Health inspection·November 7, 2019

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 observation, interview, and record review the facility failed to have accurate and updated medical records. This affected one resident, Resident #83, of 32 residents reviewed for accurate medical records. The facility census was 115. Findings include: Record review revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including alcohol use with alcohol induced persisting dementia, schizophrenia, bipolar disorder, major depressive disorder with psychotic symptoms, and anxiety disorder. Licensed Practical Nurse (LPN) #310 was observed on 11/06/19 at 8:35 A.M. providing medications to Resident #83 by delivering the medications specified in the electronic medical record (EMR). LPN #310 placed memantine (for dementia) 5 milligrams (mg) one tablet, folic acid, 1 mg, one tablet, and vitamin B-1, 100 mg, one tablet into the medication cup along with seven other medications. Resident #83 was observed taking the medication immediately following LPN #310 placing all medications into the medication cup. Review of Resident #83's EMR revealed no physician order for memantine. The EMR also revealed the physician orders for folic acid and vitamin B-1 did not specify the dosage to be provided to Resident #83. The Director of Nursing (DON) and LPN #311 were interviewed on 11/06/19 at 10:25 A.M. and verified there was no order for memantine and no dosages for folic acid and vitamin B-1 in the EMR. LPN #310 was interviewed on 11/06/19 at 10:42 A.M. and stated she spoke with the pharmacy and the folic acid and vitamin B-1 dosages were clarified with the facility nurse on 04/04/18. LPN #311 was interviewed on 11/06/19 at 10:55 A.M. and provided clarification documentation for the dosages of folic acid and vitamin B-1. LPN #311 also provided the written order for the memantine as it should have been in the system. LPN #311 verified at that time of the medication pass, the order for the memantine and the dosage clarification for the folic acid and vitamin B-1 were not in the EMR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 2 of 5 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure infection control measures were maintained to prevent the potential spread of infection. This affected one (Resident #102) of two residents observed during dressing changes, one (Resident #110) of one resident observed during tracheostomy care, and 23 (Residents #10, #12, #18, #23, #24, #44, #45, #46, #53, #64, #69, #73, #82, #83, #87, #91, #94, #99, #101, #103, #116, #117, and #119) of 24 residents residing on 2 [NAME] Unit when an ice scoop was observed in the ice bin. The facility census was 115. Residents Affected - Some Findings include: 1. Review of the record revealed Resident #102 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure, encephalopathy, and pressure ulcer to sacral region. The resident was discharged to the hospital on [DATE] and returned on 10/11/19 with a diagnosis of sepsis (a life threatening inflammation throughout the body due to chemicals released in the bloodstream when the body is trying to fight infection). Review of the Nursing admission Data dated 10/11/19, indicated Resident #102 returned from the hospital with four pressure ulcers including on the right ischium, left ischium, coccyx/sacrum, and left buttock. Review of the admission Minimum Data Set (MDS) assessment indicated Resident #102 was alert and oriented and cognitively intact, was totally dependent on staff for bed mobility, and had three Stage IV pressure ulcers. A Stage IV pressure ulcer is a full thickness pressure ulcer extending into deep tissues of the body including muscle, tendon and even to the bone. Resident #102 had a physician order dated 10/21/19 for the coccyx pressure ulcer to be cleansed with normal saline, pat dry, apply calcium alginate, and an absorbent dressing daily and as needed. Resident #102 had physician orders dated 10/31/19 for the right and left ischium, for nursing staff to cleanse with normal saline, pat dry, apply zinc oxide to peri-wound skin, apply calcium alginate, and an absorbent dressing daily and as needed. Calcium alginate is a highly absorbent dressing used to promote the optimal environment for healing. On 11/06/19 at 11:30 A.M., Licensed Practical Nurse (LPN) #401 was observed setting up the clean field and preparing the dressing supplies to change Resident #102's dressings. Staff had informed her the resident's dressings were soiled. Upon observation, the dressings were found to be clean and intact. LPN #401 washed her hands then covered the clean field and prepared dressing supplies with a clean drape. Later on 11/06/19 at 1:53 P.M., LPN #401 was observed changing Resident #102's dressings to three areas, the coccyx, left ischium, and right ischium. The LPN washed her hands and donned gloves prior to removing the dressing to the resident's coccyx. She washed her hands and donned gloves after removing the dressing. LPN #401 cleansed the wound with saline moistened gauze pads then measured the wound. The coccyx wound was 1.0 centimeters (cm) long by 1.5 cm wide by 0.3 cm deep. She described the wound bed as 100% (percent) granulation tissue (pink healthy, healing tissue). LPN #401 then tore a piece of calcium alginate from a square 4 by 4 inch piece, fluffed it and placed the calcium alginate on the wound bed and covered it with a border foam dressing. The nurse did not wash or cleanse her hands after cleaning the pressure ulcer or prior to tearing the calcium alginate and