Health inspection·September 4, 2024

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility did not ensure the physician and/or nurse practitioner was notified of abnormal laboratory results for Resident #113. This affected one resident (#113) of three residents reviewed for physician notification of laboratory results. The facility census was 144. Findings include : Review of the medical record for Resident #113 revealed an admission date of 02/22/24. Diagnoses included intracranial hemorrhage, hyperparathyroidism, cocaine abuse, hypertension, chronic kidney disease stage four, and hemiplegia. Review of the Minimum Data Set ( MDS) 3.0 assessment dated [DATE] revealed cognition was intact and the resident needed substantial assistance to walk ten feet, transfer from the toilet, and transfer from bed to chair. Review of physician orders dated 07/17/24 revealed an order for CBC ( complete blood count) with differential, Comprehensive Metabolic Panel ( CMP) and magnesium to be drawn on 07/18/24 with special instructions of monitoring for chronic kidney disease. Review of the progress note dated 07/18/24 at 1:24 P.M. written by Licensed Practical Nurse (LPN) #527 revealed Resident #113 was compliant with blood draw. Review of the progress note dated 07/18/24 at 1:09 P.M. revealed the Nurse Practitioner (NP) had a follow up assessment for Resident #113 regarding hypertension and chronic kidney failure stage four. The NP noted there were no recent labs to review and to monitor labs as needed. Review of CMP specimen collected 07/18/24 final report revealed the following lab results: potassium 5.3 milliequivalent (meq) was within normal range ( 3.5 to 5.3 meq/liter), Blood [NAME] Nitrogen ( BUN) was 71 and high ( normal reference range was 7 to 25 milligrams/deciliter (mg/dl) and Creatinine 3.2 mg/dl was high ( normal reference range was 0.6 to 1.2 mg/dl) . Review of a progress note dated 07/18/24 at 4:58 P.M. written by Nursing Supervisor (NS) #700 revealed Resident #113's family was notified regarding recent labs that had been ordered and CNP had been in to assess. There was nothing in the progress note to indicate the ordering physician or NP had Page 1 of 4 365832 365832 09/04/2024 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0773 been notified of the results. Level of Harm - Minimal harm or potential for actual harm Review of a progress note dated 07/24/24 at 11:05 A.M. written by NA #700 revealed the NP was contacted regarding labs on 07/18/24 and the NP requested new labs to be done STAT (immediately) due to chronic kidney disease. Residents Affected - Few Review of STAT CMP dated 07/24/24 final report revealed SR #113's potassium was 5.8 meq/dl and high, BUN was 81 and high, and Creatinine was high at 3.6 mg/dl. Review of a progress note dated 07/24/24 at 6:49 P.M. written by LPN #565 revealed the lab results were reported to the NP and new orders for Lokelma was ordered and a new BMP in the morning. Resident #113 was placed on Normal Saline intravenously (IV) 100 milliliters per hour for one liter. The residents daughter was notified by LPN # 565. Interview on 08/28/24 at 12:40 P.M. with LPN #527 revealed she faxed the labs drawn on 07/18/24 to the NP on 07/18/24 but the fax did not reach the NP's office to review the labs. LPN #527 confirmed she did not document she faxed these labs to the NP to review and there was no evidence to show the NP ever received and reviewed those labs. LPN #527 verified abnormal labs were considered a change of condition and the NP should have been notified and addressed the abnormal labs. Interview on 08/28/24 at 1:00 P.M. with the Director of Nursing ( DON) revealed she reviewed labs every morning and if a lab was to be done it was the responsibility of the nurse supervisor to ensure the practitioner was notified at the end of each shift. The floor nurse supervisor received a facility document called Homework to review daily to ensure labs were not missed. The DON stated on 07/22/24 the DON questioned why there was no interventions for Resident #113's high BUN lab level from the lab draw on 07/18/24. After an audit was conducted, NS #700 revealed they did not ensure the NP was notified regarding the high BUN level from 07/18/24 labs. Review of the facility policy titled Change in Condition dated 06/27/24 revealed the licensed nurse would recognize and intervene in the event of a change in condition. The Provider would be notified as soon as possible. The deficient practice was corrected on 07/25/24 when the facility implemented the following corrective actions: • On 07/23/24 the facility identified that the lab work completed for Resident #113 on 07/18/24 was not reported to the Nurse Practitioner ( NP) . • On 07/24/24 the NP evaluated Resident #113 and ordered a STAT lab to be obtained and a STAT dose of Lokelma was administered and IV fluid was ordered after review of STAT labs. • On 07/24/24 the Director of Nursing (DON) completed audits of all current resident's medical records for validation of laboratory testing and results reported to the practitioner from the past thirty 365832 Page 2 of 4 365832 09/04/2024 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0773 days. All labs were found to have been reported to the practitioner. Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Few On 07/24/24 the DON educated all nursing staff in person or by phone related to immediate reporting of resident change in condition pertaining to laboratory results and timely follow up for physician orders. All education was completed by 07/25/24. • On 07/25/24 the specified nurse was placed on a Performance Improvement Plan regarding follow through with reporting of labs. • On 07/25/24 the facility conducted an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) Action Plan to review during the meeting. The Medical Director was in attendance by phone on 07/25/24. • Beginning 07/25/24 the facility implemented a plan for twice a week audits of laboratory testing documentation and reporting results to the physician. The audits will continue for four weeks then monthly times two months. Results of the audits would be submitted to the QAPI Committee for further review and recommendation. There were no further residents experiencing a change in condition related to laboratory results not reported to the physician or documented as such in the resident records from 07/25/24 to the date of this survey 09/04/24. This deficiency represents non-compliance investigated under Complaint Number OH00157080. 365832 Page 3 of 4 365832 09/04/2024 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and review of facility policy, the facility did not ensure garbage was properly disposed of to prevent the harborage pests. This had the potential to affect all 144 residents. The facility census was 144. Residents Affected - Many Findings include: Observation on 08/28/24 at 9:30 A.M. with Maintenance Director #539 revealed the three outside dumpsters near the facility kitchen doors did not have lids covering trash, a sour smell permeated around the dumpsters with wet boxes and leaf and twig debris piled up around the dumpsters. Maintenance Director #539 verified the findings on 08/28/24 at 9:30 A.M. and stated it was difficult to get behind the dumpsters to pick up the boxes and clean the area, and there should be lids to cover the trash. Interview with Exterminator #646 on 08/28/24 at 12:31 P.M. revealed garbage containment and sanitation was important to prevent and control pests. Review of the facility policy titled Pest Control dated 8/12/18 revealed routine pest control would be placed to prevent pest infiltration. Maintenance of the garbage storage area to prevent harboring and feeding of pests. Outside dumpsters doors and lids would be kept shut and secure. This deficiency represents noncompliance as an incidental finding during the investigation of Complaint Number OH00157080. 365832 Page 4 of 4