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Inspection visit

Inspection

TROY REHABILITATION AND HEALTHCARE CENTERCMS #3652781 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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 record review, review of hospital documentation, staff interview, local health department interview, review of Legionella water testing, review of electronic mail (email) correspondence, and policy review, the facility failed to implement their water management policy and respond to the local health department (LHD) recommendations to remediate their water system to reduce the presence of microorganisms including Legionella. This affected one (#129) of three residents reviewed for Legionella and had the potential to affect all 128 residents residing in the facility. The facility census was 128. Residents Affected - Many Findings include: Review of medical record for Resident #129 revealed an admission date of 03/23/23 and discharge date of 12/09/24. Diagnoses included but not limited to acute kidney failure, gastrointestinal hemorrhage, hypovolemic shock, Legionnaire's disease, atrial fibrillation, cocaine abuse, dermatitis, dependence on renal dialysis, and other pericardial effusion (noninflammatory). Review of Minimum Data Set (MDS) assessment for Resident #129 revealed the resident was cognitively intact. Resident #129 required extensive assistance for activities of daily living with the exception of eating and oral care which required set up or clean-up assistance. Resident #129 used a non-invasive mechanical ventilator and was on dialysis. Review of Pulmonary and Critical Care notes from the hospital dated 11/22/24 revealed the resident was admitted for acute gastrointestinal bleed, hemorrhagic shock, acute blood loss anemia, acute hypoxemic respiratory failure as evidenced by oxygen saturations less than 89 percent on room air, in addition to requiring greater than or equal to five liters of oxygen, and end stage renal disease on in house dialysis with evidence of volume overload. Plan was to admit to intensive care unit, continue ventilator support, wean per protocol, obtain arterial blood gases and chest x-ray, may require bronchoscopy, and repeat chemistries. Resident #129 was transferred to this hospital on [DATE] from the local hospital. Review of hospital documentation from the local hospital dated 11/20/24 for Resident #129 revealed retrocardiac opacity on x-ray etiology not certain however in view of leukocytosis will consider pneumonia as a differential and treat. Cultures will be drawn to check strep and Legionella antigen. Labs were not drawn as the resident was transferred to another hospital on [DATE] for the GI bleed. Review of lab result for Legionella dated 11/28/24 revealed the specimen was collected on 11/28/24 and reported as positive on 11/29/24. Interview on 12/23/24 at 10:18 A.M. with the Administrator and Director of Nursing (DON) revealed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 365278 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the LHD notified them Resident #129 in the hospital had tested positive for Legionnaire's disease. The Administrator stated they had spoken to the LHD several times since then. The DON stated the LHD asked questions such as how they cleaned their CPAP/BiPAP tubing, what water they used for them, dialysis information, and questions regarding any construction or water leaks. Interview on 12/23/24 at 1:11 P.M. with Maintenance Director (MD) #530 revealed on 12/23/24 was the first day he had been notified of a presumptive case of Legionella. MD #530 stated the facility did chlorine testing three times a week. MD #530 stated that was how he was told to test for Legionella in the water. MD #530 verified he had not done any other testing for Legionella. MD #530 verified he had not installed any filters on water outlets on the hot water distribution loop where the resident resided. Interview on 12/23/24 at 2:31 P.M. with the Administrator verified the facility did not test the water for Legionella after they were made aware of the suspected case. The Administrator verified they did not follow the facility policy for suspected Legionella. Interview on 12/23/24 at 2:57 P.M. with Environmental Health Director (EHD) #326 from the LHD revealed they sent an email on 12/17/24 to the facility regarding the information they needed to go forward with the investigation. EHD #326 stated the facility had not yet done what the LHD asked them to do. EHD #326 stated the facility had been ignoring them by not returning calls, emails, or calls being dropped when transferred. Interview on 12/23/24 at 3:17 P.M. with the Administrator revealed she denied getting an email until 12/18/24 when she was out of the building. The Administrator verified the email was sent to her on 12/17/24. The Administrator stated that she did not see the section regarding sending information. The Administrator stated she had only seen the section where they were going to schedule a call with the Ohio Department of Health (ODH), the LHD, and the administration of the facility. The Administrator stated they had a call with Water Management #09 today at 4:00 P.M. to come and test the water. The Administrator verified the LHD had resent her an email on 12/23/24 requesting information and when they received the information they would set up the call. The