Health inspection·December 14, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, record review and interview the facility failed to provide housekeeping services to ensure the resident environment, including bathrooms were maintained in a clean and sanitary manner. This affected 18 residents (#1, #9, #10, #15, #16, #17, #19, #27, #31, #33, #34, #38, #40, #42, #45, #46, #49, and #52) of 60 residents residing in the facility. Findings Included: Initial tour on 12/04/22 from 7:30 A.M. to 8:40 A.M. revealed concerns regarding the cleanliness and upkeep of the facility. Interviews were conducted with seven residents (Resident #10, Resident #17, Resident #19, Resident #31, Resident #40, Resident #46, and Resident #49) from 8:30 A.M. to 6:00 P.M. on 12/04/22, 12/05/22 and 12/06/22. All seven residents voiced concerns about the cleanliness of the environment. The interviews revealed that housekeeping rarely come into rooms and clean. The room cleaning schedule was not clear to the residents. They indicated there was no consistent housekeeping staff. Interview with the Administrator and Regional Corporate Nurse #181 on 12/05/22 from 11:30 A.M. to 12:10 P.M. revealed they presently have an interim director of housekeeping since the last director was let go. They were unsure the last day the previous director worked. Both staff members were unable to state how long the original director was gone for. They verified the interim director was also over laundry services. Interview on 12/05/22 at 1:30 P.M. with interim laundry director #140 revealed he had been filling in cleaning rooms on the floors for the past month. He verified that he was the only housekeeping employee currently and was trying to keep up and make sure that rooms were cleaned at least once a week. Continued interview with interim laundry director #140 revealed the original laundry director has been gone for about two to three months. He stated when he took over there were a few staff members for laundry and housekeeping but now it is just him. He stated he rotates through and tries to get all the rooms cleaned at least once a week but was not always able to get that done. He stated the nurses and State Tested Nurse Aides (STNA) were responsible for cleaning the COVID rooms and frequently touched areas in the facility. He verified there was no documentation it was completed. He indicated there was a stocked cart located on the unit for use by the nursing staff to clean common areas. The cart was not observed at the time and the interim laundry director #140 indicated it most be back downstairs to be restocked. Page 1 of 13 365310 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0584 A second tour of the facility occurred on 12/05/22 at 1:55 P.M. further revealed: Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]'s bathroom was observed with dirt and black marks on the corners of the floor. The seal around the toilet was brown and the tile by the seal was also stained brown. Residents Affected - Some Bathrooms in rooms [ROOM NUMBER] were observed with dirt and debris on the bathroom floors and the floors were stained brownish tan in places. Stains were observed intermittently on the base board. The bathroom floor in room [ROOM NUMBER] was stained with brownish stains around the toilet. The corners of the baseboards were observed to have dirt and debris. room [ROOM NUMBER]'s bathroom had stains on the inside of the toilet and dirt and debris on the bathroom floor. room [ROOM NUMBER]'s bathroom floor was observed stained brown around the toilet seal and on the tile. A broom and unemptied dustpan, containing old food particles, paper, dirt, and dust, was observed in the corner of room [ROOM NUMBER]. The bathroom floor was observed with dirty stained baseboards and the tile floor in the bathroom had brownish stains. The above findings were verified by the Interim Housekeeping Director #140 and the Maintenance Director #110 at the time of the tour. Review of Resident Council Meeting Minutes from the past year revealed residents in attendance at the meetings had voiced concerns about staff and per resident council meeting minutes residents were asked to help clean their rooms and to take out their trash due to being short in housekeeping. A resident council meeting was held with the residents during the survey. The residents present also voiced concerns related to housekeeping services. This deficiency represents non-compliance investigated under Complaint Number OH00137923. 365310 Page 2 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to ensure discharge planning was completed for one resident (Resident #25) out of two residents (#25 and #61) reviewed for discharge planning. The facility census was 60. Residents Affected - Few Findings include: Review of Resident #25's medical record revealed and admission date of 07/29/21 with diagnoses to include but not limited to diabetes mellitus, schizophrenia, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and required supervision. Review of the care of plan for Resident #25 revealed he was at the facility long term care (LTC). Review of social service note dated 07/31/21 at 10:28 A.M. revealed Resident #25 chose a full code status and discharge plans were to utilize the Home Choice Program for possible assisted living. Review of social service note dated 06/09/22 at 8:34 A.M. revealed social worker