Health inspection·June 21, 2021

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interviews, the facility failed to provide the correct Quality Improvement Organization (QIO) information to residents who were completing therapy. This affected three (Resident #22, Resident #243 and Resident #244) of three reviewed for liability notices. The facility also failed to provide 48-hour notice of the non coverage to the residents. This affected two (Resident #243 and Resident #244) of three reviewed for liability notices. The census was 43. Residents Affected - Few Findings include: 1. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 06/10/21. The letter did not provide the correct QIO information if the resident wanted to appeal. 2. Review of Resident #243's medical record revealed the resident was admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 12/15/20. The letter did not provide the correct QIO information if the resident wanted to appeal. Resident #243 signed his NOMNC on 12/15/20. 3. Review of Resident #244's medical record revealed the resident was admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 04/26/21. The letter did not provide the correct QIO information if the resident wanted to appeal. Resident #244 signed her NOMNC on 04/26/21. On 06/16/21 11:10 P.M. Receptionist #511 and Physical Therapist #586 verified the letters to the residents did not provide the correct QIO information and Resident's #243 and #244 signed their NOMNC's on the last covered day of therapy. Page 1 of 8 366266 366266 06/21/2021 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and resident interview the facility failed to ensure Resident #5 was free from unnecessary restraint. This affected one (Resident #5) of two residents reviewed for elopement. The facility census was 43. Residents Affected - Few Findings Include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder and psychotic disorder. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment and exhibited no physical, verbal or wandering behaviors. Review of the physician orders dated 12/17/19 revealed an order for a wanderguard to right wrist and to check placement every shift. A Wanderguard Bracelet triggers alarms and locks monitored doors to prevent the wearer from leaving an area unattended. Review of the policy entitled Wanderguard System dated 06/12/12 revealed ongoing assessment of the resident shall occur to identify changes in patterns, routines, or medical symptoms of the resident. Interventions shall be modified, as needed, to address any changes. Interview with the Assistant Director of Nursing (ADON) on 06/15/21 at 11:30 A.M. revealed the facility used an elopement/wandering assessment to assess the need for a Wanderguard. The ADON also explained Resident #5 came in with numerous behavioral issues (including exit seeking behaviors), a medication adjustment was done and Resident #5 stopped having wandering and related behaviors. The ADON further stated that he felt as if the facility never fully trusted her again and never removed the Wanderguard. Review of the elopement/wandering assessments for 06/10/21, 03/12/21, 12/11/20, 09/21/20 and 06/22/20 revealed the resident was at a low risk for wandering and elopement. Interview with Resident #5 on 06/15/21 at 1:10 P.M. revealed she hated the Wanderguard bracelet and found it to be totally unnecessary and felt like she was being treated as a bank robber. Review of the policy entitled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 01/01/17 revealed Residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical symptoms. 366266 Page 2 of 8 366266 06/21/2021 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, review of personnel files and the abuse policy and procedure, the facility failed to develop and implement policies and procedures to include screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property This affected nine of nine employees whose personnel files were reviewed for screening against the State of Ohio Nurse Aide Registry (Dietary Aide (DA) #587 , Registered Nurse (RN) #570, Maintenance Director (MD) #505, Activities Assistant (AA) #533 and State Tested Nursing Assistants (STNAs) #507, #526, #536, #540, #567). This had the potential to affect all 43 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel files for DA #587 , RN #570, MD #505, AA #533 and STNA's #507, #526, #536, #540, #567 revealed no evidence they were screened using the State of Ohio Nurse Aide Registry. The identification of findings would be necessary to determine if any employee had actions identified that would validate allegations of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property. Interview with the Assistant Director of Nursing on 06/17/21 at 12:50 P.M. verified their was no evidence that DA #587 , RN #570, MD #505, AA #533 and STNA's #507, #526, #536, #540, #567 were screened using the State of Ohio Nurse Aide Registry. Review of the policy entitled Abuse, Mistreatment, Neglect Exploitation and Misappropriation of Resident Property dated 01/01/17 revealed the facility will do the following prior to hiring a new employee Check with the Ohio nurse registry and any other registries for unlicensed persons that the Facility has reason to believe contain information on an individual, prior to the use of that individual. 366266 Page 3 of 8 366266 06/21/2021 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 staff interview the facility failed to ensure Pre admission Screen and Resident Review (PASRR) forms were completed timely as required and addressed all applicable mental health and developmental disability diagnoses. This affected two of three residents reviewed for PASRR compliance. The facility census was 43. Residents Affected - Few Findings Include: 1. Resident #12 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, overactive bladder and constipation. Further review of the medical record revealed Resident #12 was admitted to the facility on a hospital exemption form which in turn required the completion of the PASRR form within thirty days of admission. Review of the PASRR in the medical record revealed Resident #12's PASRR was completed on 06/16/21. 2. Resident #19 was admitted to the facility on [DATE] with diagnoses that included alcohol dependence, cerebral palsy and lack of coordination. Further review of the medical record revealed Resident #19 was admitted to the facility on a hospital exemption form which in-turn requires the completion of the PASRR form within thirty days of admission. Review of the PASRR in the medical record revealed Resident #19's PASRR was completed on 05/12/21 and the PASRR did not address Resident #19's diagnosis of cerebral palsy. Interview with the Assistant Director of Nursing on 06/16/21 at 10:10 A.M. verified that Resident #12 and Resident #19 PASRRs were not not completed within the 30 day time frame as required and that Resident #19's PASRR did not address her cerebral palsy diagnosis. 366266 Page 4 of 8 366266 06/21/2021 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure resident care plans were revised to reflect current resident medical/behavioral conditions. This affected one (Resident #5) of two residents reviewed for elopement. The facility census was 43. Findings Include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder and psychotic disorder. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact and exhibited no physical, verbal or wandering behaviors. Review of the physician order dated 12/17/19 revealed an order for a wanderguard to right wrist and to check placement every shift. Review of the elopement/wandering assessment for 12/16/19 revealed Resident #5 was at a high risk for wandering. Review of subsequent elopement/wandering assessments from 06/10/21, 03/12/21, 12/11/20, 09/21/20 and 06/22/20 revealed the resident was at a low risk for wandering and elopement. The medical record was also absent of any wandering behaviors. Review of the care plan dated 01/03/20 revealed Resident #5 exhibits exit-seeking behavior as evidenced by: Family has voiced concerns that would indicate the resident may have wandering tendencies or try to leave., Resident displays distress over placement., Resident displays restlessness or agitation., Resident has history of verbally expressing the desire to go home, packed belongings to go home. has also been known to walk up to the alarm system to see if it locks when she approaches it. Interview with the Assistant Director of Nursing (ADON) on 06/15/21 at 11:30 A.M. verified Resident #5's care plan was not updated to reflect current wandering behaviors. 366266 Page 5 of 8 366266 06/21/2021 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

