Health inspection·August 24, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to ensure call lights were within reach of residents. This affected two residents (#25 and #52) of four residents observed for call lights. The facility census was 105. Residents Affected - Few Findings include: 1. Observation on 08/22/23 at 8:12 A.M. revealed Resident #25's call light was on the floor next to his bed. Interview with Resident #25 at time of observation revealed he was completely paralyzed and was unable to get his call light off the floor. Resident #25 stated his call light was often not within reach and would have to yell out for staff to assist him. Observation on 08/22/23 at 2:04 A.M. with Director of Nursing (DON) confirmed Resident #25's call light remained on the floor. 2. Observation on 08/22/23 at 9:40 A.M. revealed Resident #52's call light was wrapped around her bed rail and on the floor. Observation was confirmed with Registered Nurse (RN) #310. RN #310 stated Resident #52's call light was usually clipped to the resident's pillow. RN #310 attempted to clip the call light to Resident #52's pillow and no clip was on the call light. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00145421. Page 1 of 13 365071 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure complete and accurate care plans. This affected two residents (#25 and #36) of four residents reviewed for care plans. The facility census was 105. Findings include: 1. Review of Resident #25's medical records revealed an admission date of 03/23/23. Diagnoses included quadriplegia and colostomy. Review of Resident #25's care plan dated 07/11/23 did not include colostomy care. Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed resident had intact cognition. Resident #25 had a colostomy for bowel elimination. Review of physician orders dated 08/22/23 revealed to provide colostomy care every shift and as needed. 2. Review of Resident #36's medical records revealed an admission date of 06/15/23. Diagnoses included paraplegia and altered mental status. Review of Resident #36's care plan dated 07/10/23 did not include colostomy or urinary catheter care. Interview on 08/22/23 at 2:04 P.M. with Director of Nursing (DON) confirmed Residents #25 and #36's care plans did not include colostomy or urinary catheter care. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00145421. 365071 Page 2 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure residents were turned and repositioned as needed. This affected one resident (#25) of four residents observed for activities of daily living (ADL) care. The facility census was 105. Residents Affected - Few Findings include: Review of Resident #25's medical records revealed an admission date of 03/23/23. Diagnosis included quadriplegia. Review of the care plan dated 07/11/23 did not include turning or reposition interventions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition. Resident #25 required total dependence on staff for bed mobility, toileting, and personal hygiene. Observation on 08/22/23 at 7:25 A.M. revealed Resident #25 was asleep in bed positioned on his back toward his right side. Interview on 08/22/23 at 8:12 A.M. with Resident #25 revealed he had been asking the staff to get him up into his power wheelchair since it had been repaired on 08/18/23; however, staff had not gotten him up. Resident #25 stated he would like to be up more often and stated he was paralyzed and unable to reposition himself in bed. Observation on 08/22/23 at 10:25 A.M. revealed Resident #25 remained in the same position as previous observation. Resident #25 stated he had informed the Director of Nursing (DON) he had requested assistance out of bed; however, he had not received assistance yet. Observation on 08/22/23 at 11:52 A.M. revealed Resident #25 remained in the same position as previous observation and stated he had asked staff to get him up before lunch; however, he had not been assisted up yet. Interview on 08/22/23 at 1:28 P.M. with State Tested Nursing Assistant (STNA) #332 revealed she had been aware Resident #25 had not been assisted with repositioning and was often left in bed for long periods of time. Interview on 08/22/23 at 2:04 P.M. with the DON revealed she had spoken with Resident #25 at approximately 10:30 A.M. and was aware the resident had requested to be up out of bed. The DON stated she was not aware Resident #25 had not been assisted up and confirmed the resident had remained in bed and was in the same position as previous observations. Interview on 08/23/23 at 8:08 A.M. with STNA #204 revealed he had observed Resident #25 up in his wheelchair when he had arrived on 08/22/23 at 7:00 P.M. and stated he was surprised to see him in his wheelchair due to the resident was rarely up when he arrived. This deficiency represents non-compliance investigated under Master Complaint Number OH00145421. 365071 Page 3 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

