Health inspection·February 20, 2020

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure to ask residents their dietary choices and preferences. This affected one (Resident #244) of one resident reviewed for choices. The facility census was 44. Findings Include: Resident #244 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, high blood pressure and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #244 was moderately cognitively impaired and required extensive assistance for activities of daily living. Interview with Resident #244 on 02/18/20 at 8:30 A.M. revealed she had a great dislike of scrambled eggs. It was noted during the interview that Resident #244 had a breakfast tray that was all eaten except for a large pile of scrambled eggs. Resident #244 also explained that she had never been asked about food preferences and choices during her stay at the facility. Review of the physical and electronic medical records revealed no evidence that Resident #244 was asked about food preferences. Interview with Dietary Manager #555 on 02/19/20 a revealed she or the facilities dietitian typically asked residents about food preferences on admission and documented such preferences in the medical record. Dietary Manager #555 verified their was no evidence that food preferences were discussed with Resident #244, and she was unaware of Resident #244's dislike of scrambled eggs. Page 1 of 7 366458 366458 02/20/2020 Ahc of Landerhaven LLC 2108 Lander Road Mayfield Heights, OH 44124

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 staff interview, the facility failed to ensure appropriate notices were given to residents upon the discontinuation of skilled therapy services. This affected two residents (Residents #18 and #21) of three residents reviewed for beneficiary notices. The facility census was 44. Residents Affected - Few Findings include: 1. Resident #18 was admitted to the facility on [DATE] with diagnoses including pneumonia, sepsis and unsteadiness on feet. Review of the medical record revealed she was discharged from skilled services on 02/17/20 and chose to remain in the facility. Review of the notices given to Resident #18 revealed she was given a notice of Medicare non coverage (NOMNC) as required; however, the additional required skilled nursing advanced beneficiary notice (SNFABN) was not given to Resident #18. 2. Resident #21 was admitted to the facility 10/11/19 with diagnoses including seizures, high blood pressure and major depressive disorder. Review of the medical revealed she was discharged from skilled services on 11/27/19 and chose to remain in the facility. Review of the notices given to Resident #21 revealed she was given a NOMNC as required; however, the additional required SNFABN was not given to Resident #21. Interview with Social Service Worker #995 on 02/18/20 at 2:15 P.M. verified no SNFABN was given to Residents #18 and #21 as required. 366458 Page 2 of 7 366458 02/20/2020 Ahc of Landerhaven LLC 2108 Lander Road Mayfield Heights, OH 44124

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident and staff interviews, the facility failed to ensure call lights were within reach for Residents #26 and #247 and failed to ensure skin assessment were completed per physician's orders for Residents #33 and #243. This affected four of 44 residents residing in the facility. Residents Affected - Some Findings include: 1. Resident #247 was a admitted to the facility on [DATE] with diagnoses including legal blindness, bipolar disorder and high blood pressure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #247 was moderately cognitively impaired and required hands on assistance of one person for activities of daily living. Observation of Resident #247 on 02/18/20 at 9:30 A.M. revealed he was lying on the left hand side of the bed on his stomach, and his call light was on the floor on the right side of the bed. Interview with Resident #247 on 02/18/20 at 9:33 A.M. revealed his call light was always on the floor. Interview with Licensed Practical Nurse (LPN) #200 on 02/18/20 at 9:35 A.M. verified the placement of Resident #247's call light on the floor and also revealed that Resident #247 was capable of pressing and using his call light appropriately. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, major depressive disorder and carpal tunnel syndrome. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #26 was severely cognitive impaired and required extensive assistance for activities of daily living. Observation of Resident #26 on 02/18/20 at 9:52 A.M. revealed he was lying in bed with no call light within visible reach. Interview with LPN #201 on 02/18/20 at 9:55 A.M. verified Resident #26's call light was not within reach and that Resident #26 used a touch pad sensor with his chin to call for help due to his paralysis. 3. Resident #33 was admitted to the facility on [DATE] with diagnoses including sepsis, multiple fractures of the ribs, falls, hypertensive heart disease with hear failure, contusion of left lower leg, and acute embolism and thrombosis of unspecified deep veins of right distal lower extremity. Review of the physician's order dated 01/06/2020 revealed Skin Assessment Weekly Special Instructions: Following Nursing Schedule Once A Day on Tue 07:00 AM - 03:00 PM with no end date listed. Review of the observations (assessments) portion of the medical record revealed the only skin assessments completed on Resident #33 were on 01/07/2020, 01/18/2020, 01/22/2020, 02/12/2020 and 02/18/2020. 366458 Page 3 of 7 366458 02/20/2020 Ahc of Landerhaven LLC 2108 Lander Road Mayfield Heights, OH 44124

