Health inspection·April 19, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights were within reach and/or answered timely for all residents. This affected four residents ( #129, #142, #184 and #208) of five residents observed for call light response. The facility census was 164. Findings include: 1.Review of the open medical record for Resident #142 revealed an admission date of 03/16/22. Diagnoses included pulmonary fibrosis, vascular dementia, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 Assessment, dated 03/06/23, revealed Resident #142 had a severe cognitive impairment and required extensive assistance for activities of daily living (ADLs). Review of the care plan dated 04/15/23 revealed Resident #142 had the potential for self-care deficit related to vascular dementia and a history of falls. Interventions included assist with care and tasks, Resident #184 was unable to complete herself, create a safe environment by keeping obstacles from path, and call bell within reach, monitor ability and limitations, and ensure call light was within reach at all times. Observation on 04/12/23 at 10:40 A.M. revealed Resident #142 was sitting in her lounge chair. The call light was placed over the night stand several feet away from Resident #142. Resident #142 verified she was unable to reach the call light. Observation and interview on 04/12/23 at 10:42 A.M. with Registered Nurse (RN) #332 confirmed Resident #142 could not stand without assistants and Resident #142 was unable to reach her call light. 2. Review of the open medical record for Resident #184 revealed an admission date of 07/20/22. Diagnoses included chronic kidney disease, chronic obstructive pulmonary disease, and vascular dementia. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 03/06/23, revealed Resident #184 had a severe cognitive impairment and required extensive assistance for activities of daily living (ADLs). Review of the care plan dated 04/15/23 revealed Resident #184 had the potential for self-care deficit related to malaise, muscle weakness, osteoarthritis, and dementia. Interventions included assist with care and tasks Resident #184 was unable to complete herself, create a safe environment by Page 1 of 8 366045 366045 04/19/2023 Jennings Hall 10204 Granger Road Garfield Heights, OH 44125

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some keeping obstacles from path and call bell within reach, monitor ability and limitations, and ensure call light was within reach at all times. Observation on 04/12/23 at 11:00 A.M. revealed Resident #184 was sitting up in her chair in her room next to her bed. Observation revealed the call light was bundled up and located behind the nightstand out of reach of Resident #184. Resident #184 verified she was unable to reach the call light. Observation and interview on 04/12/23 at 11:02 A.M. with Speech Therapist #333 verified Resident #184's call light was behind the night stand and Resident #184 would not be able to reach the call light. 3. Record review for Resident #208 revealed an admission date of 06/12/19. Diagnosis included Parkinson's disease, unspecified convulsions, and dysphagia. Record review of the MDS dated [DATE] revealed Resident #208 had severe cognitive impairment and required extensive assistants of one to two for ADLS. Record review of the care plan for Resident #208 dated 03/12/23 revealed Resident #208 had a potential for self-care deficit related to lack of coordination, muscle weakness and Parkinson's disease. Interventions included call light within reach at all times. Observation on 04/13/23 at 3:32 P.M. revealed Resident #208 was up in his chair. As the surveyor was passing Resident #208's room, Resident #208 called out to the surveyor for assistants. Observation revealed Resident #208 was unable to reach his call light located on his bed and no other staff was in the area. Resident #208 was requesting assistants. Observation and interview on 04/13/23 at 3:35 P.M. with Licensed Practical Nurse (LPN) #325 confirmed Resident #208 was not able to reach or get to his call light located on the bed. 4. Review of the open medical record for Resident #129 revealed an admission date of 09/10/21. Diagnoses included vascular dementia with agitation, anxiety disorder, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) 3.0 Assessment, dated 03/30/23, revealed Resident #129 had a moderate cognitive impairment and required extensive assistance for activities of daily living (ADLs). Review of the care plan dated 04/15/23 revealed Resident #129 had the potential for self-care deficit related to dementia, general muscle weakness, somnolence, and bilateral upper extremity muscle wasting. Interventions included assist with care and tasks Resident #129 was unable to complete herself, create a safe environment by keeping obstacles from path and call bell within reach, monitor ability and limitations, and ensure call light was within reach. On 04/13/23 at 2:03 P.M., observation of the memory care unit revealed Resident #129's call light was on and there was no audible indicator for the call light. Resident #129's room was around the corner from the unit entrance and was not visible from the entrance. At that time, the three staff members for the unit were congregated by the unit entrance talking amongst themselves. At 2:10 P.M., the Administrator entered the unit, spoke to the staff by the entrance, and then left the unit. At 2:14 P.M., staff began making popcorn in the kitchenette by the unit entrance. At 2:23 P.M., Licensed Practical Nurse (LPN) #310 entered the memory care unit and began walking down the hallway. At 2:24 366045 Page 2 of 8 366045 04/19/2023 Jennings Hall 10204 Granger Road Garfield Heights, OH 44125

