Health inspection·September 19, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents had accurate advance directives within the medical records. This affected four residents (Residents #14, #43, #59, and #62) of twelve residents reviewed for advanced directives. Findings include: 1. Review of medical record for Resident #14 revealed admission date of 06/25/22 with diagnoses including revealed diabetes mellitus, hepatitis C, gout, end stage renal disease, dependence on renal dialysis, and right below knee amputation. Review of physician's order dated 06/25/22 revealed Resident #14 was a full code. Review on 09/12/22 at 3:57 P.M. of Resident #14's hard medical chart revealed no indication of code status. Interview on 09/12/22 at 4:28 P.M. with Licensed Practical Nurse (LPN) #313 confirmed there was no indication of code status in hard medical chart. LPN #313 indicated the code status was supposed to be indicated in hard medical chart. Interview on 09/12/22 at 4:29 P.M. with Social Services Designee (SSD) #314 confirmed there was no code status in hard medical chart for Resident #14. SSD confirmed code status was supposed to be indicated in hard medical chart even if full code. SSD #314 displayed the full code status document which was to be placed in the hard medical chart under the advance directive tab. Interview on 09/12/22 at 4:45 P.M. with Director of Nursing (DON) confirmed code status was to be entered in computer and medical records. DON confirmed there was no code status in the hard medical chart. 2. Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease, hypertension, nicotine dependence, and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had intact cognition and required limited to extensive assistance for activities of daily living. Review of the physician's orders for Resident #43 revealed there was no order for code status in Page 1 of 23 366441 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0578 the computer or in the hard medical chart. Level of Harm - Minimal harm or potential for actual harm Review of Resident #43's hard medical chart revealed no document to indicate code status. Residents Affected - Some Interview on 09/12/22 at 4:28 P.M. with LPN #313 confirmed there was no code status in the orders or in the hard medical chart. LPN #313 revealed the code status is supposed to be in the orders and in the hard medical chart. Interview on 09/12/22 at 4:29 P.M. with Social Service Designee (SSD) #314 confirmed there was no code status in the computer or the hard medical chart. SSD #314 revealed there is supposed to be code status in the computer and hard medical chart, even full code status. SSD #314 showed the full code status document which was to be placed in the hard medical chart under the advance directive tab. Interview on 09/12/22 at 4:45 P.M. with DON confirmed code status is to be entered in computer and hard medical chart. DON confirmed there was no code status in the computer or the hard medical chart. 3. Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of depression, hypertension, chronic obstructive pulmonary disease, rheumatoid arthritis, and methicillin-resistant Staphylococcus aureus. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 had intact cognition and required limited assistance for activities of daily living. Review of the physician's orders for Resident #59 revealed there was no order for code status in the computer or in the hard medical chart. Review of Resident #59's hard medical chart revealed no document to indicate code status. Interview on 09/12/22 at 4:28 P.M. with LPN #313 confirmed there was no code status in the orders or in the hard medical chart for resident #59. LPN #313 revealed the code status is supposed to be in the orders and in the hard medical chart. Interview on 09/12/22 at 4:29 P.M. with Social Service Designee (SSD) #314 confirmed there was no code status in the computer or the hard medical chart for Resident #59. SSD #314 revealed there was supposed to be code status in the computer and hard medical chart, even full code status. SSD #314 showed the full code status document which was to be placed in the hard medical chart under the advance directive tab. Interview on 09/12/22 at 4:45 P.M. with DON confirmed code status is to be entered in computer and hard medical chart. DON confirmed there was no code status in the computer or the hard medical chart. 4. Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE] with diagnosis of acute kidney failure, diabetes mellitus type 2, hypertension, anxiety disorder, depression, heart failure, and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 had intact cognition and was independent to supervision for activities of daily living. 366441 Page 2 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the physician's orders for Resident #62 revealed there was an order dated 05/12/22 for full code status in the computer. Review of Resident #62's hard medical chart revealed no document to indicate code status. Interview on 09/12/22 at 4:28 P.M. with LPN #313 confirmed there was full code status in the orders and no code status in the hard medical chart for Resident #62. LPN #313 revealed the code status is supposed to be in the orders and in the hard medical chart. Interview on 09/12/22 at 4:29 P.M. with Social Service Designee (SSD) #314 confirmed there was full code status in the computer and no code status in the hard medical chart for resident #62. SSD #314 revealed there was supposed to be code status in the computer and hard medical chart, even full code status. SSD #314 showed the full code status document which was to be placed in the hard medical chart under the advance directive tab. Interview on 09/12/22 at 4:45 P.M. with DON confirmed code status is to be entered in computer and hard medical chart. DON confirmed there was a code status in the computer and no code status in the hard medical chart. 366441 Page 3 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

