Health inspection·November 7, 2023

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and review of facility policy the facility failed to ensure Resident #18's oxygen E cylinders (a portable three-foot-tall aluminum tank with compressed oxygen) were not misappropriated for other resident's use. This affected one resident (#18) out of three residents (#18, #35 and #45) reviewed for misappropriation of oxygen and had the potential to affect 14 residents (#7, #17, #18, #31, #34, #36, #37, #45, #46, #47, #51, #54, #63, and #74) with orders for oxygen. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed an admission date of 09/29/18 with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety, and dementia. Review of the care plan dated 01/26/21 revealed Resident #18 was on oxygen therapy. Interventions included administering oxygen as ordered, assessing pulse oximetry as indicated, assess, monitor, and educate resident on signs of respiratory distress, and provide portable oxygen. Review of the Hospice Initial Certification dated 03/25/23 and completed by Hospice Medical Director #610 revealed Resident #18 had a terminal diagnosis of COPD. He was dependent on continuous oxygen. Review of the Hospice Facility Reimbursement at admission Form dated 03/25/23 and completed by Hospice Register Nurse (RN) #609 revealed hospice would supply Resident #18's oxygen. Review of the care plan dated 03/30/23 revealed Resident #18 was on hospice services. Interventions included hospice would collaborate care with facility staff, contact hospice for changes in resident condition, and medications as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had impaired cognition. He used a wheelchair for locomotion and was able to wheel his wheelchair 50 feet with two turns independently. He had oxygen. Review of email dated 10/31/23 at 12:50 P.M. sent to the Hospice Administration by State Tested Nursing Assistant (STNA) #606 revealed per STNA #607 at the facility, Resident #18 was out of oxygen tanks as the facility had other residents that went on appointments and took Resident #18's four oxygen tanks. The email revealed Resident #18 had no portable oxygen left to use and was using his oxygen concentrator. Review of the November 2023 physician orders revealed Resident #18 had an oxygen order dated Page 1 of 6 365492 365492 11/07/2023 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 05/22/23 for two to five liters per minute via nasal cannula and may titrate for shortness of breath and maintain oxygen saturation rate above 92 percent. He also had an order for hospice services dated 03/27/23. Interview on 11/06/23 at 8:01 A.M. with Resident #18 revealed he was confused in the interview and unable to provide details regarding his oxygen. Observation on 11/06/23 from 11:42 A.M. to 12:20 P.M. revealed Resident #18 was able to independently self-propel in his wheelchair throughout the facility and had a portable E cylinder on the back of his wheelchair. Interview on 11/06/23 at 1:53 P.M. with Hospice Nurse Practitioner (NP)/ Chief Quality Officer #621 revealed Hospice STNA #606 had gone into the facility on [DATE] and discovered the facility was using Resident #18's portable oxygen for other residents. She revealed Resident #18 no longer had any portable oxygen to use and had to use an oxygen concentrator. She revealed STNA #606 contacted hospice administration by email of the issue, and hospice ordered Resident #18 more portable oxygen. She revealed Resident #18 was then limited with his ability to get around throughout the facility as he was not able to freely get around because he was hooked up to an oxygen concentrator. Interview on 11/06/23 at 4:43 P.M. with the Director of Nursing (DON) revealed she had never had staff use Resident #18's portable E cylinder for other residents' use. She verified Resident #18's oxygen was supplied by hospice for his own personal use. Interview on 11/07/23 at 7:51 A.M. with STNA #607 revealed there was one day a few weeks ago that Resident #51 had an appointment out of the facility and needed one portable E cylinder and Resident #74 was scheduled to go on a home visit and needed three portable E cylinders. She revealed the facility had no portable oxygen in the facility to send with Resident #51 and Resident #74. She revealed she told the DON the issue who told her to use Resident #18's portable oxygen E cylinders. She revealed she retrieved one E cylinder out of his room for Resident #51 to go on her appointment. She revealed she knew staff also took three other E cylinders from his room for Resident #74. She verified that she knew that hospice supplied Resident #18 with his personal portable oxygen E cylinders and that it was not the facility oxygen. She verified Resident #18 was left with no portable oxygen to use and had to only use his oxygen concentrator. She verified Resident #18 was independent in propelling his wheelchair throughout the facility and was unable to do this when he was without portable oxygen. Interview on 11/07/23 at 8:19 A.M. with Hospice STNA #606 revealed on 10/31/23 she came into the facility to care for Resident #18 and found him trying to propel his wheelchair, but he was connected to his concentrator. She revealed she went to obtain one of his a portable E cylinders as she had known that four cylinders were recently delivered but that there was none in his room. She revealed she asked STNA #607 that was assigned to his unit where his E cylinders had gone, and STNA #607 stated that they used his E cylinders on other residents as the other residents had appointments out of the facility. She revealed STNA #607 stated the facility did not have any portable E cylinders to use for the other residents. She revealed Resident #18 had no portable oxygen left and he had to remain connected to his oxygen concentrator instead of using portable oxygen. She revealed Resident #18 enjoyed propelling throughout the facility independently in his wheelchair and not confined to one space. She revealed she notified her team lead; Hospice Licensed Social Worker #608 of the concern, and she ordered Resident #18 more oxygen E cylinders. 