Health inspection·January 4, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #53 was free from verbal abuse. This finding affected one (Resident #53) of three residents reviewed for abuse. Findings include: Review of Resident #53's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, vascular dementia and anxiety disorder. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of an Emotional/Verbal Abuse Self-Reported Incident (SRI) Form Tracking #241367 dated 11/20/23 revealed on 11/17/23 at approximately 1:45 P.M., the Hospice State Tested Nursing Assistant (STNA) #810 asked Licensed Practical Nurse (LPN) #811 (facility staff) to assist her with care for the resident. While performing the care, Resident #53 started getting verbally and physically aggressive with the nurse. The nurse continued to assist the STNA with care but got overwhelmed with the aggressiveness from the resident and spoke to the resident unprofessionally. The Hospice STNA spoke to her hospice case manager regarding the incident that day. The Administrator was notified by the family on 11/20/23 and the investigation was opened. The SRI was unsubstantiated (evidence indicates abuse, neglect or misappropriation did not occur). Review of a Witness Statement dated 11/22/23 authored by Hospice STNA #810 indicated on Friday, 11/17/23, the STNA needed help with caring for Resident #53 and asked LPN #811 for assistance. The witness statement indicated STNA #810 felt the nurse was being verbally and physically aggressive with the resident and she reported the concern to the case manager and the Hospice Director of Nursing (DON). Review of a Witness Statement dated 11/22/23 authored by Hospice Registered Nurse (RN) #814 indicated the nurse notified the direct manager immediately after she was informed of the incident. RN #814 encouraged STNA #810 to notify the facility DON and notify the resident's daughter. Interview on 01/02/24 at 9:11 A.M. with the Administrator indicated a nurse got overwhelmed and did not typically work the unit that Resident #53 resides on. The Administrator confirmed she viewed the surveillance video provided by Resident #53's family and thought the nurse lost her cool. The Administrator confirmed the facility was not aware of the abuse allegation until 11/20/23 and at that Page 1 of 8 366454 366454 01/04/2024 Avenue at Macedonia 9730 Valley View Road Macedonia, OH 44056

F 0600 time, a SRI with an investigation was initiated. Level of Harm - Minimal harm or potential for actual harm Interview on 01/02/24 at 11:56 A.M. with the Administrator indicated LPN #811 was removed from the schedule for three days while the investigation was in process. She stated she felt the nurse was new and overwhelmed by Resident #53's behaviors. Residents Affected - Few Telephone interview on 01/02/24 at 4:46 P.M. with Resident #53's Daughter #813 (emergency contact number one) indicated she had observed on video surveillance that LPN #811 had called the resident an explicit name and was unprofessional during resident care. She stated that the behavior was unacceptable, and she brought the behavior to the attention of the Administrator on 11/20/23 and requested LPN #811 to not provide care to Resident #53 during resident care. Daughter #813 stated she was unsure if she could provide the video surveillance on this date because the video overwrites with new information daily. Interview on 01/03/24 at 9:01 A.M. with the Administrator indicated she could not recall if LPN #811 had called Resident #53 names or used inappropriate language while caring for the resident when she observed the surveillance video provided by the family members on 11/20/23. Telephone interview on 01/03/24 at 9:31 A.M. with Hospice STNA #810 stated she was in the room when LPN #811 used inappropriate language and called Resident #53 an explicit name. She stated she also felt the nurse was unnecessarily rough with the resident. She stated she went to the front of the building and did not see the administration staff in the office and that was why she did not report the concern timely to the facility. She stated she called her supervising hospice nurse and reported the concern. Review of the undated Abuse Prohibition policy indicated each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. This deficiency represents non-compliance investigated under Complaint Number OH00149369. 366454 Page 2 of 8 366454 01/04/2024 Avenue at Macedonia 9730 Valley View Road Macedonia, OH 44056

