Health inspection·August 7, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide care in a dignified manner for Resident #75 related to insulin medication administration and for Resident #42 related to personal/incontinence care. This affected one resident (#75) of three residents observed for insulin administration and one resident (#42) of two residents reviewed for dignity. Findings include: 1. Review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes muscle weakness and heart failure. Review of Resident #75's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #75's physician's orders revealed an order dated 12/21/17 to administer Novolog five units subcutaneously before meals for diabetes and hold if the resident's blood sugar was less than 125. Observation on 08/04/19 at 11:59 A.M. with Registered Nurse (RN) #801 revealed the nurse turned the insulin selector knob to five units on Resident #75's Novolog Flex Pen prior to placing an administration needle on the insulin pen. Resident #75 was observed in the dining room sitting at a table with Residents #36 and #51. Further observation revealed RN #801 informed Resident #75 he was administering the insulin injection, crouched down beside the resident in the dining room on the resident's left side, lifted her shirt and administered the resident's insulin in the left abdomen. Interview on 08/04/19 at 12:03 P.M. with RN #801 confirmed he did not provide Resident #75 with dignity and respect by lifting the resident's shirt in the dining room and administering the insulin with other residents observing the medication administration. 2. Review of Resident #42's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute cystitis with hematuria (blood in the urine), chronic stage three moderate kidney disease, dysuria (discomfort with urinating), and abscess of the testis. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment. The resident required limited assist for transfers, walking, and personal hygiene, supervision with bed mobility, extensive assistance for dressing, toileting, and personal hygiene. Review of care plan dated 06/20/19 revealed focuses for a history of smearing feces, episodes of bowel incontinence, and a self-care deficit. Further review of the care plan revealed a toileting Page 1 of 16 365492 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few program initiated on 01/29/19 due to bladder incontinence with a goal to achieve less than seven episodes of incontinence per week in the next review. However, the care plan did not have a focus, goal or interventions related to toileting behaviors. On 08/04/19 at 10:40 A.M. Resident #42 was observed sitting in a wheelchair wearing a wet incontinence brief and no pants. The wheelchair seat was wet, and underneath the wheelchair was a urine-smelling puddle of liquid. Resident #42's bed was observed to be yellow-tinged and saturated. The room had a strong foul odor. Interview on 08/04/19 at 11:20 A.M. with State Tested Nursing Assistant (STNA) #859 verified the above observation. On 08/05/19 at 11:17 A.M. Resident #42 was observed sitting in his room, and the room had a strong urine odor. On 08/05/19 at 3:12 P.M. a strong foul urine odor was observed at the doorway of Resident #42's room. Interview on 08/05/19 at 3:13 P.M. with STNA #862 verified the strong foul urine odor coming from Resident #42's room, and indicated the odor was there daily because Resident #42 was so incontinent, and often the urine goes all over the bed and the floor. Interview on 08/05/19 at 4:24 P.M. with Licensed Practical Nurse (LPN) #875 revealed Resident #42 used incontinence briefs daily and often urinated on the floor. LPN #875 stated Resident #42 would put urine soaked or soiled clothes into the closet, or put the same soiled clothes on. Interview on 08/05/19 at 4:33 P.M. with Unit Manager #874 revealed Resident #42's room odor was behavioral from throwing briefs on the floor under the bed and urinating on the floor on purpose. Interview on 08/05/19 at 5:24 P.M. Nurse Practitioner (NP) #900 revealed Resident #42 had a history of toileting behaviors and his incontinence was not a physical problem. NP #900 indicated Resident #42 experienced pain using the urinal due to the scrotal abscess which would contribute to why he urinated on the floor and had depression. Interview on 08/06/19 at 7:12 A.M. with LPN #804 revealed Resident #42 would take himself to the bathroom but urinate on the floor, or would have the urinal and still urinate on the floor. LPN #804 stated Resident #42 placed incontinent clothes into the closet. LPN #804 verified Resident #42's room had a strong foul odor daily. Interview on 08/06/19 at 7:32 A.M. with Housekeeping #877 revealed Resident #42's room was cleaned once daily after lunch due to hoarding drinks. Housekeeping #877 verified Resident #42's room had a daily foul odor. Housekeeping #877 