Health inspection·May 25, 2022

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, resident and staff interviews, and policy review the facility failed implement its abuse and neglect policy and procedure related abuse reporting to the state agency. This affected one (Resident #35) of one resident reviewed for abuse and neglect. The facility census was 54. Residents Affected - Few Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including dementia, schizophrenia, and anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was cognitively intact and required extensive assistance of two staff for the completion of her activities of daily living. Interview with Residents #35 on 05/22/22 at 11:59 A.M. revealed approximately one week ago (exact date and time unable to be recalled by the resident) State Tested Nursing Assistant (STNA) #900 yelled at Resident #35 after refusing to put a topical powder on her buttocks. Resident #35 stated STNA #900 was rude and abusive in the way that she talked to me. Resident #35 stated she had not told any facility staff about the incident and really did not want STNA #900 to take care of her anymore. The Administrator was notified of Resident #35's verbal abuse allegation on 05/22/22 at 12:12 P.M. by the surveyor. Review of the Ohio Department of Health's Enhanced Information Dissemination and Collection (EIDC) system (system used by facilities to report allegations of abuse, neglect, misappropriation, and exploitation) on 05/24/22 at 8:11 A.M. revealed no self-reported incident had been initiated by the facility as required to address Resident #35's verbal abuse allegation. Interview with the Administrator and Director of Nursing on 05/24/22 between 8:40 A.M. and 8:50 A.M. verified no self-reported incident was initiated and that the facility conducted their own investigation interviewing Resident #35, and the resident recanted her story and thus they did not feel any abuse had occurred. Review of the policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property, dated 11/28/16, under the sub section initial reporting revealed all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property must be reported immediately (2 hours if abuse allegation or serious injury; all other incidents not later than 24 hours) to both the Administrator and the Ohio Department of Health (ODH). When possible, ODH will be notified using by using the online EIDC system. Page 1 of 7 366057 366057 05/25/2022 Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130

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, resident and staff interviews, and policy review the facility failed to report and allegation of verbal abuse to the state agency as required. This affected one (Resident #35) of one resident reviewed for abuse and neglect. The facility census was 54. Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including dementia, schizophrenia, and anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was cognitively intact and required extensive assistance of two staff for the completion of her activities of daily living. Interview with Residents #35 on 05/22/22 at 11:59 A.M. revealed approximately one week ago (exact date and time unable to be recalled by the resident) State Tested Nursing Assistant (STNA) #900 yelled at Resident #35 after refusing to put a topical powder on her buttocks. Resident #35 stated STNA #900 was rude and abusive in the way that she talked to me. Resident #35 stated she had not told any facility staff about the incident and really did not want STNA #900 to take care of her anymore. The Administrator was notified of Resident #35's verbal abuse allegation on 05/22/22 at 12:12 P.M. by the surveyor. Review of the Ohio Department of Health's Enhanced Information Dissemination and Collection (EIDC) system (system used by facilities to report allegations of abuse, neglect, misappropriation, and exploitation) on 05/24/22 at 8:11 A.M. revealed no self-reported incident had been initiated by the facility as required to address Resident #35's verbal abuse allegation. Interview with the Administrator and Director of Nursing on 05/24/22 between 8:40 A.M. and 8:50 A.M. verified no self-reported incident was initiated and that the facility conducted their own investigation interviewing Resident #35, and the resident recanted her story and thus they did not feel any abuse had occurred. Review of the policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property, dated 11/28/16, under the sub section initial reporting revealed all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property must be reported immediately (2 hours if abuse allegation or serious injury; all other incidents not later than 24 hours) to both the Administrator and the Ohio Department of Health (ODH). When possible, ODH will be notified using by using the online EIDC system. 366057 Page 2 of 7 366057 05/25/2022 Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to accurately code the pre-admission screening and resident review (PASRR) accurately on the Minimum Data Set (MDS) 3.0 assessment. This affected five (Resident's #5, #27, #32, #34 and #38) of eleven residents identified as having a level two mental illness or intellectual disability. The facility census was 54. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, bi-polar disorder, and major depressive disorder. Review of the level two determination from the Ohio Department of Mental Health dated 03/01/22 revealed Resident #5 had a serious mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #5 dated 12/31/21 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 2. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including schizophrenia, anorexia, and major depressive disorder. Review of the level two determination from the Ohio Department of Mental Health dated 03/01/22 revealed Resident #5 had a serious mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #27 dated 03/10/22 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome, personality disorder, and major depressive disorder. Review of the level two determination from the Ohio Department of Mental Health dated 08/30/18 revealed Resident #32 had a serious mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #32 dated 01/01/22 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 4. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including schizophrenia, unspecified intellectual disabilities, and anxiety disorder. Review of the level two determination from the Ohio Department of Developmental Disabilities dated 04/11/22 revealed Resident #34 had a level intellectual disability 366057 Page 3 of 7 366057 05/25/2022 Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #34 dated 04/05/22 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 5. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, dementia, and post-traumatic stress disorder. Review of the level two determination from the Ohio Department of Mental Health dated 07/13/21 revealed Resident #38 had a serious mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #38 dated 04/04/22 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Social Worker #631 verified the incorrect coding of the above resident PASRR statuses during an interview on 05/24/22 at 10:12 A.M. 366057 Page 4 of 7 366057 05/25/2022 Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete a preadmission screen and resident review (PASRR) timely as required. This affected one (Resident #42) of six residents reviewed for PASRR status. The facility census was 54. Residents Affected - Few Findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, seizures, violent behavior, anoxic brain damage, and bipolar disorder. Review of the medical record revealed Resident #42's PASRR screen was not completed until 05/23/22. The screen noted Resident #42 as having a level two developmental disability requiring further review from the Ohio Department of Developmental Disabilities. Social Worker #631 verified that Resident #42's PASRR was not completed timely as required during an interview on 05/24/22 at 2:15 P.M. 366057 Page 5 of 7 366057 05/25/2022 Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive resident centered activities care plan for Resident #24. This affected one (Resident #24) of one resident review for activities. The facility census was 54. Findings Include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including aphasia, major depressive disorder, and dysphagia. Review of the care plan for Resident #24 reviewed no evidence of any care plan to addresses activities and recreational needs for Resident #24. Activities Director #629 verified the lack of activities care plan during an interview on 05/25/22 at 10:10 A.M. 366057 Page 6 of 7 366057 05/25/2022 Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pharmacy recommendations were addressed by the physician in a timely manner. This affected one (Resident #16) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: Review of Resident #16's medical record revealed an admission date of 02/27/22 with diagnoses including diabetes mellitus type two with hyperglycemia, schizophrenia, squamous cell carcinoma, protein-calorie malnutrition, pulmonary fibrosis, dementia with behavior disturbance, psychosis, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had impaired cognition, behavioral symptoms directed towards others, history of falls, and decreased mobility requiring wheelchair. Review of the monthly pharmacy recommendations to the attending physician dated 02/28/22 and again on 03/29/22, revealed the pharmacist made a recommendation to discontinue the use of one of two multiple vitamin supplements namely the Thera M Plus (multiple vitamins-minerals) or the Multivitamin tablet (multiple vitamin). The physician addressed the pharmacist recommendations to discontinue the Thera M Plus tablet on 04/04/22. Review of the monthly pharmacy recommendations to the attending physician dated 02/28/22 and again on 03/29/22, revealed the pharmacist made a recommendation to change the frequency of MiraLax Powder 17 grams (laxative) from one scoop by mouth for constipation PRN (as needed) to one scoop by mouth every 24 hours (once daily) for constipation. The physician addressed the pharmacist recommendations to change the specific frequency on 05/24/22. On 05/25/22 at 9:58 A.M. the Director of Nursing (DON) verified the recommendation was not addressed in a timely manner and stated Certified Nurse Practitioner (CNP) #667 was responsible to address the recommendations on Thursdays. The DON verified that the facility expectation was for physicians to respond within 30 days of pharmacy recommendations. 366057 Page 7 of 7