Health inspection·June 5, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to provide comprehensive, individualized and necessary diabetic ulcer (wound that commonly appears on the feet as a complication of diabetes often from lack of sensation or blood flow) assessment and care for Resident #151. This affected one resident (#151) out of three residents reviewed for diabetic/vascular/ pressure related wound care. The facility identified six residents (#111, #150, #151, #154, #162, and #163) with pressure/ vascular/ diabetic wounds. Residents Affected - Few Actual harm occurred on 05/08/24 when the facility failed to adequately assess and implement diabetic ulcer wound care for Resident #151, a new admission who had intact cognition and was dependent on staff with activities of daily living (ADL) including bed mobility and transfers. On 05/08/24, Resident #151 was admitted to the facility with a diabetic ulcer to his right plantar foot that measured 0.5 centimeter (cm) in length, 0.5 cm in width, and had no depth. The facility failed to re-evaluate, measure, and document Resident #151's wound again until 05/20/24 at which time it had increased in size measuring 3.5 cm in length, 1.5 cm in width, and 0.2 cm in depth with 100 percent granulation (new tissue during healing process). The facility did not complete another wound evaluation until 06/03/24 and failed to complete daily treatments as ordered resulting in Resident #151's diabetic ulcer deteriorating and containing 40 percent slough (dead tissue) to the wound bed. Findings include: Review of the medical record revealed Resident #151 had an admission date of 05/08/24 with diagnoses including paranoid schizophrenia, diabetes, cauda equina syndrome (compressed nerve roots at the bottom of the spinal cord), and hypertension. Review of clinical census revealed no documented evidence Resident #151 was out of the building on 06/01/24. Review of the May 2024 Treatment Administration Record (TAR) revealed Resident #151 had an order to cleanse the right plantar foot with normal saline, pat dry, apply silver alginate (highly absorbent, and antimicrobial dressing) to wound bed, cover with an abdominal (ABD) pad, and wrap with Kerlix gauze and an Ace wrap every night shift. The TAR was blank for 05/29/24, indicating no documented evidence that the treatment was completed. Review of the Nursing Admit/ Readmit No Care Plan- V2 dated 05/08/24 and completed by Licensed practical Nurse (LPN) #613 revealed Resident #151 had a vascular ulcer to his right plantar foot that measured 0.5 cm in length, 0.5 cm in width, and had no depth. Review of the medical record including nursing notes, Wound- Weekly Observation Tool assessments, and Wound Nurse Practitioner (NP) #612 consults revealed there was no documentation since his Page 1 of 6 365355 365355 06/05/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0684 admission on [DATE] until 05/20/24 that Resident #151 was evaluated, including measurements of the wounds and/ or description of the wound (if any changes). Level of Harm - Actual harm Residents Affected - Few Review of the care plan dated 05/09/24 revealed Resident #151 had actual impaired skin integrity related to a vascular wound to his right plantar foot. Interventions included encourage the resident to float heels as tolerated, encourage turn and reposition every two hours, and weekly treatment documentation to include measurement of each area of skin breakdown, exudate (drainage), and changes in observation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #151 had intact cognition. He was dependent on staff assistance with rolling left to right (bed mobility), transfers, and toileting. He was at risk of developing pressure ulcers. He had two venous/arterial ulcers. Review of Wound NP #612's progress note dated 05/20/24 revealed the initial consult evaluation revealed Resident #151 had a diabetic ulcer to his right plantar foot. The wound measured 3.5 cm in length, 1.5 cm in width and 0.2cm in depth. The wound bed contained 100 percent granulation tissue and there was no documented evidence of slough. She ordered to cleanse with normal saline, pat dry, apply silver alginate to the wound bed, cover with an ABD pad, and wrap with Kerlix gauze daily and as needed. Review of the Wound- Weekly Observation Tool dated 05/20/24 and completed by LPN/ Assistant Director of Nursing (ADON)/ Wound Nurse #609 revealed Resident #151's right plantar diabetic ulcer had 100 percent granulating tissue present. The wound measured 3.5 cm in length, 1.5 cm in width, and 0.2 cm in depth. Wound NP #612 ordered to continue the same treatment. Review