Health inspection·September 28, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on record review, interview, and facility policy review the facility failed to timely notify the physician and dietitian of Resident #294's continued refusal of daily weights. This affected one resident (#294) of four residents reviewed for weights. The facility census was 98. Findings include: Review of Resident #294's medical record revealed an admission date of 08/31/23 with diagnoses including chronic systolic congestive heart failure, stage IV chronic kidney disease, and depression. Review of the physician's orders revealed Resident #294 had an order dated 09/05/23 for daily weights related to a diagnosis of congestive heart failure. Further review of the medical record and medication administration record (MAR) for September 2023 revealed Resident #294's weights were marked as refused on 09/05/23, 09/06/23, 09/08/23, 09/10/23, 09/11/23, 09/12/23, 09/13/23, 09/15/23, 09/17/23, 09/18/23, and 09/20/23. No response was indicated on 09/07/23, 09/14/23, and 09/19/23. Review of the electronic medical record under the weight monitoring tab for Resident #294 revealed a weight was obtained on 09/09/23 at 200 pounds and again on 09/16/23 at 197 pounds. No further weights were documented prior to surveyor intervention on 09/21/23. Review of Resident #294's weight on 09/21/23 revealed a weight of 240 pounds, with no reweight initiated by the facility. The physician was notified of the significant weight gain and ordered STAT labs since the weight gain was from 200 pounds on 09/09/23 to 240 pounds on 09/21/23. Weights obtained on 09/22/23 and 09/23/23 were also 240 pounds. Review of the lab results dated 09/25/23 revealed no critical findings and no new physician orders. Review of Resident #294's care plan initiated on 08/31/23 did not reflect any interventions for weight monitoring. Interview on 09/20/23 at 1:19 P.M. with Licensed Practical Nurse (LPN) #1133 confirmed daily weights were not recorded in the paper chart for Resident #294. Interview on 09/20/23 at 2:30 P.M. with the Director of Nursing (DON) revealed Resident #294's orders for daily weights were to be completed between 3:00 A.M. and 7:00 A.M., and Resident #294 refused to be weighed. When the DON was asked if it was a convenient agreed upon time for Resident #294, she stated it may have been towards 7:00 A.M. but agreed a later time may have been better accepted Page 1 of 52 365828 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0580 and had not discussed with Resident #294 his reason for continued refusals. Level of Harm - Minimal harm or potential for actual harm Review of the physician orders for Resident #294 revealed a new order on 09/21/23 for daily weights to be obtained after 7:00 A.M. Residents Affected - Few Interview on 09/20/23 at 2:33 P.M. with Resident #294 revealed staff have asked him several times about being weighed between 3:00 A.M. and 7:00 A.M. but he was sleeping and refused because he wanted to continue sleeping. Review of the nursing progress notes from 09/05/23 to 09/21/23 revealed no documented evidence of physician and dietitian notification of the refusals of daily weights and no documented evidence of education provided to Resident #294 of the importance of daily weights for monitoring his diagnosis of congestive heart failure. Interview on 09/25/23 at 12:19 P.M. with the DON confirmed she did not have further documented evidence of physician and/or dietitian notification or resident education for Resident #294's refusals of daily weights. Review of the facility policy titled Weight Policy, revised 11/2018, revealed weights will be obtained in a timely and accurate manner, documented, and responded to appropriately. Residents will be weighed per physician orders and the physician, registered dietitian, and resident or resident representative will be notified of significant changes in weight. 365828 Page 2 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, self-reported incident (SRI) review, and facility policy review, the facility failed to prevent resident-to-resident abuse. This affected one resident (Resident #81) of four residents reviewed for abuse. The facility census was 98. Findings Include: 1. Resident #81 was admitted to the facility on [DATE] with diagnoses including depression, bipolar disorder, psychotic disorder with delusions, and schizophrenia. The resident resides on the facility's secured unit. Review of the comprehensive admission minimum data set (MDS) assessment dated [DATE] revealed Resident #81 was moderately cognitively impaired, exhibited no behaviors during the assessment period, and was non-ambulatory. Review of Resident #81's care plans revealed he was at risk for altered cognitive function related to schizophrenia and would have alterations in behavior leading to abusive attacks on staff and residents. Review of the nursing progress note dated 08/12/23 at 3:00 A.M. revealed Resident #81 returned from a local Emergency Department (ED) with no new orders. At 3:05 A.M. Registered Nurse (RN) #1113 notified the resident's physician had been sent to the ED for evaluation of facial injuries sustained during a resident-to-resident altercation. 2.Resident #73 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease, bipolar disorder, depression, and anxiety. The resident resided on the facility's secured unit. Review of the comprehensive quarterly MDS assessment dated [DATE] revealed Resident #73 was moderately cognitively impaired, wandered several days during the assessment period, and was independently ambulatory. Review of the care plans revealed Resident #73 had newly implemented plans, dated 09/25/23, regarding impaired cognitive function, impaired thought processes, wandering, and behavior problems. Review of the nursing progress note dated 08/12/23 revealed Resident #73 assaulted Resident #81 at approximately 11:30 P.M. on 08/11/23. Resident #73 was very aggressive, and the agency nurse called 911 but they never arrived at the facility. The resident continued to walk into other resident's rooms and threatened to hit the staff. Continued review of the nursing progress notes revealed the resident's behaviors continued to increase including his wandering and aggressiveness. Resident #73 was transferred to the ED on 08/22/23 due to increased agitation and aggression. After being evaluated the resident returned to the facility with no new orders. On 09/26/23 Resident #73 had an initial evaluation by the facility psychiatrist for his increased aggression, combativeness, and wandering. Review of the facility's SRI #238031, dated 08/12/23, revealed Resident #73 hit Resident #81 in the face after Resident #81 told Resident #73 to stay out of his room. Resident #73 had been having 365828 Page 3 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few increased behaviors in the previous several months, was wandering in and out of other resident's room, and was difficult to redirect. Resident #81 requested to be sent to the ED for evaluation and returned with no new orders. The police were notified while at the ED and interviewed Resident #81 who declined to file charges. When the facility attempted to talk to Resident #73 about the incident, the resident did not want to discuss the incident/did not remember the incident. The facility obtained witness statements, did skin checks on all the residents on the unit. Resident #73's room was changed to the opposite end of the unit as an intervention to prevent further abuse. All staff were educated on abuse. The facility unsubstantiated the allegation of abuse as as no abuse per definition has occurred with alleged incident. Interview with Social Services Director (SSD) #1164 on 09/25/23 at 10:50 A.M. revealed Resident #73 has not been seen by the facility psychiatrist. The resident's primary physician is the one who orders his psychotropic medication (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system to treat mental health issues). SSD #1164 confirmed the resident's behaviors had been escalating over the last few months. He was referred to a contracted mental health services company approximately three months ago, but they never assessed him until a few days ago as there was a mix up with the referral. The company uses nonpharmacological interventions for treatment. Review of the facility's Abuse, Neglect, and Exploitation policy, last revised 10/01/22, revealed the definition of abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's policy revealed to prevent abuse, neglect, and exploitation requires ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. 365828 Page 4 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

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, interview, and facility policy review, the facility failed to implement their abuse policy regarding an allegation of resident-to-resident abuse. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98. Residents Affected - Few Findings include: 1.Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen and there was a small skin alteration to the resident's left wrist and the back of her neck. Resident #55 said that during the smoke break she was passing through in her motorized wheelchair. The resident said she excused herself while passing another resident who became agitated and called Resident #55 an inappropriate name. The two residents then became involved in a verbal altercation in which they called each other inappropriate names. The second resident then started to walk away when Resident #55 called him another name. The second resident then turned around and walked back to Resident #55 and told her if she continued to call him names, he would slap her. Resident #55 called him another name and the second resident slapped her. Resident #55 then said she would report him and re-entered the building from the smoke area. The second resident also re-entered the building and began choking Resident #55. Staff immediately separated the residents. Resident #55 said she had called the local police department and filed a report. Resident #55's injuries were treated. The resident's emergency contact was notified and came to the facility. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109. Further review of the nursing progress notes revealed on 09/06/23 Social Service Director (SSD) #1164 interviewed Resident #55 who indicated she felt safe in the facility. Review of Resident #55's care plan revealed a care plan was initiated on 02/22/23 that the resident made abusive attacks on staff and/or other residents, including physically and verbally abusive behaviors. Resident #55 refused a request for an interview on 09/21/23 at 11:55 A.M. 2. Resident #68 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy. Review of the comprehensive MDS admissions assessment dated [DATE] revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period. Review of the nursing progress notes dated 09/02/23 revealed LPN #1134 heard a commotion in the 365828 Page 5 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and placed Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and ADON #1109 of the incident. Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false statements to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed. Resident #68 refused an interview on 09/21/23 at 12:05 P.M. Interview with the Administrator on 09/20/23 at 3:40 P.M. revealed she was not aware of any resident-to-resident allegation of abuse for Residents #55 and #68 on 09/02/23. The Administrator stated no Self-Reported Incident (SRI) form was submitted as she was unaware of any abuse. The Administrator said she was on vacation when the incident was alleged to have occurred. The Administrator reviewed the nursing progress note for Resident #55 dated 09/02/23 and said the incident must not have occurred as the resident has her personal phone number and the resident would have called her immediately. The Administrator said she would go and speak with Resident #55 and then call LPN #1134 to determine what happened. A second interview with the Administrator on 09/20/23 at 4:40 P.M. revealed she had just spoken with Resident #55 who denied the incident ever happened. Resident #55 told the Administrator Resident #68 would never hurt her and she did not know why LPN #1134 would say that. The Administrator said the incident should have been on the facility's 24-hour report and does not know why the Director of Nursing (DON) would not have been made aware of the alleged altercation. The Administrator stated she would enter an investigation and close it out immediately as nothing had happened. Interview with the DON on 09/21/23 at 11:45 A.M. revealed she had seen the documentation by LPN #1134 on the 24-hour report and that she spoke with Resident #55 and Resident #68 who denied they had had an altercation. The DON confirmed she did not speak with LPN #1134 about the incident and felt LPN #1134 notified ADON #1109 as that was the first person who she thought of. The DON said she did not initiate an SRI at the time as she was not authorized to, only the Administrator was able to initiate one. A telephone call was made to LPN #1134 on 09/21/23 at 4:50 P.M. and a voice mail message was left requesting a return phone call. As of 09/26/23 at 12:10 P.M. no return call was received. Review of the facility's Abuse, Neglect, and Exploitation, last revised 10/01/22, revealed the definition of abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. An alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet 365828 Page 6 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been investigated, and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The policy also revealed an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. All allegations of abuse are to be reported immediately, but no later than two hours after the allegation is made if serious bodily harm occurs. If serious bodily injury did not occur, then the required agencies must be notified within 24 hours of the allegation being made. 365828 Page 7 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