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 record review and staff interview the facility failed to ensure physician orders were followed as written and medication was not given without a physician order. This affected two (Residents #5 and #42) of fifteen sampled residents. The facility census was 43. Residents Affected - Few Findings Include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder and psychotic disorder. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact and exhibited no physical, verbal or wandering behaviors. Review of the physician order dated 12/17/19 revealed an order for a wanderguard to right wrist and to check placement every shift. Review of both the electronic and paper medical records revealed no evidence of monitoring of the placement of Resident #5's Wanderguard. Interview with the Assistant Director of Nursing (ADON) on 06/15/21 at 11:30 A.M. verified their was no evidence of monitoring of the Wanderguard placement. The ADON explained that the paper order was never transcribed in to the electronic system for appropriate documentation and monitoring. 2. Resident #192 was admitted to the facility on [DATE] with diagnoses that included low back pain, muscle weakness and major depressive disorder. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #192 was cognitively intact and required supervision for activities of daily living. Resident #192 was discharged home with home health services on 01/09/20 Review of the physician orders for January 2020 for Resident #192 revealed Resident #192 received a lidocaine patch 5% every day for pain. Resident #42 was admitted to the facility on [DATE] with diagnoses that included pneumonia, muscle weakness and abnormal posture. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #42 was cognitively intact and required extensive assistance of two staff persons for activities of daily living. Resident #42 was discharged home with home health services on 01/27/20. Review of the physician orders for January 2020 for Resident #42 revealed Resident #42 received acetaminophen 1000 milligrams (mg) every six hours for pain. No other orders were noted in the medical record to address pain related issues/concerns Review of self reported incident (SRI) tracking #186489 on 01/05/20, revealed it was reported a staff nurse used Resident #192's medication for another resident . Review of the facility investigation revealed Resident #42 was complaining of left leg/hip pain, and Registered Nurse #590 indicated that she borrowed a lidocaine patch (pain reliving patch) that had been ordered and dispensed for Resident #142. The facility concluded that the lidocaine patch was in fact applied to Resident #42 without a valid physicians order. The facility Administrator verified the events of the SRI in an interview on 06/16/21 at 12:05 P.M. 366266 Page 6 of 8 366266 06/21/2021 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of the policy entitled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 01/01/17 revealed Residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Residents Affected - Few 366266 Page 7 of 8 366266 06/21/2021 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

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 and staff interview the facility failed to ensure a Wanderguard (device used for alerting staff of exit seeking from a resident) was functioning properly. This affected one (Resident #5) of two residents reviewed for elopement. The facility census was 43. Findings Include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder and psychotic disorder. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact and exhibited no physical, verbal or wandering behaviors. Review of the physician order dated 12/17/19 revealed an order for a wanderguard to right wrist and to check placement every shift. Observation of Resident #5 ambulating on 06/15/21 at 11:20 A.M. with the Director of Nursing revealed Resident #5's Wanderguard bracelet did not set off any alarms as designed when Resident #5 was near an exit door. The Director of Nursing verified Resident #5's Wanderguard was not functioning properly at the time of observation. Review of the policy entitled Wanderguard System dated 06/12/12 revealed When alarms are utilized, additional monitoring shall be provided, including but not limited to. Verifying alarms are working properly. 366266 Page 8 of 8