Health inspection·August 28, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to notify the physician for Resident #61 when Resident #61 did not receive the ordered treatment of permethrin cream (treatment used for scabies caused by the itch mite Sarcoptes scabiei which produces a highly contagious skin rash) on the date of 07/26/23 when it should have been administered to Resident #61. This affected one resident (Resident #61) out of seven residents (Resident #26, #36, #54, #61, #62, #96, and #103) reviewed for notification of changes. The facility census was 117. Findings included: Review of the medical record for Resident #61 revealed an admission date of 01/13/23 and diagnoses included psychosis, dementia, and chronic obstructive pulmonary disease. Review of quarterly Minimum Data Set (MDS) dated [DATE] and revealed Resident #61 was cognitively impaired as his brief interview for mental status (BIMS) score was a nine. He required supervision only with bed mobility, transfers, and ambulation. Review of a nursing note dated 07/21/23 at 11:27 A.M. and completed by Licensed Practical Nurse (LPN) #341 revealed Resident #61 complained of dry itchy skin to arms and legs. The note revealed Primary Care Physician (PCP) #400 was notified and ordered [NAME] lotion. Review of a nursing note dated 07/25/23 at 7:05 P.M. and completed by LPN #341 revealed Resident #61 was seen per PCP #400 due to re-occurring rash to body and she referred to dermatologist and ordered permethrin treatment. Review of July 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed Resident #61 had an order to receive permethrin external cream five percent apply all over body topically one time on 07/26/23 for re-occurring rash and shower off on 07/27/23. The MAR was blank on 07/26/23 indicating the treatment was not completed as ordered. Review of nursing notes dated from 07/25/23 to 08/03/23 revealed there was no documentation PCP #400 was notified Resident #61 had not received his one-time permethrin cream ordered for 07/26/23. He had not received the cream until 08/03/23. Review of Wound Observation Tool dated 07/27/23 and completed by Unit Manager/ LPN #344 revealed Resident #61 had a rash that was red to his body. The assessment revealed PCP #400 was notified and ordered permethrin cream to be applied and then to repeat the treatment in one week. Page 1 of 13 365290 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Physician Progress Note dated 08/01/23 and completed by PCP #400 revealed Resident #61 continued to have an itchy rash to arms, neck, abdomen, and he was treated with permethrin and had a dermatology appointment. (There was no documentation PCP #400 was aware Resident #61 missed his permethrin treatment on 07/26/23). Interview and observation on 08/23/23 at 11:34 A.M. with Resident #61 revealed he had a rash in his groin, around his legs and just about everywhere. He revealed it itched especially all night which kept him up at night. He stated, it is miserable. Interview on 08/24/23 at 9:45 A.M. with Administrator and Interim Director of Nursing (DON) verified Resident #61's permethrin cream was not documented as given on 07/26/23 and that it was not given until 08/03/23. They verified there was no documentation PCP #400 was notified the cream was not administered on 07/26/23 Review of facility policy labeled, Change in a Resident's Condition or Status dated May 2017 revealed the facility shall promptly notify the attending physician of changes in medical condition and/ or status. The policy revealed the nurse would notify the physician when there has been need to alter the resident's medical treatment, and refusal of treatment or medication. This deficiency represents non-compliance investigated under MASTER Complaint Number OH0000145650, Complaint Number OH00145621, OH00145594 and OH00145593. 365290 Page 2 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility did not ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 117 residents receiving meals from the kitchen excluding . Zero residents in the facility were identified as not eating any foods by mouth. The facility census was 117. Findings include: Observation of the facility kitchen on 08/21/23 at 10:20 A. M. with Dietary Manager (DM) #399 revealed the entire perimeter of the kitchen floor where the walls met the floor contained heavy collections of food crumbs, particles of food, black and brown stains and grime with highest build up behind large equipment and food preparation tables. In the dish room there were two large trash cans full of