Health inspection·March 28, 2019

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to accurately inform residents of their discharge date s from Medicare Part A affecting Residents #270, #272 and #273. This affected three of four residents reviewed for beneficiary notifications. Residents Affected - Few Findings Include: 1. Resident #270 was admitted to facility on 07/03/18. Her clinical census report revealed her last covered day (LCD) of Medicare A as 07/24/18 and Medicaid would start on 07/25/18 as a payment source. Resident #270 was issued a Notice of Medicare Non-Coverage form (NOMNC) for a LCD of 07/30/18 and it was signed by Resident #270 on 07/27/18. Further review of Resident #270's record revealed a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). It was issued with a start date of 07/30/18 and was signed by Resident #270 on 07/27/18. Interview on 03/27/19 at 6:01 P.M. with the Administrator and Social Service Designee (SSD) #407 revealed SSD #407 was notified by Physical Therapy of residents LCD and she will initiate the NOMNC, and SNF ABN if required, with the resident, or family, or responsible party. She was aware they need signed at least 48 hours prior to the LCD. 2. Resident #272 was admitted to facility on 06/01/18. His clinical census report revealed his LCD of Medicare A as 11/08/18 and Medicaid Pending would start on 11/09/18 as a payment source. Resident #272 was issued a NOMNC with a LCD of 11/08/18 and was signed by the resident on 11/09/18. Further review of Resident #272's record revealed a SNF ABN with no start date and signed by the resident on 11/09/18. Interview on 03/27/19 at 6:01 P.M. with the Administrator and SSD #407 she was notified by physical therapy of residents LCD and she initiates the NOMNC, and SNF ABN if required, with the resident, or family, or responsible party. She was aware they need signed at least 48 hours prior to the LCD. 3. Resident #273 was admitted to facility on 11/07/18. Her clinical census report revealed her LCD of Medicare A coverage was 11/30/18 and Private Pay would start on 12/01/18 as a payment source. Resident #273 had Medicare Health Maintenance Organization (HMO) insurance. The Medicare HMO sent the facility a Notice of Denial of Medicare Coverage, NDMCP CMS-10003, dated 11/27/18 and effective 11/29/18. The notice stated As of 11/29/18, you will have used the full 100-day benefit per the benefit period in the skilled nursing facility. Therefore, as of 11/30/18 you are no longer eligible for coverage in a skilled nursing facility. The facility should have issued Resident #273 a Notice of Exclusion from Medicare Benefits, Skilled Nursing Facility (NEMB SNF, CMS-20014). Page 1 of 20 365520 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0582 Interview on 03/27/19 at 6:01 P.M. with the Administrator and SSD #407 revealed neither party was familiar with the Notice of Denial of Medicare Coverage, NDMCP CMS-10003. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365520 Page 2 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, record review and interview, the facility failed to ensure a clean and sanitary smoking area. This finding affected Resident #268 and had the potential to affect all twenty-four smokers (Residents #1, #4, #5, #20, #24, #26, #27, #33, #34, #35, #39, #40, #41, #42, #47, #48, #50, #52, #53, #59, #63, #65, #267 and #268) who reside in the facility and smoke in the courtyard. The facility census was 70. Findings include: Observation on 03/25/19 at 10:07 A.M. with State Tested Nursing Assistant (STNA) #405 revealed residents were allowed in the courtyard for a designated smoke break. Further observation revealed the courtyard had a large amount of cigarette butts on the cement and grass areas of the courtyard. Interview with STNA #405 at the time of the observation revealed the residents sometimes cleaned up the courtyard. Observation on 03/26/19 at 10:45 A.M. with STNA #405 revealed the smoking courtyard area had a large amount of cigarette butts in the grass area of the courtyard. Interview at the time of the observation with STNA #405 indicated staff would try to clean the courtyard and residents would throw the cigarette butts on the ground again. Observation on 03/26/19 at 10:48 A.M. revealed Resident #268 was in the courtyard with supervision provided by STNA #405 and the resident was observed flicking ashes from his cigarette on the ground. Interview on 03/26/19 at 11:22 A.M. with STNA #405 confirmed Resident #268 probably flicked his cigarette butt on the ground but he did not actually see him flick it and the resident would only put the cigarette butt into the fire proof receptacle when instructed. The facility identified twenty-four smokers who used the smoking courtyard, Residents #1, #4, #5, #20, #24, #26, #27, #33, #34, #35, #39, #40, #41, #42, #47, #48, #50, #52, #53, #59, #63, #65, #267 and #268. Interview on 03/26/19 at 2:10 P.M. with the Administrator confirmed staff were to clean the courtyard after every smoke break and Resident #268 was a newer resident who was receptive for redirection by staff to place cigarette butts in the fire proof receptacles. The Administrator confirmed the courtyard was not in sanitary condition and stated, staff supervising residents needed to be on top of it to make sure the courtyard was clean. Review of the Smoking Policy and Procedure dated 03/23/19 indicated facility staff would supervise residents while smoking who were indicated to need supervision and smokers were only allowed in areas of the facility was was designated smoking areas. 365520 Page 3 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

