Health inspection·March 7, 2019

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 Minimum Data Set (MDS) assessments were completed accurately for Residents #19, Resident #33, and Resident #41. This affected three of 17 residents reviewed for accurate MDS assessments. Residents Affected - Few Findings include: 1. Resident #19 was initially admitted to the facility on [DATE] with diagnoses including obsessive compulsive disorder, anxiety disorder, major depressive disorder, and mood disorder. Review of the Medication Administration Record (MAR) for March 2018 Resident #19 received the following MDS monitored medications: Abilify (an antipsychotic) 10 milligrams (mg) every morning, Basaglar (an insulin) injection of 10 units at bedtime, and Clomipramine (an antidepressant) 100 mg at bedtime. Resident #19's quarterly MDS assessment with an assessment reference date (ARD) of 03/24/18 stated Resident #19 did not receive any insulin injections, any antipsychotic medication, or any antidepressant medications during the assessment reference period. Review of Resident #19's medical record revealed a pharmacy recommendation dated 03/19/18 which requested a gradual dose reduction (GDR) of Resident #19's Abilify (an antipsychotic). Resident #19's physician responded on 05/21/18 indicating a GDR was clinically contraindicated secondary to prior reduction attempts had failed. Review of Resident #19's quarterly MDS with an ARD of 06/24/18 revealed Resident #19 received seven days of an antipsychotic medication during the reference period. However, this MDS did not reflect the GDR was clinically contraindicated by the physician. The MAR for December 2018 revealed Resident #19 received Abilify (an antipsychotic) 10 mg every morning. Resident #19's medical record also revealed a pharmacy recommendation dated 12/04/18 which requested a GDR of Resident #19's Abilify (an antipsychotic) and Clomipramine (an antidepressant). Resident #19's physician responded on 12/06/18 indicating a GDR was clinically contraindicated due to risks of symptoms worsening on 12/06/18. Review of Resident #19's annual MDS with an ARD of 12/19/18 stated Resident #19 received seven days of antipsychotic medications during the reference period, however under clarification of whether or not antipsychotics were received, the MDS was marked antipsychotics were not received and a GDR attempt was not documented as clinically contraindicated by the physician. The above findings were reviewed and verified with the Administrator and Licensed Practical Nurse (LPN) #504 on 03/07/19 at 11:45 A.M. 2. Resident #33 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses of Page 1 of 5 366346 366346 03/07/2019 Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087

F 0641 Alzheimer's disease, anxiety disorder, restlessness and agitation, and sepsis. Level of Harm - Minimal harm or potential for actual harm The significant change MDS assessment with an ARD of 10/22/18, and a quarterly MDS assessment with an ARD of 01/08/19 indicated interviews with Resident #33 should be completed for the cognitive and mood assessments. However, the dashes were listed in place of the answers. For both of these MDS assessments, the facility staff completed the assessments for cognition and mood. The significant change MDS with the ARD of 10/22/18 was marked as completed on 10/25/18 and the quarterly MDS with the ARD of 01/08/19 was marked as completed on 01/14/19. Residents Affected - Few Review of the Resident Assessment Instrument (RAI) Manual stated if the resident interview was not conducted within the look-back period (preferably the day before or the day of) the ARD, item C0100 (should the resident interview be conducted) must be coded yes, and the standard no information code which is a dash would be entered in the resident interview items. The RAI Manual also stated do not complete the Staff Assessment for Mental Status items if the resident interview should have been conducted, but was not done. The above findings were reviewed and verified with the Administrator and LPN #504 on 03/07/19 at 11:45 A.M. 3. Resident #41 was initially admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, psychosis, major depressive disorder, delirium, and Alzheimer's disease. Resident #41's medical record revealed a pharmacy recommendation dated 11/19/18 which requested a GDR of Resident #41's Risperdal (an antipsychotic). Resident #41's physician responded on 12/06/18 indicating the GDR was clinically contraindicated secondary to Resident #41's combative and paranoid behaviors. Review of Resident #41's quarterly MDS with an ARD of 01/16/19 revealed Resident #41 received seven days of the antipsychotic medications during the reference period, however this MDS did not reflect the GDR was clinically contraindicated by the physician. Resident #41's quarterly MDS with an ARD of 01/16/19 also revealed Resident #41 to have adequate hearing, clear speech, to be usually understood and able to understand others, and to have adequate vision. Resident #41 was marked as severely cognitively impaired having scored a zero on the