Health inspection·May 12, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm 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, resident record review, staff interviews, and facility policy Residents Affected - Few review, the facility failed to ensure residents were treated with dignity and respect. This affected three residents (#41, #217, and #226) of three residents reviewed for resident rights and dignity. The facility census was 66. Findings include: 1. Review of Resident #41''s medical records revealed an admission date of 09/11/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, obstructive and reflux uropathy, presence of urogenital implants and type two diabetes mellitus. Review of the physician orders for May 2025 revealed an order to provide a privacy cover for the indwelling urinary catheter drainage bag every shift. Review of the care plan revised 04/07/25 revealed Resident #41 had an indwelling urinary catheter. Interventions included ensuring Resident #41 had a privacy cover for the indwelling urinary catheter drainage bag. Observations on 04/28/25 at 10:30 A.M. and on 04/29/25 at 7:37 A.M. revealed Resident #41 was in her bed and the urinary catheter drainage bag was not covered by a privacy bag. Interview on 04/28/25 at 10:57 A.M. with Licensed Practical Nurse (LPN) #242 confirmed there was no privacy cover for Resident #41's urinary catheter drainage bag. Interview on 04/29/25 at 1:34 P.M. with the Director of Nursing (DON) confirmed urinary catheter drainage bags were to have privacy covers intact and Resident #41's did not. Review of the facility policy, Indwelling Urinary Catheter Care Procedure, revised 07/15/24, revealed to ensure the drainage bag was covered with privacy/dignity cover. 2. Review of the medical record for Resident #226 revealed an admission date of 04/24/25. Diagnoses included malignant neoplasm of esophagus and dementia. Page 1 of 32 365492 365492 05/12/2025 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 Review of the physician orders for April and May 2025 revealed orders for catheter care to provide a privacy cover for the indwelling urinary catheter drainage bag. Review of the care plan dated 04/26/25 revealed Resident #226 was on enhanced barrier precautions (EBP) for a urinary catheter. Interventions included to ensuring Resident #41 had a privacy cover for urinary catheter drainage bag. Observations on 04/28/25 at 10:53 A.M. revealed the urinary catheter drainage bag did not have a privacy cover on. Interview on 04/28/25 at 10:57 A.M. with LPN #242 confirmed there was no privacy cover for Resident 226's urinary catheter drainage bag. Observation on 04/29/25 at 7:39 A.M. revealed Resident #226's urinary catheter drainage bag was facing the open door with no privacy cover on. Interview on 04/29/25 at 7:41 A.M. with LPN #228 confirmed Resident #226's urinary catheter drainage did not have a privacy cover on and was facing the open door. Interview on 04/29/25 at 12:37 P.M. with the DON confirmed there was no privacy cover on Resident #226's urinary catheter drainage bag. Review of the facility policy, Indwelling Urinary Catheter Care Procedure, revised 07/15/24, revealed to ensure the drainage bag was covered with privacy/dignity cover. 3. Review of the medical record for Resident #217 revealed an admission date of 04/25/25. Diagnoses included type two diabetes mellitus (DM), pain right and left knee, anxiety, depression, long term use of anticoagulants, and overactive bladder. Review of the admission Minimum data Set (MDS) assessment dated [DATE] revealed it was in progress. Review of the admission assessment for bowel and bladder revealed Resident #217 was continent of bladder and bowel. Interview with Resident #217 on 04/28/25 at 11:31 A.M. revealed she did not have a handle on her toilet, and it didn't flush. Resident #217 reported it was like this on admission and not fixed. Resident #217 reported she knew it didn't work because staff had to empty the bedside commode into the toilet and dump buckets of water to get it to flush. Resident #217 reported she saw it on Sunday, 04/27/25 when she was assisted to the shower. Resident #217 reported she asked if maintenance was here, and staff said yes, they would let him know. Resident #217 reported it still hasn't been fixed. Observation on 04/28/25 at 11:31 A.M. of Resident #217's bathroom revealed the toilet did not have a handle on it to flush. Interview on 04/29/25 at 10:22 A.M. with Maintenance Director #269 confirmed the toilet handle was missing for Resident #217's toilet. Maintenance Director #269 reported he was notified today, 04/29/25 and immediately fixed it. Interview on 04/29/25 at 1:34 P.M. with DON confirmed Resident #217'S toilet did not work; the 365492 Page 2 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0550 Level of Harm - Minimal harm or potential for actual harm handle was missing. The DON reported Maintenance Director #269 repaired it today. The DON stated if maintenance had known, it would have been taken care of, and Resident #217 should have been given another room upon admission or had it fixed. Residents Affected - Few 365492 Page 3 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy, the facility failed to ensure Resident #51's/Power of Attorney's (POA's) request to have her medication discontinued was completed timely. This affected one resident (#51) of one residents reviewed for choices. The facility census was 66. Findings include: Review of Resident #51's medical record revealed an initial admission date of 07/31/22 with diagnoses including multiple sclerosis (MS), obstructive and reflux uropathy, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and muscle weakness. Review of Resident #51's physician orders dated 02/12/25 revealed Avonex (interferon beta-1a) syringe kit 30 micrograms (mcg) per 0.5 milliliter (mL), one injection, intramuscular, once a day on Wednesdays at 12:30 P.M. Resident #51's Avonex was discontinued on 04/23/25. Review of Resident #51's progress notes dated 02/24/25 at 4:03 P.M. included Physician #277 was called regarding Resident #51's daughter request for Avonex injection to be discontinued. Physician #277 stated Avonex needed to be discontinued and approved by neurology. All new orders to be addressed with daughter. Review of Resident #51's progress notes dated 02/24/25 through 04/23/25 did not reveal Resident #51's neurologist was contacted regarding discontinuing Resident #51's Avonex injection. Review of Resident #51's Medication Administration Record (MAR) from 02/24/25 through 04/23/25 revealed Resident #51 received an Avonex injection every week until it was discontinued on 04/23/25. Review of Resident #51's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had severe cognitive impairment. Resident #51 used a wheelchair. Resident #51 required setup or clean-up assistance for eating and was dependent on staff for toileting hygiene, personal hygiene, and bathing. Resident #51 required substantial to maximal assistance for the ability to roll from lying on back to the left or right side and was dependent on staff for the ability to transfer to and from a bed to a chair. Resident #51 used a mechanical lift for transfers. Review of Resident #51's progress notes dated 04/23/25 at 6:29 P.M. revealed Resident #51 and her POA (Power of Attorney) requested her Avonex injection be discontinued. Resident #51's physician was contacted and was in agreement per Resident #51's choice to have her Avonex discontinued. Resident #51 would be monitored for adverse effects. Review of Resident #51's care plan dated 04/27/25 included Resident #51 had a diagnosis of MS. Resident #51 would develop coping strategies to help adapt to a diagnosis of MS. Interventions included administering medications as ordered and evaluating and recording effectiveness and evaluating and reporting adverse side effects. Observation on 04/28/25 at 11:38 A.M. of Resident #51 revealed she was sitting in a chair in her room and POA #278 was in the room with her. 365492 Page 4 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/28/25 at 11:38 A.M. of POA #278 revealed she asked the facility to discontinue Resident #51's Avonex injection a couple months ago. POA #278 stated she thought the Avonex was discontinued until Resident #51 told her she received an injection in her hip a week or so ago. POA #278 stated she was upset Resident #51 continued to receive the Avonex injections after they requested for it to be discontinued. Interview on 05/05/25 at 2:09 P.M. of the Director of Nursing (DON) confirmed there was no follow up by the facility for Resident #51's POA's request to have her Avonex discontinued from 02/24/25 through 04/23/25 when she called the physician and had Resident #51's Avonex discontinued. The DON started working at the facility around 03/11/25 and could not state why there was no follow up until she contacted Resident #51's physician. Review of the undated facility policy titled Your Rights and Protections as a Nursing Home Resident included a resident had the right to participate in the decisions that affect their care. A resident's legal guardian had the right to look at all their medical records and make important decisions on their behalf. 365492 Page 5 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

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 record review, observation and interviews, the facility failed to ensure Resident #217 had a working toilet. This affected one resident (#217) of one residents reviewed for accommodation of needs. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #217 revealed an admission date of 04/25/25. Diagnoses included type two diabetes mellitus (DM), pain right and left knee, anxiety, depression, long term use of anticoagulants, and overactive bladder. Review of the admission Minimum data Set (MDS) assessment dated [DATE] revealed it was in progress. Review of the admission assessment for bowel and bladder revealed Resident #217 was continent of bladder and bowel. Interview with Resident #217 on 04/28/25 at 11:31 A.M. revealed she did not have a handle on her toilet, and it didn't flush. Resident #217 reported it was like this on admission and not fixed. Resident #217 reported she knew it didn't work because staff had to empty the bedside commode into the toilet and dump buckets of water to get it to flush. Resident #217 reported she saw it on Sunday, 04/27/25 when she was assisted to the shower. Resident #217 reported she asked if maintenance was here, and staff said yes, they would let him know. Resident #217 reported it still hasn't been fixed. Observation on 04/28/25 at 11:31 A.M. of Resident #217's bathroom revealed the toilet did not have a handle on it to flush. Interview on 04/29/25 at 10:22 A.M. with Maintenance Director #269 confirmed the toilet handle was missing for Resident #217's toilet. Maintenance Director #269 reported he was notified today, 04/29/25 and immediately fixed it. Interview on 04/29/25 at 1:34 P.M. with DON confirmed Resident #217'S toilet did not work; the handle was missing. The DON reported Maintenance Director #269 repaired it today. The DON stated if maintenance had known, it would have been taken care of, and Resident #217 should have been given another room upon admission or had it fixed. 