365492 Page 2 of 6 365492 11/07/2023 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0602 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Ohio Resident Abuse Policy, dated 08/30/23, revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents and misappropriation of resident property by anyone. The policy revealed misappropriation was the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Residents Affected - Few This deficiency represents non-compliance investigated under Master Complaint Number OH00147974. 365492 Page 3 of 6 365492 11/07/2023 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, closed record review, facility policy review and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of pressure ulcers for Resident #76. Residents Affected - Few Actual Harm occurred on 08/26/23 when Resident #76, who was a paraplegic and required extensive assistance to total dependence from staff for activities of daily living (ADL) including bed mobility, toileting, and transfers was found to have an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his sacrum (area at the base of the spinal cord) and a deep tissue injury (an injury to the soft tissue under the skin due to pressure and was usually over a boney prominence) to his right buttock. There was no documented evidence adequate interventions and monitoring were in place to prevent the development of these wounds or to ensure the wounds were identified prior to being an unstageable and/ or a deep tissue injury. This affected one resident (#76) of three residents reviewed for pressure ulcers. Findings include: Review of the closed medical record for Resident #76 revealed an admission date of 07/26/23. Resident #76 was discharged home on [DATE]. Resident #76 had diagnoses including paraplegia, spinal stenosis, muscle weakness, and injury of the thoracic spinal cord. Review of admission Weekly Skin Evaluation dated 07/26/23 and completed by Licensed Practical Nurse (LPN)/ Assistant Director of Nursing (ADON) revealed Resident #76 had no skin issues on admission. Review of care plan dated 07/27/23 revealed Resident #76 had the potential for skin breakdown related to incontinence of bowel and paraplegia. Interventions included complete a Braden scale risk assessment and skin checks per protocol, turn and reposition as indicated, pressure relieving devices as indicated, and skin assessments per protocol. Review of care plan dated 07/27/23 revealed Resident #76 had ADL self-care deficit related to paraplegia, thoracic spinal cord injury, impaired mobility, and required staff assistance to complete his ADL's. Interventions included transfer with two staff assist, and assist with ADL's including dressing, grooming, and toileting. Review of admission/ Medicare five-day Minimum Data Set (MDS) 3.0 assessment, dated 08/01/23 revealed Resident #76 had intact cognition. The assessment revealed the resident required extensive assistance from one staff with bed mobility and toileting, total dependence on two staff with transfers and an inability to ambulate. The assessment also noted the resident was at risk for pressure ulcers but had no pressure ulcers on admission. Review of Weekly Skin Evaluation dated 08/20/23 and completed by LPN #603 revealed Resident #76 had no skin issues. Review of Braden Scale Pressure Ulcer Risk assessment dated [DATE] and completed by the Director of Nursing (DON) revealed the resident was at risk for developing pressure ulcers as he was slightly limited with sensory perception, occasionally moist, chairfast, his mobility was slightly limited, and he had a potential problem with friction and shear. 365492 Page 4 of 6 365492 11/07/2023 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of Weekly Skin Evaluation dated 08/26/23 and completed by Registered Nurse (RN) #601 revealed Resident #76 had newly identified skin issues that included an unstageable pressure wound to his sacrum area and a deep tissue injury to his right buttock. Review of a nursing note dated 08/26/23 at 6:23 P.M. and completed by RN #601 revealed Resident #76 had an in house acquired unstageable pressure wound to his sacrum area that measured a length of 5.0 centimeter (cm), width of 10.0 cm, and depth of 0.1 cm. The note revealed the skin impairment was not noted on admission and was a new wound. The note revealed Primary Care Physician #602 was notified and ordered treatment for the area. Review of nursing note dated 08/26/23 at 6:49 P.M. and completed by RN #601 revealed Resident #76 had an in house acquired deep tissue injury to his right buttocks that measured a length of 5.0 cm, width of 9.0 cm, and the depth was unable to be determined. The note revealed the skin impairment was not present on admission and was a new wound. The note revealed the Primary Care Physician #602 was notified and ordered treatment for the area. Review of Weekly Wound assessment dated [DATE] and completed by RN #601 revealed Resident #76 had an unstageable pressure ulcer to his sacrum area that measured a length of 5.0 cm, width of 10.0 cm and a depth of 0.1 cm. The assessment revealed the wound was facility acquired