Health inspection·May 10, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure call lights were within reach and accessible for Residents #14, and #72. This affected two residents (#14 and #72) of 197 residents reviewed for call light placement. The facility census was 197. Residents Affected - Few Findings include: 1. Record review revealed Resident #14 was admitted on [DATE] to the facility with diagnoses that included but not limited to seizures, hemiplegia, epilepsy, and multiple fractures of the pelvis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired and required extensive assistance of two staff for mobility, transfer, and toilet. Observation on 05/07/23 at 11:45 A.M. revealed Resident #14 was lying in bed. Resident #14's call light was observed lying on nightstand and not within reach of resident. Resident # 14 stated that she was getting over pneumonia. At the time of observation, Licensed Practical Nurse (LPN) #626 verified call light was out of reach and that Resident #14 can utilize call light. Review of care plans dated 09/28/20 with a revision date of 07/05/22 revealed Resident #14 had a potential risk for falls related to impaired mobility. Interventions include but are not limited to making sure the resident's call light is within reach and encouraging the resident to use it for assistance as needed. 2. Record review revealed Resident #72 was admitted on [DATE] to the facility with diagnoses that included but not limited to heart failure, paranoid schizophrenia, dementia, and repeated falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 was cognitively intact and required extensive assistance of two staff for mobility, transfer, and toilet. Observation on 05/07/23 at 10:49 A.M. revealed Resident #72 was lying in bed. Resident #72's call light was observed lying on the floor and not within reach of the resident. At time of observation, State Tested Nurse Aide (STNA) #800 verified call light was out of reach and that Resident #72 can utilize call light. Review of care plans dated 01/31/19 with a revision date of 08/03/22 revealed Resident #14 had a potential risk for falls related to weakness and falls prior to admission. Interventions include but are not limited to a working and reachable call light. Page 1 of 10 365883 365883 05/10/2023 St Augustine Manor 7801 Detroit Ave Cleveland, OH 44102

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 observation, record review and interview, the facility failed to ensure wound care was completed as ordered. This finding affected one (Resident #143) of three residents reviewed for wounds. Residents Affected - Few Findings include: Review of Resident #143's medical record revealed she was readmitted on [DATE] with diagnoses including diabetes, difficulty in walking and chronic obstructive pulmonary disease. Review of Resident #143's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition. Review of Resident #143's physician orders revealed an order dated 02/20/23 to cleanse the left lower extremity skin tear with normal saline, pat dry, apply an adaptic (non stick dressing) followed by a foam dressing three times a week and as needed. The wound care was due every day shift on Monday, Wednesday and Friday. Review of Resident #143' treatment administration records (TARS) from 05/01/23 to 05/08/23 revealed the skin tear wound treatment was documented as completed on 05/05/23 on the TAR. Observation on 05/07/23 at 10:24 A.M. revealed the dressing on Resident #143's left shin skin tear was dated 05/03/23. Interview on 05/05/23 at 10:25 A.M. with Licensed Practical Nurse (LPN) #756 verified the skin tear dressing was not completed on 05/05/23 as ordered but it was documented as completed on the TAR. 365883 Page 2 of 10 365883 05/10/2023 St Augustine Manor 7801 Detroit Ave Cleveland, OH 44102

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #165's pressure relieving foam boots were implemented as ordered. This finding affected one (Resident #165) of two residents reviewed for pressure wounds. The facility census was 197. Residents Affected - Few Findings include: Review of Resident #165's medical record revealed he was admitted on [DATE] with diagnoses including muscle weakness, aphasia following a cerebral infarction and diabetes insipidus. Review of Resident #165's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited a memory problem. The medical record did not reveal current pressure ulcer wounds. Review of Resident #165's physician orders revealed an order dated 11/28/22 for pressure reduction boots to the bilateral feet as a preventative measure and check for placement. Review of Resident #165's Skin Care Plan indicated he was at risk for the development of skin breakdown and the intervention dated 11/29/22 indicated to apply pressure reduction boots to both feet as a preventative measure. Check placement every shift. Review of Resident #165's medication administration records (MARS) and treatment administration records (TARS) from 05/01/23 to 05/08/23 revealed the pressure reduction boots placement checks were scheduled twice daily from 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M. Observation on 05/07/23 at 10:17 A.M. revealed Resident #165 was lying in bed. His right foot was observed outside of the sheet and his foot was lying on the bed with no pillow in place. He did not have a pressure reduction boot on his right foot during the observation. Interview on 05/07/23 at 10:22 A.M. with Licensed Practical Nurse (LPN) #636 confirmed Resident #165's pressure reduction boots were not on his bilateral feet and he was lying in bed with both heels on the bed. She denied he had skin breakdown or pressure ulcers. Observation on 05/09/23 at 8:20 A.M. revealed Resident #165 was lying in bed and his bilateral heels were observed on the bed. He did not have pressure reduction boots in place. Interview on 05/09/23 at 8:24 A.M. with Assistant Director of Nursing (ADON) #634 confirmed Resident #165's bilateral pressure reduction boots were not implemented per the order. Review of the Prevention of Skin Breakdown policy revised 08/18 indicated the charge nurse would communicate with the caregivers related to appropriate prevention measures including, but not limited to turn and reposition orders, incontinence care, pressure reduction devices and input from nutrition. 365883 Page 3 of 10 365883 05/10/2023 St Augustine Manor 7801 Detroit Ave Cleveland, OH 44102

