Health inspection·April 4, 2024

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review the facility failed to ensure residents/resident representative participated in care planning. This affected three residents (#39, #48 and #49) of three reviewed for care conferences. Findings include: Review of Resident #39's medical records revealed an admission date of 10/22/23. Diagnoses included paraplegia and stroke. Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had impaired cognition. Review of Resident #39's care plan dated 03/14/24 revealed Resident #39 had impaired cognition. Interventions included communicate with family and caregivers regarding needs. Review of Resident #48's medical records revealed an admission date of 03/24/23. Diagnoses included cognitive deficits and stroke. Review of Resident #48's MDS assessment dated [DATE] revealed Resident #48 had impaired cognition. Review of the care plan dated 03/14/24 revealed Resident #48 had impaired cognition. Interventions included communicate with family and caregivers regarding needs. Review of Resident #49's medical records revealed an admission date of 01/23/24. Diagnoses included cognitive deficits and need for personal care assistance. Review of Resident #49's MDS assessment dated [DATE] revealed Resident #49 had impaired cognition. Interview on 04/02/24 at 1:36 P.M. with Licensed Social Worker (LSW) #366 revealed care conferences were to be completed at least quarterly and if a resident had a significant change in condition. LSW #366 reviewed the medical records of Residents #49, #39 and #38 and was unable to locate any documented evidence of care conferences being held to discuss care planning with the residents or the residents' responsible party. Interview on 04/02/24 at 2:22 P.M. with Unit Manager, Licensed Practical Nurse (LPN) #330 revealed she had spoken with Resident #49's family regarding wanting to set up a care conference. Resident #49's family had given her their phone number and LPN #330 gave the information to LSW #366. LPN #330 stated Resident #49's family had approached her a second time and stated LSW #366 had not called to set up the care conference. LPN #330 again informed LSW #366 of Resident #49's family request for a care conference to discuss the resident's care. Review of facility policy titled Care Planning revised September, 2013 revealed residents and family were encouraged to participate in the development and revisions of the resident's care plan. Page 1 of 11 365355 365355 04/04/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0553 This deficiency represents non-compliance investigated under Complaint Number OH00152534. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365355 Page 2 of 11 365355 04/04/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, and interview the facility failed to ensure call lights were within reach and accessible for residents. This affected one (Resident #46) of six residents observed for call light placement. The facility census was 58. Residents Affected - Few Findings include: Observation on 04/01/24 at 8:52 A.M. revealed Resident #46 was yelling out. Upon entering Resident #46's room a strong odor of urine was detected. Resident #46's call light was observed on the floor behind the bed. This observation was confirmed at 9:15 A.M. by the Director of Nursing (DON). The DON stated call lights should be within reach of residents. Review of Resident #46's care plan dated 02/28/24 revealed staff were to encourage Resident #46 to use call light. 365355 Page 3 of 11 365355 04/04/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

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. Based on observation and interview the facility failed to provide a clean and sanitary environment. This affected four (#15, #46, #48 and #58) of six residents whose rooms were observed. The facility census was 58. Findings include: 1. Observation of Resident #46's room on 04/01/24 at 8:52 A.M. revealed two pieces of bread with jelly on the fall mat next to Resident #46's bed with numerous ants on the bread and surrounding the area. The observation was confirmed by the Director of Nursing (DON) on 04/01/24 at 9:15 A.M. 2. Observation of Resident #55's room on 04/01/24 at 8:54 A.M. revealed a large brown dried stain on Resident #55's bed sheets and various food debris on the floor and underneath Resident #55's bed. This was confirmed with State Tested Nurse Aide (STNA) #340 at the time of the observation. 3. Observation of Resident #48's room on 04/01/24 at 11:04 A.M. revealed various debris and dirt on the floor and underneath Resident #48's bed. This was confirmed with STNA #340 at the time of the observation. 