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, interview, and facility policy review the facility failed to report an allegation of resident-to-resident abuse to the state agency within the required time frames. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98. Findings include: 1.Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen and there was a small skin alteration to the resident's left wrist and the back of her neck. Resident #55 said that during the smoke break she was passing through in her motorized wheelchair. The resident said she excused herself while passing another resident who became agitated and called Resident #55 an inappropriate name. The two residents then became involved in a verbal altercation in which they called each other inappropriate names. The second resident then started to walk away when Resident #55 called him another name. The second resident then turned around and walked back to Resident #55 and told her if she continued to call him names, he would slap her. Resident #55 called him another name and the second resident slapped her. Resident #55 then said she would report him and re-entered the building from the smoke area. The second resident also re-entered the building and began choking Resident #55. Staff immediately separated the residents. Resident #55 said she had called the local police department and filed a report. Resident #55's injuries were treated. The resident's emergency contact was notified and came to the facility. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109. Further review of the nursing progress notes revealed on 09/06/23 Social Service Director (SSD) #1164 interviewed Resident #55 who indicated she felt safe in the facility. Review of Resident #55's care plan revealed a care plan was initiated on 02/22/23 that the resident made abusive attacks on staff and/or other residents, including physically and verbally abusive behaviors. Resident #55 refused a request for an interview on 09/21/23 at 11:55 A.M. 2. Resident #68 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy. Review of the comprehensive MDS admissions assessment, dated 08/13/23, revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period. 365828 Page 8 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nursing progress notes dated 09/02/23 revealed LPN #1134 heard a commotion in the hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and place Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and ADON #1109 of the incident. Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false statements in order to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed. Resident #68 refused an interview on 09/21/23 at 12:05 P.M. Interview with the Administrator on 09/20/23 at 3:40 P.M. revealed she was not aware of any resident-to-resident allegation of abuse for Residents #55 and #68 on 09/02/23. The Administrator stated no Self-Reported Incident (SRI) form was submitted as she was unaware of any abuse allegation. The Administrator said she was on vacation when the incident was alleged to have occurred. The Administrator reviewed the nursing progress note for Resident #55 dated 09/02/23 and said the incident must not have occurred as she knew Resident #55 from another facility and the resident had her personal phone number. Resident #55 would have called her immediately had anything happened to her. The Administrator said she would go and speak with Resident #55 and then call LPN #1134 to determine what happened. A second interview with the Administrator on 09/20/23 at 4:40 P.M. revealed she had just spoken with Resident #55 who denied the incident ever happened. Resident #55 told the Administrator Resident #68 would never hurt her and she did not know why LPN #1134 would say that. The Administrator said the incident should have been on the facility's 24-hour report and does not know why the Director of Nursing (DON) would not have been made aware of the alleged altercation. The Administrator stated she would submit an SRI and close it out immediately as nothing had happened. Interview with the DON on 09/21/23 at 11:45 A.M. revealed she had seen the documentation by LPN #1134 on the 24-hour report and that she spoke with Resident #55 and Resident #68 who denied they had had an altercation. The DON confirmed she did not speak with LPN #1134 about the incident and felt LPN #1134 notified ADON #1109 as that was the first person who she thought of. The DON said she did not initiate an SRI at the time as she was not authorized to, only the Administrator was able to initiate one. A telephone call was made to LPN #1134 on 09/21/23 at 4:50 P.M. and a voice mail message was left requesting a return phone call. As of 09/26/23 at 12:10 P.M. no return call was received. The facility submitted a Self-Reported Incident (SRI) on 09/20/23. An SRI is a report a facility is required to submit to the state agency regarding any allegation of abuse, neglect, exploitation, or injury of unknown origin. Review of the SRI revealed the date of discovery of the allegation of abuse was 09/20/23. Review of the nursing progress notes for Residents #55 and #68 revealed LPN #1134 365828 Page 9 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notified the Administrator and ADON #1109 were notified of the incident on 09/02/23 when it occurred. The DON confirmed on 09/21/23 at 11:45 A.M. she was aware of the incident and did not file an SRI with the state agency. Review of the facility's Abuse, Neglect, and Exploitation, last revised 10/01/22, revealed the definition of abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. An alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated, and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. All allegations of abuse are to be reported immediately, but no later than two hours after the allegation is made if serious bodily harm occurs. If serious bodily injury did not occur, then the required agencies must be notified within 24 hours of the allegation being made. 365828 Page 10 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to investigate an allegation of resident-to-resident abuse. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98. Residents Affected - Few Findings include: 1.Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen and there was a small skin alteration to the resident's left wrist and the back of her neck. Resident #55 said that during the smoke break she was passing through in her motorized wheelchair. The resident said she excused herself while passing another resident who became agitated and called Resident #55 an inappropriate name. The two residents then became involved in a verbal altercation in which they called each other inappropriate names. The second resident then started to walk away when Resident #55 called him another name. The second resident then turned around and walked back to Resident #55 and told her if she continued to call him names, he would slap her. Resident #55 called him another name and the second resident slapped her. Resident #55 then said she would report him and re-entered the building from the smoke area. The second resident also re-entered the building and began choking Resident #55. Staff immediately separated the residents. Resident #55 said she had called the local police department and filed a report. Resident #55's injuries were treated. The resident's emergency contact was notified and came to the facility. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109. Further review of the nursing progress notes revealed on 09/06/23 Social Service Director (SSD) #1164 interviewed Resident #55 who indicated she felt safe in the facility. Review of Resident #55's care plan revealed a care plan was initiated on 02/22/23 that the resident made abusive attacks on staff and/or other residents, including physically and verbally abusive behaviors. Resident #55 refused a request for an interview on 09/21/23 at 11:55 A.M. 2. Resident #68 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy. Review of the comprehensive MDS admissions assessment, dated 08/13/23, revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period. Review of the nursing progress notes dated 09/02/23 revealed LPN #1134 heard a commotion in the 365828 Page 11 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and placed Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and ADON #1109 of the incident. Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false statements in order to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed. Resident #68 refused an interview on 09/21/23 at 12:05 P.M. Interview with the Administrator on 09/20/23 at 3:40 P.M. revealed she was not aware of any resident-to-resident allegation of abuse for Residents #55 and #68 on 09/02/23. The Administrator stated no Self-Reported Incident (SRI) form was submitted as she was unaware of any abuse. The Administrator said she was on vacation when the incident was alleged to have occurred. The Administrator reviewed the nursing progress note for Resident #55 dated 09/02/23 and said the incident must not have occurred ass the resident has her personal phone number, and the resident would have called her immediately. The Administrator said she would go and speak with Resident #55 and then call LPN #1134 to determine what happened. A second interview with the Administrator on 09/20/23 at 4:40 P.M. revealed she had just spoken with Resident #55 who denied the incident ever happened. Resident #55 told the Administrator Resident #68 would never hurt her and she did not know why LPN #1134 would say that. The Administrator said the incident should have been on the facility's 24-hour report and does not know why the Director of Nursing (DON) would not have been made aware of the alleged altercation. The Administrator stated she would enter an investigation and close it out immediately as nothing had happened. Interview with the DON on 09/21/23 at 11:45 A.M. revealed she had seen the documentation by LPN #1134 on the 24-hour report and that she spoke with Resident #55 and Resident #68 who denied they had had an altercation. The DON confirmed she did not speak with LPN #1134 about the incident and felt LPN #1134 notified ADON #1109 as that was the first person who she thought of. The DON said she did not initiate an SRI at the time as she was not authorized to, only the Administrator was able to initiate one. A telephone call was made to LPN #1134 on 09/21/23 at 4:50 P.M. and a voice mail message was left requesting a return phone call. As of 09/26/23 at 12:10 P.M. no return call was received. Review of the facility's Abuse, Neglect, and Exploitation, last revised 10/01/22, revealed the definition of abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. An alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet 365828 Page 12 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0610 Level of Harm - Minimal harm or potential for actual harm been investigated, and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The policy also revealed an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Residents Affected - Few 365828 Page 13 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review the facility failed to develop care plans regarding behaviors and medications usage. This affected three residents (#55, #73, and #68) of four residents reviewed for behaviors and psychotropic medications. The facility census was 98. Findings include: 1. Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the physician's orders for Resident #55 revealed an order for: • Acyclovir (an antiviral medication) 400 milligrams (mg) by mouth twice a day for Herpes Viral Infection dated 03/28/23. • Amitriptyline (a psychotropic medication) 75 mg by mouth twice a day for Anxiety, Depression, and Schizophrenia, dated 06/19/23. • Eliquis (an anticoagulant) 5 mg by mouth twice a day for atrial fibrillation, dated 04/04/23. Review of the care plans for Resident #55 revealed no care plans addressing the use of the listed medication or the associated viral infection. Interview with Registered Nurse (RN) #1167 on 09/26/23 at 1:42 P.M. confirmed care plans should have been developed for the medications Resident #55 receives. 2. Resident #73 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease, bipolar disorder, depression, and anxiety. The resident resided on the facility's secured unit. Review of the comprehensive quarterly MDS assessment dated [DATE] revealed Resident #73 was moderately cognitively impaired, wandered several days during the assessment period, and was independently ambulatory. Review of the physician's orders for Resident #73 revealed an order for: 365828 Page 14 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0656 • Level of Harm - Minimal harm or potential for actual harm Albuterol (an inhaled respiratory medication) 2 puffs orally every six hours as needed for shortness of breath due to Chronic Obstructive Pulmonary Disease (COPD), dated 11/16/22. Residents Affected - Few • Incruse Ellipta (an inhaled respiratory medication) 62.5 micrograms (mcg)/ACT aerosol Powder 1 puff daily for COPD, dated 7/21/23. Review of the nursing progress notes for Resident #73 revealed increasing episodes of agitation, combativeness, aggressiveness, and wandering since July 2023. On 08/12/23 the resident struck Resident #80 in the face when told to get out of the resident's room. Review of the care plans revealed Resident #73 had newly implemented plans, dated 09/25/23, regarding impaired cognitive function, impaired thought processes, wandering, and behavior problems. No care plan was found regarding the medications used for treating COPD or the risks to the resident's health for a diagnosis of COPD. Review of the facility's Care Plans, Comprehensive Person-Centered policy, last revised December 2016, includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs are to be developed and implemented for each resident. The care plan will also describe the services that are to be provided to meet those goals. Interview with RN #1167 on 09/26/23 at 1:42 P.M. confirmed Resident #73's care plans should have been developed for the resident's behaviors and for the resident's diagnosis of COPD and the associated medications. 3. Resident #68 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy. Review of the comprehensive MDS admissions assessment, dated 08/13/23, revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period. Review of the nursing progress notes dated 09/02/23 revealed Licensed Practical Nurse (LPN) #1134 heard a commotion in the hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and placed Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109 of the incident. Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false 365828 Page 15 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few statements in order to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed. Resident #68 refused an interview on 09/21/23 at 12:05 P.M. Interview with RN #1167 on 09/26/23 at 1:42 P.M. confirmed Resident #68's care plans should have been developed for the resident's behaviors earlier than they were. 365828 Page 16 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to ensure care plans were updated and accurate for Residents #7, #14, #35, #73, #80, #244 and #294. This affected seven residents (#7, #14, #35, #73, #80, #244 and #294) of 23 residents reviewed for assessments. The facility census was 98. