Inspection·May 9, 2019

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 observation, record review and staff interview the facility failed ensure monitoring of Resident #56's condition following a witnessed injury to the left ankle. This affected one (Resident #56) of two residents reviewed for accidents. The facility census was 61. Residents Affected - Few Findings include: Resident #56 was admitted to the facility 04/22/19 with admitting diagnoses that included cerebral infarction, hypertension, muscle weakness, dysphagia, difficulty walking, and personal history of falls. Review of the admission fall risk assessment dated [DATE] revealed the [AGE] year old resident was a high risk for falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment and required two person assist for bed mobility, transfers and toileting. Observations conducted during the breakfast meal in the 300 Hall dining room on 05/07/19 from 7:50 A.M. to 8:30 A.M. revealed Resident #56 seated in a wheelchair at the dining room table with four other residents. Resident #56 was alert and oriented, had a blanket around her shoulders and stated she felt it was chilly in the room but did not want another blanket. The observation revealed Resident #56 had an elastic bandage wrap, commonly called an ace bandage to her left ankle. An interview was conducted with Resident #56 on 05/07/19 at 10:00 A.M. in the resident's room. Observation during the interview revealed the elastic bandage was in place to the resident's ankle. Upon query, Resident #56 replied staff were transferring the resident to the toilet, turned her too hard and twisted her ankle. Resident #56 stated the injury was unintentional and did not hurt very bad now. Review of nursing progress notes, treatment records and physician orders from admission to 05/08/19 revealed no documentation of an incident or injury for Resident #56, no documentation the facility was monitoring the resident for bruising or swelling to her ankle, no documentation when or how long the resident's ankle was wrapped and no physician orders for an ace wrap to her ankle. Review of a nurses notes' dated 05/08/19 at 7:31 P.M. documented the resident had dark purple bruising to the resident's left ankle, around the second and third digits on the left foot and bruising to the right foot. Resident #56 told the nurse she did not know how the bruising occurred. The nurse notified the physician and family. An additional note at 8:18 P.M. documented the bruising may be caused from bumping feet while transferring or while propelling self in wheelchair. Review of results of a left ankle X-ray exam dated 05/08/19 at 8:21 P.M. revealed Resident #56 had a fractured left ankle. Nursing documentation dated 05/09/19 at 12:34 A.M. revealed results of X-rays of the resident's ankles and feet were sent to the physician, new orders were received for pain medication and an orthopedic consult related to the left ankle, and the resident was to be non-weight bearing to her left leg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/09/19 at 9:45 A.M. with the Administrator and Director of Nursing (DON) the Administrator and DON stated in the evening on 05/08/19 staff discovered bruises to the feet and ankle of Resident #56. The Administrator stated the nurse reported the findings to the administrative team and physician, an investigation was initiated, and the resident said no one intentionally hurt her, so there was no way to determine when the injury actually occurred. The DON and Administrator were unable to explain why Resident #56 was observed with an ace wrap to her ankle two days previously but revealed they would investigate further. An interview was conducted 05/09/19 at 11:40 A.M. with the daughter of Resident #56. During the interview the daughter stated the resident had her ankle wrapped the previous week. The daughter said the resident stated staff were getting her off the toilet, turned her too fast and she twisted her ankle. The daughter stated an aide caring for the resident at the time also said the same thing about what happened but, was unable to remember which aide confirmed the injury. During an interview on 05/09/19 at 12:50 P.M. with the Therapy Director (TD) #900, TD #900 confirmed on 05/06/19 Resident #56 received therapy in the department and it was noted the resident had an ace wrap to her left ankle. TD #900 stated the reason for the ace wrap was unknown but there was no order at that time for the resident to not walk on that leg. A follow up interview was conducted with the DON and Administrator on 05/09/19 at 3:00 P.M. During the interview the DON stated further investigation by the facility revealed on 04/28/19 staff assisted Resident #56 to the toilet and back to her wheelchair and the resident told the staff she rolled her ankle. The next day when the resident had some swelling of her ankle and discomfort to the area, the nurse obtained an order for the ace wrap and ice as needed. The DON confirmed there was no documentation of the incident, the pain and swelling noted the next day or any physician order for treatment written. The DON confirmed the 04/28/19 incident and discomfort was not reported to the next shift for staff to monitor the resident's ankle for changes and document the use of the ace wrap. The DON also confirmed there was no other incident documented that might explain