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, and record review, the facility failed to ensure regular nail care was provided for Resident #23. This affected one resident (Resident #23) of three reviewed for activities of daily living care. The facility census was 75. Residents Affected - Few Findings include: Review of medical record for Resident #23 revealed admission date of 03/11/22 with diagnoses including rectal cancer, depression, anxiety disorder, unspecified side hemiplegia, and vital hepatitis C. Review of the care plan dated 03/14/22 revealed Resident #23 had activities of daily living (ADL) self-care deficit. Interventions included to assist with ADL of grooming, assist of two for bathing and hygiene, and refer to therapy as needed. Review of Medicare Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #23 required extensive one staff assistance for personal hygiene and one staff physical help for bathing. Review of Monthly Nursing Note dated 09/12/22 revealed Resident #23 was alert, oriented, pleasant, and cooperative with care. The nursing note indicated no concerns with resident condition. Review of shower sheets from August 2022 to September 2022 revealed Resident #23 last had nail care on 08/23/22. Observation on 09/12/22 at 9:14 A.M. revealed Resident #23 was sitting at edge of bed and fingernails were noted to be very long and broken. Resident #23 reported his nails needed trimmed and no staff had offered to assist him with nail care. Interview on 09/15/22 at 9:03 A.M. with State Tested Nursing Assistant (STNA) #315 revealed they were unsure who is responsible for providing nail care. STNA #315 indicated they had been working in the facility for a month and had not provided nail care yet. Interview on 09/15/22 at 9:05 A.M. with Agency STNA #317 revealed care for fingernails was to be completed during showers unless the resident had diabetes. Interview on 09/15/22 at 2:04 P.M. with STNA #320 revealed STNAs are unable to cut fingernails as they would be unsure if the resident had diabetes or not. Interview on 09/15/22 at 4:26 P.M. with Resident #23 revealed no staff had been in yet to complete nail care. Resident #23 showed hands revealing long, jagged, and discolored fingernails on both hands. Interview on 09/15/22 at 4:31 P.M. with Licensed Practical Nurse (LPN) #323 revealed showers are provided twice per week and nail care should be completed at the same time. LPN #323 observed Resident #23's nails and confirmed the nails were unacceptable length, discolored, and jagged. LPN #323 indicated she was unsure when Resident #23 last had nail care. LPN #323 indicated she would gather 366441 Page 4 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0677 supplies and provide nail care for Resident #23. Level of Harm - Minimal harm or potential for actual harm Interview on 09/15/22 at 4:39 P.M. with Director of Nursing (DON) revealed they were unaware of the issues with Resident #23's nails. Residents Affected - Few Review of facility policy, Morning Care/AM Care, dated 09/01/22 revealed morning care will be offered each day. Morning care provided should include provide fingernail care. 366441 Page 5 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure regular podiatry care was provided for Resident #23. This affected one resident (Resident #23) of three reviewed for activities of daily living care. Residents Affected - Few Findings include: Review of medical record for Resident #23 revealed admission date of 03/11/22 with diagnoses including rectal cancer, depression, anxiety disorder, unspecified side hemiplegia, and vital hepatitis C. Review of the care plan dated 03/14/22 revealed Resident #23 had activities of daily living (ADL) self-care deficit. Interventions included to assist with ADL of grooming, assist of two for bathing and hygiene, and refer to therapy as needed. Review of physician's order dated 06/11/22 revealed Resident #23 may see podiatrist. Review of Medicare Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #23 required extensive one staff assistance for personal hygiene and one staff physical help for bathing. Review of Weekly Skin Evaluation dated 09/09/22 revealed no skin issues. Review of Monthly Nursing Note dated 09/12/22 revealed Resident #23 was alert, oriented, pleasant, and cooperative with care. The nursing note indicated no concerns with resident condition. Observation on 09/12/22 at 9:14 A.M. revealed Resident #23 was sitting at edge of bed and toenails were noted to be thick and very long. Resident #23 reported no staff had offered to assist him with nail care. Interview on 09/15/22 at 9:03 A.M. with State Tested Nursing Assistant (STNA) #315 revealed they were unsure who is responsible for providing nail care. STNA #315 indicated they had been working in the facility for a month and had not provided nail care yet. Interview on 09/15/22 at 9:05 A.M. with Agency STNA #317 revealed care for nails was to be completed during showers unless the resident had diabetes. Interview on 09/15/22 at 2:04 P.M. with STNA #320 revealed STNAs are unable to cut nails as they would be unsure if the resident had diabetes or not. Interview on 09/15/22 at 4:26 P.M. with Resident #23 revealed no staff had been in yet to complete nail care. Interview on 09/15/22 at 4:31 P.M. with Licensed Practical Nurse (LPN) #323 revealed showers are provided twice per week and nail care should be completed at the same time. LPN #323 observed Resident #23's toenails and confirmed the nails were unacceptable length, thick, and discolored. LPN #323 indicated she was unsure when Resident #23 last had nail care. LPN #323 indicated she would gather 366441 Page 6 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supplies and provide fingernail care for Resident #23 and Resident #23 would need to see podiatry services. Interview on 09/15/22 at 4:34 P.M. with Social Service Designee (SSD) #314 revealed they were unsure when Resident #23 last had podiatry services. SSD #314 indicated podiatry was scheduled to visit on 09/26/22 and Resident #23 could be added to the list. Interview on 09/15/22 at 4:39 P.M. with Director of Nursing (DON) revealed they were unaware of the issues with Resident #23's nails. Interview on 09/19/22 at 10:23 A.M. with SSD #314 confirmed Resident #23 had not been since by podiatry since admission and Resident #23 was added to podiatry list for the upcoming visit. SSD #314 indicated Resident #23 was not signed up for any podiatry services, however had seen other ancillary services. Review of facility policy, Morning Care/AM Care, dated 09/01/22 revealed morning care will be offered each day. Morning care provided should include provide fingernail care. Review of facility policy, Social Services Policy, dated 04/16/21 revealed social services was responsible for coordinating needed ancillary services. 