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/21/22. Diagnoses included schizophrenia, diabetes, chronic obstructive pulmonary disease (COPD), and gastro esophageal reflux disease (GERD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired. She required supervision for transfers and was independent with no set up help for bed mobility, dressing, toileting, eating, and hygiene. She occasionally rejected care. Review of the elopement assessment dated [DATE] revealed Resident #7 resided on a secured unit. Review of a nurse's note dated 08/28/23 revealed Resident #7 room was changed to a room on the first floor which was not a secured unit. Review of the physician's orders for September 2023 revealed an order for a secured unit due to a diagnosis of schizophrenia. Review of the care plan dated 09/07/23 revealed Resident #7 had a psychiatric diagnosis which required supervision on a secured unit. Interventions included meeting criteria for placement on a secured unit and quarterly reviews for continued appropriateness of placement on a secured unit. Interview on 09/20/23 at 2:54 P.M. with the Director of Nursing (DON) confirmed the care plan for Resident #7 was not updated when the resident no longer required placement on a secured unit. 2. Review of the medical record for Resident #14 revealed an admission date of 10/05/21. Diagnoses included vascular disease, diabetes, hypertension, and paraplegia. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired. He required total assistance of two people for transfers, total assistance of one person for toilet use and extensive assistance of one person for bed mobility, dressing, and hygiene. The resident did not have any behaviors or rejection of care. Review of the care plan dated 09/07/23 revealed no evidence Resident #14 had refused care. Review of the progress notes dated 06/29/23 through 09/25/23 revealed Resident #14 often refused personal hygiene and general care services. Interview on 09/26/23 at 1:35 PM with Licensed Practical Nurse (LPN) #1116 reveal Resident #14 did 365828 Page 17 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0657 refuse care at times. Level of Harm - Minimal harm or potential for actual harm Interview on 09/26/23 at 1:37 PM with the Administrator confirmed Resident #14 had no evidence of refusals being addressed in his care plan. Residents Affected - Some 3. Review of the medical record for Resident #35 revealed an admission date of 10/29/16. Diagnoses included diabetes, asthma, and epilepsy. Review of the quarterly MDS assessment dated [DATE] revealed Resident #35 was cognitively intact. She required total assistance of two people for transfers, total assistance of one person for toilet use, extensive assistance of two people for bed mobility, extensive assistance of one person for dressing and limited assistance of one person for hygiene. She was independent with eating and had no weight loss or dental issues. Review of the care plan dated 05/22/23 revealed Resident #35 was at risk for dental or chewing problems due to some missing natural teeth. Interventions included assisting with oral hygiene including denture care, monitoring wait for any changes, and notifying the doctor if there were problems with chewing or swallowing. Interview and observation of Resident #35 on 9/20/23 at 11:26 A.M. revealed she had all her own natural teeth. Interview on 09/20/23 at 2:50 P.M. with the DON Confirmed the care plan for Resident #35 was inaccurate. 4. Review of the medical record for resident #80 revealed and admission date of 05/31/23. Diagnoses included diabetes, hypertension, depression, anxiety, and heart failure. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #80 was moderately cognitively impaired. She required supervision and set up help for bed mobility, transfers, dressing, eating, toilet use, and hygiene. She had trouble falling and staying asleep, she felt down and depressed, had little interest in doing things, had trouble concentrating and displayed no behaviors. Review of the care plan dated 06/01/23 revealed no evidence depression and anxiety were addressed. Interview on 09/21/23 at 9:48 A.M. with the DON confirmed there was no care plan for depression and anxiety for Resident #80. 5. Review of the medical record for Resident #244 revealed an admission date of 08/14/23. Diagnoses included diabetes, hypoxia (low oxygen levels), spinal stenosis (narrowing of the spine), and chronic obstructive pulmonary disease. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #244 was moderately cognitively impaired. He required limited assistance from one person for bed mobility, transfers, toilet use, dressing, and personal hygiene, and was at risk for pressure ulcers. He was on oxygen. Review of the physician's orders for September 2023 revealed an order for Ace wraps to the lower extremities every morning. 365828 Page 18 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0657 Review of the care plan dated 08/15/23 revealed no evidence Ace wraps were addressed. Level of Harm - Minimal harm or potential for actual harm Interview on 09/21/23 at 9:47 A.M. with the DON revealed Resident #244 had an order for Ace wraps to his legs every morning for edema. She confirmed this was not addressed in the Resident's care plan. Residents Affected - Some 6. Review of the medical record for Resident #294 revealed an admission date of 08/31/23 with diagnoses including chronic systolic congestive heart failure, stage IV chronic kidney disease, and depression. Review of the admission MDS assessment dated [DATE] revealed Resident #294 had moderate cognitive impairment. Review of activities of daily living (ADL) revealed Resident #294 required supervision for transfers, dressing, eating, and toileting and was independent for personal hygiene. Review of the physician's orders for Resident #294 revealed an order dated 09/05/23 for daily weights related to a diagnosis of congestive heart failure. Review of the care plan for Resident #294 initiated on 08/31/23 did not reveal interventions related to weight monitoring and no modifications following the 09/05/23 order for daily weights. Interview on 09/25/23 at 2:16 P.M. with the DON confirmed Resident #294's care plan did not have an intervention listed for weight monitoring and was not revised to reflect the 09/05/23 order for daily weights. Review of the facility policy titled Care Plans, Comprehensive, Person Centered, dated December 2016, revealed care plans would be revised as resident conditions and needs changed. 7. Resident #73 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease, bipolar disorder, depression, and anxiety. The resident resided on the facility's secured unit. Review of the quarterly MDS assessment dated [DATE] revealed Resident #73 was moderately cognitively impaired, wandered several days during the assessment period, and was independently ambulatory. Review of the physician's orders for Resident #73 revealed an order for: • Depakote Sprinkles (a medication used to treat seizures and as a mood stabilizer) 125 mg by mouth twice a day for vascular dementia, dated 08/15/23. • Seroquel (an antipsychotic) 300 mg by mouth once a day for dementia with behaviors, dated 11/15/23. Review of the nursing progress notes for Resident #73 revealed increasing episodes of agitation, combativeness, aggressiveness, and wandering since July 2023. On 08/12/23 the resident struck Resident #80 in the face when told to get out of the resident's room. 365828 Page 19 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the care plans revealed Resident #73's psychotropic medication care plan was not initiated until 07/25/23 despite being on Seroquel since his 11/15/23 admission. The care plan was also not revised to include the addition of Depakote Sprinkles on 08/15/23. Interview with Registered Nurse (RN) #1167 on 09/26/23 at 1:42 P.M. confirmed Resident #73's care plans should have been revised to accurately reflect the resident's current medications. Review of the facility's Care Plans, Comprehensive Person-Centered policy, last revised December 2016, includes measurable objectives and timetables are to be developed and implemented to meet the resident's physical, psychosocial and functional needs are to be developed and implemented for each resident. The care plan will also describe the services that are to be provided to meet those goals. The care plans are to be reviewed and updated whenever there has been a significant change in condition, when the desired outcome is not met, when the resident is readmitted to the facility after a hospital stay, and at least quarterly in conjunction with the required quarterly MDS assessment. 365828 Page 20 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

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 record reviews, interviews, and facility policy review the facility failed to adequately monitor Resident #90 after a significant change in condition and failed to follow physician orders for daily weights for Resident #294. This affected one resident (#90) out of three residents reviewed for death and one resident (#294) of four residents reviewed for weights. The facility census was 98. Residents Affected - Few Findings include: 1.Review of the closed medical record for Resident #90 revealed an admission date of 02/28/19 with diagnoses including diabetes, hypertension, altered mental status, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was severely cognitively impaired. She required total assistance of two people for bed mobility and transfers and extensive assistance of one person for dressing, toilet use, and hygiene. She had no issues with swallowing and had one fall since the previous assessment, with no injury. Review of the fall risk assessment dated [DATE] revealed Resident #90 was at moderate risk for falls. Review of the August 2023 physician's orders revealed orders dated 04/01/21 for a regular diet with nectar thick liquids, 08/19/23 to record vital signs every four hours for 24 hours, two liters of oxygen to keep oxygen saturation level (SpO2) above 92 percent (%), a STAT (immediate) chest x-ray, to call the nurse practitioner if the resident's heart rate was 110 or higher and/or her systolic blood pressure decreased to 100 or lower every shift and ten liters of oxygen via a non-rebreather mask until her oxygen levels reached 100% with a call to the nurse practitioner if her oxygen decreased to 92% or lower per shift. Review of the nursing note dated 08/17/23 at 11:30 A.M. revealed Resident #90 was sitting near the nurse's station when dietary staff member was transporting the breakfast cart and Resident #90 began to ambulate via wheelchair in the path of the cart and fell out of the chair. Resident #90 was assessed for injury, and an abrasion was observed to her right knee. Vital signs were assessed: temperature of 98 degrees Fahrenheit (F), pulse 91, respirations 18, blood pressure 147/82 and SpO2 100 % on room air. Review of the neurological assessment sheet initiated on 08/17/23 at 10:30 A.M. were as follows: • 08/17/23 at 10:30 A.M. blood pressure 147/92, pulse 91, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. • 08/17/23 at 10:45 A.M. blood pressure 145/90, pulse 88, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. • 365828 Page 21 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 08/17/23 at 11:00 A.M. blood pressure 146/88, pulse 82, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. • 08/17/23 at 11:30 A.M. blood pressure 142/82, pulse 78, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. • 08/17/23 at 12:00 P.M. blood pressure 149/66, pulse 75, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. • 08/17/23 at 12:30 P.M. blood pressure 141/74, pulse 78, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. • 08/17/23 at 1:30 P.M. blood pressure 144/78, pulse 76, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. • 08/17/23 at 2:30 P.M. blood pressure 141/57, pulse 82, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. • 08/17/23 at 7:00 P.M. blood pressure 148/60, pulse 77, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. • 08/18/23 at 7:00 A.M. blood pressure 144/65, pulse 84, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. • 08/18/23 at 7:00 P.M. blood pressure 153/73, respirations 19, range of motion and strength normal, pupils were equal and reactive to light. No pulse was assessed. • 08/19/23 at 7:00 A.M. blood pressure 134/74, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. No pulse was assessed. Review of the nursing note dated 08/17/23 at 1:06 P.M. revealed the intervention for Resident #90's 365828 Page 22 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fall was to include transporting the resident from the dining room after meals to area of choice close to nurse's station out of the hallways. Review of the nursing note dated 08/18/23 at 8:24 P.M. revealed staff notified the nurse that Resident #90 had medium emesis and appeared to be in respiratory distress. Upon entering the resident's room, the nurse observed emesis on the bed and floor. The emesis was pink tinged and had chunks of food in it. Resident #90 was sitting on the side of the bed breathing rapidly but was not using accessory muscles. Her blood pressure was 153/79, pulse 109, temperature 97.9 degrees F, respirations 22, and SpO2 was 78% on room air. Staff immediately administered oxygen via nasal canula and her SpO2 increased to 82%. Assessment of abdomen completed without abnormal findings. No signs and symptoms of discomfort were observed. Call placed to the on call Optum Certified Nurse Practitioner (CNP). New orders were obtained to place resident on ten liters (10 L) of oxygen via a non-rebreather mask. Administer Zofran (antiemetic) 8 milligrams (mg) by mouth times one dose. Obtain full set of vital signs every four hours for twenty-four hours and notify Optum of a heart rate greater than 110 beats per minute, systolic blood pressure less than 100, and SpO2 less than 92%. All orders were implemented. SpO2 was noted at 96% on 10 L oxygen via mask. Resident #90's Power of Attorney (POA) was notified of the situation and plan of action. All concerns were addressed at this time. Resident #90's POA also gave verbal consent to send the resident to the emergency room (ER) if health status declined any further. Shortly after, Optum nurse called this nurse back to check health status and was informed Resident #90 was improving and SpO2 was noted at 100 %. New orders were obtained for STAT (immediate) two view chest x-ray to rule out pneumonia and STAT complete blood count (CBC) w/differential and complete metabolic panel (CMP). Staff currently awaiting arrival. CNP also ordered staff to remove the non-rebreather mask and place the resident on six