Health inspection·December 1, 2023

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 interview, record review, and review of facility policy the facility failed to ensure there was adequate incontinence care products. This affected two residents (#40 and #66) out of three residents reviewed for proper incontinence care supplies. This had the potential to affect 59 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10. #11, #12, #13, #14, #15, #16, #17, #19, #20, #21, #22, #24, #25, #27, #28, #30, #31, #32, #33, #33, #34, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #51, #52, #53, #54, #55, #58, #59, #60, #62, #63, #64, #65, #66, #68, and #69) that were identified by the facility as requiring incontinence care products. The facility census was 71. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 11/21/22 with diagnoses including chronic kidney disease, heart failure, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66's cognitive status was not assessed. She required two- person assistance with bed mobility and toileting. She was always incontinent of bowel and bladder. Review of the undated care plan revealed Resident #66 had an activities of daily living (ADL) self-care deficit related to weakness. Interventions included assist with ADL including dressing, grooming, toileting, feeding, and oral care. Interview on 11/28/23 at 2:35 P.M. with Resident #66 and Resident #66's daughter, who was in her room, revealed the facility did not have enough supplies as Resident #66 stated the staff put her in too small of a brief (incontinent product). She revealed she wears a large and they frequently run out of that size. Resident #66 stated it is too small, hurts as it rubs. She then revealed at times the staff put on a double extra-large brief which does not fit properly. Resident #66's daughter stated that Resident #66 frequently brings up this concern to her that the staff run out of the correct size of brief. She revealed she had brought up this concern six months ago at a care conference as well today, 11/28/23, as it continued to be an issue. Resident #66 revealed she had the correct size on today, 11/28/23. 2. Review of medical record for Resident #40 revealed an admission date of 10/19/12 with diagnoses including chronic pain, vascular disorder of the intestine, and anxiety. Review of the care plan dated 07/02/18 revealed Resident #40 had occasional bladder incontinence. Interventions included providing incontinence care as needed, monitoring peri-area for redness, and assessing resident pattern of urination. There was nothing in her care plan regarding her preference Page 1 of 7 365492 365492 12/01/2023 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0558 to wear pull ups. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS assessment dated [DATE] revealed Resident #40 had intact cognition as her brief interview for mental status (BIMS) score was a 15. She was independent with toileting. She was always continent of urine and frequently incontinent of bowel. Residents Affected - Few Interview on 11/29/23 at 10:37 A.M. with Resident #40 revealed she wore a pull up as she toileted herself and was able to apply and change the pull up as needed on her own. She revealed the facility runs out of her pull ups and only then had what she called diapers which she does not like to wear as she cannot put them on or remove them herself. She revealed when she does not have a pull up then she cannot independently go to the restroom and had to ask for staff assistance, which she does not like to do, as she stated then staff had to change the diaper. She revealed they had run out of her pull ups at least once this month. 3. Review of witness statement dated 11/28/23 and completed by Marketing/ admission Director #610 revealed on 11/14/23 at 5:30 P.M. a nursing assistant came to her and stated the facility had no briefs for the residents. The statement revealed that the staff was told to open the depends on and tape them shut. The statement revealed she told the nursing assistant that the facility would not be taping the briefs. She then confirmed with the nurses and State Tested Nursing Assistants (STNAs) on the 200-hall that there were no briefs. She notified the Administrator and was given the company credit card to purchase briefs at a store where she purchased briefs in various sizes. 4. Interview on 11/28/23 at 11:23 A.M. with Registered Nurse (RN) #600 revealed the facility did not have enough supplies, especially incontinence products. She revealed the STNAs always state they were out of briefs and/or did not have the correct size for the residents to wear. Interview on 11/28/23 at 11:27 A.M. with Licensed Practical Nurse (LPN) #601 revealed the facility runs out of certain sizes of briefs and had to utilize a size on a resident that was either too big and/or too small. She revealed in the past month there were several times that she worked that they did not have proper incontinence care supplies. Interview on 11/28/23 at 11:31 A.M. with STNA #602 revealed the facility did not have sufficient supplies to care for the residents, especially Tuesdays and/or Wednesdays, the days before the supply shipment came in as they routinely ran out of supplies, especially incontinence care products including briefs. She revealed they were always running out of the correct size and often had to use a smaller size brief for a resident. She stated she squeezed them in as what else we supposed to do. She revealed she had told management regarding the supply issue but that they did not seem to do anything about it. Interview on 11/28/23 at 11:40 A.M. with STNA #603 revealed that frequently the facility runs out of the correct size of briefs. She revealed she questioned