366441 Page 7 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure meal intakes were monitored. This affected five residents (Resident #8, #14, #23, #61, and #62) of five residents reviewed for nutrition monitoring. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #8 revealed admission date of 08/30/21 with diagnoses including catatonic disorder, depression, and hyperlipidemia. Resident #8 had physician's order dated 09/01/21 for a regular diet. Review of the care plan dated 06/17/22 revealed Resident #8 was at increased nutritional risk. Interventions included monitor dietary intake, monitor need for increased nutritional intervention, and provide diet as ordered. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #8 was independent during meals. Review of electronic medical record (EMR) meal intake documentation from September 2022 revealed no documentation of meal intake for breakfast, lunch, or dinner. Review of paper medical record for meal intakes from September 2022 revealed no documentation of meal intake for breakfast, lunch, and dinner. Interview on 09/14/22 at 2:14 P.M. with State Tested Nursing Assistant (STNA) #315 revealed meal intakes are charted in EMR. Interview on 09/14/22 at 2:33 P.M. with Agency STNA #316 reported they did not have username or password for EMR and was unable to complete charting. Interview on 09/15/22 at 9:05 A.M. with Agency STNA #317 indicated meal intakes are charted in EMR. Interview on 09/15/22 at 9:37 A.M. with Registered Dietitian (RD) #318 revealed there has been a challenge to get staff to complete meal intake documentation. Interview on 09/15/22 at 11:32 A.M. with Director of Nursing (DON) revealed the corporate office had changed STNA documentation workstation to kiosk only, however the kiosks were not working correctly. DON indicated the facility had not received new kiosks. DON indicated at times the STNAs were able to document from desktop computers, but most of the charting should be on paper. Interview on 09/15/22 at 1:56 P.M. with Agency STNA #319 revealed it was the first time covering at the facility and they were told charting was completed on EMR. STNA #139 indicated they had not gotten a password or username yet. Interview on 09/15/22 at 2:04 P.M. with STNA #320 revealed the aides had to use paper charting at times. STNA #320 indicated most of the younger STNAs don't know how to do the paper charting, so if the computers are down then they won't chart. 366441 Page 8 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Follow up interview on 09/15/22 at 2:47 P.M. with DON confirmed if the charting was not in the paper logbook or in EMR then it was not completed. DON confirmed above findings. 2. Review of the medical record for Resident #14 revealed admission date of 06/25/22 with diagnoses including diabetes mellitus, end stage renal disease, iron deficiency anemia, and dependence on renal dialysis. Resident #14 had physician's order dated 07/01/22 for renal and diabetic diet restrictions with double protein at meals. Review of the Minimum Data Set (MDS) 3.0 five-day assessment dated [DATE] revealed Resident #14 was independent during meals. Review of Medical Nutritional Therapy assessment dated [DATE] revealed meal intake percentages indicated pending for Resident #14. Review of the care plan dated 07/29/22 revealed Resident #14 was at increased nutritional risk. Interventions included monitor dietary intake, monitor need for increased nutritional intervention, and provide diet as ordered. Review of electronic medical record (EMR) meal intake documentation from September 2022 revealed no documentation of meal intake for breakfast, lunch, or dinner. Review of paper medical record for meal intakes from September 2022 revealed no documentation of meal intake for breakfast, lunch, and dinner. Interview on 09/14/22 at 2:14 P.M. with STNA #315 revealed meal intakes are charted in EMR. Interview on 09/14/22 at 2:33 P.M. with Agency STNA #316 reported they did not have username or password for EMR and was unable to complete charting. Interview on 09/15/22 at 9:05 A.M. with Agency STNA #317 indicated meal intakes are charted in EMR. Interview on 09/15/22 at 9:37 A.M. with RD #318 revealed there has been a challenge to get staff to complete meal intake documentation. Interview on 09/15/22 at 11:32 A.M. with DON revealed the corporate office had changed STNA documentation workstation to kiosk only, however the kiosks were not working correctly. DON indicated the facility had not received new kiosks. DON indicated at times the STNAs were able to document from desktop computers, but most of the charting should be on paper. Interview on 09/15/22 at 1:56 P.M. with Agency STNA #319 revealed it was the first time covering at the facility and they were told charting was completed on EMR. STNA #139 indicated they had not gotten a password or username yet. Interview on 09/15/22 at 2:04 P.M. with STNA #320 revealed the aides had to use paper charting at times. STNA #320 indicated most of the younger STNAs don't know how to do the paper charting, so if the computers are down then they won't chart. 366441 Page 9 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Minimal harm or potential for actual harm Follow up interview on 09/15/22 at 2:47 P.M. with DON confirmed if the charting was not in the paper logbook or in EMR then it was not completed. DON confirmed above findings. 