Health inspection·December 21, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, medical record review, and policy review, the facility failed to ensure a resident was assessed for self-administration of medication and ensure medications were not left unattended at the resident's bedside. This affected one resident (#277) of one observed for unattended medications. The facility census was 72. Residents Affected - Few Findings Include: Review of the medical record for Resident #277 revealed an admission date of 12/07/23 with diagnoses that included dependence on renal dialysis, end stage renal disease, and rheumatoid arthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #277 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #277 required assistance with activities of daily living (ADL). Review of the care plan dated 12/14/23 revealed Resident #277 had an ADL self-care deficit with interventions that included assistance with ADLs as needed. Review of the medical record revealed no assessments for self-administration of medications or no physician orders for medications to be left at the bedside. Observation and interview on 12/19/23 at 9:30 A.M. revealed Resident #277 in bed in her room, with a medication cup that contained two white colored pills, one yellow pill, one maroon/burgundy color pill, and one peach colored pill. The five pills were located on Resident #277's bedside table. Resident #277 revealed she informed Registered Nurse (RN) #567 that she would take them after she finished her breakfast. Observation and interview on 12/19/23 at 9:40 A.M. with RN #567 verified the five pills left at Resident #277's bedside. RN #567 revealed Resident #277's medications were not to be left unattended at her bedside and Resident #277 should have taken them in her presence. Review of the facility document titled General Dose Preparation and Medication Administration revised 01/01/23, revealed staff were to ensure medications were not left unattended and to observe the consumption of the medications. Page 1 of 3 366395 366395 12/21/2023 Oaks of Brecksville 8757 Brecksville Road Brecksville, OH 44141

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the state ombudsman was notified of resident transfers to the hospital and of discharges. This affected four residents (#23, #41, #54 and #69) of four residents reviewed for hospitalization. The facility census was 72. Findings Include: 1. Review of Resident #23's medical record identified admission to the facility occurred on 06/28/23, with medical diagnoses that included chronic obstructive pulmonary disease, methicillin resistant staphylococcus aureus infection, and hypertension. The record identified Resident #23 discharged home on [DATE] and subsequently admitted on [DATE], and then had transferred to the hospital on [DATE], 10/28/23 and 11/06/23. Review of the medical record revealed no evidence the state ombudsman was notified of Resident #23's discharge home on [DATE] and transfers to the hospital on [DATE], 10/28/23 and 11/06/23. Review of the ombudsman notification logs dated June, July, August, September, October, and November 2023 revealed no documented notifications for Resident #23 for 10/28/23 and 11/06/23. Interview on 12/20/23 at 3:05 P.M. with Social Services Designee (SSD) #505 confirmed the above findings. 2. Review of Resident #54's medical record identified admission to the facility occurred on 10/22/22, with medical diagnoses that included type 2 diabetes, anxiety and hyperlipidemia. The record identified Resident #54 transferred to the hospital on [DATE] and 10/06/23. Review of the medical record revealed no evidence the state ombudsman was notified of Resident #54's transfers to the hospital on [DATE] and 10/06/23. Review of the ombudsman notification logs dated June, July, August, September, October, and November 2023 revealed no documented notifications for Resident #54 for 09/12/23 and 10/06/23. Interview on 12/20/23 at 3:05 P.M. with Social Services Designee (SSD) #505 confirmed the above findings. 3. Review of the medical record for Resident #41 revealed an admission date of 10/29/21. Diagnoses for Resident #41 included but were not limited to malignant neoplasm of oropharynx, fracture of other specified skull and facial bones, gastro-esophageal reflux disease, severe protein-calorie malnutrition, epilepsy, hypothyroidism, an anxiety disorder. Review of Resident #41's medical record revealed he was transferred to the hospital on [DATE], 01/17/23, 01/31/23, 06/09/23, and 07/04/23. Review of the medical record revealed no evidence the state ombudsman was notified of Resident 366395 Page 2 of 3 366395 12/21/2023 Oaks of Brecksville 8757 Brecksville Road Brecksville, OH 44141

F 0623 #41's transfers to the hospital on [DATE], 01/31/23, 06/09/23, and 07/04/23. Level of Harm - Potential for minimal harm Review of the ombudsmen notification logs dated January 2023 through November 2023 revealed no documented notifications for Resident #41 for 12/26/22, 01/31/23, 06/09/23, and 07/04/23. Residents Affected - Some Interview on 12/20/23 at 3:05 P.M. with Social Services Designee (SSD) #505 confirmed the above findings. 4. Review of the medical record for Resident #69 revealed an admission date of 09/11/23. Diagnoses included but were not limited to malignant neoplasm of liver and intrahepatic bile duct, malignant neoplasm of rectum, hypothermia, acidosis, acute kidney failure, atrial fibrillation, and depression. Review of Resident #69's medical record revealed he was transferred to the hospital on [DATE]. Review of the medical record revealed no evidence the state ombudsman was notified of Resident #69's transfers to the hospital on [DATE]. Review of the ombudsmen notification logs dated January 2023 through November 2023 revealed no documented notifications for Resident #69 for 10/02/23. Interview on 12/20/23 at 3:05 P.M. with Social Services Designee (SSD) #505 confirmed the above findings. 366395 Page 3 of 3