Health inspection·May 18, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to ensure the resident's environment was kept clean, neat, well lit, and homelike. This had the potential to affect all 34 residents residing in the facility. Residents Affected - Some Findings include: During the initial tour of the facility on 05/15/23 from 8:43 A.M. through 9:20 A.M. revealed light bulbs were burned out in the main hall by rooms #101, #107, #109, #111, #116, #208, #212, #301, #304, #308, #309, #310, #312, #313, one of two bulbs of a two-light sconce in the TV room, four can lights in the nurse's station and one ballast. There were no coverings of ballast light bulbs by rooms #104, #112, #116, #120, #202, #206, #301, #305, #317, #321, #323, outside the central bath and eight around the nurse's station. There were multiple heavily soiled spots in the carpeting throughout the facility. Interview on 05/15/23 at 2:16 P.M. with Maintenance #261 verified the burned-out light bulbs and stated the bulbs were ordered but failed to produce the order requisition. He verified the multiple stains in the carpets. He verified the missing plastic coverings over the ballasts stating they were plastic and broken resulting in no longer able to be used. Page 1 of 12 366377 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

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 interview and record review the facility failed to have an accurate Minimum Data Set (MDS) for Resident #3, Resident #4, Resident #7, Resident #8, and Resident #15. This affected five residents (#3, #4, #7, #8, and #15) of fifteen residents reviewed for MDS accuracy. The facility census was 34. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 01/27/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, cervical disc displacement, diabetes, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] stated Resident #4 was not receiving hospice care. Review of the care plan revealed Resident #4 started hospice on 02/04/22. Interview on 05/18/23 at 1:09 P.M. with the Director of Nursing (DON) verified Resident #4 was on hospice. 2. Review of the medical record for Resident #8 revealed an admission date of 03/25/22. Diagnoses included Alzheimer's, diabetes, glaucoma, and the need for assistance with personal care. Review of the annual MDS assessment dated [DATE] revealed Resident #8 had intact cognition. The resident's hearing and vision were not assessed and bed mobility, transfers, locomotion, eating, toilet use, and personal hygiene had only occurred once or twice. Review of the facility form FLM Functional Abilities and Goals dated 03/31/23, 04/01/23, and 04/02/23 were not completed. Resident #8's functional abilities were not reviewed for the MDS. Interview on 05/17/23 at 4:17 P.M. with the DON revealed the facility's previous DON had not completed the functional assessment component for the off-site MDS nurse to accurately complete Resident #8's MDS. 3. Review of the medical record for Resident #15 revealed an admission date of 12/04/20. Diagnoses included Alzheimer's, vascular dementia with agitation, and insomnia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 had impaired cognition. Bed mobility, locomotion, dressing, eating, toilet use, and personal hygiene had only occurred once or twice. Interview on 05/17/23 at 4:17 P.M. with the DON revealed the facility's previous DON had not completed the functional assessment component for the off-site MDS nurse to accurately complete Resident #15's MDS. 4. Review of the medical record for Resident #3 revealed an admission date of 06/27/22. Diagnoses included multiple sclerosis, quadriplegia and abnormalities of gait and mobility. 366377 Page 2 of 12 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly MDS assessment dated [DATE] did not address the whole G section, which is bed mobility, locomotion on and off the unit, walking, eating, personal hygiene, toilet use, personal hygiene, and dressing. Interview on 05/17/23 at 4:17 P.M. with the DON revealed the facility's previous DON had not completed the functional assessment component for the off-site MDS nurse to accurately complete the MDS. 5. Review of the medical record for Resident #7 revealed an admission date of 9/20/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, protein-calorie malnutrition, chronic viral hepatitis C, anemia, and partial seizures intractable with status epilepticus. Review of the quarterly MDS assessment dated [DATE] did not address Resident #7's oral/swallowing section. Resident #7 was care planned as being edentulous (no teeth). Interview on 05/17/23 at 4:17 P.M. with the DON revealed the facility's previous DON had not completed the functional assessment component for the off-site MDS nurse to accurately complete the MDS. 366377 Page 3 of 12 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