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review and interview, the facility failed to ensure Resident #193 was provided adequate supervision during care to prevent a fall. This finding affected one (Resident #193) of two residents reviewed for falls. The facility census was 197 Findings include: Review of Resident #193's medical record revealed he was admitted [DATE] and readmitted on [DATE] with diagnoses including post traumatic seizures, muscle weakness and aphasia. Review of Resident #193's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated he exhibited severe cognitive impairment and required extensive two person assist for bed mobility and toilet use. He required total dependence two person assist for transfers and total dependence one person assist for dressing and eating. Review of Resident #193's physician orders revealed an order dated 11/16/22 and discontinued 05/04/23 to transfer the resident with a Hoyer mechanical lift with the assistance of two staff members every shift. Review of Resident #193's Morse Fall Scale form dated 12/26/22 revealed the resident was high risk for falls. Review of Resident #193's Un-Witnessed Fall Investigation form dated 01/25/23 at 11:53 A.M. indicated the resident was observed sitting on the floor with his legs stretched out in front of him on the right side of the bed. The nurse observed the resident's bed in a raised position with a Hoyer pad on the bed. Review of Resident #193's progress note dated 01/25/23 at 3:32 P.M. authored by Registered Nurse (RN) Unit Manager #708 indicated at approximately 11:53 A.M., the nurse was informed the resident was on the floor. Upon entering the resident's room, the nurse observed the resident sitting on the floor, with his legs stretched out in front of him on the right side of the bed. Non-skid socks were on his bilateral feet. The nurse observed the resident's bed to be locked and in a raised position with a Hoyer pad on the bed. The State Tested Nurse Aide (STNA) indicated she provided the resident with personal care, placed a Hoyer pad underneath the resident and turned around to get assistance as well as the Hoyer mechanical lift when she heard a loud noise and observed the resident on the floor. Resident #193 was sent to the hospital and no apparent injuries were noted. Interview on 05/09/23 at 9:23 A.M. with RN Unit Manager #708 indicated the STNA told her that Resident #193 was on the floor. She assessed the resident with no apparent injuries. She confirmed his bed was in a high position. Interview on 05/09/23 at 9:41 A.M. with Rehab Director #797 indicated Resident #193 did not have an attention span and would try to jump out of the bed at any given moment. Telephone interview on 05/09/23 at 9:46 A.M. with STNA #900 stated she was providing personal care to Resident #193 with the bed in a high position and then left the room to get assistance with transferring the resident using a Hoyer mechanical lift. She indicated she was outside of the room when 365883 Page 4 of 10 365883 05/10/2023 St Augustine Manor 7801 Detroit Ave Cleveland, OH 44102

F 0689 she heard a crash and observed Resident #193 on the floor. She denied Resident #193 had any injuries. Level of Harm - Minimal harm or potential for actual harm Review of the Fall Management policy dated 11/16 indicated the facility would identify residents who were at risk for falls and would develop a Plan of Care and implement resident-specific interventions to manage falls and to try to keep the resident free from injury. Residents Affected - Few 365883 Page 5 of 10 365883 05/10/2023 St Augustine Manor 7801 Detroit Ave Cleveland, OH 44102