365492 Page 6 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the fire department report and review of the facility policy, the facility failed to ensure Resident #167 had a safe discharge. The facility failed to ensure Resident #65 had an accurate and thorough assessment for a change in condition and transfer to the hospital. This affected two residents (#65 and #167) out of three residents reviewed for discharge. The facility census was 66. Findings include: 1. Review of Resident #167's medical record revealed an admission date of [DATE] with diagnoses including diabetes mellitus with ketoacidosis without coma, paroxysmal atrial fibrillation, influenza, acute respiratory failure with hypoxia. Resident #167 was discharged from the facility on [DATE]. Review of Resident #167's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #167 had severe cognitive impairment. Resident #167 required substantial to maximal assistance for toileting hygiene, personal hygiene, dressing, bathing and bed mobility. Review of Resident #167's care plan dated [DATE] included Resident #167 had a decline in functional abilities related to recent illness and hospitalization. Resident #167's needs would be met with staff assistance, and Resident #167 would return home as hoped after therapy. Interventions included assessing, documenting, reporting changes in activities of daily living (ADL) ability, any potential for improvement and reasons for inability to perform ADLs; encourage to participate to the fullest extent possible. Review of Resident #167's progress notes dated [DATE] at 1:02 P.M. written by Registered Nurse (RN) #205 included Resident #167 was discharged home today with her husband. Instructions gone over with both Resident #167 and her husband. Resident #167 was instructed to follow up with her primary care physician. Resident #167 and her husband verbalized understanding of her medication regimen. Interview on [DATE] at 9:29 A.M. of Resident #167's daughter revealed Resident #167 was given Resident #38's medication when she was discharged from the facility. Resident #167's daughter stated she was not present when Resident #167 was discharged , and Resident #167's husband could not read. Resident #167's daughter stated Resident #167 was confused and took Resident #38's medication for at least two days before it was discovered the medication belonged to another resident. Resident #167's daughter indicated Resident #167 did not suffer any negative effects from taking the medication. Resident #167's daughter stated she would take a picture of the medication and send it to the surveyor. Resident #167's daughter stated she told the Social Worker after Resident #167 was discharged that Resident #167 was given Resident #38's medication along with her medications and the Social Worker just stated I'm sorry and nothing else was done. Resident #167's daughter did not know the name of the Social Worker. Observation of a picture dated [DATE] at 9:35 A.M. sent by Resident #167's daughter revealed a medication card labeled with Resident #38's name and the medication was pantoprazole sodium DR (delayed release) 40 milligram (mg) tablet (medication to reduce stomach acid), one tablet by mouth once a day. 365492 Page 7 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0628 Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 9:32 A.M. of Social Service Designee (SSD) #239 revealed she called Resident #167's daughter after Resident #167 was discharged from the facility and filled out a PCP (primary care provider) transitional appointment form. SSD #239 stated she did not remember Resident #167's daughter telling her she received Resident #38's medication, but if Resident #167's daughter told her she received the wrong medications they would be in the comment section of the PCP transitional appointment form. Residents Affected - Few Interview on [DATE] at 11:44 A.M. of RN #205 revealed she did not remember discharging Resident #167 from the facility. RN #205 stated that when she discharged a resident among other things, she printed off the face sheet, physician orders, discharge summary, medications and would go over the resident's medications to make sure they understood how to administer them. RN #205 indicated when she instructed the residents about their medications, she used the medication cards and orders to explain what medications to take and how often to take them. RN #205 stated she had no knowledge of Resident #167 being sent home with the wrong medications, but Resident #167's and Resident #38's medication cards were next to each other in the cart, and it was possible Resident #38's medication card was in the wrong spot. Interview on [DATE] at 3:43 P.M. of the Director of Nursing (DON) and Regional Clinical Director (RCD) #273 revealed they were not aware Resident #167 was sent home with Resident #38's medication. RCD #273 stated there should have been an incident report written and education provided to the staff. RCD #273 was unable to provide Resident #167's PCP transitional appointment form. 2. Review of Resident #65's closed medical records revealed an admission date of [DATE] with diagnoses including peritoneal abscess, type two diabetes mellitus, chronic congestive heart failure, chronic kidney disease, and acute respiratory failure with hypoxia. Review of Quarterly MDS assessment dated [DATE] revealed Resident #65 had intact cognition with a score of 15/15. Review of the census in the facility computer system revealed Resident #65 was discharged to the hospital on [DATE] at 9:06 A.M. Review of the progress notes revealed a progress note dated [DATE] at 7:12 P.M. authored by Physician #280, recorded as late entry on [DATE] 7:12 P.M. revealed Physician #280 saw and examined Resident #65. The progress note reported no significant change in condition of the patient and still having leg swelling, and vital signs stable. Review of the next progress note, dated [DATE] at 5:05 A.M., recorded as late entry on [DATE] at 11:31 A.M., authored by previous RN #281, previous Director of Nursing (DON) revealed despite facilities attempts, Resident #65's needs cannot be met at this time due to respiratory distress. Resident #65 was sent with face sheet, advance directives, order summary, comprehensive care plan, Situation, Background, Assessment, and Recommendation (SBAR), and transfer form. Review of the Fire Department Form revealed a call was received from facility on [DATE] at 10:08 P.M. dispatched at 10:09 P.M. and left the scene at 10:30 P.M. to the hospital. The report further stated dispatched to the facility for report of a female in pain. Report stated, found Resident #65, alert and oriented times three in bed with no nurse present. Staff walked into the room and when asked of her complaint, Licensed Practical Nurse (LPN) #271 responded has fluid buildup, and the Physician wants her sent out and when asked if acute onset, LPN #271 replied she did not know. Recent 365492 Page 8 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication changes, diuretics, and history unknown by LPN #271. LPN #271 said she didn't check lung sounds or provide any further information and walked away. Resident #65 reported she was in stage three kidney failure, and the fluid retention has been a problem for months. Resident #65 reported no recent changes. During transport in the squad, Resident #65's pulse oxygen was 91%, and oxygen via nasal cannula was applied at 4 liters/per minute and Pulse oxygen increased to 95%. The report further stated, lower limbs have edema present, abdomen is rigid and no pain on palpitation. Interview on [DATE] at 8:17 A.M. with Physician #280 revealed facility calls him many times regarding resident status. Physician #280 reported Resident #65 had multiple medical problems to include recurrent hospital admissions for respiratory failure and fluid buildup which required paracentesis performed (paracentesis is a medical procedure where fluid is removed from the abdominal cavity). Physician #280 reported Resident #65 was sick for a while and recently made a Do Not Resuscitate Comfort Care (DNRCC) at the hospital, due to suffering for a while with ascites (buildup of fluid in the abdomen). Physician #280 reported he wasn't surprised Resident #65 had expired at the hospital days later. Interview on [DATE] at 1:23 P.M. with the DON confirmed there were no progress notes, SBAR, (format for healthcare professionals to clearly and concisely communicate information about a patient or situation, ensuring accuracy and efficiency in handoffs and other crucial communication scenarios), or transfer form. The DON reported, for a change in condition, staff were to assess the resident, contact the physician, family, follow orders, and document in the progress note and SBAR. The DON reported that if resident was sent to the hospital, staff were to document in the progress note, do an SBAR and a transfer form. The DON reported she was unable to locate the SBAR and transfer from which are to be in Matrix, computer system facility used. The DON reported initially Resident #65 was sent to the hospital on [DATE], then stated it was evening of [DATE] going into [DATE]. The DON confirmed the census in the computer was for [DATE] at 9:06 A.M. Interview was attempted on [DATE] at 5:09 P.M. and again on [DATE] at 8:56 A.M. via phone with LPN #271, who was no longer employed by the facility, she was assigned the nurse caring for Resident #65 on [DATE]. A voice message was left with call back number and requested a call back. No return call was received. Interview on [DATE] at 8:05 A.M. with RN #281, (previous DON), via phone confirmed for a change in condition staff are to assess resident, contact physician, family, follow orders, document in progress note, complete a SBAR, and if sent to hospital, complete a transfer form. RN #281 reported she put in the late entry progress note because the staff didn't do one as they should have. Review of the facility policy, Resident Change in Condition, revised [DATE], revealed the nurse will record the information related to the change in condition and subsequent events and notifications in the resident's health record. This deficiency represents non-compliance investigated under Master Complaint Number OH00164609 and Complaint Number OH00164118. 365492 Page 9 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interview, the facility failed to ensure an accurate assessment was completed for Resident #43. This affected one resident (#43) of 23 residents reviewed for assessments. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #43's clinical record revealed an admission date of 03/04/24 with diagnoses including unspecified atrial fibrillation, aphasia following cerebral infarction, unspecified osteoarthritis, and essential hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #43 revealed on section A she spoke English, and it was her preferred language. The facility answered no to the question if she needed or wanted an interpreter to communicate with a doctor of healthcare staff. Section B stated staff usually understood her. Section C on the assessment stated resident is rarely or never understood so staff assessment had to be performed regarding her cognition. The staff assessment for mental status revealed she had a memory problem and had modified independence with daily decision making. Observation of Resident # 43 on 04/28/25 revealed that she is unable to speak English, and her primary language was Italian. This was verified by Resident #43's daughter who has a room next to the resident. Interview with Certified Nursing Assistant (CNA) #212 stated that there was a communication sheet that was pinned on the wall on the other side of the room where Resident #43 was not able to reach. CNA #212 stated that it was not left at the bedside because something would spill on it. CNA #212 stated that the family was the primary communication for the resident. An interview on 04/28/25 at 10:14 A.M. indicated that Dietitian #250 had difficulty understanding Resident #43 and would call the family if there needed to be a correspondence. Interview on 4/30/25 at 3:13 P.M. with MDS Nurse #261 verified she was unaware that there was a language barrier, and she understood it as a cognition deficit. 365492 Page 10 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review, observations, interview and facility policy review, the facility failed to develop and implement a comprehensive care plan for Resident #43. This affected one resident (#43) of 23 residents reviewed for comprehensive care plans. The facility census was 66. Findings include: Review of Resident #43's clinical record revealed an admission date of 03/04/24 with the diagnoses of unspecified atrial fibrillation, aphasia following cerebral infarction, unspecified osteoarthritis, and essential hypertension. Observation of Resident #43 on 04/28/25 at 10:00A.M. revealed that she was unable to speak English. Her primary language was Italian which was verified by her daughter who has a room next to the resident. Interview on 04/28/25 at 10:25 A.M. with Certified nursing Assistant (CNA) #212 stated that there was a communication sheet that was pinned on the wall on the other side of the room where Resident #43 was unable to reach. CNA #212 stated that it was not left at the bedside because something would spill on it. CNA #212 stated that the family was the primary communication for the resident. CNA #212 does not know how else to communicate with Resident #43 other than she seems to understand some English and will answer some yes and no questions. The communication sheet was in the room at the time of the interview. An interview on 04/28/25 at 10:14 A.M. indicated Dietitian #250 had difficulty understanding Resident #43 and would call the family if there needed to be a correspondence. The dietitian was aware there was a communication sheet in the room. Review of Resident #43's care plan for communication initiated on 03/11/25 stated that Resident #43 had difficulty making herself understood related to aphasia. There was no information regarding the language barrier and/or interventions to ensure she was communicated with and understood. Interview on 4/30/25 at 3:13 P.M. with Minimum Data Set (MDS) Nurse #261 verified that the language care plan was not established until 04/28/25, during this time an interview with MDS Nurse #268 stated that she was unaware that there was a language barrier, and she understood it as a cognitive deficit. Review of the facility policy titled Comprehensive Care Planning, dated 03/20/25, stated that the facility will develop a comprehensive person-centered care plan for each resident with goals and timetables to meet the resident's medical, nursing, mental, and psychological needs. 365492 Page 11 of 32 365492 05/12/2025 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 reviews, interviews and review of the facility policy, the facility failed to ensure Resident #167 had accurate documentation related to the open areas to her posterior thighs and failed to ensure treatment instructions were given to the resident and her representative upon discharge. In addition, the facility failed to follow admission and readmission physician's orders for Resident #60. This affected resident (#167) of one resident reviewed for skin conditions, non-pressure related and one resident (#60) of two residents reviewed for change in condition. The facility census was 66. Residents Affected - Some Findings include: 1. Review of Resident #167's medical record revealed an admission date of 03/11/25 with diagnoses including diabetes mellitus with ketoacidosis without coma, paroxysmal atrial fibrillation, influenza, acute respiratory failure with hypoxia. Resident #167 was discharged from the facility on 04/03/25. Review of Resident #167's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #167 had severe cognitive impairment. Resident #167 required substantial to maximal assistance for toileting hygiene, personal hygiene, dressing, bathing and bed mobility. Resident #167 was frequently incontinent of urine and bowel. Review of Resident #167's care plan dated 03/20/25 included Resident #167 had a decline in functional abilities related to recent illness and hospitalization. Resident #167's needs would be met with staff assistance and Resident #167 would return home as hoped after therapy. Interventions included assessing, documenting, and reporting changes in activities of daily living (ADL) ability, any potential for improvement and reasons for inability to perform ADL, and encourage Resident #167 to participate to the fullest extent possible. Review of Resident #167's care plan dated 03/28/25 through 04/03/25 did not reveal a care plan related to the open areas on her posterior thighs. Review of Resident #167's progress notes dated 03/28/25 at 4:07 P.M. included a skin check that was completed, and Resident #167 had abrasions to bilateral posterior thighs, bruising to bilateral antecubital, and a reddened scabbed area to the left lower quadrant of her abdomen. New orders were obtained for Triad cream (hydrocolloid) to the abrasions and bacitracin (antibiotic ointment) to the scab every shift. Resident #167 and the resident's representative were notified. There was no documentation regarding the cause of the abrasions to Resident #167's bilateral posterior thighs. Review of Resident #167's physician orders dated 03/28/25 revealed apply bacitracin to scabbed area on left lower quadrant, every shift. Also, apply Triad to abrasions to bilateral posterior thighs every shift. Review of Resident #167's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 03/28/25 through 04/03/25 revealed Triad was applied to Resident #167's bilateral posterior thigh abrasions every shift. Review of Resident #167's progress notes dated 03/28/25 through 03/31/25 revealed no documentation regarding the open areas to her posterior thighs. 365492 Page 12 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident #167's wound notes dated 03/31/25 revealed on the right thigh was a 2.0-centimeter (cm) x 0 cm abrasion and the left thigh had a 2.0 cm x 0 cm abrasion. Review of Resident #167's progress notes dated 03/31/25 through 04/03/25 revealed no documentation regarding the open areas to her posterior thighs. Residents Affected - Some Review of Resident #167's care plan dated 03/28/25 through 04/03/25 did not reveal a care plan related to the open areas on her posterior thighs. Review of Resident #167's Observation Detail List Report, Skilled Nursing Note dated 04/03/25 at 4:08 A.M. included Resident #167's skin was intact. Interview on 05/05/25 at 3:48 P.M. of Wound Nurse/Licensed Practical Nurse (LPN/WN) #253 revealed Resident #167 had abrasions on her bilateral posterior thighs, and they looked like they were caused by her incontinence brief rubbing the back of her thighs. LPN/WN #253 stated the two areas on Resident #167's posterior thighs looked like scratches and there was no width to them, just a straight line. LPN/WN #253 stated as soon as it was reported to her, she notified the physician and received treatment orders. Interview on 05/06/25 at 11:52 A.M. of LPN/WN #253 revealed she evaluated Resident #167 on 03/31/25 and would have seen her a week later, but she discharged before a week passed. LPN/WN #253 stated she only saw Resident #167's open areas on her posterior thighs on 03/31/25. Interview on 05/06/25 at 12:55 P.M. of Family Member #279 revealed Resident #167 had open areas on the back of her thighs when she was discharged from the facility. FM #279 stated the areas were open, pink and about one inch long by a half inch wide. FM #279 stated she thought the areas were caused by Resident #167 being left on the bedpan a long time. FM #279 stated Resident #167 was not given treatment instructions when she was discharged for the open areas on her posterior thighs. Interview on 05/06/25 at 2:32 P.M. of the Director of Nursing (DON) and LPN/WN #253 confirmed Resident #167's Skilled Nursing Note dated 04/03/25 stated Resident #167 had intact skin when she was discharged . LPN/WN #253 confirmed Resident #167 had bilateral posterior thigh open areas that were being treated with Triad when she was discharged . The DON and LPN/WN #253 confirmed the Skilled Nursing Note dated 04/03/25 was incorrect. Interview on 05/06/25 at 2:48 P.M. of LPN #254 revealed she did not remember Resident #167 but stated when treatments were provided to the residents' there should be documentation about the areas such as drainage, signs of infection and if there were any changes. Review of the facility policy titled Skin and Wound Management, revised 11/05/24, included the purpose was to provide evidence based preventive skin care and wound treatment to prevent unavoidable skin complications. 