Health inspection·January 26, 2024

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, self-reported incident (SRI) review, and facility policy review the facility failed to follow their abuse policy regarding reporting allegations of abuse timely and thoroughly investigate all allegations of abuse. This affected three residents (#20, #48 and #50) of four residents reviewed for abuse. The facility census was 104. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #20 revealed admission date of 01/07/22. Diagnoses Included quadriplegia, dysfunctional bladder, depression, history of falling, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. She displayed no behaviors, hallucinations, or delusions. She used her walker to ambulate and required setup help for eating and oral hygiene. She required substantial or maximum assistance for upper body dressing and was dependent for toileting, showering or bathing, lower body dressing, and hygiene. Review of the facility SRI tracking number 242461 dated 12/26/23 and timed 2:00 P.M. revealed an incident occurred on 12/25/23 at 5:00 A.M. in which Resident #20 told State Tested Nursing Assistant (STNA) #220 that STNA #219 entered her room without knocking, waking both the resident and her roommate. The resident stated STNA #219 slammed her door when she left. Later that shift STNA #219 went to the resident's room, said something to her and slammed the door. STNA #219 was suspended pending investigation. Witness statements were not obtained by all parties working at the time of the incident. The investigation concluded STNA #219 had been rude and used profanity with Resident #20, resulting in STNA #219 being terminated. 2. Review of the medical record for Resident #48 revealed an admission date of 08/05/23. Diagnoses included epilepsy, asthma, repeated falls, anemia, and hyperlipidemia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 was rarely or never understood. She had no behaviors, hallucinations, or delusions and used a walker to ambulate. She required setup help for eating, oral hygiene, toileting, upper and lower body dressing, was dependent with showering and bathing and required maximum assistance for hygiene. Review of the facility SRI tracking number 242389 dated 12/22/23 and timed 1:07 P.M. revealed Resident #48 reported when she had a seizure earlier in the week and fell, a nurse came into her room, kicked her in the head and told her to get up while two nurses sat back and laughed. The resident had a seizure on 12/19/23 and fell in the hallway. She was sent to the hospital for her evaluation and Page 1 of 16 365879 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few returned the same day orders for medication changes. The SRI reported the resident had no injuries and had her helmet on for protection. The resident also slipped and fell from her wheelchair on 12/16/23 with no injuries noted. The resident could not identify who kicked her in the head. Initially she said it was a male and then said it was a female she reported the nurse kicked her in her head while she was in her room but both falls were in the hallway. There was no evidence an assessment was completed, or witness statements had been obtained from staff. 3. Review of the medical record for Resident #50 revealed an admission date of 10/05/22. Diagnoses included schizoaffective disorder, diabetes, chronic obstructive pulmonary disease (COPD), anxiety, and altered mental status. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #50 was cognitively intact. She displayed no psychosis, behaviors, or delusions. She required setup help for eating, supervision with oral care, toileting, showering, and hygiene. Review of the facility SRI tracking number 242443 dated 12/26/23 and timed 7:21 AM revealed Resident #50 stated two STNA's beat her up the prior day. The nurse assessed the resident and found no injuries. The resident named one of the STNA's but did not name the other. STNA #222 reported the resident was upset about not having cigarettes and started yelling, cursing and threw her walker in the hallway. Both STNA #222 and STNA #205 escorted the resident back to her room. The investigation revealed the incident 12/25/23 around 5:30 PM. An assessment was not completed until 12/25/23 at 11:30 PM. Witness statements were not obtained by all staff working at the time of the incident. The investigation revealed the incident occurred on 12/25/23 around 5:30 PM. Review of the camera footage revealed staff approached the resident appropriately after she threw her walker and walked her to her room in an appropriate manner. Interview on 01/24/24 at 11:23 A.M. with STNA #205 revealed she was working at the time of the incident. She revealed Resident #50 was upset because she did not have any cigarettes. She asked the resident to go to her room to calm down, but the resident asked to call the police and threw her walker down the hallway. STNA #205 and STNA #222 escorted the resident to her room. She confirmed Licensed Practical Nurse (LPN) #215 was on the unit at the time of the incident. Interview with the