Health inspection·October 13, 2022

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 Resident #4 was provided a reasonable accommodation to enter the facility and did not ensure Resident #50's wheelchair was serviced and repaired in a timely manner. This affected two residents (Residents #4 and #50) of two residents reviewed for accommodation of needs. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 02/22/22 with diagnoses including chronic obstructive pulmonary disease (COPD), anemia, nicotine dependence, anxiety disorder and morbid obesity. Review of the smoking assessment dated [DATE] revealed the resident was an unsupervised smoker, but required assistance getting outside in her wheelchair. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. She was totally dependent on two people for transfers and she required extensive assistance of two people for bed mobility, dressing and toilet use. Review of Resident #4's care plan dated 08/30/22 revealed the resident had COPD due to smoking. Interventions included avoiding extreme hot and cold temperatures, monitoring for signs and symptoms of respiratory insufficiency, and oxygen as tolerated. Observation on 10/12/22 at 8:22 A.M. revealed Resident #4 in a motorized wheelchair on the smoking patio. Interview at the time of the observation revealed she knew the code to get back into the building, but she could not reach the keypad. She would wait until another resident went back into the building and held the door for her so she could maneuver her wheelchair through the door. Interview on 10/12/22 at 8:30 A.M. with State Tested Nursing Assistant (STNA) #204 revealed she was aware Resident #4 was outside, but there was no procedure for letting residents back in when they went outside. She opened the door for Resident #4 so she could reenter the building. STNA #204 needed to ask this surveyor to hold the door open so Resident #4 could safely enter as the door did not stay open on its own. Observation on 10/13/22 at 10:02 A.M. revealed a doorbell had been installed on the door frame used to enter the smoking patio, directly underneath the keypad. This surveyor pushed the doorbell button and waited for an employee to respond. Within approximately two minutes, STNA #208 looked down the hall through the window of the door and saw this surveyor standing outside. She then opened the Page 1 of 8 366270 366270 10/13/2022 Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few door. Interview at the time of the observation with STNA #208 revealed she did not think the doorbell worked, she just happened to see me standing outside. She confirmed staff have to let residents outside to use the smoking patio and other residents will usually open the door if a resident does not know the code or cannot let themselves back in. Interview on 10/13/22 at 1:07 P.M. with Registered Nurse #200 confirmed there was no procedure for residents getting back into the building from the smoking patio. Review of the facility policy titled, Smoking policy - Residents, revised 04/2012 revealed smoking was only permitted outside the building, and any smoking related concerns will be noted in the resident's care plan and staff would be alerted. 2. Review of the medical records for Resident #50 revealed she was admitted on [DATE] with diagnoses including intracranial injury without loss of consciousness, depressive disorder, convulsions and anxiety. Review of the 06/14/22 invoice for Resident #50's wheelchair revealed it was a tilt in space with elevating manual leg rests and adjustable foot plates. Review of Resident #50's care plan of 07/22/22 revealed care areas for a traumatic brain injury related to a motor vehicle accident, chronic pain, extensive assistance of two for ADLs. The resident had received occupational therapy from 09/12/22 to 09/28/22. Review of the quarterly MDS 3.0 of 09/24/22 revealed the resident was severely cognitively impaired, required extensive assist of two for ADLs and was at risk of pressure ulcers. Interview on 10/11/22 at 11:04 A.M. with Resident #50 and her father revealed the facility was supposed to lengthen her wheel chair so she could fully extend her left leg about two months ago. The resident was seated in her tilt in space custom wheelchair and her left leg was in a slightly bent position with both legs elevated on an armless chair. Their were no legs rests on her wheelchair. One leg rest was visible laying against the wall in the resident's room. Further observations of Resident #50 on 10/12/22 at 10:45 A.M. and 1:55 P.M. and on 10/13/22 at 11:35 A.M. revealed the resident was using a chair to put her legs up since there were no leg rests on her chair. Interview on 10/12/22 at 8:47 A.M. with the Director of Rehab (DOR) #207 revealed that she was aware of Resident #50's not being able to fully extend her legs for awhile. DOR #207 had tried extending the wheelchair herself but she did not have the proper tools. She reported she did not call the wheelchair company for service at that time because she forgot things sometimes. She reported the one leg rest fell off recently and she had a call in for repair. Interview on 10/13/22 at 10:12 A.M. with Licensed Practical Nurse (LPN) verified Resident #50 and her father had requested the leg rests be extended on her wheelchair over a month ago but it was not done. The leg rest fell off sometime in the past week. Interview on 10/13/22 at 10:28 A.M. with Regional LPN #212 verified the service needed for Resident #50's wheelchair was not addressed in a timely manner. 366270 Page 2 of 8 366270 10/13/2022 Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076