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to timely report an allegation of verbal abuse. This finding affected one (Resident #53) of three residents reviewed for abuse. Findings include: Review of Resident #53's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, vascular dementia and anxiety disorder. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of an Emotional/Verbal Abuse Self-Reported Incident (SRI) Form Tracking #241367 dated 11/20/23 revealed on 11/17/23 at approximately 1:45 P.M., the Hospice State Tested Nursing Assistant (STNA) #810 asked Licensed Practical Nurse (LPN) #811 (facility staff) to assist her with care for the resident. While performing the care, Resident #53 started getting verbally and physically aggressive with the nurse. The nurse continued to assist the STNA with care but got overwhelmed with the aggressiveness from the resident and spoke to the resident unprofessionally. The Hospice STNA spoke to her hospice case manager regarding the incident that day. The Administrator was notified by the family on 11/20/23 and the investigation was opened. The SRI was unsubstantiated (evidence indicates abuse, neglect or misappropriation did not occur). Review of a Witness Statement dated 11/22/23 authored by Hospice STNA #810 indicated on Friday, 11/17/23, the STNA needed help with caring for Resident #53 and asked LPN #811 for assistance. The witness statement indicated STNA #810 felt the nurse was being verbally and physically aggressive with the resident and she reported the concern to the case manager and the Hospice Director of Nursing (DON). Review of a Witness Statement dated 11/22/23 authored by Hospice Registered Nurse (RN) #814 indicated the nurse notified the direct manager immediately after she was informed of the incident. RN #814 encouraged STNA #810 to notify the facility DON and notify the resident's daughter. Interview on 01/02/24 at 9:11 A.M. with the Administrator indicated a nurse got overwhelmed and did not typically work the unit that Resident #53 resides on. The Administrator confirmed she viewed the surveillance video provided by Resident #53's family and thought the nurse lost her cool. The Administrator confirmed the facility was not aware of the abuse allegation until 11/20/23 and at that time, a SRI with an investigation was initiated. Telephone interview on 01/02/24 at 4:46 P.M. with Resident #53's Daughter #813 (emergency contact number one) indicated she had observed on video surveillance that LPN #811 had called the resident an explicit name and was unprofessional during resident care. She stated that the behavior was unacceptable, and she brought the behavior to the attention of the Administrator on 11/20/23 and requested LPN #811 to not provide care to Resident #53 during resident care. Daughter #813 stated she was unsure if she could provide the video surveillance on this date because the video overwrites with new information daily. 366454 Page 3 of 8 366454 01/04/2024 Avenue at Macedonia 9730 Valley View Road Macedonia, OH 44056

F 0609 Level of Harm - Minimal harm or potential for actual harm Telephone interview on 01/03/24 at 9:31 A.M. with Hospice STNA #810 stated she was in the room when LPN #811 used inappropriate language and called Resident #53 an explicit name. She stated she also felt the nurse was unnecessarily rough with the resident. She stated she went to the front of the building and did not see the administration staff in the office and that was why she did not report the concern timely to the facility. She stated she called her supervising hospice nurse and reported the concern. Residents Affected - Few Interview on 01/03/24 at 2:00 P.M. with the Administrator confirmed she filed the required SRI with the State agency when she was made aware of Resident #53's abuse allegation. She stated the hospice staff did not report the allegation of abuse to her timely even though it was in their hospice contract. Review of the undated Abuse Prohibition policy indicated each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. This deficiency represents non-compliance investigated under Complaint Number OH00149369. 366454 Page 4 of 8 366454 01/04/2024 Avenue at Macedonia 9730 Valley View Road Macedonia, OH 44056

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 and interview, the facility failed to ensure a medication error rate of less than 5% (percent). A total of 34 medications were observed with six errors for a medication error rate of 17.64%. This finding affected two (Residents #3 and #53) of three residents observed for medication administration. Residents Affected - Few Findings include: 1. Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including schizophrenia, chronic obstructive pulmonary disease and dementia. Review of Resident #3's physician orders revealed an order dated 07/20/23 for Aspirin 81 mg (milligrams) oral tablet chewable give one tablet by mouth one time a day for heart health; an order dated 07/20/23 for Folic Acid oral tablet one mg give one tablet by mouth one time a day for health maintenance; an order dated 07/20/23 for Calcium Carbonate-Vitamin D oral tablet 600-10 mg-mcg (micrograms) give one tablet by mouth two times a day for low calcium; and an order dated 07/20/23 for Chlorhexidine Gluconate mouth/throat solution 0.12% give 0.018 gram by mouth two times a day for mouth care swish and spit; do not swallow. Observation on 01/02/24 at 6:55 A.M. with Licensed Practical Nurse (LPN) #803 of Resident #3's morning medication administration revealed fifteen medications were administered with four errors. LPN #803 administered Calcium 600 mg plus D 5 mcg and the order was for Calcium 600 mg plus D 10 mcg; administered Folic Acid 400 mcg and the order was for folic Acid One mg; administered Aspirin 81 mg enteric coated and the order was for Aspirin 81 mg chewable. LPN #803 also did not administer Chlorhexidine Gluconate 0.12% per the physician orders. A total of four medication errors were observed. Interview on 01/02/24 at 10:45 A.M. with LPN #803 confirmed she did not administer the appropriate dosage of Resident #3's Calcium 600 mg plus D 10 mcg, Folic Acid one mg, Aspirin chewable and Chlorhexidine Gluconate as indicated in the physician's orders. 2. Review of Resident #53's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, vascular dementia and major depressive disorder. Review of Resident #53's physician orders revealed an order dated 03/27/23 for therapeutic multivitamin with minerals give one tablet by mouth in the morning for skin health and an order dated 12/19/23 for Seroquel oral tablet (antipsychotic) 25 mg give two tablets by mouth two times a day for mood disorder. Observation on 01/02/24 at 7:53 A.M. with Registered Nurse (RN) #808 of Resident #53's morning medication administration revealed twelve medications were administered with two errors. RN #808 administered Seroquel 25 mg and the order was for Seroquel 50 mg; and one multi-vitamin when the order was for one multivitamin with minerals. A total of two medication errors were observed. Interview on 01/02/23 at 11:27 A.M. with RN #808 confirmed she did not administer Resident #53's Seroquel 50 mg and multi-vitamin with minerals as indicated in the physician orders. 366454 Page 5 of 8 366454 01/04/2024 Avenue at Macedonia 9730 Valley View Road Macedonia, OH 44056

