Health inspection·September 25, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure notification of a resident's change in condition and subsequent hospitalization. This affected one resident (#31) of one resident investigated for notification. The census was 108. Findings include: Review of Resident #31's record revealed an admission date of 10/02/23. Diagnoses included multiple sclerosis, diabetes mellitus II and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 required staff assistance with all activities of daily living. Further review of the medical record including progress notes revealed no documentation Resident #31's family was notified of a change in status with subsequent hospitalization. Review of the Telehealth notification dated 08/24/24 at 7:19 P.M. revealed Resident #31 on video, repeating, I feel good, I feel good, and I feel oriented, I feel oriented, and I feel good, I feel good, I'm getting ready to watch a movie, I'm getting ready to watch a movie. Then back to, I feel good. She appeared lethargic. Further review revealed nursing stating she was usually alert and oriented times four. Sending her to emergency room (ER) for further treatments and evaluation. Feel she may need a urinalysis and/or CT of head. Review of a nurse note dated 08/24/24 timed at 7:57 P.M. revealed Resident #31 was repeating words over and over. She was alert to self and place only. She did not seem like her usual self. Telehealth was notified and ordered her to be sent out. Interview with the Licensed Practical Nurse/Unit Manager #316 on 09/25/24 at 10:57 P.M. confirmed the lack of notification to the family concerning Resident #31's change in status and subsequent hospitalization. Review of the facility's undated policy Notification of Change in Condition revealed the attending practitioner would be promptly notified of significant changes in condition and the medical record must reflect the notification, response and interventions implemented to address the resident's condition. The policy also revealed when a change in condition was noted, the nursing staff would contact the resident representative. Notifications that for emergency situations required prompt notification as soon as time permitted. Examples included but were not limited to: transfer to hospital, severe change in physical or mental health and unexpected death. This deficiency represents non-compliance investigated under Complaint Number OH00157587. Page 1 of 6 366111 366111 09/25/2024 Falling Water Healthcare Center 18840 Falling Water Strongsville, OH 44136

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure dependent residents received routine showers. This affected two residents (Resident #13 and #31) of three residents (Residents #13, #31, and #70) reviewed for activities of daily living (ADLs). The facility census was 108. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 08/11/23 with diagnoses including history of traumatic brain injury, depression, anxiety disorder, and seizures. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/06/24, revealed Resident #13 had intact cognition and was dependent for ADLs. Further review of the medical record revealed no documentation of Resident #13 refusing showers. Interview on 09/24/24 at 9:30 A.M. with Resident #13 revealed he did not receive showers as scheduled. Resident #13 stated that he had to repeatedly ask for showers. Interview on 09/25/24 at 9:07 A.M. with Licensed Practical Nurse (LPN) #316 revealed LPN #316 could only find one completed shower sheet for Resident #13. LPN #316 confirmed this was the only documentation indicating Resident #13 received a shower in the past three months. Review of Resident #13's shower sheets revealed that only one shower was documented for the past three months. 2. Review of the medical record for Resident #31 revealed an admission date of 10/02/23 with diagnoses including multiple sclerosis, major depressive disorder, and anxiety disorders. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/06/24, revealed Resident #13 had intact cognition and was dependent for all ADLs except eating. Interview on 09/24/24 at 9:28 A.M. with Resident #31 revealed she did not get showered like she was supposed to. Interview on 09/25/24 at 9:07 A.M. with Licensed Practical Nurse (LPN) #316 revealed LPN #316 could only find one completed shower sheet for Resident #31. LPN #316 confirmed this was the only documentation indicating Resident #31 received a shower in the past three months. Review of the facility's policy Routine Care, dated 05/01/24 revealed routine care by a nursing assistant included but was not limited to bathing, dressing, and toileting. 366111 Page 2 of 6 366111 09/25/2024 Falling Water Healthcare Center 18840 Falling Water Strongsville, OH 44136