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 interview and record review the facility failed to have updated/revised care plans for Resident #8 and Resident #31. This affected two residents (#8 and #31) of fifteen residents reviewed for care plans. The facility census was 34. Finding include: 1. Review of the medical record for Resident #8 revealed an admission date of 03/25/22. Diagnoses included Alzheimer's, glaucoma, and the need for assistance with personal care. Review of the annual MDS assessment dated [DATE] revealed Resident #8 had intact cognition. The resident's hearing and vision were not assessed and bed mobility, transfers, locomotion, eating, toilet use, and personal hygiene had only occurred once or twice. Review of the care plan for activities of daily living (ADL) dated 10/06/22 for Resident #8 revealed a gait belt was needed for transfers. Interview on 05/18/23 at 3:18 P.M. with the Assistant Director of Nursing (ADON) #238 verified Resident #8 required a Hoyer lift (mechanical lift) for transfers, and the care plan was not accurate. 2. Review of the medical record for Resident #31 revealed an admission date of 10/01/21. Diagnoses included hemiplegia and hemiparesis of the right side, acute and chronic respiratory failure, anxiety disorder, diabetes, muscle weakness, chronic kidney disease, and contracture of the right hand. Review of the quarterly MDS assessment dated [DATE] revealed Resident #31 had impaired cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, and toilet use and extensive assistance of one staff was needed for locomotion and personal hygiene. The resident was totally dependent on two staff for dressing and bathing. Review of the care plan for ADL dated 10/12/21 revealed Resident #31 required one staff assist with a gait belt and two staff assist with a gait belt. Interview on 05/17/23 at 5:27 P.M. with State Tested Nurse Aide (STNA) #240 revealed therapy had been working with Resident #31 using a Hoyer lift and a slide board. Interview on 05/18/23 at 1:05 P.M. with ADON #238 confirmed Resident #31 required a Hoyer lift or a sliding board with therapy and verified the ADL care plan was not accurate. 366377 Page 4 of 12 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 facility policy review the facility failed to ensure Resident #8 received timely nail care and failed to ensure Resident #38 received timely oral care. The facility failed to have accurate documented evidence that Resident's #3, #8, #14 and #31 had showers as ordered and/or per preference. This affected five residents (#3, #8, #14, #31, and #38) of fifteen residents reviewed for activities of daily living (ADL) care. The facility census was 34. Residents Affected - Few Finding include: 1. Review of the medical record for Resident #8 revealed an admission date of 03/25/22. Diagnoses included Alzheimer's, glaucoma, and the need for assistance with personal care. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition. The resident's hearing and vision were not assessed and bed mobility, transfers, locomotion, eating, toilet use, and personal hygiene had only occurred once or twice. Observation on 05/15/23 at 11:41 A.M. revealed Resident #8's fingernails on right hand were very long. Interview on 05/15/23 at 11:41 A.M. with Resident #8 revealed she wanted her fingernails cut. She stated her fingernails being this long annoyed her. The resident stated she had asked to have them cut several times. The resident stated showers were also an issue. Interview on 05/15/23 at 11:49 A.M. with Assistant Director of Nursing (ADON) #238 verified Resident #8's nails needed cut. Interview on 05/16/23 04:59 PM with ADON #238 revealed the facilities primary way of documenting showers was the electronic medical record. There were no shower sheets available. Review of the bathing task forms completed they the State Tested Nursing Assistants (STNAs) for Resident #8 in April and May 2023 revealed the only thing documented was for bathing, which occurred one to three times daily. There was no indication of when/if a shower