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some P.M., LPN #310 answered Resident #129's call light, 21 minutes after it was observed to be on. No other staff on the unit walked down the hallway between 2:03 P.M. and 2:24 P.M. On 04/13/23 at 2:26 P.M., interview with LPN #310 verified she answered Resident #129's call light as soon as she entered the unit. She confirmed Resident #129's call light indicator was not visible from the unit entrance and there was no audible indicator for the call light. LPN #310 stated staff were supposed to have pagers for the call lights and staff should have been walking the halls to ensure call lights were answered. The deficiency resulted from incidental findings during the investigation of Complaint Numbers OH00141855, OH00139480, OH00138154 and OH00135223. 366045 Page 3 of 8 366045 04/19/2023 Jennings Hall 10204 Granger Road Garfield Heights, OH 44125

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, family interview and staff interview, the facility failed to ensure resident representatives were notified of significant changes, including medication changes, for Resident #268. This affected one resident (#268) of three residents reviewed for notification of change. The census was 164. Findings include: Review of the medical record for Resident #268 revealed an admission date of 10/11/22 and discharge date of 12/07/22. Diagnoses included fracture of the right rib, mild cognitive impairment, and dementia with anxiety. Review of the physician's orders for October 2022 identified orders for Lexapro (an antidepressant) five milligrams (mg) once daily for behaviors, ordered on 10/12/22. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/17/22, revealed Resident #268 had a severe cognitive impairment, required extensive assistance for activities of daily living (ADLs), and received an antidepressant medication for five out of seven days for the seven day lookback. Review of the Medication Administration Record (MAR) for October 2022 through November 2022 revealed Resident #268 received Lexapro daily from 10/13/22 to 11/15/22. Review of the nurses notes from October 2022 identified no documentation of notification to Resident #268's representative regarding the addition of Lexapro. A note dated 10/14/22 at 2:42 P.M. revealed a care conference was held with Resident #268's family and there was nothing indicating medications were reviewed at the care conference. Review of Physician #322's note dated 10/12/22 revealed Resident #268 was anxious. The note indicated Lexapro five mg daily was being added for underlying anxiety. Resident #268 had a fair to poor prognosis. On 04/12/23 at 5:00 P.M., interview with Resident #268's representative stated she was not notified about the addition of Lexapro. On 04/17/23 at 1:24 P.M., interview with Director of Nursing (DON) #313 stated the floor nurse or the physician would notify resident representatives of any changes and the notification would be documented in the chart. She said if there was no documentation of the notification, there was no way to guarantee the notification occurred. On 04/17/23 at 2:40 P.M., interview with DON #312 verified there was no evidence that Resident #268's family was notified of the new order for Lexapro. She stated the floor nurse or the physician were responsible for making the notification. She also stated the floor nurse who signed the telephone order for the Lexapro was an agency nurse who no longer worked in the facility. On 04/18/23 at 1:50 P.M., interview with Physician #322 verified he ordered Lexapro for Resident #268 for anxiety and stated he did not call the family. He stated the facility nurse was responsible 366045 Page 4 of 8 366045 04/19/2023 Jennings Hall 10204 Granger Road Garfield Heights, OH 44125