of the medical record including nursing notes, Wound- Weekly Observation Tool assessments, and Wound NP #612 consults revealed there was no documented evidence between 05/21/24 and 06/03/24 that Resident #151's wounds were evaluated, including measurements of the wounds and/or description of the wound (if any changes). Review of the Resident Out/ In Log dated from 05/30/24 to 06/03/24 revealed Resident #151 on 06/01/24 had signed out of the facility at 11:00 A.M. but signed back in that he returned on the same day, 06/01/24 at 8:00 P.M. There was no further documented evidence that Resident #151 left the facility and per documentation was present in the facility at the time his treatment was scheduled on 06/01/24 (night). Review of the June 2024 TAR revealed Resident #151 had the same treatment order to his right plantar diabetic ulcer: cleanse with normal saline, pat dry, apply silver alginate to wound bed, cover with an ABD pad, wrap with Kerlix gauze and an Ace wrap every night shift. The documentation indicated on 06/01/24 that Resident #151 was out of the facility and on 06/02/24 the treatment was not completed as the wound care team was coming in. Review of the Wound- Weekly Observation Tool dated 06/03/24 and completed by LPN/ ADON/ Wound Nurse #609 revealed Resident #151's right plantar diabetic ulcer had 60 percent granulated tissue and 40 percent slough. The wound measured 1.0 cm in length, 2.6 cm in width and unable to determine depth due to slough. Wound NP #612 ordered to change the treatment due to the slough present to cleanse with 0.125 percent Dankins (diluted bleach) solution, pat dry, apply silver alginate to wound, cover with an ABD pad and wrap with Kerlix gauze daily and as needed. 365355 Page 2 of 6 365355 06/05/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0684 Level of Harm - Actual harm Residents Affected - Few Review of Wound NP #612's progress note dated 06/03/24 revealed Resident #151 had a diabetic ulcer to his right plantar foot that measured 1.0 cm in length, 2.6 cm in width, and depth was unable to be determined as the wound bed contained 40 percent slough. There was moderate serosanguineous drainage, and the peri wound was dry and callused. She changed the treatment to cleanse the wound with 0.125 percent Dakins solution and continued silver alginate to the wound bed for autolytic debridement. Interview on 6/03/24 at 11:41 A.M. with Resident #151 revealed he was upset and frustrated as the dressing on his right foot had not been changed for several days and that he had a physician order to have his dressing changed daily. He revealed since he was admitted to the facility the nurses failed to complete his dressing on several occasions and that his wound was going to get worse because of the lack of care he was receiving. He revealed he had a fear he would need his foot amputated if not properly cared for. He also revealed he was not out of the facility on 06/01/24 at the time his wound dressing was scheduled for. Observation at the time of the interview revealed he had a sock that covered a dressing wrapped with Kerlix gauze to his right foot. The Director of Nursing (DON) assisted in pulling his sock down and identified that the date on the dressing was 05/31/24. She verified his dressing was to be completed daily and had not been completed on 06/01/24 and 06/02/24. Observation on 06/03/24 at 2:51 P.M. of wound care completed by Wound NP #612 and LPN/ ADON/ Wound Nurse #609 verified the date on the old dressing removed to his right foot was dated 05/31/24 and both verified his treatment was ordered to be done daily. LPN/ ADON/ Wound Nurse #609 cleansed the wound with normal saline. Wound NP #612 attempted to inspect the wound but stated the wound contained dried dressing that had adhered to the center of the wound bed. LPN/ ADON/ Wound Nurse #609 again proceeded to cleanse the wound and pick out the adhered pieces of dressing in the wound bed. Wound NP #612 proceeded to evaluate the wound and described it as 1.0 cm in length, 2.6 cm in width, and unable to determine depth as the wound contained 40 percent slough (dead tissue) and 60 percent granulation with moderate amount of drainage. Interview on 06/03/24 at 3:00 P.M. with Wound NP #612 revealed on her initial consult on 05/20/24 his diabetic ulcer had 100 percent granulation tissue but now, 06/03/24 she verified his wound now contained 40 percent slough. Interview on 06/03/24 at 3:46 P.M. with LPN/ ADON/ Wound Nurse #609 revealed on 06/01/24 Resident #151's treatment was not completed because he was out of the facility and on 06/02/24 his dressing was not changed because