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** 3. Review of the record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including dementia, schizophrenia, chronic kidney disease and peripheral vascular disease. Residents Affected - Some Review of the record revealed a nursing note dated 01/05/19 at 10:25 A.M. which indicated Resident #22 was heard calling for help and was found on the floor. The resident was not injured in the fall and was assisted up by staff. Review of the most recent quarterly MDS 3.0 assessment dated [DATE] did not indicate the resident had sustained a fall. An interview with the assessment nurse, LPN #400 on 03/27/19 at 4:05 P.M. confirmed the fall should have been recorded on the MDS assessment dated [DATE]. 4. Review of the record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, diabetes mellitus, weakness, dementia and a history of stroke. Review of nursing notes dated 11/12/18 at 6:45 A.M., 11/23/18 at 12:33 P.M. and 11/25/18 at 11:19 A.M. revealed Resident #47 had sustained falls on these days. He was not injured. Review of the quarterly MDS 3.0 assessment dated [DATE] did not indicate the resident had sustained any falls in the review period. An interview with the assessment nurse, LPN #400, on 03/27/19 at 9:45 A.M. confirmed these falls of Resident #47 falls should have been recorded on the MDS assessment dated [DATE]. 5. Review of the record revealed Resident #57 was admitted on [DATE] with diagnoses including dementia, hypertension, hemiplegia and chronic kidney disease. Review of the residents quarterly MDS 3.0 assessment dated [DATE] revealed the resident had an indwelling urinary catheter. Review of the resident's nursing notes and physician orders from January 2019 through the date of the survey did not indicate Resident #57 had a catheter. Review of his care plan for incontinence dated 01/30/12 and updated through 06/02/19 indicated he was incontinent of bladder. An interview with the assessment nurse, LPN #400, on 03/27/19 at 4:05 P.M. verified the resident did not have a urinary catheter currently or in the time frame prior to the quarterly MDS assessment on 03/01/19. She stated the catheter entry on the assessment was an error. Based on record review and interview, the facility failed to ensure comprehensive assessments were complete and accurate. This finding affected five (Residents #22, #33, #46, #47 and #57) of twenty-one residents reviewed for comprehensive assessments. Findings include: 1. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, end stage renal 365520 Page 4 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (kidney) disease and type two diabetes. Review of Resident #46's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. This assessment indicated Resident #46 received three doses of an antianxiety medication in the seven day look back period of 02/07/19 to 02/13/19. Review of Resident #46's physician orders revealed an order dated 11/28/18 for Lorazepam (an antianxiety medication), 0.5 mg (milligrams), give one tablet by mouth every day for dialysis days on Tuesday, Thursday and Saturdays. Review of Resident #46's medication administration records (MARS) from 02/07/19 to 02/13/19 revealed the resident received two doses of the antianxiety medication during the seven day look back period. Interview on 03/27/19 at 9:40 A.M. with Licensed Practical Nurse (LPN) #400 confirmed Resident #46's comprehensive assessment dated [DATE] did not accurately reflect the correct number of antianxiety medications administered. 2. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, major depressive disorder and delusional disorders. Review of Resident #33's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and received seven doses of an antidepressant medication during the seven day look back period of 01/22/19 to 01/28/19. Review of Resident #33's medical record, physician orders, medication administration records (MARS) and treatment administration records (TARS) did not reveal evidence the resident was ordered or administered an antidepressant during the seven day look back period. Interview on 3/26/19 at 3:28 P.M. with LPN #400 confirmed Resident #33's comprehensive assessment did not accurately reflect the resident's medication administration during the seven day look back period and verified the resident did not receive an antidepressant. 365520 Page 5 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive, resident centered care plan for Resident #53 regarding urinary/bladder infections and his need to self-catheterize. This affected one of two residents reviewed for catheters. The facility census was 70. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including diabetes, cystitis (a urinary tract infection), hematuria (blood in the urine) and paraplegia. The resident had a history of bladder and urinary tract infections. Review of his most recent quarterly minimum data set assessment dated [DATE] revealed he was alert, oriented and cognitively intact. An interview with Resident #53 on 03/26/19 at 9:34 A.M. revealed he performed self-catheterizations (procedure involving the insertion of a tube into the bladder to empty urine) four to five times daily. He stated he had done this for years. He indicated he had told facility staff several days prior that he thought he had a bladder infection. He said but had not received any type of treatment. He was unable to state why he thought he had an infection, becoming irritable as the surveyor questioned him, just stating he had had infections many times in the past and he knew when he was getting one. Review of the medical record revealed no comprehensive care planning related to his need to self-catheterize including interventions to ensure he completed the procedure correctly. There was also no comprehensive care plan to address his history of urinary tract and bladder infections and interventions to ensure he was monitored for signs and symptoms of urinary infections and/or prompt treatment for possible infections. An interview with the Director of Nursing on 03/28/19 at 3:00 P.M. verified the record did not contain a comprehensive care plan for Resident #53 related to self-catherization or risk of urinary/bladder infections. 365520 Page 6 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

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 record review and interview, the facility failed to ensure Resident #2's neurological examinations were completed as required after an unwitnessed fall. This finding affected one of five residents reviewed for accidents. Findings include: Resident #2 was admitted to facility on 10/19/16 with diagnoses including heart failure, hypertension, atrial fibrillation and schizoaffective disorder, bipolar type. His care plan, dated 12/15/18, revealed he was at increased risk for falls. Interventions included fall risk standard precautions and for staff to increase safety monitoring. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of zero, scores of zero to seven indicate severe cognitive impairment. Review of Progress Notes revealed Resident #2 had an unwitnessed fall on 12/30/18. Resident #2 was assessed for injuries and a 4.0 centimeter (cm) wide and 1.5 cm deep laceration was discovered on the front of his right lower leg. He was sent to the local emergency department and returned that evening with ten sutures. Review of the medical record revealed a neurological assessment, an assessment of muscle strength, reflexes, coordination, sensory function, pupil reaction and mental status, had been done on 01/02/19, the third day after the fall. Progress notes revealed neurological checks were done on 12/31/18 at 12:18 A.M., and 12/31/18 at 12:18 P.M. No other post fall neurological checks were found in the three days following the fall. Interview with Director of Nursing (DON) on 03/27/18 at 2:32 P.M. revealed neurological checks are to be done every shift for three days following a fall. Review of the Fall policy, dated December 1, 2018, revealed it is the purpose of the facility to identify standards of practice for post fall interventions. To ensure to the best of its ability the safety and well-being of residents who are at risk for falls. Also, after a fall of a resident, a full body assessment for injuries, including vital signs and safe movement of limbs are completed. Neurochecks should be done for head injuries or unwitnessed falls of cognitively impaired residents. Assessments should be repeated per shift for 72 hours. 365520 Page 7 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #36's catheter was changed according to the physician orders. This affected one of two resident reviewed for urinary catheters. Findings include: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including altered mental status, urinary tract infection and unspecified dementia without behavioral disturbance. Review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident exhibited severe cognitive impairment and had an indwelling urinary or Foley catheter, a tube inserted into the bladder to drain urine. Review of Resident #36's physician orders revealed an order dated 01/24/19 to change the Foley catheter every two weeks. Review of Resident #36's treatment administration records (TARS) from 02/01/19 to 03/27/19 revealed the resident's catheter was last changed on 02/21/19 and was required to be changed again on 03/07/19 and 03/21/19. The medical record, progress notes and TARS did not contain any evidence Resident #36's catheter was changed during the month of March 2019. Interview on 03/27/19 at 12:59 P.M. with Licensed Practical Nurse (LPN) #804 confirmed Resident #36's medical record did not contain evidence the resident's catheter was changed according to the physician orders. 