F 0580 Level of Harm - Minimal harm or potential for actual harm for notifying the family of medication changes if the family was not present at the time of the physician visit. Physician #322 stated Resident #268 was alert at the time of his visit, so it was likely that he discussed the new order for Lexapro with Resident #268 during the visit instead of discussing it with her representative. This deficiency represents non-compliance investigated under Complaint Number OH00139480. Residents Affected - Few 366045 Page 5 of 8 366045 04/19/2023 Jennings Hall 10204 Granger Road Garfield Heights, OH 44125

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 interview and record review, the facility failed to ensure Resident #256's CPAP (continuous positive airway pressure) machine was maintained in a clean and sanitary manner. The affected one resident (Resident #256) of three residents reviewed for use of CPAP machines. The facility census was 164. Residents Affected - Few Findings include: Record review for Resident #256 revealed an admission date of 03/17/23. Diagnosis included chronic obstructive pulmonary disease (COPD). Record review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #256 was cognitively intact. Resident #256 required extensive assistance of two for bed mobility and transfers. Record review of the care plan for Resident #256 revealed the potential for altered respiratory status related to chronic obstructive pulmonary disease (COPD) as evidence by use of CPAP machine. Interventions included to provide oxygen as ordered. Record review of the physician orders revealed Resident #256 had an order to use the CPAP machine at night and off at 6:00 A.M. Further review of the physician orders revealed no orders were present for cleaning the CPAP. Interview on 04/13 23 at 1:51 P.M. with Resident #256 confirmed staff placed her CPAP on at night and removed it in the morning. Resident #256 revealed she had been at the facility for nearly one month and no one had ever cleaned her CPAP machine including the water reservoir, tubing, masks nor anything else on the machine. Resident #256 revealed the CPAP she had at home had to be cleaned two times a week by her daughter. Interview on 04/13/23 at 12:25 P.M. with DON #312 confirmed Resident #256 did not have orders for cleaning her CPAP machine but should have. The CPAP machine should have been cleaned weekly on Sundays. DON #312 confirmed the CPAP machine had not been cleaned while at the facility. This deficiency represents non-compliance investigated under Complaint Number OH00135223. 366045 Page 6 of 8 366045 04/19/2023 Jennings Hall 10204 Granger Road Garfield Heights, OH 44125

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, interview and review of Centers for Disease Control (CDC) guidance, the facility failed to follow proper infection control procedures while doffing Personal Protective Equipment (PPE) after exiting Resident #245 and Resident #237's rooms who were diagnosed with COVID-19. This had the potential to affect all 164 residents in the facility. The facility census was 164. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #245 revealed an admission date of 04/01/22. Diagnoses included hemiplegia following cerebral infarction, heart failure, and vascular dementia. Review of the COVID-19 testing results dated 04/04/23 revealed Resident #245 tested positive for COVID-19. Review of the nurses notes from April 2023 revealed Resident #245 was on quarantine for COVID-19 from 04/04/23 to 04/13/23. Observation on 04/12/23 at 2:01 P.M. revealed State Tested Nursing Assistant (STNA) #329 donned an N-95 mask, gown and gloves and entered Resident #245's room who was on isolation for COVID-19. Observation on 04/12/23 at 2:05 P.M. revealed STNA #329 exited Resident #245's room. STNA #329 did not change her N-95 mask after exiting the room and before walking up the hall. STNA #329 revealed she received one N-95 a day and confirmed she worked with residents with covid 19 and without COVID-19 during the same shift. STNA #329 revealed she placed a new N-95 mask on in the morning when she started her shift then threw it away at the end of her 7.5-hour shift. STNA #329 confirmed she did not wear goggles while caring for Resident #245. Observation on 04/12/23 at 3:56 P.M. revealed STNA #330 donned an N-95 mask, gown, hair cap and gloves and entered Resident #245's room who was on isolation for COVID-19. STNA #330 had prescription eyeglasses on. Observation on 04/12/23 at 4:01 P.M. revealed STNA #330 exited Resident #245's room, placed hair cap in her shirt pocket, did not change the N-95 mask then walked across the hall and entered Resident #186's room (who was not on isolation) and assisted Resident #186. Observation on 04/12/23 at 4:05 P.M. revealed STNA #330 left Resident #186's room and began to enter Resident #194's room (who was not on isolation) when she was stopped by the surveyor. STNA #330 confirmed she did not wear goggles while caring for Resident #245 who was positive for COVID-19, she did not change the N-95 mask after caring for Resident #245 and she placed the hair net she wore in Resident #245's room in her shirt pocket after exiting the room. STNA #330 revealed she only changed the N-95 mask once a day, at the beginning of her shift and confirmed she did not wear any goggles. STNA #330 revealed she kept the hair net in her shirt pocket to reuse. STNA #330 confirmed she worked with residents with COVID-19 and without COVID-19 during the same shift. Interview on 04/12/23 at 4:10 P.M. with Director of Nursing (DON) #313 revealed staff should be wearing a face shield or goggles, a gown, gloves, and an N-95 mask before entering a resident room diagnosed with COVID-19. The mask should be changed if soiled and at least once a day except when going 366045 Page 7 of 8 366045 04/19/2023 Jennings Hall 10204 Granger Road Garfield Heights, OH 44125