3. Review of the medical record for Resident #23 revealed admission date of 03/11/22 with diagnoses including rectal cancer, depression, and hyperlipidemia. Residents Affected - Some Review of the care plan dated 06/15/22 revealed Resident #23 was at increased nutritional risk. Interventions included monitor dietary intake, monitor need for increased nutritional intervention, encourage resident to dine in dining room, and provide diet as ordered. Resident #23 had physician's order dated 07/01/22 for regular diet with ground textures. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #23 was independent during meals. Review of Dietary Quarterly assessment dated [DATE] revealed meal intake percentages indicated pending for Resident #23. The assessment indicated Resident #23 had significant weight loss. Review of electronic medical record (EMR) meal intake documentation from September 2022 revealed documented intake for breakfast and lunch on 09/03/22 and 09/13/22 was 0 to 25 percent. There was no additional documentation of meal intake for breakfast, lunch, or dinner. Review of paper medical record for meal intakes from September 2022 revealed no documentation of meal intake for breakfast, lunch, and dinner. Interview on 09/14/22 at 2:14 P.M. with STNA #315 revealed meal intakes are charted in EMR. Interview on 09/14/22 at 2:33 P.M. with Agency STNA #316 reported they did not have username or password for EMR and was unable to complete charting. Interview on 09/15/22 at 9:05 A.M. with Agency STNA #317 indicated meal intakes are charted in EMR. Interview on 09/15/22 at 9:37 A.M. with RD #318 revealed there has been a challenge to get staff to complete meal intake documentation. Interview on 09/15/22 at 11:32 A.M. with DON revealed the corporate office had changed STNA documentation workstation to kiosk only, however the kiosks were not working correctly. DON indicated the facility had not received new kiosks. DON indicated at times the STNAs were able to document from desktop computers, but most of the charting should be on paper. Interview on 09/15/22 at 1:56 P.M. with Agency STNA #319 revealed it was the first time covering at the facility and they were told charting was completed on EMR. STNA #139 indicated they had not gotten a password or username yet. Interview on 09/15/22 at 2:04 P.M. with STNA #320 revealed the aides had to use paper charting at times. STNA #320 indicated most of the younger STNAs don't know how to do the paper charting, so if the computers are down then they won't chart. Follow up interview on 09/15/22 at 2:47 P.M. with DON confirmed if the charting was not in the 366441 Page 10 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 paper logbook or in EMR then it was not completed. DON confirmed above findings. Level of Harm - Minimal harm or potential for actual harm 4. Review of the medical record for Resident #61 revealed admission date of 05/31/22 with diagnoses including moderate protein calorie malnutrition, depression, and gastro-esophageal reflux disease. Residents Affected - Some Resident #61 had physician's order dated 06/01/22 for regular diet. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #61 was independent during meals. Review of Dietary Quarterly assessment dated [DATE] revealed meal intake percentages indicated pending for Resident #61. The assessment indicated Resident #61 had significant weight loss. Review of the care plan dated 08/12/22 revealed Resident #61 was at increased nutritional risk. Interventions included monitor dietary intake, monitor need for increased nutritional intervention, and provide diet as ordered. Review of electronic medical record (EMR) meal intake documentation from September 2022 revealed no documentation of meal intake for breakfast, lunch, or dinner. Review of paper medical record for meal intakes from September 2022 revealed no documentation of meal intake for breakfast, lunch, and dinner. Interview on 09/14/22 at 2:14 P.M. with STNA #315 revealed meal intakes are charted in EMR. Interview on 09/14/22 at 2:33 P.M. with Agency STNA #316 reported they did not have username or password for EMR and was unable to complete charting. Interview on 09/15/22 at 9:05 A.M. with Agency STNA #317 indicated meal intakes are charted in EMR. Interview on 09/15/22 at 9:37 A.M. with RD #318 revealed there has been a challenge to get staff to complete meal intake documentation. Interview on 09/15/22 at 11:32 A.M. with DON revealed the corporate office had changed STNA documentation workstation to kiosk only, however the kiosks were not working correctly. DON indicated the facility had not received new kiosks. DON indicated at times the STNAs were able to document from desktop computers, but most of the charting should be on paper. Interview on 09/15/22 at 1:56 P.M. with Agency STNA #319 revealed it was the first time covering at the facility and they were told charting was completed on EMR. STNA #139 indicated they had not gotten a password or username yet. Interview on 09/15/22 at 2:04 P.M. with STNA #320 revealed the aides had to use paper charting at times. STNA #320 indicated most of the younger STNAs don't know how to do the paper charting, so if the computers are down then they won't chart. Follow up interview on 09/15/22 at 2:47 P.M. with DON confirmed if the charting was not in the paper logbook or in EMR then it was not completed. DON confirmed above findings. 366441 Page 11 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Review of the medical record for Resident #62 revealed admission date of 05/11/22 with diagnoses including diabetes mellitus, acute kidney failure, and morbid obesity. Resident #62 had physician's order dated 05/16/22 for diabetic diet with double protein portions. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #62 was independent during meals. Review of electronic medical record (EMR) meal intake documentation from September 2022 revealed no documentation of meal intake for breakfast, lunch, or dinner. Review of paper medical record for meal intakes revealed documentation of 100% meal intake however there was no indication as to what meal or the month the documentation was from. The record had recordings for two meals. Review of the care plan dated 08/11/22 revealed Resident #62 was at increased nutritional risk. Interventions included monitor dietary intake, monitor need for increased nutritional intervention, and provide diet as ordered. Interview on 09/14/22 at 2:14 P.M. with STNA #315 revealed meal intakes are charted in EMR. Interview on 09/14/22 at 2:33 P.M. with Agency STNA #316 reported they did not have username or password for EMR and was unable to complete charting. Interview on 09/15/22 at 9:05 A.M. with Agency STNA #317 indicated meal intakes are charted in EMR. Interview on 09/15/22 at 9:37 A.M. with RD #318 revealed there has been a challenge to get staff to complete meal intake documentation. Interview on 09/15/22 at 11:32 A.M. with DON revealed the corporate office had changed STNA documentation workstation to kiosk only, however the kiosks were not working correctly. DON indicated the facility had not received new kiosks. DON indicated at times the STNAs were able to document from desktop computers, but most of the charting should be on paper. Interview on 09/15/22 at 1:56 P.M. with Agency STNA #319 revealed it was the first time covering at the facility and they were told charting was completed on EMR. STNA #139 indicated they had not gotten a password or username yet. Interview on 09/15/22 at 2:04 P.M. with STNA #320 revealed the aides had to use paper charting at times. STNA #320 indicated most of the younger STNAs don't know how to do the paper charting, so if the computers are down then they won't chart. Follow up interview on 09/15/22 at 2:47 P.M. with DON confirmed if the charting was not in the paper logbook or in EMR then it was not completed. DON confirmed above findings. Review of facility policy titled, IT Service Request, dated 08/02/22 revealed the facility has POC kiosks for STNA documentation. Three are not powering up, two power up but have no display, and one 366441 Page 12 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Minimal harm or potential for actual harm has a missing power cord. Email chain from Information Technology (IT) and Administrator indicated on 08/10/22 new kiosks were ordered from vendor. Review of facility policy titled, ADL Documentation Policy, dated 08/12/20 revealed activities of daily living care and actual meal consumption will be documented on each shift by staff providing care. Residents Affected - Some 366441 Page 13 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and review of the facility policy, the facility failed to ensure State Tested Nursing Assistants (STNA) received 12 hours of inservices annually. This had the potential to affect all 75 of 75 residents residing in the facility. Residents Affected - Many Findings include: Record review of STNA #326's employee file revealed a hire date of 06/25/20. Record review of the the signed transcript for STNA #326 revealed a combined total of 10.10 hours of annual inservices. Record review of STNA #327 employee file revealed a hire date of 03/30/21. Record review of the the signed transcript for STNA #327 revealed a combined total of 6.70 hours of annual inservices. Interview on 09/19/22 at 9:30 A.M. with Administrator confirmed STNA #326 had a total of 10.10 hours of inservicing and STNA #327 had a total of 6.70 hours of inservicing. Administrator confirmed all STNA's were required 12 hours of inservicing annually. Record review of the policy titled, Annual Inservices revealed no less than 12 hours annual inservice training/staff education is required. Calculate the date by which nurse aid must receive annual inservice education by employment/hire date rather than the calender year. 366441 Page 14 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #25's aerosol treatment was administered properly. This affected one resident (Resident #25) of out four residents observed for medication administration. Findings include: Record review for Resident #25 revealed an admission date of 07/13/21 with diagnosis including quadriplegia, cerebrovascular disease, pneumonia, heart failure, and muscle wasting and atrophy. Record review of the annual MDS dated [DATE] revealed Resident #25 was rarely or never understood. Resident #25 had a short term and long term memory problem. Resident #25 was total dependence for all activities of daily living. Record review of the physician orders for September 2022 revealed Resident #25 had orders for albuterol solution 0.5-0.25 milligrams (mg) per three milliliters (ml) inhale orally every four hours as needed for shortness of breath. Observation on 09/13/22 at 4:15 P.M. revealed Resident #25 was lying in bed. Resident #25 had an aerosol mask that was turned sideways on his face. The aerosol tubing was not connected to the aerosol machine. The aerosol machine was running. There was no nurse in the resident room, or the hall Resident #25 was located on. Observation on 09/13/22 at 4:16 P.M. with Licensed Practical Nurse (LPN) #301 confirmed Resident #25 had an aerosol mask that was turned sideways on his face. LPN #301 confirmed the mask was positioned incorrectly on Resident #25's face and the aerosol tubing was not connected to the aerosol machine. The aerosol machine was running and the medication was not fully administered. LPN #301 assisted Resident #25 and revealed LPN #302 was Resident #25's charge nurse. Interview on 09/13/22 at 4:25 P.M. with LPN #302 confirmed she was Resident #25's charge nurse. LPN #302 revealed the aerosol treatment was initiated at around 4:00 P.M. by the previous shift nurse. LPN #302 revealed she seen Resident #25 between 4:05 P.M. and 4:10 P.M. when she had taken over the shift and the aerosol mask was applied correctly at that time and the tubing was connected to the machine with the machine running. LPN #302 confirmed Resident #25 was left unattended during the aerosol treatment and revealed she did not stay with any residents during their aerosol treatments. Interview on 09/15/22 at 11:42 A.M. with Director of Nursing confirmed nursing staff were to stay with residents during medication administration including aerosol treatments. 