Health inspection·January 25, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #10's had a sanitary room free of bed bugs. This affected one resident (Resident #10) out of three residents reviewed for bed bugs. Findings include: Review of Resident #10's medical record revealed an admission date of 11/22/18 and diagnoses included alcohol dependence with alcohol induced persisting dementia and muscle weakness. Review of Resident #10's care plan revised 01/27/22 included Resident #10 had a self-care deficit and his needs would be met. Interventions included to assist Resident #10 with ADL's (Activity of Daily Living). Review of Resident #10's Head to Toe Evaluation dated 11/19/23 included Resident #10 had bed bug bites on his neck and the majority of his back area. The areas had small red splotches all over both areas. Review of the facility Pest Control Company invoices dated 11/20/23 revealed on 11/20/23 bed bugs were found in Resident #10's bed frame in room [ROOM NUMBER]. Resident #10 resided in the bed by the door, and both beds were heated. Resident #10's bed frame, baseboards, restroom and hallway were treated. Placed traps under both beds and would follow-up. Further review of the invoices revealed there was no additional documentation regarding bed bugs until 12/19/23. Review of the Pest Control Company invoice dated 12/19/23 revealed Resident #10's room was retreated for bed bugs. The wall outlet and a crack behind Resident #10's bed was heated. The baseboard in the room and hall was treated with a chemical which targeted bed bugs. The invoice did not have evidence Resident #10's metal bed frame and springs and mattress were inspected for bed bugs. Review of the Pest Control Company invoice dated 12/26/23 included Resident #10's door frame and bed frame were treated with the heat gun. The invoice further stated, treated baseboards in the room and hallway and would follow-up. There was no documentation regarding bed bug activity or if Resident #10's mattress was inspected for bed bugs. Review of the Pest Control Company invoice dated 12/27/23 included bed bugs were reportedly seen in the laundry room. The invoice stated no bed bug activity was found and the basement hall, laundry, utility room, restroom and storage area were treated. Page 1 of 7 366110 366110 01/25/2024 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #10's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 had no upper or lower extremity impairment and used a walker. Review of the Pest Control Company invoices dated 01/02/24 through 01/10/24 included bed bugs were reportedly seen in resident rooms #202, #205, #207, #208 and the nurses station. Inspection of bagged bedding and mattresses did not reveal bed bug activity. Bed frames were heated and treated. Baseboards in the rooms, hallways, restrooms were treated. Inspection of chairs in the nurses station did not reveal bed bug activity. There was no evidence Resident #10's room, metal bed frame or mattress was inspected for bed bugs. Observation on 01/24/24 at 11:14 A.M. with State Tested Nursing Assistant (STNA) #102 of Resident #10 revealed he was lying in bed on a bare mattress. When asked why there were no sheets on his bed Resident #10 said he did not know. Resident #10 got out of bed and stood in the room while STNA #102 donned disposable gloves and lifted the mattress to check for bed bugs. When the mattress was lifted bed bugs were seen crawling on the right lower corner of the mattress. STNA #102 screamed and dropped the mattress and said did you see the bed bugs. Interview on 01/24/24 at 11:25 A.M. of Licensed Practical Nurse (LPN) #112 revealed she saw bed bugs in the facility, but not recently. LPN #112 stated the bed bugs started in Resident #10's room and his room was treated multiple times for bed bugs. LPN #112 stated Resident #10 did not leave the facility or receive visitors so he could not be bringing bed bugs into the facility. LPN #112 stated she noticed bug bites on Resident #10's back and his back was kind of red. LPN #112 indicated when a bed bug was spotted in a resident room the resident's clothes were placed in bags and securely closed and sent to the laundry department, and the resident received a skin assessment and a shower. LPN #112 stated the chairs were also removed from the room. Interview on 01/24/24 at 12:43 P.M. of the Administrator revealed she was aware bed bugs were seen in Resident #10's room and the pest control company representative was on his way to the facility. The