liters of oxygen via nasal cannula. SpO2 at 97%. No further concerns to report at this time. Staff will continue to monitor for further decline. Review of the neurological assessment sheet revealed on 08/19/23 at 7:00 A.M. Resident #90's blood pressure was 134/74 and respirations at 19, range of motion and strength normal, pupils were equal and reactive to light. No pulse was assessed. Review of the medical record revealed no further documented evidence of assessment of Resident #90 until a nursing note dated 08/19/23 at 10:44 A.M. authored by Licensed Practical Nurse (LPN) #1109 revealed when the CNP #1108 called the facility and spoke to this nurse regarding the resident's overall status. This nurse stated that Resident #90 was in stable condition with a temperature of 97.6 degrees F, blood pressure of 119/64, pulse of 108, respirations 18, and SpO2 of 90% on room air. Lungs were clear to auscultation. Resident #90 consumed all her breakfast without incident. No nausea or vomiting, and the lab came to the facility for STAT orders, and the chest x-ray was complete now pending results. CNP #1108 then ordered Augmentin 875 mg (antibiotic) by mouth twice daily for seven days, oxygen on two liters to keep SpO2 above 92%, and consult speech therapy for Monday (08/21/23). Resident #90's daughter was updated. Review of the nursing note dated 08/19/23 at 12:37 P.M. stated this writer went in to continue re-assessments of Resident #90 and the resident was observed with no visible breathing. This nurse assessment revealed the resident to be absent of all vital signs. Resident #90 absent of blood pressure, pulse, temperature below 98.6 degrees F, no palpable carotid pulse, unable to auscultate apical pulse absence of breathing one full minute. Resident #90 was noted to have oxygen via nasal cannula in proper placement. Additional shift nurse in room to verify resident was absent of all vital signs. Resident #90 was noted to be clean and dry, appearing to be resting in bed with the head of the 365828 Page 23 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few elevated upon entering the room. No change in resident's skin tone at this time of assessment. Emergency Medical Services (EMS) was contacted and noted Resident #90 to be asystole (no heartbeat) on EKG monitoring and absent of all other vital signs. EMS pronounced Resident #90 dead at 12:17 P.M. The CNP was contacted to inform of Resident #90's expiration. The family was contacted and informed of need to come immediately to the facility. Postmortem care provided by nursing staff for family viewing, the DON and Administrator were informed of Resident #90's expiration. Interview with CNP #1108 on 09/21/23 at 12:12 P.M. revealed she was in building when Resident #90 fell on [DATE], but the resident wouldn't allow an assessment as she was pushing her hand away. She did have a bump on her head. CNP #1108 could not describe how the bump looked, but it might have been a little raised. I offered to send her for a CT (computerized tomography) scan, but the resident refused, and Resident #90's daughter said she would come in. I looked at her chart over the weekend. I ordered neurological assessments and a fall protocol. I didn't think she needed to go to the ER but did offer. If a resident is a Do Not Resuscitate Comfort Care (DNRCC), I would never say no, not to send them, but I didn't think she needed to go, and would send if needed. Resident #90 was stable on Friday (08/18/23), the nurse and the daughter called me but there was another CNP on call, so I didn't answer (I was not supposed to). When I came in Monday, 08/21/23, she had died. There was an on call CNP from Friday, 08/18/23 from 5:00 P.M. until Monday, 08/21/23 at 8:00 A.M. When asked if she knew the cause of death, she stated she believed it was aspiration pneumonia. If I had been on call, I would have ordered oxygen as needed, labs, and chest x-ray. Maybe breathing treatments, albuterol and depending on chest x-ray results, steroid, vital signs every four hours or every shift. Interview with the Administrator and Director of Nursing (DON) on 09/21/23 1:35 P.M. revealed the DON did not know if Resident #90 had a head injury related to the fall, she did not see her. She stated when a chest x-ray is ordered STAT, we have to wait, it takes time for the x-ray company to get here. The Administrator stated a STAT order takes approximately six to eight hours. The Administrator stated Resident #90 had stabilized by the time they did the chest x-ray. The Administrator verified the nursing staff did not document the bump on Resident #90's head from the fall on 08/17/23 in the medical record. The DON stated she had no idea why the nurses did not assess Resident #90's vital signs every four hours as ordered by the CNP on 08/18/23. Interview with LPN #1109 on 09/21/23 at 2:39 P.M. stated she worked 08/19/23 from 7:00 A.M. to 7:00 P.M. She stated she spoke to Resident #90 on morning rounds because heard she might have aspirated. Resident #90 denied pain not in pain and shortness of breath, was wearing oxygen, and ate breakfast. She stated she spoke to the CNP who ordered antibiotics and a chest x-ray. I checked on Resident #90 after breakfast to notify her of the blood draw, and next time I went to see her (12:17 P.M.) she had expired. She stated Resident #90 had oxygen the whole time, they were trying to wean her, and she tugged at it periodically. When asked about assessments, LPN #1109 stated when she completed resident assessments, she documented them in the electronic health record. She stated she remembers doing assessments for Resident #90, but does not recall where she documented them as they were not documented in the electronic health record until her conversation with the CNP on 08/19/23 at 10:44 A.M. Review of the facility policy titled Notification of changes, dated 04/15/21, revealed the facility would promptly notify the physician of change in condition. 2. Review of Resident #294's medical record revealed an admission date of 08/31/23 with diagnoses including chronic systolic congestive heart failure, stage IV chronic kidney disease, and depression. 365828 Page 24 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the admission MDS assessment dated [DATE] revealed Resident #294 had moderate cognitive impairment. Review of activities of daily living (ADL) revealed Resident #294 required supervision for transfer, dressing, eating, and toileting and was independent for personal hygiene. Review of the physician orders for Resident #294 revealed an order dated 09/05/23 for daily weights related to a diagnosis of congestive heart failure. Further review of the medical record and medication administration record (MAR) for September 2023 between 09/05/21 and 09/20/23 revealed Resident #294's weights were marked as a refused on 09/05/23, 09/06/23, 09/08/23, 09/10/23, 09/11/23, 09/12/23, 09/13/23, 09/15/23, 09/17/23, 09/18/23, 09/20/23. No response was indicated on 09/07/23, 09/14/23, and 09/19/23. Review of the electronic medical record under the weight monitoring tab for Resident #294 revealed a weight was obtained on 09/09/23 at 200 pounds and again on 09/16/23 at 197 pounds. No further weights were documented prior to surveyor intervention on 09/21/23. Interview on 09/20/23 at 1:19 P.M. with LPN #1133 confirmed daily weights were not recorded in the paper chart for Resident #294. Interview on 09/20/23 at 2:30 P.M. with the DON revealed Resident #294's orders for daily weights were to be completed between 3:00 A.M. and 7:00 A.M. and stated Resident #294 refused to be weighed. When the DON was asked if it was a convenient agreed upon time for Resident #294, she stated it may have been towards 7:00 A.M. but agreed a later time may have been better accepted. Interview on 09/20/23 at 2:33 P.M. with Resident #294 revealed staff have asked him several times about being weighed but he was sleeping and refused because he wanted to continue sleeping. Review of the nursing progress notes from 09/05/23 to 09/21/23 did not reveal any documented evidence of a re-weight being offered as ordered nor education provided to Resident #294 of the importance of daily weights for monitoring his medical diagnoses. Review of the 09/21/23 physician order for Resident #294 revealed daily weights to be obtained at 7:00 A.M. Review of Resident #294's weight on 09/21/23 revealed a weight of 240 pounds, with no reweight initiated by the facility. Additional weight on 09/22/23 and 09/23/23 also revealed weights of 240 pounds. There was no documented evidence that the physician and dietitian were notified of the increased weight. Review of the nursing progress notes dated 09/24/23 at 7:00 A.M. revealed Nurse Practitioner was notified of right upper extremity edema with 2-3+ pitting edema including the right hand which was 2+. There was no documented evidence that the physician and dietitian were notified of the increased weight. Review of nursing progress note dated 09/24/23 at 6:40 P.M. Nurse Practitioner was contacted related to Resident #294 complaining of right forearm pain and humerus pain. Nurse attempted to view but Resident #294 refused to allow her to look and declined pain medication. Nurse Practitioner was contacted, and an ultrasound was ordered. 365828 Page 25 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nursing progress note on 09/25/23 at 9:55 A.M. revealed Nurse Practitioner was notified of resident refusal of medications, care attempts, and daily weights. Nurse Practitioner was made aware of weight gain and new orders were received for two-liter fluid restriction and STAT (immediate) labs including a complete blood count and renal panel along with STAT chest x-ray, and ace wrap for right upper extremity edema. The physician was notified of the significant weight gain and ordered STAT labs since the weight gain went from 200 pounds on 09/09/23 to 240 pounds on 09/21/23. Weights obtained on 09/22/23 and 09/23/23 were also 240 pounds. Review of the lab results dated 09/25/23 revealed no critical findings and no new physician orders. Interview on 09/25/23 at 12:19 P.M. with the DON confirmed she did not have further documented evidence of reweights being offered related to refusals or resident education provided to Resident #294 related to importance of daily weights related to his medical diagnoses. Review of the facility policy titled Weight Policy, 11/2018, revealed weights will be obtained in a timely and accurate manner, documented, and responded to appropriately. Residents will be weighed per physician orders and notified of significant changes in weight. This deficiency represents non-compliance investigated under Complaint Numbers OH00146813 and OH00146571. 365828 Page 26 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent an in-house acquired pressure ulcer for Resident #14. Residents Affected - Few Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, the area declined to a Stage IV pressure ulcer with odor noted with recommendation for hospitalization and possible amputation. This affected one resident (#14) of three residents reviewed for pressure ulcers. The facility census was 98. Findings include: Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, type II diabetes mellitus, hypertension, altered mental status, neuromuscular dysfunction of the bladder, and paraplegia. A plan of care, dated 10/05/21 included an intervention to encourage resident to turn and reposition every two hours and as needed. However, there was no documented evidence on the administration records of turning and repositioning being provided for the resident. Review of the Braden Scale for predicting pressure sore risk dated 03/16/23 revealed Resident #14 was at a low risk for pressure ulcer development. Review of a skin observation document dated 05/22/23 revealed the resident had no new skin areas noted. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was cognitively intact. The assessment revealed the resident required extensive assistance from two staff for bed mobility, extensive assistance from one staff for hygiene and was dependent on two staff for transfers. The resident had an indwelling (Foley) catheter and an ostomy. The assessment also noted the resident was at risk for skin breakdown and had no behaviors, including refusal of care. Record review revealed no updates to the resident's plan of care until 08/09/23 related to risk for pressure ulcers. Review of a skin grid dated 05/23/23 revealed Resident #14 had a new area to the left heel first identified as an unstageable SDTI measuring 7.0 centimeters (cm) in length by 5.0 cm width with an undetermined depth. The ulcer was noted to have 100 percent (%) necrotic tissue. New orders were received to cleanse the left heel with wound cleanser/normal saline, pat dry, cover with abdominal pad (ABD) and wrap with Kerlix gauze, daily and as needed. Record review revealed no evidence the dietitian was notified of the development of the left heel wound to implement nutritional interventions to promote healing. Review of the skin grid dated 06/06/23 revealed the left heel was not assessed because Resident #14 was on a leave of absence (LOA) with activities. 365828 Page 27 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of the skin grid dated 06/13/23 revealed to the left heel wound measured 7.0 cm length by 6.0 cm width with an undetermined depth due to the presence of 100% necrotic tissue. The wound was now classified as an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). There was no evidence the dietitian was notified of the presence of the ulcer at this time. Review of the skin grid dated 06/20/23 revealed the left heel wound measured 8.0 cm length by 6.0 cm width with an undetermined depth due to the presence of 100% necrotic tissue. There was no evidence the dietitian was notified of the presence of the ulcer at this time. Review of the skin grid dated 06/27/23 revealed the left heel wound measured 7.0 cm length by 4.0 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was debrided sharply manually with curette at this time. There was no evidence the dietitian was notified of the presence of the ulcer at this time. Review of the skin grid dated 07/11/23 revealed the left heel wound measured 8.0 cm length by 5.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was treated with enzymatic debridement (removal of necrotic/dead tissue), Santyl (ointment used to aid in the healing of skin ulcers), calcium alginate (dressing used to repair wounds), ABD (dressing used for wounds with heavy leakage) and Kerlix gauze. Review of the skin grid dated 07/18/23 revealed the left heel wound measured 8.5 cm length by 4.