Director of Nursing (DON) on 01/24/23 at 9:12 A.M. revealed she had no additional information in relation to the investigations for Resident's #20, #48, and #50. Interview on 01/25/24 at 11:06 A.M. with Regional Director (RD) #204 confirmed the investigations were not thorough and were not reported to the Ohio Department of Health (ODH) within two hours as required. Review of the facility policy titled Abuse, Mistreatment, Neglect Exploitation and Misappropriation of Resident Property, dated October 2022, revealed a nurse would perform an initial assessment of the resident to include range of motion, full body assessment for signs of injury, and vital signs. The investigation would include an interview with the resident, the accused, and all witnesses. Witnesses would include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident and employees who worked closely with the accused employee and/or victims the day of the incident. If there were no direct witnesses, interviews would be conducted with employees on the shift or the unit as well as other residents, and all allegations of abuse must be reported immediately to the administrator or designee. Any form of alleged abuse would be reported by the administrator or designee to ODH immediately but no later than two hours after the allegation is 365879 Page 2 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0607 made. Level of Harm - Minimal harm or potential for actual harm This deficiency represents noncompliance investigated under Master Complaint Number OH00150162 and Complaint Number OH00149748. Residents Affected - Few 365879 Page 3 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

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 review, and facility policy review the facility failed to report allegations of abuse to the state agency in a timely manner. This affected two residents (#20 and #50) of four residents reviewed for abuse. The facility census was 104. Findings include: 1. Review of the medical record for Resident #20 revealed admission date of 01/07/22. Diagnoses Included quadriplegia, dysfunctional bladder, depression, history of falling, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. She displayed no behaviors, hallucinations, or delusions. She used her walker to ambulate and required setup help for eating and oral hygiene. She required substantial or maximum assistance for upper body dressing and was dependent for toileting, showering or bathing, lower body dressing, and hygiene. Review of the facility SRI tracking number 242461 dated 12/26/23 and timed 2:00 P.M. revealed an incident occurred on 12/25/23 at 5:00 A.M. in which Resident #20 told State Tested Nursing Assistant (STNA) #220 that STNA #219 entered her room without knocking, waking both the resident and her roommate. The resident stated STNA #219 slammed her door when she left. Later that shift STNA #219 went to the resident's room, said something to her and slammed the door. STNA #219 was suspended pending investigation. Witness statements were not obtained by all parties working at the time of the incident. The investigation concluded STNA #219 had been rude and used profanity with Resident #20, resulting in STNA #219 being terminated. 2. Review of the medical record for Resident #50 revealed an admission date of 10/05/22. Diagnoses included schizoaffective disorder, diabetes, chronic obstructive pulmonary disease (COPD), anxiety, and altered mental status. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #50 was cognitively intact. She displayed no psychosis, behaviors, or delusions. She required setup help for eating, supervision with oral care, toileting, showering, and hygiene. Review of the facility SRI tracking number 242443 dated 12/26/23 and timed 7:21 AM revealed Resident #50 stated two STNA's beat her up the prior day. The nurse assessed the resident and found no injuries. The resident named one of the STNA's but did not name the other. STNA #222 reported the resident was upset about not having cigarettes and started yelling, cursing and threw her walker in the hallway. Both STNA #222 and STNA #205 escorted the resident back to her room. The investigation revealed the incident 12/25/23 around 5:30 PM. An assessment was not completed until 12/25/23 at 11:30 PM. Witness statements were not obtained by all staff working at the time of the incident. The investigation revealed the incident occurred on 12/25/23 around 5:30 PM. Review of the camera footage revealed staff approached the resident appropriately after she threw her walker and walked her to her room in an appropriate manner. Interview on 1/25/24 at 11:06 AM with Regional Director (RD) #204 confirmed the investigations were not reported to the Ohio Department of Health (ODH) within two hours as required. 365879 Page 4 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy titled Abuse, Mistreatment, Neglect Exploitation and Misappropriation of Resident Property, dated October 2022, all allegations of abuse must be reported immediately to the administrator or designee. Any form of alleged abuse would be reported by the administrator or designee to ODH immediately but no later than two hours after the allegation is made. This deficiency represents noncompliance investigated under Master Complaint Number OH00150162 and Complaint Number OH00149748. 365879 Page 5 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

