Health inspection·March 18, 2022

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, record review, and review of the facility policy the facility failed to ensure physician orders were followed and care planned interventions were implemented for Resident #230. This affected one (Resident #230) of three residents reviewed for pressure ulcers. The facility census was 149. Residents Affected - Few Findings include: Review of Resident #230's medical record revealed an admission date of 02/22/22 with diagnoses including neoplasm of uncertain behavior of other specified digestive organs, diffuse large B-cell lymphoma, type two diabetes mellitus, and heart failure. The resident was discharged from the facility on 03/14/22. Review of Resident #230's Weekly Ulcer and Wound Documentation dated 02/22/22 revealed Resident #230 had an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) to the sacrum measuring 15.9 centimeters (cm) in length by 11.6 cm width and a depth of 0.1 cm. Review of Resident #230's admission assessment dated [DATE] included Resident #230 was at a high risk for skin breakdown. Review of Resident #230's physician orders on 02/24/22 revealed a low air loss mattress to the bed, check function every shift. Review of Resident #230's Treatment Administration Record (TAR) from 03/01/22 through 03/14/22 revealed there was documentation every shift Resident #230 had a low air loss mattress on the bed, and the function was checked every shift. Review of Resident #230's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #230 was cognitively intact and required the extensive assistance of two staff for bed mobility, transfers, and toilet use. Resident #230 was frequently incontinent of urine, always incontinent of bowel, and admitted with a pressure ulcer, but location and stage were not documented. Review of Resident #230's care plan revised 03/11/22 included Resident #230 had the potential for alteration in skin integrity related to bruises easily, history of skin tears due to fragile skin condition, abnormal labs, decreased circulation, oxygenation, vitamin deficiency, mood/behavior status, at risk for malnutrition, osteoarthritis, congestive heart failure, diabetes mellitus, obstructive sleep apnea, anemia. diffuse large B cell lymphoma with poor prognosis. Resident #230 would not develop skin breakdown through review date. Interventions included low air loss pressure redistribution Page 1 of 4 365084 365084 03/18/2022 Pleasantview Care Center 7377 Ridge Rd Parma, OH 44129

F 0686 mattress to bed. Level of Harm - Minimal harm or potential for actual harm Observation on 03/14/22 at 9:24 A.M. of Resident #230 revealed she was lying in her bed and her son was at the bedside. Further observation of Resident #230 revealed she was lying on a pressure reducing mattress, not a low air loss mattress as ordered by the physician. Residents Affected - Few Interview on 03/14/22 at 9:24 A.M. with Resident #230's son revealed Resident #230 had a sore on her bottom and there had been zero improvement since Resident #230 was admitted to the facility three weeks ago. When asked why Resident #230 was not on a low air loss mattress, Resident #230's son stated he did not know what that was and as far as he knew Resident #230 was on the same mattress her entire admission. Interview on 03/14/22 at 2:51 P.M. with the Director of Nursing (DON) confirmed Resident #230's mattress was not a low air loss mattress as ordered by the physician. The DON stated it was a pressure reducing mattress, not a low air loss mattress. The DON stated if it was a low air loss mattress it would have a pump hanging at the foot of the bed, and the bed did not have a pump. The DON confirmed nurses were documenting in the TAR Resident #230 had a low air loss mattress. Interview on 03/15/22 at 8:53 A.M. with Licensed Practical Nurse (LPN) #771 confirmed she documented Resident #230 had a low air loss mattress in the TAR and did not verify Resident #230 had a low air mattress when she documented it. LPN #771 stated she did not remember if Resident #230 had a low air loss mattress. Interview on 03/17/22 at 10:00 A.M. with the DON revealed Resident #230 had a low air loss mattress, the mattress malfunctioned either on 03/12/22 or 03/13/22, Registered Nurse (RN) #663 replaced the malfunctioning mattress with a pressure reducing mattress but did not document any problems with the low air loss mattress or place a maintenance work order to have it repaired. The DON stated there was no documented evidence regarding the malfunctioning mattress in Resident #230's medical record or for a maintenance work order. Interview on 03/17/22 at 2:32 P.M. of Maintenance Director (MD) #711 revealed he did not receive a work order through the electronic system for Resident #230's malfunctioning mattress. MD #711 stated if a low air loss mattress was not functioning properly for a resident the staff could replace it with another low air loss mattress, because there were low air loss mattresses available for use located in the facility. Review of the electronic maintenance work orders with MD #711 from 03/05/22 through 03/17/22 confirmed there were no work orders initiated for Resident #230's air loss mattress malfunction. Review of Resident #230's progress notes from 03/04/22 through 03/14/22 revealed no documented evidence Resident #230's low air loss mattress was not functioning properly. Review of the facility policy titled Pressure Ulcer Prevention Protocols/Risk Assessment, dated 11/30/18, included the policy was to provide guidelines for the prediction and prevention of pressure ulcers utilizing a systemic approach and monitoring skin integrity by implementing preventative and supportive precautions appropriate for the resident's identified level of risk. Residents were considered high risk when admitted with any pressure ulcers. Pressure ulcers supportive preventative precautions would be implemented. 365084 Page 2 of 4 365084 03/18/2022 Pleasantview Care Center 7377 Ridge Rd Parma, OH 44129