and resident had court hearing with Probate Court where resident had been assigned a Guardian to assist with financial and discharge planning. Review of the social service note dated 06/29/22 at 12:38 P.M. revealed Resident #25 chose a full code status and discharge plans are to utilize the Home Choice Program for possible assisted living. Interview on 12/04/22 at 11:06 A.M. with Resident #25 revealed that he wanted to leave the facility. He indicated has a guardian, and wants to go to another facility because he was evicted from his apartment. Interview on 12/06/22 at 5:14 PM with MDS Nurse #163 revealed that when the social worker left at the end of August, everyone had to chip in and do the work. MDS Nurse was told by the business office manager that Resident # 25 was approved for Medicaid, and she assumed that because he is Medicaid, he was LTC. Further review of Resident #25's electronic or hard chart revealed no evidence of that changes in activities of daily living or functionality that would warrant LTC in a skilled nursing facility or discharge planning continued since former social worker resigned. Review of the facility policy dated 12/06 titled, Discharge Summary and Plan revealed residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies, support services that can assist in accommodating the resident's post-discharge preferences and if it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. 365310 Page 3 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on closed record review, facility policy and procedure review and interview, the facility failed to ensure a comprehensive discharge summary was completed for Resident #61 as required. This affected one resident (#61) of two residents (Residents #25 and #61) reviewed for discharge planning. The facility census was 60. Findings include: Review of Resident #61's closed medical record revealed and admission date of 08/24/22 and a discharge date of 11/08/22 with diagnoses to include but not limited to displaced bicondylar fracture of right tibia, major depressive disorder, and personal history of traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/12/22 revealed the resident was moderately cognitively impaired and required supervision. Review of the plan of care dated 08/25/22 for Resident #61 revealed Resident #61 had discharge plans to go home with friends. Interventions included but not limited to all discharge planning to be documented, investigate need for special durable medical equipment (DME), home health care (HHC), lifeline, MD f/u, outpatient therapy, resources, etc and make referrals as needed. Review of the progress note dated 11/08/22 at 11:50 A.M. revealed that Resident #61 left the shift with discharge orders to go home. Resident was COVID-19 tested upon exit with negative results. Resident took all medications with her belongings. Staff went over medication list with resident and resident understood. Interview on 12/06/22 at 3:00 P.M. with Administrator revealed the former social worker resigned and the task have been getting divided up. Administrator verified that Resident #61 had no discharge summary, and that Resident #61 was a regular discharge. Review of the facility policy dated 12/06 titled, Discharge Summary and Plan revealed when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. 365310 Page 4 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to ensure weekly weights were done per physician's orders. This affected two residents (Resident #17, and Resident #40) of five residents reviewed for nutrition. The facility census was 60. Residents Affected - Few Findings include: 1. Review of Resident #17's medical record revealed an admission date of 04/21/11 and diagnoses including type two diabetes, protein calorie malnutrition, adult failure to thrive, other schizophrenia, depression, anorexia and abnormal weight loss. Review of Resident #17's annual minimum data set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact and required supervision with set up help for eating. Resident #17 had a weight loss that was not on a prescribed weight-loss regimen coded on the assessment. Review of current physician's orders revealed an order dated 10/08/21 and revised 09/07/22 for regular diet, double portions at meals, hot dogs or hamburgers at lunch and dinner; and an order written by Registered Nurse (RN) #501 dated 09/07/22 for weekly weights one time a day every seven days for weight surveillance. Review of Resident #17's Medication Administration Records (MARs) and Treatment Administration Records (TARs) for September 2022, October 2022, November 2022 and December 2022 lacked evidence the weekly weights were completed as ordered. Review of Resident #17's weights in the electronic medical record revealed the following weights were recorded: 08/10/22, 142.0 pounds; 09/01/22, 137.6 pounds; 10/06/22, 137 pounds; 11/15/22, 136.4 pounds; 12/06/22, 138.6 pounds. No weekly weights were noted. Review of Resident #17's nutritional assessment dated [DATE] and written by Registered Dietitian (RD) #180 revealed the resident weighed 137.6 pounds with a goal weight of 166 pounds. Resident #17 had a significant weight loss over 180 days due to COVID-19. Review of Resident #17's nurse's notes from September 2022 through December 2022 revealed no refusals of weights and no weekly weights recorded. Review of a weight warning note