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Resident #243 was admitted to the facility on [DATE] with diagnoses including fracture of unspecified part of the neck, aftercare following joint replacement surgery and weakness. Review of the physician's order dated 02/05/2020 revealed Skin Assessment Weekly Special Instructions: Following Facility Schedule Once A Day on Mon, Wed 07:00 AM - 03:00 PM with no end date listed. Review of previous skin assessments for Resident #234 revealed a skin assessment was completed on 02/05/20. No other skin assessments were noted in the medical record. Interview with Director of Nursing (DON) at 3:39 P.M. on 02/19/2020 verified the lack of assessments for Residents #33 and #243. 366458 Page 4 of 7 366458 02/20/2020 Ahc of Landerhaven LLC 2108 Lander Road Mayfield Heights, OH 44124

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 auscultate the bruit, palpitate the thrill or monitor the arteriovenous (AV) fistula every shift as ordered for one of one resident (Resident #93) reviewed for dialysis. The facility census was 44. Residents Affected - Few Findings Include: Review of the medical record revealed Resident #93 was admitted to the facility on [DATE] with diagnosis including end stage renal disease with dependence on renal dialysis. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 required extensive assistance of one person for bed mobility and transfers. The resident was independent for locomotion and eating. The Brief Interview for Mental Status (BIMS) score of 12 indicated moderate cognitive impairment. A review of the physician orders from 02/2020 revealed on 02/09/20 an order to auscultate Resident #93's bruit and palpitate the thrill every shift. On 02/10/20, there was an order to monitor Resident #93's AV fistula in the right upper arm for signs and symptoms of infection-erythema, warmth, redness, and tenderness every shift. A review of the Treatments Administrative Record (TAR) from 02/09/20 through 02/19/20 revealed Resident #93's order to auscultate the bruit and palpitate thrill was completed once on 02/09/20, on two of three shifts on 02/10/20, on two of three shifts on 02/14/20 and two of three shifts on 02/17/20. The AV fistula was monitored on two of three shifts on 02/10/20, two of three shifts on 02/11/20, two of three shifts on 02/14/20 and two of three shifts on 02/17/20. Interview on 02/20/20 at 8:26 A.M. with the director of Nursing (DON) verified the physician orders to auscultate bruit, palpate thrill every shift and the order to monitor the AV fistula for signs and symptoms of infection for Resident #93 were not completed every shift. Review of the Dialysis Policy and Procedure, dated 06/2011, revealed the bruit and thrill of the fistula was to be assessed each shift. The fistula was to be checked for bleeding, edema, warmth, redness and itching. 366458 Page 5 of 7 366458 02/20/2020 Ahc of Landerhaven LLC 2108 Lander Road Mayfield Heights, OH 44124

