Health inspection·April 10, 2025

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a follow-up to a pharmacy recommendation for Resident #51 was completed as required. This affected one (Resident #51) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included dementia, high cholesterol and insomnia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was severely cognitively impaired and required extensive assistance of one staff person for completing her activities of daily living. Review of the pharmacy recommendation for Resident #51 dated 02/09/24 revealed the facilities contracted pharmacist recommended to a review of Resident #51's ordered anti-psychotic medication examined for appropriate diagnoses and necessity. Review of the physician's response to the recommendation revealed Resident #51's primary care physician requested a Psychiatric evaluation to confirm diagnoses and antipsychotic necessity. Review of both the electronic and hard charts revealed no evidence of a psychiatric evaluation. Interview with the Director of Nursing (DON) on 04/08/25 at 2:30 P.M. verified no psychiatric evaluation was completed as instructed by Resident #51's physician in response to the 02/09/24 pharmacist recommendation. Page 1 of 3 365487 365487 04/10/2025 Mount Saint Joseph Rehab Center 21800 Chardon Road Euclid, OH 44117

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure its arbitration agreement contained all necessary information. This had the potential to affect all residents. The facility census was 82. Residents Affected - Many Findings include: Review of the facilities arbitration agreement revealed the agreement did not address the selection of a neutral arbitrator for the arbitration proceedings. Further review of the agreement also revealed it did not address the selection of a neutral venue for arbitration proceedings. The agreement noted Any arbitration conducted pursuant to Article IV (of the admission agreement) shall be conducted at the facility Interview with the Administrator on 04/09/25 at 3:30 P.M. verified the facilities arbitration agreement did not address the selection of a neutral arbitrator or a neutral venue for arbitration proceedings. 365487 Page 2 of 3 365487 04/10/2025 Mount Saint Joseph Rehab Center 21800 Chardon Road Euclid, OH 44117

F 0947 Level of Harm - Potential for minimal 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 record review and interview, the facility failed to ensure certified nurse aides (CNAs) received twelve hours of in-services on an annual basis. This affected one (CNA#546) of three CNAs reviewed for employee files. This had the potential to affect all residents. The facility census was 82. Findings include: Record review of CNA#546's employee file revealed a hire date of 12/27/16. Review of the employee file revealed CNA #546 only received eight hours of continuing education in 2024. Interview with the Administrator on 04/10/25 at 12:04 P.M. confirmed the above findings. 365487 Page 3 of 3