4. Observation of Resident #15's room on 04/01/24 at 2:17 P.M. revealed an area measuring approximately 3 feet wide by 6 inches high behind Resident #15's bed that was not covered by dry wall or baseboard. Wallpaper with a large black colored stain was lifting away from the wall, and there was a large amount of crumbled drywall. The black colored stain on the wallpaper appeared to be mold. Interview with Resident #15 at time of interview revealed the observed area had looked like that for a long time. Resident #15 stated he had informed the previous maintenance director about the area. Interview with the DON at the time of the observation confirmed the findings. The DON took pictures of the area and said she would inform maintenance. At 2:50 P.M. Maintenance Director #336 entered Resident #15's room and stated he had not been aware of the area and he had been at the facility for approximately four months. While speaking with Maintenance Director #336, Regional Maintenance Director (RMD) #386 entered the room and stated the large black area on the wallpaper was likely mildew. RMD #386 removed the wallpaper from the area of the wall that was damaged. Review of Resident Council Minutes for February 2024 revealed residents expressed wanting their rooms swept more thoroughly. This deficiency represents non-compliance investigated under Complaint Number OH00152534 and OH00151679. 365355 Page 4 of 11 365355 04/04/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of an in-house acquired pressure ulcer for Resident #49. This affected one resident (#49) of three residents reviewed who were at risk for pressure ulcers. The facility census was 58. Residents Affected - Few Actual Harm occurred on 03/26/24 when Resident #49, who was cognitively impaired and dependent on staff for mobility was found to have a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible and bone, tendon or muscles is not exposed. Slough may be present) pressure ulcer to the left buttock measuring 0.8 centimeters (cm) length by 1.5 cm width with 0.3 cm depth and serosanguineous drainage. The resident reported pain to the area. There was no evidence interventions, including turning and repositioning were provided to prevent the development of the ulcer or evidence the ulcer was found prior to being a Stage III. Findings include: Review of Resident #49's medical records revealed an admission date of 05/27/22 and a readmission date of 01/23/24. Diagnoses included malnutrition, muscle weakness and need for personal care assistance. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had impaired cognition. The assessment revealed the resident was dependent on staff for toileting, bathing personal hygiene and mobility. There were no identified areas of skin impairment on the assessment. Review of a re-admission skin assessment dated [DATE] revealed the resident had no skin impairments There were no further documented skin assessments completed. Review of care plan dated 03/20/24 revealed Resident #49 was at risk for skin breakdown due to decreased mobility. Interventions included to encourage and assist Resident #49 to turn and reposition as tolerated and as needed, pressure reducing mattress and pressure reducing cushion to wheelchair. Staff to identify signs and symptoms of skin breakdown and notify appropriate staff. Review of Resident #49's progress note authored by Licensed Practical Nurse (LPN) #330 dated 03/26/24 revealed during wound care visit Resident #49 had complaints of pain in buttocks. Upon assessment with Wound Nurse Practitioner (WNP) #369 a Stage III pressure ulcer was noted on the buttock. Review of wound progress note dated 03/26/24 revealed a Stage III pressure ulcer to the left buttock that measured 0.8 centimeters (cm) length by 1.5 cm width and 0.3 cm depth. The area had a small amount of serosanguineous drainage. Review of the nursing progress notes revealed no documentation related to staff providing turning and repositioning interventions for the resident or evidence of the resident refusing turning and repositioning. Telephone interview on 04/01/24 at 12:55 P.M. with Resident #49's family revealed Resident #49 had a wound to her bottom that was a result of staff not turning and repositioning her often. 365355 Page 5 of 11 365355 04/04/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0686 Level of Harm - Actual harm Residents Affected - Few On 04/01/24 at 1:53 P.M. observation revealed LPN #330 and WNP #369 were performing wound care for Resident #49. LPN #330 stated they had just completed the wound care of Resident #49's left leg and stated she also had a wound to her buttocks. Interview with WNP #369 revealed she was made aware Resident #49 had a wound to her buttocks on 03/26/24. WNP #369 stated she had assessed Resident #49's buttocks at that time and the wound was classified as a Stage III pressure ulcer. LPN #330 stated the area had not been reported previously. Observation of Resident #49's buttock wound revealed a foam dressing dated 03/31/24. LPN #330 removed the dressing and observation revealed an open area to Resident #49's buttocks that had a moderate amount of thick yellowish colored drainage. Interview with Resident #49 at time of observation revealed staff had not assisted her with turning and repositioning often. No additional information was provided by LPN #330 or WNP #369 related to turning and repositioning for the resident. Review of facility policy titled Prevention of Pressure Ulcers/Injuries revised 07/2017 revealed staff were to assist with repositioning residents at risk for pressure ulcers at least every two hours, inspect the skin on a daily basis when performing personal care and report and document potential changes in the skin. This deficiency represents non-compliance investigated under Complaint Number OH00152534 and OH00515990. 