Health inspection·April 19, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with staff the facility failed to ensure soiled linens were not placed directly on the floor in the room of Resident #25 and #50. This affected two residents ( Resident #25 and #50) of three reviewed for a safe, clean environment. The facility census was 69. Findings included: Review of the medical record revealed Resident #25 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, cirrhosis of the liver, ascites, hypertension, mitral valve insufficiency, cardiomegaly, inguinal hernia, acute kidney disease, moderate protein-calorie malnutrition, anxiety disorder, pneumonia, respiratory failure, and muscle weakness. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, muscle weakness, edema, atrial fibrillation, hypertension, aortic valve stenosis, anemia, severe protein-calorie malnutrition, seizures, benign prostatic hyperplasia, ischemic optic neuropathy. Intervertebral disc displacement, pacemaker, skin cancer, cellulitis of the left lower leg, metabolic encephalopathy. Observation on 04/19/24 at 7:40 A.M. revealed there was soiled linen laying directly on the carpeted floor in the doorway of the room for Resident # 25 and #50. An interview with Agency Registered Nurse #102 at this time verified there was soiled linen directly on the floor of Resident #25 and #50. She stated they were there from the Night shift. She stated her shift started at 6:30 A.M. On 04/19/24 at 7:55 A.M. an interview with State Tested Nursing Assistant # 104 revealed the linen on the floor in the room of Resident #25 and #50 were from the midnight shift. She stated she started her shift at 6:30 A.M. On 04/19/24 at 1:10 P.M. an interview with the Director of Nursing verified linen should not be placed directly on the resident's floor. Review of the undated facility policy titled, Laundry and Bedding, Soiled, revealed it was the facility policy that soiled laundry and bedding would be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. This deficiency represents non-compliance investigated under Complaint Number OH00153037. Page 1 of 7 365287 365287 04/19/2024 Altercare of Cuyahoga Falls Ctr for Rehab & Nursin 2728 Bailey Rd Cuyahoga Falls, OH 44221

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, review of the facility policy and interview with the staff the facility failed to ensure aerosol masks were stored in a sanitary protective barrier while not in use for Resident #25 and #50. This affected two residents ( Resident #25 and #50) of three reviewed for respiratory care. The facility census was 69. Residents Affected - Few Findings included: 1. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, cirrhosis of the liver, ascites, hypertension, mitral valve insufficiency, cardiomegaly, inguinal hernia, acute kidney disease, moderate protein-calorie malnutrition, anxiety disorder, pneumonia, respiratory failure, and muscle weakness. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #25 had intact cognition. Review of the April 2024 physician's orders revealed Resident #25 had an order for ipratropium 0.5 milligrams and albuterol solution for nebulization 3.0 mg. every four hours as needed dated 03/31/24. Observations on 04/19/24 at 7:40 A.M. and 12:00 P.M. revealed the aerosol mask for Resident #25 was laying directly on his bedside stand and not in a protective barrier. The aerosol mask also did not have a date as to when it was last changed. On 04/19/24 at 12:10 P.M. an interview with Agency Registered Nurse (RN) #102 confirmed the aerosol mask should be placed in a protective barrier when not in use and should be dated as to when last changed. She stated she would go get a bag for his aerosol mask because there was not one in the room. She also stated the facility had a company come out and switched the aerosol masks out but she was not sure how often. Review of the undated facility policy titled, Nebulizer-(Aerosol) Handheld Treatment, revealed it was the facility's policy to administer aerosolized particles of medication safely and aseptically into the resident airway. Store the nebulizer set up in a plastic bag between treatments, each should be changed weekly and marked with the resident's name and date. 2. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, muscle weakness, edema, atrial fibrillation, hypertension, aortic valve stenosis, anemia, severe protein-calorie malnutrition, seizures, benign prostatic hyperplasia, ischemic optic neuropathy. Intervertebral disc displacement, pacemaker, skin cancer, cellulitis of the left lower leg, metabolic encephalopathy. Review of the admission Minimum Data set assessment dated [DATE] revealed Resident #50 had severely impaired cognition. Review of the April 2024 physician's orders revealed Resident #50 had an order for ipratropium 0.5 milligrams (mg) and albuterol solution for nebulization 3.0 mg. every eight hours as needed dated 03/16/24. 365287 Page 2 of 7 365287 04/19/2024 Altercare of Cuyahoga Falls Ctr for Rehab & Nursin 2728 Bailey Rd Cuyahoga Falls, OH 44221

