Health inspection·March 5, 2024

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 physician orders were in place for care or treatment of a peripherally inserted central catheter (PICC) line. This affected one (Resident #11) of one facility-identified residents with a PICC line. The facility census was 65. Residents Affected - Few Findings include: Review of medical record for Resident #11 revealed an admission date of 02/20/24 with diagnoses including congestive heart failure, epilepsy, cerebral infarction, and mixed hyperlipidemia. Review of progress note for Resident #11 dated 02/20/24 revealed the resident was admitted to facility with a PICC line to left arm used to administer medication to treat endocarditis. Review of physician's orders for Resident #11 revealed an order dated 02/21/24 for 100 milliliters (ml) daily of ceftriaxone sodium intravenously for 28 days. Review of the physician's orders revealed there were no orders for care and treatment of the of the PICC line site. Review of the plan of care for Resident #11 initiated 02/20/24 revealed it did not include interventions regarding care and treatment of the resident's PICC line. Observation on 03/04/24 at 10:20 A.M. revealed Resident #11 had an intact, transparent dressing to the PICC line on the left upper arm which was not dated. Interview on 03/04/24 at 10:25 A.M. with Resident #11 confirmed the PICC line dressing was changed at hospital and had not been changed since his admission to the facility. Interview on 03/04/24 at 11:09 A.M. with Licensed Practical Nurse (LPN) #800 confirmed the PICC line dressing to Resident #11's upper arm was not dated, and the nurse was unsure when it had been applied. Interview on 03/04/24 at 11:29 A.M. with LPN #800 confirmed Resident #11 did not have physician orders to change the dressing to the resident's PICC line. LPN #800 confirmed PICC line dressings should be changed every seven days at a minimum. Interview on 03/04/24 at 11:33 A.M. with Director of Nursing (DON) confirmed Resident #11 was admitted with a PICC line and the facility did not have physician's orders regarding care and treatment of the PICC line site. The DON further confirmed they did not know when the dressing to the resident's PICC line had been placed, but she thought it had been present upon Resident #11's admission to Page 1 of 5 365730 365730 03/05/2024 Embassy of Euclid 3 Gateway Dr Euclid, OH 44119

F 0684 the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Intravenous Therapy: Preventing Catheter-Related Infections dated October 2010 revealed PICC line dressing should be changed ever seven days or more frequently if needed. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00151489. 365730 Page 2 of 5 365730 03/05/2024 Embassy of Euclid 3 Gateway Dr Euclid, OH 44119

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. Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure resident safety during a two-staff assisted transfer. This affected one (Resident #30) of three reviewed for safe transfers. The facility census was 65. Findings include: Review of the medical record for Resident #30 revealed admission date of 05/14/23 with diagnoses including convulsions, migraine, fatigue, anxiety disorder, hyperlipidemia, and major depressive disorder. Review of plan of care for Resident #30 dated 05/17/23 revealed the required staff assistance with activities of daily living (ADLs.) Interventions included the resident required weight-bearing assistance including holding, lifting, or supporting the trunk or limbs and required non-weight bearing assistance including steadying, contact guard assistance or guided maneuvering when transferring between surfaces. Review of the therapy progress note for Resident #30 dated 09/13/23 revealed the resident was working with the occupational therapy department at the facility and required moderate assistance to sit and stand during pivot transfers. Review of Minimum Data Set (MDS) quarterly assessment for Resident #30 dated 09/21/23 revealed the resident required extensive two staff assistance for bed mobility and transfers. Review of pain assessment for Resident #30 dated 09/21/23 timed at 2:45 P.M. revealed the resident complained of throbbing pain to the left ankle which the resident rated as five on a scale of one to 10 with 10 being the worst pain. Review of progress note for Resident #30 dated 09/21/23 timed at 2:47 P.M. revealed while the resident was being transferred by staff his left foot shifted causing pain. The nurse called the nurse practitioner (NP) and obtained an order for an x-ray to the left ankle. Review of x-ray report for Resident #30 dated 09/22/23 timed at 1:53 P.M. revealed the x-ray showed a possible fracture to the left ankle of indeterminate age. Review of the change in condition evaluation for Resident #30 dated 09/22/23 timed at 5:42 P.M. revealed the resident facility provided the resident with Tylenol and assisted with leg elevation for pain the left ankle and obtained an order for the resident to be sent to the emergency room for evaluation of a possible fracture. Review of the hospital left foot x-ray for Resident #30 result dated 09/22/23 timed 9:41 P.M. revealed the resident had mild osteopenia and mild soft tissue swelling to the left ankle but there was no acute fracture or dislocation. Review of the progress note for Resident #30 dated 09/23/23 timed at 2:02 A.M. revealed the resident returned from the hospital with a boot and copies of hospital x-rays revealing a sprain to the left ankle but no fracture. 365730 Page 3 of 5 365730 03/05/2024 Embassy of Euclid 3 Gateway Dr Euclid, OH 44119