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, self-reported incident review, and facility policy review the facility failed to ensure allegations of abuse were thoroughly investigated. This affected three residents (#20, #48, and #50) of four residents reviewed for abuse. The facility census was 104. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #20 revealed admission date of 01/07/22. Diagnoses Included quadriplegia, dysfunctional bladder, depression, history of falling, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. She displayed no behaviors, hallucinations, or delusions. She used her walker to ambulate and required setup help for eating and oral hygiene. She required substantial or maximum assistance for upper body dressing and was dependent for toileting, showering or bathing, lower body dressing, and hygiene. Review of the facility SRI tracking number 242461 dated 12/26/23 and timed 2:00 P.M. revealed an incident occurred on 12/25/23 at 5:00 A.M. in which Resident #20 told State Tested Nursing Assistant (STNA) #220 that STNA #219 entered her room without knocking, waking both the resident and her roommate. The resident stated STNA #219 slammed her door when she left. Later that shift STNA #219 went to the resident's room, said something to her and slammed the door. STNA #219 was suspended pending investigation. Witness statements were not obtained by all parties working at the time of the incident. The investigation concluded STNA #219 had been rude and used profanity with Resident #20, resulting in STNA #219 being terminated. Review of the medical record for Resident #48 revealed an admission date of 08/05/23. Diagnoses included epilepsy, asthma, repeated falls, anemia, and hyperlipidemia. 2. Review of the medical record for Resident #48 revealed an admission date of 08/05/23. Diagnoses included epilepsy, asthma, repeated falls, anemia, and hyperlipidemia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 was rarely or never understood. She had no behaviors, hallucinations, or delusions and used a walker to ambulate. She required setup help for eating, oral hygiene, toileting, upper and lower body dressing, was dependent with showering and bathing and required maximum assistance for hygiene. Review of the facility SRI tracking number 242389 dated 12/22/23 and timed 1:07 P.M. revealed Resident #48 reported when she had a seizure earlier in the week and fell, a nurse came into her room, kicked her in the head and told her to get up while two nurses sat back and laughed. The resident had a seizure on 12/19/23 and fell in the hallway. She was sent to the hospital for her evaluation and returned the same day orders for medication changes. The SRI reported the resident had no injuries and had her helmet on for protection. The resident also slipped and fell from her wheelchair on 12/16/23 with no injuries noted. The resident could not identify who kicked her in the head. Initially she said it was a male and then said it was a female she reported the nurse kicked her in her head while she was in her room but both falls were in the hallway. There was no evidence an assessment was completed, or witness statements had been obtained from staff. 365879 Page 6 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of the medical record for Resident #50 revealed an admission date of 10/05/22. Diagnoses included schizoaffective disorder, diabetes, chronic obstructive pulmonary disease (COPD), anxiety, and altered mental status. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #50 was cognitively intact. She displayed no psychosis, behaviors, or delusions. She required setup help for eating, supervision with oral care, toileting, showering, and hygiene. Review of the facility SRI tracking number 242443 dated 12/26/23 and timed 7:21 AM revealed Resident #50 stated two STNA's beat her up the prior day. The nurse assessed the resident and found no injuries. The resident named one of the STNA's but did not name the other. STNA #222 reported the resident was upset about not having cigarettes and started yelling, cursing and threw her walker in the hallway. Both STNA #222 and STNA #205 escorted the resident back to her room. The investigation revealed the incident 12/25/23 around 5:30 PM. An assessment was not completed until 12/25/23 at 11:30 PM. Witness statements were not obtained by all staff working at the time of the incident. The investigation revealed the incident occurred on 12/25/23 around 5:30 PM. Review of the camera footage revealed staff approached the resident appropriately after she threw her walker and walked her to her room in an appropriate manner. Interview on 01/24/24 at 11:23 A.M. with STNA #205 revealed she was working at the time of the incident. She revealed Resident #50 was upset