Health inspection·July 18, 2019

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify and involve Resident #35's power of attorney in care conferences and care planning. This affected one of one resident reviewed for participation in care planning. The facility census was 139. Findings include: Review of the medical record for Resident #35 revealed he was admitted on [DATE] with diagnoses of Alzheimer's disease, vascular dementia, and unspecified mood disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Review of advanced directives revealed Resident #35 had a valid power of attorney in place identifying his daughter as his decision maker. Review of the nurses note dated 07/07/19 at 9:23 P.M., Resident #35's daughter was noted to express concerns of not being invited to care conferences. Interview with Medical Records #500 on 07/17/19 at 8:15 A.M. confirmed Resident #35's daughter did not receive mailed care conference notices due to not being listed as a responsible party, even though she was the power of attorney. Page 1 of 9 366071 366071 07/18/2019 MT Alverna Home Inc 6765 State Road Parma, OH 44134

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to implement its abuse policy related to an allegation of verbal abuse by Resident #82's family. This affected one of two residents reviewed for abuse (Resident #82). The facility census was 139. Residents Affected - Few Findings Include: Resident #82 was admitted the facility on 05/23/19 with diagnoses including multiple sclerosis, broken internal left knee prosthesis and chronic heart failure. Interview with the family member of Resident #82 on 07/16/19 at 2:30 P.M. revealed on 06/28/19 Physical Therapy Assistant (PTA) #900, while completing treatment with family present, began to speak to Resident #82 in a way that was not appropriate to Resident #82's family. Per Resident #82's family from the moment PTA #900 entered Resident #82's room PTA #900 had an unfriendly tone and was verbally abusive to Resident #82 regarding her home going situation and progress in therapy. PTA #900 stated the resident was going backwards and no one in her family could help her with homegoing therapy training (Resident #82 lives at home with 24-hour assistance from her husband). Per Resident #82's family member Resident #82 began to cry due to PTA #900's aggressive tone and demeaning words regarding her therapy progress and homegoing status. Interview with Resident #82 on 07/16/19 at 3:30 P.M. revealed on the evening of 06/28/19 she felt she was treated in a way no one should ever be treated by PTA #900 Review of the email provided by Resident #82's family dated 06/28/19 at 5:29 P.M. to the facilities rehab director revealed As you know, we have had a concern about the PTA, PTA #900. Today, she came in to my moms room with both me and my mom's roommate, Resident #118, present. From the moment she entered, she was curt, combative, and demeaning to the point of near verbal abuse. In an effort to diffuse the situation, I continued to try to redirect her because I could see my mother start to tear up. Interview with the facilities Administrator and Rehab Director #901 on 07/16/19 at 3:30 P.M. verified Rehab Director #901 received the email allegation of abuse by Resident #82's family. Rehab Director #901 and the Administrator also verified the facility did not conduct an investigation into the allegation of abuse or notify the state agency of the allegation of abuse. Review of the facilities Abuse/Neglect policy dated 03/27/17, revealed when suspicion of abuse, neglect or exploitation occur, an investigation is immediately warranted and to Contact the State Agency and the local ombudsman office to report the alleged abuse. 366071 Page 2 of 9 366071 07/18/2019 MT Alverna Home Inc 6765 State Road Parma, OH 44134

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. Based on record review and staff interview, the facility failed to ensure an allegation of verbal abuse was reported to the state agency as required. This affected one of two residents reviewed for abuse (Resident #82). The facility census was 139. Findings Include: Resident #82 was admitted the facility on 05/23/19 with diagnoses including multiple sclerosis, broken internal left knee prosthesis and chronic heart failure. Interview with the family member of Resident #82 on 07/16/19 at 2:30 P.M. revealed on 06/28/19 Physical Therapy Assistant (PTA) #900, while completing treatment with family present, began to speak to Resident #82 in a way that was not appropriate to Resident #82's family. Per Resident #82's family from the moment PTA #900 entered Resident #82's room PTA #900 had an unfriendly tone and was verbally abusive to Resident #82 regarding her home going situation and progress in therapy. PTA #900 stated the resident was going backwards and no one in her family could help her with homegoing therapy training (Resident #82 lives at home with 24-hour assistance from her husband). Per Resident #82's family member Resident #82 began to cry due to PTA #900's aggressive tone and demeaning words regarding her therapy progress and homegoing status. Interview with Resident #82 on 07/16/19 3:30 P.M. revealed on 06/28/19 she felt she was treated in a way no one should ever be treated by PTA #900. Review of the email provided by Resident #82's family dated 06/28/19 at 5:29 P.M. to the facilities rehab director revealed As you know, we have had a concern about the PTA, PTA #900. Today, she came in to my moms room with both me and my mom's roommate, Resident #118, present. From the moment she entered, she was curt, combative, and demeaning to the point of near verbal abuse. In an effort to diffuse the situation, I continued to try to redirect her because I could see my mother start to tear up. Review of the Ohio Department of Health's Gateway system revealed no self-reported incident related to the allegation of verbal abuse by Resident #82's family. Interview with the facilities Administrator and Rehab Director #901 on 07/16/19 at 3:30 P.M. verified the facility received the email complaint of verbal abuse by Resident #82's family, and no self-reported incident was submitted to the state agency as required. Review of the facilities Abuse/Neglect policy dated 03/27/17 revealed the facility upon receiving an allegation of abuse shall Contact the State Agency and the local ombudsman office to report the alleged abuse. 366071 Page 3 of 9 366071 07/18/2019 MT Alverna Home Inc 6765 State Road Parma, OH 44134