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 interview and record review the facility failed to ensure physician orders were in place regarding colostomy care. This affected one resident (#25) of four residents reviewed for physician orders. The facility census was 105. Residents Affected - Few Findings include: Review of Resident #25's medical records revealed an admission date of 03/23/23. Diagnoses included quadriplegia and colostomy. Review of Resident #25's care plan dated 07/11/23 did not include colostomy care. Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition. Resident #25 had a colostomy for bowel elimination. Review of the physician orders dated 08/22/23 revealed to provide colostomy care every shift and as needed. No previous orders were in place regarding Resident #25's colostomy care. Interview on 08/23/23 at 2:02 P.M. with the Director of Nursing (DON) confirmed Resident #25's physician orders did not contain colostomy care. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00145421. 365071 Page 4 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

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 observation, interview, and record review the facility failed to ensure wound dressings were changed and intact. This affected one resident (#17) of two residents observed for wound dressings. The facility census was 105. Residents Affected - Few Findings include: Review of Resident #17's medical records revealed an admission date of 10/18/22. Diagnoses included stage four pressure ulcer (Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) of the sacrum (tailbone), left sided paralysis, muscle weakness, and need for personal care assistance. Review of the care plan dated 07/26/23 revealed Resident #17 had a pressure ulcer related to immobility. Interventions included educate resident on importance of turning and reposition and being compliant with care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition. Resident #17 required total dependence with bed mobility, transfers, toileting, and personal hygiene. Resident #17 was incontinent of bowel and bladder. Resident #17 was admitted with a stage four pressure ulcer. Review of the current physician orders for August 2023 revealed Resident #17 had an ordered to cleanse the sacrum with normal saline, apply collagen powder and silver alginate (wound dressing), and cover with a foam dressing every shift. Observation of incontinence care on 08/23/23 8:08 A.M. for Resident #17 with State Tested Nursing Assistant (STNA) #204 revealed the resident had a foam dressing dated 08/20/23 that was soiled and was not intact or covering the resident's sacral wound. Interview with Resident #17 at time of observation revealed he had a wound to his buttocks prior to being admitted that had been healing and stated he had asked the nurses to change his dressing because he did not want the wound to not continue to heal. STNA #204 stated he had observed the soiled dressing and stated he was going to let the nurse know it needed to be changed. Review of Treatment Administration Record (TAR) for August 2023 revealed the wound dressing had been documented as being completed on 08/21/23, 08/22/23, and 08/23/23. Interview on 08/23/23 at 2:02 P.M. with the Director of Nursing (DON) confirmed the TAR for Resident #17's wound dressings was documented as being completed; however, treatments were not done. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00145421. 365071 Page 5 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure timely colostomy care was provided to Resident's #17 and #25. This affected two residents (#17 and #25) of two residents observed for colostomies. The facility identified four residents (#17, #25, #36 and #70) with colostomies. The facility census was 105. Findings include: 1. Review of Resident #17's medical records revealed an admission date of 10/18/22. Diagnoses included left sided paralysis, muscle weakness, and need for personal care assistance. Review of the care plan dated 07/26/23 revealed Resident #17 had a colostomy. Interventions include provide colostomy care every shift and as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition. Resident #17 was incontinent of urine and had a colostomy for bowel elimination. Review of current physician order for August 2023 revealed to provide colostomy care every shift. Interview on 08/22/23 at 8:05 A.M. with Resident #17 revealed he had a colostomy, and it had not been emptied regularly. Resident #17 stated he had asked for the bag to be emptied, and sometimes the staff would not empty it all day and the bag would leak. Resident #17 stated his bag needed to be emptied. Interview on 08/22/23 at 12:20 P.M. with Resident #17 revealed his colostomy bag had not been emptied and would prefer for the bag to be emptied before he ate, and stated, he did not want to smell the feces while he was eating. Observation on 08/22/23 at 12:40 P.M. revealed Resident #17's lunch tray had been delivered and Resident #17 stated his colostomy bag had not been emptied prior to being served. Observation on 08/22/23 at 2:04 P.M. with the Director of Nursing (DON) confirmed Resident #17's colostomy bag was full and had not been emptied. 2. Review of Resident #25's medical records revealed an admission date of 03/23/23. Diagnoses included quadriplegia and colostomy. Review of Resident #25's care plan dated 07/11/23 did not include colostomy care. Review of Resident #25's MDS assessment dated [DATE] revealed the resident had intact cognition. Resident #25 had a colostomy for bowel elimination. Review of physician orders dated 08/22/23 revealed to provide colostomy care every shift and as needed. Interview on 08/22/23 at 8:12 A.M. with Resident #25 revealed he had a colostomy bag that not been 365071 Page 6 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