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was debrided. There was no evidence the dietitian was notified of the presence of the left heel wound at this time. Review of the skin grid dated 07/25/23 revealed the left heel wound measured 7.5 cm length by 5.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. There was no evidence the dietitian was notified of the presence of the left heel wound at this time. Review of the skin grid dated 08/01/23 revealed the left heel wound measured 9.0 cm in length by 7.0 cm width with an undetermined depth due to 75% necrotic tissue and 25% granular tissue. There was no evidence the dietitian was notified of the presence of the left heel wound at this time. The assessment of the wound at this time noted it was larger and had an increase in necrotic tissue. Review of a dietary progress note dated 08/09/23 revealed Registered Dietitian (RD) #1111 was notified of the left heel wound and made recommendations for a multivitamin, Vitamin C 500 milligrams (mg) twice per day (BID) for 30 days, Zinc Sulfate 220 mg every day (QD) for 14 days and liquid protein 30 milliliters (ml) QD for 30 days to promote wound healing. Review of the skin grid dated 08/15/23 revealed the left heel wound measured 6.0 cm length by 5.0 cm width with a measurable depth of 0.3 cm. The wound was assessed to continue to have 75% necrotic tissue and 25% granular tissue. The note revealed the physician was notified of a decline in the wound status. The wound was cleansed, flushed, and irrigated, and prepared for debridement/dressing. A dressing of calcium alginate, ABD pad, and kerlix gauze was applied. The wound was now classified as a Stage IV (full-thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed) pressure ulcer. 365828 Page 28 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0686 Record review revealed as of 08/15/23 there was no evidence RD #1111's recommendations (dated 08/09/23) had been implemented. Level of Harm - Actual harm Residents Affected - Few Review of the skin grid dated 08/22/23 revealed the left heel wound measured 8.0 cm length by 5.0 cm width with 0.3 cm depth. The wound was noted to have 75% necrotic tissue and 25% granular tissue. The note indicated the physician was notified of a decline in wound status. Review of the wound progress note dated 08/22/23 and completed by Medical Doctor (MD) #1113 revealed the resident's left heel wound was declining and bone was exposed. MD #1113 recommended the resident be sent to the hospital for evaluation with the possible need for amputation; however, Resident #14 declined the recommendation at that time. Record review revealed as of 08/22/23 there was no evidence RD #1111's recommendations (dated 08/09/23) had been implemented. On 08/23/23 new physician orders were obtained for Vitamin C 500 mg BID for 30 days, Zinc Sulfate 220mg QD for 14 days and Pro Stat oral liquid 30 ml QD for 30 days. Review of the skin grid dated 09/05/23 revealed the left heel wound measured 9.0 cm length by 7.0 cm width with 0.3 cm depth. The wound was assessed to have 50% necrotic tissue and 50% granular tissue with bone exposed and an odor. MD #1113 was notified of the decline and recommended a hospital evaluation with the possible need for amputation; however, the resident continued to refuse to go to the hospital. The wound was treated with autolytic bone debridement (breakdown of damaged issue) and calcium alginate, ABD pad, and Kerlix gauze were applied. Review of the skin grid dated 09/12/23 revealed the left heel wound measured 9.0 cm length by 9.0 cm width with a depth of 0.3 cm. The wound was assessed to have 50% necrotic tissue and 50% granular tissue with bone exposed and odor. The wound was assessed to have declined. MD #1113 was notified of the decline and recommended a hospital evaluation with the possible need for amputation; however, the resident continued to refuse. The wound was treated with autolytic bone debridement and calcium alginate, ABD pad, and Kerlix gauze were applied. Review of the skin grid dated 09/19/23 revealed the left heel wound measured 9.0 cm length by 6.0 cm width with 0.3 cm depth and was assessed to show improvement. Interview on 09/26/23 at 8:09 A.M. with the Director of Nursing (DON) revealed when a recommendation from the RD comes in, the facility would implement the recommendation within seven days. She confirmed the orders for Resident #14 for Vitamin C 500 mg BID for 30 days, Zinc Sulfate 220 mg QD for 14 days and Pro Stat oral liquid 30 ml QD for 30 days were implemented 13 days after they were recommended, which was longer than it should have been. Interview on 09/26/23 at 11:09 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON)/Wound Nurse #1109 revealed she could not explain how Resident #14 developed an unstageable STDI on 05/23/23 when no new issues were reported to his skin on 05/22/23. RN #1109 revealed there was no way an injury like that could have developed in one day. Interview on 09/26/32 at 11:31 A.M. with RD #1112 (RD #1111 was not available to interview) revealed the dietician was first notified of the new heel wound for Resident #14 on 08/09/23. 365828 Page 29 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0686 Level of Harm - Actual harm Residents Affected - Few Observation on 09/26/23 at 1:33 P.M. of Resident #14's left heel revealed a wound was present with a moderate amount of reddish-brown drainage with no tunnelling. The wound measured 8.0 cm length by 6.0 cm width with no measurable depth. An interview with MD #1113 at the time of the observation revealed the wound was currently showing improvement. The MD did not provide any additional information as to how or why the pressure ulcer developed. Interview 09/28/23 at 9:47 A.M. with Resident #14 revealed the MD #1113 talked to him about needing to go to the hospital for his foot, but stated he never mentioned it might need to be amputated. Resident #14 said he did agree to go to the hospital, but never did because the wound started to get better. Interview with the Administrator on 09/28/23 at 10 45 A.M. revealed a wound culture and or/antibiotic was not ordered when the odor was first identified on 09/05/23 or anytime thereafter. Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated December 2022, revealed the facility would implement nutritional supplements as needed to aid in wound healing. Review of the policy titled Prevention of Pressures/Injuries, dated September 2023, revealed the facility would evaluate, document, and report potential changes in skin conditions. This deficient practice represents non-compliance investigated under Complaint Numbers OH00146813 and OH00146472. 365828 Page 30 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, and facility policy review the facility failed to ensure timely colostomy care was provided. This affected one resident (#14) of one resident observed for colostomy. The facility identified two residents (#10 and #14) with colostomies. The facility census was 98. Findings include: Review of Resident #14's medical record revealed an admission date of 11/05/22 with diagnoses including peripheral vascular disease, type two diabetes, and paraplegia. Review of the annual, Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated he was alert and oriented with intact cognition. Review of the MDS assessment revealed Resident #14 had a colostomy for bowel elimination and required one-person physical total dependence for managing the colostomy. Review of the care plan dated 09/07/23 revealed Resident #14 had potential for bowel and/or bladder elimination complications related to colostomy. Interventions included ostomy site would remain clean and patent, clean stoma site and change dressing per orders, and provide necessary supplies and equipment for self-care if desired. Review of the current physician orders dated 08/30/23 revealed an order to provide colostomy care every shift and as needed for stoma care and change colostomy bag as needed for colostomy care. Interview on 09/18/23 at 10:29 A.M. with Resident #14 revealed he had a colostomy, and it was not emptied and changed regularly. Resident #14 stated the facility would run out of colostomy supplies and it would take two to three days before they arrived. Resident #14 stated staff would put tape on old colostomy to keep it in place. Resident #14 stated the lack of supplies would keep him from getting out of bed due to not wanting it to burst on his clothes. Resident #14 stated his bag needed to be emptied and changed. Observation on 09/18/23 at 10:30 A.M. of Resident #14 colostomy revealed a full colostomy bag with old tape attached to skin. Observation revealed a foul odor, dried dark brown material and stains covering the tape and area around the stoma site. Interview and observation on 09/18/23 at 10:34 A.M. with Licensed Practical Nurse (LPN) #1120 revealed Resident #14 colostomy looked bad and was old. LPN #1120 revealed Resident #14 colostomy bag needed to be changed and she could not state when the last time it was changed. LPN #1120 verified the above findings during the observation. Interview on 09/20/23 at 8:03 A.M. with State Tested Nurse Assistant (STNA) #1193 revealed ostomy supplies were kept on the treatment carts or the medication carts and the facility sometimes ran out of supplies. STNA #1193 revealed, if supplies were available, staff would burp the bag if it was not damaged or replace it as needed. Interview on 09/20/23 at 8:21 A.M. with STNA #1174 revealed she helped with ostomy care; however, 365828 Page 31 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0691 the facility ran out of supplies all the time. Level of Harm - Minimal harm or potential for actual harm Interview on 09/20/23 at 9:26 A.M. with the Director of Nursing (DON) revealed all supplies were housed in the central supply room and put on appropriate units as needed. Residents Affected - Few Tour of the central supply room and interview on 09/20/23 at 9:40 A.M. with Medical Supply Staff (MSS) #1166 revealed no colostomy supplies housed in the central supply room. MSS #1166 revealed she kept the colostomy supplies in her personal office. MSS #1166 revealed she had two boxes of 10-count colostomy pouches kept in her office. Observation on 09/20/23 at 9:45 A.M. of MSS #1166 personal office revealed two boxes of 10-count colostomy pouches. Interview on 09/21/23 at 11:02 A.M. with MSS #1166 revealed staff did not have access to her office after she left for the day, except for the Administrator. MSS #1166 revealed she typically left for the day between 4:00 P.M. and 5:00 P.M. and staff were expected to gather supplies needed prior to her leaving the building. Interview on 09/21/23 at 11:15 A.M. with the Administrator revealed she typically left the building at 5:00 P.M. Review of the facility document titled Ostomy Care- Colostomy, Urostomy, and Ileostomy, revised 10/01/22, revealed the facility had a policy in place to ensure that residents who required colostomy services received care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences. Review of the document revealed the facility did not implement the policy. This deficiency represents non-compliance investigated under Master Complaint Number OH00146903. 365828 Page 32 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #50. This affected one resident (#50) of one resident reviewed for dialysis. The facility census was 98. Residents Affected - Few Findings include: Review of the medical record for Resident #50 revealed an admission date of 10/19/22 with diagnoses including diabetes mellitus with kidney complication, adult failure to thrive, paranoid schizophrenia, dependence on renal dialysis, and end stage renal disease. Review of the physician's orders dated 08/08/23 revealed an order for dialysis communication tool under the assessment tab in the electronic medical record to be completed and printed to send to dialysis with Resident #50 every Tuesday, Thursday, and Saturday for dialysis assessment. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #50 revealed she was on dialysis treatments. Review of Resident #50's care plan dated 10/19/22 revealed she is at risk for potential complications related to diagnosis of renal failure/end stage renal disease requiring renal dialysis treatment. Interventions included communicating with dialysis center staff regarding plan of care, lab values, diet, and fluid restrictions recommendations, etc. Nurse to utilize dialysis communication form for pre-dialysis assessment including obtaining vital signs. Review of dialysis communication tool forms for Resident #50 from 08/01/23 to 09/23/23 revealed dialysis communications forms for 08/01/23, 08/03/23, 08/05/23, 08/10/23, 08/12/,23, 09/02/23, 09/07/23, 09/12/23, 09/14/23, 09/16/23, and 09/21/23 were not found. Interview on 09/25/23 at 3:54 P.M. with the Administrator confirmed the facility did not have further evidence of dialysis communication forms for the identified missing dates to review. Review of the facility policy titled Dialysis, Pre and Post Care, revised 06/2021, revealed the facility will assist resident in maintaining homeostasis pre and post renal dialysis; assess and maintain patency of renal dialysis access and assess resident daily for function related to renal dialysis and coordinate resident care with dialysis staff. Staff will provide dialysis staff with the following information prior to dialysis; resident demographics, allergies, code status, admission history, medical history, dialysis access type any additional IV access, critical labs, most recent labs, isolation status and level of assist. Staff will assess care given and condition of renal dialysis access following dialysis and document receipt of dialysis run sheet and assessment findings in the medical record. 365828 Page 33 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, self-reported incident (SRI) review, and facility policy review the facility failed to implement interventions to attain or maintain a resident's highest practicable psychosocial well-being. This affected one resident (#73) of four residents reviewed for behaviors. The facility census was 98. Findings include: 1. Resident #81 was admitted to the facility on [DATE] with diagnoses including depression, bipolar disorder, psychotic disorder with delusions, and schizophrenia. The resident resides on the facility's secured unit. Review of the comprehensive admission minimum data set (MDS), dated [DATE], revealed Resident #81 was moderately cognitively impaired, exhibited no behaviors during the assessment period, and was non-ambulatory. Review of Resident #81's care plans revealed he was at risk for altered cognitive function related to schizophrenia and would have alterations in behavior leading to abusive attacks on staff and residents. Review of the nursing progress note dated 08/12/23 at 3:00 A.M. revealed Resident #81 returned from a local Emergency Department (ED) with no new orders. At 3:05 A.M. Registered Nurse (RN) #1113 notified the resident's physician had been sent to the ED for evaluation of facial injuries sustained during a resident-to-resident altercation. 