indicated Resident #42 was often incontinent on the floor but only the aides could clean it up and had to call housekeeping afterward for sanitizing. Interview on 08/06/19 at 7:38 A.M. with Housekeeping #818 revealed Resident #42's room was cleaned once daily after lunch because Resident #42 made the most mess with his food and juice. Housekeeping #818 also verified Resident #42's room had a strong foul odor daily. Housekeeping #818 indicated Resident #42 was incontinent with urine daily all over his bed, and the trash was regularly filled with wet incontinent pads. Housekeeping #818 also explained the aides were responsible to clean up any 365492 Page 2 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few puddles of urine and call housekeeping to sanitize. Housekeeping #818 indicated the aides or nurses had requested repeat sanitizing about four times each month. Interview on 08/06/19 7:47 A.M. with STNA #806 revealed Resident #42 urinated on the floor at least two to three times each shift, and placed urine soaked or stool soiled clothes under the bed, or into the chair or closet. STNA #806 verified the aides cleaned up any visible urine or stool on the floor and called housekeeping to sanitize. Interview on 08/06/19 at 9:59 A.M. with LPN #872 indicated Resident #42 voided in places such as on the floors, on mats, and in garbage cans. Interview on 08/06/19 at 10:57 A.M. with Therapist #873 revealed Resident #42 did not receive Occupational therapy focused on toileting due to the issues were related to behaviors of non-compliance such as throwing wet briefs on the floor and not physical, so treatment was not warranted. Interview on 08/06/19 at 7:22 A.M. with Maintenance #871 verified Resident #42's room was on an established once daily room cleaning curriculum for after lunch, but there was no special program to clean more than once a day. Review of undated policy titled Housekeeping Responsibilities revealed when housekeepers observe potential maintenance issues or resident problems, report them to maintenance. 365492 Page 3 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview the facility failed to check all potential new hires against the State nurse aide registry (NAR) to ensure no employee had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. This affected 14 Licensed Practical Nurses (LPNs), three Registered Nurses (RNs), three housekeeping staff, one Laundry staff, eight dietary staff and two Administrative staff whose personnel files were reviewed and had the potential to affect all 70 residents residing in the facility. Residents Affected - Many Findings include: Review of a document titled Nurse Aide Roster, dated 08/07/19 revealed the record reflected 22 State tested nursing assistants currently employed at the facility. There were no other employees listed on the Nurse Aide Roster. Review of a document titled Employee Listing, dated 08/07/19 revealed the record reflected 14 Licensed Practical Nurses (LPNs), three Registered Nurses (RNs), three housekeeping staff, one Laundry staff, eight dietary staff and two Administrative staff who had been hired since the last annual recertification survey, dated 07/19/18. Record review revealed no evidence these employees had been checked on the State NAR. On 08/07/19 at 10:51 A.M. interview with Director of Human Resources and Payroll (DHRP) #846 verified she had not been checking all potential new hire staff against the nurse aide registry. DHRP #846 explained she asked potential new hires if they historically worked in long term care and/or had been a nurse aide at any time. DHRP #846 stated if they said yes or indicated on their application they had then she would check them on the nurse aide registry. DHRP #846 revealed she did check all LPNs and RNs against the nurse aide registry but had no evidence of the nurse aide registry checks in the employee files for the LPN and RN staff. 365492 Page 4 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure Resident #4's care plan was revised to reflect oxygen titration and failed to ensure Resident #42's care plan was revised to reflect toileting behaviors. This affected two residents (#4 and #42) of five residents reviewed for care planning. Findings include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, acute respiratory failure, and hypertension. Review of the physician's orders dated 04/05/19 indicated Resident #4 was to be weaned off oxygen if tolerated and to keep her pulse oximetry above 92 percent every shift. An additional order dated 02/02/19 indicated oxygen at one liter per minute via nasal cannula to titrate for a pulse oximetry of 92 percent. Review of a physician order dated 02/17/19 indicated to change any oxygen tubing weekly and as needed on night shift on Sundays for oxygen care. Review of monthly nursing note dated 07/21/19 revealed Resident #4 used oxygen intermittently. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/22/19 revealed the resident had no cognitive impairment. The resident required extensive assistance for dressing, toileting, and personal hygiene, and needed supervision and setup for eating and walking. Review of care plan dated 07/29/19 revealed a focus area of Resident uses oxygen. However, the care plan did not have a goal or interventions related to oxygen use or titration. On 08/04/19 at 12:47 P.M. Resident #4 was observed in the dining room with an oxygen tank attached to the back of the wheelchair and the nasal cannula laying at her side. An interview with Resident #4 during the observation revealed she was weaning herself off the oxygen and used it only when she really needed it. Resident #4 further explained the nurses were aware. On 08/06/19 at 10:49 A.M. Resident #4 was observed sitting up in her wheelchair with an oxygen tank attached to the back of the wheelchair, an additional oxygen concentrator in the room was on and the nasal cannula was laying on the bed. An interview with Resident #4 during the observation revealed the nurses check her pulse oximetry at least once every morning and the oxygen was left on so she can use it when she feels short of breath. Interview on 08/06/19 at 7:06 A.M. with Licensed Practical Nurse (LPN) #804 verified Resident #4's oxygen was titrated to keep her pulse oximetry at 92 percent. LPN #804 indicated Resident #4's pulse oximetry was checked twice daily, recorded on the medication administration record, and oxygen was applied when needed. LPN #804 further explained Resident #4 was monitored periodically and assessed as needed. Interview on 08/07/19 at 9:27 A.M. with Registered Nurse (RN) #870 verified Resident #4's care plan was not revised to reflect oxygen use and titration by nursing staff. 2. Review of Resident #42's medical record revealed the resident was admitted to the facility on 365492 Page 5 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [DATE] with diagnoses including acute cystitis with hematuria (blood in the urine), chronic stage three moderate kidney disease, dysuria (discomfort with urinating), and abscess of the testis. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment. The resident required limited assist for transfers, walking, and personal hygiene, supervision with bed mobility, extensive assistance for dressing, toileting, and personal hygiene. Review of care plan dated 06/20/19 revealed focuses for a history of smearing feces, episodes of bowel incontinence, and a self-care deficit. Further review of the care plan revealed a toileting program initiated on 01/29/19 due to bladder incontinence with a goal to achieve less than seven episodes of incontinence per week in the next review. However, the care plan did not have a focus, goal or interventions related to toileting behaviors. On 08/04/19 at 10:40 A.M. Resident #42 was observed sitting in a wheelchair wearing a wet incontinence brief and no pants. The wheelchair seat was wet, and underneath the wheelchair was a urine-smelling puddle of liquid. Resident #42's bed was observed to be yellow-tinged and saturated. The room had a strong foul odor. Interview on 08/04/19 at 11:20 A.M. with State Tested Nursing Assistant (STNA) #859 verified the above observation. On 08/05/19 at 11:17 A.M. Resident #42 was observed sitting in his room, and the room had a strong foul urine odor. On 08/05/19 at 3:12 P.M. a strong foul urine odor was observed at the doorway of Resident #42's room. Interview on 08/05/19 at 3:13 P.M. with STNA #862 verified the strong foul urine odor coming from Resident #42's room, and indicated the odor was there daily because Resident #42 was so incontinent, and often the urine goes all over the bed and the floor. Interview on 08/05/19 at 4:24 P.M. with LPN #875 revealed Resident #42 used incontinence briefs daily and often urinated on the floor. LPN #875 stated Resident #42 would put urine soaked or soiled clothes into the closet, or put the same soiled clothes on. Interview on 08/05/19 at 4:33 P.M. with Unit Manager #874 stated Resident #42's room odor was behavioral from throwing briefs on the floor under the bed and urinating on the floor on purpose. Interview on 08/05/19 at 5:24 P.M. Nurse Practitioner (NP) #900 revealed Resident #42 had a history of toileting behaviors and his incontinence was not a physical problem. NP #900 indicated Resident #42 experienced pain using the urinal due to the scrotal abscess which would contribute to why he urinated on the floor and had depression. Interview on 08/06/19 at 7:12 A.M. with LPN #804 revealed Resident #42 would take himself to the bathroom but urinate on the floor, or would have the urinal and still urinate on the floor. LPN #804 stated Resident #42 placed incontinent clothes into the closet. LPN #804 verified Resident #42's room had a strong foul odor daily. Interview on 08/06/19 