Health inspection·March 19, 2024

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, self-reported incident (SRI) review and policy review, the facility failed to ensure Resident #28's allegation of misappropriation was reported within 24 hours to the State agency as required. This finding affected one resident (#28) of two residents reviewed for misappropriation. Findings include: Review of a Misappropriation SRI (tracking #245238) dated 03/15/24 indicated Resident #28 went to the activity director and reported Resident #80 had taken pills from his bag a few days ago. The investigation was ongoing. Review of Resident #28's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified fracture of the left femur, encounter for other orthopedic aftercare, and unspecified cirrhosis of the liver. Review of Resident #28's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #80's medical record revealed the resident was admitted on [DATE] with diagnoses including alcoholic cirrhosis of the liver without ascites, iron deficiency anemia, and major depressive disorder. Review of Resident #80's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Interview on 03/19/24 at 8:42 A.M. with Resident #28 revealed he had reported to Certified Occupational Therapy Assistant (COTA) #821 on 03/09/24 that Resident #80 had come into his room and took a bottle of suboxone (treats narcotic dependence) tablets (28 tablets) out of his personal belongings. He stated the resident returned the bottle with 13 tablets remaining and self-administered the other 15 tablets. Interview on 03/19/24 at 9:03 A.M. with Resident #80 revealed Resident #28 gave her the suboxone to self-administer. She would not answer further questions. Interview on 03/19/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed a Misappropriation SRI (tracking #245238) was filed on 03/15/24. Page 1 of 3 365845 365845 03/19/2024 Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Telephone interview on 03/19/24 at 9:24 A.M. with COTA #821 with Rehab Director #822 in attendance revealed Resident #28 reported that Resident #80 took a bottle of suboxone out of his personal belongings without his permission. She stated she immediately told the charge nurse and Rehab Director #822. Interview on 03/19/24 at 9:28 A.M. with Rehab Director #822 confirmed COTA #821 had reported to her on 03/09/24 at 3:56 P.M. that Resident #80 had reported misappropriation of suboxone tablets. Rehab Director #822 stated she immediately telephoned the DON to report the allegation. Interview on 03/19/24 at 9:37 A.M. with the Administrator indicated she filed Resident #28's SRI for misappropriation on 03/15/24 when the activity personnel reported it. She confirmed the allegation was reported on 03/09/24 and the SRI was not filed with the State agency within twenty-four hours as required. Review of the Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 04/21 indicated to investigate and report any allegations within timeframe's required by federal requirements. This deficiency represents non-compliance investigated under Complaint Number OH00152017. 365845 Page 2 of 3 365845 03/19/2024 Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #73's legionella testing was completed as ordered. This finding affected one resident (#73) of five resident records reviewed for infection control. Residents Affected - Few Findings include: Review of Resident #73's open medical record revealed the resident was admitted on [DATE] with diagnoses including chronic atrial fibrillation, malignant neoplasm of the prostate, and muscle weakness. Review of Resident #73's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #73's chest x-ray single view dated 02/22/24 revealed the cardiac silhouette and mediastinal contours were normal. Patchy densities were noted involving the bilateral perihilar regions. Mild prominence of the pulmonary vasculature was identified. No pleural fluid or masses were noted. No pneumothorax was present. Impression was bilateral perihilar atelectasis/infiltrate and a follow up was recommended to document resolution. Review of Resident #73's physician orders revealed an order dated 02/26/24 to obtain urine and sputum for legionella. Review of Resident #73's medical record did not reveal evidence the legionella urine antigen testing and legionella sputum testing were completed per the order dated 02/23/24 at 8:58 A.M. Interview on 03/13/24 at 11:55 A.M. with the Director of Nursing (DON) confirmed she could not find Resident #73's urine and sputum culture for legionella, and she reordered as of today's date. Review of the undated Risk Assessment and Water Management Plan for Reducing the Risk of Legionella Policy indicated if other patient's had been identified as positive for healthcare-associated Legionnaires' disease within the past 12 months, if pneumonia develops within 48 hours after admission or there have been notable changes in water quality identified, then residents who present with pneumonia will be tested for Legionnaires' disease according to the physician's order. This deficiency represents non-compliance investigated under Complaint Number OH00151945. 365845 Page 3 of 3