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to complete an investigation of an allegation of verbal abuse. This affected one of two residents reviewed for abuse (Resident #82). The facility census was 139. Residents Affected - Few Findings Include: Resident #82 was admitted the facility on 05/23/19 with diagnoses including multiple sclerosis, broken internal left knee prosthesis and chronic heart failure. Interview with the family member of Resident #82 on 07/16/19 at 2:30 P.M. revealed on 06/28/19 Physical Therapy Assistant (PTA) #900, while completing treatment with family present, began to speak to Resident #82 in a way that was not appropriate to Resident #82's family. Per Resident #82's family from the moment PTA #900 entered Resident #82's room PTA #900 had an unfriendly tone and was verbally abusive to Resident #82 regarding her home going situation and progress in therapy. PTA #900 stated the resident was going backwards and no one in her family could help her with homegoing therapy training (Resident #82 lives at home with 24-hour assistance from her husband). Per Resident #82's family member Resident #82 began to cry due to PTA #900's aggressive tone and demeaning words regarding her therapy progress and homegoing status. Interview with Resident #82 on 07/16/19 3:30 P.M. revealed on 06/28/19 she felt she was treated in a way no one should ever be treated by PTA #900. Review of the email provided by Resident #82's family dated 06/28/19 at 5:29 P.M. to the facilities rehab director revealed As you know, we have had a concern about the PTA, PTA #900. Today, she came in to my moms room with both me and my mom's roommate, Resident #118, present. From the moment she entered, she was curt, combative, and demeaning to the point of near verbal abuse. In an effort to diffuse the situation, I continued to try to redirect her because I could see my mother start to tear up. Interview with the facilities Administrator and Rehab Director #901 on 07/16/19 at 3:30 P.M. verified the facility received the email complaint of verbal abuse by Resident #82's family, and no investigation was completed by the facility in regards to the allegation of verbal abuse. Review of the facilities Abuse/Neglect policy dated 03/27/17 revealed when suspicion of abuse, neglect or exploitation occur, an investigation is immediately warranted. 366071 Page 4 of 9 366071 07/18/2019 MT Alverna Home Inc 6765 State Road Parma, OH 44134

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the state ombudsman was notified of resident transfers to the hospital. This affected one (Resident #149) of one resident reviewed for hospitalization and had the potential to affect all 139 residents currently residing in the facility. Findings include: Resident #149 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, cerebral infarction without residual deficits, and hypertension. Review of nursing progress notes and resident census records revealed Resident #149 was sent out and subsequently admitted to a local hospital on [DATE]. Resident #149 was admitted to the hospital and did not return to the facility. Review of the electronic chart revealed no evidence the state ombudsman was notified of Resident #30's transfer to the hospital. On 07/17/19 at 8:20 A.M. the Director of Social Services verified the facility did not notify the state ombudsman of Resident #149's transfer to the hospital. The Director of Social Services also revealed that the facility had not been notifying the state ombudsman of any resident transfers. 366071 Page 5 of 9 366071 07/18/2019 MT Alverna Home Inc 6765 State Road Parma, OH 44134

