Health inspection·June 1, 2023

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 record review, observation, and interview, the facility failed to ensure safety devices were implemented to prevent falls. This affected one (Resident #79) of three residents reviewed for falls. The census was 97. Findings Include: Review of medical record for Resident #79 revealed an admission date of 11/21/21. Diagnoses included Parkinson's disease, morbid obesity, anxiety disorder and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/06/22, revealed Resident #79 had intact cognition. Resident #79 required extensive assistance for bed mobility, transfers, locomotion, and toilet use. Review of the plan of care dated 12/15/21 revealed Resident #79 was at risk for falls due to psychoactive drug use, history of falling, impaired balance, weakness, and Parkinson's disease. Interventions included to ensure call light was in reach and apply a sensor pad to the bed and wheelchair dated 01/26/23. Review of fall assessments dated 02/01/23 and 05/16/23 revealed Resident #79 was at high risk for falls. Review of the incident log revealed Resident #79 had falls on 01/26/23, 04/14/23 and 05/29/23. Review of the progress note dated 01/26/23 timed 7:20 P.M. revealed Resident #79 was found lying on the floor in pain. Resident #79 stated he was going to the bathroom when he fell. Resident #79 was taken to the hospital for evaluation. A new fall intervention to help prevent further falls included a flat sensor alarm to bed and recliner. Review of the progress note dated 04/14/23 at 7:46 A.M. revealed Resident #79 was observed sitting on the floor, no injuries were noted. Staff educated Resident #79 on calling for assistance before getting up. Review of progress note dated 05/29/23 at 1:23 P.M. revealed Resident #79 was observed lying on the floor on his right side. Resident #79 was unable to verbalize what happened. Resident #79 sustained an abrasion to the right elbow. Interview on 05/31/23 at 3:22 P.M. with the wife of Resident #79 revealed Resident #79 had some Page 1 of 3 365115 365115 06/01/2023 Rae-Ann Westlake 28303 Detroit Rd Westlake, OH 44145

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few falls this year. The wife stated staff were to apply sensor pads to Resident #79's bed and wheelchair but they were lying on the floor and she didn't understand why. Observations on 05/31/23 at 4:07 P.M. revealed Resident #79 was sitting in his wheelchair. Further observation revealed the sensor pad alarm for the wheelchair was under Resident #79's bed frame at the top of the bed. The sensor pad alarm for the bed was on the floor at the opposite side of the bed unplugged. The Administrator observed and confirmed the findings. Review of facility policy titled Falls and Fall Risks, Managing, dated 2018 revealed staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factors for those at risk of falls or with a history of falls. Position-change alarms were not be used as the primary or sole intervention to prevent falls, but rather were to be used to assist the staff in identifying patterns and routines of the resident. This deficiency represents noncompliance investigated under Master Complaint Number OH00142865 and Complaint Number OH00142662. 365115 Page 2 of 3 365115 06/01/2023 Rae-Ann Westlake 28303 Detroit Rd Westlake, OH 44145

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to document treatments were completed in the treatment administration record (TAR). This affected two (Residents #41 and #65) of six residents reviewed. Findings include: 1. Review of medical record for Resident #41 revealed an admission date of 01/07/23. Diagnoses included acute and chronic respiratory failure, anxiety disorder and tracheostomy status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/04/23, revealed Resident #41 had intact cognition and required extensive assistance for bed mobility, transfers, and toilet use. Review of May 2023 TAR for Resident #41 revealed an order dated 01/26/23 for Interdry moisture wicking fabric to abdominal fold one time a day for wound care. There was no documentation the Interdry moisture wicking fabric was applied to the abdominal fold 16 of 31 days. Further review of the TAR revealed an order to apply house stock antifungal cream to bilateral breasts two times a day dated 02/15/23. There was no documentation the antifungal cream was applied 25 of 31 days. An order to cleanse right thigh with normal saline, pat dry, apply collagen powder, followed by silver alginate, and cover dated 04/26/23 was not documented as completed eight of 31 days. Interview on 06/01/23 at 12:45 P.M. with the Director of Nursing (DON) verified the missing documentation. The DON stated it was a challenge working and monitoring agency staff. 2. Review of medical record for Resident #65 revealed an admission date of 09/20/21. Diagnoses included multiple sclerosis, dysphagia, functional urinary incontinence, and other symbolic dysfunctions. Review of the quarterly MDS assessment, dated 04/10/23, revealed Resident #65 had intact cognition, was independent for eating, and required extensive assist for transfers, locomotion, and toilet use. Review of the [NAME] 2023 TAR for Resident #65 revealed an order dated 05/08/23 to 05/15/23 to cleanse coccyx with normal saline, pat dry, apply Triad cream and cover with foam dressing daily. The treatment was not documented as completed four of six days. The same order was re-written on 05/15/23 and was not documented as completed five of the remaining 16 days of the month. An order to apply house barrier cream to bilateral buttocks every shift dated 02/01/23 was not documented as completed 12 of 31 days. Interview on 06/01/23 at 12:45 P.M. with the DON verified the missing documentation. The DON stated it had been a challenge working and monitoring agency staff. This deficiency represents noncompliance investigated under Master Complaint Number OH00142865 and Complaint Number OH00142662. 365115 Page 3 of 3