365520 Page 8 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #46's arteriovenous (AV) fistula (a vascular access device surgically created for kidney dialysis) was monitored according to the physician orders. This finding affected one of one resident reviewed for dialysis. Residents Affected - Few Findings include: Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, and end stage renal (kidney) disease. Review of Resident #46's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #46's physician orders revealed a order dated 02/09/13 for nursing staff to check the left upper extremity/arm AV fistula site for bruit and thrill every shift. A bruit is a swishing sound heard when a stethoscope is placed on the AV fistula and a thrill is the vibration felt on the AV fistula. Checking for the bruit and the thrill ensure the AV fistula is patent and functioning properly. There was also a physician order dated 09/21/16 for nursing staff to monitor the AV fistula for bleeding and signs and symptoms of infection. Review of Resident #46's treatment administration records (TARS) from 03/01/19 to 03/27/19 on the 7:00 P.M. to 7:00 A.M. shift revealed no evidence the bruit and thrill were checked on 03/18/19, 03/20/19, 03/22/19, 03/23/19, 03/24/19, 03/25/19 and 03/26/19. Review of Resident #46's TARS from 03/01/19 to 03/27/19 on the 7:00 P.M. to 7:00 A.M. shift revealed no evidence the AV fistula to the left upper arm was checked for bleeding and signs and symptoms of infection on 03/20/19, 03/22/19, 03/23/19, 03/24/19, 03/25/19 and 03/26/19. Interview on 03/27/19 at 3:08 P.M. with the Director of Nursing confirmed Resident #46's TARS did not reveal evidence the thrill and bruit or the AV fistula site were monitored by nursing staff as ordered by the physician. 365520 Page 9 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure vital signs were checked as ordered prior to the administration of a blood pressure medication for Resident #47. This affected one of five residents reviewed for unnecessary medications. Residents Affected - Few Findings include: Review of the record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, diabetes mellitus, weakness, dementia and a history of stroke. Review of physician orders revealed Coreg, a blood pressure medication, was ordered on 09/27/18 and was to be administered twice a day to Resident #47. Review of the pharmacy recommendation dated 03/07/19 revealed a recommendation for a blood pressure and pulse be checked prior to the administration of Coreg, one of several blood pressure medications taken by Resident #47. The recommendation was approved by the physician and the physician wrote an order on 03/21/19 which directed nursing staff to hold the blood pressure medication if Resident #47's systolic blood pressure was less than 110 or if his heart rate was less than 60. Review of the medication administration record (MAR) record for March, 2019 revealed the physician order to check Resident #47's blood pressure and heart rate prior to administering the Coreg medication, however no vital signs were recorded. Blood pressures were checked and recorded for another blood pressure medication, Amlodipine, which was ordered for the resident every morning. The systolic blood pressure was not lower than 110. However, Resident #47's heart rate was only documented on 03/22/19 and 03/26/19. An interview with Licensed Practical Nurse (LPN) #403 on 03/27/19 at 1:15 P.M. revealed she had written the order for the parameters for the blood pressure and heart rate but had not specified which blood pressure medication to hold. On 03/27/19 at 2:45 P.M., the Director of Nursing (DON) verified the order to check Resident #47's blood pressure and heart rate had been written in response to the pharmacy recommendation to check the vital signs before he received the Coreg medication. The DON verified the physician order did not specify which blood pressure medication to hold based on the blood pressure and heart rate. The DON confirmed the physician order was not written near the Coreg medication order, to alert nurses to check these vital signs prior to the administration of this medication. She further verified the Coreg was ordered twice a day and even though the resident's blood pressure was checked in the morning when he received another blood pressure medication, the Amlodipine, his pulse was not checked daily and his blood pressure and heart rate had not been checked prior to the administration of the evening dose of Coreg on any day since the physician order was written on 03/21/19. 