Health inspection·September 11, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on medical record review, observation, and staff interview, the facility failed to ensure residents were assisted with eating in a dignified manner. This affected two (Residents #77 and #78) out of eight residents observed in public dining areas. The facility census was 87. Findings include: 1. Review of the medical record for Resident #77 revealed an admission date of 12/06/21. Diagnoses included but were not limited to unspecified Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 06/20/23, revealed Resident #77 had severely impaired cognition. Resident #77 required one-staff total assistance with eating. 2. Review of the medical record for Resident #78 revealed an admission date of 01/25/19. Diagnoses included but were not limited to unspecified sequelae of cerebral infarction. Review of the most recent MDS 3.0 assessment, dated 07/08/23, revealed Resident #78 had severely impaired cognition. Resident #78 was a one-person physical assist and required supervision assistance with eating. Observation on 09/07/23 at 8:11 A.M. revealed State Tested Nurse Aides (STNA's) #13 and #74 standing while assisting with feeding Resident #77 and Resident #78 who were seated in geri-chairs in the lounge area between the Oak and [NAME] units. During concurrent interviews on 09/07/23 at 8:11 A.M. STNA #13 and STNA #74 each verified they were feeding residents while standing and stated they always fed Residents #77 and #78 in the dining area while standing. Page 1 of 5 365088 365088 09/11/2023 Englewood Health and Rehab 425 Lauricella Court Englewood, OH 45322

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, record review, and policy review, the facility failed to ensure medications were administered as ordered. There were three medication errors out of 34 opportunities, resulting in a medication error rate of 8.82%. This affected three (Residents #24, #77, and #78) of four residents observed for medication administration. The facility census was 87. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 09/04/21. Diagnoses included but were not limited to unspecified cerebral infarction, unspecified vascular dementia, chronic obstructive pulmonary disease, and type two diabetes. Review of the medical record revealed Resident #24 had a physician order dated 01/12/23 for Vitamin B12 2000 units by mouth once daily. Observation and interview on 09/07/23 from 9:43 A.M. to 10:01 A.M. revealed Licensed Practical Nurse (LPN) #39 did not have enough Vitamin B12 500 microgram (mcg) tablets available to administer 2000 mcg as ordered and was unable to locate an additional supply of the medication after searching the facility. LPN #39 verified she was unable to administer Vitamin B12 to Resident #24 as ordered because the medication was unavailable. 2. Review of the medical record for Resident #77 revealed an admission date of 12/06/21. Resident #77's diagnoses included but were not limited to unspecified Alzheimer's disease. Review of Resident #77's medical record revealed Resident #77 had a physician order dated 12/06/21 for Cosopt 22.3-6.8 mg per milliliter (ml) instill one drop to both eyes every morning and at night for glaucoma. Observation and interview on 09/07/23 at 8:59 A.M. revealed LPN #58 was unable to administer Cosopt eye drops to Resident #77 as ordered since the medication was not available in the medication cart or the emergency drug supply. LPN #58 verified the Cosopt eye drops were unavailable, and when she checked the pharmacy records, the last bottle had been reordered on 04/22/23. 3. Review of the medical record for Resident #78 revealed an admission date of 01/25/19. Resident #78's diagnoses included but were not limited to unspecified sequelae of cerebral infarction. Review of the medical record revealed Resident #78 had a physician order for 06/20/22 for senna 8.6 mg, give two tablets by mouth once daily. Observation on 09/07/23 from 8:28 A.M. to 8:51 A.M. revealed LPN #58 prepared medications to administer to Resident #78 which included one tablet of Aspirin 81 mg, one tablet of Seroquel 100 mg, two tablets of Tylenol 325 mg, and two tablets of Senna S (senna 8.6 mg and Docusate sodium 50 mg). LPN #58 stated she was ready to give the medications to Resident #78 when the state surveyor asked LPN #58 to verify the medications prepared with the medications ordered for Resident #78. Interview on 09/07/23 at 8:51 A.M. with LPN #78 verified she had prepared and was about to administer two Senna S tablets to Resident #78 instead of two Senna tablets as ordered. The LPN stated she did not realize they were two different medications because the bottles looked so similar. 365088 Page 2 of 5 365088 09/11/2023 Englewood Health and Rehab 425 Lauricella Court Englewood, OH 45322

F 0759 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Medication Administration, dated 10/01/22, revealed medications were administered to patients according to doctor's orders, professional standards, and in a manner that prevented contamination or infection. This deficiency represents non-compliance investigated under Complaint Number OH00144915. Residents Affected - Few 365088 Page 3 of 5 365088 09/11/2023 Englewood Health and Rehab 425 Lauricella Court Englewood, OH 45322

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and policy review, the facility failed to ensure medications were stored appropriately. This had the potential to affect one (Resident #51) out of one resident who received Nitroglycerin from the Magnolia medication cart. The facility census was 87. Findings include: Observation on 09/07/23 at 9:56 A.M. revealed the Magnolia medication cart had a souffle cup labeled Nitroglycerin which contained three white oblong tablets in the top drawer. Interview on 09/07/23 at 9:57 A.M. with Licensed Practical Nurse (LPN) #39 verified the Nitroglycerin tablets (vasodilator medication) were stored improperly. LPN #39 stated Nitroglycerin tablets should be stored in a dark bottle which protected the medication from light. Review of the policy titled Medication Storage, dated 09/29/22, revealed all drugs which required light protection while in storage will remain in the original package, in a closed drawer or cabinet, or in a specially wrapped manner until the time of administration, according to manufacturer's recommendations. 365088 Page 4 of 5 365088 09/11/2023 Englewood Health and Rehab 425 Lauricella Court Englewood, OH 45322

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 Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure residents were provided assistive devices as ordered. This affected one (Resident #46) out of one resident identified as using assistive devices during meals. The facility census was 87. Residents Affected - Few Findings include: Review of the medical record for Resident #46 revealed an admission date of 12/16/20. Resident #46's diagnoses included but were not limited to unspecified seizures, unspecified dementia, and frontal lobe/executive function deficit following cerebral vascular accident. Review of Resident #46's care plan, dated 06/14/23, revealed Resident #46 was at risk for malnutrition and dehydration due to use of a mechanically altered diet, advanced age, and potential for decline related to dementia. Interventions included built up spoons, a divided plate, and a handled cup. Review of the medical record revealed Resident #46 had physician orders, dated 08/31/23, for a regular diet, dysphagia/mechanical soft texture, regular liquids, and fortified foods with a divided plate, handled cups, and built-up silverware. Observation on 09/07/23 at 8:17 A.M. revealed Resident #46 was sitting in the dining room near the Magnolia nursing station feeding himself. Resident #46's breakfast tray contained a divided plate, specialty cup with handles filled with coffee, a cup with no handles filled with cranberry juice, and regular silverware. The meal ticket on Resident #46's tray indicated Resident #46 was supposed to have a black-handled bendable spoon, two handle cup, and a divided plate. Interview on 09/07/23 at 8:18 A.M. with Resident #46 revealed he usually had silverware with black handles which included a larger spoon, like a soup spoon. Interview on 09/07/23 at 8:22 A.M. with the Director of Nursing (DON) verified Resident #46 was not provided adaptive silverware on his breakfast tray. Review of the policy titled Nutritional Management, dated 09/29/22, revealed the facility provided care and services to ensure each resident maintained acceptable parameters of nutritional status. Residents' goals and preferences were reflected in the care plan including interventions used to address specific needs such as altered consistency, physical assistance, and assistive devices. This deficiency represents non-compliance investigated under Complaint Number OH00145945. 365088 Page 5 of 5