Health inspection·April 27, 2023

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 and staff interview the facility failed to ensure a clean and well maintained environment. This affected 41 of 167 facility residents, Residents #15, #19, #22, #26, #35, #37, #38, #40, #47, #52, #59, #63, #69,#72, #73 #78, #79, #84, #87, #89, #90, #97, #98, #99, #107, #109, #110, #112, #119, #123, #124, #128, #129, #141, #145, #148, #149, #151, #560, #561 and #563 . The facility census was 167. Findings Include: During an environment tour with Housekeeping Director (HSD) #540 on 04/27/23 between 11:07 A.M. and 11:25 A.M. The following was observed and verified with HSD #540. 1. The privacy curtains of the rooms occupied by Residents #15, #19, #38, #40, #47, #52, #63, #69, #72, #79, #87, #89, #90, #98, #99, # #107, #109, #110, #112, #119, #123, #124, #128, #141, #145, #148, #149, #151, #560, #561 and #563 had significant levels of unknown substances and stains. 2. The air conditioning (AC) units in the rooms occupied by Residents #22, #35, #37 were covered by bath towels to prevent cold air from leaking in to the room. The AC unit in the room occupied by Residents #123 and #145 was covered by bed blankets to prevent cold air from leaking in to the room. The AC unit in the room occupied by Residents #107 and #563 was covered by bed blankets and taped with black colored duct tape to prevent cold air from leaking in to the room. The AC unit in the room occupied by Residents #97 and #129 was covered by loose plastic to prevent cold air from leaking in to the room. The AC vent in the rooms occupied by Residents #26, #59, #78 and #84 had a significant thick layer of dust on it. 3. The fall mats in the rooms occupied by Residents #73, #112 and #141 were extremely worn, tattered and dirty. 4. The closet in the room occupied by Residents #47 and #124 had three noticeable holes in it. 5. The floor in the room occupied by Residents #15 and #72 was noticeably dirty with stains, debris and other unknown substances. Page 1 of 10 365706 365706 04/27/2023 Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129

F 0584 6. The fan at the bedside of Resident #15 was coated in dust. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365706 Page 2 of 10 365706 04/27/2023 Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement their abuse policy and procedure in regards to reporting allegations of misappropriation to the Ohio Department of Health. This affected one resident (#180) of three residents (#33, #148, and #180) reviewed for abuse, neglect, and misappropriation of resident property. Residents Affected - Few Findings include: Review of the medical record for Resident #180 revealed an admission date of 01/11/22 and a discharge date of 04/01/23. Diagnoses included anemia, chronic obstructive pulmonary disease, vascular dementia, cocaine dependence with withdrawal, and insomnia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #180 had impaired cognition and required limited assistance of one staff for bed mobility, transfers, and ambulation. Review of the nurse practitioner note dated 02/01/23 at 10:06 A.M. revealed Resident #180 was found in the common area, was pleasantly demented, and upset that she has lost her purse. The note indicated nursing was to call her sister to see if she took the purse. Review of the progress note dated 02/01/23 at 11:17 A.M. revealed nurse practitioner on the floor at this time. New orders were received. A call was placed to responsible party to update. Message left to return call to facility. Resident updated the nurse that she could not locate her purse, her sister was visiting last night and that was the last time she saw the purse. The note further indicted the nurse would check with the sister when she returned call to see if the purse was with her. Resident #180 was aware. There were no other progress notes related to Resident #180's purse or further attempted communication with the resident's sister/family. Review of the self-reported incident (SRI) submitted on 02/09/23 revealed a date of occurrence as 02/09/23 at 9:30 A.M. The SRI narrative summary revealed Resident #180 reported to the charge nurse on 02/01/23 at 11:17 A.M. she could not locate her purse and her sister was visiting last night when she saw her purse last. The sister did not return calls to the facility. The daughter was able to state the sister did not have the purse/belongings and that she was in visiting and saw the purse and belongings on 01/31/23 between 4:00 P.M. and 5:00 P.M. Resident resided on the memory care unit with ambulatory residents with diagnoses of dementia/Alzheimer's. Resident on 02/08/23 became fixated on her inability to locate her purse. Review of the facility's investigation revealed a form titled Missing/Damaged Item Investigative Data Sheet that indicated 02/08/23 was the date the item/s was reported missing to the nurse supervisor. Description of the items missing included a medium sized, black Coach tote, [NAME] wallet, an old identification, and keys. Under follow-up investigation report section was noted on 02/09/23, Resident #180's daughter called and stated the purse, wallet, and keys must have been taken after her visit on 01/31/23 between 4:00 P.M. and 5:00 P.M. and noticed on 02/01/23 when her mom told the nurse it was missing. 