365520 Page 10 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #366's medications were administered according to the physician orders and with an error rate of less than 5% (percent). This finding affected one (Resident #366) of five residents observation for medication administration. A total of 26 medications were administered with two errors resulting in a medication error rate of 7.69%. Residents Affected - Few Findings include: Review of Resident #366's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Methicillin Resistant Staphylococcus aureus infection, septic pulmonary embolism (blood clot in the lung) and low back pain. Review of Resident #366's physician orders revealed an order dated 03/21/19 to infuse Vancomycin (an antibiotic) 1.25 grams (gm) via intravenously (IV) every twelve hours, due at 8:00 A.M. and 8:00 P.M. Review of Resident #366's physician orders revealed an order dated 03/07/19 for Humalog insulin (fast acting insulin), eight units subcutaneously with meals. There was a physician order dated 03/09/19 for accuchecks (blood glucose checks) with sliding scale insulin coverage before meals and at bedtime with Humalog insulin. For a blood sugar of zero to 150 give no insulin; for blood sugars of 151 to 200, give two units of insulin; for blood sugars of 201 to 250, give four units of insulin; for blood sugars of 251 to 300, give six units of insulin; for blood sugars of 301 to 350, give eight units of insulin; for blood sugars of 351 to 400, give ten units of insulin; and if the blood sugar was below 70 or greater than 400, notify the physician. Observation on 03/25/19 at 9:35 A.M. with Licensed Practical Nurse (LPN) #801 indicated the accucheck was completed with a result of 237 and the resident received 12 units of Humalog insulin in the right arm. Interview on 03/25/19 at 9:40 A.M. with LPN #801 confirmed Resident #366 received his breakfast at approximately 8:30 A.M. and the resident's accucheck was completed after the breakfast meal as well as the insulin. These were ordered to be completed before the breakfast meal. Observation on 03/25/19 at 10:23 A.M. with LPN #802 revealed the nurse administered the Vancomycin 1.25 gm IV at 165 cc (cubic centimeters) per hour using an IV administration pump. The Vancomycin was ordered to be given at 8:00 A.M. Interview on 03/25/19 at 11:23 A.M. with LPN #802 indicated she was unaware of the exact time Resident #366's Vancomycin was due and she thought it was scheduled to be administered at 9:00 A.M. LPN #802 confirmed the antibiotic was not administered timely and stated it was because the nursing staff on the first floor were not IV certified and she had to go to the first floor to administer the IV medications. These two medication errors were identified in 26 medications opportunities observed resulting in a medication error rate of 7.69%. 365520 Page 11 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, record review and interview, the facility failed to ensure expired medications were discarded appropriately. This finding affected three (Residents #17, #53 and #55) of three residents whose insulin was stored in the two front hall medication storage cart. Findings include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with other diabetic kidney complications, conduct disorder and bipolar disorder. Review of Resident #21's physician orders revealed an order dated 07/28/18 for Humulin N insulin, inject 20 units subcutaneously (SQ) every morning. Observation on 03/26/19 at 8:04 A.M. with Licensed Practical Nurse (LPN) #802 of the two front hall medication storage cart revealed Resident #21's Humulin N (long acting insulin) was dated 01/30/19. Interview on 03/26/19 at 8:08 A.M. with LPN #802 confirmed Resident #21's Humulin N was expired and should have been discarded. Review of the undated Stability of Common Insulins in Vials and Pens policy indicated Humulin N insulin expired thirty days after the insulin was opened at room or refrigerator temperature. 2. Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute kidney failure, major depressive disorder and type 2 diabetes mellitus with hyperglycemia. Review of Resident #53's physician orders revealed an order dated 02/13/19 for Lantus insulin, inject four units SQ at bedtime. Observation on 03/26/19 at 8:04 A.M. with LPN #802 of the two front hall medication storage cart revealed Resident #53's Lantus insulin was dated 02/13/19. Interview on 03/26/19 at 8:08 A.M. with LPN #802 confirmed Resident #53's Lantus insulin was expired and should have been discarded. Review of the undated Stability of Common Insulins in Vials and Pens policy indicated Lantus insulin expired twenty-eight days after the insulin was opened at room or refrigerator temperature. 3. Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, hyperlipidemia and type two diabetes mellitus without complications. Review of Resident #55's physician orders revealed an order dated 02/14/19 for Humulin N insulin, 30 units SQ twice daily and an order dated 03/20/19 for sliding scale insulin with blood glucose 365520 Page 12 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few checks three times a day and administer two units of Humalog insulin for a blood sugar test (BGT) result of 200 to 250, four units for BGT result of 251 to 300, six units for BGT result of 301 to 350, eight units for BGT result of 351 to 400 and to call the physician for a blood glucose level greater than 400. Observations on 03/26/19 at 8:04 A.M. with LPN #802 of the two front hall medication storage cart revealed Resident #55's Humulin N insulin was dated 02/18/19 and the resident's Humalog (fast acting insulin) was undated. Interview on 03/26/19 at 8:08 A.M. with LPN #802 confirmed Resident #55's Humulin N insulin was expired and should have been discarded. LPN #802 verified the resident's Humalog insulin was undated and they were unable to determine the expiration date. Review of the undated Stability of Common Insulins in Vials and Pens policy indicated Humulin N insulin expired 31 days after opening and Humalog insulin expired twenty-eight days after the insulin was opened at room or refrigerator temperature. 