Administrator stated she would send the same information provided to the ODH. Interview on 12/24/24 at 2:00 P.M. with Infection Preventionist/Assistant Director of Nursing (IP/ADON) #682 revealed she was the one who spoke with the LHD first. IP/ADON #682 verified she was notified on 12/02/24 of the presumptive case of Legionella. IP/ADON #682 verified the LHD inquired on whether Resident #129 had been out for any appointments or outings for the past two weeks, how the facility cleaned BiPAP/CPAP tubing, and if the resident had any respiratory symptoms. IP/ADON #682 stated the LHD contacted them again on 12/05/24 and asked about water testing. IP/ADON #682 stated she was unsure about water testing as she was not maintenance. IP/ADON #682 stated she had reach out to the LHD on 12/16/24 regarding the results she received from maintenance regarding the water testing. Interview on 12/26/24 at 8:40 A.M. via phone with EHD #326 revealed that Communicable Disease Nurse (CDN) #327 is who contacted the facility first. CDN #327 stated she first contacted the facility on 12/02/24. CDN #327 stated she inquired about whether the resident had been out of the facility within the last two weeks, had any respiratory symptoms, facility process on CPAP/BiPAP cleaning and water used for those, dialysis process, and any construction or water issues. CDN #327 stated they asked the facility to keep an eye on anybody that showed signs of pneumonia, and they may need to test for Legionella if there are respiratory symptoms since there was only one case. CDN #327 stated she talked to the facility on [DATE], 12/06/24, and 12/09/24 and always spoke to the ADON/IP for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many follow-up. CDN #327 verified that was the last time she spoke with the facility. CDN #327 stated there have been no other reported cases of Legionella since she has worked for the LHD. Interview on 01/02/25 at 2:36 P.M. with the Administrator revealed if the water comes back positive, the facility has a plan in place with the consultant that will let them know what needs to be done next. The Administrator stated that the dialysis machines have a microfilter and the consultant from the water company stated that those machines would stop all of the germs. The Administrator stated they would continue to do what they are doing until the water testing came back. Review of the water testing report reported on 01/03/25 revealed hot water tank on Transitional Care Unit three (TCU3) tested positive for Legionella. The room Resident #129 resided in tested negative for Legionella. Review of email sent from the LHD to the facility on [DATE] revealed that the health department stated that whenever there is a presumptive healthcare-associated case of Legionnaire's disease, they ask that the facility follow the Center for Disease Control (CDC) guidance for a full investigation. As part of this investigation, we would like to set up a call to discuss the next steps and requirements with the ODH. We would ask that the administrator and any facility maintenance workers be included as well. These steps will allow the facility to immediately eliminate risk of exposure by implementing restrictions, remediate their water system to reduce the presence of microorganisms (including Legionella), and improve ongoing prevention efforts by updating the water management program. Prior to the call between your administration, ODH, local health department, several materials from the facility are needed. Documents include the most recent version of the facility's water management program, any environmental Legionella samples collected within a year, a floor plan of the facility, temperature and chlorine monitoring logs for your facility, any maintenance or monitoring logs of the facilities secondary disinfection system if available, and maintenance and monitoring logs for any additional water features at the facility such as cooling towers. This is an urgent matter. Review of policy titled, Legionnaire's Disease Prevention/Treatment Best Practices, dated September 2019 revealed the facility will employ the following measures if Legionnaire's disease is detected and/or suspected: confirm the diagnosis of resident within the facility through urine antigen test or sputum test, notify the Director of Integrated Support of outbreak: Quick Response Protocol will be enacted, begin course of treatment as ordered by the physician, test water system to determine source of outbreak, implement immediate procedures to eliminate presence of Legionella bacteria and prevent further outbreak, and notify residents, families, responsible parties, employees, Department of Health, other State Agencies, and local authorities of presence of Legionnaire's Disease to await further instruction and follow-up. This deficiency represents non-compliance investigated under Complaint Number OH00160885 and continued non-compliance from the survey dated 12/16/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 3 of 3

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the January 8, 2025 survey of TROY REHABILITATION AND HEALTHCARE CENTER?

This was a inspection survey of TROY REHABILITATION AND HEALTHCARE CENTER on January 8, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at TROY REHABILITATION AND HEALTHCARE CENTER on January 8, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.