Health inspection·March 7, 2019

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 upon interview and record review the facility failed to ensure the Minimum Data Set (MDS) 3.0 assessment accurately reflected the status of use of anticoagulant medication for Resident #43, status of falls and injuries for Resident #46, and the delivery of dialysis and hospice services for Resident #68. This affected three of 23 records reviewed. The facility census was 113. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 10/09/18 with diagnoses including chest pain, dyslipidemia, history of a gastrointestinal bleed, hypothyroidism, and aspiration pneumonia. Review of the physicians orders for January 2019 revealed Resident #23 received medications related to cardiac and thyroid conditions. The resident was not ordered any anticoagulant medication. Review of the medication administration record (MAR) for January 2019 revealed the resident did not receive any anticoagulant medications from 01/05/19 through 01/11/19. Review of the Annual MDS 3.0 assessment, dated 01/11/19, revealed the assessment had been coded to indicate Resident #43 had received anticoagulant medication seven of seven days during the assessment reference period. Interview on 03/0519 at 2:39 P.M. with Registered Nurse (RN) #52 revealed the nurse who completed the MDS was new and didn't know she should not have coded the medication as an anticoagulant. Interview with Licensed Practical Nurse (LPN) #6 revealed she stated she had completed the MDS assessment and thought Clopidogrel (an antiplatelet medication) was an anticoagulant and was not aware that the Resident Assessment Instruction(RAI) Manual included specific direction that the medication was not be coded as an anticoagulant. Review of the RAI Manual revealed Clopidogrel (Plavix) was not to be coded on the MDS as an anticoagulant medication. 2. Review of the medical record for Resident #46 revealed an admission date of 09/20/18 with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, anxiety, and spondylosis. Review of the nurses notes revealed the resident had falls on 10/01/18, 10/13/18, 10/22/18, 11/11/18, and 11/16/18. After the fall on 10/13/18 the resident complained of right knee pain, rating it at 8/10. After the fall on 10/22/18 the resident complained of pain in the left hip and femur. X-rays were ordered to the left hip and femur and designated stat (urgent). Page 1 of 8 366079 366079 03/07/2019 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the MDS assessments revealed the staff had completed an admission MDS assessment on 09/30/18, a quarterly MDS assessment on 10/11/18, and another quarterly MDS assessment on 01/11/19. The MDS was coded as having had two falls with no injury and no falls with either minor or major injury. Interview on 03/05/18 at 2:37 A.M. with RN #146, who investigated the falls, revealed Resident #46 had x-rays performed after two of the falls because of pain. Interview on 03/06/19 at 4:33 P.M. with RN #52 revealed she stated she had missed falls and was not aware of the X-rays. She stated the MDS should have been coded to reflect the resident had two (or more) falls with no injury and two (or more) falls with injury except major since the previous assessment. Review of the RAI manual revealed the number of falls was to be coded in section J of the MDS and further classified as number of falls with no injury, falls with injury except major and falls with major injury. Minor injury was defined as bruises, sprains, skin tears and any fall related injury that causes pain. 3. Resident #68 was readmitted to the facility on [DATE] with diagnoses including chronic pulmonary disease, acute systolic heart failure, dementia with behavioral disturbances, and acquired absence of specific parts of the digestive system. Review of Resident #68's MDS 3.0 assessment, dated 12/14/18, indicated the resident exhibited severe cognitive impairment and received dialysis. Review of Resident #68's medical record, physician orders, medication administration records (MARS) and treatment administration records (TARS) for March 2018 revealed Resident #68 received hospice services and not dialysis. Interview on 03/07/19 at 10:47 A.M. with MDS Nurse #52 confirmed Resident #68's comprehensive assessment, dated 12/14/18, was inaccurate and the resident did receive hospice services. 366079 Page 2 of 8 366079 03/07/2019 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

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 interview and record review, the facility did not ensure care plans were consistently implemented for monitoring behavioral symptoms to justify the use of mood-altering medication. This affected two (Resident #3, Resident #20) of five residents reviewed for unnecessary medication. The facility census was 113. Findings include: 1. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, Parkinson's Disease, depression, anxiety, and anorexia. Review of resident #20's annual Minimum Data Set (MDS) 3.0 assessment, dated 01/25/19, revealed the resident required limited assist with set-up for all activities of daily living (ADL), except toilet use and personal hygiene which required a one person assist. Review of Resident #20's plan of care (no date) revealed the resident exhibited signs and symptoms of behaviors as demonstrated by delusions/hallucinations related to Lewy Body dementia, and Parkinson's Disease. Interventions included: resident will exhibit improvement in behavior - delusion/hallucinations; encourage participation in activities of choice, and provide opportunities to discuss interests and concerns; encourage performance of independent ADL and acceptance of assistance as needed; if appropriate, stop providing care and try again later after a brief break or ask another staff person to assist; intervene as needed to ensure safety and the safety of others; monitor behaviors and assist with interventions; assist in determining