F 0691 Level of Harm - Minimal harm or potential for actual harm emptied regularly. Resident #25 stated his colostomy bag needed to be emptied and he stated it was last been emptied the previous evening. Observation on 08/22/23 at 2:44 P.M. with the DON for Resident #25 confirmed the resident's colostomy bag had stool in it and the flap on the bottom of the bag was not closed. This deficiency represents non-compliance investigated under Master Complaint Number OH00145421. Residents Affected - Few 365071 Page 7 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medications were administered and documented timely. This affected one resident (#45) of three residents reviewed for medication administration. The facility census was 105. Residents Affected - Few Findings include: Review of Resident #45's medical records revealed an admission date of 01/25/19. Diagnoses included chronic pain, muscle weakness, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition. Review of the care plan dated 07/18/23 revealed Resident #45 had alteration in comfort related to chronic pain. Interventions included administer medications as ordered. Review of current physician orders for August 2023 revealed Resident #45 was ordered Roxicodone (narcotic pain medication) 30 milligrams (mg) twice daily at 9:00 A.M. and 9:00 P.M. and Roxicodone 5 mg at 3:00 A.M. and 3:00 P.M. Interview on 08/22/23 at 8:53 A.M. with Resident #45 revealed her medications were not always administered timely. Resident #45 stated she was ordered Roxicodone at 9:00 A.M. and 9:00 P.M. as well as 3:00 A.M. and 3:00 P.M. Resident #45 stated her 9:00 A.M. medication was sometimes given around lunch time and her evening medications were often late and she had to be woken up to take them. Review of time stamped Medication Administration Record (MAR) on 08/23/23 at 1:00 P.M. revealed on 08/09/23 Roxicodone 30 mg was due at 9:00 A.M. and Roxicodone 5 mg was due at 3:00 P.M., both doses had been documented as given at 7:23 P.M. on 08/11/23 Roxicodone 30 mg dose due at 9:00 A.M. was documented at 9:55 A.M. and Roxicodone 5 mg dose was due at 3:00 P.M. and was documented at 10:40 A.M., on 08/13/23 Roxicodone 5 mg dose was due at 3:00 P.M. and was documented at 6:06 P.M. on 08/14/23 Roxicodone 5 mg dose was due at 3:00 P.M. and was documented at 6:50 P.M., on 08/15/23 Roxicodone 30 mg was due at 9:00 A.M. and 5 mg dose was due at 3:00 P.M., both doses were documented at 7:53 A.M., on 08/16/23 Roxicodone 5 mg dose was due at 3:00 P.M. and dose was documented at 9:12 A.M., on 08/17/23 Roxicodone 30 mg was due at 9:00 A.M. and 5 mg dose was due at 3:00 P.M., both doses were documented at 8:32 A.M., on 08/22/23 Roxicodone 5 mg was due at 3:00 P.M. and was documented at 6:38 P.M. Interview on 08/23/23 at 1:30 P.M. with the Director of Nursing (DON) confirmed the MAR had medications being documented several hours after the ordered medication times and stated the nurses may have documented the medications during or at the end of their shifts instead of at the time the medication had actually been given. The DON stated medications should have been documented at the time they had been given. The DON stated the narcotic sheets should have the actual time the medication was given. Observation of Resident #25's narcotic sheet with the DON at 1:59 P.M. revealed a narcotic sheet for Roxicodone beginning on 08/20/23 and medications had been signed off at 9:00 A.M. and 9:00 P.M. The DON stated the narcotic sheet had been signed off by the nurses for the ordered time and were not the actual time the medications were administered. Review of the facility policy titled Administering Medications, revised 04/19, revealed medications were to be administered within one hour of their prescribed times. 365071 Page 8 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

F 0760 This deficiency represents non-compliance investigated under Complaint Number OH00140122. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365071 Page 9 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate and timely feeding assistance to Resident's #25 and #41. This affected two residents (#25 and #41) of three residents observed for feeding assistance. The facility identified six residents (#25, #34, #41, #78, #90 and #100) who required feeding assistance. The facility census was 105. Residents Affected - Few Findings include: 1. Review of Resident #25's medical records revealed an admission date of 03/23/23. Diagnosis included quadriplegia. Review of the care plan dated 07/11/23 revealed no interventions related to feeding assistance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition. Resident #25 required total assistance with eating. Interview on 08/22/23 at 8:12 A.M. with Resident #25 revealed he needed assistance with eating and stated