food and the trash cans and lids were heavily soiled with dried on food splatter. There were small black insects flying around these cans. Underneath the dish machine was evidence of the floor not being properly swept and mopped, as there was a large build up of yellow and brown staining with multiple pieces of food and food particle build up towards the back of the dish machine floor. The dollies holding the clean dish racks had a heavy buildup of residue and food particles. A small dry food storage room containing a double-door reach-in cooler showed evidence of water pooling and black staining on the floor and wall with several small black insects flying around the cooler. Interview was conducted on 08/21/23 with DM #399 at the time of this kitchen observation. DM #399 revealed she was short staffed one cook and one dietary aide so she was cooking the meal for lunch. DM #399 verified the findings during the time of the observations and said the insects in the kitchen had been a problem for a while. Review of the kitchen policy statement for sanitization, version 1.2, revealed all kitchen, kitchen areas and dining areas are kept clean, free from garbage and debris and protected from all rodents and insects. This deficiency resulted from incidental findings of non-compliance during the investigation of Master Complaint Number OH00145650 and Compliant Numbers OH00145621, OH00145594 and OH00145593 365290 Page 3 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat potentially contagious/communicable rashes per physician orders, failed to timely implement transmission-based precautions to prevent spreading the rash to other residents, failed to implement exposure control measures, failed to educate and in service staff on infection control relative to preventing the spread of potentially contagious/communicable rashes, failed to report the outbreak to the local health department, and failed to prohibit State Tested Nursing Assistant (STNA) #373, who exhibited signs of a potentially communicable/contagious rash, from direct resident contact. Residents Affected - Some Actual Harm occurred on 07/26/23 when Resident #61, who was evaluated for a body rash by his Primary Care Physician (PCP) #400 on 07/25/23 and ordered permethrin cream (a topical treatment used to treat scabies caused by the itch mite Sarcoptes scabiei which is a highly contagious skin condition) to be administered on 07/26/23 to treat the body rash, did not get the treatment of permethrin cream as ordered by the physician until the permethrin cream was reordered on 08/03/23. This resulted in seven residents (#26, #36, #54, #61, #62, #96 and #103) developing a rash with resulting severe itching, intense scratching, bleeding of rash areas, severe discomfort with statements including but not limited to feeling like their skin was on fire, felt she was dying, it is miserable, it is burning demonstrating psychosocial harm due to anxiety, disrupted routine sleep and/or hospitalization to the emergency room for worsening rash symptoms. Additionally, the facility did not exclude STNA #373 from providing direct resident care after she told a nurse on duty she had developed the rash to her arms, legs, and abdomen approximately one week ago. Instead, the nurse gave her permethrin cream to use and had her continue to work her shift. On 08/25/23 STNA #373 revealed she went to Physician #901 and was diagnosed with scabies. This affected 20 residents (Residents #12, #17, #19, #26, #27, #31, #36, #42, #45, #48, #50, #54, #62, #63, #69, #96, #102, #103, #104 and #118) who developed a rash, and/ or received permethrin treatment out of 41 residents (Resident #5, #6, #9, #12, #17, #19, #24, #26, #27, #31, #36, #40, #42, #45, #46, #48, #50, #54, #55, #57, #60, #61, #62, #63, #69, #76, #78, #82, #80, #87, #88, #90, #96, #102, #103, #104, #108, #111, #115, #117, #118) residing on the secured unit and had the potential to affect all 117 residents residing at the facility as STNA #373 had worked other units other than the secured unit in the last two weeks. Findings included: 1. Review of the medical record for Resident #61 revealed an admission date of 01/13/23 and diagnoses included psychosis, dementia, and chronic obstructive pulmonary disease. Resident #61 lived on the secured unit of the facility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/02/23, revealed Resident #61 was cognitively impaired. He required supervision only with bed mobility, transfers, and ambulation. Review of a nursing note dated 07/21/23 at 11:27 A.M. and completed by Licensed Practical Nurse (LPN) #341 revealed Resident #61 complained of dry, itchy skin to arms and legs. The note revealed PCP #400 was notified and ordered [NAME] lotion (an anti-itch lotion). 