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 (Resident #34) of eight residents reviewed for elopement care plans. Findings include: Review of the medical record for Resident #34 revealed an admission date of 05/01/22 with diagnoses including bipolar disorder, depression, amnesia and post traumatic stress disorder (PTSD). Review of the progress note dated 06/08/22 and timed 5:44 P.M. revealed Resident #34 was walking in town when a police officer found her. When Resident #34 returned to the facility, the Director of Nursing (DON) was notified of the incident and contacted the guardian. It was agreed Resident #34's privileges to leave the facility would be revoked. Review of the care plan dated 08/23/22 revealed Resident #34 was a low risk for elopement. Interventions included ensuring safety during periods of confusion or anxiety, unsupervised smoke breaks and being able to walk to the store per the resident's Power of Attorney (POA). Review of the elopement/wandering assessment dated [DATE] revealed Resident #34 was at a low risk for wandering and elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 was cognitively intact and exhibited no physical, verbal or wandering behaviors. Resident #34 had a legal guardian. Review of the nurse's notes dated 07/11/22, 08/13/22, 09/23/22, 10/03/22, 10/04/22 and 10/05/22 revealed Resident #34 left the building without permission from her guardian. Interview with the Director of Nursing on 10/13/22 at 1:34 P.M. verified Resident #34's care plan was not updated to reflect current elopement behaviors. 366270 Page 3 of 8 366270 10/13/2022 Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076

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 Based on interview, and record review, the facility failed to ensure Resident #41's bowel pattern was effectively managed. This affected one resident (Resident #41) of two residents reviewed for constipation. Residents Affected - Few Findings include: Review of medical record for Resident #41 revealed an admission date of 12/21/21 and diagnoses included morbid obesity, heart failure, chronic respiratory failure, diabetes, and kidney failure. He did not have a diagnosis of constipation. Review of care plan dated 12/22/21 revealed Resident #41 had an activities of daily living self-care performance deficit related to impaired balance, and morbid obesity. Interventions included he required staff assist with transfers, bed mobility, and toileting. Review of comprehensive care plan dated 12/22/21 revealed Resident #41 did not have a care plan for constipation. Review of electronic medical record dated from 09/14/22 to 10/13/22 under bowel continence task bar revealed Resident #41 had a large bowl movement on 09/14/22 but then did not have another bowel movement until 09/22/22 (seven days later) and it was documented that Resident #41 was constipated, and the bowel movement was hard. Resident #41 then did not have another large bowel movement documented until 10/02/22 (ten days later). Resident then had a large bowel movement 10/08/22 (five days later) and it was documented that Resident #41 was constipated and the bowel movement was hard. Review of nursing notes from 09/14/22 to 10/13/22 revealed there was no documentation Resident #41's Primary Care Physician #900 was notified that Resident #41 went from 09/15/22 to 09/22/22 (7 days), 09/23/22 to 10/10/02/22 (10 days), and 10/3/22 to 10/08/22 (five days) without bowel movements. There also was no documentation the Primary Care Physician #900 was notified on 09/22/22 and on 10/08/22 that Resident #41 was constipated and had a hard bowel movement. Review of quarterly Minimum Data Set (MDS) 3.0 dated 09/21/22 revealed Resident #41 had intact cognition. He required extensive assist of two people with bed mobility and was totally dependent of two people with transfer. He was totally dependent of one person with toileting and was unable to ambulate. Review of October 2022 physician orders revealed Resident #41 did not have any orders if he did not have a bowel movement in three days. The physician orders revealed he did not receive any medications for constipation. Interview on 10/13/22 at 10:30 A.M. with Resident #41 revealed he had issues with constipation all his life especially because he takes a lot of medications that caused him to be constipated. He also revealed he had not been out of bed since admission mainly because of his obesity which also caused him to be constipated. He revealed sometimes he went four to five days without having a bowel movement and possibly longer as Resident #41 stated he did not keep track. Resident #41 revealed the nursing staff at the facility never checked to see if he had any signs of constipation and/ or never offered any as needed medications to assist in having a bowel movement. He revealed at times his bowel movement was very hard. 366270 Page 4 of 8 366270 10/13/2022 Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10:33 A.M. with Director of Nursing verified the documentation per the electronic task bar that Resident #41 did not have a bowel from 09/15/22 to 09/22/22 (7 days), 09/23/22 to 10/10/02/22 (10 days), and 10/3/22 to 10/08/22 (five days). She also verified in the task bar it was documented on 09/22/22 and on 10/08/22 that Resident #41 was constipated and had hard bowel movements. She verified Primary Care Physician #900 was not notified regarding Resident #41 not having a routine bowel movement and/ or Resident #41 being constipated and having hard bowel movement. She revealed the nurse was to check the electronic medical record and if a resident did not have a bowel movement within three days the nurse should either give if ordered an as needed medication for constipation and if a resident did not have an as needed medication ordered for constipation, then the nurse was to contact the physician for orders. Review of facility policy labeled, Bowel (Lower Gastrointestinal Tract) Disorders- Clinical Protocol, dated September 2017 revealed the staff and physician would monitor the individual's response to interventions and overall progress for example overall degrees of comfort or distress, frequency, and consistency of bowel movements. The policy revealed the physician would adjust interventions based on identification of causes, responses, and other relevant factors. 