365520 Page 13 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the results of laboratory testing for Resident #53 were reported promptly to the ordering physician. This affected one of two residents reviewed for catheters. Findings include: Review of the record of Resident #53 revealed he was admitted to the facility on [DATE] with diagnoses including diabetes, cystitis (urinary tract infection), hematuria (blood in the urine) and paraplegia. The resident had a history of bladder and urinary tract infections. Review of his most recent quarterly Minimum Data Set assessment dated [DATE] revealed he was alert, oriented and cognitively intact. Review of a nursing note dated 03/19/19 at 2:30 P.M. revealed Resident #53 told staff he had a bladder infection, stating he had one in the past and knew how it felt. The note indicated the resident catheterized (insertion of a tube into the bladder to drain the urine from the bladder) himself and denied pain or bleeding, but did state there was puss when he did the catheterization. The note indicated the physician was notified and an order was given for a urinalysis test to be completed. The urine specimen was sent that day. Review of a physician note dated 03/21/19 revealed the physician saw the resident and was aware of the urine concern. The note indicated the physician was waiting for the results of the urinalysis test. An interview with Resident #53 on 03/26/19 at 9:34 AM revealed he performed self-catheterizations four to five times daily. He stated he had done this for years. He also indicated he had told facility staff several days prior he thought he had a bladder infection. He said he had not received any type of treatment. He was unable to state why he thought he had an infection, becoming irritable as the surveyor questioned him, just stating he had had infections many times in the past and he knew when he was getting one. An interview with Resident #53 on 03/26/18 at 8:30 A.M. revealed him eating breakfast in his room. He stated he had still not received any treatment or medication for the infection. Review of a progress note dated 03/26/19 at 4:17 P.M. revealed the physician was notified of the final results of the urinalysis and ordered Ceftin, an antibiotic to be given for seven days. The note indicated the resident was notified of the new medication. Review of the urinalysis report, which was added to the record after the order was received on 03/26/19, revealed the results of the urinalysis testing was faxed to the facility on [DATE] at 12:48 P.M. There was no indication the results of the testing, which indicated the resident had an infection with Escherichia coli, bacteria, red and white blood cells and a high number of leukocytes (all marked as abnormal on the report), were called to the physician when it was received on 03/22/19. A hand written note on the form dated 03/22/19 indicated the physician was notified on 03/26/19 and an order was given for antibiotics to given to Resident #53. 365520 Page 14 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0773 Level of Harm - Minimal harm or potential for actual harm An interview with the Director of Nursing (DON) on 03/28/19 at 12:15 P.M. verified the record did not contain evidence that the resident's laboratory results were reported to the physician when they were received on 03/22/19. The DON verified when the results were called to the physician on 03/26/19, he started an antibiotic to treat the resident's urinary infection. Residents Affected - Few 365520 Page 15 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2. An observation of puree food preparation in the kitchen with Dietary Manager #402 was completed on 03/28/19 at 10:30 A.M. DM #402 prepared the pureed food, and was assisted by DA #403, who obtained the containers to store the food and covered the food. DA #403 was also noted to be performing other kitchen tasks. DA #403 had a hair covering for his head, but had a short beard, which was not covered. An interview with DA #403 on 03/28/19 at 10:35 A.M. revealed he did not know he had to cover his facial hair. An interview with DM #402 and Registered Dietician #404 on 03/28/19 at 10:45 A.M. revealed their understanding that staff with facial hair should cover that hair when in the kitchen or working directly with food. A facility dietary policy dated March 2011, revealed all dietary employees would wear a hair net or other covering, which would cover all hair. The policy also indicated beards and facial hair should be contained. Based on observation and interview, the facility failed to ensure staff used a beard restraint when preparing and plating food for