dated 09/07/22 and written by RD #180 revealed she recommended double portions with meals and weekly weights for Resident #17. Review of a care plan revised 08/08/22 revealed Resident #17 had potential for alteration in nutrition and hydration related to poor appetite and had history of weight loss and refusal of supplements. Interventions were listed and included obtain weights as ordered. Interview on 12/04/22 at 9:47 A.M. with Resident #17 revealed he thought he had some weight loss and indicated he fed himself. Phone interview on 12/06/22 at 2:08 P.M. with RD #180 revealed residents' weights could be recorded on the MAR or the TAR if they were not listed under the weights and vitals tab of the electronic 365310 Page 5 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical record. RD #180 indicated she recommended weekly weights for Resident #17 which were ordered 09/08/22 and also shared that weights were not always done. RD #180 was made aware Resident #17's weekly weights were not done per physician's orders during the interview. Interview on 12/06/22 at 3:10 P.M. with RN #501 and Chief Nursing Officer (CNO) #181 verified no weekly weights were completed for Resident #17 as ordered. RN #501 stated a physician's order would be written and then would carry over to the MAR. RN #501 explained the electronic medical record system had an update and this affected where an entered order would transfer over to. RN #501 verified Resident #17's order for weekly weights never carried over to the MAR so the weights were not obtained as ordered. 2. Review of Resident #40's medical record revealed an admission date of 07/09/20 and diagnoses including multiple sclerosis, mild protein calorie malnutrition, type two diabetes, asthma, depression, opioid dependence and obsessive-compulsive disorder. Review of Resident #40's quarterly MDS assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired, required the physical assistance of one staff with eating and had significant weight loss that was not from a prescribed weight loss regimen. Review of Resident #40's discontinued physician's orders revealed an order dated 08/19/22 for weekly weights every day shift each Wednesday for weight surveillance. The order was discontinued on 10/10/22. Review of Resident #40's MARs and TARs for August 2022, September 2022 and October 2022 lacked evidence that weekly weights were completed as ordered. Review of Resident #40's weights in the electronic medical records revealed the following weights were recorded: 08/18/22, 223 pounds; 10/16/22, 270 pounds (re-weighed); 10/19/22, 195 pounds; 12/06/22, 193 pounds. Review of a dietary note dated 08/18/22 and written by RD #180 revealed staff were concerned about Resident #40's declining by mouth intake. Most recent weight was 229 pounds and remained stable over 180 days. Resident intakes were generally good but were poor yesterday. Remains on a regular diet with ensure plus daily. Will suggest weekly weights. Review of additional nurses' notes from August 2022 through October 2022 revealed no refusals of weights and no weekly weights recorded. Review of a care plan revised 06/29/22 revealed Resident #40 had potential for alteration in nutrition and hydration related to morbid obesity, mild malnutrition, diabetes and anemia. Weight loss noted while in hospital. Interventions were listed and included obtain weights as ordered. Interview on 12/04/22 at 9:19 A.M. with Resident #40 revealed he lost 50 to 60 pounds in the last 12 months. Interview on 12/07/22 at 11:15 A.M. with RD #180 revealed she came to the facility once a week. RD #180 sent a list of her dietary recommendations to the DON, RN #501, the Administrator, the dietary manager and corporate staff. RD #180 would check to see the orders were written but did not check further to see the weights were actually being done. RD #180 stated she was made aware on 12/06/22 365310 Page 6 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that the orders for weekly weights did not go on the MAR and verified the weekly weights were not obtained for Resident #40 as ordered. RD #180 also stated Resident #40 refused weights and was made aware during the interview Resident #40's nurse's notes and care plan did not reflect this. Review of the facility policy, Weights Monitoring, dated 2022 revealed a weight monitoring schedule will be developed upon admission for all residents. Weights should be recorded at the time obtained. Residents with weight loss should be monitored weekly. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. 365310 Page 7 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on record review and interview, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This had the potential to affect all 60 residents. The facility census was 60. Findings include: Review of personnel record for State Tested Nurse Aide (STNA) #114 revealed a hire date of 11/08/22; there was no documentation of demonstrated competencies. Review of personnel record for STNA #136 revealed a hire date of 05/25/22; there was no documentation of demonstrated competencies. Review of personnel record for STNA #165 revealed a hire date of 06/22/22 with no documentation of of demonstrated competencies. Interview on 12/06/22 at 10:02 A.M. with Human Resource Director (HR) #125 revealed that there were no documented competencies for newly hired STNAs. HR #125 stated that the Staffing Coordinator schedules the STNAs three days on the floor but verified there was no checklist or sign off. Interview on 12/07/22 at 9:28 A.M. with Staffing Coordinator #108 verified there was no documentation of of demonstrated competencies. 