Health inspection·December 28, 2019

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interviews and staff interviews, the facility failed to ensure 22 residents (Residents #2, #3, #5, #6, #7, #8, #11, #12, #13, #15, #17, #19, #23, #29, #30, #31, #34, #37, #38, #39, #43 and #45) were informed, in advance, of proposed treatment and provided the option to choose or decline. The facility census was 48. Residents Affected - Some Findings include: Interview with Resident #17 occurred on 12/27/19 at 2:14 P.M. Resident #17 identified on 12/12/19 a unknown male came into her room told her he was getting her free diabetic shoes and custom molded inserts. Resident #17 revealed, the man then measured her feet and took pictures of them. Resident #17 confirmed she was never asked, prior to this person's arrival if she wished to obtain this service. The interview identified her roommate, Resident #8, whom can not provide any consent, was also measured for these shoes. Interview with the facility Administrator on 12/27/19 at 2:46 P.M. was completed. The interview confirmed the facility could provide no evidence each of the 22 residents (Residents #2, #3, #5, #6, #7, #8, #11, #12, #13, #15, #17, #19, #23, #29, #30, #31, #34, #37, #38, #39, #43 and #45) whom were measured for diabetic shoes and or inserts on 12/12/19, were provided information regarding the proposed treatment to make an informed decision. Interview with Social Services Director (SSD) #73 was conducted on 12/27/19 at 3:04 P.M. SSD #73 provided a listing of 22 residents (Residents #2, #3, #5, #6, #7, #8, #11, #12, #13, #15, #17, #19, #23, #29, #30, #31, #34, #37, #38, #39, #43 and #45) whom were listed as having a medical diagnosis of diabetes. The form identified the above patients are not Medicare Part A (skilled) or Hospice, unless otherwise noted, was used by the company to measure residents feet for the shoes. The interview confirmed a person from an outside company came to the facility on [DATE] and measured each of the 22 residents feet and took photographs. The interview confirmed there was no evidence any of the residents and/ or their families were asked prior to this occurring. Review of the listing of the 22 residents included Resident #12, whom was bed-bound and receiving hospice services. Resident #37 was additionally identified as receiving hospice services, for end of life care. Page 1 of 10 365452 365452 12/28/2019 Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on medical record review, family and staff interviews, the facility failed to ensure one (Resident #25) of 16 sampled residents/families were invited to participate, on at least a quarterly basis, to plan their care meeting. The facility census was 48. Findings include: Review of Resident #25's medical record identified admission occurred 01/19/19 with medical diagnosis including dementia, repeated falls and colon cancer. The record identified an initial care planning conference occurred on 01/25/19, which included Resident #25's family. The record lacked any evidence of additional care planning meetings in which the family/resident was invited to participate. The record identified a significant change in condition assessment was completed on 11/13/19 (due to initiation of hospice), a quarterly assessment was completed on 10/28/19 and 07/20/19. The facility was noted to conducted the meetings without family participation. Interview with Resident #25's daughter occurred on 12/27/19 at 1:45 P.M. The interview identified the family had not been invited to participate in any care plan meetings since Resident #25's admission to the facility. The interview confirmed they would like to be able to attend the meetings regarding their father's care. The interview revealed the family had concerns regarding lack of showers and lack of daily shaving, which would be Resident #25's normal wishes prior to coming to the facility. Interview with Licensed Practical Nurse (LPN)/ Minimum Data Set (MDS) Coordinator #61 occurred on 12/27/19 at 9:05 A.M. He stated he is the person whom sets the schedules for the care plan meetings and provides the list to Receptionist #122. LPN #61 identified he thinks Receptionist #122 is the person who is inviting families/residents. He stated the meetings are set up at the times of the MDS assessments, at least quarterly and with significant changes in condition. The interview identified Receptionist #122 was currently on vacation and could not locate any evidence of invitations to care planning meetings investigations. 