because she did not have any cigarettes. She asked the resident to go to her room to calm down, but the resident asked to call the police and threw her walker down the hallway. STNA #205 and STNA #222 escorted the resident to her room. She confirmed Licensed Practical Nurse (LPN) #215 was on the unit at the time of the incident. Interview with the Director of Nursing (DON) on 01/24/23 at 9:12 A.M. revealed she had no additional information in relation to the investigations for Resident's #20, #48, and #50. Interview on 01/25/24 at 11:06 A.M. with Regional Director (RD) #204 confirmed the investigations were not thorough and were not reported to the Ohio Department of Health (ODH) within two hours as required. Review of the facility policy titled Abuse, Mistreatment, Neglect Exploitation and Misappropriation of Resident Property, dated October 2022, revealed a nurse would perform an initial assessment of the resident to include range of motion, full body assessment for signs of injury and vital signs. The investigation would include an interview with the resident, the accused, and all witnesses. Witnesses would include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident and employees who worked closely with the accused employee and/or victims the day of the incident. If there were no direct witnesses, interviews would be conducted with employees on the shift or the unit as well as other residents. This deficiency represents noncompliance investigated under Master Complaint Number OH00150162 and Complaint Number OH00149748. 365879 Page 7 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review, interview, and facility policy review the facility failed to ensure care plans were updated annually and as needed. This affected one resident (#43) of ten residents reviewed for accurate care plans. The facility census was 104. Findings include: Review of the medical record for Resident #43 revealed an admission date of 11/03/16. Diagnoses included schizoaffective disorder, vascular dementia, unspecified convulsions, and cataracts. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was rarely or never understood. He required substantial or maximum assistance for toileting, hygiene, and lower body dressing, partial assistance for upper body dressing, and supervision for eating. Review of the physician's orders for January 2023 revealed orders for Depakote sprinkles 125 milligrams (mg) by mouth (PO) two times per day (BID) for seizures beginning on 08/12/21, Melatonin tablet 6 mg PO at bedtime (HS) beginning 12/05/21, Medroxyprogesterone 10 mg PO BID for sexual behaviors beginning 02/10/22, monitoring for pain every shift beginning 06/14/22, and physical therapy services three to five times a week for 30 days beginning 01/04/24. Review of the resident's care plan history revealed care plans dated 6/21/21 and 01/15/24. Interview on 11/24/24 at 3:37 P.M. with the Director of Nursing (DON) confirmed prior to 01/15/24, the residents care plan had not been updated since 06/21/21. Review of the facility policy titled Care Plan Policy, dated October 2022, revealed the care plan would be updated as needed, within seven days of the time the change is identified or ordered and be reviewed and updated by the team routinely and as indicated by significant changes in status, medications, care, treatment, resident preferences and goals. This deficiency is an incidental finding discovered during the complaint investigation. 365879 Page 8 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 falls were thoroughly investigated and failed to ensure safe smoking practices. This affected five residents (#43, #48, #58, #60, and #80) of seven residents reviewed for accidents. The facility census was 104. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 11/03/16. Diagnoses included schizoaffective disorder, vascular dementia, unspecified convulsions, and cataracts. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was rarely or never understood. He required substantial or maximum assistance for toileting, hygiene, and lower body dressing, partial assistance for upper body dressing, and supervision for eating. Review of the fall risk assessment dated [DATE] revealed Resident #43 was at high risk for falls. Review of the care plan dated 06/24/21 revealed Resident #43 was at risk for falls due to dementia, medication usage, and unsteadiness on feet. Interventions included ensuring the call light was in reach, ensuring the appropriate footwear was in use during ambulation, supplying the appropriate equipment as needed, and reviewing past falls in an attempt to determine a cause. Review of the physician's orders for January 2023 revealed an order for a perimeter mattress to the edge of the bed at all times and encouraging the resident to wear nonskid socks or slippers when out of bed. Review of the fall investigation dated 11/30/23 at 11:11 A.M. revealed Resident #43 was standing in the hallway holding on to the rail when he started walking, took two steps and lost his balance. He fell backwards and hit his head on the wall. Neurological checks were initiated, and vital signs were obtained. The resident's guardian and the physician were notified. No witness statements were obtained from staff working at the time of the incident, and no review of past falls to determine a root cause. The residents electronic medical record had no documented evidence a fall occurred on 11/30/23. 