Health inspection·August 26, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to maintain resident care equipment in a clean and sanitary condition. This affected three (#4, #75, and #76) of three residents reviewed for environment. The census was 73. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 03/16/24. Diagnoses included heart failure, chronic kidney disease, anxiety disorder, depression, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #4 revealed the resident had an intact cognition. Resident #4 required set and clean up assistance with eating. Resident #4 was dependent for all other activities of daily living. Observation during medication administration on 08/26/24 at 8:00 A.M. revealed Resident #4's power wheelchair was dirty. The right arm rest and controller were leaning over the side of the chair. The arm rest had dried food debris caked (approximately six inches in diameter) on the padding located on the top of the arm rest and on the frame/bracket below the arm rest. There was also dried food debris caked on the right front wheel and frame of the wheelchair. Interview on 08/26/24 at 8:05 A.M., with State Tested Nurse Aide (STNA) #100 verified the observation of Resident #4's power wheelchair and stated Resident #4 had behaviors including throwing food on floor and on the wheelchair. STNA #100 stated staff must clean Resident #4's wheelchair after every meal. STNA #100 also stated staff place a bag over the right arm rest to prevent food from getting on the chair. Review of the facility policy tilted, Cleaning and Disinfecting of Resident Care Equipment, dated 2024, lacked information directing staff on how and why to clean/sanitize resident wheelchairs. 2. Review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, type two diabetes, and atrial fibrillation. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #75 was cognitively intact and required hands on assistance of one staff person for completing activities of daily living. Review of the care plan dated 07/10/24 revealed Resident #75 was at risk for falls related to a right leg amputation with interventions that included a fall mat to the floor to the side of the bed. Page 1 of 2 366395 366395 08/26/2024 Oaks of Brecksville 8757 Brecksville Road Brecksville, OH 44141

F 0921 Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included brain aneurysm, dementia, epilepsy, and bipolar disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #76 was moderately cognitively impaired and required hands on assistance for completing her activities of daily living. Residents Affected - Few Review of the care plan dated 03/25/24 revealed Resident #76 was at risk for falls due to impaired cognition and impaired mobility. Review of the care plan interventions revealed a intervention for a mat to floor next to the bed. Observation on 08/26/24 at approximately 11:00 A.M. revealed both Resident #75 and Resident #76's mats used for fall interventions were not clean with various areas of brown and other colored substance on each of the mats. Additionally, Resident #75's mat had significant tears in the exterior. The Administrator verified the conditions of Resident #75 and Resident #76's mats in an interview on 08/26/24 at 11:00 A.M. This deficiency represents non-compliance investigated under Complaint Number OH00156493. 366395 Page 2 of 2