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. Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #232 implemented safe smoking practices while residing in the facility. This affected one resident (Resident #232) of three residents reviewed for safe smoking practices. The facility census was 149. Findings include: Review of Resident #232's medical record revealed an admission date of 03/08/22 with diagnoses including sepsis, cutaneous abscess of right upper limb, and chronic obstructive pulmonary disease. Review of Resident #232's medical record and progress notes from 03/08/22 through 03/14/22 did not reveal documentation Resident #232 used tobacco and was educated on the smoking policy and risks of smoking. Review of Resident #232's admission Assessment and Baseline Care Plan dated 03/08/22 did not reveal documentation Resident #232 used tobacco and was educated on the smoking policy and risks of smoking. Observation on 03/14/22 at 11:40 A.M. revealed Resident #232 walked out of his room with his surgical mask on. Resident #232 walked outside to the smoking area, pulled a lighter and cigarettes out of his pocket and began to smoke a cigarette. There were no facility staff present while Resident #232 smoked his cigarette. Interview on 03/14/22 at 11:52 A.M. with Resident #232 stated he walked outside and smoked whenever he wanted to. Resident #232 stated he kept his cigarettes and lighter in his pocket, and as he was talking, he pulled the cigarettes and lighter out of his right pocket to show the surveyor. Resident #232 stated facility staff was not always outside with him when he was smoking. Interview on 03/14/22 at 12:32 P.M. of Licensed Practical Nurse (LPN) #771 confirmed she was not aware Resident #232 smoked and verified he had his cigarettes and lighter in his pocket. Interview on 03/15/22 at 3:55 P.M. with Assistant Director of Nursing/Registered Nurse (ADON/RN) #790 revealed she did not know Resident #232 was a smoker and explained the smoking policy to him and made sure he was aware of supervised smoking times. ADON/RN #790 stated she did not know why smoking was not documented on Resident #232's admission assessment and told Resident #232 to make sure the nurse had his cigarettes and lighter. ADON/RN #790 stated residents needed supervised during smoke breaks. Review of the facility list of residents that smoke on 03/14/22 did not include Resident #232. Review of the undated facility policy titled Smoking Rules and Responsibilities included no residents were permitted to keep cigarettes, cigars, lighters or any other smoking materials on their person. All residents must be supervised by staff during designated smoking times only. All residents who choose to smoke are evaluated by the facility upon admission, quarterly, and as needed to determine if the resident needs any assistive devices to ensure their safety. 365084 Page 3 of 4 365084 03/18/2022 Pleasantview Care Center 7377 Ridge Rd Parma, OH 44129

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, and facility policy review the facility failed to ensure food was stored and prepared appropriately to prevent potential foodborne illness. This had the potential to affect 139 residents who received meals in the facility. The facility identified 10 residents (Residents #14, #30, #56, #69, #87, #95, #122, #241, #378 and #429) as receiving no food by mouth. The facility census was 149. Findings include: Observation on 03/14/22 at 8:03 A.M. while completing the initial kitchen tour with Dietary [NAME] #661 revealed two tray carts with debris in the bottom of the carts, a straw on the floor of one cart, a food lid and debris in the bottom of a second cart, and two kitchen mixers had encrusted food materials behind the mixing bowls of the industrial mixer. While in the walk-in freezer ice buildup was observed on food items underneath the condenser, and two moldy oranges were found in the bin of oranges in the walk-in refrigerator. At the time of the observation, Dietary [NAME] #661 confirmed the findings. Observation on 03/15/22 at 9:10 A.M. of pureed food preparation with Dietary [NAME] #661 revealed she removed the robot coupe bowl and washed it in the sink with soapy water and replaced it on the robot coupe to complete second item. Dietary #661 confirmed she did not run the bowl through the dish machine for sanitation. Review of the facility policy titled, Cleaning Instructions: Food Preparation Appliances, dated 2017, revealed small appliances will be cleaned and sanitized after each use. Review of the facility policy titled, Cleaning and Sanitation of Dining and Food Service Areas, dated 2017, revealed the nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive schedule. Review of the facility policy titled, Cleaning Instructions: Food Carts, dated 2017, revealed food carts will be cleaned and sanitized immediately after each use. 365084 Page 4 of 4