Administrator stated bed bugs were seen off and on in the facility, and the pest control company was called immediately when they were spotted. The Administrator indicated when bed bugs were found residents were moved out of their room and given a shower. The contents of the room was packed into bags, clothes were sent to the laundry and washed and dried on high heat. The Administrator stated residents were kept out of their room for 72 hours after the room was treated for bed bugs. The Administrator stated Resident #10 often took the sheets off his bed and she did not know why. Review of Resident #10's progress notes dated 01/24/24 at 1:46 P.M. included bug observed in Resident #10's room and protocol initiated. Area on Resident #10's back had minimal pink pimples observed prior to episode. Review of Resident #10's Weekly Skin Evaluation dated 01/24/24 included Resident #10 had current skin issues. Resident #10's skin was intact and he had red pimples to back, observed prior to incident. Interview on 01/24/24 at 2:01 P.M. of Pest Control Company Representative (PCCR) #143 revealed the facility had a monthly service contract and he would provide preventative maintenance and treat common areas and baseboards for ants. PCCR #143 indicated if he was told about other pests he would treat for that particular pest once he identified it. PCCR #143 stated 11/20/23 was the first time he was notified about bed bugs and they were in Resident #10's room. PCCR #143 stated he inspected the 366110 Page 2 of 7 366110 01/25/2024 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room and found bed bugs on Resident #10's metal bed frame and the bed bugs were also inside the springs of the metal frame. PCCR #143 indicated he treated Resident #10's metal bed frame with a heat gun, and sprayed the baseboards in the room with a chemical specifically made to kill bed bugs. PCCR #143 stated he did not see bed bugs on Resident #10's mattress, did not treat the mattress, and he did not know if the mattress was replaced. PCCR #143 revealed he inspected the furniture and if he did not see signs of bed bugs he did not treat the furniture. PCCR #143 stated he did not write it down on the invoice but he put a bait station for bed bugs under Resident #10's bed. PCCR #143 indicated Resident #10's room was the only room he found bed bugs, and sometimes the staff found bugs they thought were bed bugs but turned out to be another type of bug. PCCR #143 stated he retreated Resident #10's room on 12/26/24 but he did not see evidence of bed bugs and found no evidence of bed bugs in the facility until today. Observation on 01/24/24 at 2:25 P.M. of Resident #10's room with PCCR #143 revealed a bed bug trap was located under the bed and did not have evidence of bed bugs. Further observation of Resident #10's doorframe revealed little black spots along the bottom portion of the door frame and PCCR #143 stated this was evidence bed bugs were in the wall and the door frame and those areas needed treated. PCCR #143 stated he also found live bed bugs around the zipper of the mattress, and under the flap. When asked PCCR #143 stated it would be a good idea to replace the bed frame and the mattress. Interview on 01/24/24 at 3:02 P.M. of PCCR #143 revealed the facility was going to replace the mattress and the metal bed frame. PCCR #143 stated on 12/19/23 he treated Resident #10's door and cracks and crevices in the room for bed bugs because he saw activity. PCCR #143 stated on 12/19/23 he did not see bed bug activity on the mattress. PCCR #143 stated bed bugs stayed where the host was and could stay confined to one room because they did not move around unless they hitchhiked. Interview on 01/24/24 at 4:09 P.M. of the Administrator revealed the facility did not replace Resident #10's metal bed frame on 11/20/23 because PCCR #143 did not recommend they do that until 01/24/24. Interview on 01/25/24 at 9:43 A.M. of Maintenance Supervisor (MS) #116 revealed he was not aware and was not told Resident #10's metal bed frame and springs had bed bugs detected on them on 11/20/23. MS #116 stated if he was told he would have immediately taken Resident #10's mattress and metal frame out of the room. MS #116 stated he might not have been told because he was out of the building for some reason, and PCCR #143 usually gave him a summary of his visit. MS #116 stated he replaced Resident #10's mattress on 11/20/23 but no one mentioned finding bed bugs on the metal bed frame or bed bugs were hiding in the springs