2. Review of the medical record for Resident #48 revealed an admission date of 08/05/23. Diagnoses included epilepsy, asthma, repeated falls, anemia, and hyperlipidemia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 was rarely or never understood. She had no behaviors, hallucinations, or delusions and used a walker and wheelchair to ambulate. She required setup help for eating, oral hygiene, toileting, upper and lower body dressing was dependent per showering and bathing and required maximum assistance for hygiene. She had one fall with no injury and one with a major injury since the prior assessment. Review of the fall risk assessment dated [DATE] revealed Resident #48 was at moderate risk for falls. 365879 Page 9 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the care plan dated 11/27/23 revealed Resident #48 was at risk for falls due to a history of falling, seizure medication, noncompliance, and declining to use her wheelchair. Interventions included a dump seat to her wheelchair, formatting her mattress to her bed, a soft helmet at all times, and physical and occupational therapy evaluations as needed. Review of the fall investigation dated 12/29/23 at 9:07 A.M. revealed Resident #48 was in the hallway near the elevator standing next to her wheelchair, walking, and stumbling to get back to her chair. She lost her balance and fell to the ground landing on her buttocks. The resident was educated on the importance of staying in her wheelchair for safety reasons. The resident did have her safety helmet on at the time. There were no witness statements from staff working at the time of the incident. Interview with the Director of Nursing (DON) on 1/24/23 at 9:12 A.M. revealed she had no additional information in relation to the investigations into Resident's #43 and #48. Interview on 1/25/24 at 11:06 AM with Regional Director (RD) #204 confirmed the investigations for Residents #43 and #48 were not thorough. Review of the facility policy titled Fall Policy, dated April 2021, revealed the facility would assure proper review of resident falls and implementations of interventions to attempt to prevent falls. 3. Review of the medical record for Resident #58 revealed an admission date of 09/30/22. Diagnoses included schizophrenia, depression, pre-diabetes, and anxiety. Review of the care plan dated 01/03/24 revealed Resident #58 chose to smoke. Interventions included smoking in designated areas, assessing for safety awareness, monitoring for compliance with the smoking policy and providing education regarding smoking. Review of the smoking safety screen dated 01/02/24 revealed Resident #58 was safe to smoke with supervision. 4. Review of the medical record for Resident #60 revealed an admission date of 01/12/22. Diagnoses included schizophrenia, depression, hypertension, anxiety, and arthritis. Review of the care plan dated 12/01/23 revealed Resident #60 chose to smoke. Interventions included smoking and designated areas, assessing for safety awareness and supervision while smoking. Review of the smoking safety screen dated 12/14/23 revealed Resident #60 was safe to smoke with supervision. 5. Review of the medical record for Resident #80 revealed and admission date of 01/09/23. Diagnoses included schizoaffective disorder, bipolar disorder, asthma, nicotine dependence, and anxiety. Review of the care plan dated 12/14/23 23 revealed Resident #80 chose to smoke. Interventions included smoking and designated areas, assessing for safety awareness, and supervision while smoking. Review of the smoking safety screen dated 10/11/23 revealed Resident #80 was safe to smoke with supervision. 365879 Page 10 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Minimal harm or potential for actual harm Observation on 01/25/24 at 9:24 A.M. revealed Resident's #58, #60 and #80 were smoking in the smoking room, unsupervised. Interview on 01/25/24 at 9:26 A.M. with Licensed Practical Nurse (LPN) #215 revealed staff should be in the smoke room with residents at all times when they are smoking. Residents Affected - Some Interview with the DON on 01/25/24 at 9:28 A.M. confirmed staff needed to be in the room or standing at the window where they could see residents while they were smoking. Interview on 01/25/24 at 9:30 A.M. with state tested nurse's aide (STNA) #216 confirmed he was aware residents could not be unsupervised while in the smoke room. He confirmed he was not watching Residents #58, #60 and #80 while smoking. Review of the facility policy titled Safety of Resident 07/01/18, revealed residents would smoke in designated areas during supervised and scheduled times. This deficiency represents noncompliance investigated under Master Complaint Number and Complaint Number OH00150140. 