if her behavior is stimulated by certain activities, noise levels, persons or events; notify resident's Medical Doctor (MD) if his/her behavior interferes with functioning, interactions with others, and/or daily routine; refer to the psychiatrist and/or psychologist services as needed, and follow treatment recommendations. Review of Resident #20's plan of care (no date) revealed the resident was at increased risk for adverse side effects and injury related to falls do to the need of psychotropic medication to manage the symptoms of anxiety, depression delusions and hallucinations, Lewy body dementia, and Parkinson's. Interventions included: administer medication as ordered, and monitor for adverse reactions such as sedation, unsteady gait decreased appetite, weight loss, dry mouth, uncontrolled body movements, dizziness, and report to MD; attempt gradual dosage reductions (GDR) if recommended by the psychiatrist, pharmacist or MD; monitor for behavior listed on log, every shift, and document on behaviors log, if increase in negative behavior is noted report to MD or physiatrist; monitor for increased falls. Review of Resident #20's nurses notes from 12/06/18 to 03/04/19 revealed no documented evidence nurses documented the monitoring of the resident signs or symptoms of delusion or hallucinations. Review of monthly pharmacy reviews, dated 11/01/18 to 02/19, revealed no irregularities, except for 01/23/19 when the pharmacist documented the resident was being treated for Parkinson's, depression, and anxiety with the history of hallucinations. Please note medications treating Parkinson's can cause psychosis. Dose reductions could be attempted to reduce psychosis. The physician responded on 01/25/19, no change at this time. GDR contraindicated due to patient currently showing symptoms. GDR could result in negative outcomes at this time. Review of Resident #20's monthly Behavior Flow Sheets, dated 11/01/18 to 02/18/19, revealed the monthly flow sheets identified behaviors as depressed mood and increased anxiety. Further review of the 366079 Page 3 of 8 366079 03/07/2019 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monthly Behavior Flow Sheets revealed when behavior did occur, staff did not consistently document the type of behavior, such as what type of anxiety symptoms, if a behavior was marked with the number two, it was unclear if it was two separate behavioral incidents or one behavioral incident with two behaviors. Staff did not consistently document if interventions attempted were affective. Monthly Behavior Flow Sheets did not monitor for delusions or hallucinations as indicated in the plan of care. February Behavior Flow Sheet, dated from 02/19/19 to 02/28/19, was blank and contained no documented evidence staff monitored the resident's behavior. This was verified through interview with the Director of Nursing on 03/06/19 at 12:10 P.M. 2. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes, congestive heart failure, atrial fibrillation, and hypertension. Review of Resident #3's quarterly MDS 3.0 assessment, dated 02/09/19, revealed the resident was independent with set-up only for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Resident #3's plan of care (no date) revealed the resident showed signs/symptoms of depression, crying, withdrawal, and anger. Interventions included: refer to psychiatrist and/or psychologist services when appropriate, and follow any treatment recommendations; administer medications as ordered; approach in a calm manner, and speak in a calm voice; Resident #3 will receive counseling once a week from counselor; encourage independence in choices of daily routine; notify MD if resident's signs/symptoms of depression increase or begin to interfere with the daily routine and or functioning; provide resident with opportunities to discuss issues and concerns. Review of Resident #3's nurses notes from 12/06/18 to 03/04/19 revealed no documented evidence nurses documented the monitoring of the resident signs or symptoms of crying, withdrawal or anger behaviors. Review of Resident #3's monthly Behavior Flow Sheets, dated 11/01/18 to 02/18/19, revealed the monthly flow sheets identified behaviors as depression and did not include monitoring for crying and anger behaviors. Further review of the monthly Behavior Flow Sheets revealed when behavior did occur, staff did not consistently document the type of behavior, such as what type of depressive symptoms the resident displayed, if a behavior was marked with the number 3, it was unclear if it was three separate behavioral incidents or one behavioral incident with three behaviors. Monthly Behavior Flow Sheets did not monitor for crying, withdrawal, or anger behaviors as indicated per the plan of care. February Behavior Flow Sheet, dated from 02/19/19 to 02/28/19, was blank and contained no documented evidence staff monitored the resident's behavior. This was verified through interview with the Director of Nursing on 03/06/19 at 2:30 P.M. 366079 Page 4 of 8 366079 03/07/2019 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure incontinence check and changes were completed every two hours for Resident #39. This affected one of two residents reviewed for bowel/bladder incontinence. The facility census was 113. Findings include: Resident #39 was admitted to the facility on [DATE]. Her admitting diagnoses included dementia, glaucoma, benign neoplasm of the colon, epilepsy, and anemia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/08/19, revealed Resident #39 had severe cognitive impairment. She was totally dependent on staff for bed mobility, dressing, toileting, and personal hygiene. She was always incontinent of bowel and bladder. Her plan of care, dated 12/19/18, included an intervention to check and change the resident every two hours. Observation of this resident on 03/06/19 from 9:53 A.M. to 2:30 P.M. revealed that the resident was not checked and changed every two hours