2.Resident #73 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease, bipolar disorder, depression, and anxiety. The resident resided on the facility's secured unit. Review of the comprehensive quarterly MDS assessment dated [DATE] revealed Resident #73 was moderately cognitively impaired, wandered several days during the assessment period, and was independently ambulatory. Review of the care plans revealed Resident #73 had newly implemented plans, dated 09/25/23, regarding impaired cognitive function, impaired thought processes, wandering, and behavior problems. Review of the nursing progress note dated 08/12/23 revealed Resident #73 assaulted Resident #81 at approximately 11:30 P.M. on 08/11/23. Resident #73 was very aggressive, and the agency nurse called 911 but they never arrived at the facility. The resident continued to walk into other resident's rooms and threatened to hit the staff. Continued review of the nursing progress notes revealed the resident's behaviors continued to increase including his wandering and aggressiveness. Resident #73 was transferred to the ED on 08/22/23 due to increased agitation and aggression. After being evaluated the resident returned to the facility with no new orders. On 09/26/23 Resident #73 had an initial evaluation by the facility psychiatrist for his increased aggression, combativeness, and wandering. Review of the facility's SRI #238031, dated 08/12/23, revealed Resident #73 hit Resident #81 in the 365828 Page 34 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few face after Resident #81 told Resident #73 to stay out of his room. Resident #73 had been having increased behaviors in the previous several months, was wandering in and out of other resident's room, and was difficult to redirect. Resident #81 requested to be sent to the ED for evaluation and returned with no new orders. The police were notified while at the ED and interviewed Resident #81 who declined to file charges. When the facility attempted to talk to Resident #73 about the incident, the resident did not want to discuss the incident/did not remember the incident. The facility obtained witness statements, did skin checks on all the residents on the unit. Resident #73's room was changed to the opposite end of the unit as an intervention to prevent further abuse. All staff were educated on abuse. The facility unsubstantiated the allegation of abuse as as no abuse per definition has occurred with alleged incident. Interview with Social Services Director (SSD) #1164 on 09/25/23 at 10:50 A.M. confirmed Resident #73 has not been seen by the facility's psychiatrist. The resident's primary physician is the one who orders his psychotropic medication (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system to treat mental health issues). SSD #1164 confirmed the resident's behaviors had been escalating over the last few months. He was referred to a contracted mental health services company approximately three months ago, but they never assessed him until a few days ago as there was a mix up with the referral. The company uses nonpharmacological interventions for treatment. SSD #1164 confirmed she did not follow up with the contracted mental health services company regarding the referral to determine if the assessment had been completed. Interview with the Administrator on 09/25/23 at 5:00 P.M. revealed not all residents need to be followed by a psychiatrist. Review of the facility's Abuse, Neglect, and Exploitation, last revised 10/01/22, revealed the definition of abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's policy revealed to prevent abuse, neglect, and exploitation requires ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. 365828 Page 35 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of pain medication for Resident #80. This affected one resident (#80) of five residents reviewed for unnecessary medication use. The facility census was 98. Residents Affected - Few Findings include: Review of the medical record for Resident #80 revealed and admission date of 05/31/23. Diagnoses included diabetes, hypertension, depression, anxiety, and heart failure. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #80 was moderately cognitively impaired. She required supervision and set up help for bed mobility, transfers, dressing, eating, toilet use, and hygiene. She had trouble falling and staying asleep, she felt down and depressed, had little interest in doing things, had trouble concentrating and displayed no behavior. Review of the physician's orders for September 2023 revealed Resident #80 was ordered Percocet (opioid pain medication) 5-325 milligram (mg) tablet every six hours as needed (prn) for pain and Acetaminophen (analgesic) 325 mg two tablets every six hours prn for pain. Review of the Medication Administration Record (MAR) for September 2023 revealed Resident #80 received Percocet 5-325 mg for a pain level of zero on a one to ten scale with ten being the worst, two times on 09/02/23, a pain level of seven once on 09/02/23, a pain level of three once on 09/03/23, a pain level of ten once on 09/05/23, a pain level of eight once on 09/08/23, a pain level of three once on 09/09/23 and a pain level of ten once on 09/09/23, a pain level of three two times on 09/10/23, a pain level of five on once on 09/11/23, a pain level of eight two times on 09/12/23, a pain level of four one time on 09/13/23, a pain level of ten two times on 09/15/23, a pain level of three once on 09/16/23 and a pain level of ten once on 09/16/23 and a pain level of two once on 09/17/23. The resident received Acetaminophen 325mg for a pain level of ten on 09/15/23 and 09/16/23. Review of the progress notes for September 2023 revealed non-pharmacological interventions were attempted prior to Percocet administration once on 09/02/23, 09/03/23, 09/08/23, 09/09/23, 09/10/23, once on 09/12/23 and once on 09/15/23. There was no evidence non-pharmacological interventions were attempted prior to Acetaminophen administration on 09/15/23 and 09/16/23. Interview on 09/20/23 at 1:31 P.M. with Licensed Practical Nurse (LPN) #1133 revealed if non-pharmacological interventions were attempted, they would be documented in progress notes. She revealed she would use her nursing judgment to determine whether to administer Acetaminophen or Percocet. If the resident reported a pain level from one to four, she would administer Acetaminophen, if a pain level of five through ten was reported she would administer Percocet. Interview on 09/20/23 at 2:53 P.M. with the Director of Nursing (DON) confirmed the physician's order did not specify when to administer Acetaminophen versus Percocet. She revealed if nonpharmacological interventions were attempted, they would be documented in the progress notes. She also revealed she would use her judgment to determine whether to administer Acetaminophen or Percocet. Generally, if a resident reported a pain level of five or higher, she would administer Percocet. Review of the facility policy titled Pain Management, dated 08/22/22, revealed non-pharmacological 365828 Page 36 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0757 interventions would be attempted prior to administering pain medicine, and lower doses of medication would be attempted prior to administering stronger doses. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365828 Page 37 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, facility policy review, and facility invoices, the facility failed to serve hot and palatable foods. This had the potential to affect all residents. The facility identified 97 of 98 residents that received food from the kitchen. Resident #5 was identified as receiving no food by mouth. The facility census was 98. Residents Affected - Many Findings include: Interview with Resident #14 on 09/18/23 at 10:29 A.M. revealed the facility's food was horrible. Interview with Resident #44 on 09/18/23 at 10:41 A.M. revealed the facility's food was nasty and cold. Interview with Resident #343 on 09/18/23 at 10:49 A.M. revealed the facility's food was poor and not much to it with taste. During tray line service on 09/18/23 beginning at 11:45 A.M., the kitchen was noted to be without an insulated base and covers for plates while plating the second-floor unit. Observation revealed State Tested Nurse (STNA) #1146 was measuring out cling wrap and placing it over each lunch meal plate. Interview on 09/18/23 at the time of the observation of the plating of the lunch meal, Food Service Supervisor (FSS) #1145, revealed there were multiple trays that did not have insulated tops and/or bottoms due to not having any available for use. FSS #1145 revealed the facility ordered insulated tops and bottoms a few weeks ago and were waiting for delivery. FSS #1145 revealed there were 28 plates that would be served without insulated tops and bottoms and effected whether the meals would stay warm. Demonstration of the test tray with FSS #1145 on 09/18/23 at 1:30 P.M. revealed the tray consisted of baked pasta with Italian sausage (noodles with sliced Italian sausage), salad, and a slice of bread. The baked pasta with Italian sausage was noted to be barely warm with little seasoning and measured a temperature of 109 degrees Fahrenheit, the salad was made fresh to order, and the slice of bread was room temperature. FSS #1145 verified the findings of the test tray at the time of observation. Review of the facility document titled WebstaurantStore Sales Invoice revealed the facility placed an order for 48 cranberry insulated meal delivery bases and 48 insulated dome plate covers. Further review of the document revealed the facility did not place an order for the insulated plate bases and covers until day of the annual survey, 09/18/23. Review of the facility document titled Monitoring Food Temperatures for Meal Service, dated 2020, revealed the facility had a policy in place to ensure foods were served at palatable temperatures. Further review of the policy revealed hot foods were to be at 120 degrees Fahrenheit or greater to promote palatability for the residents. Review of the document revealed the facility did not implement the policy. 365828 Page 38 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview the facility failed to ensure foods were stored in a matter to prevent contamination. This had the potential to affect all residents. The facility identified 97 of 98 residents that received food from the kitchen. Resident #5 was identified as receiving no food by mouth. The facility census was 98. Findings include: During the initial kitchen tour on 09/18/23 between 8:30 A.M. and 9:00 A.M. the following was observed: • On 09/18/23 at 8:30 A.M. the ice machine was observed to be open with ice exposed to air and the door was broken and placed on top of the ice machine. • During the tour of the kitchen there were piles of oatmeal spilled at the entryway to the kitchen with other food, dirt, and various spills throughout the kitchen. The trashcan located near the handwashing station adjacent to the kitchen office space, was full and overflowing, the garbage dumpster was open and full of trash spilling out, and multiple small flying bugs were observed throughout the kitchen. • During the tour Dietary Aide (DA) #1137 was observed to be without hair covering. In the dry pantry area, the following was observed: • A container holding white flour with the scoop inside. • An open bag of macaroni noodles • An open package of tortillas • An open container of ground black pepper and Montreal chicken seasonings • 365828 Page 39 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0812 An open bag of powdered sugar Level of Harm - Minimal harm or potential for actual harm • An open can of thick and easy thickener Residents Affected - Many In the walk-in cooler the following was observed: • A bag of salad undated and open to air • A container of orange liquid drink uncovered. • A container of yellow liquid drink uncovered. • A bag of Monterey jack cheese undated and open to air • A block of American cheese slices undated • A package of lunch meat undated Dietary Aide (DA) #1137 verified the above findings at the time of the observations. Observation and Interview on 09/18/23 between 9:15 A.M. and 9:45 A.M. during the second tour of the kitchen, State Tested Nurse Assistant (STNA) #1200 was observed entering the kitchen without hair covering. STNA #1200 revealed she did not know how to put a hairnet on. Food Service Supervisor (FSS) #1145, during second tour of the kitchen, confirmed and verified the ice machine door was broken, STNA #1200 was without her hair covering, and multiple small flying bugs and/or insects identified as gnats/fruit flies were observed. 365828 Page 40 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, personnel file review, job description review, interview, review of a facility Legionella water management plan documentation, review of Centers for Disease Control and Prevention (CDC) guidance, review of facility self-reported incidents (SRI), and review of the Occupational Safety and Health Standards (OSHA) standards for safe oxygen storage the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Tthe facility failed to prevent an in-house acquired pressure ulcer for Resident #14. Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, the area declined to a Stage IV pressure ulcer with odor noted with recommendation for hospitalization and possible amputation. In addition, the facility failed to fully implement a complete water management program to prevent the growth of Legionella bacteria. In addition, the facility failed to maintain standard infection control protocols regarding isolation precautions. This had the potential to affect all 98 residents residing in the facility. The facility failed to timely notify the physician and dietitian of Resident #294's continued refusal of daily weights, failed to ensure care plans were updated and accurate for seven residents (Residents #7, #14, #35, #73, #80, #244 and #294), failed to develop care plans for Residents # 68, #73, and #82 regarding psychotropic meds and behaviors, failed to adequately monitor Resident #90 after a significant change in condition, failed to serve hot and palatable foods and failed to ensure food was stored in a manner to prevent contamination for all residents except Resident #5 who received nothing by mouth, the facility failed to ensure their environment was maintained in a clean and sanitary manner affecting Resident #4, #14, #18, #23, #33, #46, #68, #76, and #77, the facility failed to ensure kitchen and resident rooms were free from pests potentially affecting all residents, the facility failed to prevent resident-to-resident abuse affecting Resident #81, the facility failed eliminate risk hazards when a staff member pushing a dietary cart ran into Resident #90 causing the resident to fall out of her wheelchair, the facility failed to ensure oxygen tanks were stored and secured in a safe manner. This had the potential to affect all 98 residents residing in the facility. Residents Affected - Many Findings include: During the annual and complaint surveys, observations, record reviews and interviews resulted in concerns including but not limited to treatment of pressure ulcers resulting in harm, infection control, care planning, environmental concerns, water management, physician and dietitian notification, monitoring residents after a significant change in condition, palatable foods, food storage, pest control, resident-to-resident abuse, risk hazards, oxygen storage. 