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Many Based on record review, interview, and the facility submitted Payroll Based Journal (PBJ) tracking information, the facility failed to ensure the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 108 residents residing in the facility. Findings include: Review of the PBJ Staffing Data Report form submitted from 10/01/23 to 12/31/23 revealed on the following dates submitted for the first quarter of the fiscal year 2024, the facility was low on RN hours in the building on 10/01 (Sunday); 10/14 (Saturday); 10/15 (Sunday); 10/28 (Saturday); 10/29 (Sunday); 11/11 (Saturday); 11/12 (Sunday); 11/25 (Saturday), and 11/26 (Sunday). Interview on 09/25/24 at 7:54 A.M. with the Administrator revealed she began working at the facility in April 2024 and at that time was told there was a concern with getting registered nurses hired. The administrator stated they hired RNs since then and they should be okay now. Review of schedules and assignment sheets from 10/01/23 to 12/31/23 with Payroll Specialist (PS) #279 on 09/25/24 at 8:47 A.M. confirmed a RN was not present in the building for at least eight consecutive hours a day, seven days a week as required on the following dates during the first fiscal quarter of 2024: 10/01 (Sunday); 10/14 (Saturday); 10/15 (Sunday); 10/28 (Saturday); 10/29 (Sunday) 11/11 (Saturday); 11/12 (Sunday); 11/25 (Saturday), and 11/26 (Sunday). Review of schedules and assignment sheets from 01/01/24 through 03/31/24 with PS #279 on 09/25/24 at 8:47 A.M. revealed a RN was not present in the building for at least eight consecutive hours a day, seven days a week as required on the following dates during the second fiscal quarter of 2024: 01/06 (Saturday); 02/17 (Saturday); 02/18 (Sunday); 03/16 (Saturday); 03/17 (Sunday), and 03/31 (Sunday). Review of schedules and assignment sheets from 04/01/24 through 06/30/24 with PS #279 on 09/25/24 at 8:57 A.M. revealed a RN was not present in the building for at least eight consecutive hours a day, seven days a week as required on the following dates during the third fiscal quarter of 2024: 04/13 (Saturday); 04/14 (Sunday), and on 06/30 (Sunday) when the scheduled RN left four hours early related to an emergency. The deficient practice was corrected on 07/01/24 when the facility implemented the following corrective actions. • On 05/01/24 The scheduler, Director of Nursing (DON) and Administrator were in-serviced on the need to have a RN in the building 24 hours seven days a week by the Regional Director of Operations. • 366111 Page 3 of 6 366111 09/25/2024 Falling Water Healthcare Center 18840 Falling Water Strongsville, OH 44136

F 0727 Level of Harm - Minimal harm or potential for actual harm On 05/01/24, the corporation started daily meetings to ensure RN coverage. The attendees included the Administrator, DON, Regional Director of Operations (RDO), Facility Scheduler, and Divisional Director of Workforce Management. The daily meetings looked forward regarding staffing and reached out and offered overtime to staff in sister facilities to ensure appropriate coverage. Residents Affected - Many • On 05/01/24, the corporation started weekly Zoom meetings to audit RN coverage. The attendees included the Administrator, DON, Regional Director of Operations (RDO), Facility Scheduler, and Divisional Director of Workforce Management. This weekly meeting monitored RN coverage and looked at the past week to ensure proper RN coverage. • On 05/01/24 the facility implemented an on-call RN, who would work eight consecutive hours if a RN called off on a weekend. • On 05/01/24, the facility implemented a corporate scholarship program within the facility for RNs from foreign countries that did not have Ohio RN licensure. This included curricular and practicum training at the facility. The Bachelor degreed RNs from their country of origin would sit for the United States National Council Licensure Exam (US NCLEX) exam and upon passing would be hired by the facility. The facility hired four RNs (RN #258, RN # 268, RN #252, and RN #900), who received housing, meals and transportation. The RNs were contracted for three years of employment and worked as State Tested Nurse Aides (STNAs) after becoming certified until passing the NCLEX. • Review of the personnel files for RN #258, RN # 268, RN #252, and RN #900 revealed each had required licenses and appropriate screening and hiring procedures were followed. • On 05/20/24, RN #252 was hired. • On 07/22/24, an Assisted Director of Nursing (RN) was hired. • On 08/20/24, RN #301 was hired. • On 09/19/24, RN #900 was hired. • 366111 Page 4 of 6 366111 09/25/2024 Falling Water Healthcare Center 18840 Falling Water Strongsville, OH 44136

F 0727 Level of Harm - Minimal harm or potential for actual harm Review of schedules and assignment sheets from 07/01/24 through 09/22/24 with PS #279 on 09/25/24 at 9:07 A.M. revealed a RN was present in the building for at least eight consecutive hours a day, seven days a week as required. This deficiency represents non-compliance investigated under Complaint Number OH00157574. Residents Affected - Many 366111 Page 5 of 6 366111 09/25/2024 Falling Water Healthcare Center 18840 Falling Water Strongsville, OH 44136

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview, and policy review the facility failed to ensure infection control measures were followed during medication administration. This affected one of four residents observed during medication administration, Resident (#59). The census was 108. Residents Affected - Few Findings include: Record review for Resident #59 revealed an admission date of 11/13/23. Diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration, epilepsy and alcohol abuse with intoxication. Review of the Minimum Data Set (MDS) 3.0 assessment revealed Resident #59 required assistance from staff for activities of daily living. Review of Resident #59's physician orders revealed on order dated 12/08/23 for levetiracetam oral tablet 750 milligrams (mg). Give two tablets by mouth every morning and at bedtime for epilepsy. Observation on 09/24/24 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #315 preparing to administer medication for Resident #59. LPN #315 popped two levetiracetam tablets directly into her hand from a blister pack then put them in the medication cup that was on the medication cart. Interview with LPN #315 immediately after popping the two tablets of levetiracetam directly into her bare hand revealed she did it because they were large tablets. Review of the facility policy Medication Administration, dated 04/16/24 revealed the procedures for administering medications included not touching the medications with bare hands when opening a liquid or dose pack. 366111 Page 6 of 6