Health inspection·July 28, 2022

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 call lights were maintained within reach of residents. This affected one of four residents reviewed for environmental concerns (Resident #28). The census was 66. Residents Affected - Few Findings include: 1. Observation on 07/25/22 at 9:41 A.M. revealed Resident #28 was in her room sitting in a chair equipped with a chair alarm. Her call light was in the bottom drawer of a dresser to her right, out of her immediate line of sight. It appeared to be out of her reach. Resident #28 was not interviewable. Interview with Registered Nurse #440 on 07/25/22 at 9:49 A.M. confirmed the above findings. She was familiar with Resident #28 and said the resident was capable of using her call light to request help. Following this interview, Registered Nurse #440 brought the padded call light (a call light which activates with light force anywhere on its surface instead of needing a pushed button) into reach of the resident. 2. Observation on 07/26/22 at 8:35 A.M. revealed Resident #28 was in her room sitting in a chair equipped with a chair alarm. Her call light was observed on the floor, out of her immediate reach and line of sight. Interview with the Director of Nursing on 07/26/22 at 8:37 A.M. confirmed the above observation. Following the interview, she placed the call light into Resident #28's reach. Record review of Resident #28 revealed she was admitted [DATE] and had diagnoses including schizoaffective disorder, cerebral infarction, and osteoporosis. Her minimum data set assessment dated [DATE] revealed she needed limited assistance to transfer and walk in her room, and extensive assistance for toileting and hygiene. Her care plan noted she had impaired cognition including forgetfulness and confusion, that she had impaired vision (with a care plan to always keep the call light in the same place), and behaviors including combativeness during care and not using the call light for assistance. Review of her care plan and progress notes for the last three months revealed no specific mention the resident of throwing or discarding her call light. Page 1 of 4 365492 365492 07/28/2022 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

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 notify the responsible party after Resident #18 was found on the floor. This affected one of three residents (#18, #47 and #48) reviewed for notification of change. Findings include: Review of the medical record for Resident #18 revealed an admission date of 01/28/22. Diagnoses included chronic diastolic heart failure, atrial fibrillation, cerebral infarction and osteoarthritis. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had impaired cognition, required extensive assistance for bed mobility, and was totally dependent for transfers. Review of a head to toe assessment dated [DATE] revealed Resident #18 was found on the floor next to her bed, slumped over to her left side. The form indicated neither the family nor the physician were notified. Interview on 07/25/22 at 1:06 P.M. with Resident #18's daughter revealed she was not notified of the incident on 07/10/22 until a few days later. She believed she heard about it from the hospice nurse. Phone interview on 07/27/22 at 2:28 P.M. with Registered Nurse (RN) #436 revealed staff should notify physician, family after an incident. RN #436 said he worked the shift after the incident and did not recall notifying the family or physician regarding the 07/10/22 incident. Interview on 07/28/22 at 8:22 A.M. with RN #439, who was working the night of the incident, revealed she had not notified the physician or the responsible party. She stated she thought the following shift contacted them at a more reasonable time. Interview on 07/28/22 at 9:02 A.M. with the Director of Nursing (DON) revealed the expectation was for staff to notify the physician and the responsible party after any incident within a reasonable timeframe. Review of the facility policy titled Resident Change in Condition Policy, dated 07/02/21 revealed the facility should notify the resident/physician or provider/family/responsible party when there was an incident involving the resident. Review of the facility policy titled Incident/Accident Policy, revised 10/22/21 revealed the facility should notify the provider and responsible party as soon as practicably possible. 365492 Page 2 of 4 365492 07/28/2022 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 record review and interview the facility failed to ensure staff contacted and communicated with hospice staff regarding Resident #18 being found on the floor. This affected one of three residents reviewed for hospice services. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed an admission date of 01/28/22. Diagnoses included chronic diastolic heart failure, atrial fibrillation, cerebral infarction and osteoarthritis. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had impaired cognition, required extensive assistance for bed mobility, and was totally dependent for transfers. Review of the July 2022 physician orders revealed Resident #18 was under the care of hospice. Review of a head to toe assessment dated [DATE] revealed Resident #18 was found on the floor next to her bed, slumped over to her left side. The form indicated neither the family nor the physician were notified. There was no documentation related to notification of hospice. Review of the care plan dated 05/08/22 revealed the facility was to work together with the hospice provider to meet Resident #18's needs including fall interventions. Phone interview on 07/27/22 at 2:28 P.M. with Registered Nurse (RN) #436 revealed staff should notify hospice if involved after an incident. RN #436 said he worked the shift after the incident and did not recall notifying hospice regarding the 07/10/22 incident. Phone interview on 07/27/22 at 2:40 P.M. with Chief Quality Officer (CQO) #461 from the contracted hospice provider revealed the hospice nurse who followed Resident #18 was not available, however CQO #461 had his notes. The notes indicated the hospice nurse was not aware of the incident until his visit on 07/19/22. CQO #461 stated the hospice aide notes indicated she was not aware of the incident on her visit on 7/15/22. CQO #461's expectation was the facility would call at the time of the incident or within a reasonable timeframe so their nurse could make a visit to offer support and services. Interview on 07/28/22 at 8:22 A.M. with RN #439, who was working the night of the incident, revealed she had not notified the hospice provider. She stated she thought the following shift contacted them at a more reasonable time. Interview on 07/28/22 at 9:02 A.M. with the Director of Nursing (DON) revealed the expectation was for staff to notify the hospice provider, if applicable, after any incident within a reasonable timeframe. A subsequent interview with CQO #461 on 07/28/22 at 10:25 A.M. revealed there were no representatives from hospice in the facility on 07/11/22. The hospice provider was in the facility on 07/13/22. 365492 Page 3 of 4 365492 07/28/2022 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 administer medications with an error rate of under 5.0 percent. This affected two (Resident #8 and #42) of six (Resident #6, #14, #49, #8, #20, and #42) residents observed for medication administration. The total census was 66. Residents Affected - Few Findings include: 1. Observation of medication administration for Resident #8 by Licensed Practical Nurse (LPN) #462 on [DATE] at 7:42 A.M. revealed the nurse drew the ordered omeprazole (a gastric acid reducer) from a pill card with a labeled expiration date of [DATE] and placed it in the cup with other medications to be administered. The surveyor confirmed the above finding with LPN #462 at the time of the observation. Following surveyor intervention, LPN #301 discarded the omeprazole and drew a new dose from a container which was not expired. 2. Observation of medication administration for Resident #42 by LPN #425 on [DATE] at 8:23 A.M. revealed one of the medications was one-half pill of metoprolol 25 milligrams (an anti-hypertensive), creating a dose of 12.5 milligrams. The pill was pre-split within the medication card and labeled as having a total dose of 12.5 milligrams per half pill. LPN #201 administered one of these halved pills to the resident. Record review of Resident #42 revealed an order dated [DATE] for 25 milligrams of metoprolol to be given twice daily. Her orders contained no mention of any parallel dose to 12.5 milligrams to be given. The surveyor confirmed the above findings with LPN #425 on [DATE] at 9:46 A.M. The above findings created two medication errors out of 31 total observed medication administrations, creating a medication error rate of 6.4%. This deficiency substantiate Complaint number OH00132181. 365492 Page 4 of 4