of the bed frame. MS #116 stated he inspected Resident #10's room the day after it was treated and did not see signs of bed bugs. Interview on 01/25/24 at 11:33 A.M. of PCCR #143 revealed when he treated a room for bed bugs he followed up on it and documented when he returned and inspected the room. PCCR #143 stated he did not remember if he told the Administrator or MS #116 bed bugs were found in Resident #10's metal bed frame springs. PCCR #143 stated he always gave a summary of his visit to the Administrator or MS #116 but did not always document who he spoke to. Review of the facility policy titled Pest Control Policy dated 02/01/19 included routine pest control procedures would be in place to prevent pest infiltration. Appropriate action would be taken to eliminate any reported pest situation in the department. This deficiency represents non-compliance investigated under Complaint Number OH00149630. 366110 Page 3 of 7 366110 01/25/2024 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

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 interview, record review, review of the facility policy, review of the facility fall investigation, and review of the Emergency Medical Services report the facility failed to ensure care and services and individualized care planned interventions for Resident #38 were implemented resulting in a fall. This affected one resident (Resident #38) out of three residents reviewed for falls. The facility census was 37. Findings include: Review of Resident #38's medical record revealed an admission date of 11/27/23 and diagnoses included burn of third degree of left lower limb, burn of third degree of multiple sites of left shoulder and upper limb, morbid obesity and atrial fibrillation. Review of Resident #38's Admission, readmission Evaluation dated 11/28/23 revealed Resident #38 was high risk for falls. Review of Resident #38's care plan dated 11/28/23 included Resident #38 was at risk for falls characterized by history of falls, injury and or multiple risk factors. Resident #38 would have minimized risk for falls and minimized injuries related to falls through the next review. Interventions included implement preventative fall interventions, devices; maintain call bell within reach; maintain resident's needed items within reach. There was no evidence of individualized fall interventions for Resident #38 including an air mattress or a perimeter mattress. Review of Resident #38's care plan revised 11/30/23 included Resident #38 had and ADL (Activity of Daily Living) self-care deficit related to third degree burns and decreased mobility. Resident #38's needs would be met with staff assistance as needed. Interventions included Resident #38 required assistance of two staff members for bathing, bed mobility, toileting, and transfers using a mechanical lift. Review of Resident #38's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 had severe cognitive impairment. Resident #38 had impairment on both sides of her upper and lower extremities. Resident #38 used a wheelchair and was dependent on staff for Activities of Daily Living, bathing, bed mobility and transfers. Resident #38 was always incontinent of bowel and bladder. Review of the facility Fall Committee Meeting Minutes dated 12/05/23 revealed Resident #38 was a new resident, a high fall risk, and new interventions were air mattress and perimeter mattress. Review of Resident #38's physician orders dated 12/05/23 revealed alternating air pressure mattress. Review of Resident #38's physician orders dated 12/05/23 through 01/15/24 did not reveal orders for a perimeter mattress. Review of Resident #38's Physical Therapy Discharge summary dated [DATE] included Resident #38 had minimal to no attempts to initiate bed mobility tasks and was significantly limited by pain and impaired cognition, resulting in poor carryover and difficulty participating in mobility tasks. Resident 366110 Page 4 of 7 366110 01/25/2024 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

