Health inspection·March 14, 2024

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure timely notification to the physician or nurse practitioner (NP) of abnormal laboratory values for Resident #68. This affected one resident (Resident #68) of three reviewed for laboratory tests. The facility census was 77. Findings include: Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin) osteomyelitis to the right ankle and foot, thrombus (blood clot) and embolism (blockage caused by a blood clot) in the right lower extremity, crest syndrome (a type of collagen vascular disease), asthma, systemic sclerosis (chronic hardening and tightening of the skin and connective tissues), chronic obstructive pulmonary disease, amputation, Raynaud's syndrome (condition of decrease blood flow to the fingers), Buerger's disease (blood vessels swell which can prevent blood flow), atrial fibrillation, aortic aneurysm, hypertension, congestive heart failure, and cellulitis. Review of the Five-Day Medicare Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #68 had intact cognition. Review of the physician order dated 10/09/23 revealed Resident #68 had an order for a complete blood count (a test measuring the concentration of hemoglobin, a protein contained in red blood cells that is responsible for carrying oxygen to the tissues) every Monday. On 10/31/23 the order was revised to repeat the complete blood count (CBC) in one month. Review of the laboratory tests for November 2023 revealed Resident #68's hemoglobin levels were between 7.6 to 7.9 (normal hemoglobin is between 12.0 to 16.0). Review of progress notes and physician notes for November 2023 revealed the hemoglobin levels were being reviewed by the physician or NP and no new orders were given. On 11/21/23 a physician progress note indicated Resident #68 was being seen for management of chronic conditions after a hospital stay in June 2023 for hip surgery complicated by anemia for which she had received blood transfusions. The plan was to monitor the anemia and related lab tests. Review of the laboratory test dated 12/05/23 revealed Resident #68's hemoglobin was 6.3 which was flagged on the test as being a critical lab. On 12/07/23 NP #201 hand wrote on the test to give two units of packed red blood cells. Page 1 of 4 366463 366463 03/14/2024 Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physician order dated 12/08/23 revealed Resident #68 had an order to type and crossmatch to be done today and then she was to be transfused on 12/09/23. On 03/12/24 at 2:20 P.M. an interview with Nurse Practitioner (NP) # 201 revealed there were some issues with the facility not notifying her promptly of laboratory results. NP #201 said the staff would place the laboratory results into a folder for her, she visited the facility three days a week, and would review and sign the laboratory results during visits. When asked why the 12/05/23 laboratory results for Resident #68 were not signed by her until 12/07/23, NP #201 indicated she would do some research and get back to the surveyor with an answer. On 03/12/24 at 2:30 P.M. an interview with Registered Nurse (RN) #104 revealed she placed laboratory results for Resident #68 in the folder for NP #201 but did not notify the NP immediately of the results. RN #104 said the physician or NP should have been notified immediately of the laboratory results for Resident #68. On 03/13/24 at 9:20 A.M. a follow-up interview with NP #201 revealed she remembered finding Resident #68's lab results from 12/05/23 in her folder when she showed up at the facility to do rounds on 12/07/23. NP #201 stated she had notified the DON they were in her folder but she should have been notified immediately considering those lab results were considered critical. NP #201 stated because Resident #68 was not showing any symptoms related to the low hemoglobin of 6.3, she would not have sent her out to the hospital so scheduling Resident #68 for an outpatient transfusion appointment on 12/09/23 was appropriate and treatment had not been delayed. NP #201 said she still should be notified immediately of any abnormal laboratory tests for any resident instead of the staff just putting the results in her folder for her next visit. This deficiency represents non-compliance investigated under Complaint Number OH000151433. 366463 Page 2 of 4 366463 03/14/2024 Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review, interviews with staff and review of facility policy, the facility failed to ensure appropriate meal substitutions were given to residents ordered pureed and mechanical soft diets. This affected 11 residents (Resident #2, #5, #10, #13, #19, #23, #26, #43, #50, #54, #63) the facility identified as requiring a pureed or mechanical soft diet of 76 residents receiving meals from the kitchen. The facility identified Resident #37 as receiving nothing by mouth (NPO) The facility census was 77. Findings included: Observation of meal service on 03/12/24 from 10:40 A.M. to 12:10 P.M. revealed the meal prepared was cheese tortellini, Italian green beans, garlic bread and mandarin oranges. Dietary Manager (DM) #105 indicated they did not have mandarin oranges, so they were substituting with fruit cocktail and all mechanical soft and pureed diets were getting vanilla pudding. Review of the facility meal spreadsheet for 03/12/24 revealed mechanical soft and pureed diets were to get mandarin oranges (fruit cocktail) not vanilla pudding. On 03/12/24 at 12:16 P.M. an interview with DM #105 confirmed vanilla pudding was not an appropriate substitution for fruit for the residents who received pureed and mechanical soft diets. On 03/12/24 at 12:28 P.M. an interview with Corporate Dietitian #200 verified vanilla pudding was not an appropriate substitution for fruit with the residents who received pureed and mechanical soft diet unless it was a resident's preference. Review of the undated facility policy titled, Meal Substitutions, revealed menu substitutions would be made after discussion with the director of food and nutritional services whenever possible. Substitutions may need to be made for uncontrollable situations. Staff must choose any food on the Menu Substitution list within the same list to substitute for the unavailable item. Review of the Menu Substitution list revealed for canned fruit a suitable substitution would be fruit drink, fresh fruit, or dried fruit. Vanilla pudding was not on the list of items to be used for a substitution. This deficiency represents non-compliance investigated under Complaint Number OH00151601. 366463 Page 3 of 4 366463 03/14/2024 Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691

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, interview with staff, and review of facility policy, the facility failed to ensure the kitchen staff wore beard nets and hair nets appropriately to prevent contamination of food. This affected all 76 residents in the facility who ate meals from the kitchen except Resident #37 who the facility identified as receiving nothing by mouth (NPO). The facility census was 77. Findings included: Observation during meal preparation on 03/12/24 at 10:40 A.M. revealed [NAME] #400 and Dietary Aide (DA) #401 were not wearing a beard net on their beard while preparing food. Also, Dietary Aide #402 did not have her front bangs under her hair net while preparing drinks. On 03/12/24 at 11:00 A.M. an interview with Dietary Mangers # 105 confirmed [NAME] #400, DA #401 and DA #402 did not have on beard nets or have all hair appropriately covered while preparing food in the kitchen. Review of the undated facility policy titled, Employee Sanitation Practices, revealed all employees would wear hair restraints including hairnets, hat and/or beard covers to prevent hair from contacting exposed food. This deficiency represents non-compliance investigated under Complaint Number OH00151601. 366463 Page 4 of 4