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations on 04/19/24 at 7:40 A.M. and 12:00 P.M. revealed the aerosol mask for Resident #50 was laying directly on his bedside stand and not in a protective barrier. The aerosol mask also did not have a date as to when it was last changed. On 04/19/24 at 12:10 P.M. an interview with Agency Registered Nurse #102 confirmed the aerosol mask should be placed in a protective barrier when not in use and should be dated as to when last changed. She stated she would go get a bag for his aerosol mask because there was not one in the room. She also stated the facility had a company come out and switched the aerosol masks out but she was not sure how often. Review of the undated facility policy titled, Nebulizer-(Aerosol) Handheld Treatment, revealed it was the facility's policy to administer aerosolized particles of medication safely and aseptically into the resident airway. Store the nebulizer set up in a plastic bag between treatments, each should be changed weekly and marked with the resident's name and date. This deficiency represents noncompliance as an incidental finding during the investigation of Master Complaint Number OH00153037 and Complaint Number OH00152758. 365287 Page 3 of 7 365287 04/19/2024 Altercare of Cuyahoga Falls Ctr for Rehab & Nursin 2728 Bailey Rd Cuyahoga Falls, OH 44221

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record and interview with staff the facility failed to maintain a medication error rate of less than five percent. Ten errors occurred within 31 opportunities for error resulting in a medication error rate of 32.2 %. This affected one resident (Resident #5) of four reviewed for medication administration. The facility census was 69. Residents Affected - Few Fining included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included convulsions, encephalopathy, clostridium difficile, temporo-parietal lesion, cognitive communication deficit, dysphagia, cerebral infarction, anemia, hypertension, embolism and thrombosis of the deep veins of the right upper extremity, asthma, aphasia, dysphagia, osteoarthritis, gastrostomy, alcohol abuse and intracerebral hemorrhage. Review of the admission Minimum Data set assessment dated [DATE] revealed Resident #5 had severely impaired cognition and she had a feeding tube. Review of the April physician's orders revealed Resident #5 had order for amlodipine 5 milligrams (mg) one tablet per gastric tube once daily, ascorbic acid (vitamin C) 500 mg two tablets per gastric tube once daily, budesonide-formoterol aerosol inhaler 80-4.5 mcg two puffs once daily, multi-vitamin one tablet per gastric tube once daily, apixaban 5 mg one tablet per gastric tube twice daily, fluticasone propionate nasal spray 50 micrograms (mcg) one spray in each nostril daily once daily, fludrocortisone 0.1 mg one tablet via gastric tube once daily, folic acid 1.0 mg one tablet via gastric tube once daily, hydrocortisone 10 mg one and half tablets via gastric tube once daily, and thiamine 100 mg one tablet via gastric tube once daily. An order dated 04/16/24 revealed Resident #5 could eat a mechanical soft diet with thin liquids. Review of the progress note dated 04/03/4 at 4:47 A.M. revealed Resident #5 received her medication via peg tube. Observation of medication administration on 04/19/24 at 8:17 A.M. revealed Agency Registered Nurse (RN) #100 crushed amlodipine 5 mg one tablet, ascorbic acid (vitamin C) 500 mg two tablets, multi-vitamin one tablet, apixaban 5 mg one tablet , fludrocortisone 0.1 mg one tablet, folic acid 1.0 mg one tablet, hydrocortisone 10 mg one and half tablets and thiamine 100 mg one tablet. She placed them in applesauce and administered the medication to Resident #5 orally when the order stated they were to be given via gastric tube. She also placed her budesonide-formoterol aerosol inhaler and fluticasone propionate nasal spray in her pocket and left Resident #5 room, signed the medications off in the computer and moved her medication cart down the hallway without administering them to Resident #5. On 04/19/24 at 8:25 A.M. an interview with Agency RN #100 revealed she was told in report Resident #5 could take her small pills crushed in applesauce and administered oral but her larger pills needed to be crushed and administered via gastric tube. She verified she gave her medication orally when the physicain's orders stated there to be given via gastric tube. She also verified at this time she had not administered the fluticasone propionate nasal spray and budesonide-formoterol aerosol inhaler to Resident #5 and they were still in her pocket. 365287 Page 4 of 7 365287 04/19/2024 Altercare of Cuyahoga Falls Ctr for Rehab & Nursin 2728 Bailey Rd Cuyahoga Falls, OH 44221