F 0689 Level of Harm - Minimal harm or potential for actual harm #38 required 24 hours a day, seven days a week hands on assist for all mobility tasks. Interventions provided included therapeutic exercises, therapeutic activities, nursing staff education and training, positioning and pressure relief techniques and bed mobility training. Review of Resident #38's physician orders dated 12/19/23 revealed pleasure foods diet, pureed texture. Residents Affected - Few Review of Resident #38's local city EMS (Emergency Medical Services) Patient Care Report dated 01/15/24 revealed a 911 call was received on 01/15/24 at 6:56 A.M. and EMS was on scene at 7:14 A.M. Upon arrival Resident #38 was found sitting in a chair at the nurse's station. Resident #38 was alert to normal per staff, had a fall at 6:00 A.M. from her bed and was found prone on the floor by staff. Resident #38 complained of head pain via the fall and denied LOC (loss of consciousness). Resident #38 was on Eliquis (anticoagulant) and had a small contusion to her forehead. Vital signs were obtained (136/52 blood pressure, strong and regular pulse of 80, respirations 16) and Resident #38 was transported to the local hospital Emergency Department. Staff said they called at 6:00 A.M. when Resident #38 fell but the 911 call time was 6:56 A.M. Review of Resident #38's progress notes dated 01/15/24 included a nursing assistant called for the nurse due to Resident #38 fell out of bed and was laying on the floor. Vital signs were taken and were wnl (within normal limits) and Resident #38 was assisted off the floor and cleaned up. Resident #38 did not complain of pain, her physician was contacted and an order to send Resident #38 to the local hospital was obtained. Review of Resident #38's Post Fall Huddle Form dated 01/16/24 included Resident #38's fall was located in her room and she said she was looking for her brother. Resident #38 was last visualized at 4:30 A.M. and she was lying in bed. It was unknown when Resident #38 was last toileted and Resident #38's undergarment was wet. Resident #38 was wearing Prevalon boots. It was unknown if all current interventions were in place. Resident #38 was assisted off the floor using a mechanical lift. The five whys and root cause stated to center resident in bed, utilize two people, height of bed, and fluids. Review of Resident #38's fall investigation dated 01/17/24 included Resident #38 was transferred to the hospital on [DATE] following being found on the floor. Resident #38 received continuous tube feeding and her head of the bed was elevated. The State Tested Nursing Assistant (STNA) and Licensed Practical Nurse (LPN) both indicated Resident #38 was calling out for water during the night and the head of her bed was raised to give her water orally. When the STNA observed Resident #38 on the floor between the bed and window on the side of the bed the tube feeding was positioned she noted the head of the bed was in an elevated position like when Resident #38 received water orally. Resident #38 did not have adequate upright trunk control and was dependent on staff for all aspects of ADL and mobility. If the head of Resident #38's was elevated, she could not maintain upright posture and if she leaned forward or coughed or had a spasm and her upper body moved forward she would be unable to reposition herself and gravity might have resulted in Resident #38 falling forward from the bed. When Resident #38 was observed on the floor she was in the face down position with her chin resting on the tube feeding pole and one hand was around the pole. The actual cause of the fall was unable to be determined but this could be a plausible explanation. Interview on 01/24/24 at 12:31 P.M. of Registered Nurse/Regional Director of Clinical Services (RN/RDCS) #144 revealed Resident #38 had a fall on 01/15/24 and was transferred to the local hospital Emergency Department. RN/RDCS #144 stated Resident #38's communication was inconsistent and she mumbled. RN/RDCS #144 stated the fall investigation was inconclusive, Resident #38 was dependent on staff 366110 Page 5 of 7 366110 01/25/2024 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for care and did not have upright trunk control. RN/RDCS #144 stated Resident #38 received tube feeding, the head of her bed was elevated due to tube feeding and she could have pureed pleasure foods. RN/RDCS #144 stated Resident #38's bed did not have grab bars and when her weight shifted forward she was not able to stop herself. RN/RDCS #144 stated she interviewed the staff who cared for Resident #38 when she fell and the head of her bed might have been up at approximately 60 degrees and the fall was unwitnessed. RN/RDCS #144 indicated the aide who cared for Resident #38 said she put the head of Resident #38's bed up earlier in the night, but lowered it after she provided care. RN/RDCS #144 stated the nurse (LPN #145) said she raised the head of the bed to give Resident #38 water and she might have forgotten to put the head of her bed