management, but they continued to never order the sizes that they needed to do proper care. She revealed this resulted in the staff having to make do with what we have. She revealed she had to several times place a resident in either too large of a brief and the urine leaks out and/or too small of a brief which was most likely uncomfortable. She revealed staff had to take pull ups, rip the sides open and tape two of them together to make a larger brief. She revealed she has had residents complain to her regarding not having the proper supplies. Interview on 11/28/23 at 3:00 P.M. with LPN #606 revealed the facility ran out of many supplies 365492 Page 2 of 7 365492 12/01/2023 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few including dressings, wipes, and incontinence care products frequently. She verified she was on duty when they were completely out of briefs and the staff had to modify pull ups by taping them together to use on the residents. She revealed she had seen them do it as she had provided them with the tape. She revealed it was almost a daily thing of not having the supplies needed to care for the residents. Interview on 11/28/23 at 4:35 P.M. with the Director of Nursing revealed she attended the care conference for Resident #66 and revealed that there was nothing said about supplies. Interview on 11/28/23 at 10:30 A.M. with LPN #612 revealed at times they did not have enough supplies, especially incontinence care products as they seemed to run out frequently. She revealed she was on duty one day when the staff were taping incontinence care products together to make one larger brief. Interview on 11/28/23 at 10:50 A.M. with the Director of Nursing verified she was aware of one time they had run out of a certain size brief and that the Marketing and Admissions Director #610 went to the store to purchase the briefs. She revealed she was not aware staff were taping incontinence products together to modify the product for residents. Interview on 11/29/23 at 11:15 A.M. with the Administrator revealed there was one day that the facility was out of briefs, and she had Marketing and Admissions Director #610 go to the store to purchase them. She revealed she ordered the supplies at the facility and felt she ordered sufficient supplies including incontinence care products. She revealed she felt staff say that the facility did not have supplies including incontinence products, but staff just do not look for the supplies. Interview on 11/29/23 at 12:47 A.M. with Activities Director #613 revealed she attended the care conference on 11/28/23 for Resident #66 and revealed the family brought up the lack of supplies, including not having enough of her treatment cream and her incontinence products. She revealed the family mentioned Resident #66 needed a large brief, and the facility was short on them. Interview on 11/29/23 at 2:31 P.M. with the Marketing/ admission Director #610 verified on 11/14/23 STNA #611 came to her upset and stated that the facility was out of briefs, including all sizes except for the pull-ups. She revealed the staff were told to rip the sides of the pull ups and then tape them closed. She revealed she was unsure who had given the directive to tape the pull ups closed. She revealed she went to the 200-hall nursing station, and the nurses and aides stated that they were out of all sizes of briefs and only had pull-ups that they were ripping open and taping them shut to improvise. She verified she was unsure how long they had been taping the pull ups and/or how long they had been out of briefs. She revealed she contacted the Administrator who sent her to the store to purchase the incontinence products. Review of the facility policy labeled, Resident Rights and Facility Responsibilities, dated 09/03/20, revealed it was the facilities policy to comply with all resident rights. Review of the undated Ohio Nursing Home Patient [NAME] of Rights revealed the bill of rights was a list of legal rights by all nursing home residents. It revealed residents had the right to adequate and appropriate medical treatment and nursing care. This deficiency represents non-compliance investigated under Master Complaint Number OH00148353. 365492 Page 3 of 7 365492 12/01/2023 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 interview, observation, record review, review of facility infection control policy, and review of Center of Disease Control and Prevention (CDC) donning guidelines revealed the facility failed to ensure staff donned proper fitting personal protective gowns to enter resident's rooms on droplet isolation precautions due to COVID-19. This affected 11 residents (#4, #5, #14, #19, #23, #26, #34, #39 #50, #54, and #74) on droplet isolation precautions for Covid-19 and had the potential to affect all 71 residents residing in the facility. Residents Affected - Many Findings include: 1. Observation on initial tour of the facility on 11/28/23 from 11:05 A.M. to 11:43 A.M. revealed the following residents were on droplet isolation precaution: Residents #4 #5, #23, #26, #39, #54, and #74. They had a sign posted on their doors indicating they were on droplet isolation precautions and had white bins on the outside of their doors. The bins contained personal protective equipment (PPE) including short sleeved rain ponchos (a kind of loose-fitting outer garment usually worn as a raincoat). There were no long-sleeved gowns noted in the bins. 2. Review of the medical record for Resident #5 revealed an admission date of 10/28/23 with diagnoses including altered mental status, heart failure, and end stage renal disease. He tested positive for COVID- 19 on 11/18/23 at the facility. Review of the care plan dated 10/30/23 revealed Resident #5 had an activities of self-care deficit. Interventions included assist with activities of daily living (ADL) (dressing, grooming, toileting, and transfer with one person assist). He did not have a care plan regarding having COVID-19 and/or droplet isolation precautions. Review of the November 2023 Physician Orders for Resident #5 revealed on 11/18/23 he had an order due to infection to maintain combined droplet and contact precautions per transmission-based precautions. The order revealed to not discontinue isolation until the resident met criteria for discontinuation of isolation per CDC guidelines using either symptom based, testing based strategy, and/or a physician order. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. He required assistance with his ADL including substantial to maximum assist with bathing and was totally dependent for toileting. Observation on 11/28/23 at 12:33 P.M. of State Tested Nursing Assistant (STNA) #605 revealed she donned PPE including a rain poncho that's sleeves only came to her elbow region exposing the lower part of her bilateral arms and was loose around the neck as she entered Resident #5's room to provide him with his lunch tray. STNA #605 proceeded to place his tray on the bedside table and move the tray across him in his bed as she proceeded to set up his tray by reaching across Resident #5. Interview on 11/28/23 at 12:38 P.M. with STNA #605 verified Resident #5 was on droplet isolation precautions as he had COVID-19. She also verified the rain poncho sleeves only came down to her elbows, and the lower part of her bilateral arms were exposed. She verified most likely her forearms either touched his bedside table, his bed, and/or Resident #5 as she was setting up his tray. 365492 Page 4 of 7 365492 12/01/2023 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 - Many 2. Review of the medical record review revealed Resident #23 has an admission date of 11/18/23 with diagnoses including chronic obstructive pulmonary disease, hypertension, asthma, and cellulitis of his right lower limb. He was diagnosed with COVID-19 on 11/22/23. Review of the November 2023 Physician Orders for Resident #23 revealed on 11/22/23 he had an order due to infection to maintain combined droplet and contact precautions per transmission-based precautions. The order revealed to not discontinue isolation until the resident met criteria for discontinuation of isolation per CDC guidelines using either symptom based, testing based strategy, and/or a physician order. Review of the care plan dated 11/20/23 revealed Resident #23 had a self-care deficit related to cellulitis, edema of the lower extremities, and impaired mobility. Interventions included he needed assistance with his ADL (dressing, grooming, toileting, feeding, and oral care). Review of the care plan dated 11/22/23 revealed Resident #23 had a respiratory infection related to COVID-19. Interventions included encouraging frequent coughing, turning and deep breathing, and staff would follow droplet isolation precautions as ordered including PPE and proper hand hygiene. Observation on 11/28/23 at 12:25 P.M. revealed STNA #602 donned PPE to enter Resident #23's room. She proceeded to apply a rain poncho that did not completely cover her bilateral arms leaving one third of her arm uncovered. Observation revealed she was wearing a burgundy long sleeved jacket under her poncho. She proceeded to take Resident #23 his tray and placed it on a bedside table right next to Resident #23's recliner. She proceeded to assist with setting up his tray directly next to Resident #23. She then exited his room by doffing the PPE, including the rain poncho but continued to wear her burgundy long sleeved jacket out of the room to continue to pass the rest of the trays. Interview on 11/28/23 at 12:28 P.M. with STNA #602 verified the poncho did not completely cover her bilateral arms, and that her long sleeved uniform jacket was exposed. She verified her uniform jacket most likely touched Resident #23's bedside table and/or him while she was setting up his tray, and she continued to wear the jacket outside of the room to pass the other trays. She revealed there was no other option as the facility did not have long sleeved gowns. Interview on 11/29/23 at 9:16 A.M. with Resident #23 revealed he was sitting in his recliner, and he stated he had COVID-19. He revealed he was not able to stop coughing as he was coughing during the interview. Interview on 11/28/23 at 11:23 A.M. with Registered Nurse (RN) #600 revealed the facility did not have the proper PPE to utilize in residents' rooms that were in droplet isolation due to COVID-19. She revealed the facility only had rain ponchos that were short sleeved and exposed the lower part of staff's arms. She revealed she felt this was unsafe and had let management know but felt that they did not do anything as they still did not have the proper gowns to use. Interview on 11/28/23 at 11:27 A.M. with Licensed Practical Nurse (LPN) #601 revealed the facility only had short sleeved rain ponchos to utilize in the droplet isolation rooms, and the ponchos did not cover the entire arm. She then proceeded to grab a poncho to put on to demonstrate. The poncho was loose fitting around the neck and only covered three fourths of her arm exposing the bottom of her bilateral arms. She revealed it had been a long time since the facility had the correct gowns, and she was upset stating, how was the rain poncho supposed to protect staff properly and prevent the spread of COVID-19 when it did not cover (as she pointed to her lower part of her arm)? 