residents to prevent hair from contaminating food during meal service. This finding had the potential to affect all seventy residents residing in the facility who received meals from the kitchen and the dining rooms. Findings include: 1. Observation on 03/25/19 at 12:08 P.M. revealed Dining Aide (DA) #401 was in the main dining room on the first floor plating food from a steam table for resident consumption and the staff member had a black beard with no beard restraint in place. Observation on 03/26/19 at 8:40 A.M. revealed DA #401 was in the main dining room on the first floor plating food from a steam table for resident consumption and the staff member had a black beard with no beard restraint in place. Interview on 03/26/19 at 9:20 A.M. with DA #401 confirmed he was aware that he should have had a beard restraint in place however his chin was irritated and he did not want to wear one. 365520 Page 16 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

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 record review and interview, the facility failed to ensure Resident #36's and Resident #44's medical records contained complete and accurate documentation. This affected one (Resident #36) of five residents reviewed for accidents and one (Resident #44) of two residents reviewed for hospitalizations. Findings include: 1. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including altered mental status, hyperlipidemia and urinary tract infection. Review of Resident #36's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment. Review of Resident #36's progress note dated 03/13/19 at 5:51 P.M. indicated the resident was transported to an appointment with an escort at the hospital. The State Tested Nursing Assistant (STNA) escorted the resident, notified and updated the staff that the hospital staff escorted the resident to have labs drawn and let the resident leave without the nursing facility escort. The physician was notified, the hospital police and the local police department were notified. Review of Resident #36's progress note dated 03/14/19 at 3:40 P.M. indicated the documentation was a late entry and the resident returned to the facility with his daughter and son. The resident's skin was clean, dry and intact upon arrival and the Foley (a urinary drainage system) was clean, dry and intact with no new concerns observed on the shift by the nurse. Review of Resident #36's witness investigation statement dated 03/13/19, authored by STNA #803, indicated, I took the resident to an appointment at the hospital. After his appointment, he went to the outpatient lab then they released him. I did not know that the resident had been released until much later. When I realized that the resident was missing, I reported it to the hospital security then to the local police. Interview on 03/27/19 10:21 A.M. with the Administrator confirmed Resident #36's medical record did not contain accurate documentation of the care that the resident received during the physician visit including of the exact time the hospital staff escorted the resident to the lab for testing, when the lab released the resident unescorted, how long the resident was walking unescorted out of the hospital and when the resident was located and returned to the resident's family. The Administrator confirmed the medical record did not accurately reflect the resident's care and supervision on 03/13/19. 2. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes, dysphagia (trouble swallowing), and dementia. Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment. Review of Resident #44's progress note dated 03/09/19 at 2:05 P.M. revealed the responsible party was made aware and indicated a nursing order was obtained per the physician to send the resident to the emergency room. 365520 Page 17 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #44's Situation, Background, Assessment and Recommendation (SBAR) form dated 03/09/19 revealed the resident had a fever and hypotension (low blood pressure). Interview on 03/28/19 at 11:08 A.M. with the Director of Nursing confirmed Resident #44's medical record did not contain complete and accurate documentation of the care and interventions the resident was provided during the resident's decline in health status on 03/09/19. 365520 Page 18 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to establish an effective infection prevention, control and monitoring program. This had the potential to affect all 70 residents who resided in the facility. Residents Affected - Many Findings include: An interview with the Director of Nursing (DON) on 03/28/19 at 1:30 P.M. revealed she was the infection control designee for the facility. She provided three months of her tracking for infections and antibiotic use in the facility. She stated she had started her position in January 2019 and did not have the tracking or any information regarding infection control tracking prior to January 2019. Review of the information provided by the DON for January 2019 revealed eight entries for residents who had received antibiotics for the month on a form titled, Antibiotic Use Tracking Sheet. For