365355 Page 6 of 11 365355 04/04/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review the facility failed to ensure timely incontinence care was provided and failed to ensure adequate care of a suprapubic urinary catheter. This affected one resident (#46) of three residents observed for incontinence care and one resident (#15) of two residents observed for suprapubic catheter care. The facility census was 58. Findings include: 1. Review of Resident #15's medical records revealed an admission date of 10/24/23. Diagnoses included bladder dysfunction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Resident #15 had a suprapubic urinary catheter (tube inserted through the abdominal wall for urinary elimination). Review of the care plan dated 02/28/24 revealed Resident #15 was at risk for complications related to the suprapubic catheter. Interventions included monitor for signs and symptoms of infection. Review of Resident #15's physician orders for April 2024 revealed cleanse suprapubic catheter site with soap and water every night. Interview on 04/01/24 at 2:17 P.M. with Resident #15 revealed he was incontinent of bowel and had a urinary catheter. Resident #15 stated was checked for incontinence but sometimes he was not checked for long periods of time. Observation of incontinence care for Resident #15 with the Director of Nursing (DON) and State Tested Nurse Aide (STNA) #322 revealed Resident #15's suprapubic catheter had a large amount of dried crusted debris on the gauze, catheter tubing and around the insertion site. Further observation revealed the skin around the insertion site was red and excoriated. Resident #15's groin area had a foul odor and a brownish colored paste was observed in the groin area. Interview with the DON at the time of the observation revealed the brownish colored paste appeared to be old antifungal powder. Resident #15 stated they don't clean that area, they just put more powder on it. The DON further confirmed the crusted area around the suprapubic insertion site area. STNA #322 stated she had not performed catheter care today and was unable to state when the area had last been cleaned. Resident #15 stated his catheter was not cleaned regularly. Review of facility policy titled Suprapubic Catheter Care, revised October 2010, revealed to cleanse around the catheter site with soap and water. The policy did not indicate how often to clean around the suprapubic catheter site. 2. Review of Resident #46's medical records revealed an admission ate 05/26/22. Diagnoses include dementia and failure to thrive. Review of the MDS assessment dated [DATE] revealed Resident #46 was rarely understood and was incontinent of bowel and bladder. Review of the care plan dated 01/09/24 revealed Resident #46 was incontinent of bowel and bladder. Interventions included check for incontinence every two hours. Observation on 04/01/24 at 8:52 A.M. revealed Resident #46 was yelling out. Upon entering Resident #46's room a strong odor of urine was detected. Resident #46 was not interviewable. 365355 Page 7 of 11 365355 04/04/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/01/24 at 9:15 A.M. revealed the Director of Nursing (DON) entering Resident #46's room. Interview with the DON at the time of the observation confirmed the odor of urine. The DON stated she would obtain additional assistance and check Resident #46 for incontinence. Observation of incontinence care for Resident #46 with the DON and State Tested Nursing Assistant (STNA) #340 revealed Resident #46 was incontinent of a large amount of urine that had soaked through the two incontinence briefs she was wearing, the bed pad, the sheets, and onto the mattress. Resident #46's gown was soaked with urine and the sheets had a dried yellow urine stain. Interview with STNA #340 revealed she had not provided incontinence care for Resident #46 since she had started her shift at 7:00 A.M. This deficiency represents non-compliance investigated under Complaint Number OH00152534 and OH00515990. 365355 Page 8 of 11 365355 04/04/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

