Interview on 05/02/19 at 5:32 P.M. with MDS Licensed Practical Nurse (LPN) #830 stated there were no restraints in the facility. LPN #830 verified Resident #68 did not have a restraint on his wheelchair and had no restraint in use. LPN #830 verified the MDS for Resident #74 showed half bed rails were used as a restraint. LPN #830 stated Resident #74's side rails were used to assist with bed mobility and not a restraint. LPN #830 verified Resident #68 and Resident #74's MDS assessments were inaccurate. Page 1 of 3 366323 366323 05/10/2019 Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, pharmacy reviews and interview, the facility failed to follow physician orders. This affected one (Resident #40) of five residents reviewed for unnecessary medications. The census was 95. Residents Affected - Few Findings Include: Review of the medical record for Resident #40 revealed an admission date of 02/13/06 with diagnoses including Vitamin D-3 deficiency, depression and heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had impaired cognition. Review of the pharmacy consultation report dated 12/19/18 revealed Resident #40 had an order for Vitamin D-3 5000 units was to be given one tablet by mouth in the evening every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. Resident #40 had an above normal Vitamin D level, and Vitamin D-3 medication should be adjusted. A new order from the physician was given to change the Vitamin D-3 5,000 units every other day, even days, signed by the physician on 12/31/18. Review of the pharmacy consultation report dated 01/23/19 revealed Resident #40 had two orders for Vitamin D-3. One order for Vitamin D-3 5,000 units was to give one tablet by mouth in the evening every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday, and another order for Vitamin D3 5,000 units, one tablet by mouth in the evening on even days. Review of medication administration records (MAR) for January 2019 revealed Resident #40 received Vitamin D-3 5000 one tablet by mouth in the evening every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday at 4:00 P.M. and another Vitamin D3 5000 units, one tablet by mouth in the evening on even days at 7:00 P.M. Interview on 05/01/19 at 3:00 P.M. with the Director of Nursing (DON) verified that Resident #40 did receive a double dose of Vitamin D-3 every even day during the month of January 2019. The DON verified the original order for Vitamin D-3 should have been discontinued on 12/31/19, when the physician gave the new order. 366323 Page 2 of 3 366323 05/10/2019 Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264

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 interview, the facility failed to prevent possible physical contamination of food during tray line service. This affected all 95 residents who received food from the kitchen. Facility census was 95. Findings include: Observation on 05/01/19 at 9:52 A.M., 10:03 A.M., and 10:27 A.M. of the lunch tray line service, Dietary Staff #812, Dietary Staff #815 and Dietary Manager #808 were observed to have beards that were not covered. Interview on 05/01/19 at 10:35 A.M. with Kitchen Manager #808 confirmed beard hair nets were not used. He stated they were on order and due to arrive during the week. 366323 Page 3 of 3