1. A situation resulting in Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, the area declined to a Stage IV pressure ulcer with odor noted with recommendation for hospitalization and possible amputation. Review of a dietary progress note dated 08/09/23 revealed Registered Dietitian (RD) #1111 was notified of the left heel wound and made recommendations for a multivitamin, Vitamin C 500 milligrams (mg) twice per day (BID) for 30 days, Zinc Sulfate 365828 Page 41 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0835 Level of Harm - Minimal harm or potential for actual harm 220 mg every day (QD) for 14 days and liquid protein 30 milliliters (ml) QD for 30 days to promote wound healing. Record review revealed as of 08/22/23 there was no evidence RD #1111's recommendations (dated 08/09/23) had been implemented. Interview with the Administrator on 09/28/23 at 10 45 A.M. revealed a wound culture and or/antibiotic was not ordered when the odor was first identified on 09/05/23 or anytime thereafter. Residents Affected - Many 2. Upon entry to the facility, it was discovered nine residents had tested positive for COVID 19 in the last two to three days. Within an hour of our arrival to the facility, five more residents were reported as testing positive for COVID 19. During observations, it was determined staff did not practice appropriate infection control procedures while caring for COVID 19 positive residents as evidenced by staff entering and exiting both COVID 19 positive and negative rooms without the appropriate personal protective equipment (PPE), and not clearly identifying rooms with COVID part 19 positive residents. In addition, the facility did not provide influenza vaccine information and education to all residents. 3. Review of the physician's orders revealed Resident #294 had an order dated 09/05/23 for daily weights related to a diagnosis of congestive heart failure. Interview on 09/20/23 at 1:19 P.M. with Licensed Practical Nurse (LPN) #1133 confirmed daily weights were not recorded in the paper chart for Resident #294. Review of the nursing progress notes from 09/05/23 to 09/21/23 revealed no documented evidence of physician and dietitian notification of the refusals of daily weights and no documented evidence of education provided to Resident #294 of the importance of daily weights for monitoring his diagnosis of congestive heart failure. Interview on 09/25/23 at 12:19 P.M. with the DON confirmed she did not have further documented evidence of physician and/or dietitian notification or resident education for Resident #294's refusals of daily weights. 4. Care plans were not updated and inaccurate for seven residents (Residents #7, #14, #35, #73, #80, #244 and #294). Interview on 09/21/23 at 1:35 PM with the Administrator revealed she was aware there were issues with documentation in the facility, however the facility had taken no actions to correct the concern. 5. The facility failed to develop care plans for Residents # 68, #73, and #82 regarding psychotropic meds and behaviors. 6. The facility failed to adequately monitor Resident #90 after a significant change in condition. Review of the nursing note dated 08/18/23 at 8:24 P.M. revealed staff notified the nurse that Resident #90 had medium emesis and appeared to be in respiratory distress. Upon entering the resident's room, the nurse observed emesis on the bed and floor. The emesis was pink tinged and had chunks of food in it. Resident #90 was sitting on the side of the bed breathing rapidly but was not using accessory muscles. Her blood pressure was 153/79, pulse 109, temperature 97.9 degrees Fahrenheit (F), respirations 22, and oxygen saturation (SpO2) was 78 percent (%) on room air. Staff immediately administered oxygen via nasal canula and her SpO2 increased to 82%. Assessment of abdomen completed without abnormal findings. No signs and symptoms of discomfort were observed. Call placed to the on call Optum Certified Nurse Practitioner (CNP). New orders were obtained to place resident on ten liters (10 L) of oxygen via a non-rebreather mask. Administer Zofran (antiemetic) 8 milligrams (mg) by mouth times one dose. Obtain full set of vital signs every four hours for twenty-four hours and notify Optum of a heart rate greater than 110 beats per minute, systolic blood pressure less than 100, and SpO2 less than 92%. All orders implemented. SpO2 was noted at 96% on 10 L oxygen via mask. Resident #90's Power of Attorney (POA) was notified of the situation and plan of action. All concerns were addressed at this time. Resident #90's Power of Attorney (POA) also gave verbal consent to send the resident 365828 Page 42 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many to the emergency room (ER) if health status declined any further. Shortly after, Optum nurse called this to nurse back check health status and was informed Resident #90 was improving and SpO2 was noted at 100%. New orders were obtained for STAT (immediate) two view chest x-ray to rule out pneumonia and STAT complete blood count (CBC) w/differential and complete metabolic panel (CMP). Staff currently awaiting arrival. CNP also ordered staff to remove masks and place the resident on six liters of oxygen via nasal cannula. SpO2 at 97%. No further concerns to report at this time. Staff will continue to monitor for further decline. Review of the medical record revealed no further documented evidence of assessment of Resident #90 until a nursing note dated 08/19/23 at 10:44 A.M. authored by Licensed Practical Nurse (LPN) #1109 revealed when the CNP #1108 called the facility and spoke to this nurse regarding the resident's overall status. This nurse stated that Resident #90 was in stable condition with a temperature of 97.6 degrees F, blood pressure of 119/64, pulse of 108, respirations 18, and SpO2 of 90% on room air. Lungs were clear to auscultation. Resident #90 consumed all her breakfast without incident. No nausea or vomiting, and the lab came to the facility for STAT orders, and the chest x-ray was complete now pending results. CNP #1108 then ordered Augmentin 875 mg (antibiotic) by mouth twice daily for seven days, oxygen on two liters to keep SpO2 above 92%, and consult speech therapy for Monday (08/21/23). Resident #90's daughter was updated. Review of the nursing note dated 08/19/23 at 12:37 P.M. stated this writer went in to continue re-assessments of Resident #90 and the resident was observed with no visible breathing. This nurse assessment revealed the resident to be absent of all vital signs. Resident #90 absent of blood pressure, pulse, temperature below 98.6 degrees F, no palpable carotid pulse, unable to auscultate apical pulse absence of breathing one full minute. Resident #90 was noted to have oxygen via nasal cannula in proper placement. Additional shift nurse in room to verify resident was absent of all vital signs. Resident #90 was noted to be clean and dry, appearing to be resting in bed with the head of the elevated upon entering the room. No change in resident's skin tone at this time of assessment. Emergency Medical Services (EMS) was contacted and noted Resident #90 to be asystole (no heartbeat) on EKG monitoring and absent of all other vital signs. EMS pronounced Resident #90 dead at 12:17 P.M. The CNP was contacted to inform of Resident #90's expiration. The family was contacted and informed of need to come immediately to the facility. Postmortem care provided by nursing staff for family viewing, the DON and Administrator were informed of Resident #90's expiration. Interview with the DON on 09/21/23 1:35 P.M. revealed she had no idea why the nurses did not assess Resident #90's vital signs every four hours as ordered by the CNP on 08/18/23. 7. The facility failed to serve hot and palatable foods and failed to ensure food was stored in a manner to prevent contamination for all residents except Resident #5. 8. The facility failed to ensure their environment was maintained in a clean and sanitary manner affecting Resident #4, #14, #18, #23, #33, #46, #68, #76, and #77 and the facility failed to ensure kitchen and resident rooms were free from pests potentially affecting all residents. 9. Review of the facility's SRI #238031, dated 08/12/23, revealed Resident #73 hit Resident #81 in the face after Resident #81 told Resident #73 to stay out of his room. Resident #73 had been having increased behaviors in the previous several months, was wandering in and out of other resident's room, and was difficult to redirect. Resident #81 requested to be sent to the ED for evaluation and returned with no new orders. The police were notified while at the ED and interviewed Resident #81 who declined to file charges. When the facility attempted to talk to Resident #73 about the incident, the resident did not want to discuss the incident/did not remember the incident. The facility obtained witness statements, did skin checks on all the residents on the unit. Resident #73's room was changed to the opposite end of the unit as an intervention to prevent further abuse. All staff were educated on abuse. The 365828 Page 43 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many facility unsubstantiated the allegation of abuse as as no abuse per definition has occurred with alleged incident. 10. Review of the nursing note dated 08/17/23 at 11:30 A.M. revealed Resident #90 was sitting in close proximity to the nurse's station when dietary staff member was transporting the breakfast cart and Resident #90 began to ambulate via wheelchair in the path of the cart and fell out of the chair. Resident #90 was assessed for injury, and an abrasion was observed to her right knee. Vital signs were assessed: temperature of 98 degrees Fahrenheit (F), pulse 91, respirations 18, blood pressure 147/82, and oxygen saturation (SpO2) 100 percent (%) on room air. 11. Observation of the oxygen storage area on 09/19/23 at 9:40 A.M. revealed the facilities oxygen storage was located inside a fenced area on the back dock with a no smoking sign on the wall behind it. The area revealed large amounts of combustible leaves mixed with cigarette butts underneath and around the 22 oxygen tanks stored in the fenced area. Review of the Administrator's personnel file revealed a hire date of 08/22/22. Review of undated facility Job Description for the Administrator revealed she was responsible for the direct the day-to-day functions of the facility in accordance with federal, state, and local standards, guidelines. The description revealed the Administrator was delegated the administrative authority, responsibility, and accountability necessary for carrying out the assigned duties including clinical and administrative activities of the facility. This deficiency represents non-compliance investigated under Complaint Number OH00146813. 365828 Page 44 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 98 residents in the facility. Findings include: Review of the PBJ report for Fiscal Year (FY) Quarter 2 (January 1, 2023 through March 31, 2023) revealed the facility triggered failing to submit data for the quarter and one-star staffing rating as identified areas of concerns. Interview on 09/20/23 at 12:04 P.M. with the Administrator and Facility Owner (FO) #5500 revealed FO #5500 was responsible for the submission of data to CMS regarding the PBJ. Interview revealed PBJ staffing information for FY Quarter 2 was never reported. Interview revealed FO #5500 submitted staffing information for the PBJ to CMS on 08/14/23 for FY Quarter 3. Review of the facility document titled CMS Submission Report PBJ Final File Validation Report dated 08/14/23 revealed the facility submitted PBJ staffing information for FY Quarter 3 and was unable to produce any other required documentation regarding the PBJ for FY Quarter 2. 365828 Page 45 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