or bed bath was given. Interview on 05/17/23 at 9:28 A.M. with the Director of Nursing (DON) and ADON #238 verified the bathing task sheets were the only information on bathing available and did not show when the resident had received a shower or bath. Interviews on 05/17/23 at 10:43 A.M. and 5:39 P.M. with STNAs #200 and STNA #240 revealed the bathing task form was filled out in the electronic medical record when a resident was washed up for the morning, or during the day or evening, not a full bed bath or shower. The STNA filled out a shower sheet when a resident was given a bath or shower. The facility had a shower schedule at the nurses' station. Interview on 05/17/23 10:49 A.M. with STNA #200 revealed Resident #8 didn't get out of bed per her choice. She received bed baths. Interview on 05/17/23 at 5:30 P.M. with STNA #240 revealed Resident #8 received both shower and bed 366377 Page 5 of 12 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0677 baths, but usually a bed bath because she didn't get up much. Level of Harm - Minimal harm or potential for actual harm Interview on 05/18/23 at 11:16 A.M. with Registered Nurse (RN) #233 revealed Resident #8 usually refused showers. Residents Affected - Few 2. Review of the medical record for Resident #14 revealed an admission date of 10/29/22. Diagnoses included Multiple Sclerosis, bipolar disorder, morbid obesity, and need for assistance with personal care. Review of the quarterly MDS assessment 05/08/23 revealed Resident #14 had moderate cognitive impairment. The resident required the extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use, and extensive assistance of one staff for locomotion and personal hygiene. The resident was totally dependent on staff for bathing. Interview on 05/15/23 at 2:29 P.M. with Resident #14 revealed he was cleaned up every other day but did not get showers. Interview on 05/16/23 at 4:59 P.M. with ADON #238 revealed the facilities' primary way of documenting showers was the electronic medical record. There were no shower sheets available. Review of the bathing task forms completed for Resident #14 in April and May 2023 revealed the only thing documented was for bathing, which occurred one to three times most days. There was no indication of when/if a shower or bed bath was given. Interview on 05/17/23 at 9:28 A.M. with the DON and ADON #238 verified the bathing task sheets were the only information on bathing available and did not show when the resident had received a shower or bath. Interviews on 05/17/23 at 10:43 A.M. and 5:39 P.M. with STNAs #200 and STNA #240 revealed the bathing task form was filled out in the electronic medical record when a resident was washed up for the morning, or during the day or evening, not a full bed bath or shower. The STNA filled out a shower sheet when a resident was given a bath or shower. The facility had a shower schedule at the nurses' station. Interview on 05/17/23 at 5:39 P.M. with STNA #240 revealed Resident #14 received bed baths. Interview on 05/18/23 at 11:34 A.M. with RN #233 revealed Resident #14 won't take a shower. The resident didn't want to get up and swore at staff when they tried to get him out of bed. 3. Review of the medical record for Resident #31 revealed an admission date of 10/01/21. Diagnoses included hemiplegia and hemiparesis of the right side, acute and chronic respiratory failure, anxiety disorder, diabetes, muscle weakness, chronic kidney disease, and contracture of the right hand. Review of the quarterly MDS assessment dated [DATE] revealed Resident #31 had impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toilet use and extensive assistance of one staff for locomotion and personal hygiene. The resident was totally dependent on two staff for dressing and bathing. Review of the annual MDS assessment dated [DATE] revealed it was Very Important to Resident #31 to 366377 Page 6 of 12 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0677 choose between a shower and a bed bath. Level of Harm - Minimal harm or potential for actual harm Review of the physician's orders for May 2023 revealed an order dated 10/05/21 for Resident #31 to receive a shower on Tuesdays and Fridays, on the three to eleven shift. Residents Affected - Few Interview on 05/15/23 at 11:32 A.M. with Resident #31 stated he was not getting his showers. Interview on 05/16/23 at 4:59 P.M. with ADON #238 revealed the facilities' primary way of documenting showers was the electronic