Health inspection·November 13, 2023

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of safety data sheets, review of job descriptions, and review of facility policy, the facility failed to ensure corrosive toilet cleaning products were securely stored on the memory care unit. This affected one resident (Resident #50) of three residents reviewed for accident hazards and had the potential to affect the 11 other residents (#1, #18, #19, #38, #40, #44, #46, #47, #54, #68, and #70) the facility identified as being independently ambulatory, cognitively impaired, and resided on the memory care unit. The facility census was 73. Findings include: Review of the medical record for Resident #50 revealed an admission date of 01/14/23. Diagnoses included cerebral infarction (stroke), dementia, Alzheimer's disease, and unspecified disorientation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was severely impaired cognitively, rejected care and wandered daily, and could walk ten feet in a room, corridor, or similar space independently. Review of the care plan dated 08/11/23 revealed Resident #50 had a potential for injury related to wandering, Alzheimer's, dementia, and confusion with a goal Resident #50 would wander in safe locations and would have safety maintained. Interventions included observe for wandering, know the resident's whereabouts, determine pattern to wandering, provide one on one visits as needed, and complete safety checks as needed. Review of Resident #50's progress note, authored by License Practical Nurse (LPN) #328 and dated 11/05/23 at 10:47 A.M., revealed the author was alerted by an unidentified resident who stated no don't drink that referring to Resident #50 who was immediately observed by LPN #328 with a bottle of cleaning solution sitting next to the Resident #50 on the floor. LPN #328 asked the resident if he had drank the cleaning solution and Resident #50 responded in an expletive and stated why won't you let me die but did not indicate if he had drank it or not. LPN #328 called the physician assistant who ordered Resident #50 to be sent out to the hospital for an evaluation. Review of the hospital records for Resident #50 dated 11/05/23 revealed the physician noted it was unclear if the resident ingested a caustic substance, he was hemodynamically stable, not ill appearing or sweating, no abnormality noted to his mucus membranes or throat upon exam. The staff from the Page 1 of 3 366346 366346 11/13/2023 Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility had reported to the hospital staff Resident #50 had a history of suicidal ideation so the resident was admitted for monitoring and a psychiatric evaluation. Further review of progress notes for Resident #50 revealed he was admitted back to the facility on [DATE]. Review of Safety Data Sheet, dated 04/15/15, identified Cling Bowl Cleaner (toilet cleaner) as having a hazardous identification of corrosive, serious eye damage, and skin corrosion. Review of the job description for the position of housekeeping aide which was signed by Housekeeping #323 on 02/17/23, revealed essential job duties included making sure all safety measures were used when housekeeping duties were being performed, which included securing chemicals. Interview on 11/08/23 at 8:11 A.M. with Housekeeping #323 revealed as she was getting the cleaning products out of the locked cabinet in the housekeeping cart on 11/05/23, she placed them temporarily on the ledge of the housekeeping cart where the mop bucket was stored until she had gotten all the products she needed. Housekeeping #323 stated when she grabbed all the cleaning products from the ledge of the housekeeping cart, she must have forgotten the toilet bowl cleaner, which was left sitting on the ledge where the mop bucket was stored. Housekeeping #323 confirmed she had left the toilet bowl cleaner unsecured on the dementia unit on 11/05/23 and chemicals needed to be secure and locked when not in use. Interview on 11/08/23 at 10:30 A.M. with State Tested Nursing Assistant (STNA) #363 revealed on 11/05/23, Resident #50 was found sitting in a chair with a bottle of toilet bowl cleaner sitting on the floor next to him but had not seen him drink it. Interview on 11/08/23 at 10:39 A.M. with LPN #328 revealed on 11/05/23 she had seen a bottle of cleaner next to Resident #50 but had not seen him drink it. Interview on 11/13/23 at 8:26 A.M. with STNA #342 revealed on 11/05/23 she saw a bottle of toilet bowl cleaner sitting on the floor next to Resident #50 but had not seen him drink it. Review of facility policy Dementia Care Policy, revised March 2022, revealed the facility would provide the necessary care and services to any resident who displayed or was diagnosed with dementia which would be person-centered and would reflect the resident's goals while maximizing the resident's dignity, autonomy, privacy, socializations, independence, choice, and safety. The deficient practice was corrected on 11/06/23 when the facility implemented the following corrective actions: • On 11/05/23 all residents on the memory care unit were assessed by staff as free from exposure to accident hazards. • On 11/05/23, the entire building was swept by the Housekeeping Director (HD) #324 for any unsecured chemicals, with none found. 366346 Page 2 of 3 366346 11/13/2023 Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087

F 0689 • Level of Harm - Minimal harm or potential for actual harm On 11/05/23, the entire housekeeping department, which consisted of seven employees, was educated on securing chemicals by the Director of Nursing (DON). Residents Affected - Few • On 11/05/23, both housekeeping carts were inspected by the HD #324 to ensure locking mechanisms and all parts were in working order, with no concerns found. • On 11/06/23, all 67 facility staff were educated by the DON or designee on safety and securing of chemicals. • Starting on 11/06/23, the Administrator of designee began randomly auditing two housekeepers each business day for safety and security of chemicals for two weeks and randomly thereafter. • Starting on 11/06/23, HD #324 or designee began auditing chemicals on the housekeeping cart at the beginning and the end of the shift, each business day for two weeks and randomly thereafter. • The results of the audits would be reviewed by the Quality Assurance Committee. There were no further incidents of non-compliance related to residents being exposed to accident hazards through the date of this survey completed on 11/13/23. This deficiency represents non-compliance investigated under Complaint Number OH00148127. 366346 Page 3 of 3