366441 Page 15 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of manufacture's guidelines, the facility failed to ensure a medication error rate of less than five percent (%). Four errors occurred within 26 opportunities for error resulting in a medication error rate of 15.38%. This affected two residents (Resident #25 and #31) of four residents observed during the mediation administration observation. The facility census was 75. Residents Affected - Few Findings include: 1. Review of Resident #25's medical records revealed an admission date of 07/13/21 with diagnoses including hyperglycemia, necrotizing fasciitis, quadriplegia, dysphagia, heart failure, and chronic kidney disease. Review of the care plan dated 07/12/22 revealed the resident had risk for unstable blood glucose related to diabetes. Review of the Minimum Data Set (MDS) dated [DATE] revealed had severely impaired cognition and required total care of two plus for bed mobility, transfers, toileting, and bathing. Resident #25 required total care of one assistance for dressing and hygiene. Resident #25 was total dependence for eating with one assistance via tube feeding. Review of the physician order for September 2022 revealed resident was to receive Ferrous Sulfate 325 milligram (mg) via peg tube every 12 hours. Ferrous Sulfate was not to be crushed for administration. Observation of medication administration on 09/13/22 at 8:10 A.M. revealed Licensed Practical Nurse (LPN) #311 reported only Ferrous Sulfate 325 mg tablet form was available not liquid. LPN #311 reported she was unable to crush tablet and give via peg tube and required liquid Ferrous Sulfate. LPN #311 checked to see if any liquid Ferrous Sulfate was available. LPN #311 reported there was no Ferrous Sulfate liquid form. LPN #311 reported she would have to contact the pharmacy and physician regarding this medication. LPN #311 did not give Resident #25 Ferrous Sulfate 325 mg as ordered. Review of the Medication Administration Record (MAR) for 09/13/22, revealed Ferrous Sulfate 325 mg dose was not available and not given to Resident #25. The MAR for 09/13/22, revealed a new order dated 09/13/22 at 9:00 P.M. for Ferrous Sulfate Liquid 220 (44 Fe) MG/milliliter (ML), to give 7.5 mg every 12 hours for supplement. Interview on 09/13/22 at 10:31 A.M. with LPN #311 verified Resident #25 did not receive Ferrous Sulfate 325 mg as ordered from the physician due to not being available as required in a liquid form. Review of facility policy, LTC Facility's Pharmacy Services and Procedure Manual, General Dose Preparation and Medication Administration, revised 01/01/22, revealed, verify each time a medication is administered that is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule. 2. Review of Resident #31's medical records revealed an admission date of 03/02/22 with diagnoses 366441 Page 16 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0759 Level of Harm - Minimal harm or potential for actual harm including type 2 diabetes mellitus with hyperglycemic, chronic obstructive pulmonary disease with acute exacerbation, schizophrenia, anxiety disorder, depressive disorder, and migraine. Review of the care plan dated 07/12/22 revealed the resident had risk for unstable blood glucose related to diabetes. Residents Affected - Few Review of the Minimum Data Set (MDS) dated [DATE] revealed had moderately impaired cognition and required extensive assistance of one for bed mobility, transfers, dressing, toileting, hygiene, and bathing. Review of Resident #31's physician order for September 2022 revealed resident was ordered Jardiance 25 mg tablet to give one tablet my mouth one time a day and Folic Acid tablet 500 microgram (mcg) (1 mg) by mouth one time a day for supplement. Resident #31 was also ordered Humalog KwikPen Solution Pen-injector 100 unit/milliliter (ML) Insulin Lispro (1 unit dial) to be administered per sliding scale. Inject as per sliding scale: if 151 to 200, give 2 units (u); 201 to 250 give 4 u; 251 to 300 give 6 u; 301 to 350 give 8 u; 351 to 400 give 10 u; and 401 to 500 notify medical doctor if over 400, subcutaneously before meals and at bedtime for diabetes mellitus. Observation of medication administration on 09/14/22 at 07:42 A.M. revealed Licensed Practical Nurse (LPN) #302 reported there was no Jardiance 25 mg tablet available. LPN #302 reported she would need to re-order. LPN #302 reported it was reordered on 08/29/22, but she would reorder again. LPN #302 did not give Resident #31 her Jardiance 25 mg as ordered by the physician. In addition, LPN #302 removed 2 capsules of Folic Acid 400 mcg into medicine cup with other medications. Once all medications were put in medicine cup and LPN #302 was about to administer the medication this surveyor stopped her and asked her to check the bottle label for the folic acid. LPN #302 checked the labeled bottle of folic acid which was for 400 mcg not the 500 mcg as ordered by the physician. LPN #302 discarded the 2 capsules of Folic Acid into the sharp's container. LPN #302 checked with Central Supply for Folic Acid 500 mcg and there were none available. LPN #302 checked with Director of Nursing (DON) who reported no Folic Acid 500 mcg but would get some. Review of the MAR for September 2022 revealed Resident #31 did not receive her Jardiance 25 mg dose on 09/13/22 and 09/14/22 at scheduled time of 09:00 A.M. and did not receive her Folic Acid 500 mcg at 09:00 A.M. as ordered by the physician. Interview on 09/14/22 at 7:42 A.M. with LPN #302 verified Jardiance 25 mg was not available to be given as ordered. LPN #302 verified she was about to administer Folic Acid 400 mcg to Resident #31 which was not the ordered dose by the physician. LPN #302 confirmed the wrong dose of Folic Acid was prepared in the medicine cup to be administered. Observation on 09/14/22 of Resident #31's at 11:00 A.M. revealed the resident's blood sugar was 185. Per sliding scale order, Resident #31 was to receive 2 units of insulin. During medication administration observation on 09/14/22 at 11:34 A.M., LPN #302 prepared Resident #31's Lispro KwikPen insulin (a disposable prefilled insulin pen used for injection) by securing a new needle onto the KwikPen and set the dial at 2 units of insulin per sliding scale. LPN #302 did not prime the insulin pen as required before drawing up insulin