365452 Page 2 of 10 365452 12/28/2019 Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, family and staff interviews, the facility failed to provide one (Resident #25) of two residents, whom was dependent, with daily shaving. The facility census was 48. Residents Affected - Few Findings include: Review of Resident #25's medical record identified admission occurred 01/19/19 with medical diagnoses including dementia, repeated falls, colon cancer and anemia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 required extensive assistance of one staff with all activities of daily living (ADL). Review of Resident #25's written plan of care identified he was unable to perform his ADL. The written plan did not evidence the residents preferences to be shaved daily. The plan did not address what the staff should do if the resident refused showers and or shaving. Interview with Resident #25's daughter occurred on 12/27/19 at 1:45 P.M. The interview identified the family had come in several times to visit, and the resident had not been showered or shaved. The interview confirmed Resident #25 always shaved daily throughout his life and that would be his preference. Observation of Resident #25 occurred on 12/26/19 at 11:48 A.M. Resident #25 was noted to have approximately one inch to one and a half inches of facial hair. Resident #25 was unable to identify if he wished to be shaved daily and/ or the last time he received a shave. Observation of Resident #25 occurred on 12/27/19 at 7:24 A.M. and 9:18 A.M. Resident #25 remained unshaved. Interview with State Tested Nursing Assistant (STNA) #101 was completed on 12/27/19 at 11:28 A.M. The interview confirmed Resident #25 most recent shower was completed on 12/18/19. The interview confirmed he was listed as refusing showers on 12/21/19 and 12/25/19, and she was unsure of the last time he had been shaved. Interview with STNA #33 was conducted on 12/27/19 at 2:13 P.M. The interview confirmed she did provide Resident #25 with a shave because she noticed he really needed one, when he came down to the first floor. STNA #33 confirmed she was not the person whom was taking care of the resident and was in the building for administrative duties today. 365452 Page 3 of 10 365452 12/28/2019 Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #46 received activities to meet his current and past interests. This affected one resident (Resident #46) of one resident reviewed for activities. Residents Affected - Few Findings include: Resident #46 was admitted on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, dementia and Alzheimer's Disease. Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was severely impaired, was totally dependent on staff for transfers and required extensive assistance with locomotion. Resident #46's Activity assessment dated [DATE] revealed the resident was a former railroad engineer and was active in his Catholic religion. Resident #46's active comprehensive care plan revealed a focus for alteration in supervised/organized recreation characterized by little or no involvement, and lack of attendance related to preference for independent self-directed activities. Intervention to address this focus included but were not limited to activities will provide the resident with low functioning activities to ensure achievement of maximum therapeutic benefits from activities. Review of Resident #46's Monthly Activity Participation Record for November 2019 and December 2019, revealed no evidence the resident participated in religious services or activity related to railroads. Review of his one on one (1:1) program documentation revealed he had one 1:1 activity in November 2019 and one in December 2019. Resident did receive one Catholic service on 11/14/19, but this was through hospice services. Observations on 12/26/19 at 10:15 A.M., 12/27/19 at 9:35 A.M. and 1:16 P.M. revealed the resident was sitting in the common area watching television. Interview on 12/27/19 at 1:20 P.M. with Activities Director (AD) #58 revealed she meets with Resident #46 daily for about ten minutes, but does not record this activity on his participation log. AD #58 revealed she was unaware the resident was a railroad engineer, therefore there was no evidence the resident participated in railroad related activities. AD #58 confirmed there was no evidence the resident participated in religious services. AD #58 revealed Resident #46 observed group activities often, and the resident was required two 1:1 activities a month. AD #58 confirmed there was evidence he only received one 1:1 activity in November and December 2019. 365452 Page 4 of 10 365452 12/28/2019 Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observations, medical record reviews, resident and staff interviews, the facility failed to ensure adequate staffing was available to ensure eight residents (Residents #3, #14, #17, #21, #22, #28, #36 and #46) of 48 residents received medications timely on 12/26/19. The facility census was 48. Findings include: Review of Resident #17's medical record identified admission to the facility occurred on 06/05/17, with medical diagnoses including paraplegia, chronic kidney disease, borderline personality, post-traumatic stress disorder (PTSD), Lupus, neurogenic bladder, anemia, anxiety, diabetes mellitus and morbid obesity. The record revealed Resident #17 was cognitively intact and able to make her needs know. Interview with Resident #17 occurred on 