bruises found on the resident's ankle on 05/08/19 that led to the discovery of a fracture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observation and interview, the facility failed to ensure food was stored at the appropriate temperatures and prepared under sanitary conditions. This had the potential to affect 54 of 61 residents who currently resided in the facility and received meals from the kitchen. Four Residents (#11, #40, #43, and #210) were identified as not receiving food by mouth. Findings include: 1. An initial tour of the kitchen was conducted on 05/06/19 at 8:59 P.M. with the Assistant Dietary Manager (ADM) #817 and Registered Dietitian (RD) #802 who revealed a three door, stainless steel under the counter cooling unit used to store resident foods for meal service. The left door to the cooling unit was ajar with approximately a half inch gap between the seal and the door. The left door moved freely and without suction indicating that the door was unable to be securely shut. ADM #817 pointed out that the internal thermometer was reading in the red zone with a temperature of 44 degrees Fahrenheit (F). The inside of the cooling unit did not have internal walls separating each section with a door so any cold air escaping from the unit would effect the temperature of the whole unit. ADM #817 tested the remaining two doors and the doors sealed properly to the door frame. ADM #817 took internal food temperatures with a digital touch point thermometer of a pan of egg salad dated 05/04/19 and it was 44 degrees F. A small pan of noodles dated 05/06/19 measured at 44.5 degrees F. The cooler contained multiple pans of food including egg salad, noodles, luncheon meats and pancake batter which ADM #817 indicated were for the next days resident meal service. ADM #817 stated the cooling unit had been looked at by maintenance in the past (date unknown) for the same issue so she would throw the food away and have maintenance look at it in the morning. ADM #817 indicated the morning and afternoon cooks were responsible for recording temperatures on the unit in the morning and afternoon and had not reported any irregularities with the cooler temperatures. ADM #817 stated she had not checked the unit before closing the kitchen. Record review was conducted of the kitchen document titled Kitchen Refrigeration Temperature Log, dated May 2019. The documented indicated that the under the counter unit had been reading between 35-40 degrees F. An interview was conducted on 05/07/19 at 9:01 A.M. with Maintenance Director #805 who verified the loose seal on the left door of the three door under the counter cooling unit, and he said he would have a local refrigeration company look it over for repair. Record review was conducted of the facility policy titled Food Preparation and Storage, dated 2005, that indicated perishable food would be stored under refrigeration at or below 41 degrees F. 2. During the initial tour of the kitchen on 05/06/19 from 8:59 P.M. to 9:14 P.M. a large, stainless steel floor mixer was observed to be uncovered and in a high traffic area of the kitchen between the entrance door and the main food production area. Inside of the large mixing bowl was a collection of brown sediment. The entire beater shaft and beater guard that hung directly over the mixing bowl was heavily coated in a white dried on food residue. Interview was conducted on 05/06/19 at 9:14 P.M. with ADM #805 and RD #802 who verified the mixer was not clean nor covered and it was used to make various batters and dessert mixes for the resident meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, the facility did not ensure Resident #43 had a properly functioning call light. This affected one of twenty four residents reviewed for physical environment. The facility census was 61. Residents Affected - Few Findings include: Record review was conducted for Resident #43 who was admitted to the facility on [DATE] with diagnoses including stroke, protein-calorie malnutrition and feeding tube placement. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had mild cognitive impairment, was frequently incontinent of urine and always incontinent of bowel, and needed extensive assist of two staff for transfers and toileting. The plan of care initiated on 03/06/19 revealed he needed help with his activities of daily living and his call light should be kept within reach. Observation and interview was conducted on 05/07/19 at 3:12 P.M. with Resident #43 who revealed he had pushed his call light 15 times and no one was coming to help him. The resident pushed the call light again in front of the state agent and the call light did not activate by sound or light. LPN #816 was asked to look at his call light and verified that his call light was not working and she would notify maintenance. Observation was conducted on 5/8/19 at 8:44 A.M. of Resident #43's call light which was working by sound and light function. Interview was conducted on 05/08/19 at 9:01 A.M. with Maintenance Director (MD) #805 who verified the call light in Resident #43's room was broke and he had to replace the cord and the switch in the wall to fix it. MD #805 added he did not do routine call light audits so he would have had no way to know it had been nonfunctional unless someone reported it was not working. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 5 of 5