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, interview and review of facility policy the facility failed to ensure insulin vials were dated after opening. This affected one resident (#2) of two residents reviewed who received insulin. The facility census was 58. Findings include: Review of Resident #2's medical records revealed an admission date of 01/02/24. Diagnoses included diabetes. Review of Resident #2's physician orders for April 2024 revealed Resident #2 was ordered Lantus (long acting insulin) six units in the morning and Humalog (fast acting insulin) before meals according to a sliding scale. Observation of medication administration on 04/01/24 at 8:30 A.M. with Licensed Practical Nurse (LPN) #335 revealed LPN #335 obtained Resident #2 blood sugar and the glucometer read high (no numeric value was registered). LPN #335 informed Resident #2 she would need to contact the physician for orders. LPN #335 received an order to administer 16 units of Humalog. Resident #2 was informed of the physician orders and stated to LPN #335 that's too much, I'll take six units. LPN #335 contacted the physician and stated he agreed to the administration of six units of Humalog. Further observation revealed LPN #335 obtained a vial of Humalog that was previously opened but did not have date as to when it was opened. LPN #335 proceeded to draw up six units of Humalog and entered Resident #2's room. LPN #335 administered the six units of Humalog and returned to the medication cart. LPN #335 confirmed Resident #2's Humalog vial did not have an open date and Resident #2's vial of Lantus was also undated as to when it was opened. LPN #335 stated insulin vials should be dated when opened and stated she was unsure how long each of the insulin were good after opening. Review of the Medscape website revealed opened Humalog 10 milliliter vials should be stored at room temperature, less than 86 degrees Fahrenheit (F) or refrigerate at 36-46 degrees F for up to 28 days. Further review of the Medscape website revealed an open Lantus (in use) vial or pen could be stored for 28 days. Review of facility policy titled Insulin Administration revised September 2024 revealed upon opening a new vial of insulin record the expiration date on the bottle. 365355 Page 9 of 11 365355 04/04/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

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 interview and record review the facility failed to ensure accurate documentation of narcotics in the electronic medical records. This affected one resident (#2) of three residents reviewed for documentation. The facility census was 58. Findings include: Review of Resident #2's medial records revealed an admission date of 01/02/24. Diagnoses included low back pain. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition. Review of Resident #2's care plan dated 03/14/24 revealed Resident #2 was on opioid pain medication. Review of Resident #2's physician orders for March through April 2024 revealed Resident #2 was ordered oxycodone (narcotic pain medication) 5 milligrams (mg) every eight hours as needed. Review of Resident #2's narcotic count sheet from 03/19/24 through 03/29/24 revealed oxycodone was signed out as administered on 03/19/24 at 5:30 A.M. and 8:30 P.M.; on 03/20/24 at 10:12 P.M.; on 03/21/24 at 3:30 P.M. and 3:30 A.M.; on 03/22/24 at 2:30 P.M.; on 03/23/24 at 3:25 A.M.; on 03/23/24 at 7:00 P.M.; on 03/24/24 at 4:00 A.M., 2:00 P.M., and 10:00 P.M.; on 03/26/24 at 9:00 A.M., and 6:00 P.M.; on 03/27/24 at 12:00 P.M.; on 03/28/24 at 3:00 P.M., and on 03/29/24 at 6:00 A.M. and 2:00 P.M. Review of Resident #2's Medication Administration Record (MAR) for March 2024 revealed no documentation regarding the administration of oxycodone from 03/19/24 through 03/29/24. Interview on 04/02/24 at 7:50 A.M. with Resident #2 revealed he had pain due to back surgery and requested and received his pain medication every eight hours. Review of Resident #2's narcotic count sheet and MAR with Regional Operation Manager (ROM) #371 on 04/02/24 at 2:14 P.M. confirmed the oxycodone signed off on the narcotic count sheet was not documented as administered on the MAR. ROM #371 stated narcotics were to be documented on both the narcotic count sheets as well as in the MAR. 365355 Page 10 of 11 365355 04/04/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and facility policy review, the facility failed to ensure appropriate infection control techniques were used during and after insulin administration. This affected one resident (#2) of one resident observed for insulin administration. The facility census was 58. Residents Affected - Few Findings include: Review of Resident #2's medical records revealed an admission date of 01/02/24. Diagnoses included diabetes. Review of Resident #2's physician orders for April 2024 revealed Resident #2 was ordered Lantus (long acting insulin) six units in the morning and Humalog (fast acting insulin) before meals according to a sliding scale. Observation of medication administration on 04/01/24 at 8:30 A.M. revealed Licensed Practical Nurse (LPN) #335 drawing up six units of Humalog insulin and entering Resident #2's room. LPN #335 did not don gloves and administered the Humalog insulin by injecting the insulin into Resident #2's subcutaneous tissue. LPN #335 then proceeded to exit the room without washing her hands or using hand sanitizer. Interview with LPN #335 confirmed she did not wear gloves when administering the insulin via subcutaneous injection; she stated she must have forgotten. LPN #335 also confirmed hand hygiene was not completed prior to exiting Resident #2's room. Review of facility policy titled Insulin Administration revised September 2014 revealed staff were to wash their hands after insulin administration. 365355 Page 11 of 11