7:47 A.M. with STNA #806 revealed Resident #42 urinated on the floor at least 365492 Page 6 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few two to three times each shift, and placed urine soaked or stool soiled clothes under the bed, or into the chair or closet. STNA #806 verified the aides cleaned up any visible urine or stool on the floor and called housekeeping to sanitize. Interview on 08/07/19 at 9:27 A.M. with RN #870 verified Resident #42's care plan was not revised to reflect toileting behaviors. Review of policy titled Care Plan, last revised 04/06/17, revealed there may be additional problem areas not triggered by the MDS, which would need to be addressed in the Care Plan. The MDS Coordinator was to review the 24-Hour Report daily for significant changes or changes in resident's ADL status and the Care Planning coordinator would add minor changes in resident's status to the existing Care Plans on a daily basis. 365492 Page 7 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

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 observation, record review and interview the facility failed to ensure Resident #23's wound care was completed as ordered in the physician orders and failed to ensure treatment orders were documented accurately for the resident. This affected one resident (Resident #23) of one resident reviewed for non-pressure related skin conditions. Residents Affected - Few Findings include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including essential hypertension, muscle weakness and altered mental status. Review of Resident #23's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #23's physician's orders revealed an order dated 07/30/19 to cleanse the wound with normal saline, pat dry, apply Vaseline with a Q-tip to the wound, cover with a non-adherent dressing and secure with paper tape every day shift for wound care for four weeks. Review of Resident #23's medication administration record (MAR) and treatment administration record (TAR) from 08/01/19 to 08/04/19 revealed the wound care was documented as completed on 08/01/19 and 08/03/19. The date of 08/02/19 for Resident #23's wound care did not have staff initials and was blank on the TAR. Observation on 08/04/19 at 2:30 P.M. revealed Resident #23 had a wound dressing on the top right side of his head and the dressing was dated 08/01/19. Interview on 08/04/19 at 2:15 P.M. with Resident #23 indicated he had skin cancer to his scalp area and he wished the dressing would be completed more often than every couple of days. Interview on 08/04/19 at 2:43 P.M. with the Director of Nursing (DON) confirmed the dressing on Resident #23's top right side of his head was dated 08/01/19 and the wound care was not completed per the physician orders. In addition, observation on 08/06/19 at 10:39 A.M. with Licensed Practical Nurse (LPN) #802 revealed Resident #23's wound dressing on the resident's right side of his head was a border foam dressing. Interview on 08/06/19 at 10:41 A.M. with LPN #802 confirmed the wound dressing she removed from Resident's #23's right side of his head was a border foam dressing and not a non-adherent dressing with paper tape as ordered by the physician. Interview on 08/06/19 at 11:07 A.M with LPN #803 indicated she obtained a physician order from the nurse practitioner for a border foam dressing to be applied to Resident #23's right side of his head on 08/01/19 and did not put the order in the computer or the resident's record. LPN #803 verified she passed the order verbally to the next shift nursing staff during report. Review of the undated Wound and Dressing Care policy indicated to follow the physician's order for the type and frequency of treatment. 365492 Page 8 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #130's right buttock pressure ulcer dressing was completed as ordered by the physician. This affected one resident (#130) of two residents reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of Resident #130's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including essential hypertension, weakness and diabetes type two. Review of Resident #130's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #130's physician orders revealed an order dated 07/31/19 to cleanse area to the buttocks with normal saline, pat dry, apply zinc oxide and cover with a foam dressing every night shift for skin care. Review of Resident #130's biweekly skin observation form, dated 08/01/19 revealed the resident had a right gluteal fold pressure ulcer with an open area to the lower portion. Review of Resident #130's medication administration record (MAR) and treatment administration record (TAR) from 08/01/19 to 08/06/19 revealed staff documented the resident's wound care was completed on 08/01/19, 08/02/19, 08/03/19 and 08/04/19. Neither the MAR or TAR reflected the resident's coccyx wound care was completed on 08/05/19 as ordered. Observation on 08/06/19 at 2:45 P.M. with Licensed Practical Nurse (LPN) #804 and LPN #805 of Resident #130's right buttock (right gluteal fold) pressure ulcer with State Tested Nursing Assistant (STNA) #806 providing assistance to the nurses revealed the wound dressing that was in place was dated 08/01/19. Interview on 08/06/19 at 3:06 P.M. with STNA #806 confirmed Resident #130's right buttock wound dressing was dated 08/01/19. Review of the undated Wound and Dressing Care policy indicated to follow the physician's order for the type and frequency of treatment. 365492 Page 9 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