365706 Page 3 of 10 365706 04/27/2023 Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/27/23 at 11:07 A.M. with the Administrator verified Resident #180 initially reported her purse missing to the nurse on 02/01/23. The Administrator stated she submitted the SRI to the Ohio Department of Health (ODH) on 02/09/23 because that was when Resident #180's daughter first notified her that the resident's purse was missing. The Administrator stated the nurse should have completed a missing item form and given it to the social worker. The Administrator stated staff looked for Resident #180's missing purse after Resident #180 had reported it but was unable to locate the purse. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 10/24/22 revealed, under initial report to ODH, all other allegations involving neglect, exploitation, mistreatment, misappropriation of resident property and injuries of unknown source would be reported to ODH immediately, but no later than 24 hours from the time the incident/allegation was made known to the staff member. 365706 Page 4 of 10 365706 04/27/2023 Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure timely reporting of misappropriation to the Ohio Department of Health. This affected one resident (#180) of three residents (#33, #148, and #180) reviewed for abuse, neglect, and misappropriation of resident property. Findings Include: Review of the medical record for Resident #180 revealed an admission date of 01/11/22 and a discharge date of 04/01/23. Diagnoses included anemia, chronic obstructive pulmonary disease, vascular dementia, cocaine dependence with withdrawal, and insomnia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #180 had impaired cognition and required limited assistance of one staff for bed mobility, transfers, and ambulation. Review of the nurse practitioner note dated 02/01/23 at 10:06 A.M. revealed Resident #180 was found in the common area, was pleasantly demented, and upset that she has lost her purse. The note indicated nursing was to call her sister to see if she took the purse. Review of the progress note dated 02/01/23 at 11:17 A.M. revealed nurse practitioner on the floor at this time. New orders were received. A call was placed to responsible party to update. Message left to return call to facility. Resident updated the nurse that she could not locate her purse, her sister was visiting last night and that was the last time she saw the purse. The note further indicted the nurse would check with the sister when she returned call to see if the purse was with her. Resident #180 was aware. There were no other progress notes related to Resident #180's purse or further attempted communication with the resident's sister/family. Review of the self-reported incident (SRI) submitted on 02/09/23 revealed a date of occurrence as 02/09/23 at 9:30 A.M. The SRI narrative summary revealed Resident #180 reported to the charge nurse on 02/01/23 at 11:17 A.M. she could not locate her purse and her sister was visiting last night when she saw her purse last. The sister did not return calls to the facility. The daughter was able to state the sister did not have the purse/belongings and that she was in visiting and saw the purse and belongings on 01/31/23 between 4:00 P.M. and 5:00 P.M. Resident resided on the memory care unit with ambulatory residents with diagnoses of dementia/Alzheimer's. Resident on 02/08/23 became fixated on her inability to locate her purse. Review of the facility's investigation revealed a form titled Missing/Damaged Item Investigative Data Sheet that indicated 02/08/23 was the date the item/s was reported missing to the nurse supervisor. Description of the items missing included a medium sized, black Coach tote, [NAME] wallet, an old identification, and keys. Under follow-up investigation report section was noted on 02/09/23, Resident #180's daughter called and stated the purse, wallet, and keys must have been taken after her visit on 01/31/23 between 4:00 P.M. and 5:00 P.M. and noticed on 02/01/23 when her mom told the nurse it was missing. Interview on 04/27/23 at 11:07 A.M. with the Administrator verified Resident #180 initially reported her purse missing to the nurse on 02/01/23. The Administrator stated she submitted the SRI to the 365706 Page 5 of 10 365706 04/27/2023 Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ohio Department of Health (ODH) on 02/09/23 because that was when Resident #180's daughter first notified her that the resident's purse was missing. The Administrator stated the nurse should have completed a missing item form and given it to the social worker. The Administrator stated staff looked for Resident #180's missing purse after Resident #180 had reported it but was unable to locate the purse. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 10/24/22 revealed, under initial report to ODH, all other allegations involving neglect, exploitation, mistreatment, misappropriation of resident property and injuries of unknown source would be reported to ODH immediately, but no later than 24 hours from the time the incident/allegation was made known to the staff member. 365706 Page 6 of 10 365706 04/27/2023 Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129

