Health inspection·February 21, 2019

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some 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 interview and record review, the facility failed to notify the office of the Long-Term Care Ombudsman of resident's transfers to the hospital. This affected two (Resident's #11 and #44) of two residents reviewed for hospitalization. The facility census was 40. Findings include: Record review revealed Resident #11 was admitted on [DATE]. Diagnoses included dementia, anxiety, hypertension, tachycardia (a fast heart rate) and bradycardia (a slow heart rate). Review of Resident #11's progress notes revealed on 02/05/19 at 12:22 P.M., Resident #11 had a low-grade temperature and was slow in responding to staff. The physician was notified and gave a new order to send resident to the hospital. There was no documentation found to indicate the office of the Long-Term Care Ombudsman was notified of Resident #11's transfer to the hospital. Record review revealed Resident #44 was admitted on [DATE]. Diagnoses included seizures, dementia, hypertension, atrial fibrillation an irregular heartbeat. Review of Resident's #44 progress notes revealed on 10/06/18 at 12:32 A.M., Resident #44 had severe pain right flank, between ribs and hip, pain. There was no documentation found to indicate the office of the Long-Term Care Ombudsman was notified of Resident #44's transfer to the hospital. Interview on 02/21/19 at 4:31 P.M. with Clinical Regulatory Specialist verified there was no evidence the Office of the Long-Term Care Ombudsman was notified of Resident's #11 and #44 transfers to the hospital. The facility was not notifying the Long-Term Care Ombudsman of residents that were transferred to the hospital. Page 1 of 4 366266 366266 02/21/2019 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

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 on record review and interview, the facility failed to ensure accurate resident assessments. This affected two residents (Resident's #14 and #31) of 21 residents reviewed for accurate assessments. The facility census was 40. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, dementia with behavioral disturbances, dysphagia, and acquired absence of kidney. Review of Resident #14's Minimum Data Set (MDS) 3.0 assessment, dated 12/21/18, indicated the resident exhibited severe cognitive impairment and did not receive any opioids for pain. Review of Resident #14's medical record, physician orders, medication administration records (MAR) and treatment administration records (TAR) for December 2018 revealed Resident #14 received three doses of the opioid Ultram during the assessment period. Interview on 02/22/19 at 10:10 A.M. with MDS Nurse #32 confirmed Resident #14's comprehensive MDS 3.0 assessment, dated 12/21/18, was inaccurate, and the resident did receive three doses of the opioid Ultram during the assessment reference period. 2. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including dysphagia, Alzheimer's, major depressive disorder, dementia with behavioral disturbances, and convulsions. Review of Resident #31's MDS 3.0 assessment, dated 01/13/19, indicated the resident had severe cognitive impairment, required assistance with most activities of daily living (ADL), was frequently incontinent of urine, and always incontinent of bowel. The MDS indicated toilet use did not occur. Interview on 02/22/19 at 4:56 P.M. with MDS Nurse # 32 confirmed Resident #14's comprehensive MDS 3.0 assessment, dated 01/13/19, was inaccurate, and the resident did require extensive assist of two persons for toileting. 366266 Page 2 of 4 366266 02/21/2019 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, review of Centers for Disease Control (CDC) guidelines and policy review, the facility failed to ensure appropriate infection control procedures were enacted for two residents (Resident #194 and Resident #38) of 22 residents reviewed for infection control procedures. The facility census was 40. Residents Affected - Few Findings Include: 1. Review of the medical record revealed Resident #194 was admitted to the facility on [DATE] with diagnoses including post-operative therapy after cervical spinal surgery, a positive test for the Influenza A virus, neuromuscular dysfunction of the bladder (a condition causing difficulty with bladder control), heart disease, chronic obstructive pulmonary disease, and chronic kidney disease. Review of the medical record revealed on 02/17/19 Resident #194 developed a fever of 101.7 degrees Fahrenheit (F), a low oxygen saturation rate of 90% on room air (the normal range should be 94% to 100% on room air), and increased pain with periods of confusion. The resident was given Tylenol (pain reliever and fever reducer), which did bring down his temperature to 99.7 degrees F. On 02/18/19 Resident #194's condition continued to decline as the resident became increasingly weaker, sliding out of his wheelchair and needing three staff members to assist him back into bed, an increased temperature of 99.6 degrees F, and a decrease in his oxygen saturation level to 93% on room air. The resident's wife requested he be sent to the local emergency room (ER) for evaluation which Medical Director (MD) #200 ordered. The facility called 911,and the resident was transported to the ER. Resident #194 was admitted overnight with a diagnosis of Influenza A (a contagious respiratory virus). The resident was readmitted to the facility on [DATE] with a prescription for Tamiflu (an anti-viral medication used to treat influenza) and was placed in isolation to