365879 Page 11 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. 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 notify the physician of a radiology report for Resident #48 in a timely manner. This affected one resident (#48) of three residents reviewed for notification. The facility census was 104. Residents Affected - Few Findings include: Review of the medical record for Resident #48 revealed an admission date of 08/05/23. Diagnoses included epilepsy, asthma, repeated falls, anemia, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was rarely or never understood. She had no behaviors, hallucinations, or delusions and used a walker and wheelchair to ambulate. She required setup help for eating, oral hygiene, toileting, upper and lower body dressing, was dependent for showering and bathing, and required maximum assistance for hygiene. She had one fall with no injury and one with a major injury since the prior assessment. Review of the fall risk assessment dated [DATE] revealed Resident #48 was at a moderate risk for falls. Review of the care plan dated 11/27/23 revealed Resident #48 was at risk for falls due to a history of falling, seizure medication noncompliance and declining to use her wheelchair. Interventions included a dump seat to her wheelchair, formatting her mattress to her bed, a soft helmet at all times, and physical and occupational therapy evaluations as needed. Review of the fall investigation dated 12/29/23 at 9:07 A.M. revealed Resident #48 was in the hallway near the elevator standing next to her wheelchair, walking and stumbling to get back to her chair. She lost her balance and fell to the ground landing on her buttocks. The resident was educated on the importance of staying in her wheelchair for safety reasons. The resident did have her safety helmet on at the time. There were witness statements from staff working at the time of the incident. Review of the nursing progress note dated 12/29/23 at 12:00 P.M. revealed Resident #48 was in the hallway at the nurse's station standing up while her wheelchair was on the side of her. The nurse asked the resident to sit down, and she stopped her, falling to the floor. Her vital signs were obtained, and neurological checks initiated. Her power of attorney and the nurse practitioner were notified. Review of the nursing progress note dated 12/29/23 at 4:26 P.M. revealed the nurse practitioner ordered an x-ray, the nurse at the x-ray company was notified, and the order was placed in the electronic medical record. Review of the medical record revealed an x-ray of the residents' elbow and shoulder were completed 12/30/23 at 11:13 A.M. Review of the nursing progress note dated 01/02/24 at 8:45 A.M. revealed the results of the x-ray were reported to the nurse practitioner, five days after the x-ray was order. The resident had a new order for a sling due to a fracture to her right elbow, according to the nurse practitioner. 365879 Page 12 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0777 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/24/23 at 9:44 A.M. with the Director of Nursing (DON) revealed the x-ray was reviewed by the unit manager on 01/02/24 at 1:33 P.M. She confirmed the facility did not follow up once an x-ray had been obtained, the facility waited to receive the report from the x-ray company. Interview on 01/25/24 at 11:14 A.M. X-ray Employee #217 revealed once an image was obtained it went to the radiologists to be read. Once that was completed, the report was sent to the facility. In this case, the report was completed at 10:21 A.M. and emailed to five facility e-mail addresses at 10:22 A.M. on 12/31/23. They did not receive a response from the facility. Interview on 01/25/24 at 11:30 A.M. with Nurse Practitioner #218 revealed she was notified of the results of the x-ray results for Resident #48 on 01/02/23. Review of the facility policy titled Notification of Change in Condition, dated February 2022, revealed the facility would notify the physician and or resident/representative in a timely manner for a change in resident condition, including x-ray results. This deficiency represents noncompliance investigated under Complaint Number OH00150140. 365879 Page 13 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure medical records were accurate and complete. This affected two residents (#48 and #63) of ten residents reviewed for assessments. The facility census was 104. Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 08/05/23. Diagnoses included epilepsy, asthma, repeated falls, anemia, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was rarely or never understood. She had no behaviors, hallucinations, or delusion and used a walker and wheelchair to ambulate. She required setup help for eating, oral hygiene, toileting, upper and lower body dressing, was dependent for showering and bathing, and required maximum assistance for hygiene. Review of the care plan dated 11/27/23 revealed Resident #48 was at risk for falls due to history of falling, seizures, and medication noncompliance. Interventions included a head-to-toe assessment every shift. 