Health inspection·November 16, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 and interview the facility failed to provide dignified feeding assistance to Resident #15 and Resident #217. This affected two residents (#15 and #217) of four residents observed for feeding assistance. The facility identified eight residents (#15, #19, #32, #34, #64, #76, #87, and #217) who required feeding assistance. The facility census was 113. Findings include: 1. Review of Resident #15's medical records revealed an admission date of 08/24/22. Diagnoses included dementia, anorexia and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed no cognition score due to Resident #15 was rarely understood. Resident #15 required extensive assistance with eating. Review of the care plan dated 11/03/23 revealed Resident #15 was at risk for nutritional deficits. Interventions included provide assistance at meals. Observation was conducted on 11/14/23 at 8:43 A.M. of the breakfast meal for Resident #15. The observation revealed State Tested Nursing Assistant (STNA) #972 was providing feeding assistance to Resident #15 in a common dinning area. STNA #972 stood next to Resident #15 while feeding and did not engage Resident #15 with conversation or eye contact while providing feeding assistance. Interview with STNA #972 at the time of the observation confirmed she was standing up next to Resident #15 and had not tried to engage the resident. Resident #15 was not interviewable. 2. Review of Resident #217's medical records revealed an admission date of 10/24/23. Diagnoses included Alzheimer's and macular eye degeneration. Review of MDS assessment dated [DATE] revealed no recorded cognition score due to Resident #217 was rarely understood. Resident #217 required extensive assistance with eating. Review of the care plan dated 11/08/23 revealed Resident #217 was at risk for nutritional deficits. Interventions included provide assistance at meals. Observation was conducted on 11/14/23 at 8:47 A.M. of the breakfast meal for Resident #217. The observation revealed STNA #973 was providing feeding assistance to Resident #217 in the residents room. STNA #973 was observed to have been standing up next to Resident #217 and did not engage Resident #217 with conversation or eye contact while providing feeding assistance. Interview with STNA #973 at Page 1 of 8 366079 366079 11/16/2023 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0550 Level of Harm - Minimal harm or potential for actual harm time of observation confirmed she standing up next to Resident #217 and had not tried to engage the resident. Resident #217 was not interviewable. Review of facility policy titled Feeding of Residents revised 07/28/21 revealed staff should engage with resident and maintain eye contact and conversation to create a pleasant dining experience. Residents Affected - Few 366079 Page 2 of 8 366079 11/16/2023 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and facility policy review the facility failed to ensure resident's wishes regarding advanced directives were accurate and clearly identified in a resident's medical record. This affected one resident (Resident #76) of five residents reviewed for advanced directives. The facility census was 113. Findings include: Review of Resident #76's medical record revealed an admission date of [DATE] and a facility re-entry date of [DATE] with diagnoses including myositis ossificans traumatica, adult failure to thrive, severe protein calorie malnutrition, anorexia, dementia, stage three chronic kidney disease, and longstanding persistent atrial fibrillation. Review of physician orders for Resident #76 dated [DATE] revealed a Do Not Resuscitate Comfort Care Arrest (DNR CC-Arrest) order which instructed Do Not intubate Protocol is activated when the patient experiences cardiac or respiratory arrest and further clarifies all other necessary treatments should be initiated prior to arrest. Review of Resident #76's electronic medical record on [DATE] revealed no code status and no advanced directive paperwork and review of the hard chart revealed no indication of code status or documentation of advanced directives. Interview on [DATE] at 10:25 A.M. with Licensed Practical Nurse (LPN) #970 and Central Supply/Medical Records staff (CSMR) #912 confirmed resident code status and any advanced directive documents could be found in the front of the hard chart but both LPN #970 and CSMR #912 were unable to find it. CSMR #912 further confirmed she would be printing and placing a copy of Resident #76's DNRCC-Arrest paperwork in the hard chart and presented the surveyor with what she referred to as a unit report which contained resident code statuses and pointed out the nurses can see from this printed report that Resident #76 was a DNRCC-A. LPN #970 acknowledged she was aware of this form and noted it gets updated whenever the unit census changes. Interview on [DATE] at 10:40 A.M. with LPN #971 confirmed she would look at the order summary report for code status orders and follow accordingly if resident code status was not readily found in the front of the hard chart or profile in the electronic medical record. Interview on [DATE] at 03:17 P.M. with State Tested Nurse Aide (STNA) #907 confirmed there was a printed nursing report on each nursing unit containing important resident information, including resident code statuses. Interview on [DATE] at 08:40 A.M. with Medication Technician #893 confirmed if she needed to know a resident code status, she could find it on the team report sheet, which she pulled out of a drawer on the unit to show the surveyor the report sheet contained code status orders for each unit resident. Interview on [DATE] at 09:57 A.M. with STNA #839 confirmed she did not know Resident #76's code status. When asked how she would find code status, she said to ask one of the nurses. 