365310 Page 8 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and staff interview the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 60 residents residing in the facility. Findings include: Review of the posted nursing staff information and staff schedule revealed on Saturday 11/26/22 and Sunday 11/27/22 there was no RN present working in the facility on either of those dates. Interview on 12/07/22 at 9:28 A.M. with Staffing Coordinator #108 verified there was no RN coverage on 11/26/22 and 11/27/22. 365310 Page 9 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure that nurse aides were evaluated annually. This had the potential to affect all 60 residents who resided in the facility. The facility census was 60. Residents Affected - Many Findings include: Review of personnel record for State Tested Nurse Aide (STNA) #119 revealed a hire date of 04/06/21 with no documentation of a completed annual evaluation. Review of personnel record for STNA #138 revealed a hire date of 02/16/87 with no documentation of a completed annual evaluation. Review of personnel record for STNA #175 revealed a hire date of 03/22/20 with no documentation of a completed annual evaluation. Interview on 12/06/22 at 10:02 A.M. with Human Resource Director (HR) #125 revealed that there were no documented annual evaluations. 365310 Page 10 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

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 and interview, the facility failed to insure medications were properly stored. This affected three residents (#12, #21 and #49) of three residents review for medications not properly stored. The facility census was 60. Findings Included: An initial tour of this facility on 12/04/22 from 8:30 A.M. to 9:15 A.M. revealed loose pills were observed on the floor in two different rooms, the room for Resident #12 and Resident #21 and the room for Resident #49. Upon entrance into Resident #12 and Resident #21 room at 8:40 A.M. a small round white pill was observed laying on the floor close to the entrance of the bathroom. Interview with Licensed Practical Nurse (LPN) #177 on 12/04/22 verified the pill was in the room on the floor which she stated 'looked like Remeron. LPN #177 returned back to the room after looking up the pill and stated it was Remeron. Neither Resident #12 or Resident #21 were on Remeron. At 9:10 A.M. observation of Resident 49's room revealed two pills on the floor next to the baseboard by the door. Interview with LPN #144 at 9:15 A.M. verified two pills were found on the floor in Resident #49's room. LPN #144 verified the medications were Crestor 20 mg and Chlorthalid 25 mg. Resident #49 resided in the room and was taking Crestor daily but was not taking the Chlorthalid. 365310 Page 11 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, taste test and policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected four residents (#11, #12, #15 and #35) of four residents who were prescribed pureed diets. The facility census was 60. Findings include: Observation and interview on 12/06/22 at 11:09 AM with [NAME] #118, revealed the pureed meat sauce had pieces of meat still in the product. Dietary Manager (DM) #139 tasted the meat sauce and told [NAME] #118 to puree the meat sauce more. Cook #118 then stated, I already did the purees for lunch, so this puree isn't needed. [NAME] #118 was asked to portion out some of the already purred food. The green beans were not smooth and contained fibrous strings. DM #139 verified these finding at 11:11 A.M. on 12/06/22. The facility identified four residents, Resident #11, #12, #15 and #35 who received a pureed diet prepared by the kitchen. Review of the undated facility policy titled, Pureed Food Preparation revealed facility will prepare pureed foods in a manner that sustains nutritional value and taste. The foods will be pureed to assure the desired consistency. 365310 Page 12 of 13 365310 12/14/2022 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on personnel record review and staff interview, the facility failed to provide documented evidence of dementia training for all staff. The facility had a secure unit. This had the potential to affect all 60 residents that resided in the facility. Findings Include: Review of personnel record for State Tested Nurse Aide (STNA) #114 revealed a hire date of 11/08/22 with no documentation of dementia training. Review of personnel record for STNA #136 revealed a hire date of 05/25/22 with no documentation of dementia training. Review of personnel record for STNA #165 revealed a hire date of 06/22/22 with no documentation of dementia training. Review of personnel record for STNA #827 revealed a hire date of 10/29/19 with no documentation of dementia training. Review of personnel record for STNA #828 revealed a hire date of 07/15/20 with no documentation of dementia training. Review of personnel record for STNA #829 revealed a hire date of 01/12/21 with no documentation of dementia training. Interview on 12/07/22 at 9:28 A.M. with Staffing Coordinator #108 verified there was no documentation of dementia training. 365310 Page 13 of 13