F 0880 Provide and implement an infection prevention and control program. 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 staff failed to use appropriate personal protective equipment (gloves) during medication administration which affected Resident #42. The facility staff failed to use appropriate personal protective equipment and perform hand hygiene practices during wound care which affected Resident #26. The facility failed to provide an alcohol-based hand sanitizer product for all facility dispensers within resident care areas, and the facility did not maintain clean oscillating fans in the clean laundry area. This affected Residents #26 and #42 and had the potential to affect all 44 residents residing in the facility. Residents Affected - Many Findings include: 1. On 02/19/20 at 8:18 A.M. during medication administration observation Licensed Practical Nurse (LPN) #318 entered Resident #42's room to obtain a blood sugar reading. Without placing gloves on, LPN #318 wiped Resident #42's finger with an alcohol wipe, penetrated the finger with a disposable lancet, used a glucometer (blood sugar testing) strip to collect the blood sample, and covered the collection site with a tissue. Interview on 02/19/20 at 8:24 A.M. with LPN #318 confirmed gloves were not worn when she obtained the blood sample for the blood sugar reading for Resident #42. Review of facility policy entitled, Infection Control Practices/Precautions, dated May 2019, revealed, when in contact with any bodily fluid, the nurse must wear gloves when lancing fingers for blood sugar. 2. On 02/19/20 at 11:09 A.M. during wound care observation LPN #306 removed Resident #26's sacral dressing with gloved hands while State Tested Nursing Assistant (STNA) #346 and STNA #347 supported Resident #26 in position. LPN #306 discarded the soiled dressing, removed her gloves, washed her hands and donned a new pair of gloves, then cleansed the sacral wound with normal saline and clean gauze. Without changing her soiled gloves, LPN #306 opened a clean border dressing, picked up a new tube of zinc oxide cream, removed the cap and requested STNA #347 remove the protective seal from the tip of the tube. With an ungloved hand and using her fingernails, STNA #347 lifted and peeled the protective seal from the tip of the new tube of zinc oxide cream. With the same soiled gloves, LPN #306 applied a small amount of zinc oxide cream to the clean border dressing, and then placed the dressing onto Resident #26's sacral wound. Interview on 02/19/20 at 11:16 A.M. with STNA #347 verified she did not wear gloves to remove the protective seal on the zinc oxide cream to assist LPN #306 during Resident #26's wound care. Interview on 02/19/20 at 11:17 A.M. with LPN #306 confirmed she did not change her gloves and wash her hands after cleansing Resident #26's wound and before applying any creams or dressings, and verified STNA #347 did not wear gloves when she removed the protective seal on the zinc oxide tube. LPN #306 indicated the top of the zinc oxide tube should not have been touched without a gloved hand. Review of facility policy entitled, Licensed Nurse - Skin Condition Discovery and Documentation, dated April 2018, revealed all dressing changes and cultures, if indicated, will be completed and documented in a manner compliant with accepted standards of clinical practice. It is the policy of this facility to use clean technique. 366458 Page 6 of 7 366458 02/20/2020 Ahc of Landerhaven LLC 2108 Lander Road Mayfield Heights, OH 44124

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3. On 02/19/20 at 9:51 A.M. during laundry room tour with Maintenance #513 revealed two oscillating fans in the clean linen area directed toward the facility dryers and a clean linen cart with folded linen observed on the cart. One small oscillating fan was observed unplugged sitting on the laundry folding counter visibly dirty with dirt and debris attached to the face of the fan. One larger standing fan was observed plugged in and functioning, blowing air toward the clean linen and was visibly dirty with dirt and debris attached to the face of the fan. Interview at the time of the observation confirmed the observation, verified the fans were used by laundry staff, and confirmed the large fan was dirty and blowing air toward the clean linen. 4. On 02/19/20 at 9:51 A.M. during laundry room tour with Maintenance #513 revealed facility hand sanitizer dispensers held a non-alcohol based hand sanitizing gel product. Interview at the time of the observation revealed hand sanitizer dispensers are located in each facility hallway and housekeepers stock the dispensers with a non-alcohol based hand sanitizing gel. Interview on 02/20/20 at 9:06 A.M. with Director of Nursing (DON) confirmed all staff were educated on and had a policy to use alcohol based hand sanitizer. DON verified the facility maintained thirteen hand sanitizer dispensers throughout the facility in resident care areas. Interview on 02/20/20 at 9:08 A.M. with STNA #352 confirmed she used the hand sanitizer dispensers when assisting with resident care unless handwashing was more appropriate. Interview on 02/20/20 at 9:09 A.M. with STNA #347 confirmed she used the hand sanitizer dispensers during resident care unless handwashing was more appropriate. Review of facility in-service provided to all staff between 09/30/19 and 02/03/20 online with Relias Learning entitled, Infection Control and Prevention, dated 2016, revealed, proper hand hygiene is one component of standard precautions. It refers to handwashing with soap and water or the use of an alcohol-based hand rub, commonly abbreviated ABHR. Review of facility policy entitled, Hand Washing/Hand Hygiene, dated October 2015, revealed use of a waterless alcohol-based gel/foam hand rub when appropriate in place of handwashing. Review of the Centers for Disease Control and Prevention website for providers located at https://www.cdc.gov/handhygiene/providers/index.html revealed, alcohol-based products are more effective for standard handwashing or hand antisepsis by health care workers (HCWs) than soap or anti-microbial soaps, located in publication, Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/[NAME]/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51 (No. RR-16):11. 366458 Page 7 of 7