and was identified that day, 08/26/23. The assessment revealed under wound bed appearance that it was marked as N/A (not applicable) and the peri wound appearance was pink. Review of Weekly Wound assessment dated [DATE] and completed by RN #601 revealed Resident #76 had a deep tissue injury to his right buttock that measured a length of 5.0 cm, width of 9.0 cm, and the depth was unable to be determined. The assessment revealed the wound was facility acquired and was identified that day, 08/26/23. There was no drainage, and the peri wound was pink. Review of facility form labeled, Pressure Injury Avoid Ability Analysis (that was submitted to the surveyor on 11/08/23 prior to exit after this concern was brought to facility attention) signed per Wound Physician #604 and dated 09/08/23 revealed based on the interdisciplinary analysis of the resident's condition he felt the sustained pressure ulcers were unavoidable. The analysis revealed Resident #76 was a paraplegic and had failure to thrive/ protein malnutrition (However, Resident #76 had no weight loss as his weight per the assessment was 237 pounds and his admission weight was 216 pounds). He had bilateral lower and upper extremity edema and muscle wasting. He was alert, chair bound, limited with mobility and Resident #76 agreed to pressure reduction interventions. (Wound Physician #604 had not evaluated Resident #76 until 09/22/23 as this was his initial evaluation and only evaluation while Resident #76 resided at the facility). Review of Weekly Wound assessment dated [DATE] and completed by RN #601 revealed Resident #76 had an unstageable pressure ulcer to his sacrum area that measured a length of 6.0 cm, width of 6.4 cm, and the depth was unable to be determined. The area had moderate amount of serous drainage and contained 20 percent slough. Record review revealed an order to clean his wound with Dakin's (antiseptic) solution, apply Santyl (ointment used to remove damaged tissue) to the wound bed, and cover with calcium alginate (highly absorbent dressing) and foam dressing. Review of Wound Physician #604's progress note dated 09/22/23 revealed he completed an initial evaluation for Resident #76's sacrum wound and classified as an unstageable pressure ulcer that measured a length of 6.0 cm, width of 6.4 cm and the depth was unable to be determined. The wound bed involved muscle and 20 percent slough. The note revealed the drainage was moderate with excoriation noted 365492 Page 5 of 6 365492 11/07/2023 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0686 Level of Harm - Actual harm to the peri wound area. Resident #76 also was initially evaluated for his wound to his right buttock that was also classified as an unstageable pressure ulcer and his wound bed was covered with 100 percent moist eschar (dead tissue). His right buttock measured a length of 7.4 cm, width of 4.5 cm, and the depth was unable to be determined. Residents Affected - Few Review of Weekly Wound assessment dated [DATE] and completed by RN #601 revealed Resident #76 continued to have an unstageable pressure area to his right buttock that measured a length of 7.4 cm, width of 4.5 cm and the depth was unable to be determined. The wound contained 100 percent black eschar with moderate serous drainage. He had an order for Santyl and calcium alginate to the wound and cover with a foam dressing. Interview on 11/06/23 at 8:55 A.M. with Resident #76 revealed he was a paraplegic and required staff assistance with turning and repositioning. During the interview, the resident voiced concerns staff did not turn him every two hours as at times he went for prolonged periods of time without being turned, lying flat on his back. He revealed State Tested Nursing Assistant (STNA) #605 refused to turn him as she stated, I ain't got time. He revealed because staff did not turn him as he required, he developed pressure ulcers to his right hip and tailbone region. Interview on 11/06/23 at 4:43 P.M. with the DON verified on 08/26/23 RN #601 found an unstageable pressure ulcer to Resident #76's sacrum area and a deep tissue injury to his right buttock. She verified both areas were not present on admission and that Resident #76 required extensive to total dependence with his ADL's including for turning, toileting, and transfers. She verified Resident #76 was not seen per Wound Physician #604 until 09/22/23, and that this was his initial consult. Interview on 11/07/23 at 12:57 P.M. with RN #601 revealed staff had come and got him on 08/26/26 to show him Resident #76's pressure ulcers. He revealed he could not remember the details but remembered that both wounds were like slushy black eschar and he was surprised at how bad the wounds were. He revealed Resident #76 was a paraplegic and required staff to turn and reposition him in bed. He revealed he was never aware Resident #76 refused to be turned and felt the resident was compliant with care. Review of the facility policy titled Pressure injury prevention and Treatment Policy, dated 07/17/13, revealed new pressure injuries would not develop unless the individual's clinical condition demonstrates that they were unavoidable. The policy revealed to remember to inspect the skin daily and keep off the pressure points. The policy revealed pressure ulcer reduction tips included follow individual turning and positioning schedule, turn at least every two hours while in bed, reposition at least every hour while in chair shifting weight every 15 minutes, and use lift sheet or device to reduce shear and friction. This deficiency represents non-compliance investigated under Complaint Number OH00147375. 365492 Page 6 of 6