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). This finding affected two (Residents #75 and #125) of six residents observed for medication administration. A total of 26 medications were administered with two errors for a medication error rate of 7.69%. Residents Affected - Few Findings include: 1. Review of Resident #125's medical record revealed he was readmitted on [DATE] with diagnoses including type two diabetes, end stage renal disease and muscle weakness. Review of Resident #125's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition. Review of Resident #125's physician orders revealed an order dated 10/09/22 to administer lispro insulin (fast acting) if the blood sugar was zero to 149 administer then administer no units; 150 to 199 administer one unit; 200 to 249 administer two units, 250 to 299 administer three units, 300 to 349 administer five units, 350 to 399 administer seven units and if greater than 400 call the provider. Administer the insulin before meals for diabetes mellitus. Observation on 05/07/23 at 8:12 A.M. with Registered Nurse (RN) #737 of Resident #125's medication administration revealed eight medications were administered with one error. She checked his blood sugar using a glucometer blood glucose testing (BGT) machine with a result of 164. She stated she had to go to the medication storage room for the lispro insulin. Upon entering the resident's room, the breakfast tray was sitting on the bedside table and the meal was 100% consumed. Interview on 05/07/23 at 8:26 A.M. with RN #737 indicated she was unaware Resident #125's breakfast tray had arrived. She also confirmed she obtained the BGT after the breakfast meal was consumed and administered the insulin after the breakfast meal. She also indicated she did not administer Resident #78 or #71's insulin prior to the breakfast meal because she had been busy and she had yet to administer the insulin. She confirmed all meal trays had been delivered. 2. Review of Resident #75's medical record revealed he was admitted on [DATE] with diagnoses including unspecified dementia, muscle weakness and difficulty in walking. Review of Resident #75's MDS 3.0 assessment dated [DATE] revealed he exhibited a memory problem. Review of Resident #75's physician orders revealed an order dated 07/24/21 for cholecalciferol tablet (vitamin D3) administer 75 mcg (micrograms) by mouth one time a day for a deficiency (3000 units). Observation on 05/07/23 at 8:20 A.M. revealed Licensed Practical Nurse (LPN) #672 administered six medications to Resident #75 with one error. LPN #672 administered vitamin D3 1000 units (one tablet) and the order was for vitamin D3 3000 units (three tablets). Interview on 05/07/23 at 8:25 A.M. with LPN #672 confirmed she did not administer Resident #75's correct dosage of vitamin D3. A total of 26 medications were administered with two errors for a medication error rate of 7.69%. 365883 Page 6 of 10 365883 05/10/2023 St Augustine Manor 7801 Detroit Ave Cleveland, OH 44102

F 0759 Level of Harm - Minimal harm or potential for actual harm Review of the Medication Administration Times policy revised 10/14 indicated medication administration would be scheduled according to the resident's preference, past history and manufacturer's recommendations and physician orders. Residents Affected - Few 365883 Page 7 of 10 365883 05/10/2023 St Augustine Manor 7801 Detroit Ave Cleveland, OH 44102

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. Review of Resident #143's medical record revealed she was readmitted on [DATE] with diagnoses including diabetes mellitus, endocarditis and muscle weakness. Residents Affected - Some Review of Resident #143's physician orders revealed an order dated 02/14/23 to administer lispro (fast acting insulin) per sliding scale if the blood glucose test (BGT) was 150 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units; 351 to 400 inject 10 units and if greater than 401 inject 12 units and call the physician subcutaneously before meals and at bedtime for diabetes. Review of Resident #166's medical record revealed he was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including type one diabetes mellitus with hyperglycemia, chronic respiratory failure and major depressive disorder. Review of Resident #166's physician orders revealed an order dated 03/23/23 revealed to administer lispro per sliding scale and if the BGT was 150 to 200 inject two units; 201 to 250 inject six units, 251 to 300 inject eight units; 301 to 350 inject 10 units, 351 to 400 inject 14 units and call the physician for a BGT above 400 before meals and at bedtime related to type one diabetes mellitus with hyperglycemia. Observation on 05/07/23 at 11:03 A.M. with LPN #756 completed a BGT test for Resident #143 with a result of 116 and the resident did not require insulin. Observation on 05/07/23 at 11:07 A.M. revealed LPN #756 sanitized the BGT machine with an alcohol wipe (70% isopropyl alcohol). Observation on 05/07/23 at 11:08 A.M. revealed LPN #756 obtained Resident #166's blood sugar using the BGT machine with a result of 255. She then sanitized the glucometer with an alcohol wipe. Observation on 05/07/23 at 11:16 A.M. revealed LPN #756 adminsitered eight units of humalog to Resident #166 for a BGT of 255. Interview on 05/07/23 at 11:30 A.M. with LPN #756 confirmed she did not have the appropriate sanitizing wipes in the medication cart so she used an alcohol wipe to sanitize the glucometer following Resident #143's blood sugar and then she obtained Resident #166's blood sugar using the improperly sanitized BGT machine. She also confirmed she did not have the appropriate sanitizing wipes for the morning medication pass and she used the alcohol wipes to clean the glucometer after she completed BGT's for Residents #143, #166 and #99 during the morning medication pass. She acknowledged the alcohol wipe did not disinfect the BGT machine to prevent the potential for cross-contamination of blood borne pathogens per the facility policy. Review of the Blood Glucose Testing policy revised 10/14 indicated to clean the machine with a bleach wipe. This deficiency represents non-compliance investigated under Complaint Number OH00141614. Based on observation, record review, interview, facility policy review, and review of the Centers 365883 Page 8 of 10 365883 05/10/2023 St Augustine Manor 7801 Detroit Ave Cleveland, OH 44102