365290 Page 4 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 Level of Harm - Actual harm Residents Affected - Some Review of a nursing note dated 07/25/23 at 7:05 P.M. and completed by LPN #341 revealed Resident #61 was seen per Primary Care Physician (PCP) #400 due to re-occurring rash to body and she referred to dermatologist and ordered permethrin treatment. Review of the July 2023 Medication Administration Record (MAR) revealed Resident #61 had an order to receive permethrin external cream five percent apply all over body topically one time on 07/26/23 for re-occurring rash and shower off on 07/27/23. The MAR was blank on 07/26/23 indicating the treatment was not completed as ordered by the physician. Review of the July 2023 Treatment Administration Record (TAR) revealed Resident #61 was placed on contact isolation precautions from 07/27/23 through 07/31/23 when the contact precautions were discontinued. There was no evidence on the TAR to indicate Resident #61 was placed on contact isolation precautions on 07/25/23 when PCP #400 ordered the permethrin treatment and there was no evidence of contact isolation precautions on 07/26/23. Review of the August 2023 MAR and TAR revealed on 08/03/23 at 10:38 P.M. Resident #61 received permethrin cream five percent topically all over his body due to re-occurring rash. This was his first treatment of permethrin cream, since it had not been given on 07/26/23 per physician order. There was no order for Resident #61 to be on contact isolation precautions from 08/01/23 to 08/03/23 per the TAR. Review of nursing notes dated from 07/25/23 to 08/03/23 revealed there was no documentation PCP #400 was notified Resident #61 had not received his one-time permethrin cream ordered for 07/26/23 and he had not received the treatment until 08/03/23. Review of nursing notes also revealed no evidence Resident #61 was on contact isolation on 07/25/23 and 07/26/23 after PCP #400 had ordered permethrin for potential scabies on 07/25/23. There was also no documentation per the nursing notes that he was on contact isolation from 08/01/23 to 08/03/23. Review of the Wound Observation Tool dated 07/27/23 and completed by Unit Manager/ LPN #344 revealed Resident #61 had a red rash to his body. The assessment revealed PCP #400 was notified and ordered permethrin cream to be applied and then to repeat the treatment in one week. Review of the resident census revealed Resident #61 received a roommate (Resident #9) on 07/28/23 and continued to live as roommates despite Resident #61 not receiving the permethrin cream (scabies treatment) as ordered for 07/26/23. Review of Physician Progress Note dated 08/01/23 and completed by PCP #400 revealed Resident #61 continued to have an itchy rash to arms, neck, abdomen, and he was treated with permethrin and had a dermatology appointment. There was no documentation PCP #400 was aware Resident #61 missed his permethrin treatment on 07/26/23. Interview and observation on 08/23/23 at 11:34 A.M. with Resident #61 revealed he had a rash in his groin, around his legs and just about everywhere. He revealed it itched especially all night which kept him up at night. He stated, it is miserable. Interview on 08/24/23 at 9:45 A.M. with Administrator and Interim Director of Nursing (DON) verified Resident #61's permethrin cream was not documented as given on 07/26/23 as well as he was not on contact isolation for the entire duration of the rash after the permethrin cream was ordered on 07/25/23 until it was finally given on 08/03/23. 365290 Page 5 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 Level of Harm - Actual harm Residents Affected - Some Review of Dermatopathology Report, dated as collected on 08/15/23 and reported on 08/22/23, revealed Resident #61 had a biopsy to left forearm showing irregularly acanthotic and spongiotic epidermis with dermal inflammatory reaction. The report's comments section documented a medication reaction and spongiotic dermatitis were not ruled out. It is to be noted the biopsy was completed after permethrin cream was administered to Resident #61 on 08/03/23. 