the wound team was consulting (the next day). LPN/ ADON/ Wound Nurse #609 verified per the census Resident #151 was not out of the facility on 06/01/24 at the time the dressing was due to be changed, and the nurse should have completed the dressing change on 06/02/24 as the Wound NP #612 was not scheduled to come in until the next day, 06/03/24. She stated, I do not have any excuse why it was not done since Friday (05/31/24). She revealed that there was a wound assessment completed on admission, 05/08/24, but verified there was no other documented evidence measurements and/or assessment of his wound were completed until 05/20/24. She verified there were no other assessment/measurements completed from 05/20/24 until today, 06/03/24. She revealed Wound NP #612 was the only one that assessed, and measured the wounds and that she took her assessments/measurements and input the findings into the resident's medical record. She revealed she was unsure why Wound NP #612 had not seen Resident #151 from 05/08/24 to 05/20/24 and that she thought he had refused her services and/or was not in his room on her last wound round on 05/30/24 and was not seen. She verified that she did not assess and measure the wound if the resident refused and/or was not in the building at the time the Wound NP #612 until the next scheduled Wound NP #612 visit. 365355 Page 3 of 6 365355 06/05/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0684 Level of Harm - Actual harm Interview on 06/03/24 at 4:43 P.M. with Regional Nurse #600 revealed all wounds including diabetic ulcers were to be evaluated, measured, and documented at least weekly in the medical record. She verified even if a resident was not seen by Wound NP #612, the nurse at the facility was to complete the evaluation, measurements, and documentation at least every seven days. Residents Affected - Few Review of the undated Wound Report Non-Pressure and unsigned revealed a form with seven residents on it including Resident #151. The form revealed Resident #151 had a diabetic ulcer to right plantar foot that measured 1.0 cm in length, 2.6 cm in width and no depth. The area was unchanged and had moderate serosanguinous drainage. (this form was presented to the surveyor on 06/04/24 at 12:10 P.M. after the concern was brought to the attention of the facility of Resident #151's ulcer not having documentation in his medical record of being assessed at least weekly). Review of the undated facility policy labeled, Wound and Skin Care revealed if an ulcer was present then the resident would be placed on a wound program which would include the area to be measured and tracked weekly and as needed until resolved. The treatment wound be initiated as ordered by the physician. The policy revealed documentation of the ulcer would include measurements in centimeters of the wound and the amount, type, color and odor of the drainage. The policy revealed all wounds would be assessed weekly and the ineffectiveness or progress of healing would be reported to the physician as needed. This deficiency represents non-compliance investigated under Complaint Number OH00153870. 365355 Page 4 of 6 365355 06/05/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

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 interview, observation, record review and review of the facility policy, the facility failed to ensure Residents #142 and #154 were free of significant medication errors. This affected two residents (#142 and #154) out of five residents observed for medication administration. The facility census was 68. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #154 revealed an admission date of 03/27/20 with diagnoses including paraplegia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cardiomyopathy, and epilepsy. Review of the care plan dated 01/11/24 revealed Resident #154 had hypertension. Interventions included administering anti-hypertensive medications as ordered, monitoring for side effects such as orthostatic hypotension and increased heart rate. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #154 had impaired cognition. Review of the June 2024 Medication Administration Recird (MAR) revealed Resident #154 had a physician order to receive Metoprolol Tartrate (beta- blocker that affects the heart and circulation used to treat angina, hypertension, and heart failure) 37.5 milligram (mg) tablet by mouth two times a day that was scheduled for 9:00 A.M. and 9:00 P.M. He also had an order for Sodium Bicarbonate 650 mg tablet by mouth three times a day for minerals / electrolyte replacement that was scheduled for 9:00 A.M., 2:00 P.M., and 9:00 P.M. Observation on 06/03/24 at 11:13 A.M. revealed Licensed Practical Nurse (LPN) #602 obtained Resident #154's blood pressure and it was 156/86. She then proceeded to administer his morning medications including Metoprolol 37.5 mg by mouth, and Sodium Bicarbonate 650 mg with his med pass supplement. Interview on 06/03/ 24 at 11:17 A.M. with LPN #602 verified on the electronic medication record the medications were marked as red indicating they were late. She verified Resident #154's Metoprolol 37.5 mg and Sodium Bicarbonate 650 mg were scheduled to be administered at 9:00 A.M. every morning and that she did not administer both medications until 11:13 A.M. She verified that Resident #154 received his Metoprolol twice a day as his next scheduled dose was at 9:00 P.M., and he received his Sodium Bicarbonate three times a day as his next scheduled dose was at 2:00 P.M. Interview on 06/04/24 at 8:22 A.M. with Regional Nurse #600 revealed all medications should be arising or evening and that a specific time should not be assigned unless ordered by the physician. She verified Resident #154's Metoprolol Tartrate was ordered to be administered at 9:00 A.M. and he received it twice daily (9:00 A.M. and 9:00 P.M.). She also verified his Sodium Bicarbonate was ordered at 9:00 A.M. and this was to be administered three times a day at (9:00 A.M., 2:00 P.M., and 9:00 P.M. She verified medications with a specific time were to be administered up to one hour before or up to one hour after the time ordered for. Interview on 06/04/24 at 8:51 A.M. with Resident #154 revealed he appeared cognitively impaired and was reluctant to answer and/ or provide any details regarding his medication administration. 365355 Page 5 of 6 365355 06/05/2024 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the undated website labeled, Drugs. Com revealed Metoprolol Tartate should be taken at the same time each day and to take the medication as directed by the physician. 2. Review of the medical record for Resident #142 revealed an admission date of 01/24/24 with diagnoses including dysphagia, hemiplegia affecting left dominant side following cerebral infarction, and severe protein calorie malnutrition. Review of the care plan dated 01/25/24 revealed Resident #142 was at risk for bleeding related to aspirin therapy. Interventions included monitor for increased bruising, use soft toothbrush, use electric razor, and monitor for signs of bleeding. Review of the quarterly MDS assessment dated [DATE] revealed Resident #142 had intact cognition. Review of the June 2024 MAR revealed Resident #142 had a physician order for aspirin chewable 81 mg tablet by mouth one time a day as a blood thinner. Observation on 06/04/24 at 8:02 A.M. revealed LPN #604 poured one Aspirin 81 mg enteric coated (EC) tablet from the bottle, proceeded to crush all Resident #142's morning medications including the aspirin EC and administered in his med pass supplement drink. Interview on 06/04/24 at 8:14 A.M. with LPN #604 verified Resident #142 had an order for aspirin chewable tablet not aspirin enteric coated as she revealed that was the only type of aspirin they had in the facility as they did not have the chewable form as ordered. She verified aspirin enteric coated was not to be crushed but stated that was the only type she had. She revealed Resident #142 required his medications to be crushed and stated she had no choice. Interview on 06/04/24 at 9:26 A.M. with Resident #142 revealed that his stomach hurt on and off as he stated it was from the food at the facility. Review of the website WebMD.com labeled, Aspirin EC, Delayed Release (Enteric Coated)- Uses, Side effects and More revealed aspirin EC tablets should be swallowed whole. Aspirin EC tablets should not be crushed or chewed as this can increase stomach upset. Review of the facility policy labeled, Administering Medications, last revised December 2012, revealed medications shall be administered safe, timely and as prescribed. Medications must be administered in accordance with the orders, including any time frames. The policy revealed medications must be administered within one hour of the prescribed time unless otherwise specified. There was nothing regarding the crushing of medications in the policy. Review of the facility policy labeled, Do Not Crush List, dated 06/04/24, revealed it can be hard to keep track of all the different medications that should not be crushed. The policy listed common medications that should not be crushed, cut or chewed that included aspirin EC. This deficiency represents non-compliance investigated under Complaint Number OH00153870. 365355 Page 6 of 6