Health inspection·March 28, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review the facility failed to honor Resident #72's preferences for showers. This affected one resident (#72) of two residents reviewed for showers. The facility census was 67. Findings include: Review of the medical record for Resident #72 revealed she was admitted on [DATE] with diagnoses including hypertension (high blood pressure), diabetes mellitus, and muscle weakness. Review of the undated shower schedule revealed Resident #72 received her showers on Wednesdays and Saturdays from 3:00 P.M. to 11:00 P.M. Review of the shower sheet dated 03/09/24 revealed Resident #72 refused her shower on afternoons and wanted her showers in the mornings. Review of the nursing progress note dated 03/12/24 revealed Resident #72 wanted to change her shower times from the evenings to the mornings. Interview on 03/25/24 at 9:44 A.M. with Resident #72 revealed she wanted her showers earlier in the day. She stated she had asked the facility staff, and they told her she had to take them later in the day. Interview on 03/26/24 at 3:30 P.M. with Registered Nurse (RN) #331 verified Resident #72's showers were scheduled on Wednesdays and Saturdays on the evening shift. Review of the shower sheet dated 03/09/24 and nursing progress note dated 03/12/24 with RN #331 verified Resident #72 wanted her showers in the mornings. Review of the facility policy titled, Resident Care, revised June 2018, revealed the facility staff would provide general care as necessary for each resident per their preferences when able and per physician orders. The policy stated residents would be bathed or assisted to shower or bathe routinely and as needed per their preference. Page 1 of 2 365753 365753 03/28/2024 Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130

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 interview, medical record review, and facility policy review, the facility failed to document weekly weights in the medical record for Resident #9. This affected one resident (#9) of four residents reviewed for nutrition services. The facility census was 67. Findings include: Review of the medical record for Resident #9 revealed an admission date of 08/30/06 with diagnoses including aphasia, right non-dominant side hemiplegia, hypokalemia, and diabetes mellitus. Review of the physician's orders revealed an order dated 02/28/24 Resident #9 was to have weekly weights on Wednesdays. Review the Weight Summary revealed on 02/28/24 Resident #9 weighed 162.4 pounds and on 03/06/24 Resident #9 weighed 147.3 pounds. There were no additional weights recorded for 03/13/24 and 03/20/24. Review of the Treatment Administration Record (TAR) for March 2024 revealed missing weight documentation for 03/13/24 and 03/20/24. Review of the Medical Nutrition and Hydration assessment dated [DATE] revealed Resident #9 had significant weight loss over one month and six months. The dietitian noted Resident #9 needed a re-weight to confirm weight loss and was on weekly weights for monitoring. Interview on 03/27/24 at 2:43 P.M. with Registered Dietitian (RD) #340 confirmed there were no weekly weights completed for Resident #9 on 03/13/24 and 03/20/24 as ordered. RD #340 indicated he was unsure why the weights were not completed. Interview on 03/28/24 at 1:20 P.M. with Regional Director of Clinical Services #331 revealed the staff reported they had completed the weights but were unable to locate the actual documentation. Interview on 03/28/24 at 2:22 P.M. with Licensed Practical Nurse (LPN) #287 revealed she was the unit manager for Resident #9's unit. LPN #287 indicated on 03/20/24 Resident #9 refused to be weighed; however, indicated the refusal was not documented in the medical record. Follow up interview on 03/28/24 at 2:35 P.M. with LPN #287 revealed she had contacted the nurse's aide who obtained Resident #9's weight on 03/13/24. LPN #9 indicated the aide reported Resident #9 weighed between 148 and 149 pounds. The aide was unable to remember the exact weight. LPN #287 confirmed the weight was documented in the medical record. LPN #287 indicated she was responsible for ensuring weights were completed and documented as ordered. Review of the facility policy Weight Policy, dated 03/01/22, revealed weights would be obtained in a timely and accurate manner, documented and responded to appropriately. 365753 Page 2 of 2