2. Review of the medical record for Resident #60 revealed an admission date of 04/04/25 with diagnoses including Parkingson's disease, rash and other nonspecific skin eruptions, hypothyroidism, hyperlipidemia, urinary tract infection, prediabetic, bullous disease (a rare skin condition causing large, fluid-filled blisters). The wound observation dated 04/05/25 revealed Resident #60 had a foot infection and a rash over 90 % of her body. 365492 Page 13 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the hospital discharge documentation dated 04/04/25 at 3:25 P.M. indicated that Resident #60's medications to start and continue were Ivermectin three milligram tablets (medication to treat parasites), take 4.5 milligrams one time to start on 04/08/25; acetaminophen 500 milligrams (analgesic), take 1,000 milligrams by mouth once daily, last administration 04/04/25 at 8:28 A.M.; atorvastatin 40 milligram tablet (statin) once a day, last given 04/04/25 at 8:28 A.M.; Vitamin D3 1,000 units (supplement) daily; hydroxyzine pamoate 25 milligrams (antihistamine), take one capsule three times a day for itching; Nystatin ointment (antifungal), apply one application to affected area two times a day for seven days; Kenalog cream 0.5 percent (corticosteroid), apply one application to affected area two times a day for 14 days. Review of the electronic medication administration record (eMAR) indicated that acetaminophen was administered at 10:11 P.M. on 04/04/25. Hydroxyzine for itching as needed was not administered while Resident #60 was in the facility from 04/04/25 through 04/06/25. The Nystatin cream was first administered at 9:00 A.M. on 04/06/25, Resident #60 was admitted to the facility on [DATE] at approximately 6:00 P.M. The Nystatin cream was ordered to be administered on 04/04/25 at 6:00 P.M., 04/05/25 at 9:00 A.M. and 6:00 P.M. Resident # 60 did not receive the hydroxyzine as ordered while in the facility from 04/04/26 to 04/06/25. Kenalog 0.5 percent cream, apply one application two times a day was not administered until 04/06/25 at 9:00 A.M. Interview on 04/30/25 at 2:13 P.M. with Regional Nurse # 273, verified that the medications were not administered as ordered by the physician. Review of the ambulance transfer report dated 04/06/25 from the facility to the local hospital for Resident #60 details Resident #60 had pus filled blisters all over her hands and feet that she did not have two days before on admission. Resident #60's husband was concerned about the blisters, the doctor was called, and Resident #60 was advised to go to the emergency room. The nurse stated that there was a high suspicion of scabies. The resident was taken to the emergency room, and the report was given to the registered nurse (RN). Review of the hospital records dated 04/10/25 at 3:37 P.M. revealed Resident # 60 arrived at the local hospital on [DATE] at 2:25 P.M. with a worsening rash. Resident #60 was lethargic but arousable, would grimace only to sternal rub and noxious stimuli. The emergency medical services indicated that Resident #60 was hypoxic in the 80% oxygen saturation during transport and was placed on four liters of oxygen and recovered to 100% oxygen saturation. Documented pictures from admission to the hospital show excessive blisters on the body. A review of Resident #60's after visit summary form on 04/10/25 at 3:37 P.M. indicated that Resident # 60 had a biopsy on the top of the left hand resulting in three sutures to be removed date range 04/14/25 to 04/17/25. Review of the hospital discharge information dated 04/10/25 stated Resident #60 was started in intravenous steroids with a consultation with dermatology for possible Bullous skin lesions. A biopsy of the left hand for review was completed. There were no biopsy results available to review. These orders were transcribed and followed on readmission. Review of the re-admission assessment dated [DATE] completed by RN #204 that there was no skin integrity issues documented on assessment. Review of the medical record revealed the first skin assessment for Resident #60 upon readmission 365492 Page 14 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0684 Level of Harm - Minimal harm or potential for actual harm from the hospital (04/10/25) was not completed until 04/29/25 at 12:04 P.M. The only documentation on the skin assessment included a checkmark by blisters. There was no mention of the sutures to the left hand. Review of medical records documentation from 04/10/25 to 04/29/25 revealed no orders to monitor or remove the sutures to resident #60's left hand. Residents Affected - Some Review of the medical record revealed LPN #242 removed the sutures on 04/30/25 at 5:58 P.M. from Resident #60's left hand per physician orders, and there was a scant among of bloody drainage to area on top of the hand. Review of Resident #60's physician's orders revealed an order dated 05/01/25 to clean the top of the left the hand and apply a Band-Aid. (The order was given on 04/30/35 but not documented until 05/01/25 per LPN #242). Interview with LPN #242 on 05/01/25 at 11:53 A.M. regarding the suture removal order revealed LPN #242 was approached by Resident #60's husband on 04/30/25 demanding that someone take the sutures out of his wife's hand or he would get scissors and remove them himself. LPN #242 was not aware of stitches in Resident #60's hand and did not monitor them. The doctor was called and gave an order to remove the stitches. The doctor was called on 04/30/25 at approximately 5:30 P.M. according to LPN #242. Interview on 05/01/25 12:00 P.M. with the DON verified RN #204's re-admission skin assessment was incomplete. A telephone interview with Resident #60's husband on 05/01/25 at 3:45 P.M. verified that he approached the nurse's station on Wednesday 04/30/25 demanding that the nurse take the stitches out now or he would do it himself. Complaint that no one even looks at her skin daily, stating that the stitches had been in there since 04/09/25. The nurse came in about 20 minutes later and removed the stitches that had scabbed over. A telephone interview with the Medical Director on 05/01/25 at 3:40 P.M. confirmed that he did give the order to remove the stitches for Resident #60 on 04/30/25 when called by LPN #242 and that he had no documentation to verify that the stitches were assessed after her return from the hospital on [DATE]. Review of the facility policy titled Skin and Wound Best Practices, dated 11/05/24, stated the facility will monitor and provide treatments as ordered to residents with identified skin issues. The facility will provide routine skin care and observations to ensure integrity of the skin. Review of the facility policy titled Resident Change in Condition Policy, dated 06/27/24, stated licensed nurses will recognize and intervene in the event of a change in a resident's condition, and there will be a significant change assessment completed to notify the doctor and family. The nurse will address and assess the resident as needed continuously till stable or interventions are in place. This deficiency represents non-compliance investigated under Master Complaint Number OH00164609 and Complaint Number OH00164118. 365492 Page 15 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of therapy recommendations and facility policy review, the facility failed to ensure Resident #51 received restorative services per therapy recommendations. This affected one resident (#51) out of three residents reviewed for therapy recommendations. The facility census was 66. Findings include: Review of Resident #51's medical record revealed an initial admission date of 07/31/22 with diagnoses including multiple sclerosis (MS), obstructive and reflux uropathy, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and muscle weakness. Review of Resident #51's care plan dated 06/12/24 included Resident #51 was at risk for deterioration in activities of daily living (ADL) related to diagnosis of MS. Resident #51 would continue to feed self-daily and participate in ADL as able daily. Interventions included physical therapy (PT) and occupational therapy (OT) for strengthening and endurance as indicated. Review of Resident #51's PT Treatment Encounter Note dated 02/11/25 included Resident #51 presented with continued fixed contractures to bilateral hips, knees at 90 degrees which is baseline for Resident #51 and had not worsened. Resident #51presented with no change in range of motion (ROM), strength, transfers, balance at this time and was at baseline prior level of function (PLOF), maximal functional potential in the facility. Additional Skilled Services, Restorative Nursing Program (RNP) to provide bilateral lower extremity (BLE) ROM with care and positioning to decrease further contractures and promote good skin integrity, and comfort in and out of bed . Review of Resident #51's physician orders dated 02/11/25 through 04/21/25 did not reveal orders from therapy with recommendations for BLE ROM to decrease further contractures and promote good skin integrity. Review of Resident #51's aide charting dated 04/01/25 through 04/30/25 did not reveal evidence BLE ROM was completed. Review of Resident #51's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had severe cognitive impairment. Resident #51 used a wheelchair. Resident #51 required setup or clean-up assistance for eating and was dependent on staff for toileting hygiene, personal hygiene, and bathing. Resident #51 required substantial to maximal assistance for the ability to roll from lying on back to the left or right side and was dependent on staff for the ability to transfer to and from a bed to a chair. Resident #51 used a mechanical lift for transfers. Observation on 04/28/25 at 9:55 A.M. of Resident #51 revealed she was lying in bed with the door half closed calling out for help. Resident #51 was lying in bed with a low air loss mattress and a perimeter mattress overlay and was pulling on the mattress and trying to lift herself up. Resident #51 was lying partly on her right side with her legs pulled up towards her chest and asked if someone could assist her out of bed. Interview on 04/28/25 at 11:38 A.M. of Resident #51's Power of Attorney (POA) #278 revealed she was 365492 Page 16 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0688 Level of Harm - Minimal harm or potential for actual harm frustrated with the care Resident #51 received at the facility. POA #278 stated there were multiple issues, she had been to Resident #51's care plan meetings and felt like I am talking to a wall because things did not change. POA #278 indicated Resident #51 did not have contractures of her legs when she first came to the facility, and she started noticing the contractures around the end of 2024. POA #278 stated they never seem to do any ROM or anything with her. Residents Affected - Few Interview on 04/29/25 at 2:12 P.M. of Director of Rehab (DOR) #282 revealed Resident #51 had a PT evaluation on 02/11/25 to determine potential deficits with ROM, strength, bed functional mobility and positioning. DOR #282 stated the evaluation revealed Resident #51 was at her baseline, and Resident #51 could maintain a sitting position, but could not walk. DOR #282 stated Resident #51 was set up for restorative services for ROM after her PT evaluation on 02/11/25 per a nursing request. DOR #282 indicated a form with Resident #51's therapy recommendations was completed and given to nursing after the PT evaluation on 02/11/25. DOR #282 indicated the aides were trained if needed. Interview on 04/29/25 at 4:57 P.M. of the Director of Nursing (DON) revealed she was newly hired and started working in the facility around the middle of March 2025. The DON stated up until about a week ago, the facility did not have a restorative program, and if therapy made recommendations, there should be a physician order for the recommendations in Resident #51's record. Interview on 04/30/25 at 10:05 A.M. of DOR #282 revealed she was unable to find Resident #51's completed therapy recommendation form after Resident #51's evaluation on 02/11/25. DOR #282 stated she could not remember if a form was completed after Resident #51's evaluation on 02/11/25. Interview on 04/30/25 at 11:06 A.M. of the DON revealed if nursing received a referral from therapy, therapy would keep the original referral form and provide a copy for nursing. There would also be an order in Resident #51's record if a therapy referral was received. The DON confirmed there were no orders per therapy in Resident #51's medical record dated 02/11/25 through 04/21/25 when Resident #51's restorative program was initiated. Review of the facility policy Restorative Nursing Referral and Process Policy, revised 03/11/22, included the referral form was filled out by the referring therapist and given to the Director of Rehab. The Director of Rehab brought all referrals to weekly utilization review (UR) meetings for the restorative nurse. The Decision Tool would be completed to determine if the resident was appropriate for the program according to the admission guidelines. 