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/05/24 at 9:26 A.M. with Resident #30 confirmed during a two-person transfer on 09/21/23 his left leg got caught under the bed. Resident #30 reported initially the x-ray taken at the facility indicated he had an ankle fracture, but the hospital x-ray said it was a sprain. Resident #30 confirmed State Tested Nursing Assistants (STNAs) #802 and #804 were completing a two-person transfer and one STNA had a bad wrist. Resident #30 confirmed while being transferred his foot got caught under lower frame of bed and he asked the STNAs to stop. Resident #30 confirmed one of the STNAs stopped but the other did not. Interview on 03/05/24 at 10:22 A.M. with STNA #802 confirmed she was not the assigned nurse aide for Resident #30 but was asked on 09/21/23 by STNA #804 to assist in the transfer. STNA #802 confirmed while assisting STNA #804 with a manual transfer, STNA #804's wrist gave out and caused Resident #30 to dip down on left side. STNA #802 confirmed Resident #30's left foot slipped under the bed during transfer. STNA #802 confirmed STNA #804 was wearing a wrist brace at time of incident and Resident #30 verbalized pain when he dipped down on left side. STNA #802 confirmed they re-stabilized Resident #30 to keep him from falling, got him into the bed, and went to get nurse. STNA #802 confirmed when they re-stabilized Resident #30 his foot came out from under bed. Interview on 03/05/24 at 10:56 A.M. with STNA #804 confirmed she was unable to remember the details of the wheelchair to bed transfer for Resident #30 on 09/21/23. STNA #804 confirmed Resident #30's left leg got hit or tangled up during the transfer. STNA #804 confirmed she was Resident #30's assigned nurse aide and had asked for help from STNA #802 for a two-person arm and arm transfer from wheelchair to bed. STNA #804 confirmed Resident #30 told them to stop during the transfer. STNA #804 confirmed she could not recall if she was wearing a wrist brace on 09/21/23. Interview on 03/05/24 at 11:01 A.M. with Certified Occupational Therapist Assistant (COTA) #808 confirmed Resident #30 was a two person transfer at the time of the incident in September 2023. Interview on 03/05/24 at 11:10 A.M. with Licensed Practical Nurse (LPN) #809 confirmed she was notified by an STNA on 09/21/23 that Resident #30 had twisted his ankle and was complaining of pain following a pivot transfer. LPN #809 confirmed she was unable to remember which STNA had notified her, but the resident complained of pain and discomfort to the ankle, and she elevated Resident #30's foot and obtained a physician's order for a left ankle x-ray. Interview on 03/05/24 at 1:06 P.M. with the Director of Nursing (DON) confirmed was notified Resident #30 had complained of ankle pain following a transfer on 09/21/23 but she he was unaware Resident #30's foot had gotten stuck and was unsure if STNA #804 wore a wrist brace. The DON confirmed if a staff member had an injury, they should notify human resources and a two-person arm and arm transfer would be unsafe if a staff member had a physical injury. Interview on 03/05/24 at 1:16 P.M. with Human Resources Director (HRD) #810 confirmed she was unaware of STNA #804 wearing a wrist brace on 09/21/23. Interview on 03/05/24 at 1:53 P.M. with STNA #802 confirmed she and STNA #804 had not been using a gait belt when transferring Resident #30 on 09/21/23. STNA #802 confirmed gait belts were available for use, but she had held onto Resident #30's right arm and the back of his pants during the transfer. Interview on 03/05/24 at 2:46 P.M. with COTA #808 confirmed staff should utilize a gait belt when performing a manual resident transfer. 365730 Page 4 of 5 365730 03/05/2024 Embassy of Euclid 3 Gateway Dr Euclid, OH 44119

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Safe Lifting and Movement of Residents dated July 2017 revealed in order to protect the safety and well-being of staff and residents and to promote quality care the facility utilized appropriate techniques and devices to lift and move residents. Staff responsible for direct care would be trained in the use of gait belts. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00151192. 365730 Page 5 of 5