medical record. There were no shower sheets available. Review of the bathing task forms completed for April and May 2023 revealed the only thing documented was for bathing, which occurred one to three times daily. There was no indication of when/if a shower or bed bath was given. Interview on 05/17/23 at 9:28 A.M. with the DON and ADON #238 verified the bathing task sheets were the only information on bathing available and did not show when the resident had received a shower or bath. Interview on 05/17/23 at 10:43 A.M. with STNA #200 revealed Resident #31 usually received bed baths because he did not want to get up to go to the shower. Occasionally the resident would agree to a shower. The facility had a shower schedule. When the STNA did a shower, a shower sheet was filled out. There was a place to indicate whether a shower or bed bath was done. Interviews on 05/17/23 at 10:43 A.M. and 5:39 P.M. with STNAs #200 and STNA #240 revealed the bathing task form was filled out in the electronic medical record when a resident was washed up for the morning, or during the day or evening, not a full bed bath or shower. The STNA filled out a shower sheet when a resident was given a bath or shower. The facility had a shower schedule at the nurses' station. Interview on 05/17/23 at 5:27 P.M. with STNA #240 revealed Resident #31 received bed baths a couple times a week. STNAs filled out shower sheets and it indicated whether it was a bed bath or shower. There was a shower schedule at nurses' station. 4. Interview on 05/17/23 at 9:00 A.M. with Resident #38's daughter, who had been staying with him night and day since 05/15/23 revealed not one person had cleaned his mouth or given him a shower. Observation on 05/17/23 at 9:01 A.M. revealed a toothbrush and toothpaste in his bathroom, that were still in their sealed packaging. There were no toothettes observed in his room on 05/15/23 or 05/16/23. Observation on 05/18/23 at 2:00 P.M. of Resident #38's teeth revealed they were caked with food particles. Review of Resident #38's MDS 05/08/23 for ADL revealed he required extensive assistance from one staff using physical assistance for hygiene. Interview on 05/18/23 at 2:01 P.M. with Registered Nurse (RN) #262 verified Resident #38's toothbrush and toothpaste were still in their original, sealed packaging, and there were no toothettes in his room. 366377 Page 7 of 12 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0677 Level of Harm - Minimal harm or potential for actual harm 5. Interview on 05/15/23 at 4:37 P.M. with Resident #3 and her son revealed she did not receive showers according to the schedule. Interviews on 05/17/23 at 9:20 A.M. with ADON #238 and DON revealed there was no documented evidence Resident #3 had been given a shower since his arrival on 05/03/23. Residents Affected - Few Review of the Resident #3's MDS assessment 04/02/23 for ADL revealed she was totally dependent on staff for personal hygiene. Review of the facility policy titled Activities of Daily Living, Supporting, dated 2018 revealed the facility did not follow their policy and provide hygiene care. 366377 Page 8 of 12 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and observation the facility failed to administer medications with an error rate of 5 percent (%) or less. This affected Resident and #3 and Resident #17, two of five residents observed medication administration. There were three errors out of 30 opportunities resulting in an error rate of 10%. Residents Affected - Few Findings include: 1. Observation on 05/17/23 at 8:19 A.M. revealed Licensed Practical Nurse (LPN) #275 was administering medication to Resident #3. LPN #275 administered vitamin B complex with vitamin C tablet (supplement) orally. Record review for Resident #3 revealed a physician order written on 04/25/23 for vitamin B complex daily. Interview with LPN #275 at 9:00 A.M. revealed the incorrect medication of vitamin B complex with vitamin C had been administered to Resident #3. Observation on 05/17/23 at 8:19 A.M. revealed LPN #275 was administering medication to Resident #3. LPN #275 administered Refresh Plus Ophthalmic Solution 0.5%. One drop in each eye. Record review for Resident #3 revealed a physician order written on 04/25/23 for Refresh Plus Ophthalmic Solution 0.5% two drops in each eye. Interview with LPN #275 at approximately 9:00 A.M. revealed the incorrect number of drops of Refresh Plus Ophthalmic Solution 0.5% one drop had been administered to Resident #3. 