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** 2. Entrance to the facility on [DATE] at 8:00 A.M. revealed no signage indicating Covid-19 was present in the facility. Residents Affected - Many Upon entrance to the facility on [DATE] at 8:00 A.M. the facility identified 14 residents (#296, #83, #4, #68, #64, #19, #39, #33, #40, #20, #29, #74, #62, and #80) who had tested positive for Covid-19 since 09/14/23. The first two residents who tested positive were Residents #296 and #83. The facility placed all residents who were positive on one wing except for two residents (Residents #68 and #64) who refused to change rooms. Observation of the Covid-19 unit on 09/18/23 beginning at 12:35 P.M. revealed no signage was located on the doors to the unit advising visitors there were Covid-19 residents residing on the unit. State Tested Nursing Assistant (STNA) #1176 was passing lunch trays to the residents residing on the Covid-19 unit. At 12:59 P.M. STNA #1176, wearing a surgical mask, entered Covid-19 positive Residents #19 and #29's room to deliver lunch trays. STNA #1176 was not wearing Personal Protective Equipment (PPE) of a protective disposable gown, an N95 mask, or goggles. STNA #1176 confirmed upon exiting the room, she did not wear the required PPE equipment for Covid-19 and since the whole unit was positive for Covid she did not need to wear PPE if she was just passing lunch trays. No cart with isolation supplies were located outside of the residents' room nor was there signage instructing visitors to contact the nurse before entering or what PPE were required to enter the room. STNA #1176 re-entered the residents' room after putting on PPE of a gown and gloves but did not don an N95 mask. After exiting the room, STNA #1176 was still wearing the soiled PPE gown and gloves then proceeded to enter Resident #20's room who was also Covid-19 positive. No hand sanitizer was used prior to entering the resident's room. Upon exiting Resident #20's room, STNA #1176 confirmed she was not wearing an N95 mask and that she had not removed the soiled PPE she was wearing upon entering the room. STNA #1176 then removed the soiled PPE and donned an N95 mask, re-entered Resident #20's to deliver the lunch tray, exited the room wearing the soiled PPE, picked up the lunch tray for Resident #62 and entered the resident's room without changing PPE. Assistant Director of Nursing (ADON) #1109 entered the Covid-19 unit and confirmed STNA #1176 should be wearing an N95 mask. At 1:11 P.M. STNA # 1176 exited the room of Residents #40, #83, and #296 who were also positive for Covid-19. STNA #1176 did not remove her PPE prior to exiting the room but removed it in the hallway and placed it in the soiled waste bin located outside of the room. No hand sanitization occurred. STNA #1176 then opened the top drawer of the isolation supply cart looking for hand sanitizer. After being unable to locate any, she went to another isolation cart on the hall and found hand sanitizer there and sanitized. At 1:22 P.M. STNA #1176 removed the food cart from the Covid-19 wing and pushed it out to the nurses' station located outside the Covid-19 wing. The cart contained used glasses, cups, silverware, and napkins. STNA #1176 left the doors to the Covid-19 unit propped open. STNA #1176 confirmed she did not realize the used trays were contaminated and returned the food cart to the Covid-19 wing then closed the doors to the unit. Interview with the Administrator on 09/18/23 at 3:16 P.M. revealed a letter was provided to all residents on 09/14/23 that residents had tested positive for Covid-19, and a letter was mailed out to all the responsible parties the same day as well. Interview with the Director of Nursing (DON) on 09/18/23 at 3:17 P.M. revealed Residents #84, #295, #56, #292, and #293 resided on the Covid-19 unit tested negative but refused to change rooms so were left on the Covid-19 wing. Resident #4, who also tested positive for Covid-19, left the facility against medical advice on 09/16/23. 365828 Page 46 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview with the Administrator on 09/19/23 at 4:10 P.M. revealed Resident #85 tested positive today for Covid-19. She was not tested when all the other residents were due to being on a leave of absence and just returned today. Observation of the Covid-19 unit on 09/20/23 at 9:50 A.M. revealed a sign was present on the doors to the wing instructing visitors to see the nurse before entering. No PPE was located for visitors to put on prior to entering the unit. Interview with the family of Resident #295 on 09/20/23 at 10:05 A.M. revealed their brother was admitted to the facility recently after being discharged from the hospital for rehabilitation. The family said he was admitted to the hospital with Covid-19, but isolation precautions had ended prior to his transfer to the facility. Their brother was also being treated for cancer. They did not find out his room was on the Covid-19 unit until an agency nurse informed them two days ago. The family stated they would never have approved of his being on the Covid-19 unit if they had known. The family confirmed none of them had received notification of the facility having Covid-19 positive residents. Interview with Assistant Director of Nursing (ADON) #1109 on 09/21/23 at 9:12 A.M. revealed the last in-service regarding infection control standards was completed on 09/18/23. The last in-service prior to that was held on 08/20/23. Review of the facility's Management of Coronavirus COVID-19 policy, last revised 05/31/23, revealed clear signage should limit entrance and provide directions to visitors of Covid-19 positive residents. Dedicated staff should be assigned to the Covid-19 unit. Documentation for Covid-19 residents is to include any change of condition, interventions implemented, type of precautions, and the date and time precautions were discontinued. This deficiency represents non-compliance investigated under Master Complaint Number OH00146903. Based on observation, record review, facility policy review, review of a facility Legionella water management plan documentation, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to fully implement a complete water management program to prevent the growth of Legionella bacteria. In addition, the facility failed to maintain standard infection control protocols regarding isolation precautions. This had the potential to affect all 98 residents residing in the facility. Findings include: 1. Interview on 09/25/23 at 9:29 A.M. with the Administrator confirmed she did not have documented evidence of facility Legionella testing for 2022. Review of the facility policy titled Legionella Surveillance and Detection, revised July 2017, revealed Legionnaire's disease will be included as part of our infection surveillance activities. Review of the facility policy titled Infection Control/Water Systems, revised 03/23, revealed the facility will conduct routine water temperatures checks, conduct additional temperatures with any water service interruptions, chemical testing when necessary, maintain open communications with the city officials in order to be aware of any water alerts from the city and if there a suspected case of Legionnaires' disease but lacked any specific information about how the facility would intervene when control measures were not met, failed to address ongoing monitoring of the plan's effectiveness, 365828 Page 47 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and revealed no documentation of preventative measures or testing of the water system besides temperature monitoring to maintain the water system free of Legionella bacteria. Review of the CDC webpage revealed guidance under the title of, Overview of Water Management Programs, and revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Such programs are now an industry standard for many buildings in the United States. Further review of the webpage under the subsection titled, Key Elements, revealed there were seven key elements of a Legionella water management program which included to establish a water management program team, describe the building water systems using text and flow diagrams Burden of Waterborne Disease, identify areas where Legionella could grow and spread, decide where control measures should be applied and how to monitor them, establish ways to intervene when control limits are not met, make sure the program is running as designed (verification) and is effective (validation), and document and communicate all the activities. 365828 Page 48 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and facility policy review the facility failed to obtain signed consents or declinations and evidence of education for influenza vaccinations for Residents #40 and #62. This affected two residents (#40 and #62) of six residents reviewed for immunizations. Residents Affected - Some Findings include: 1.Review of the medical record or Resident #40 revealed an admission dated 12/04/18 with diagnoses including dementia, diabetes mellitus, morbid obesity, and schizophrenia. Review of Resident #40's medical record under the immunization tab revealed influenza consent was refused but no date was listed. Review from 09/01/22 to 03/31/22 of nursing progress notes or under the miscellaneous tab did not reveal any documented evidence of influenza immunization being offered or education being provided for the influenza vaccine. 2. Review of the medical record for Resident #62 revealed an admission date of 01/24/20 with diagnoses including unspecified protein-calorie malnutrition, atrial fibrillation, peripheral vascular disease, and acquired absence of right leg above knee. Review of Resident #62's medical record revealed a 12/28/22 progress note stating Resident #62 declined the influenza vaccine despite education, but no signed documentation was found. Interview on 09/21/23 at 9:54 A.M. with the Director of Nursing (DON) confirmed she was unable to provide written documentation for the influenza vaccination for Residents #40 and #62. Review of the facility policy titled Influenza Vaccination, revised 03/01/22, revealed influenza vaccinations will be routinely offered annually from October 1st through March 31st unless medically contraindicated, the individual has already been immunized or refuses to receive the vaccine. The resident's medical record will include documentation that the resident and/or the representative was provided education regarding the benefits and potential side effects of immunization and that the resident received or did not receive the immunization due to medical contraindication or refusal. Individuals receiving the influenza vaccination, or their legal representative will be required to sign a consent form prior to the administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record. This deficiency represents non-complaince investigated under Master Complaint Number OH00146903. 365828 Page 49 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview, and facility floor plan review the facility failed to ensure its environment was maintained in a clean and sanitary manner. This affected 9 residents (#4, #14, #18, #23, #33, #46, #68, #76, and #77) with the potential to affect all residents. The facility census was 98. Findings include: Observation during the initial kitchen tour on 09/18/23 between 8:30 A.M. and 9:00 A.M. with Dietary Aide (DA) #1137 of the designated outside area for the garbage dumpsters (loading dock) revealed two signs attached to the building reading No Smoking. Observation revealed a black square rug, adjacent to the on and off ramp, with approximately 13 cigarette ends and multiple new and old crumbled leaves on top of the rug. Interview during tour with DA #1137 revealed the area was not a designated smoking area; however, staff used the area to smoke often. DA #1137 verified the above findings at the time of the tour. Observation and verification on 09/18/23 at 1:13 P.M. with Maintenance Director (MD) #1159 of Residents #4, #23, and #46 room revealed a ceiling vent exposed and hanging from the ceiling. Observation and verification on 09/19/23 at 9:42 A.M. with MD #1159 of Residents #76 and #77 room, revealed blue wall paint bubbled up and peeling below and all around the air conditioning unit on the wall near the window. The wall adjacent to the air conditioning unit also had white paint bubbled up and peeling with various cracks and scrapes. Observations and verification on 09/19/23 at 10:15 A.M. with Facility Owner (FO) #5500 revealed the heating vents located outside of Residents #14, #18, #33, and #68 rooms and inside of Residents #4, #46 and #23 rooms were uncovered with the heat registers exposed with significant dust, grime, dirt buildup, and rust. Interview on 09/20/23 at 8:03 A.M. with State Tested Nurse Assistant (STNA) #1193 revealed residents had designated smoking areas and staff were to smoke in their cars. STNA #1193 revealed the outside areas near the garbage dumpsters and loading dock was not a designated smoking area. Review of the facility floor plans revealed the designated outside area for the garbage dumpsters (loading dock) was not a designated smoking area. This deficiency represents non-compliance investigated under Master Complaint Number OH00146903 and Complaint Number OH00146813. 365828 Page 50 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, record review, and facility invoices, the facility failed to ensure the facility, including the kitchen and resident rooms, was free from pests (ants, flies, and gnats/fruit flies). This affected the kitchen and three residents' rooms (#4, #23, and #46). The facility census was 98. Residents Affected - Few Findings include: During the initial kitchen tour on 09/18/23 between 8:30 A.M. and 9:00 A.M. approximately two to three flies and seven to eight gnats/fruit flies were noted swirling around the trashcan, food serving and preparation areas. During the second tour of the kitchen between 9:15 A.M. and 9:45 A.M., Food Service Supervisor (FSS) #1145 confirmed and verified the existence of the flies and gnats/fruit flies. FSS #1145 revealed that the facility utilized extermination services but could not confirm the date of the last visit and treatment. Observation on 09/18/23 at 10:20 A.M. of Residents #4, #23, and #46 room, revealed approximately 23 small ants crawling on the floor near the entrance to the room. Interview on 09/18/23 at 10:23 A.M. with State Tested Nurse Assistant (STNA) #1176 verified the ants crawling on the floor near the entrance of the room. STNA #1176 revealed she had not seen any treatments for pests. Interview on 09/18/23 at 10:25 A.M. with Housekeeper (HKP) #1151 verified the ants. HKP #1151 revealed she attempted to clean resident rooms and common areas clean throughout the day but revealed she had not cleaned Residents #4, #23, and #46 room at the time of the observation. Review of the facility invoice documentation titled High Rock Pest Control, dated May, June, July, August, and September of 2023, revealed the facility utilized pest control services that provided general treatment to the facility including the kitchen, dining rooms, and common areas, however, was determined ineffective at the time of the observations. This deficiency represents non-compliance investigated under Complaint Number OH00146813. 365828 Page 51 of 52 365828 09/28/2023 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, facility policy review, and review of the Occupational Safety and Health Standards (OSHA) standards for safe oxygen storage the facility failed to ensure oxygen tanks were stored and secured in a safe manner. This had the potential to affect all 98 residents in the facility. Residents Affected - Many Findings include: Observation of the oxygen storage area on 09/19/23 at 9:40 A.M. revealed the facilities oxygen storage was located inside a fenced area on the back dock with a no smoking sign on the wall behind it. The area revealed large amounts of combustible leaves mixed with cigarette butts underneath and around the 22 oxygen tanks stored in the fenced area. Interview on 09/19/23 at 9:40 A.M. with Director of Maintenance #1150 confirmed the observation and revealed staff were not to smoke near the area. Review of the facility policy titled Resident Smoking Policy, dated June 2018, revealed oxygen tanks were prohibited in smoking areas. Review of the OSHA standards for safe oxygen storage, amended 03/07/1996, revealed the bulk oxygen storage location shall be permanently placarded to indicate: OXYGEN - NO SMOKING - NO OPEN FLAMES, or an equivalent warning. Long dry grass shall be cut back within 15 feet of any bulk oxygen storage container. 365828 Page 52 of 52