F 0880 into a COVID-19 room, the mask should be changed when exiting the room. Level of Harm - Minimal harm or potential for actual harm Interview on 04/12/23 at 4:39 P.M. with the Administrator revealed each staff member changed their mask once a day, staff did not change their mask between caring for residents with COVID-19 and non-COVID-19 because she thought there was still a mask shortage. Administrator confirmed she had no difficulty in ordering masks and masks were available at multiple resources including online. Residents Affected - Many 3. Review of the open medical record for Resident #237 revealed an admission date of 02/07/22. Diagnoses included peripheral vascular disease, cognitive communication deficit, and hemiplegia. Review of the COVID-19 testing results dated 04/06/23 revealed Resident #237 tested positive for COVID-19. Review of the nurses notes for April 2023 revealed Resident #237 was on quarantine for COVID-19 from 04/06/23 to 04/16/23. Review of the physician's orders for Resident #237 for April 2023 identified no orders regarding isolation or quarantine for COVID-19. Observation on 04/13/23 at 11:47 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #327 donned PPE including a gown, goggles, N-95 mask and gloves to enter Resident #237's room. LPN #327 administered medications to Resident #237, doffed the PPE except for the goggles. LPN #327 did not doff or clean the goggles worn in Resident #237's room. LPN #327 verified he did not clean his goggles after exiting Resident #237's room revealing he cleaned his goggles at the end of each shift and obtained new goggles once a week. LPN #327 confirmed he worked with residents with covid 19 and without COVID-19 during the same shift and revealed he was never instructed to clean or remove his goggles after exiting a room with COVID-19. Review of the CDC guidance titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 dated, 06/03/20, included before caring for patients with confirmed or suspected COVID-19, healthcare personnel (HCP) must receive comprehensive training on when and what PPE is necessary, how to don (put on) and doff (take off) PPE, limitations of PPE, and proper care, maintenance, and disposal of PPE. HCP must demonstrate competency in performing appropriate infection control practices and procedures. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care: remove gloves, remove gown, HCP may now exit patient room, perform hand hygiene, remove face shield or goggles, remove and discard respirator, perform hand hygiene after removing the respirator. Record review of the facility COVID-19 line list revealed the first positive resident case for COVID-19 at the facility was Resident #265 who tested positive on 03/23/23. Resident #159 tested positive for COVID-19 on 04/03/23. An additional 13 residents, Resident #245, #130, #270, #170, #178, #271, #272, #237, #214, #273, #274, #158, and #126 tested positive from 04/04/23 through 04/10/23. Review of facility policy titled Covid 19 Isolation, dated 05/26/22, did not include what the staff member was to donn or how to doff PPE. This deficiency represents non-compliance investigated under Complaint Number OH00141855. 366045 Page 8 of 8