Inspection·November 21, 2019

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on observation, record review and interview, the facility failed to implement a comprehensive and individualized pain management program for Resident #243 to treat the resident's gout. Actual harm occurred when Resident #243 experienced extreme pain, moaning and yelling out due to pain in toes related to a medical diagnosis of gout with a lack of intervention and/or administration of effective pain medication between 11/18/19 at 8:30 A.M. and 11/19/19 at 8:00 P.M. This affected one resident (#243) of three residents reviewed for pain. Residents Affected - Few Findings include: Resident #243 was admitted to this facility on 10/31/19. On 11/06/19 the resident was sent out to the hospital for mental status change. He was readmitted to this facility on 11/13/19. His admitting diagnoses included pneumonia, chronic gout, chronic kidney disease, type II diabetes and enterocolitis due to clostridium difficile. On 11/18/19 at 8:30 A.M. the resident's significant other approached this surveyor stating that she needed to get the doctor to come and look at her husband. She stated he was in terrible pain and no one was doing anything. On 11/18/19 at 8:35 A.M. Licensed Practical Nurse (LPN) #300 was informed the resident was having severe pain and needed to be seen. She was observed entering the resident's room at 8:45 A.M. Observation on 11/18/19 at 8:50 A.M. revealed the resident sitting up on the left side of the bed with his feet positioned on the floor. The resident was not wearing socks. The resident was rocking back and forth on the bed moaning. When asked if he was in pain, the resident stated it's awful, it really hurts. The right and left great toes were red along with redness on the top of both feet to the arch of both feet. Interview with LPN #300 on 11/18/19 at 9:10 A.M. revealed that she was going to contact the physician for medication for this resident. Observation on 11/18/19 at 9:35 A.M. the resident was repositioned in semi- fowlers position in bed. His feet were in bed and he was yelling at his significant other to take the covers off his feet because his toes really hurt. Observation on 11/18/19 at 11:00 A.M. revealed the resident sitting up at the side of the bed. His feet were observed on the floor. The resident was again rocking back and forth. This surveyor approached the resident, and he stated he did not want to talk because his toes hurt. Per interview with his significant other at this time, the physician was supposed to come in to see him. She verified the resident was still in pain. Interview with LPN #300 on 11/18/19 at 11:40 A.M. revealed that she had contacted the physician, and the nurse practitioner was going to see him. She stated she did medicate him with Tylenol (pain medication). Review of the physician order dated 11/18/19 at 11:30 A.M. stated the resident was receive Colchicine 0.625 milligrams (mg), an anti-inflammatory medication, twice a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few Review of nursing progress notes dated 11/18/19 at 12:39 P.M. revealed documentation from the nurse practitioner stating the resident was found sitting up in bed in no acute distress. The resident was calm and cooperative. The resident complained of gout to his great toes on both feet. Interview with the resident's significant other on 11/19/19 at 9:50 A.M. revealed he was in a lot of pain. She stated she was constantly calling the nurse yesterday to get the medication for him due to his gout pain. She was very frustrated and stated she could not get anyone to help him. Observation of the resident on 11/19/19 at 11:00 A.M. revealed the resident asleep in bed. The resident's significant other stated the resident had finally fallen asleep, and she hoped he slept for awhile because he was not feeling good and still having pain, and had not eaten anything. When asked if he got the medicine for his gout, she stated no. She stated he had not received anything for pain. She stated he now had other things going on and was now having bad abdominal pain on top of the gout pain. Further review of the physician orders revealed he was ordered Tylenol 325 mg two tablets every four hours as needed for general discomfort. Review of the resident's Medication Administration Record (MAR) for the month of November 2019 revealed he had not received Tylenol for his complaints of gout pain. Review of the MAR for the Colchicine for the month of November 2019 revealed the resident was ordered the Colchicine twice a day at 11:30 A.M. on 11/18/19. He had not received the evening dose of Colchicine on 11/18/19 or the morning dose of Colchicine on 11/19/19. Review of the nursing progress notes dated 11/18/19 at 10:58 P.M. revealed the Colchicine had not been given because it was not available. Review of the nursing progress notes dated 11/19/19 at 8:00 A.M. revealed the Colchicine was not given because it had not been delivered from the pharmacy. Review of the MAR revealed the evening dose of Colchicine on 11/19/19 was not administered because the resident refused all medication due to abdominal pain and nausea. Interview with LPN #304 on 11/21/19 at 10:00 A.M. revealed she took care of the resident on Monday (11/18/19) night shift. She stated the resident was complaining of gout pain, but she could not remember if he was showing signs and/or symptoms of pain. She verified she did not give the resident his ordered dose of Colchicine because she did not have the medication. She also stated there was a discrepancy with the order because the nurse practitioner ordered 0.625 mg, and Colchicine only comes in 0.6 mg. She contacted the physician the night of 11/18/19 to verify the ordered dosage amount and how often it should be given. She stated the physician did call her back, and he clarified the order to read Colchicine 0.6 mg two times a day. She then contacted the pharmacy and told them the correct order, and she told them she needed the medication delivered. When questioned if the she had given the resident anything for pain since she did not have the Colchicine, she stated she did not remember. She stated if she had given the resident Tylenol, she would have signed it off. Interview on 11/21/19 at 12:30 P.M., State Tested Nursing Assistant (STNA) #305 stated she had taken care of Resident #243 on 11/19/19. When asked if he had complained of pain, she stated sometimes it was hard to tell because he had behaviors. She stated he had a habit of screaming out a lot, and when he screamed out it could be because he needed help getting him to the bathroom or due to pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 The STNA did remember while she was taking him to the bathroom, he complained of gout pain and constipation. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with the Director of Nursing (DON) on 11/21/19 at 1:30 P.M. revealed the resident has behaviors. She stated he always yelled out but that does not mean he is yelling out in pain. When asked how staff knew the difference, she stated the staff go in to see what he needs. When asked about the resident being in pain and not getting his medication for his gout, she verified one nurse stated she gave him Tylenol. When the DON reviewed the MAR, she verified nothing was signed off showing the resident received Tylenol, and the Colchicine indicated it was not administered on 11/18/19 and 11/19/19. Event ID: Facility ID: 365706 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 medications for Resident #247 and Resident #167 were properly stored prior to administration and were not left unattended in the residents' rooms. This affected two residents (Residents #247 and #167) of 26 residents whose rooms were observed. The facility census was 194. Findings include: 1. Record review revealed Resident #247 was admitted to the facility on [DATE] with admitting medical diagnoses including anemia, congestive heart failure, type II diabetes, partial mastectomy, hypertension and right pneumothorax. Review of the resident's physician's orders dated 11/16/19 revealed orders for: Imbruvica 420 milligrams (mg) tablet to receive half of the tablet daily for cancer Simvastatin 40 mg by mouth daily for high cholesterol Metoprolol 50 mg daily for hypertension Sitagliptin-Metformin 50-1000 mg daily for diabetes Valsartan 160 mg daily for hypertension and heart failure Xarelto 10 mg daily, a blood thinner Cephalexin 500 mg every 12 hours, an antibiotic Tizanidine 2 mg every 12 hours for muscle relaxation Record review revealed the resident did not have an order to self-administer medications. Interview with Resident #247 on 11/18/19 at 8:30 A.M. revealed she was alert and oriented. The resident revealed she required staff assistance to get up, reposition and ambulate. Observation and interview on 11/18/19 at 8:50 A.M. revealed the resident was lying in bed and her daughter was sitting at her bedside. On the bedside table next to the resident was a small medication cup filled with pudding. This resident informed the surveyor she had a narrowed esophagus and could not take a lot of things at once. She stated the nurse attempted to give her medications that were crushed in the pudding, but she could only swallow one small teaspoon. She stated the nurse left the medications in the pudding at her bedside for her to take when she could. There was no nurse located in the resident's room. When the resident was asked at this time if she wishes to self-administer her medication she stated no, she did not want that responsibility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Licensed Practical Nurse (LPN) #300 on 11/18/19 at 10:00 A.M. verified she did leave a medication cup with pudding and crushed medications at the resident's bedside. She stated the resident had a hard time swallowing it all, and the daughter had instructed the nurse to leave the medication in the pudding at the bedside, and her mom would take it when she could. 2. Review of Resident #167's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, cardiac arrhythmia, dementia in other diseases, hypertension, hypothyroidism and gout. Review of Resident #167's plan of care dated 06/24/19 revealed the resident refused medications. Interventions included administer medications as ordered, monitor and document for side effects and effectiveness. Review of Resident #167's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/04/19, revealed Resident #167 had moderately impaired cognitive skills for daily decision making. Resident #167 required supervision of one staff for bed mobility, transfers and eating. Review of the November 2019 physician's orders for Resident #167 revealed the resident did not have an order to self-administer medications. Review of the Resident #167's medical record revealed no evidence of an assessment to self-administer medications. Review of the November 2019 Medication Administration Record revealed Resident #167 had orders for the medications that included Aspirin, Vitamin D capsule (supplement), Effexor (antidepressant), Omega 3 fish oil capsule (supplement), Amlodipine (antianginal), Hydralazine (for hypertension) that were documented as being administered by staff. Observation of Resident #167 on 11/18/19 at 10:55 A.M. revealed the resident was lying in bed with a medicine cup of various pills on the tray table next to the bed. Observation and interview on 11/18/19 from 10:57 A.M. to 11:04 A.M. with LPN #302 verified medications were left at the resident's bedside. LPN #302 stated they were from this morning but believed she may have an order for that. LPN #302 reviewed Resident #167's physician's order and verified she did not have an order for self-medication administration or medication to be left at the bedside. LPN #302 stated she did not administrator Resident #167's medications but had seen the medication tech go to her room. She stated staff should have ensured the medications were taken. Reviewed facility policy titled Medication Administration- General Guidelines revised on 01/24/14, revealed under the Administration section, the resident was always observed after administration to ensure the dose was completely ingested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to ensure reverse isolation protocol was followed as ordered for Resident #247. This affected one of one resident who was in reverse isolation. Residents Affected - Few Findings include: Review of the medical record revealed Resident #247 was admitted to this facility on 11/16/19. Her admitting medical diagnoses included anemia, congestive heart failure, type II diabetes, partial mastectomy, hypertension and right pneumothorax. This resident's Minimum Data Set (MDS) 3.0 assessment was not completed due to the resident was a new admission. Interview with the resident on 11/18/19 at 8:30 A.M. revealed she was alert and oriented. She stated she could not get up, reposition herself or ambulate without assistance. Review of the physician orders dated 11/15/19 an order for protective reverse isolation precautions. The order further stated to wear gown, mask and gloves as needed. Wash hands when touching the environment and with direct patient care. All care activities and therapies were to be provided in the resident's room. The resident was to remain in her room for the duration of the reverse isolation. Observation on 11/18/19 at 8:20 A.M. revealed Licensed Practical Nurse (LPN) #300 in Resident #247's room administering medication. The nurse was observed with no mask or protective gown on. She did have on gloves at the time. Interview with LPN #300 on 11/18/19 at 10:00 A.M. revealed she did go into the resident's room without the proper personal protective equipment and did not follow reverse isolation protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 7 of 7