to ensure correct insulin coverage is provided. LPN #31 used hand sanitizer and was about to enter Resident #31's room to administer insulin when this surveyor asked her to stop and informed, she did not prime the insulin pen. 366441 Page 17 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/14/22 at 11:34 A.M. with LPN #302 revealed she did not understand why or how to prime the insulin pen. LPN #302 reported she knows to prime insulin from a vial and a syringe, which was incorrect. LPN #302 verified she did not prime the insulin pen. Interview on 09/14/22 at 7:05 A.M. with DON confirmed insulin pens are required to be primed (discard 2 units) for 2 units before drawing up insulin dosage to ensure correct dosage of insulin is provided to the resident. Interview on 09/15/22 at 11:19 A.M. with DON verified Resident #31 did not receive ordered medication of Jardiance 25 mg on 09/13/22 and 09/14/22. DON verified Resident #31 did not have Folic Acid 500 mg available to administer per physician order. Review of facility policy, LTC Facility's Pharmacy Services and Procedure Manual, General Dose Preparation and Medication Administration, revised 01/01/22, revealed, verify each time a medication is administered that is is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule. Review of manufacturer's instructions for Insulin Lispro Injection KwikPen (pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf) revealed guidelines to prime before each injection, if you do not prime before each injection, you may get too much or too little insulin. 366441 Page 18 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

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 interview and record review, the facility failed to document Resident #126's hospitalization. This affected one resident (Resident #126) of four residents reviewed for hospitalization. Findings include: Record review of the medical records for Resident #126 revealed an admission date of 08/26/22 with diagnosis including paraplegia, neurogenic bowel, neuromuscular dysfunction of bladder and necrotizing fasciitis. Record review of the admission assessment dated [DATE] at 6:00 P.M. revealed Resident #126 arrived at the facility on 08/26/2022 at 6:00 P.M. for rehabilitation. Resident#126 had a discharge goal to return to the community. Resident #126 was alert and oriented and required one person assist for toileting. Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #126 was cognitively intact. Record review of the care plan dated 09/02/22 revealed Resident#126 had an activity of daily living (ADL) self care deficit. Interventions included toileting with assist of one to two people. Interview on 09/12/22 at 10:25 A.M. with Resident #126 revealed he called 911 on his first night at the facility. Resident #126 revealed he called 911 because he was sitting in feces and they would not clean him up so he went to the hospital. Record review for Resident #126 revealed no documentation in the hard chart medical record or in the electronic medical record (Point Click Care), including the census, nurses notes or assessments of Resident #126 calling 911, going to the hospital or returning from the hospital at any time since admission on [DATE] at 6:00 P.M. Interview 09/19/22 at 9:22 A.M. with Director of Nursing (DON) revealed on Resident #126's first night at the facility, he didn't want to be there. DON confirmed Resident #126 called 911 the first night, 08/26/22, and told police he didn't want to be there, he wanted to go back to the hospital. Resident #126 stated no one was answering his call light for two hours. DON revealed she checked the facility cameras and Resident #126's call light was not on. DON revealed she checked Resident #126's call light and it was working. DON revealed Resident #126 had a bowel movement earlier after arrival and was assisted. DON revealed the ambulance took Resident #126 to the hospital (could not recall the time). DON revealed Resident #126 was clean and dry when he went to the hospital and returned from the hospital within two hours. DON revealed the staff at the hospital talked to Resident #126, Resident #126 wanted to return to his home in the community, and the hospital staff told him if he did not return to the facility, it would be considered against medical advise (AMA) due to seriousness of his wounds, so Resident #126 returned to the facility. DON confirmed Resident #126 had no documentation in the hard chart or electronic medical records of Resident #126 calling 911, leaving the facility to go to the hospital or returning from the hospital. DON revealed if she did not document neither do the nursing staff. DON confirmed she had no police report regarding the incident. 366441 Page 19 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/19/22 at 9:49 A.M. with Business Office Manager (BOMB) confirmed Resident #126 census did not show Resident #126 went to the hospital at any point since admission. BOMB revealed Resident #126 was gone from the facility to the hospital no more than two hours and due to insurance time, it was not required to document the change in Resident #126's census. Interview on 09/19/22 at 10:06 A.M. with Licensed Practical Nurse (LPN) #329 confirmed she was the charge nurse for Resident #126 when he was admitted on [DATE], LPN #329 confirmed Resident #126 called 911 on 08/26/22 (unsure of time), the police came and the 911 ambulance with a stretcher. LPN #329 revealed Resident #126 did not tell the staff he was calling 911 and had not asked for assistance due to incontinence. LPN #329 revealed Resident #126 told her he wanted to go back to the hospital because he felt his wound was infected. LPN #329 revealed Resident #126 was admitted to the facility the night before, and this incident was the following morning. LPN #329 confirmed she did not document any of the incident, Resident #126 calling 911, leaving the facility or returning from the hospital due to she was busy doing other things. Interview on 09/19/22 at 10:30 A.M. with DON revealed the facility had no policy for documentation required for admission and discharge of a resident. 