365492 Page 5 of 7 365492 12/01/2023 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 - Many Interview on 11/28/23 at 11:31 A.M. with STNA #602 revealed the facility did not have proper personal protective gowns to wear in the droplet isolation rooms as they only had rain ponchos which covered only the upper part of her arms since they were short sleeved. Interview on 11/28/23 at 11:40 A.M. with STNA #603 revealed the facility did not have appropriate PPE as they did not have proper gowns. She revealed they only had rain ponchos to use to enter rooms of residents who were positive for COVID-19. She revealed the rain ponchos were short sleeved exposing most of the lower portion of her bilateral arms. She revealed residents were actively coughing during their personal hygiene care, and she was concerned that droplets were getting onto her arms exposing her as well as then possibly exposing other residents. Interview on 11/28/23 at 3:00 P.M. with LPN #606 revealed the facility had been without personal protective gowns for at least a week and that she had been entering COVID-19 positive residents' rooms without proper gowns to provide care as there was nothing else to wear. She revealed she knew the management was aware that there were no gowns as they had seen staff utilizing rain ponchos. She revealed the rain ponchos were short sleeved, not covering the entire arms. Interview on 11/29/23 at 8:17 A.M. with Infection Control Preventionist/ LPN #607 revealed she was aware staff had been utilizing rain ponchos as gowns to enter residents' rooms positive for COVID-19 on droplet precautions. She verified the ponchos were short sleeved and only came halfway to three fourths depending on a staff's arm length. She verified that this was not correct donning of PPE as a gown should come all the way to the wrist region over the end of the glove to not expose the staff's arms. She revealed she was not sure how long the facility was without long sleeved gowns stating, at least a few days. She revealed she did not order the supplies but was aware that staff had told the Administrator that they were out of gowns. She revealed she did not know what the facility was doing to rectify the issue as again stated, I do not order the supplies. She verified the facility followed the CDC donning guidelines labeled, Sequence for Putting on Personal Protective Equipment (PPE) as that was what she educated the staff on as proper dinning of PPE. Interview on 11/29/23 at 8:47 A.M. with Laundry Housekeeping Supervisor #609 revealed it had been a while since the facility had long sleeved gowns to utilize in resident rooms that were on droplet precautions. She revealed the facility only had rain ponchos for the housekeepers to wear while cleaning COVID-19 positive rooms. She revealed the ponchos were short sleeved and did not completely cover a staff's bilateral arms. She stated she had been utilizing ponchos to clean the rooms. She stated, everyone has brought up the concern several times including herself to the Administrator and the Director of Nursing. She revealed the reply had always been we will check on it, but they did not order the proper gowns as the facility was still without. Interview on 11/29/23 at 10:50 A.M. with the Director of Nursing revealed she was made aware yesterday, 11/28/23, during the survey that the facility was out of long-sleeved gowns for staff to utilize while entering resident rooms on droplet precautions, and that staff were utilizing rain ponchos in place of the gowns. She verified that the ponchos were short sleeved and did not completely cover staff's bilateral arms. Interview on 11/29/23 at 11:15 A.M. with the Administrator revealed she only found out yesterday, 11/28/23, during the survey that staff were utilizing short sleeved rain ponchos instead of long-sleeved gowns to enter resident's rooms on droplet precautions. She revealed she was angry as she did not realize staff were doing this and verified that the rain poncho was not proper PPE as they did not properly cover staff's bilateral arms. 365492 Page 6 of 7 365492 12/01/2023 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility invoice #3003637 dated 09/20/23 revealed the facility ordered two cases of isolation gowns. The facility had no other invoices from 09/20/23 to 11/28/23 that they had ordered isolation gowns. Review of the facility list revealed from 11/14/23 to 11/28/23 the facility had 11 residents that tested positive for COVID-19: Resident #4, #5, #14, #19, #23, #26, #34, #39 #50, #54, and #74. Residents Affected - Many Review of the undated CDC donning guidelines labeled, Sequence for Putting on Personal Protective Equipment (PPE) revealed when applying gown, a gown was to fully cover the torso from neck to knees, arms to end of wrist and wrap around the back. The gown then should be fastened behind the neck and waist. Review of the facility policy labeled, Infection Control: Isolation and Precautions, dated 05/24/23, revealed to wear a gown that was appropriate to protect skin and prevent soiling or contamination of clothing during procedures and patient care activities when contact with blood, body fluids, secretions or excretions was anticipated. Review of the facility policy labeled, Infection Prevention and Control Program, dated 09/11/23, revealed it is the facility policy to maintain an organized, effective facility- wide program designed to systemically prevent, identify, control, and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and healthcare works. The policy revealed the infection control preventionist responsibilities included to assure compliance with state and federal regulatory standards as they pertain to infection prevention and control matters within the facility. This deficiency represents non-compliance investigated under Master Complaint Number OH00148353 and Focused Infection Control (FIC) survey. 365492 Page 7 of 7