for incontinence. Interview with State Tested Nurse Aide (STNA) #43 on 03/06/19 at 2:00 P.M., she indicated she did not remember the time she put the resident in the dining room. When she was informed it was 9:53 A.M., she agreed that the resident was not checked and changed since 9:53 A.M. 366079 Page 5 of 8 366079 03/07/2019 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to ensure medications were properly stored in the medication cart, failed to ensure opened vials of medications were dated and timed, and failed to ensure expired medications were disposed of. This had the potential to affect 19 residents (Resident #150, Resident #305, Resident #248, Resident #151, Resident #303, Resident #307, Resident #302, Resident #54, Resident #69, Resident #148, Resident #89, Resident #300, Resident #301, Resident #299, Resident #249, Resident #306, Resident #298, Resident #5) out of 19 newly admitted resident who might have received the tuberculin skin test, one resident (Resident #299) out of one resident who was taking Regular Insulin, and seven residents (Resident #158, Resident #38, Resident #24, Resident #67, Resident #12, Resident #92, and Resident #29) out of seven residents who were ordered Dulcolax suppositories on an as needed bases. The facility census was 113. Findings Include: 1. During review of medication storage on 03/06/18 at 3:00 P.M. it was revealed on Team A of the facility that the medication refrigerator had a multi-dose tuberculin vial that was opened and not dated. Interview with Licensed Practical Nurse (LPN) # 50 on 03/06/18 at 3:30 P.M. verified the above finding. 2. Observation and inspection of Team 1's medication refrigerator revealed that a bag of 14 Docusate sodium suppositories (laxative)10 mg that expired on 12/18/18. Interview with Registered Nurse (RN) #88 on 03/06/19 at 4:10 P.M. verified that these suppositories were expired. 3. Observation of the medication refrigerator on the skilled unit revealed that a vial of Regular Insulin was opened and not dated or timed. Interview with RN #117 verified the above finding on 03/06/17 at 4:30 P.M. 366079 Page 6 of 8 366079 03/07/2019 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure consistent use of adaptive equipment for one resident (Resident # 87) of 111 residents observed for dining. (Residents #3 and #25 were identified by the facility as receiving nothing by mouth). The facility census was 113 residents. Residents Affected - Few Findings include: Review of Resident #87's medical record revealed a readmission date of 6/27/18 and diagnoses including Huntington's disease, anxiety disorder, and dementia without behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/13/19, revealed Resident #87 was cognitively impaired, had a mechanically altered diet, and was on regimen to gain weight. Review of the Nutritional Assessment, dated 12/13/19, revealed that Resident #87 received a pureed diet and fluids in sipper cup to reduce spillage. Review of a nutritional care plan, dated 02/14/19, revealed Resident #87 was to use sipper cup for fluids, no straws. Observation of the dinner meal on 03/04/19 at 5:28 P.M. revealed that Resident #87 was feeding herself with a glass of juice at her place setting instead of a sipper cup. Registered Dietitian #103 verified that Resident # 87 should have had a sipper cup and went to the kitchen for a sipper cup. . 366079 Page 7 of 8 366079 03/07/2019 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview, the facility failed to ensure four out of five pantries and one snack refrigerator were maintained in a clean and sanitary manner. This had the potential to affect the 111 residents who ate meals from the facility's kitchen. Two residents (Resident #56 and Resident #98) received enteral nutrition. Findings include: 1. Observations during the tour of the pantries located on all units on 03/04/19 from 8:40 A.M. through 9:00 A.M. with Dietary Manager (DM) #84 revealed four out of five pantries were not maintained in a clean and sanitary manner. Pantry located on Team A unit on 03/04/19 at 8:40 A.M. revealed food splatter was located on the lower cabinet doors, food crumbs on the bottom of the reach-in refrigerator, and the gaskets on the reach-in refrigerator were dirty. This was verified by DM #84 at 8:40 A.M. Pantry located on Team B unit on 03/04/19 at 8:49 A.M. revealed food splatter on the hot plate and inside the microwave. This was verified by DM #84 at 8:49 A.M. Pantry located on the Skilled unit on 03/04/19 at 8:56 A.M. revealed food splatter located on the lower cabinet doors, food crumbs on the bottom of the reach-in refrigerator, and the gaskets on the reach-in refrigerator were dirty. This was verified by DM #84 at 8:56 A.M. Pantry located on Team 1 unit on 03/04/19 at 9:01 A.M. revealed food splatter was located on the lower cabinet doors, food crumbs on the bottom of the reach-in refrigerator, the gaskets on the reach-in refrigerator were dirty, and the microwave had dried food splatter in it. This was verified by DM #84 at 9:01 A.M. 2. Observation of the resident snack refrigerator behind the nurse's station on Team A revealed a salad in a plastic container and a foil covered sandwich that was not dated and/ or timed. This refrigerator also had staff food included with resident snack food. The bottom shelf of the refrigerator had a brown stain on it. This finding was verified by Licensed Practical Nurse (LPN) #50 on 03/06/19 at 4:00 P.M. When this nurse was asked about staff food being stored in a resident's snack refrigerator, she stated she did not know that they could not do it. 3. Observation of the resident's snack refrigerator on Team B revealed four peanut butter and jelly sandwiches that were not dated or timed. The finding was verified by LPN #111 on 03/06/19 at 4:10 P.M. Review of the Sanitation Policy on 03/04/19 revealed that all work surfaces would be cleaned and sanitized. This was verified by the DM #84. 366079 Page 8 of 8