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, record review and interview the facility failed to ensure urinary catheter drainage collection bags were maintained in a clean, sanitary manner and off the floor to prevent the risk of developing a urinary tract infection. This affected two residents (#283 and #52) of seven residents identified to have urinary catheters. Findings include: 1. Record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, sepsis and urinary tract infection. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/28/19 revealed Resident #52 required total dependence of two staff for all activities of daily living (ADL) and had a urinary catheter. Resident #52 was assessed to be severe cognitively impaired. Review of laboratory testing results, dated 08/04/19 revealed the resident's urine was positive for the bacteria Pseudomonas aeruginosa and Escherichia coli extended-spectrum beta-lactamases (ESBL) resulting in the physician ordering the antibiotic Cipro 500 milligrams twice a day until 08/12/19. Observation on 08/05/19 at 7:28 A.M., 08/06/19 at 5:00 P.M. and 08/07/19 at 9:40 A.M. revealed the resident's urinary catheter bag was directly on the floor. On 08/05/19 at 7:28 A.M. and on 08/07/19 at 9:40 A.M. Licensed Practical Nurse (LPN) #808 verified the urinary catheter was on the floor. Review of the undated facility policy titled Catheter care urinary male-female revealed the catheter bag was to be hung on the bed frame and avoid letting it touch the floor. 2. Review of Resident #283's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including urinary tract infection, chronic kidney disease, and malignant neoplasm of the bladder. Review of a physician's order, dated 07/23/19 indicated an indwelling urinary catheter was to be maintained to a continuous drainage bag and changed as needed, the catheter bag was to be covered every shift, catheter care was to be provided every shift and as needed, and catheter output was to be documented every shift. Review of the quarterly MDS 3.0 assessment, dated 07/26/19 revealed the resident had no cognitive impairment. The resident required extensive assist with bed mobility, dressing, toileting, and personal hygiene, limited assistance with transfers and walking, and supervision with eating, Review of skilled nursing note dated 08/03/19 revealed Resident #283 was skilled for a urinary tract infection and bladder cancer. On 08/04/19 at 11:55 A.M. Resident #283 was observed lying in bed with his catheter bag laying flat on the floor at the left side of the bed. 365492 Page 10 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0690 Level of Harm - Minimal harm or potential for actual harm Interview on 08/04/19 at 12:01 P.M. with State Tested Nursing Assistant #859 verified the catheter bag was laying flat on the floor. Review of the undated facility policy titled Catheter care urinary male-female revealed the catheter bag was to be hung on the bed frame and avoid letting it touch the floor. Residents Affected - Few 365492 Page 11 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain a medication error rate of less than 5% (percent). The medication error rate was calculated to be 11.11% and included three medication errors of 27 medication administration opportunities. This affected two residents (#16 and #75) of six residents observed for medication administration. Residents Affected - Few Findings include: 1. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including fibromyalgia, type two diabetes mellitus without complications and muscle weakness. Review of Resident #16's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #16's physician's orders revealed an order, dated 07/26/19 for Humulin N KwikPen (long acting insulin) inject 46 units subcutaneously in the afternoon for routine monitoring and an order dated 02/26/19 for Novolog (short acting insulin) inject as per sliding scale if 0 to 100 give no units, 101 to 150 give five units, 151 to 200 give eight units, 201 to 250 give twelve units, 251 to 300 give sixteen units, 301 to 350 give twenty units, 351 to 999 call the physician before meals for diabetes. Review of Resident #16's medication administration record (MAR) from 08/01/19 