365492 Page 17 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #51's care planned interventions for falls were implemented. This affected one resident (#51) out of three residents reviewed for falls. The facility census was 66. Findings include: Review of Resident #51's medical record revealed an initial admission date of 07/31/22 with diagnoses including multiple sclerosis (MS), obstructive and reflux uropathy, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and muscle weakness. Review of the facility incident log revealed Resident #51 had an unwitnessed fall on 03/25/25 at 5:32 A.M. and a fall on 04/25/25 at 10:26 A.M. Review of Resident #51's fall investigation included on 03/25/25 at 5:15 A.M. Resident #51 was noted lying on the floor at the side of the bed. The resident was assisted back to bed. Resident #51 had contracted bilateral lower extremities (BLE). The new intervention was to have body pillows to the left and right side of the body while in bed for proper positioning for fall prevention. Review of Resident #51's progress notes and physician orders dated 03/25/25 through 05/05/25 did not reveal evidence Resident #51 had body pillows in place. Review of Resident #51's care plan edited 03/26/25 included Resident #51 was at risk for falling related to history of falls and diagnosis including MS. Resident #51 would remain free from injury. Interventions included Resident #51 was to have body pillows to the left and right side of the body while in bed for proper positioning for fall prevention, observe frequently, and place in supervised area when out of bed. Review of Resident #51's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had severe cognitive impairment. Resident #51 used a wheelchair. Resident #51 required setup or clean-up assistance for eating and was dependent on staff for toileting hygiene, personal hygiene, and bathing. Resident #51 required substantial to maximal assistance for the ability to roll from lying on back to the left or right side and was dependent on staff for the ability to transfer to and from a bed to a chair. Resident #51 used a mechanical lift for transfers. Interview on 04/28/25 at 12:56 P.M. of Resident #51's daughter revealed Resident #51 had a couple falls recently, and the facility did not have fall interventions in place. Observation on 05/05/25 at 9:53 A.M. revealed Resident #51 was lying in bed. Resident #51 was slumped in the bed and leaning to the right. Resident #51 did not have body pillows to the left and right side of her body for proper positioning. Interview on 05/05/25 at 9:53 A.M. of Certified Nursing Assistant (CNA) #270, Licensed Practical Nurse (LPN)'s #216 and #258 confirmed Resident #51 did not have body pillows on the left and right side of her body for proper positioning and confirmed there were no body pillows observed in her room. CNA #270 and LPN's #216 and #258 stated they were not aware Resident #51 needed body pillows. 365492 Page 18 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/05/25 at 9:46 A.M. of Director of Rehab (DOR) #282 revealed the therapy department did not provide body pillows for residents but would help with aide training if it was requested by nursing. Interview on 05/05/25 at 2:55 P.M. of Resident #51's Power of Attorney (POA) #278 revealed she did not know Resident #51 was supposed to have body pillows placed for proper body positioning and had never seen staff use body pillows. Interview on 05/05/25 at 4:00 P.M. of the Director of Nursing (DON) revealed the fall committee met every Tuesday and the interdisciplinary team (IDT) had to be in agreement with fall interventions. Once the IDT meeting was finished, the team waited a week to close the event because they wanted to make sure the fall interventions were in place and functional. Observation on 05/05/25 at 4:00 P.M. of Resident #51 with the DON confirmed Resident #51 was sitting in a wheelchair in her room and was not in an area supervised by staff. The DON stated POA #278 did not always let the facility know when she left and did not bring Resident #51 to the common area. The DON confirmed there were no body pillows seen on Resident #51's bed or in the room. The DON checked Resident #51's physician orders from 03/25/25 through 05/05/25 and confirmed there were no orders for body pillows. The DON indicated the orders must have been overlooked. The DON stated the facility was using regular pillows for body pillows and the correct term was not used in the care plan. Interview on 05/06/25 at 10:20 A.M. of Resident #51's POA #278 revealed when Resident #51 was out of bed and sitting in her room she did not see staff checking on her. POA #278 stated no staff ever asked her to let them know when she left so they could place Resident #51 in a supervised area. POA #278 stated no staff asked her to transport Resident #51 to a supervised area when she left the facility. Review of the facility policy titled Fall Prevention and Management Policy, revised 08/06/24, included residents would be assessed for fall risk on admission, quarterly and as needed. Falls would be reviewed by an interdisciplinary team and any new interventions identified would be implemented and the care plan updated as necessary. 365492 Page 19 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of speech therapy (ST) evaluation and review of facility policy, the facility failed to ensure Resident #51's physician orders were followed and failed to ensure Resident #51's ST and care planned interventions were implemented for a significant weight loss. This affected one resident (#51) out of three residents reviewed for weight loss. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #51's medical record revealed an initial admission date of 07/31/22 with diagnoses including multiple sclerosis (MS), obstructive and reflux uropathy, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and muscle weakness. Review of Resident #51's physician orders dated 02/05/25 revealed ST evaluation, and treat as necessary. Review of Resident #51's physician orders dated 02/10/25 revealed to encourage Resident #51 to eat meals in the dining room and document refusals, every day. Review of Resident #51's Speech and Language Pathology (SLP) Evaluation and Plan of Treatment dated 02/11/25 included recommendations for finger foods, mechanical soft textures, thin liquids, straw drinking, close supervision for oral intake, alternation of liquid, solids, rate modification, bolus size modifications, general swallow techniques, precautions and lingual sweep, re-swallow, upright posture during meals, and upright posture for greater than 30 minutes after meals. Review of Resident #51's weight record revealed a weight of 88.0 pounds on 02/18/25 and a weight of 83 pounds on 04/03/25. This was an unplanned 5.68 percent weight loss. Review of Resident #51's care plan edited 03/09/25 included Resident #51 was at risk for deterioration in activities of daily living (ADL) related to diagnosis of MS. Resident #51 would continue to feed herself daily and participate in ADL as able daily. Interventions included assisting with eating all meals and snacks, and beverages. Review of Resident #51's care plan edited 03/11/25 included Resident #51 had increased nutrition and hydration risk related to diagnoses. Resident #51 would be free of significant weight changes every month, five percent plus or minus, per nursing grand rounds and weight reports. Interventions included to monitor dietary intake and provide diet per order. Review of Resident #51's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had severe cognitive impairment. Resident #51 used a wheelchair. Resident #51 required setup or clean-up assistance for eating and was dependent on staff for toileting hygiene, personal hygiene, and bathing. Resident #51 required substantial to maximal assistance for the ability to roll from lying on back to the left or right side and was dependent on staff for the ability to transfer to and from a bed to a chair. Resident #51 used a mechanical lift for transfers. Review of Resident #51's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 04/01/25 through 04/30/25 included encourage Resident #51 to eat meals in the dining room and document refusals. There were checkmarks every day for the breakfast, lunch and dinner meals 365492 Page 20 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicating Resident #51 was encouraged to eat her meals in the dining room. There were no documented refusals. Review of Resident #51's meal and supplement intake record dated 04/01/25 through 05/01/25 revealed on 04/02/25 there was no breakfast, lunch or dinner intake or supplements documented, on 04/06/25, 04/08/25, 04/10/25 there were no supplements documented, on 04/07/25 and 04/09/25 there was no dinner intake or supplements documented, on 04/11/25 and 04/30/25 there was no breakfast, lunch or dinner intake documented, on 04/12/25, 04/14/25, 04/15/25, 04/16/25, 04/18/25, 04/20/25, 04/22/25, 04/24/25, 04/26/25, 04/27/25 there was no dinner intake documented, on 04/19/25 there was no lunch or dinner intake documented, on 04/21/25 there was no breakfast or dinner documented, on 04/28/25 there was no breakfast or lunch intake documented, and on 04/29/25 there was no lunch intake documented. Review of Resident #51's care plan edited 04/27/25 included Resident #51 required a restorative program to maintain self-performance in feeding herself food and fluids and maintain current range of motion (ROM) to upper and lower extremities. Resident #51 would maintain self-performance in feeding herself food and fluids 50 to 75 percent of meals with setup and verbal cues. Interventions including encouraging Resident #51 to eat meals in the dining room. Observation on 04/28/25 at 9:55 A.M. revealed Resident #51's door to her room was partially closed, and Resident #51 could be heard yelling out for assistance. Resident #51 was lying in her bed which had a low air loss mattress and a perimeter mattress overlay observed on the bed. Resident #51 was pulling at the perimeter mattress trying to get out of bed. Resident #51 asked the surveyor for help getting out of bed. Interview on 04/28/25 at 9:55 A.M. of Certified Nursing Assistant (CNA) #274 and Licensed Practical Nurse (LPN) #229 revealed they confirmed Resident #51 was calling out for help and trying to get out of bed. LPN #229 stated Resident #51 is always like that, she does that often during the day. CNA #274 and LPN #229 entered Resident #51's room to assist her when the surveyor asked them if they would help her. Observation on 04/28/25 at 12:24 P.M. of Resident #51 revealed she was lying in bed, had slid down in the bed and was slumped to the left side. Resident #51's bedside table was positioned about a foot above Resident #51, and a meal tray could be seen on the bedside table. While slumped to the side, Resident #51 reached up about twelve inches to pick up some of her food and begin to eat it. There were no staff members in the room assisting Resident #51. Interview on 04/28/25 at 1:11 P.M. of CNA #257 and CNA #274 revealed Resident #51 usually ate in the dining room and not in her room. CNA's #257 and #274 confirmed Resident #51 did not eat in the dining room today for breakfast or lunch and was in her room for both meals. CNA #274 stated Resident #51 did not typically like to be taken to the dining room for breakfast and preferred to eat in her room. CNA's #257 and #274 confirmed they did not attempt to assist Resident #51 out of bed or encourage Resident #51 to be assisted out of bed for breakfast or lunch. CNA #274 stated Resident #51 had leg contractures and did not like to be out of bed for long periods of time. Interview on 04/28/25 at 3:59 P.M. of CNA #274 revealed Resident #51 did not need help eating, but was usually in the dining room at mealtimes. Review of Resident #51's physician orders dated 04/29/25 revealed Pesco vegetarian, mechanical soft. Resident #51 was a vegetarian. 365492 Page 21 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/29/25 at 8:43 A.M. of Resident #51 revealed she was lying in her bed, had slid down in the bed and was slumped to the right side. Resident #51's meal tray was on the bedside table, and the table was raised about twelve inches above Resident #51. She had to reach to pick her food off the tray to eat it. There were no staff members in Resident #51's room assisting her with her meal. CNA #274 confirmed there was no staff member assisting Resident #51 with her meal and she was not positioned properly in bed and had to reach up to pick her food off the meal tray to eat it. Observation on 04/29/25 at 12:42 P.M. of Resident #51 with Registered Dietitian (RD) #206 revealed Resident #51 was sitting in a padded wheelchair in her room next to the bed and was eating her lunch. There were no staff members, including CNAs, providing meal assistance or supervision while Resident #51 was eating. Observation of Resident #51's meal tray revealed milk, mashed potatoes, mandarin oranges and a roll. RD #206 confirmed there were only carbohydrates and no protein item other than milk on Resident #51's meal tray. RD #206 stated the facility was having issues with residents' meal tickets and were trying to correct the problem. Review of Resident #51's meal ticket which was on the meal tray revealed she was a vegetarian, and the main entree of chicken and dumplings and green beans were also listed on the ticket. RD #206 stated the ticket was incorrect and Resident #51 should not have chicken and dumplings listed on her meal ticket. RD #206 confirmed there were no green beans on Resident #51's meal tray either. RD #206 indicated Resident #51 received milk at her meals and there was protein in the milk. Resident #206 stated she had a grilled cheese sandwich and already ate it. RD #206 confirmed there was no evidence Resident #51 received a grilled cheese sandwich. RD #206 confirmed there were no staff members in Resident #51's room providing supervision and assistance while she ate. Interview on 04/29/25 at 12:58 P.M. of RD #206 and Mobile Dietitian #275 revealed the facility had vegetarian items on hand, the meal tickets were not as clear as they should be, and the facility had to find a better way to complete meal tickets. Mobile Dietitian #275 stated there was a set up error in the system, and they were trying to fix it. Mobile Dietitian #275 stated Resident #51 received supplements in between meals, and mighty shakes for breakfast. Interview on 04/29/25 at 3:35 P.M. of RD #206 revealed Resident #51 did not have special needs documented in the needs area of her meal preference including using a straw. Observation on 04/29/25 at 5:06 P.M. of the dinner meal being served in the common area dining room of the 200-hall revealed Resident #51 was not sitting in the dining area but was lying in her bed. Interview on 04/29/25 at 5:10 P.M. of LPN #229 confirmed Resident #51 was not out of her bed, or in the dining area for the dinner meal. LPN #229 stated Resident #51 did not always want to be out of bed for meals, but she did not ask her or encourage her to get out of bed for the meal. LPN #229 confirmed she marked Resident #51's MAR and TAR stating that she encouraged Resident #51 to get out of bed. LPN #229 stated if Resident #51 stayed in her room to eat and Resident #51 was served finger foods staff did not need to stay with her, and if a meal such as fish was served like today, staff would be in Resident #51's room assisting her with eating. Observation on 04/30/25 at 7:25 A.M. of Resident #51 revealed she was lying in bed, had slid down in the bed and was slumped to the right. CNA #274 delivered Resident #51's meal tray to her room and placed it on the bedside table, which was raised about one foot above Resident #51, and she had to reach up about a foot to get her food. CNA #274 set the meal up and walked out of the room without properly positioning Resident #51 or assisting, supervising her with her meal. CNA #274 confirmed Resident #51 was in an awkward position to eat her meal, and she did not properly position her or stay 365492 Page 22 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0692 in the room to help her or supervise her while she ate. Level of Harm - Minimal harm or potential for actual harm Interview on 04/30/25 at 7:40 A.M. of CNA #274 revealed Resident #51 did not usually get up for breakfast, and she did not attempt to get her up or encourage her to get up. Residents Affected - Few Interview on 04/30/25 at 7:41 A.M. of CNA #260 revealed she did not encourage or attempt to assist Resident #51 out of bed for the breakfast meal. CNA #260 was not aware Resident #51 was supposed to be in a chair and not lying in bed when she ate her meals. Interview on 04/30/25 at 10:13 A.M. of RD #206 and Mobile Dietitian #275 revealed they were aware of Resident #51's weight loss, and when Resident #51's nutrition quarterly review was completed, a mighty shake was added to Resident #51's breakfast meal. Review of Resident #51's meal intakes revealed she was eating 0 to 100 percent of her meals. RD #206 stated Resident #51 liked her supplements and if she ate her entire meal the calories would be sufficient. Interview on 04/30/25 at 10:44 A.M. of ST #276 revealed she evaluated Resident #51 on 02/11/25. ST #276 stated Resident #51 had severe cognitive impairment, and her communication was at baseline. ST #276 stated Resident #51's swallowing was normal, she was able to self-feed, her chewing was normal, and she did not pick her up because she was at her baseline. ST #276 indicated her recommendations were finger foods, mechanical soft diet with thin liquids and using a straw. ST #276 stated using a straw and sipping from it was easier for upper body ROM. ST #276 stated she recommended strategies for staff alternating between solids and liquids, modifying rate of intake, small bites and small sips. ST #276 revealed Resident #51 needed staff supervision, and staff should set her meal up and stay in the room if she did not want to go to the dining room, but Resident #51 was usually in the dining room. ST #276 indicated she was not aware Resident #51 was not in the dining room for meals where staff could assist her, and she had communicated to staff that Resident #51 should be in an upright posture for meals and in the dining room for all meals. ST #276 stated she talked to the nurses on 02/11/25 about her recommendations. ST #276 stated if Resident #51 was in her room for meals she should have an aide in the room, or checking on her frequently, and Resident #51 should be out of bed and sitting upright in a chair. ST #276 stated Resident #51 should not be lying in bed for oral intake. ST #276 stated she updated Resident #51's daughter with her recommendations and was in frequent communication with her. Observation on 04/30/25 at 1:07 P.M. of Resident #51 lying in bed with the head of the bed elevated eating her lunch meal, and CNA #260 was sitting next to the bed. Review of Resident #51's weight record dated 05/01/25 revealed her weight was 83.4 pounds. Review of Resident #51's MAR and TAR dated 05/01/25 through 05/04/25 included encourage Resident #51 to eat meals in the dining room and document refusals. There were checkmarks every day for the breakfast, lunch and dinner meals indicating Resident #51 was encouraged to eat her meals in the dining room. There were no documented refusals. Observation on 05/01/25 at 8:10 A.M. of Resident #51 revealed she was lying in bed, had slid down in the bed and was slumped to the right side. Resident #51's breakfast tray was in front of her on the bedside table, and there was no straw on the meal tray. CNA #270 confirmed Resident #51 was not out of bed for the breakfast meal and was not properly positioned in bed while eating her breakfast. Interview on 05/01/25 at 9:03 A.M. of LPN #216 revealed Resident #51 was pleasant, and she did not 365492 Page 23 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have problems assisting Resident #51 out of bed. LPN #216 was not aware Resident #51 should be out of bed for all meals and confirmed Resident #51 was in bed when the breakfast meal was served. Interview on 05/01/25 at 10:21 A.M. of CNA #270 revealed Resident #51 was easy going and sweet, was not combative, did not refuse care, and some days did not want to wake up for breakfast. CNA #270 stated she did not try to get Resident #51 out of bed for breakfast and did not know she was supposed to be in a chair when eating her meals. CNA #270 stated she set up Resident #51's meal tray for breakfast but did not stay in the room with her. Review of the facility Clinical Systems Review: Unintended Weight Loss and Strategies for Prevention included to identify appropriate prevention strategies to avoid weight loss. Why do residents lose weight? Identified risks not acted upon, interventions were not in place on care plan or were not followed, poor communication of resident needs among and between staff, staff were not seeing risks, interventions needed when assisting residents at meals or observing consumption of supplements when interacting with residents (poor documentation of meal intakes:, not observing, reviewing residents who were identified as at risk frequently enough. Unintended weight loss can be significant (large amounts in a short period of time) or insidious (a few pounds a month for several months) and both were serious and should be prevented or addressed. 