2. Review of the medical record for Resident #62 revealed an admission date of 07/19/22 and diagnoses included dementia, and hypertension. Review of the annual MDS dated [DATE] revealed Resident #62 was cognitively impaired and required supervision with most her activities of daily living. Review of Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review dated 07/26/23 and completed by Unit Manager/ LPN #344 revealed Resident #62 had a rash to her bilateral arms and legs with scabs. Review of Skin Observation Tool dated 07/28/23 and unauthored revealed Resident #62 had a dry rash to her body with some scabbed areas. Review of July MAR and TAR for Resident #62 revealed she had an order for contact precautions dated to start 07/27/23 at 7:00 P.M. and was treated with permethrin external cream for her rash on 07/28/23. There was no evidence contact precaution started on 07/26/23 when on the shower review it was documented she had a rash (as well as other residents in the secured unit had a rash and being treated with permethrin cream). Interview on 08/22/23 at 7:42 P.M. with STNA #402 revealed she was giving Resident #62 a shower recently and during the shower Resident #62 stated, her skin was on fire, she felt she was dying. She revealed all the residents scratch all the time and cannot get a good night sleep. Interview and observation on 08/23/23 at 3:01 P.M. of Resident #62 revealed she was sitting in the lounge and a visible red splotchy rash noted to her bilateral arms with dry flaky skin. She was unable to provide any information during the interview except that she had a rash. Interview on 08/24/23 at 9:45 A.M. with Administrator and Interim DON verified the facility had no documentation Resident #62 was placed on transmission-based precaution before 07/27/23. 3. Review of medical record for Resident #54 revealed an admission date of 05/29/23 and diagnoses included dementia, and hypertension. Review of quarterly MDS dated [DATE] and revealed she had impaired cognition. Review of July 2023 physician orders revealed Resident #54 had an order dated 07/21/23 for [NAME] lotion as needed to apply to itchy skin. She then had orders dated 07/26/23 to be placed on contact isolation and permethrin external cream. Review of nursing notes dated 07/21/23 at 5:50 P.M. and completed by LPN #343 revealed PCP #400 was in facility and notified of new red itchy areas and new orders were received. Review of the Wound Observation Tool dated 07/27/23 and completed by Unit Manager/ LPN #344 365290 Page 6 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 revealed Resident #54 had a rash to her stomach area that was acquired on 07/26/23. The assessment revealed PCP #400 ordered permethrin and to repeat the cream in one week. Level of Harm - Actual harm Residents Affected - Some Interview and observation on 08/22/23 at 7:54 P.M. revealed Resident #54 sitting in her chair in her room and when asked if she had a rash she stated, it was burning and was red. She then proceeded to show this surveyor a rash to her chest and arms as she pulled down her shirt. She revealed the rash just does not go away. She revealed the rash was uncomfortable and that it does keep her up at night as the rash was itchy. She revealed she had the rash a long time but was unable to provide details to how long and was unsure if she seen a physician for the rash as she stated that was why she was at the facility as she was unable to remember things. Review of nursing notes dated from 07/27/23 to 08/22/23 revealed no other documentation regarding her rash and/ or physician notification that the rash continued as observed on 08/22/23. 4. Review of medical record for Resident #96 revealed an admission date of 12/20/22 and her diagnoses included Alzheimer's disease, hypertension, and diabetes. Review of quarterly MDS dated [DATE] revealed Resident #96 had impaired cognition and required supervision only with most her activities of daily living. Review of the Wound Observation Tool dated 07/27/23 and completed by Unit Manager/ LPN #344 revealed on 07/26/23 Resident #96 had a rash to her body. PCP #400 was notified and ordered permethrin cream topically and repeat in one week. Interview and observation on 08/22/23 at 7:58 P.M. with Resident #96 revealed she had a rash all over but mainly her back. She revealed it itched all the time. She showed this surveyor her bilateral arms and a red rash with scratch marks noted to her bilateral arms. She revealed the rash itched and sometimes woke her up at night causing her not to sleep well. Interview on 08/23/23 at 12:03 P.M. with Activities Director #342 revealed several residents had rashes on the secured unit and recently Resident #96 was in her room when she was passing out the mail and she was digging and scratching hard at her leg intensely causing her leg to bleed all over. She revealed she felt bad as she seemed very uncomfortable as well as several other residents. 