366079 Page 3 of 8 366079 11/16/2023 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0578 Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 02:32 P.M. with the Administrator confirmed there was no advanced directive paperwork in Resident #76's electronic medical record. She further stated there was no DNR paperwork uploaded to the electronic medical record due to an issue from Resident #76's last hospital admission. The administrator proceeded to present an order in the medical record date [DATE] indicating Resident #76 was a full code and added Resident #76 was not a DNRCC-A. Residents Affected - Few Interview on [DATE] at 02:50 P.M. with the Director of Nursing (DON) confirmed Resident #76 was a full code. The DON further confirmed the code status in Resident #76's profile was blank and the order for a full code was dated [DATE]. The DON also confirmed there was a code status order for a DNRCC-A effective from [DATE] to [DATE] and no signed advanced directive documentation, adding staff would have performed cardiopulmonary resuscitation (CPR) even if the order for a DNR was present if they did not have the signed DNR paperwork because that was the way we do it here. Review of admission paperwork from re-entry to the facility on [DATE] revealed hospital discharge orders indicated Resident #76 was a full code. Review of the undated Advanced Directive Procedure revealed the facility will determine whether the resident has any advanced directive upon admission, resident wishes will be communicated with facility staff, and all advanced directive document copies will be obtained and located with the resident's medical record. 366079 Page 4 of 8 366079 11/16/2023 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

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 observation, record review and interview the facility failed to ensure physician orders were followed for the use of Prevalon boots. This affected one resident (#7) of two residents observed for Prevalon boots. The facility census was 113. Residents Affected - Few Findings include: Review of the medical record for Resident #7 revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a memory problem, inattention, altered level of consciousness, and was a two-person total dependence for activities of daily living (ADLs). Review of the care plan dated 9/21/23 revealed Resident #7 medical conditions required monitoring and managed as ordered and interventions included to administer medications and treatments as ordered. Review of the physician orders dated 06/21/22 revealed an order for Prevalon boots every shift. Observation on 11/13/23 at 10:12 A.M. revealed Resident #7 was in bed with her Prevalon boots located on the floor near the bathroom entrance. Observation and interview on 11/16/23 at 8:44 A.M. with Registered Nurse (RN) #814, revealed Resident #7 was in bed without her Prevalon boots on. Resident #7 had multiple signs posted in her room that indicated her Prevalon boots were to be put on in the morning. RN #814 verified and confirmed Resident #7's Prevalon boots were not on and were located on the floor next to a reclining chair. 366079 Page 5 of 8 366079 11/16/2023 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure flammable materials were not left in resident rooms. This affected one resident (#21) of four residents reviewed for accident hazards. The facility census was 113. Review of Resident #21's medical records revealed an admission date of 02/01/19. Diagnoses included schizoaffective disorder and anxiety. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. Resident #21 required supervision with transfers, ambulation and personal hygiene. Review of the care plan dated 09/20/23 revealed Resident #21 was an independent smoker. Review of smoking assessment dated [DATE] revealed Resident #21 was safe to smoke unsupervised. Observation on 11/15/23 at 7:53 A.M. revealed Resident #21 had a pack of cigarettes, lighter and a canister of lighter fluid on his dresser. Interview on 11/15/23 at 11:29 A.M. with State Tested Nursing Assistant (STNA) #949 confirmed Resident #21 was an independent smoker and was able to keep his smoking materials in his room. Observation of Resident #21's room with STNA #949 at time of interview confirmed the canister of light fluid and STNA #949 stated Resident #21 should not have that substance in his room. Interview on 11/15/23 at 2:11 P.M. with Administrator revealed Resident #21 should not have had light fluid in his room and she stated she had educated Resident #21 on not having hazardous material in his room. 366079 Page 6 of 8 366079 11/16/2023 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview the facility failed to maintain a clean, safe, sanitary and well-maintained environment. This had the potential to affect all residents. The facility census was 113. Residents Affected - Many Findings include: An environmental tour was conducted on 11/16/23 between 10:45 A.M. and 11:20 A.M. with the Administrator. The following was observed and verified with the Administrator at the time of discovery. • Carpeted areas throughout the facility in resident rooms and common areas were noted with stains and debris throughout. • The unit three air purifier had a thick coating of dust and debris covering every part of its filter. • The room occupied by Resident #43 was noted with a non-hospital grade power strip with four outlets in use plugged in to the wall. • The poles used to hang intravenous (IV) medication used by Residents #53 and #219 were not clean. • The bathroom in Resident #52's room and had noticeable cobwebs on the light fixture about the mirror. • The recliner chair in Resident #36's room was dirty and with numerous unknown debris on it. • The footboard on the bed used by Resident #220 was detached from one side. • The bathroom in Resident #224's room contained an open yellow biohazard bag. • 366079 Page 7 of 8 366079 11/16/2023 Eliza Jennings Home 10603 Detroit Avenue Cleveland, OH 44102

F 0921 The rooms occupied by Residents #1,#75 and #76 had noticeable water stains on the ceiling. Level of Harm - Minimal harm or potential for actual harm • The room occupied by Resident #69 had a significant crack in the wall. Residents Affected - Many • The tube feed poles utilized by Residents #25,#69 and #73 were stained with residual tube feed and other debris. 2. Observation of the laundry area on 11/16/23 at 11:30 A.M. revealed the area behind the washer and dryer was dirty and full of numerous debris, lint and other items. A pile of towels was noted to be behind the washer and was discolored brown and full of unknown dirt and debris. Observations of the back panels of dryers revealed significant lint build up. Laundry Aide (LA) #897 11/16/23 verified the above findings at the time of observations. 366079 Page 8 of 8