365492 Page 24 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on observation, medical record review, hospital record review, facility policy review, staff, and resident interviews, the facility failed to develop and implement a comprehensive, individualized, and effective pain management program for Resident #220 who was admitted with acute pain from unspecified fracture of upper and lower end of left tibia, and nondisplaced cervical fracture caused by a motor vehicle accident. Residents Affected - Few Actual Harm occurred beginning on 04/25/25 when Resident #220 did not receive the ordered medication pain reliever Oxycodone five milligram immediate release tablet every four hours as needed. The medication was not administered until 04/26/25 at 2:26 P.M. During this time, Resident #220 had complaints of unrelieved pain making it hard to sleep, perform day-to-day activities, and sleep. This affected one resident (#220) of the four residents reviewed for pain management. The facility census was 66. Findings include: Review of Resident #220's medical record revealed an admission date of 04/25/25 at 5:47 P.M. Resident #220 had diagnoses of traumatic shock, unspecified fracture of upper and lower end of the left tibia, nondisplaced fracture of first cervical vertebra because of a motor vehicle accident, anxiety disorder, major depressive disorder, and essential hypertension, diabetes, and muscle weakness are other diagnoses. Review of Resident #220's hospital discharge medication administration records for 04/25/25 included acetaminophen 325 milligrams (analgesic), take two tablets every six hours scheduled, last administration before discharge was 1:11 P.M. on 04/25/25; methocarbamol 1,000 milligram tablet (muscle relaxer), take three times a day last administered on 04/24/25 at 12:46 P.M.; and Oxycodone 10 milligrams (opioid pain medication) immediate release tablet every four hours as needed last given at 12:46 P.M. on 04/25/25. Review of Resident #220's discharge pain medication list from the local hospital dated 04/25/25 revealed the following medication orders: acetaminophen 325 milligram tablets, take two tablets every six hours scheduled, methocarbamol 1,000 milligram tablet to be given three times a day scheduled, Bengay cream (topical analgesic), one application to be applied topically three times a day scheduled, Oxycodone five milligram immediate release tablet to be given every four hours as needed, Ibuprofen 400 milligram tablet (non-steroidal anti-inflammatory drug) was ordered every six hours as needed. Resident #220 was sent (to the facility) with a written prescription for the Oxycodone five milligrams every four hours as needed for severe pain with a pain scale of seven to 10, 15 tablets were to be dispensed. Review of the admission assessment documentation dated 04/25/25 at 10:37 P.M. revealed Resident #220 arrived at the facility with the prescription for Oxycodone, and it was faxed to the pharmacy. A fax message from the pharmacy on 04/26/25 at 8:33 A.M. indicated that the faxed prescription was missing prescribers' signature, and please obtain a new order and fax to the pharmacy. Review of Resident #220's medication administration record (MAR) dated 04/25/25 to 05/08/25 revealed that pain monitoring every shift was started on 04/26/25 with pain on day shift marked as a four, night shift pain scale was marked a nine. The acetaminophen order for every six hours was first offered on 04/26/25 at 6:00 A.M. but not administered documented as sleeping, the next administration 365492 Page 25 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0697 Level of Harm - Actual harm Residents Affected - Few indicated the medication was administered at 12:00 P.M. by Licensed Practical Nurse (LPN) #258. The administration of the Ibuprofen 400 milligrams every six hours was administered on 04/29/25 at 12:00 P.M. The Bengay cream was documented on 04/25/25 at 10:00 P.M. as refused, 04/26/25 at 6:00 A.M. administration documentation was refused. The Bengay was documented as unavailable from 04/26/25 at 10:00 P.M. through 04/28/25 at 6:00 A.M. The methocarbamol 1,000 milligrams was documented on 04/25/25 at 10:00 P.M. as ordered. Resident #220's admission assessment on 04/25/25 indicated Resident #220 had experienced pain almost constantly over the past five days. When Resident #220 was asked if his pain made it hard to sleep, perform day-to-day activities, and sleep he indicated almost constantly. The description of pain from Resident #220 was severe with voicing concerns as throbbing. Informational questions about the causes and alleviations of the pain were not completed in the assessment. Interview with Resident #220 on 05/05/25 at 8:21 A.M. revealed he brought the prescription for Oxycodone with him and gave it to the nurse when he arrived to the facility around 6:00 P.M. The nurse took a long time to come see me and they just don't understand the pain I am in. I should not beg for my own medication; they have not been in a car accident and fractured their bodies. Resident #220 stated the nurses would come in and blame the pharmacy and the doctor would blame the nurses for the Oxycodone not being given causing me to be in so much pain. Resident #220 stated that Saturday afternoon was the first time that any real pain medications were given and because it took so long, it didn't work well until he had a build-up of the medication. During the interview, Resident #220 indicated that he could not wait to go home and care for himself. Interview with admitting LPN #207 on 05/05/25 at 10:32 A.M. revealed Resident#200 was admitted with a prescription, and she faxed it to the pharmacy when she got a chance. She stated Resident #220 was polite but uncomfortable. The resident had a lot of medical issues going on. The LPN revealed it took me a while to get the resident's assessment done. Interview with LPN #258 on 05/05/25 at 8:52 A.M. revealed that LPN #258 was the nurse on 04/26/25 day shift that encountered Resident #220 with unrelieved pain. LPN #258 administered acetaminophen 325 milligrams, two tablets at 12:00 P.M. stating that the resident was in a lot of pain and that he guessed the medication was lost in transit. Resident #200 was not combative but very uncomfortable. LPN#258 sent a fax to the pharmacy on 04/26/25 for authorization to get Oxycodone five milligrams immediate release tablet pulled from the facility contingency box. The approval authorization was received at 1:59 P.M. for six tablets to be removed from the contingency box. Resident #220 received Oxycodone five milligrams immediate release tablet at 2:23 P.M. on 04/26/25 follow up documentation for effectiveness was somewhat. Interview with the Director of Nursing (DON) on 05/01/25 at 2:46 P.M. verified on the electronic MAR that Resident #220 did not receive prescription pain medication until 04/26/25 at 2:23 P.M. stating, she could not help how long the pharmacy takes sometimes, and there must be an authorization to pull the medication from the contingency unit. She verified that the prior authorization was approved on 04/26/25 at 1:59 P.M. She confirmed that Resident #220 had not received pain medications for nine hours before he was admitted and that interventions could have been documented, stating that documentation was a big problem in the facility. Review of the facility policy titled Pain Management, revised on 01/08/25 revealed when there was a pain indicator, the intensity, characteristics, and frequency would be documented. Non-pharmacological interventions would be attempted prior to administration of as needed pain medication. When it 365492 Page 26 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0697 Level of Harm - Actual harm was determined that the resident was having pain all documentation would be in place. Interventions such as contingency boxes would be utilized and the doctor would be notified of an increased pain as appropriate. It was the policy of the facility to assess pain or the potential for pain and a goal to reach and maintain the residents' highest level of well-being physically, mentally, and psychosocially. Residents Affected - Few 365492 Page 27 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review, the facility failed to store and label drugs according to manufacture guidelines. This affected seven residents (#57, #49, #27, #41, #38, #46, and #4) and had the potential to affect all residents receiving insulin. The facility identified 17 residents (#1, # 4, #10, #22, #27, #32, #33, #34, #38, #46, #49, #57, #219, #220, #221, #225) with orders for insulin. The facility's census was 66. Findings include: Observation of the medication cart on [DATE] at 10:03 A.M. identified Lispor Kwikpen opened for Resident #57. There were two Basaglar Kwikpens for Resident #49 opened and dated [DATE] and [DATE]. Resident # 27 had an opened Lantus Solostar Pen with no open date on the device or the bag it was in. Interview on [DATE] at the time of the observation with Licensed Practical Nurse (LPN) #258 and Minimum Data Set (MDS) Coordinator/LPN #268 verified the insulin pens were not dated and/or they were expired according to manufacturing standards. Observation of the medication cart on [DATE] at 10:42 A.M. revealed Resident #41's insulin vial was used and not dated when opened. There was a Lispro vial that did not have an open date on it for Resident #38. Resident #46's Humalog vial had been used and no open date marked on the bottle. Resident #4 had a Lispro vial not dated. Interview on [DATE] at the time of the observation with registered Nurse (RN) #205 verified that these items were not marked with open dates and there was no way to determine the length of time these items had been in use. Interview with the Director of Nursing (DON) on [DATE] at 12:25 P.M. verified that the items were discarded and they were being reordered through the pharmacy. The DON stated that the policy was to date all items opened in the medication carts. Review of the facility Medication Administration Policy section for storage and labeling of drugs indicates that the licensed nurse will ensure that there are open dates on all items opened and discard according the manufacturing and medical stand 365492 Page 28 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, the facility failed to ensure a complete and accurate medical record for Resident #10. This affected one resident (#10) of three residents reviewed for activities of daily living (ADL). The facility census was 66. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/21/17 with diagnoses including functional quadriplegia, muscle weakness, contracture of hand, and dystonia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. The resident was dependent on staff for bathing. Interview on 04/29/25 at 8:02 A.M. with Resident #10 stated she didn't always get showers when she was supposed to. Review of the shower sheets from 04/26/25, 04/23/25, 04/19/25, 04/16/25, 04/12/25, 04/09/25, 04/05/25, 04/02/25, 03/29/25, 03/26/25, 03/22/25, 03/19/25, 03/15/25, 03/12/25, 03/08/25, 03/05/25, 03/01/25, and 02/26/25 revealed the shower sheets had not been completed accurately. Only the skin check portion was marked. The shower/bed bath areas were blank. Review of the shower sheets with Resident #10 revealed the resident had received ten showers and eight bed baths during the time period reviewed. However, they had not been documented 12 of 18 times. Interview on 04/30/25 at 2:35 P.M. the Director of Nursing (DON) verified shower sheets had not been completed accurately. 365492 Page 29 of 32 365492 05/12/2025 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 record review, observation, staff interview and facility policy review, the facility failed to ensure infection control practices were being implemented for Transmission Based Precautions (TBP) for Resident #218 with Coronavirus Disease 19 (COVID-19). This affected one resident (#218) out of one resident reviewed for TBP. This had the potential to affect 12 residents (#2, #16, #24, #29, #34, #43, #60, #218, #220, #224, #227, #228) on Certified Nursing Assistant (CNA) #252's assignment. The facility failed to ensure Resident #226's indwelling Foley catheter drainage bag was not on the floor. This affected one resident (#226) of three residents reviewed for indwelling Foley catheters. The facility failed to ensure infection control was maintained during incontinence care for Resident #22. This affected one resident (#22) of three residents reviewed for incontinence care. In addition, the facility failed to properly clean a glucometer prior to checking a blood sugar for Resident #58 and failed to remove her gloves and wash her hands after administering insulin to Resident #58. This affected one resident (#58) of one resident reviewed for blood glucose testing had the potential to affect 16 additional residents (#1,# 4, #10, #22, #23, #32, #33, #34, #38, #46, #49, #57, #219, #220, #221, #225) identified by the facility as requiring fingerstick blood sugar glucometer checks. The facility census was 66. Residents Affected - Some Findings Include: 1. Review of the medical record for Resident #218 revealed an admission date of 4/24/25 and a discharge date of 05/03/25 to home. Diagnoses included COVID-19, pneumonia, and acute and chronic respiratory failure with hypoxia. Review of the physician orders for April 2025 and May 2025 revealed an order for Isolation/ TBP: Droplet Precautions/isolation related to COVID-19 and Isolation/TBP: Resident #218 received all care and services in room while on TBP. Review of the care plan dated 04/24/25 revealed Resident #218 was admitted on isolation droplet precautions with all care and services in room. Interventions to include educating resident/visitors on isolation, maintaining isolation droplet precautions every shift, performing hand hygiene, wearing a mask, gown, gloves, eye protection before entering room. Observation on 04/28/25 at 12:11 P.M. during lunch meal pass revealed CNA #252 donned gown, gloves, surgical mask, and face shield to enter Resident #218's room, on COVID-19/TBP room. Interview on 04/28/25 at 12:15 P.M. with CNA #252 confirmed he did not wear the required N95 mask, (also known as a respirator, is a personal protective device that filters out at least 95% of airborne particles that are 0.3 microns or larger) to enter the TBP room for Resident #218. CNA #252 reported he thought he only needed the surgical mask to pass the meal trays. Interview on 04/28/25 at 2:18 P.M. with Resident #218, only resident in the facility on contact isolation due to admitted from hospital with COVID-19, revealed staff do not always wear personal protective equipment (PPE) when entering her room. Interview on 04/28/25 at 3:03 P.M. with the Director of Nursing (DON) confirmed CNA #252 was required to wear an N95 mask to enter a TBP room, for Resident #218. The DON reported she will start education. 365492 Page 30 of 32 365492 05/12/2025 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 policy, Transmission-Based Precautions and Isolation Policy, revised 03/20/25, revealed airborne precautions to prevent transmission of the infectious over long distances when suspended in the air. Residents should be placed in a private room with door closed, and healthcare staff provided with N95 or higher respirators, gloves, gown, and eye protection are worn adhering to standard precaution guidelines. Residents Affected - Some 2. Review of the medical record for Resident #226 revealed an admission date of 04/24/25. Diagnoses included malignant neoplasm of esophagus and dementia. Review of the Brief Interview for Mental Status (BIMS) dated revealed Resident #226 had intact cognition with a score of 13/15. Observation on 04/28/25 at 10:53 A.M. revealed Resident #226's indwelling Foley catheter drainage bag was on the floor with no privacy cover. Interview on 04/28/25 at 10:57 A.M. with Licensed Practical Nurse (LPN) #242 confirmed Resident #226's indwelling Foley catheter drainage bag was on the floor. Interview on 04/29/25 at 12:37 P.M. with the DON confirmed the indwelling Foley catheter drainage bag was not to be on the floor due to infection control concerns. Review of the facility policy, Indwelling Urinary Catheter Care Procedure, revised 07/15/24, revealed the urinary drainage bag must be placed below the bladder level but not on the floor. 3.Review of the medical record for Resident #22 revealed an admission date of 0710/24. Diagnoses included dementia, type two diabetes mellitus, malignant neoplasm of parotoid gland, breast, retroperitoneum, and Alzheimer's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had severely impaired cognition. The resident was frequently incontinent of bowel and bladder. Observation on 04/30/25 at 8:09 A.M. of incontinence care revealed CNA #257 gathered supplies, knocked on door, and explained the procedure to Resident #22 and her daughter. CNA #257 washed her hands and donned gloves. CNA #257 filled a basin with warm water. CNA #257 placed two washcloths in the basin, then removed Resident #22's brief which contained a moderate amount of urine. CNA #257 removed one washcloth and applied the no rinse body wash and performed peri care using separate ends of the washcloth, she then placed the soiled washcloth back in the basin of water with a new washcloth in the basin. CNA #257 removed the other washcloth from the basin and rinsed the peri area, then placed the soiled washcloth back in the basin of water. CNA #257 then patted dry the peri area. CNA #257 then removed the two washcloths from the basin of water and put two new washcloths in the basin of water. CNA #257 then assisted Resident #22 to turn to her left side. CNA #257 removed one washcloth from the basin, applied no rinse body wash and provided incontinence care to the buttocks. CNA #257 then placed the soiled washcloth back into the basin of water and removed the other washcloth to rinse the buttocks. CNA #257 placed the rinse washcloth back into the basin of water. CNA #257 dried the buttocks, applied a new brief, removed the basin and dirty washcloths/towel, removed her gloves and washed her hands. CNA #257 repositioned Resident #22 in bed, placed the bed in low position and placed the call light within the resident's reach. Interview on 04/30/25 at 8:32 A.M. with CNA #257 confirmed she should not have placed the 365492 Page 31 of 32 365492 05/12/2025 Grand River Health & Rehab Center 1515 Brookstone Blvd Painesville, OH 44077

F 0880 contaminated washcloths back in the water with the clean washcloths. Level of Harm - Minimal harm or potential for actual harm Interview on 04/30/25 at 8:37 A.M. with the DON confirmed CNA #257 should not have placed the contaminated washcloths back in the water with the clean washcloths. The DON reported the facility had a lot of infection control issues, and she would be doing in-services. Residents Affected - Some Review of the facility policy, Infection Prevention and Control Program, revised 02/19/24, revealed the policy is to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and contract healthcare workers. 4. Review of Resident #58's clinical record revealed an admission date of 03/28/25 with diagnoses including type two diabetes, multiple fractures of the ribs, right side, strain of muscles. strain of muscles, acute respiratory, myelodysplastic syndrome, muscle weakness, and difficulty with walking. Review of Resident # 58's physician's orders revealed an order for Lispro insulin pen; 100 unit/milliliter (mL); amount: Per sliding scale order: if blood sugar is 151 to 200, give 1 unit, if blood sugar is 201 to 250, give 2 units, if blood sugar is 251 to 300, give 3 units, if blood sugar is 301 to 350, give 4 units, if blood sugar is 351 to 400, give 4 units, if blood sugar is greater than 400, give 5 units, if blood sugar is greater than 400, call the medical doctor (MD). Give insulin subcutaneous four times a day at 7:00 A.M., 11:00 A.M., 4:00 P.M., 9:00 P.M. Observation of LPN # 208 on 04/30/25 at 11:22 A.M. providing insulin administration to Resident #58. LPN #208 introduced herself to Resident #58 then washed her hands, placing a barrier down, and pulled the glucometer out of a container with Resident #58's name on it. The blood glucose reading was 169. LPN #208 then cleaned device with disposable disinfectant cloth, placed the device in container wrapped in wet cloth. LPN #208 drew up the insulin and primed the needle, then asked Resident #58 the location to place the injection in; Resident # 58 stated the abdominal area. Resident #58 received 1 unit per sliding scale. Observation continued on 04/30/25 at 11:31 A.M. with LPN # 208 pushing the resident into the restroom with her gloves on. On 04/30/25 at 11:45 A.M. interview with LPN# 208 confirmed that she was to clean the glucometer before using it and verified that she cannot guarantee that the glucometer was cleaned before use, and that her gloves needed take off and her hands washed before assisting the resident after administration of the insulin. On 04/30/25 at 12:46 P.M. an interview with the DON confirmed that the staff were being educated, the glucometer should have been cleaned before checking the resident's blood sugar, and the nurse should have taken her gloves off and washed her hands after insulin administration. Review of the facility policy titled Glucometer/Point of Care Blood Testing and Disinfection Procedure, dated 12/27/23, stated that whenever possible, individual meters will be assigned to each resident. Whether shared or assigned to a singular resident, blood testing meters will be disinfected between each use (before use- the clinician should assume the meter is dirty and disinfect before use) according to manufacture instructions and infection control guidelines. The procedure stated gloves need to be removed and disposed of with hand hygiene following after procedure. This deficiency represents noncompliance investigated under Complaint Number OH00164118. 365492 Page 32 of 32