February and March 2019 (through the date of the survey), the tracking sheets indicated four residents had received antibiotics for those months. The DON also provided, Monthly Reports of Facility Infections, which contained a breakdown for the months of January, February and March 2019. The January report appeared to be incomplete, with only five infections analyzed, which did not match the eight entries on the antibiotic use tracking form for January. She also provide one facility map for February 2019, which indicated one infection in one resident room. This did not correlate with the four infections noted on the antibiotic use tracking form for February 2019. The DON indicated she obtained the information on the forms from review of resident records, reports from the nurses about new infections and from monthly records of antibiotic use she received from the pharmacy. She stated she then compiled the information and tracked it by floors and halls using facility maps to determine if infection trends could be found. She stated she would inservice staff if a trend was found and perform checks of infection control practices. When asked for documentation of the monthly reports received from the pharmacy with antibiotics ordered, the DON stated she would obtain them When they were received via fax and reviewed with the DON on 03/28/19 at 2:00 P.M., the pharmacy report indicated there were 19 orders for antibiotics in January 2019, 13 antibiotics for February 2019 and 12 antibiotics for March 2019. The DON verified she had not reviewed the monthly pharmacy reports prior to reviewing them with the surveyor. She said she could not explain the large number of infections/antibiotics ordered versus the number tracked on the facility forms. She verified she was unable to confirm an accurate accounting of infections in the facility since January 2019 and could not provide information showing a comprehensive monitoring of infections in the facility. 365520 Page 19 of 20 365520 03/28/2019 Phoenix of Maple Heights 19900 Clare Ave Maple Heights, OH 44137

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure an effective antibiotic use and monitoring program. This had the potential to affect all 70 residents who resided in the facility. Residents Affected - Many Findings include: An interview with the Director of Nursing (DON) on 03/28/19 at 1:30 P.M. revealed she was the infection control designee for the facility. She provided three months of her tracking for infections and antibiotic use in the facility. She stated she had started in her position in January 2019 and did not have any of the tracking or information regarding infection control prior to January 2019. Review of the information provided by the DON for January 2019 revealed eight entries for residents who had received antibiotics for the month on a form titled, Antibiotic Use Tracking Sheet. For February and March 2018 (through the date of the survey), the tracking sheets indicated four residents had received antibiotics for those months. The DON also provided, Monthly Reports of Facility Infections, which contained a breakdown for January, February and March 2019. The January 2019 report appeared to be incomplete, with only five infections analyzed, which did not correlate with the eight entries on the antibiotic use tracking form. She also provide one facility map for February 2019, which indicated one infection in one resident room. This did not correlated with the four infections listed on the February 2019 antibiotic use tracking form. The DON indicated she obtained the information on the forms from review of resident records, reports from the nurses about new infections and from monthly records of antibiotic use she received from the pharmacy. She stated she then compiled the information and tracked it by floors and halls using facility maps to determine if infection trends could be found. She stated she would inservice staff if a trend was found and perform checks of infection control practices. When asked for documentation of the monthly reports received from the pharmacy, the director of nursing stated she would obtain them for the surveyor. When they were received via fax and reviewed with the DON on 03/28/19 at 2:00 P.M., the pharmacy report indicated 19 orders for antibiotics in January 2019, 13 for February 2019 and 12 for March 2019. The DON stated she had not reviewed the monthly pharmacy reports prior to reviewing them with the surveyor, and could not explain the large number of infections/antibiotics ordered versus the number tracked on the facility forms. She verified she was unable to confirm an accurate accounting of infections in the facility since January 2019 and could not provide information showing a comprehensive monitoring of infections in the facility. She verified she could not provide any other information regarding the facility antibiotic stewardship program. Review of the facility policy for antibiotic stewardship, dated January 2019, revealed the facility would track, record and analyze infections to ensure antibiotic are only used when truly needed. 365520 Page 20 of 20