2. Review of the medical record for Resident #63 revealed an admission date of 10/24/17. Diagnoses included asthma, prediabetes, schizoaffective disorder, anxiety, muscle weakness, urinary incontinence, and nicotine dependence. Review of the quarterly MDS assessment dated [DATE] revealed Resident #63 was cognitively intact. He required setup help for eating and oral hygiene, supervision for toileting, showering, upper and lower body dressing, and hygiene. Review of the care plan dated 09/27/23 revealed Resident #63 was at risk for falls due to a decline in mobility, incontinence, asthma, and psychotropic medication usage. Interventions included ensuring the call light was in reach, ensuring the resident was wearing appropriate footwear when ambulating, and a review of past falls in an attempt to determine the root cause of the fall. Review of the fall risk assessment dated [DATE] revealed Resident #63 was at low risk for falls. Review of the fall investigation dated 12/22/23 at 1:30 P.M. revealed Resident #63 was walking outside when he turned and lost his balance, falling on his right side. The resident was assessed for range of motion and skin conditions, neurological checks were initiated. Review of the progress note dated 12/22/23 at 2:52 P.M. revealed Resident #63 told the nurse he was outside and lost his balance as he was turning, falling on the right side of his body. He denied pain, range of motion was normal, his skin was intact, and neurological checks were started. The nurse practitioner and representative were notified of the event. Review of the facility provided document titled Cityview neurocheck worksheet revealed neuro checks for Resident #63 began on 12/22/23 at 1:30 P.M. and continued on every shift until 12/27/23 at 2:00 P.M. 365879 Page 14 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 12/23/23 at 2:36 P.M. revealed Resident #63 left for a leave of absence with his family. He was planning to return to the facility on [DATE]. He was not in the facility at the time the neurological checks were documented as completed. Review of the progress note dated 12/26/23 at 11:42 A.M. revealed Resident #63 was assessed and no injuries were found. Interview on 1/24/24 at 10:17 A.M. with the Director of Nursing (DON) revealed head to toe assessments would be documented in the electronic medical record (EMR) under the assessment tab. She confirmed there was no evidence head to toe assessments were completed each shift for Resident #48. Interview with the DON on 01/25/24 at 11:00 A.M. revealed she did not know who completed the neurological checks for Resident #63 as the document was unsigned. She could not explain how neurological checks were being done while the resident was on leave of absence. Review of the facility policy titled Documentation Guidelines: All Departments, dated December 2021, revealed documentation would reflect a true picture of the current services provided to the resident and would be complete prior to the end of the shift. Any changes in care and services would be reflected in the resident's care plan. This deficiency represents noncompliance investigated under Complaint Number OH00150140. 365879 Page 15 of 16 365879 01/26/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Many Based on observation, interview, and record review the facility failed to fix a broken basement door lock to maintain safe environment. This had the potential to affect all 104 residents living in the facility. Findings include: Observation of the double basement doors on 01/24/24 at 10:30 A.M. revealed the doors were situated at ground level near the loading dock and provided access to the dumpsters. Both doors were unlocked. The open doors had potential to grant outsiders access into the facility with access to an elevator that led to residential floors specifically the second and fourth floors without a necessary security code. Interview on 01/24/24 at 10:46 A.M. with the Administrator who verified the basement door was not locked, and a code was not needed to use the basement elevator to reach residential floors. The Administrator stated the door had been open with outside access since March 2023. The Administrator further revealed that in the last complaint survey done on 01/03/24, the facility was to have a contractor look at the lock and order a new part. The Administrator stated he ordered two Electromagnetic Door Lock Holding Force for Access Control and two brackets on 01/19/24 from Amazon. Observation on 01/24/24 at 1:50 P.M. verified the basement door leading to the loading dock was locked to prevent outsiders from entering. The deficient practice was corrected on 01/24/24 when the facility implemented the following corrective action: • On 01/19/24 the Administrator ordered two Electromagnetic Door Holding Force for Access Control locks and two brackets. • On 01/24/24 at 1:50 P.M. observation of the Electromagnetic Door Holding Force lock placed, and door was locked to prevent outside access. This deficiency represents noncompliance investigated under Complaint Number OH00150140. 365879 Page 16 of 16