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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 366346 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)