to 08/04/19 revealed the Humulin N with an administration time of 11:00 A.M. was administered per the physician order and the resident's blood sugar on 08/04/19 at 11:00 a.m. was 202 with 12 units of Novolog insulin administered. Observation on 08/04/19 at 11:51 A.M. revealed Registered Nurse (RN) #801 administered Resident #16's lunch medication administration. The RN turned the Novolog Flex Pen (short acting insulin) insulin dose selector knob to twelve units before placing an administration needle on the insulin pen. RN #801 then turned the Humulin N Flex Pen or Qwikpen (long acting insulin) dose selector knob to forty-six units before placing an administration needle on the insulin pen. RN #801 knocked on Resident #16's door and notified the resident it was time for her insulin before administering the Novolog insulin in her right abdomen and the Humulin N insulin in the left abdomen. RN #801 did not prime either of the insulin Flex Pens after the insulin administration needle was placed on the pens as required to ensure the correct dose of the medications were administered. Interview on 08/04/19 at 12:03 P.M. RN #801 confirmed he was unaware that he had to prime insulin Flex Pens prior to administration of insulin per the manufacturer insert or directions. 2. Review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes muscle weakness and heart failure. Review of Resident #75's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #75's physician's orders revealed an order dated 12/21/17 to administer Novolog five units subcutaneously before meals for diabetes and hold if the resident's blood sugar was less than 125. 365492 Page 12 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #75's medication administration record (MAR) from on 08/04/19 revealed the resident's blood sugar was 131 and five units of Novolog was administered for the 12:00 P.M. medication time documented on the MAR. Observation on 08/04/19 at 11:59 A.M. with RN #801 revealed the nurse turned the insulin selector knob to five units on Resident #75's Novolog Flex Pen prior to placing an administration needle on the insulin pen. Resident #75 was observed in the dining room sitting at a table with Residents #36 and #51. RN #801 took Resident #75's Novolog insulin into the dining room, told the resident he was administering the insulin, crouched down beside the resident in the dining room on the resident's left side, lifted her shirt and administered the resident's insulin in the left abdomen. RN #801 did not prime the insulin Flex Pen after the insulin administration needle was placed on the pen as required to ensure the correct dose of the medication was administered. Interview on 08/04/19 at 12:03 P.M. with RN #801 confirmed he was unaware he had to prime Flex Pens prior to administration of insulin per the manufacturer insert or directions. Review of A Guide to Using Your Novolog Flex Pen form, dated May 2016 confirmed the steps to administering insulin included to remove the cap, attach a new needle, prime your pen by turning the dose selector to two units and then press and hold the dose button making sure a drop appears, select your dose and give the injection. 365492 Page 13 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on record review and staff interview the facility failed to ensure current contracted Hospice service providers were listed on the Facility Assessment. This had the potential to affect all 70 residents residing in the facility. Findings include: An interview was conducted on 08/07/19 at 11:34 A.M. with the Director of Nursing who revealed there were two local Hospice providers contracted with the facility to provide services to those residents in need of Hospice services: Hospice provider #1 and Hospice provider #2. Review of the two agreements for services revealed an agreement with Hospice provider #1 dated 10/12/15 and an agreement with Hospice provider #2 dated 01/01/19. Review of the Facility Assessment, with a review date of 07/16/19 revealed the assessment did not list the contracts for the provision of services by Hospice Provider #1 or #2. The document did list a Hospice provider no longer providing services to residents in the facility. On 08/07/19 at 11:44 A.M. interview with the Director of Nursing verified the current Facility Assessment was not updated to include the services of Hospice provider #1 and #2. 365492 Page 14 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain adequate infection control practices to prevent the spread of infection during medication administration for Resident #16 and Resident #75 and during wound care for Resident #51. This affected two residents (#16 and #75) of six residents observed for medication administration and one resident (#51) of three residents reviewed for wound care. Residents Affected - Few Findings include: 1. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including fibromyalgia, type two diabetes mellitus without complications and muscle weakness. Review of Resident #16's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #16's physician's orders revealed an order dated 07/26/19 for Humulin N KwikPen inject 46 units subcutaneously in the afternoon for routine monitoring and an order dated 02/26/19 for Novolog inject as per sliding scale if 0 to 100 give no units, 101 to 150 give five units, 151 to 200 give eight units, 201 to 250 give twelve units, 251 to 300 give sixteen units, 301 to 350 give twenty units, 351 to 999 call the physician before meals for diabetes. Observation on 08/04/19 at 11:51 A.M. revealed Registered Nurse (RN) #801 was observed administering Resident #16's lunch medication. The RN used a Novolog Flex Pen (short acting insulin) and turned the insulin dose selector knob to twelve units before placing an administration needle on the insulin pen. RN #801 then used a Humulin N Flex Pen or Qwikpen (long acting insulin) and turned the insulin dose selector knob to forty-six units before placing an administration needle on the insulin pen. RN #801 knocked on Resident #16's door and notified the resident it was time for her insulin before administering the Novolog in her right abdomen and the Humulin N in the left abdomen. During the observation, RN #801 did not wash his hands prior to administration of Resident #16's insulin or put gloves on prior to administration of the insulin and did not wash his hands following the administration of the insulin. Interview on 08/04/19 at 12:03 P.M. with RN #801 confirmed he should have washed his hands and put on gloves but it was no big deal as he did not touch the needle portion of the insulin Flex Pen prior to administering Resident #16's insulin. 2. Review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes muscle weakness and heart failure. Review of Resident #75's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #75's physician's orders revealed an order dated 12/21/17 to administer Novolog five units subcutaneously before meals for diabetes and hold if the resident's blood sugar was less than 125. On 08/04/19 at 11:59 A.M. RN #801 was observed to come out Resident #16's room and returned to the medication administration cart. The nurse then took Resident #75's Novolog Flex Pen out of the medication cart and turned the insulin selector knob to five units prior to placing an administration 365492 Page 15 of 16 365492 08/07/2019 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needle on the insulin pen. Resident #75 was observed in the dining room sitting at a table with Resident #36 and #51. RN #801 took Resident #75's Novolog insulin into the dining room, told the resident he was administering the insulin, crouched down beside the resident in the dining room on the resident's left side, lifted her shirt and administered the resident's insulin in the left abdomen. During the observation, RN #801 did not wash his hands prior to the administration of the insulin or put gloves on prior to the administration of the insulin and did not wash his hands following administration of the insulin. Interview on 08/04/19 at 12:03 P.M. with RN #801 confirmed he should have washed his hands and put on gloves but it was no big deal as he did not touch the needle portion of the insulin Flex Pen prior to administering Resident #75's insulin. Review of the Insulin Administration policy, dated 10/15/15 revealed only the person who draws up the insulin for the injection can inject it. The policy revealed to wash hands and apply gloves, perform subcutaneous injection and then wash hands. 3. Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including functional quadriplegia, epilepsy and diabetes mellitus II. Review of a weekly wound assessment, dated 08/06/19 revealed Resident #51 had an unstageable wound on her sacral area. Record review revealed the resident had a physician's order to cleanse the area to the sacrum, pat dry, apply Santyl and moist gauze and cover with an absorbent dressing. On 08/06/19 at 11:01 A.M., Licensed Practical Nurse (LPN) #800 was observed completing a dressing change for Residents #51's sacral wound. The LPN placed her supplies on a clean towel which she placed on the bedside table. She then washed her hands, applied gloves and removed the old dressing. Without first removing her soiled gloves or washing her hands, LPN #800 proceeded to clean the wound area with a clean 4 x 4 gauze pad that she saturated with normal saline. On 08/06/19 at 11:10 A.M., LPN #800 verified she did not remove her gloves or wash her hands after removing the old dressing and prior to cleaning the resident's sacral wound. Review of the facility policy titled wound management, dated 01/18/17 revealed a resident was to receive care consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. 365492 Page 16 of 16