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 interview the facility failed to ensure Resident #76 and #7's care plan. This affected two of 31 residents reviewed for care plans. The facility census was 139. Findings include: 1. Record review of Resident #76 revealed an admission date of 03/24/19. Diagnoses included unspecified dementia with behavioral disturbance, lymphedema, heart failure, and localized edema. The annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. Review of the current care plan was silent for edema. Review of the physician's note dated 02/27/19 revealed Resident #76 had severe pedal edema and purplish discoloration. It was explained to Resident #76 that since she refused the compression stockings she needed to elevate her lower extremities. The plan was to encourage frequent elevation of the lower extremities. Another physician's note dated 06/19/19 revealed Resident #76 exhibited edema. Observation on 07/16/19 at 9:29 A.M. revealed Resident #76 was observed sitting in her wheelchair in her room. Resident #76's were both very swollen, she had no socks on, and her feet were flat on the ground. Interview on 07/17/19 at 8:52 A.M. with Resident #76 revealed the her feet are alwys swollen, and staff do encourage her to elevate them. Resident #76 stated her feet were fine as they were. Resident #76 stated she just didn't want to have them propped up doing nothing. Interview on 07/17/19 at 3:42 P.M. with Unit Manager (UM) #505 revealed the unit managers managed the care plans. UM #505 stated Resident #76 had ongoing issues with edema and refused treatment and elevation of her feet. UM #505 verified Resident #76 did not have a care plan regarding her edema. 2. Review of the medical record for Resident #7 revealed he was admitted on [DATE] with poliomyelitis, weakness, and chronic obstructive pulmonary disease. Review of the MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment, and impairment to the upper extremity on one side requiring extensive assistance with dressing, toileting, personal hygiene, transfers, bed mobility, and locomotion. During an initial facility tour on 07/15/19 at 11:37 A.M., Resident #7 was observed with a left hand contracture and without a splint or brace applied. Review of the care plan for Resident #7 revealed no problem area to address limited range of motion (ROM) of the left hand contracture. Interview on 07/17/19 at 10:51 A.M. with Rehab Director #901 verified Resident #7 was admitted with a left hand contracture and completed physical and occupational therapy on 04/02/19 with a recommendation to use a foam roll in the hand. Interview on 07/17/19 at 12:08 P.M. with Unit Manager #502 confirmed the care plan for Resident #7 366071 Page 6 of 9 366071 07/18/2019 MT Alverna Home Inc 6765 State Road Parma, OH 44134

F 0656 effective 03/06/19 did not contain a problem area to address limited ROM of the left hand contracture. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366071 Page 7 of 9 366071 07/18/2019 MT Alverna Home Inc 6765 State Road Parma, OH 44134

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 and interview, the facility failed to revise the care plan for Resident #30. This affected one resident of two residents reviewed for non-pressure skin conditions. The facility census was 139. Findings include: Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including weakness, hypertension, and hypothyroidism. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed impaired cognition. Resident #30 required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers and toilet use. Review of the physician's notes dated 07/05/19 revealed Resident #30 had complained of a itchy rash that started a month ago. Physical exam revealed a patch of scattered macules (flat, distinct, discolored area of skin). Resident #30 was treated with Triamcinlone cream (treatment for itchiness and redness). Review of the care plan dated 04/22/19 for pressure sores and skin was silent for the rash and the treatment of the rash. Interview on 07/15/19 at 3:36 P.M. with Resident #30 revealed she had a rash on stomach for about two months, and it had gotten worse and had spread. Resident #30 stated as of this day she was told she was being referred to see a dermatologist. Interview on 07/17/19 at 3:31 P.M. and at 3:35 P.M. with State Tested Nurse Aide (STNA) #507 and Registered Nurse (RN) #506 revealed Resident #76 has had a rash that came and went in different areas of her body, but the current rash had worsen and spread. Interview on 07/17/19 at 3:48 P.M. with Unit Manager (UM) #505 stated he was aware of Resident #30's rash and confirmed he had not revised her care plan. 366071 Page 8 of 9 366071 07/18/2019 MT Alverna Home Inc 6765 State Road Parma, OH 44134

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure the Medical Director (MD) and the Administrator attended the Quality Assessment and Assurance (QAA) and the Quality Assurance Performance Improvement (QAPI) meetings quarterly. This had the potential to affect all 139 residents residing in the facility. Residents Affected - Many Findings include: Interview on 07/18/19 at 1:40 P.M. with Administrator, Director of Nursing (DON), and the Director Resident Services (DRS) #503 revealed the QAA and QAPI meetings are conducted monthly with facility department directors, DON,and Administrator, but the Medical Director and contracted services staff attend quarterly. Review of the sign in sheets titled, Monthly QAA and Ethics Committee Meeting Sign-In Sheet dated 07/23/18, 01/22/19, and 04/29/19 revealed only on 04/29/19 the Administrator and Medical Director were in attendance. Interview on 07/18/19 at 1:57 P.M. and 2:15 P.M. the DRS #503 confirmed the Medical Director and the Administrator were not in attendance for the QAA and QAPI meetings on 07/23/18 and 01/22/19. DRS #503 stated she didn't have a sign in sheet for the October 2018 meeting. 366071 Page 9 of 9