there had been occasions when he had not received a meal or assistance with his meals. Observation on 08/22/23 at 12:37 P.M. revealed Resident #25's lunch tray had been brought into his room by State Tested Nursing Assistant (STNA) #312, almost immediately after STNA #312 had entered Resident #25's room, she had exited the room with the tray. Interview with STNA #312 at time of observation revealed Resident #25 did not wanted his meal and requested a sandwich instead. STNA #312 stated she would contact the kitchen and have a sandwich sent up. Observation on 08/22/23 1:24 P.M. revealed STNA #312 was assisting Resident #25 with his sandwich and stated the kitchen had not sent his sandwich and she had gone to the kitchen and get it. Interview on 08/22/23 at 1:28 P.M. with STNA #322 revealed she was aware Resident #25 had not been assisted with his meals regularly. 2. Review of Resident #41's medical records revealed an admission date of 04/16/22. Diagnoses included legal blindness and need for personal care assistance. Review of the MDS assessment dated [DATE] revealed Resident #41 had intact cognition. Resident #41 required partial to moderate assistance with eating. Review of the care plan dated 07/18/23 revealed Resident #41 had nutritional problems related chronic disease. Interventions included provide assistance with eating as needed. Observation on 08/22/23 at 12:42 P.M. revealed Resident #41 was eating her lunch using her fingers. Interview with Resident #41 at time of observation revealed the resident was legally blind and was unable to see her meal tray. Resident #41 stated the staff was supposed to assist her with eating; however, they usually just set the tray down and left it. Resident #41 stated she would prefer the staff to assist her with meals because she had made a mess when she ate by herself. Interview on 08/22/23 at 12:50 P.M. with STNA #276 revealed Resident #41 should have been a fed; 365071 Page 10 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

F 0810 however, she had not been told to feed the resident. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Master Complaint Number OH00145421. Residents Affected - Few 365071 Page 11 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility failed to provide a clean and sanitary environment. This affected four residents (#16, #24, #25 and #44) and had the potential to affect all 105 residents residing in the facility. Findings include: Observation on 08/22/23 at 7:20 A.M. revealed a strong odor of urine at the end of the 100-hall. Observation on 08/22/23 at 7:22 A.M. revealed dirty meal trays and two overflowing trashcans in a common dining area on the 100-hall. Observation on 08/22/23 at 7:30 A.M. revealed dirty meal trays and two overflowing trashcans in a common dining area on the third floor. Observation on 08/22/23 at 7:42 A.M. revealed dirty meal trays from the previous meal and an overflowing trashcan in a common dining area on the second floor. Observation on 08/22/23 at 8:05 A.M. revealed a large amount of tube feed underneath Resident #16's bed and along the baseboards. Resident #16 was not interviewable. Observation on 08/22/23 at 8:12 A.M. revealed Resident #25's wall next to his bed had various areas with brown splatters on it. Resident #25 stated he was not sure what the brown splatters were, and they had been there since he was moved into that room. Interview on 08/22/23 at 10:20 A.M. with Housekeeper #213 revealed he had adequate amounts of cleaning supplies. Housekeeper #213 stated he had observed the dirty meal tray and overflowing trashcans in the common dining area that had been left from the previous shift. Observation on 08/22/23 at 12:10 P.M. revealed Resident #44's bathroom had stool on the floor and walls and wall underneath the resident's window had large amounts of greenish brown splatter on it. Resident #44 was not present at time of observation. Observation of Resident #44's room was confirmed by State Tested Nursing Assistant (STNA) #255 and stated she was not sure when the resident's room had been last cleaned. Observation on 08/22/23 at 1:28 P.M. with STNA #322 revealed Resident #24's room had a strong urine odor. Further observation revealed STNA #322 had removed Resident #16's blanket on her bed and a large yellow stain was observed on the resident's sheets. STNA #322 stated Resident #24 was often left wet and staff and had not cleaned her bed or bedding after the resident had been incontinent. Observation with STNA #322 for Resident #25 revealed his bedding had a large yellowish colored stain near the resident's urinary catheter, and underneath of the residents left heel sheet had a green colored stain and underneath his right heel was a reddish-brown stain. Observation on 08/23/23 at 8:08 A.M. revealed tube feed remained on the floor and baseboard of Resident #16's bed. Observation was confirmed by STNA #204, and STNA stated, No one cleans in this place. 365071 Page 12 of 13 365071 08/24/2023 Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122

F 0921 This deficiency represents non-compliance investigated under Master Complaint Number OH00145421. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365071 Page 13 of 13