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 observation, interview, and record review, the facility failed to ensure treatments for skin impairments were provided as ordered for Resident #11. This affected one Resident (#11) of two residents reviewed for skin impairment. The facility census was 167. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed admission date of 03/22/22 and diagnoses including spastic quadriplegia cerebral palsy, multiple sclerosis, and Barrett's esophagus. Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #11 had intact cognition. Resident #11 required total two staff assistance for bed mobility and transfers. The assessment indicated Resident #11 was at risk for pressure injuries and had interventions including pressure reducing device for bed, applications of non-surgical dressings, and application of ointment or medications. Review of the plan of care dated 04/11/22 revealed Resident #11 was at risk for alterations in skin integrity related to immobility, multiple sclerosis, and quadriplegic cerebral palsy. Interventions included administer treatments as ordered, monitor effectiveness of treatments, low air loss mattress, monitor and report suspicious skin areas, and provide assistance with bed mobility. Review of the physician's order dated 04/20/23 revealed to cleanse scab to right lower extremity with normal saline and pat dry. Apply abdominal (ABD) pad (a gauze pad used to absorb discharges from heavily draining wounds) and wrap with Kerlix (gauze wrap used to provide cushion and protect wound areas). Complete treatment every Tuesday, Thursday, and Saturday. Review of the physician's order dated 04/20/23 revealed to cleanse right foot with normal saline and pat dry. Apply ABD pad and wrap with Kerlix. Complete treatment every Tuesday, Thursday, and Saturday. Review of the physician's order dated 04/20/23 revealed to cleanse left foot with normal saline and pat dry. Apply ABD pad and wrap with Kerlix. Complete treatment every Tuesday, Thursday, and Saturday. Observation on 04/27/23 at 11:16 A.M. with Licensed Practical Nurse (LPN) #564 revealed Resident #11 laying in bed with sheets covering lower body. LPN #564 applied gloves and with Resident #11's permission pulled back sheets revealing his legs. Resident #11 had a dressing on the left foot dated 04/20/23 and an undated dressing on right lower leg. The dressing on Resident #11's right lower leg was loosely wrapped and was no longer covering the scabbed area. Resident #11 had scattered scabbing on the bottom of the right foot which was not covered with dressing per orders. LPN #564 confirmed the dressing on left foot was dated 04/20/23 and was not changed as ordered. LPN #564 confirmed the dressing on the right lower leg was no longer covering the area and was undated. LPN #564 confirmed there was no dressing on right foot as ordered. Interview with Resident #11 at time of observation revealed a nurse had changed the dressing on his right lower leg on 04/24/23 because the dressing was soiled with feces. Resident #11 stated worry about which nurse was assigned to him and reported he feared he would not get the care he was ordered with agency staff. Observation on 04/27/23 at 11:51 A.M. of Resident #11's lower legs with the Director of Nursing 365706 Page 7 of 10 365706 04/27/2023 Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (DON) confirmed lack of dressing on right foot as ordered, confirmed lack of date and uncovered area on right lower leg, and confirmed dressing on left foot was dated 04/20/23 and had not been changed on 04/22/23 and 04/25/23 as ordered. Interview on 04/27/23 at 2:00 P.M. with Wound Nurse #549 revealed Resident #11 had chronic eczema and dermatitis which caused the scabbing. Review of facility policy Skin Care Management dated 06/08/22 revealed residents with identified skin breakdown would be regularly assessed and have treatments as ordered. 365706 Page 8 of 10 365706 04/27/2023 Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and review of the manufacturer formulary, the facility failed to change an enteral tube feeding bag per manufacturer guidelines. This affected one Resident (Resident #91) of two residents reviewed for tube feeding. The facility census was 167. Findings include: Review of the medical record for Resident #91 revealed an admission date of 08/15/19. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinson's disease, dysphagia (difficulty swallowing), unspecified protein-calorie malnutrition, and adult failure to thrive. Review of the 03/17/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #91 revealed a Brief Interview of Mental Status (BIMS) score of 11 which indicated Resident #91 had moderate cognitive impairment. Review of the activities of daily living (ADLs) portion of the assessment revealed Resident #91 had total dependence of two staff for bed mobility and transfer; total dependence of one staff for toileting, personal hygiene, and bathing, and extensive assist of one staff for dressing. Resident # 91 was frequently incontinent of bladder and incontinent of bowel. Resident #91 had significant non prescribed weight loss and was receiving an enteral tube feeding. Review of the 04/21/23 physician's order for Resident #91 revealed the resident had an enteral feeding order for Isosource 1.5 calorie oral liquid to be given at a rate of 43 milliliters (ml) per hour via percutaneous endoscopic gastrostomy (PEG) tube every shift continuously. Observation on 04/24/23 at 10:41 A.M. revealed Resident #91 awake laying in bed with the head of the bed elevated. An intravenous (IV) pole with Resident #91's open system enteral tube feeding bag was hanging with a change date of 04/22/23, time of 8:00 A.M., and listed running at 43 ml per hour. Interview on 04/24/23 at 10:45 A.M. with Licensed Practical Nurse (LPN) #564 confirmed Resident #91's enteral tube feeding was running at 43 ml per hour and the bag was dated 04/22/23 with a last change time of 8:00 A.M. LPN #564 stated she was unsure why it had not been changed. Interview on 04/25/23 at 1:08 P.M. with LPN #546 revealed open system enteral tube feeding bags were to be changed every 24 to 48 hours when the tube feeding ran out. Interview on 04/25/23 at 1:12 P.M. with the Director of Nursing (DON) confirmed the facility policy did not specify a time frame to change the tube feeding bag, but the open tube feeding bag was to be changed at a minimum of every 24 hours. Review of the manufacturer formulary from Nestle Health Science titled; Your Nutrition and Tube Feeding Formulas revealed, under the formula hang time section for open systems, the hang time was up to eight hours for ready to use liquids. 365706 Page 9 of 10 365706 04/27/2023 Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129

F 0711 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure physicians orders were signed and dated. This affected five of 37 residents whose physician orders were reviewed, Residents #38, #47, #66, #80 and #93. The facility census was 167. Findings Include: 1. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses that included heart attack, urinary retention and malnutrition. Further review of the medical record revealed the monthly recapitulation of physician orders for March 2023 and February 2023 and telephone orders from 02/10/23 and 12/20/22 were not signed and dated by Resident #38's physician. 2. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses that included abnormal weight loss, pulmonary embolism and syphilis. Further review of the medical record revealed the monthly recapitulation of physician orders for April 2023, March 2023, February 2023, January 2023 and December 2022 and telephone orders from 01/30/23 and 12/22/22 were not signed and dated by Resident #47's physician. 3. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses that included dementia, acute kidney failure and abnormal weight loss. Further review of the medical record revealed the monthly recapitulation of physician orders for April 2023, March 2023, February 2023, January 2023, December 2022, November 2022 and October 2022 were not signed and dated by Resident #66's physician. 4. Medical record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses that included type two diabetes, depression and chronic kidney disease. Further review of the medical record revealed the monthly recapitulation of physician orders for April 2023, March 2023, February 2023, January 2023, December 2022 and November 2022, telephone orders from 03/03/23, 02/22/23, 01/23/23, 01/13/23 and 12/09/22, and x-ray orders from 03/02/23 were not signed and dated by Resident #80's physician. 5. Medical record review revealed Resident #93 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depression and psoriasis. Further review of the medical record revealed the monthly recapitulation of physician orders for April 2023, March 2023, January 2023, December 2022, November 2022, October 2022 and September 2022 were not signed and dated by Resident #93's physician. Interview with the Director of Nursing on 04/27/23 at 3:45 P.M. verified the lack of physician signatures and dates as noted above. 365706 Page 10 of 10