down afterwards. Interview on 01/24/24 at 4:03 P.M. of Licensed Practical Nurse/Minimum Data Set (LPN/MDS) #106 confirmed Resident #38 was a high fall risk and there were no individualized interventions in her care plan. LPN/MDS #106 stated Resident #38's interventions included to have her call light in reach and have needed items in reach. LPN/MDS #106 stated Resident #38 did not have a fall yet and after she had a fall LPN/MDS #106 would build more individualized interventions into her care plan. Interview on 01/25/24 at 11:38 A.M. of Director of Rehab (DOR) #142 revealed Resident #38 was evaluated by Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) while she resided in the facility. DOR #142 stated ST recommended to allow Resident #38 to have pleasure foods with feeding assistance and supervision, and tube feeding was primary form of nutrition. DOR #142 indicated Resident #38 was in a lot of pain and was unable to participate with OT and PT. DOR #142 stated Resident #38 was totally dependent on staff for mobility, was unable to perform static sitting (maintain one alignment for a prolonged period of time, sitting upright and stationary), and would fall over because she could not stay upright. DOR #142 stated Resident #38 would not be able to tolerate sitting. DOR #142 stated Resident #38 was recommended to have an air mattress with a perimeter mattress around the air mattress. DOR #142 indicated the perimeter mattress was around the air mattress because the air mattress was a slippery surface and it would be easy for Resident #38 to slide out of the neutral position. DOR #142 stated pillows were used for positioning for edema management and would not typically keep a resident in bed. DOR #142 stated a perimeter mattress was recommended with an air mattress to keep Resident #38 from sliding out of bed. Interview on 01/25/24 at 12:29 P.M. of STNA #138 revealed Resident #38 required two staff for her care and could not sit up on her own. STNA #138 stated Resident would not be able to right herself if she fell over. Interview on 01/25/24 at 1:01 P.M. of RN/RDCS #144 confirmed Resident #38 was a high fall risk and an intervention would be to ensure call lights were in reach and the bed was in low position when care not being provided. RN/RDCS #144 stated Resident #38's bed was in the low position when she fell but confirmed there was no evidence the bed was in low position in Resident #38's medical record including care plan, fall investigation and progress notes. RN/RDCS #144 confirmed Resident #38's care plan did not have individualized interventions, and confirmed there was no evidence Resident #38 had a perimeter mattress including in the care plan, physician orders and progress notes. Interview on 01/25/24 at 1:42 P.M. of STNA #104 revealed Resident #38 asked for water about 40 minutes before she fell, she did not raise the head of her bed higher and brought the water cup with a straw to Resident #38's lips so she could drink the water. STNA #104 stated she left Resident #38's room after she gave her water to provide care for other residents and did not know what happened after that until she walked by Resident #38's room and did not see her in the bed. STNA #104 stated she asked LPN #145 if she knew where Resident #38 was and she said no, and STNA #104 went back to her 366110 Page 6 of 7 366110 01/25/2024 Crawford Manor Healthcare Center 1802 Crawford Rd Cleveland, OH 44106

F 0689 Level of Harm - Minimal harm or potential for actual harm room and found Resident #38 on the floor, face down, holding the tube feeding pole. STNA #104 indicated the head of Resident #38's bed was elevated more than when she was in the room giving her water. STNA #104 stated LPN #145 told her she gave Resident #38 water before she fell. STNA #104 stated Resident #38 did not have a perimeter mattress on the bed or grab bars and she wished she did because she was so upset and cried when she found Resident #38 on the floor. Residents Affected - Few Review of the facility policy titled Fall Prevention and Management Policy dated 12/09/19 included residents would be assessed for fall risk on admission, quarterly, after any fall, and as needed. Individualized interventions would be implemented based on the assessment and care planned accordingly. Providers would be consulted regarding risks and interventions, feedback and any further approaches recommended. This deficiency is an example of continued non-compliance from the survey dated 12/28/23. 366110 Page 7 of 7