Health inspection·August 21, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to accurately document an incident of maggots in Resident #42's tracheostomy in the medical record. This affected one resident (#42) out of three residents reviewed for tracheostomy care. The facility census was 58. Findings include: Review of the medical record for the Resident #42 revealed an admission date of 12/07/22 and a readmission date of 05/25/22. Diagnoses included end stage renal disease, dependence on respirator, epilepsy, major depressive disorder, glomerular disease in systemic lupus, dependence on renal dialysis, and cerebral infarction. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. The resident required extensive assistance with two staff for mobility, total dependence of two staff for transfers, extensive assistance of one staff for personal hygiene, and supervision with set-up help only for eating. Review of the physician's order for August 2023 revealed Resident #42 had an order for tracheostomy care every shift. Interview on 08/21/23 at 9:34 A.M. with the Director of Nursing (DON) revealed that on 07/27/23 at 6:30 P.M. she received a call from Licensed Practical Nurse (LPN) #212 said there was a maggot on Resident #42's tracheostomy and one on the bedside table. LPN #212 got Respiratory Therapist (RT) #209 to provide tracheostomy care. Resident #42 would only let RT #209 change out her split sponge and briefly suction. LPN #212 contacted the Nurse Practitioner and Respiratory Pulmonary Nurse Practitioner (RPNP) #210. RPNP #210 stated that she would be in the next day and change out the tracheostomy. On the morning of 07/28/23, Wound Doctor #213 came in and stated that he saw no maggots. The DON stated that she did a soft file on the maggots; there was no documentation regarding the maggots in Resident #42's medical record. RPNP #210 came in the next day, changed the tracheostomy and there were no signs of maggots. RPNP #210 did education with Resident #42 and attempted to call the resident's mother and mother hung up on RPNP #210. The DON stated that there were no issues with maggots since. Phone interview on 08/21/23 at 3:07 P.M. with RT #209 revealed that she was an as needed (PRN) RT and earlier that day Resident #42 refused to be suctioned and would only let her change the split pad. If she remembers correctly, Resident #42 was combative, and there was a bug on the tray table, but she could not identify it. Page 1 of 3 366359 366359 08/21/2023 Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135

F 0842 Level of Harm - Minimal harm or potential for actual harm Phone interview on 08/21/23 at 3:25 P.M. with RPNP #210 revealed that she did not see maggots. She changed the tracheostomy and spoke to LPN #212 about the maggots. Review of the medical record revealed it was silent to the concerns of maggots in Resident #42's tracheostomy. Residents Affected - Few This deficiency is an incidental finding discovered during the investigation of Complaint Number OH00145628. 366359 Page 2 of 3 366359 08/21/2023 Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, the facility failed to maintain appropriate hand hygiene during the tracheostomy care for Resident #42. This affected one resident (#42) out of three residents reviewed for tracheostomy care. This had to potential to affect 18 additional residents (#2, #7, #9, #10, #12, #14, #15, #20, #23, #24, #25, #26, #29, #39, #40, #43, #59, and #60) who had tracheostomies residing in the facility. The facility census was 58. Residents Affected - Few Findings include: Review of the medical record for the Resident #42 revealed an admission date of 12/07/22 and a readmission date of 05/25/22. Diagnoses included end stage renal disease, dependence on respirator, epilepsy, major depressive disorder, glomerular disease in systemic lupus, dependence on renal dialysis, and cerebral infarction. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. The resident required extensive assistance with two staff for mobility, total dependence of two staff for transfers, extensive assistance of one staff for personal hygiene, and supervision with set-up help only for eating. Review of the physician's order for August 2023 revealed Resident #42 had an order for tracheostomy care every shift. Observation of tracheostomy care on 08/21/23 at 12:00 P.M. with Respiratory Therapist (RT) #201 revealed RT #201 had to get a bedside table from across the hall. RT #201 wiped it down and washed his hands and brought the bedside table to Resident #42's room. RT #201 pulled a set of gloves out of his pocket, donned the gloves, and proceeded to put on a barrier on the table. He took out the old disposable cannula from Resident #42's tracheostomy and washed the area with the items provided in the kit. RT #201 then put the gloves that were in the kit over the same soiled gloves that he took the old cannula out and proceeded to put the new cannula in and applying a new split sponge around the tracheostomy. RT #201 did not need to suction Resident #42. RT #201 verified that he did not take off the soiled gloves that he removed the old cannula with and did not perform hand hygiene or prior to donning new gloves. He stated it was practice to just put on the new gloves over the first pair of soiled gloves. Review of the undated facility policy titled Hand Hygiene revealed that if a task requires gloves, perform hand hygiene prior to donning gloves. This deficiency was an incidental finding discovered during the investigation of Complaint Number OH00145628. 366359 Page 3 of 3