placing it on the wound bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 3 of 5 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LPN #401 washed her hands and donned gloves and removed the dressing to Resident #102's left ischium. She washed her hands/donned gloves, cleansed the wound, and measured the wound. LPN #401 measured the left ischium wound as being 6.5 cm long by 2 cm wide with undermining from 11 o'clock to 1 o'clock with a maximum depth of 2.5 cm. The wound bed was 80% granulation tissue, 10% slough (nonviable tissue), and 10% tendon visible. Using the same soiled gloves, the LPN tore a piece of calcium alginate from the same 4 by 4 inch piece, placed it in the wound bed, applied zinc oxide to skin surrounding wound, and covered it with a border dressing. LPN #401 did not wash or cleanse her hands after cleaning the ulcer or prior to tearing the calcium alginate and placing it on the wound bed. LPN #401 washed her hands and donned gloves and removed the dressing to Resident #102's right ischium. She washed her hands/donned gloves, cleansed the wound, and measured the wound. LPN #401 measured the right ischium as being 0.5 cm long by 1.0 cm wide by 1.3 cm deep and indicated the wound bed was pink granulation tissue. She measured a second open area next to the right ischium ulcer as being 1.0 cm long by 1.5 cm wide by 0.3 deep. LPN #401 indicated the second area was new. She described the wound bed as pink granulation tissue. Using the same soiled gloves, the LPN tore a piece of calcium alginate from the same 4 by 4 inch piece, placed it in the wound beds, applied zinc oxide to the skin surround the wounds, and covered them with a border dressing. LPN #401 did not wash or cleanse her hands after cleaning the ulcers or prior to tearing the calcium alginate and placing it on the wound beds. During an interview on 11/06/19 at 2:11 P.M., LPN #401 agreed she did not wash or cleanse her hands after cleaning the wound and/or prior to tearing the piece of calcium alginate and placing it on the wound bed. Review of the facility's Handwashing/Hand Hygiene Policy (undated) indicated hands should be cleansed with alcohol-based hand rub or soap and water before handling clean or soiled dressing, after contact with blood or bodily fluids, and after contact with a resident's intact skin. 2. Review of the record revealed Resident #110 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure, hemiplegia with weakness affecting the dominant side of the body, vascular dementia, and dependence on a respirator/ventilator. The resident had physician orders dated 09/11/18 for tracheostomy (an opening in the neck to place a tube for breathing in the person's windpipe) care every day shift and as needed and suction as needed for secretions. Review of the annual MDS 3.0 assessment dated [DATE] indicated Resident #110 had short and long term memory deficits. She was dependent on staff for all activities of daily living and received special treatments including oxygen, suctioning, tracheostomy care, and use of the invasive mechanical ventilator. On 11/07/19 at 7:22 A.M., Respiratory Therapist (RT) #406 was observed providing suctioning and tracheostomy care to Resident #110. The resident was in bed with the head of the bed up at 45 degrees and on 3 liters oxygen via tracheostomy. RT #406 washed her hands and donned gloves, assessed Resident #110, and provided suctioning through a contained in-line (sterile) system. The respiratory therapist then suctioned secretions from the resident's mouth using a Yankauer and wiped secretions from the area around the resident's mouth. She removed her gloves, opened the tracheostomy kit, and prepared the tracheostomy care supplies. RT #406 then donned sterile gloves and provided tracheostomy care. The respiratory therapy did not wash or cleanse her hands between glove changes. During an interview on 11/07/19 at 7:48 A.M., RT #406 agreed she did not wash or cleanse her hands (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 4 of 5 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 365796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westpark Healthcare Campus 4401 W 150th Street Cleveland, OH 44135 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some after taking off the soiled gloves and/or prior to putting on the clean, sterile gloves. She indicated she has never done this. Review of the facility's Handwashing/Hand Hygiene Policy (undated) indicated the facility considers hand hygiene the primary means to prevent the spread of infection. Hand hygiene should be done by using an alcohol-based hand rub or washing with soap and water before applying/after removing non-sterile gloves and before donning sterile gloves. 3. Observation of the 2 [NAME] Unit ice cooler on 11/06/19 at 8:15 A.M. revealed the ice scoop was inside the cooler with the handle touching the ice. Interview with LPN #311 at the time of the observation verified the findings. Observation of the 2 [NAME] Unit ice cooler on 11/07/19 at 7:32 A.M. revealed the ice scoop was again inside the cooler with the handle touching the ice. Interview with LPN #314 confirmed the findings at the time of the observation. The facility identified 23 residents (Residents #10, #12, #18, #23, #24, #44, #45, #46, #53, #64, #69, #73, #82, #83, #87, #91, #94, #99, #101, #103, #116, #117, and #119) of the 24 residents residing on 2 [NAME] Unit who would could have received ice from this bin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365796 If continuation sheet Page 5 of 5