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/19/24 at 1:10 P.M. an interview with the Director of Nursing verified Resident #5 did not have an order for her medication to be given orally however she stated she did have a mechanically soft diet so she could take the medications crushed in applesauce orally with no concerns. Review of the facility policy titled, Medication Administration-General Guidelines, dated 05/20 revealed medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The five rights; right resident, right drug, right dose, right route, and right time, were applied for each medication being administered. A triple check of these five rights was recommended at three steps in the process of preparation of a medication for administration: (1) when the medication was selected, (2) when the dose was removed from the container, and finally (3) just after the dose was prepared and the medication was put away. This deficiency represents non-compliance investigated under Complaint Number OH00152758. 365287 Page 5 of 7 365287 04/19/2024 Altercare of Cuyahoga Falls Ctr for Rehab & Nursin 2728 Bailey Rd Cuyahoga Falls, OH 44221

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 observations, review of the medical record, review of the facility policy and interview with staff the facility failed to administer medication as ordered for Resident #5. This affected one resident (Resident #5) of four residents observed for medication administration. The facility census was 69. Residents Affected - Few Findings included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included convulsions, encephalopathy, clostridium difficile, temporo-parietal lesion, cognitive communication deficit, dysphagia, cerebral infarction, anemia, hypertension, embolism and thrombosis of the deep veins of the right upper extremity, asthma, aphasia, dysphagia, osteoarthritis, gastrostomy, alcohol abuse and intracerebral hemorrhage. Review of the admission Minimum Data set assessment dated [DATE] revealed Resident #5 had severely impaired cognition and she had a feeding tube. Review of the April physician's orders revealed Resident #5 had order for amlodipine 5 milligrams (mg) one tablet per gastric tube once daily, ascorbic acid (vitamin C) 500 mg two tablets per gastric tube once daily, budesonide-formoterol aerosol inhaler 80-4.5 mcg two puffs once daily, multi-vitamin one tablet per gastric tube once daily, apixaban 5 mg one tablet per gastric tube twice daily, fluticasone propionate nasal spray 50 micrograms (mcg) one spray in each nostril daily once daily, fludrocortisone 0.1 mg one tablet via gastric tube once daily, folic acid 1.0 mg one tablet via gastric tube once daily, hydrocortisone 10 mg one and half tablets via gastric tube once daily, and thiamine 100 mg one tablet via gastric tube once daily. Further review of the physician orders for April 2024 revealed an order dated 04/16/24 for a mechanical soft diet with thin liquids. Review of the progress note dated 04/03/24 at 4:47 A.M. revealed Resident #5 received her medication via peg tube. Observation of medication administration on 04/19/24 at 8:17 A.M. revealed Agency Registered Nurse (RN) #100 crushed amlodipine 5 mg one tablet, ascorbic acid (vitamin C) 500 mg two tablets, multi-vitamin one tablet, apixaban 5 mg one tablet , fludrocortisone 0.1 mg one tablet, folic acid 1.0 mg one tablet, hydrocortisone 10 mg one and half tablets and thiamine 100 mg one tablet. She placed them in applesauce and administered the medication to Resident #5 orally when the order stated they were to be given via gastric tube. She also placed her budesonide-formoterol aerosol inhaler and fluticasone propionate nasal spray in her pocket and left Resident #5 room, signed the medications off in the computer and moved her medication cart down the hallway without administering them to Resident #5. Resident #5 demonstrated no difficulty swallowing the mixture of medications in applesauce during the observation. On 04/19/24 at 8:25 A.M. an interview with Agency RN #100 revealed she was told in report Resident #5 could take her small pills crushed in applesauce and administered oral but her larger pills needed to be crushed and administered via gastric tube. She verified she gave her medication orally when the physician's orders stated they had to be given via gastric tube. She also verified at this time she had not administered the fluticasone propionate nasal spray and budesonide-formoterol aerosol 365287 Page 6 of 7 365287 04/19/2024 Altercare of Cuyahoga Falls Ctr for Rehab & Nursin 2728 Bailey Rd Cuyahoga Falls, OH 44221

F 0760 inhaler to Resident #5 and they were still in her pocket. Level of Harm - Minimal harm or potential for actual harm On 04/19/24 at 1:10 P.M. an interview with the Director of Nursing verified Resident #5 did not have an order for her medication to be given orally however she stated she did have a mechanical soft diet so she could take the medications orally crushed in applesauce with no concerns. Residents Affected - Few Review of the facility policy titled, Medication Administration-General Guidelines, dated 05/20 revealed medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The five rights; right resident, right drug, right dose, right route, and right time, were applied for each medication being administered. A triple check of these five rights was recommended at three steps in the process of preparation of a medication for administration: (1) when the medication was selected, (2) when the dose was removed from the container, and finally (3) just after the dose was prepared and the medication was put away. This deficiency represents non-compliance investigated under Complaint Number OH00152758. 365287 Page 7 of 7