Brief Interview for Mental Status (BIMS) with fluctuating inattention and disorganized thinking. However, under the mood section, the mood interview was marked as should not be conducted because the resident was rarely/ never understood. Review of the RAI manual stated staff were to attempt to conduct the interview with ALL residents. Staff are to code zero for no, if the interview should not be conducted because the resident is rarely/ never understood or cannot respond verbally, in writing, or using another method, or an interpreter is needed but not available, then skip to staff assessment. Code one for yes if the resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available, they continue to resident mood interview. The RAI manual further stated do not complete the staff assessment of resident mood items if the resident interview should have been conducted. The above findings were reviewed and verified with the Administrator and LPN #504 on 03/07/19 at 11:45 A.M. 366346 Page 2 of 5 366346 03/07/2019 Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to administer medications with an error rate of 5% or less. This affected Resident #20 and Resident #28, two of six residents observed receiving medications. There were two errors out of 26 opportunities resulting in an error rate of 7.69%. Residents Affected - Few Findings include: 1. Observation on 03/07/19 at 8:02 A.M. revealed Licensed Practical Nurse (LPN) #502 was administering medications to Resident #20. LPN #502 administered cholecalciferol tablet, a vitamin D supplement, 1,000 units orally. Record review for Resident #20 revealed a physician order written on 12/14/18 for a cholecalciferol tablet, 10,000 units daily. Review of the physician order summary report dated 03/01/19 revealed there continued to be an active physician order for cholecalciferol tablet, 10,000 units daily. Interview with LPN #502 on 03/07/19 at approximately 8:50 A.M. verified the incorrect dose of cholecalciferol had been administered to Resident #20. 2. Observation on 03/07/19 at 8:27 A.M. revealed LPN #503 administered two chewable calcium carbonate tablets, 750 milligrams (mg) each, by mouth to Resident #28. Record review for Resident #28 revealed a physician order was written on 10/11/18 for chewable calcium carbonate tablets, 500 mg, two tablets by mouth in the morning for gastroesophageal reflux disease. Review of the physician order summary report dated 03/01/19 revealed there continued to be an active physician order for chewable calcium carbonate tablets, 500 mg, two tablets by mouth in the morning. Interview with LPN #502 on 03/07/19 at approximately 8:55 A.M. verified the incorrect dose of chewable calcium carbonate tablets had been administered to Resident #28. There were 26 opportunities with two identified medication errors resulting in an error rate of 7.69% This concern was reviewed and verified with the Director of Nursing on 03/07/19 at 9:00 A.M. 366346 Page 3 of 5 366346 03/07/2019 Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to appropriately store, label and date bread items and frozen items in the reach in freezer. This had the potential to affect 63 residents in the facility who receive food from the kitchen. The facility identified one resident, Resident #267, who was ordered nothing by mouth. The facility census was 64. Findings include: During the initial kitchen tour on 03/04/19 at 9:00 A.M. with Dietary Manager (DM) #500, a bread cart was observed with six and a half loaves of white bread, fourteen loaves of wheat bread, thirteen packages of white dinner rolls, and four packages of white sandwich buns which were all undated and did not have a good if used by date. DM #500 and Dietary Technician (DT) #501 verified on 03/04/19 at 9:00 A.M. these bread items did not have dates. DM #500 stated the facility received the bread frozen from the supplier twice a week and the facility would then remove the bread from the freezer as needed. DM #500 verified the bread should have been dated when removed from the box from the freezer. Observation of the reach in freezer on 03/04/19 at 9:19 A.M. with DM #500 and DT #501 revealed two and a half bags of frozen french fries and a half bag of frozen chicken fingers which were opened or had slices in the packaging and were undated. DM #500 and DT #501 verified this observation. DT #501 stated the items should have been dated when opened and said the sliced bags must have happened when the boxes were initially opened. 366346 Page 4 of 5 366346 03/07/2019 Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interviews, the facility failed to keep the trash dumpster area free from debris. This had the potential to affect all of the 64 residents residing in the facility. Residents Affected - Many Findings include: During the initial kitchen tour on 03/04/19 at 9:00 A.M. with Dietary Manager (DM) #500, the facility trash dumpster, located outside, was observed. There were 10 large trash bags filled with trash laying on the ground around the bottom of the dumpster. DM #500 verified this observation and concern at 9:14 A.M. 366346 Page 5 of 5