2. Observation on 05/17/23 at 8:45 A.M. revealed Registered Nurse (RN) #262 was administering medication to Resident #17. RN #262 administered aspirin EC (enteric coated) 81 milligrams (mg). Record review for Resident #17 revealed a physician order written on 12/17/22 for aspirin DR (delayed release) 81 mg. Interview with RN #262 at approximately 9:07 A.M. revealed the incorrect medication of aspirin EC 81 mg had been administered to Resident #17. 366377 Page 9 of 12 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect all 34 residents. Residents Affected - Many Findings include: Observation of the facility's garbage disposal area with Dietary Director #218 on 05/15/23 at 9:53 A.M. revealed both lids were open on the dumpster. There was some trash and leaves accumulated around the dumpster. Dietary Director #218 verified the above findings at the time of observation. 366377 Page 10 of 12 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview the facility failed to ensure staff hands were cleansed between residents when passing out meal trays to residents in their rooms for three residents (#17, #32 and #34), failed to ensure dirty linen was kept off the floor for Resident #38, failed to ensure urinary catheter bag was kept off the floor and catheter care was done properly for Resident #3. This affected five residents (#3, #17, #32, #34 and #38) of 34 residents reviewed for infection control. The facility census was 34. Residents Affected - Some Findings include: 1. Observation on 05/15/23 at 4:37 P.M. revealed Resident #3's urinary catheter bag was on the floor under her bed. Interview on 05/15/23 at 5:09 P.M. with the Licensed Practical Nurse/Unit Manager (LPN/UM) #238 verified the catheter bag was on the floor under the bed. 2. Observation on 05/16/23 at 4:15 P.M. during the emptying of Resident #'s catheter/leg bag revealed State Tested Nursing Assistant (STNA) #234 did not place a barrier on the floor under the urinal. STNA #234 did not disinfect off the tip of the catheter/leg bag before reconnecting it. Interview on 05/16/23 at 4:20 P.M. with STNA #234 verified he did not place a barrier under the urinal, nor did he disinfect the tip of the catheter/leg bag before reconnecting it. Review of the facility policy titled Catheter Care, Urinary, dated 08/22, revealed the facility did not use aseptic technique when handling or manipulating the drainage system. The catheter tubing and drainage bag are to be kept off the floor. 3. Observation on 05/17/23 at 11:52 A.M. during the meal tray pass revealed STNA #276 took lunch trays into three different rooms (Resident's #17, #32, and #34), moved items on the bed side table without cleansing her hands in between the room. Interview on 05/17/23 at 11:58 A.M. with STNA #276 verified she did not cleanse her hands between the three rooms she delivered lunch trays to Resident's #17, #32, and #34. 4. Observation on 05/18/23 at 11:14 A.M. of a pile of dirty linens lying directly on the floor of Resident #38 room. The bed had been stripped when therapy got Resident #38 out of bed. Interview with LPN/UM #238 on 08/18/23 at 11:17 A.M. with verified the pile of dirty linens lying directly on the carpeted floor in the room of Resident #38. Review of the facility policy titled, Policies and Practices-Infection Control, dated 10/18 revealed the facility did not maintain a safe or sanitary environment to help prevent and manage transmission of diseases and infections. 366377 Page 11 of 12 366377 05/18/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and facility policy review the facility failed to provide documented evidence an antibiotic stewardship program was in place. This affected six residents (#2, #21, #23, #32, #38, and #141) and had the potential to affect all 34 residents residing in the facility. Residents Affected - Many Findings include: Review of the infection control documentation revealed no documented evidence that an antibiotic stewardship program was in place. Interview on 05/17/23 at 5:22 P.M. with the Director of Nursing (DON) and Administrator revealed antibiotic stewardship was stopped during the COVID-19 pandemic as the task was waivered and had not started back up yet. Review of the facility matrix revealed Residents #2, #21, #23, #32, #38, and #141 were on antibiotics. Review of the facility policy titled Antibiotic Stewardship, dated 12/16, revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. 366377 Page 12 of 12