F 0759 A total of 34 medications were administered with six errors for a medication error rate of 17.64%. Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Specific Medication Administration Procedures/Administration Procedures for All Medications revised 08/2014 indicated the policy was to administer medications in a safe and effective manner. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00149369. 366454 Page 6 of 8 366454 01/04/2024 Avenue at Macedonia 9730 Valley View Road Macedonia, OH 44056

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #42 and Resident #53 were served food items per the dietary menu and meal ticket. This finding affected two (Residents #42 and #53) of three residents reviewed for meals. Findings include: 1. Review of Resident #42's medical record revealed the resident was admitted on [DATE] with diagnoses including autistic disorder, quadriplegia and epilepsy. Review of Resident #42's physician orders revealed an order dated 02/09/23 for a regular diet, pureed texture with a thin liquids consistency for pleasure. Review of Resident #42's breakfast meal ticket dated 01/02/24 indicated the beverage was water, a banana and yogurt with the pureed meal. Observation on 01/02/23 at 8:38 A.M. revealed Resident #42's breakfast meal tray was sitting on his overbed table by the wall out of reach of the resident. Observation on 01/02/24 at 8:49 A.M. revealed State Tested Nursing Assistant (STNA) #809 came in to assist the resident with the breakfast meal. The meal consisted of pureed eggs, pureed bread, yogurt cream of wheat. The tray did not include a banana as indicated on the meal ticket. Interview on 01/02/24 at 8:51 A.M. with STNA #809 confirmed Resident #42 was not served the banana on his meal tray as indicated on the meal ticket. Interview on 01/02/24 at 11:56 A.M. with the Administrator indicated the kitchen ran out of fresh fruit and that was why there was not fruit on Residents #42 and #53's breakfast trays. She stated she educated the kitchen staff to replace with canned fruit and they obtained the fresh fruit from the store. 2. Review of Resident #53's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, vascular dementia and major depressive disorder. Review of Resident #53's physician orders revealed an order dated 03/30/23 for a regular diet, with a regular texture with thin liquids consistency and finger foods for all meals. Review of Resident #53's breakfast meal ticket dated 01/02/24 revealed a regular diet with finger foods including fresh fruit, hot coffee, ginger ale, six ounce cranberry juice, a hard boiled egg, six ounce sausage biscuit and one danish. Observation on 01/02/24 at 8:15 A.M. with the Administrator of Resident #53's breakfast meal revealed the resident was served a hard boiled egg, ginger ale in a two-handled cup, a biscuit with a piece of sausage on top and a danish. 366454 Page 7 of 8 366454 01/04/2024 Avenue at Macedonia 9730 Valley View Road Macedonia, OH 44056

F 0803 Level of Harm - Minimal harm or potential for actual harm Interview on 01/02/24 at 8:18 A.M. with the Administrator of Resident #53's breakfast meal confirmed the resident did not have fresh fruit or cranberry juice served to the resident per the resident's meal ticket. This deficiency represents non-compliance investigated under Complaint Number OH00149369. Residents Affected - Few 366454 Page 8 of 8