12/26/19 at 9:42 A.M. and revealed she believed there was not enough staff working in the facility. The resident stated at times she had a difficult time being put to bed when she wanted to be. The resident additionally identified her medications, scheduled for 8:00 A.M. this morning, had not been administered, including her insulin. Observation of Registered Nurse (RN) #118 was completed on 12/26/19 at 10:03 A.M. RN #118 confirmed she was still in the process of passing morning medications, including Resident #17's. The interview identified a nurse called off this morning and she was called in to replace that person. RN #118 identified she had eight residents (Resident #3, #14, #17, #21, #22, #28, #36 and #46) medications still to administer all whom resided on the second floor east side of the building. RN #118 confirmed she typically worked on the evening shift and was called into to work following the nurse calling off. Review of a nursing call off form dated 12/25/19 at 8:00 P.M. identified the nurse for 2 East unit called off for her 6:30 A.M. to 6:30 P.M. shift for 12/26/19. Review of the time card for RN #118, whom replaced the nurse whom called off, revealed she arrived at the facility at 9:30 A.M. Interview on 12/28/19 at 11:55 A.M. with the Director of Nursing (DON) revealed she was unaware the nurse called off on 12/25/19 until 12/26/19 at 8:10 A.M. The DON revealed it was a communication issue as the nurse downstairs started medication pass downstairs, rather than going upstairs to give insulin to the residents upstairs. The interview confirmed there were eight residents at 10:03 A.M. who had not received medications, including three residents (Resident #17, #21 and #28) who had insulin orders to be given with meals. The DON verified medications should be given within one hour of the ordered time. This deficiency substantiates Complaint Number OH00109011. 365452 Page 5 of 10 365452 12/28/2019 Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medication administration observation, medical record review, review of manufacture's recommendations and staff interviews, the facility failed to ensure insulin pens were properly utilized to ensure adequate dosing. This affected Resident #38 and had the potential to affect 11 additional residents (Resident #4, #13, #16, #17, #21, #22, #23, #24, #26, #28 and #45) identified as utilizing insulin pens. The facility census was 48. Findings include: Medication administration observation occurred with Registered Nurse (RN) #110 on 12/27/19 at 7:30 A.M. RN #110 prepared medications for Resident #38, which included a Lispro insulin pen and Flovent inhaler (corticosteriod). RN #110 was unable to locate the Lispro insulin pen for Resident #38 and obtained a new one. She set the dial to four units of Lispro insulin and administered the medication to Resident #38. RN #110 did not prime the insulin pen prior to setting and/or giving the dose of insulin to the resident. Review of Resident #38's medical record revealed admission to the facility occurred on 11/26/14 with medical diagnoses including diabetes and chronic respiratory failure. The record revealed on 12/26/19 the physician's orders included Lispro insulin four units subcutaneously (sq) with the Kwikpen (pre-filled syringe). Interview with RN #110 on 12/27/19 at 7:53 A.M., following the administration, verified at no time did she prime the insulin pen, and she was unaware of the need to do this with all insulin pens. Review of the manufactures instructions recommended priming the insulin pen before each injection. Priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. 365452 Page 6 of 10 365452 12/28/2019 Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, review of manufacturer's recommendations and staff interviews, the facility failed to ensure one (Resident #38) of three sampled residents received medications as ordered by the physician. Medication administration observation identified two of 27 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 7.4%. This had the potential to affect all 48 residents residing in the facility. Residents Affected - Few Findings include: Medication administration was observed with Registered Nurse (RN) #110 on 12/27/19 at 7:30 A.M. RN #110 prepared medications for Resident #38 which included a Lispro insulin pen and Flovent inhaler (corticosteriod). RN #110 administered two puffs of the Flovent inhaler for Resident #38. RN #110 also administered four units of Lispro insulin subcutaneously (sq). Review of Resident #38's medical record revealed admission to the facility occurred on 11/26/14 with medical diagnoses including diabetes and chronic respiratory failure. The record revealed on 12/26/19 the physician's orders included the Flovent 220 micrograms (mcg) one puff two times a day and Lispro insulin four units sq three times daily . Interview with RN #110 on 12/27/19 at 7:53 A.M., following the observation, confirmed at no time did she prime the insulin pen, and she was unaware of the need to do so with all insulin pens. She also verified she gave Resident #38 two puffs of the Flovent inhaler, and the current physician's order was to administer one puff. Review of the manufactures instructions recommended priming the insulin pen before each injection. Priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. 365452 Page 7 of 10 365452 12/28/2019 Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212

