Health inspection·October 5, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the physician was notified of an elevated lab value for Resident #5. This affected one resident (#5) of three residents reviewed for infections. The facility census was 69. Findings include: Review of the medical record for Resident #5 revealed an admission date of 6/22/2023. Diagnoses included displaced fracture of cervical vertebra, displaced fracture of clavicle, and osteoarthritis. The resident was discharged to the hospital on [DATE]. Review of the Medicare-5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, walking, dressing, and toilet use. Review of physician orders for August 2023 identified orders for a complete blood count (CBC) and basic metabolic panel (BMP) every Friday starting 07/07/23. A Urinalysis (UA) and Culture and Sensitivity (C&S) were ordered on 08/17/23. Review of lab results from 08/04/23 revealed Resident #5's white blood cell count was 11.0 (normal range is 4.0 to 11.0), on 08/11/23 the resident's white blood cell count was 11.3, and on 08/18/23 the resident's white blood cell count had more than tripled to 34.4, indicating the resident had an infection. Review of the nurses' notes dated 08/18/23 at 10:04 A.M. through 08/21/23 at 10:12 A.M. revealed no documented evidence the physician was notified of Resident #5's elevated white blood cell count from 08/18/23. Interview on 10/05/23 at 3:43 P.M. with the Director of Nursing (DON) verified the lack of documented evidence regarding physician notification of the elevated white blood cell count from 08/18/23. This deficiency represents non-compliance investigated under Complaint Number OH00146849. Page 1 of 2 365487 365487 10/05/2023 Mount Saint Joseph Rehab Center 21800 Chardon Road Euclid, OH 44117

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure Resident #5 was adequately monitored after a change in condition. This affected one resident (#5) of three residents reviewed for change in condition. The facility census was 69. Residents Affected - Few Findings include: Review of the medical record for Resident #5 revealed an admission date of 6/22/2023. Diagnoses included displaced fracture of cervical vertebra, displaced fracture of clavicle, and osteoarthritis. The resident was discharged to the hospital on [DATE]. Review of the Medicare-5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, walking, dressing, and toilet use. Review of the Progress Note from 08/18/23 at 9:18 P.M. revealed Resident #5's vital signs were obtained at 8:00 P.M. The resident's blood pressure was 167/59, pulse was 119, respirations 16, temperature was 96.4 degrees Fahrenheit, and the pulse oximeter (pulse ox) was without a number. The physician was called at 8:05 P.M. and informed of the resident's condition. The physical ordered Resident #5 to be sent to the hospital. At 8:10 P.M. an emergency call was placed, and the Emergency Medical Squad (EMS) arrived at 8.15 P.M. and saw the resident with pulse oximetry on his right finger without a figure, at 8.30 P.M. the resident's pulse ox was 97 percent (%). EMS felt it was no longer necessary to take the resident to the hospital. The physician and daughter were notified. The resident was responsive but very lethargic. The next resident assessment was completed on 08/21/23 at 10:12 A.M. Resident #5 was alert and oriented, forgetful at times. There were no complaints of pain or discomfort. No respiratory distress was noted, pulse ox was 97% on room air. Interview 10/05/23 at 3:43 P.M. with the Director of Nursing (DON) verified there were no assessments for Resident #5 after a change of condition was identified on 08/18/23 at 9:18 P.M. until 08/21/23 at 10:12 A.M. This deficiency represents non-compliance investigated under Complaint Number OH00146849. 365487 Page 2 of 2