Health inspection·November 15, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family and staff interviews, medical record review, review of the facility's Self-Reported Incidents, and review of camera footage, the facility failed to ensure a resident who was dependent on staff for activities of daily living (ADL) was safely repositioned in bed. This affected one (Resident #1) of three residents reviewed for ADL care. The facility census was 158. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included dementia, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment and required substantial/maximal assistance from staff to roll to the right and left side. Review of the facility's Self-Reported Incident (SRI) dated 11/06/23 revealed Resident #1's power of attorney (POA) (also Resident #1's grandson) reported an allegation of physical abuse towards Resident #1. The POA stated when watching the video of care provided to Resident #1 revealed on 11/04/23 (the facility had 11/04/23 but the video was marked 11/05/23), State Tested Nursing Aide (STNA) #317 repositioned Resident #1 in bed and resulted in Resident #1 hitting her head on the railing. STNA #317 did not console or check to see if Resident #1 was okay after Resident #1 hit her head on the railing during repositioning. The POA also reported STNA #317 was rough with getting Resident #1 dressed over the weekend (11/04/23 or 11/05/23) as well. STNA #317 received safe repositioning education, abuse, customer service, and adverse events. The abuse was unsubstantiated based off the review of the video and STNA #317's statement where the head bump on the railing was not intentional on 11/14/23. Further review of the facility's SRIs dated 10/122/23 revealed STNA #317 was mentioned as an alleged perpetrator in a physical abuse allegation towards another resident (Resident #102). As a result of the investigation dated 10/30/23, staff received education on how to safely transfer Resident #102. Review of the video clip from Resident #1's room dated 11/05/23 at 1:03 P.M. with Resident #1's POA revealed a nurse and STNA #317 transferred Resident #1 to her bed. The nurse leaves the room and STNA #317 pulls Resident #1's hip and right arm towards her and then Resident #1 hits her head on the siderail. Resident #1 stated ouch my head. STNA #317 does not respond to Resident #1's comment and continues to remove the Hoyer pad and does not reposition Resident #1 off the siderail. Resident #1's head was resting on the siderail when Resident #1 was turned over and Resident #1 told STNA #317 she would hit her and bite her. STNA #317 continued to remove the pad and did not check Resident #1's head for any injury. Page 1 of 3 366045 366045 11/15/2023 Jennings Hall 10204 Granger Road Garfield Heights, OH 44125

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Telephone interview on 11/08/23 at 12:33 P.M. with the POA revealed he has a video camera in Resident #1's room. On 11/05/23 at 1:03 P.M., Resident #1 was being cared for by STNA #317 and the STNA was being too rough. When the STNA #317 was rolling her over, Resident #1 hit her head on the siderail and yelled out Ouch that hurt my head. STNA #317 did not console Resident #1. STNA #317 just kept doing her care. The POA stated he went in the next day and spoke with Supervisor Registered Nurse (RN) #305 about the incident and showed her the video clip of the incident. RN #305 did not know anything about the incident of Resident #1 hitting her head on the siderail. RN #305 stated this was the first time she heard about the incident, STNA #317 had not reported the incident. Interview on 11/08/23 at 1:42 P.M. with RN #305 verified the POA showed her the video of Resident #1 being turned in bed and hitting her head on the siderail. STNA #317 did nothing and did not tell anyone of the incident immediately. RN #305 stated Resident #1's POA showed the video to her on Monday evening (11/06/23). When the POA told her of the incident, STNA #317 was suspended, she notified the Administrator, and started an investigation. RN #305 stated from her perception of the video, STNA #317 did not intentionally bump Resident #1's head. RN #305 stated the interview she had with STNA #317 revealed she did not think Resident #1 hit her head hard and may have turned her with more force than needed causing her to hit her head. RN #305 verified STNA #317 should have checked Resident #1 for an injury or should have asked her if she was ok. RN #305 verified STNA #317 should have reported the incident to the nurse immediately. Interview on 11/15/23 11:05 A.M. with STNA #317 revealed she was the aide taking care of Resident #1 on 11/05/23. STNA #317 stated she was removing the lift pad from under Resident #1 when she pulled Resident #1 towards her making Resident #1 hit her head on the bed. She did not think she hit her head very hard, and she did not see any red mark. STNA #317 stated she was busy and forgot to notify the nurse that Resident #1 hit her head on the siderail, and it slipped her mind to tell the nurses. This deficiency represents non-compliance investigated under Complaint Number OH00147500. 366045 Page 2 of 3 366045 11/15/2023 Jennings Hall 10204 Granger Road Garfield Heights, OH 44125

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of camera footage and picture, and family and staff interviews, the facility failed to ensure all residents received medication as ordered by the physician. This affected one (Resident #1) of five residents reviewed for medication administration. The facility census was 158. Findings include: Review of the medical record for Resident #1 revealed an admission date 07/02/23. Diagnoses included dementia, atrial fibrillation, hypertension, and pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Review of the physician orders for November 2023 revealed Xanax 0.25 milligram (mg) tablet as needed every four hours for anxiety was discontinued on 11/03/23. Xanax 0.25 mg half tablet as needed every four hour for anxiety was started on 11/03/23. Review of the camera footage from Resident #1's room revealed on 11/03/23 at 4:56 P.M., Resident #1's grandson was visiting Resident #1. Licensed Practical Nurse (LPN) #319 came into Resident #1's room to administer Resident #1's medication. LPN #319 came into the room with a medication cup with pudding and crushed medications in it. As she was giving Resident #1 her medications by spoon, the grandson was giving sips of nectar thickened water. LPN #319 was by the side of Resident #1's bed, and the grandson heard something drop. The nurse picked up the medicine cup off the floor and turned to leave. She threw the spoon and medication cup in the garbage. The grandson asked if LPN #319 if she was done administering Resident #1's medications and she replied yes and walked out of the room. The grandson walked over to the trash can and took the pill cup and spoon from Resident #1's garbage can. There was still pudding and medications on the spoon and in the cup. The grandson took a picture of the spoon and cup and left the room with the items. Review of the grandson's picture taken on 11/03/23 at 4:56 P.M. revealed there was crushed medications in the pill cup and medications and pudding on the spoon. Telephone interview on 11/08/23 at 12:56 P.M. with Resident #1's grandson revealed on 11/03/23 at 4:56 P.M., he was visiting Resident #1 and LPN #319 came into Resident #1's room to give Resident #1 her afternoon medication. LPN #319 came into the room with a medication cup with pudding and crushed medications in it. LPN #319 threw the spoon and medicine cup in the Resident #1's garbage can inside her room. The grandson asked if she was done giving Resident #1's medications and she stated yes and walked out of the room. The grandson walked over to the trash can, saw the pill cup and spoon in the garbage and noticed there was still pudding and medications on the spoon and in the cup. The grandson took it out of the trash, took a picture of it and took it to Registered Nurse (RN) #305 and told her what happened. She stated what can I say. Interview on 11/08/23 at 12:56 P.M. with Supervisor Registered Nurse (RN) #305 verified she observed the picture and contents of the medication cup the grandson showed her on 11/03/23. RN #305 verified Resident #1 did not receive all of her medications and the nurse should have given all the pudding that had medications in it as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00147500. 366045 Page 3 of 3