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** 3. Resident #21 was admitted on [DATE] with diagnoses including type one diabetes mellitus, history of diabetic foot ulcer, morbid obesity, hyperlipidemia, lymphedema, hypothyroidism, abnormal glucose, venous insufficiency, hypertension, cellulitis of right lower limb, and chronic embolism and thrombosis of deep veins of unspecified lower extremity. Resident #21 was followed by endocrinology for blood glucose control. Residents Affected - Some Resident #21's physician's order dated 09/25/19 revealed she was ordered insulin regular human (conc) solution, 500 unit per milliliter, inject 145 units subcutaneously one time a day at 8:00 A.M. and inject 65 units subcutaneously one time a day at 11:30 A.M. for type one diabetes mellitus with hyperglycemia. Review of Resident #21's physician's order dated 12/26/19 revealed per certified nurse practitioner, may administer morning medications late, one time order on this date. Interview on 12/28/19 at 12:00 P.M. with Director of Nursing (DON) revealed although Resident #21's insulin was administered late, Resident #21 did not have any ill effect as a result of late medication. This deficiency substantiates Complaint Number OH00109011. Based on observation, medical record review, resident and staff interviews, the facility failed to ensure insulin was administered according to physician's orders. The affected three residents (Residents #17, #21 and #28) of three residents observed for medication administration. The facility census was 48. Findings include: 1. Review of Resident #28's medical record identified admission to the facility occurred on 10/30/15 with medical diagnoses including mild cognitive impairment, panic disorder, bipolar disorder, Hepatitis C and diabetes. The record revealed physician's orders for December 2019 included Levemir insulin 10 units in the morning and Novolog insulin 13 units with meals. 2. Review of Resident #17's medical record identified admission to the facility occurred on 06/05/17 with medical diagnoses including paraplegia, chronic kidney disease, borderline personality, post-traumatic stress disorder (PTSD), Lupus, neurogenic bladder, anemia, anxiety, diabetes mellitus and morbid obesity. The record revealed Resident #17 was cognitively intact and able to make her needs know. Interview with Resident #17 occurred on 12/26/19 at 9:42 A.M. and identified she believed there was not enough staff working in the facility. The resident stated at times she had a difficult time being put to bed when she wanted to be. The resident additionally stated her medications, scheduled for 8:00 A.M. this morning, had not been administered, including her insulin. Observation of Registered Nurse (RN) #118 was completed on 12/26/19 at 10:03 A.M. RN#118 verified she was still in the process of passing morning medications, including medications for Residents #17, #21 and #28. She stated a nurse called off this morning and she was called in to replace that person. RN #118 stated she had eight resident's medications left to administer all whom resided on the 365452 Page 8 of 10 365452 12/28/2019 Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212

F 0760 second floor, east side of the building. RN #118 confirmed Residents #17, #21 and #28 had insulin ordered which not been administered at the time ordered by the physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365452 Page 9 of 10 365452 12/28/2019 Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure Resident #24 was served the correct portion size of pureed chili. This affected one resident (Resident #24) of one resident observed to be served a pureed diet, with the potential to affect two residents (Resident #24 and Resident #37) who were ordered a pureed diet in the facility. Findings include: Review of the Menu Extension spreadsheet for lunch on 12/27/19, revealed residents on a pureed diet should be served pureed chili with a number six scoop. Review of the Disher Scoop Sizes and Conversions- Chefs Resources form, undated, revealed a number six scoop was 5.33 ounces and a number eight scoop was 4 ounces. Observation on 12/27/19 at 12:10 P.M. revealed [NAME] #104 used a number eight scoop to serve pureed chili to Resident #24. Interview with Dietary Technician #77 at this time confirmed a number eight scoop was used, and the spreadsheet identified a number six scoop. Review of the list of resident diets, provided by the facility, revealed Resident #24 and Resident #37 were ordered a pureed diet. 365452 Page 10 of 10