366270 Page 5 of 8 366270 10/13/2022 Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident #39 received her medications consistently per physician orders. This affected one resident (Resident #39) of eight residents reviewed for pharmacy services. Findings include: Review of the medical record for Resident #39 revealed she was admitted on [DATE] with diagnoses including chronic pancreatitis, major depressive disorder, anxiety, rheumatoid arthritis, type II diabetes and bipolar disorder. Review of physician orders revealed the resident received Actemra Solution Prefilled Syringe 162 milligrams (mg)/0.9 milliliter (ml) subcutaneously one time a day every 14 days related to rheumatoid arthritis, Motegrity tablet 2 mg in the morning related to constipation, and Vyvanse Capsule 30 mg tablet and 40 mg tablet, each once a day related to attention deficit-hyperactivity disorder. Review of the annual Minimum Data Summary (MDS) 3.0 of 09/24/22 revealed Resident #39 was cognitively intact, had severe depression, was independent for activities of daily living and received scheduled medication for pain. Review of the care plan of 09/28/22 revealed care areas for pain, rheumatoid arthritis, and the potential for constipation. Review of the medication administration records from 06/01/22 to 10/12/22 revealed Resident #39 did not receive: Motegrity 06/029/22 through 07/20/22, Vyvanse 30 mg 08/25/22 through 08/28/22, Vyvanse 40 mg 08/15/22 through 08/24/22. The Actemra Solution Prefilled Syringe scheduled for 08/20/22 was not received until 08/24/22 and the dose scheduled for 09/17/22 was not received until 10/01/22. Review of progress notes from 06/30/22 to 09/17/22 revealed Resident #39's medications mentioned above were not available for refill due to a lack of insurance authorization. Interview on 10/13/22 at 10:07 A.M. with Licensed Practical Nurse (LPN) #209 verified Resident #39 goes without her Motegrity, Vyvanse and Actemra due to waiting for insurance approvals. The physician was notified and the resident was able to voice her needs, including need for an enema if needed. Interview on 10/13/22 at 10:14 A.M. with Resident #39 revealed she had an increase in pain and discomfort when she did not receive her medications as prescribed. Interview on 10/13/22 at 11:02 A.M. with Director of Nursing (DON) revealed she completes a request for the medications and sends to the insurance company every time Resident #39 runs out of Motegrity, Vyvanse and Actemra. She verified the resident went without her medications during this process. The resident's insurance, managed medicaid, had quit paying her stay at the facility due to her level of functioning. The resident was considered private pay and had a significant outstanding balance. She was unable to provide an option to ensure the resident continued to receive her medications as ordered. 366270 Page 6 of 8 366270 10/13/2022 Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076

F 0755 Level of Harm - Minimal harm or potential for actual harm Interview on 10/13/22 at 2:14 P.M. with Regional Registered Nurse (RN) #200 verified Resident #39 should not be going without her medication and there should be some way to cover the cost, as they were covering her room and board. The resident's level of care needed reviewed and other options explored. Residents Affected - Few 366270 Page 7 of 8 366270 10/13/2022 Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on interview, observation, and record review, the facility failed to ensure Resident #31's insulin was dated after it was opened. This affected one resident (Resident #31) out of four residents (Resident #5, #28, #31, #39) that received insulin on the north cart two. Findings included: Review of medical record for Resident #31 revealed an admission date of 10/30/18 and her diagnoses included diabetes, morbid obesity, and chronic obstructive pulmonary disease. Review of care plan dated 11/05/18 revealed Resident #31 had diabetes and her interventions included administer insulin per physician orders, and check blood glucose levels per orders. Review of physician order dated 04/29/22 revealed Resident #31 had an order for Novolog insulin inject six units subcutaneously (SQ) three times a day before meals that was scheduled for 5:00 A, M., 12:00 P.M. and 5:00 P.M. Observation on 10/12/22 at 11:32 A.M. revealed Resident #31's Novolog insulin was undated when Licensed Practical Nurse (LPN) #210 took out the insulin out of north cart two. Observation then revealed LPN #210 administered six units of the Novolog insulin as ordered to Resident #31's left arm. Interview on 10/12/22 at 11:39 A.M. with LPN #210 verified Resident #31's Novolog insulin was not dated when it was opened, and she did not now when it was opened. She verified the insulin should have been dated when it was opened. Review of Novolog Injection package insert/ prescribing information dated 10/01/21 revealed the insulin should be refrigerated until first used, after first used the insulin was to be stored at room temperature and discarded after 28 days. Review of facility policy labeled, Labeling of Medication Containers, dated April 2019, revealed all medication maintained in the facility were to be properly labeled in accordance with current state and federal guidelines and regulation. The policy did not include anything in regard to ensuring insulin and/ or other medications were dated when opened. 366270 Page 8 of 8