Health inspection·March 27, 2025

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. Based on observation, record review, resident interview, staff interview, and review of facility policies the facility failed to ensure medications were secured properly. This affected one (Resident #10) of four residents observed for medication administration. Findings include: Review of medical record noted Resident #10 had an admission date of 10/02/24. Diagnoses included chronic obstructive pulmonary disease, unspecified, pain unspecified, post-traumatic stress disorder, depression, type two diabetes mellitus with diabetic neuropathy, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment 03/25/25 noted Resident #10 had intact cognition. Review of the medical record revealed Resident #10 had no assessment for the self-administration of medication. Observation on 03/24/25 at 9:49 A.M. noted Resident #10 lying in bed with a cup of medications at bedside. Resident #10 verified the cup of medications at bedside and stated staff left the medications for her to take when she was ready. Interview 03/24/25 at 9:52 A.M., Licensed Practical Nurse (LPN) #501 stated she left the medications at the bedside because the resident is alert and will take them when she is ready. LPN #501 stated she would check on Resident #10 in a little bit to see if she took her medications. Interview on 03/24/25 at 10:00 A.M., the Director of Nursing (DON) stated no medications are to be left with residents at bedside, no matter how alert the resident is. The DON stated all staff would receive education immediately. Interview on 03/25/25 at 5:40 P.M. with the DON #645 verified there was no assessment completed indicating Resident #10 could self-administer medications. Review of the facility policy titled, Medication Administration, dated 08/22/22 stated medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Nurses are to observe residents consume medications. Review of the facility policy titled Bedside Storage of Medication, dated 2017 noted residents who Page 1 of 3 365825 365825 03/27/2025 Grande Oaks 24579 Broadway Ave Oakwood Village, OH 44146

F 0761 Level of Harm - Minimal harm or potential for actual harm are able to self-administer medications may be allowed to store bedside medication per policy. A written doctor's order for bedside storage of medication is placed in the resident's medical record, bedside storage of medications is indicated on the resident medication administration record for appropriate medications. Residents Affected - Few 365825 Page 2 of 3 365825 03/27/2025 Grande Oaks 24579 Broadway Ave Oakwood Village, OH 44146

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 record review, observation and interview, the facility failed to properly disinfect a glucometer after checking blood sugars. This affected one (Resident #13) of one resident observed for blood sugar monitoring and had the potential to affect 17 residents who required blood sugar monitoring residing on the 100 hall. Residents Affected - Few Findings include: Review of medical record for Resident #13 noted an admission date of 06/26/24. Diagnosis included type two diabetes mellitus with diabetic neuropathy, unspecified. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] noted Resident #13 had intact cognition. Review of plan of care dated 06/26/24 noted Resident #13 was at risk for hyper/hypoglycemia related to diabetes. Interventions included to obtain blood sugars as ordered. Review of physician order dated 07/19/24 noted staff were to obtain blood sugars twice a day related to diabetes. Observations on 03/24/25 at 4:11 P.M., Licensed Practical Nurse (LPN) #501 obtained a blood sugar for Resident #13. LPN #501 walked back to the medication cart and cleaned the glucometer with an alcohol wipe. LPN #501 was asked what product was normally used to clean the glucometer; LPN #501 struggled to provide an answer. Interview on 03/24/25 at 4:15 P.M., the Director of Nursing (DON) stated staff should not be using alcohol wipes to sanitize glucometers. DON #645 stated she would provide training for all nursing staff. Review of the manufacturers guide for the glucometer noted the glucometer should be cleaned using Environmental Protection Agency (EPA) registered wipes. Review of the facility policy titled Glucometer Disinfection, dated 2023 noted glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectants that is effective against Human Immunodeficiency (HIV) virus, hepatitis C and hepatitis B virus. 365825 Page 3 of 3