366441 Page 20 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, facility policy review, and review of online resources for the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore personal protective equipment (PPE) as required when entering Resident #127 and #266's room who were under droplet precautions for COVID-19 observation. This had the potential to affect all 75 residents residing in the facility. Residents Affected - Many Findings include: Review of medical record for Resident #127 revealed admission date 09/09/22 and a physician order dated 09/12/22 to 09/15/22 for droplet precautions. Review of the immunization record revealed Resident #127 had declined the COVID-19 vaccination. Review of medical record for Resident #266 revealed admission date of 09/12/22 and a physician order dated 09/13/22 to 09/20/22 for droplet precautions. Review of the immunization record revealed Resident #266 was not up to date on COVID-19 vaccination series. Observation on 09/14/22 at 8:08 A.M. revealed between Resident #127's room and #266's room there was a sign indicating droplet precautions and a bin with PPE storage. Observation on 09/14/22 at 8:20 A.M. revealed Licensed Practical Nurse (LPN) #301 entered Resident #266's room to deliver a breakfast tray. LPN #301 was wearing N95 face mask and eye protection. LPN #301 set up Resident #266's breakfast tray and exited room. LPN #301 continued to pass trays without hand hygiene. Observation on 09/14/22 at 8:22 A.M. revealed LPN #301 entered Resident #127's room to deliver a breakfast tray. LPN #301 was wearing N95 face mask and eye protection. LPN #301 set up Resident #127's breakfast and washed hands prior to exiting room. Interview on 09/14/22 at 8:24 A.M. with LPN #301 revealed LPN #301 was unaware of which resident was on droplet precautions and indicated they would need to check electronic medical records for both residents. Interview on 09/14/22 at 8:33 A.M. with LPN #301 confirmed both Resident #127 and Resident #266 should be on droplet precautions for new admission COVID-19 observation. LPN #301 confirmed she did not wear appropriate PPE when entered Resident #127 and Resident #266's rooms. LPN #301 stated the appropriate PPE to wear for droplet precautions was gown, N95 mask, eye protection, and gloves. Review of an online resource per the CDC titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 02/02/2022, revealed in general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission. Review of facility policy titled, Transmission-Based Precautions Policy, dated 07/21/22, revealed when in a resident room identified with droplet precautions staff should wear gloves, gown, eye 366441 Page 21 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0880 protection, and mask. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled, Clinical Staff Personal Protective Equipment (PPE) Usage Guide, undated, revealed staff must wear N95 respirator mask, eye protection, gown, and gloves in resident room when a resident is under COVID-19 observation. Residents Affected - Many 366441 Page 22 of 23 366441 09/19/2022 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0881 Implement a program that monitors antibiotic use. 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 ensure the duration of Resident #18 antibiotic use was implemented and monitored properly. This affected one resident (Resident #18) out of three residents reviewed for urinary tract infections. The facility census was 75. Residents Affected - Few Findings include: Record review revealed Resident #18 had an admission date of 05/24/21 with diagnosis including dementia and multiple fractures of the pelvis. Record review of the care plan for Resident #18 dated 05/25/21 revealed Resident #18 had altered genitourinary status with a history of urinary tract infections (UTI) prior to admission. Interventions included to administer medications as indicated by the physician. Record review quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was rarely or never understood. Record review of the urine specimen for Resident #18 collected on 08/02/22 revealed the urine was positive for nitrates with many bacteria presen , blood 1+, slightly cloudy, and mucous was present. The culture revealed sensitive to nitrofurantoin (macrobid). Record review of the physician orders for September 2022 revealed an order for macrobid 100 milligrams (mg) by mouth every 12 hours for a UTI. The medication was initiated on 08/03/22. Record review of the Medication Administration Record (MAR) revealed macrobid was initiated 08/03/22 at 9:00 P.M. and continued on 09/14/22 at 9:00 A.M. Record review from Medscape of dosage recommendations for macrobid revealed treatment for a UTI included macrobid 100 mg by mouth every 12 hours for seven days. For long term use prophylaxis/suppression was 50 to 100 mg by mouth at night (one time a day) for up to 12 months. Interview on 09/14/22 at 9:50 A.M. with Director of Nursing (DON) revealed she had just seen Resident #18 was still receiving macrobid and would call the Certified Nurse Practitioner (CNP) #324 to find out why she was still on it. Interview on 09/15/22 at 10:59 A.M. with Infection Preventionist (IP) #325 revealed she monitored antibiotic orders daily to assure residents were not medicated unnecessarily with antibiotics. IP #325 confirmed Resident #18 started a treatment of macrobid 100 mg by mouth every 12 hours for a UTI on 08/03/22. There was no stop date on the order for macrobid. IP #325 revealed she would have normally contacted the CNP to clarify the order but she had been off work or working short periods for the last month and did not review the antibiotic order for Resident #18. Phone Interview on 09/15/22 at 4:35 P.M. with CNP #325 and DON present confirmed the antibiotic dose (macrobid 100 mg by mouth every 12 hours) for Resident #18 was used to treat the UTI initiated on 08/03/22. CNP #325 confirmed the normal dose range for macrobid was for seven to 10 days for treatment of an active UTI and the medication dose should have been decreased to a prophylactic dose after the UTI was resolved. 366441 Page 23 of 23