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for Disease Control (CDC) guidance, the facility failed to maintain proper infection control procedures for enhanced barrier precautions and failed to ensure the multi-use glucometer blood testing (BGT) machine was disinfected and sanitized effectively to prevent the potential for cross-contamination of blood borne pathogens. This affected Resident #162 who was in enhanced barrier precautions of 28 residents with physician orders for enhanced barrier precautions residing on the fourth floor including Resident #25, #31, #33, #63, #87, #91, #146, #149, #159, #162, #180, #196, #198, #200, #354, #358, #454, #455, #456, #457, #459, #460, #462, #463, #466, #468, #469 and had the potential to affect an additional eighteen residents residing on the 4th floor who were not in enhanced barrier precautions or isolation precautions and the finding affected Resident #166 who received a BGT on the 2 [NAME] Unit and had the potential to affect two additional residents (Residents #99 and #143) who receive BGT's on the 2 [NAME] unit. The census was 197. Findings include: 1. Review of the medical record for Resident #162 revealed an admission date of 08/20/20. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident had impaired cognition and required extensive assistance for bed mobility, transfer, dressing, toilet, and hygiene. Review of physician order dated 04/18/23 revealed the resident #162 was to be on enhanced barrier precautions due to wounds with no end date. Observation on 05/07/23 at 8:56 A.M. revealed an enhanced barrier precaution sign on Resident #162's door with yellow caddy hanging on door with (PPE) to include gowns, gloves, masks. Licensed Practical Nurse (LPN) #742 walked into the room and took the blood pressure, pulse, administered medications, and assisted resident with opening items on the breakfast tray. LPN #742 did not have on the required PPE of a gown and gloves while providing direct care. Interview on 05/07/23 at 8:58 A.M. with LPN #742 verified she did not don personal protective equipment (PPE) before entering room to take vital signs, administer medications and assisted with opening meal items. LPN #742 stated she thinks the resident is in isolation for open areas, but he doesn't have any open areas. LPN #742 confirmed there was a sign on the door stating resident was in enhanced barrier precautions. LPN #742 reported she did not know why he was in enhanced barrier precautions. The facility procedure is to wear a gown and gloves with patient contact when the sign is on their door. On 05/08/23 at 1:20 P.M. notified Administrator regarding observation concern of staff not doing (PPE) for enhanced barrier precaution while providing direct care to Resident #162. Interview on 05/09/23 at 2:01 P.M. ADON/Infection Control Preventionist verified enhanced barrier precautions staff are to wear the following (PPE) to include gown, gloves, and surgical mask when providing care to the resident. Before exiting the room to doff gown, gloves, and surgical mask and perform hand hygiene. After exiting the room to apply a new surgical mask from the yellow caddy handing on the door with PPE included. Interview on 05/10/23 at 7:16 A.M. with Administrator verified for enhanced barrier precautions staff are to wear the following PPE to include gown, gloves, and surgical mask when providing care to the resident. Before exiting the room to doff gown, gloves, and surgical mask and perform hand hygiene. After exiting the room to apply a new surgical mask from the yellow caddy handing on the door 365883 Page 9 of 10 365883 05/10/2023 St Augustine Manor 7801 Detroit Ave Cleveland, OH 44102

F 0880 with PPE included. Level of Harm - Minimal harm or potential for actual harm Review of facility policy, Enhanced Barrier Precautions, revised 08/2022, revealed implementation of enhanced barrier precautions to make gowns and gloves available immediately outside of the resident's room. Residents Affected - Some Review of the CDC guidance updated 09/27/22 titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed health care personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 365883 Page 10 of 10