prevent further exposure to other residents, visitors, and staff. A sign was placed on the resident's doorframe instructing visitors to speak with the nurse prior to entering the resident's room. Observation of Resident #194's room on 02/20/19 at 10:30 A.M. revealed a sign posted on the door frame asking visitors to see the nurse prior to entering the room. The Centers for Disease Control (CDC) recommendations for droplet precautions include placing the infected resident in a private room if possible, wearing a face mask whenever entering the room, having the infected resident wear a face mask if it is necessary to leave the room, and to notify anyone having contact with the resident of the necessary precautions to be utilized to prevent others from becoming ill. No personal protective equipment (PPE) was available for staff and visitors to put on prior to entering Resident #194's room. PPE is used to protect staff and visitors from exposure to potential infections. Influenza A requires droplet precautions as the virus can be spread through coughing and respiratory secretions. There was no sink in the room for staff or visitors to wash their hands before exiting the room. Interview with Licensed Practical Nurse (LPN) #32, the facility's Infection Control Preventionist, on 02/20/19 at 11:43 A.M. revealed Resident #194 was placed on isolation precautions for Influenza A on 02/19/19 when he was re-admitted to the facility upon his discharge from a local hospital. LPN #32 stated if the resident had to leave his room he must wear a face mask in order to prevent further spread of the virus. This surveyor and LPN #32 went to Resident #194's room and no isolation equipment was found in the hallway. LPN #32 said all PPE was kept inside the resident's room. When questioned if she realized all PPE was contaminated from being stored in an isolation room, LPN #32 replied she had thought it would be okay. 366266 Page 3 of 4 366266 02/21/2019 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Director of Nursing (DON) and the Regulatory Compliance Nurse Registered Nurse (RN) #95, and the Assistant Administrator (RN #53) on 02/20/19 revealed they also believed having the required PPE inside Resident #194's room would be acceptable, but they have now placed the equipment outside the resident's room. An interview was conducted with Housekeeper (Hskg) #22 on 02/21/19 at 8:10 A.M., when questioned about what was required from a housekeeper when a resident was placed on droplet precautions for influenza, Hskg #22 said supplies were placed outside the door, she would put on any PPE the nurse instructs her to wear, and she always wore gloves. Hskg #22 said she always put on gloves to clean a room but did not know she was supposed to be wearing a face mask until 02/20/19 when face masks were placed outside of Resident #194's room. When questioned what she does when she is ready to leave the room Hskg said she takes off her mask and gloves and places them in her garbage can on her cleaning cart. Hskg #22 said she would normally wash her hands before leaving the room, but since Resident #194's room did not have a sink, she leaves the room and then washes her hands in another resident's room. Observation of Resident #194's room on 02/21/19 at 10:00 A.M. revealed PPE supplies were now located outside of the resident's room. 2. Review of Resident's #38 medical record revealed diagnoses of diabetes and hypertension. February 2019 physicians' orders revealed Resident #38 and an order for Metoprolol 50 milligrams (mg.), used to lower blood pressure, twice a day and an order to check blood sugar levels before meals and at bedtime. Observation on 02/22/19 at 8:25 A.M. of the medication administration for Resident #38 by RN #12 revealed without washing or sanitizing hands she popped the Metoprolol pill form the blister packed card into a medication cup and added applesauce, poured a glass of water and proceeded to Resident's #38 room. RN #12 pulled out a plastic baggy from the nightstand that contained supplies for the accu-check, a glucometer is a meter used to measure blood sugar, a lancet (a pricking needle to obtain a drop of blood), test strips, and alcohol wipes. The glucometer was set up and without applying gloves. RN #12 wiped Resident's #38 finger with an alcohol and pricked with lancet to obtain a blood sample and a glucose reading then placed the glucometer back into the plastic baggy with the clean supplies without disinfecting the glucometer. RN #12 spooned the Metoprolol into resident's mouth then threw the used lancet into the garbage, washed her hands and exited the room. Interview with RN #12 on 02/22/19 at 8:35 A.M. revealed no hand washing occurred prior to preparing medication, and she did not apply gloves before performing Resident #38 accu-check. Disinfecting did not occur prior to returning the glucometer back into the baggy. RN #12 revealed she washes her hands prior to medication administration, wears gloves while performing accu-check and disinfects glucometer after use however, this did not occur due to being nervous. Interview on 02/22/19 at 8:53 A.M. with the Director of Nursing (DON) verified the findings and proceeded to Resident's #38 room, retrieved the used lancet out of the garbage container and placed it in the sharps container on the medication cart. Review of policy titled 'Obtaining a fingerstick glucose level, revised October 2011, revealed the glucometer is to be disinfected between resident uses. Clean gloves are to be worn for accu-checks and used lancets are to be disposed in sharps containers. 366266 Page 4 of 4