5. Review of medical record for Resident #103 revealed an admission date of 07/21/23 with diagnoses including Alzheimer's disease, diabetes, anxiety, and hypertension. A diagnosis of scabies on 08/10/23 was added to her medical diagnosis list. Review of care plan dated 07/21/23 revealed Resident #103 was at risk for actual and/ or potential skin impairment as on 07/27/23 she was receiving treatment due to roommate's rash. Intervention included treatment as ordered, skin check weekly, and observe skin during care. Review of unauthored Skin Observation Tool dated 07/25/23 revealed a second skin check was completed and skin was intact with no areas noted. Review of Skin Monitoring: Comprehensive CNA Shower Review dated 07/26/23 completed by Unit Manager/ LPN #344 revealed skin was clear. There were no additional skin observations noted as completed from 07/25/23 to 08/10/23. 365290 Page 7 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 Review of July 2023 MAR revealed Resident #103 received permethrin external cream five percent apply to neck to toes topically times one dose and then shower and remove on 07/27/23. Level of Harm - Actual harm Residents Affected - Some Review of nursing notes dated 07/27/23 to 08/23/23 revealed no documentation regarding Resident #103's rash and/ or notification to the Power of Attorney (POA) regarding the permethrin cream ordered on 07/27/23. Review of nursing note dated 08/08/23 at 4:53 P.M. and completed by LPN #343 revealed staff notified the nurse that Resident #103 felt itchy on her thighs and small raised areas were noted. The note revealed Resident #103 denied pain just felt itchy. The note revealed PCP #400 was notified and ordered [NAME] (anti-itch moisturizing lotion) lotion five percent as needed for areas. Review of nursing note dated 08/10/23 at 2:32 P.M. and completed by Unit Manager/ LPN #338 revealed Resident #103's daughter was in concerned about the itchy areas to her inner thighs. The note revealed her daughter wanted her sent to the emergency room (ER) for an evaluation. Review of nursing note dated 08/10/23 at 4:35 P.M. and completed by Unit Manager/ LPN #338 revealed Resident #103 returned from the emergency room with a diagnosis of scabies and new orders. Review of After Visit Summary dated 08/10/23 and completed by ER Physician Assistant #900 revealed Resident #103 was seen due to rash. Resident #103 was provided information regarding scabies and nonspecific rash. She was ordered hydrocortisone ointment 2.5 percent to apply to affected areas twice a day for `14 days and permethrin five percent to apply to affected area times one dose for pruritic (itchy) rash. Observation on 08/22/23 from 7:30 P.M. to 8:25 P.M. revealed Resident #103 was unable to be interview due to cognitive ability and no signs of a rash were visibly seen. 6. Review of the medical record for Resident #36 revealed an admission date of 03/27/23 and diagnoses included dementia, anxiety, and diabetes. Review of the significant change MDS dated [DATE] revealed she was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Review of a nursing note dated 07/26/23 at 7:15 P.M. and completed by Unit Manager/ LPN #344 revealed Resident #36's power of attorney (POA) was notified she received permethrin cream as preventative and had a possible exposure to scabies and was asked if the resident was itching or had a rash and the POA stated not at this time. Review of nursing notes dated 08/08/23 at 1:39 P.M. and completed by LPN #341 revealed during Resident #36's shower she had small red spots/ rash noted to lower back along with some scratch marks. The note revealed she stated it itched sometimes. The note revealed PCP #400 was notified and ordered [NAME] anti-inch lotion since she was treated with the permethrin cream on 07/26/23. Interview on 08/22/23 at 7:30 P.M. with Resident #36 revealed she had a rash as well as all the residents on the unit had a rash. She revealed her rash was on her chest and she had the rash for two to three weeks. She revealed she felt it was caused by staff washing all their clothes together and not keeping it separate. Observation revealed during the interview she was itching her bilateral arms and the sides of her abdomen. 365290 Page 8 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 7. Review of medical record for Resident #26 revealed an admission date of 02/11/22 and diagnoses included psychosis, bipolar disorder, and dementia. Level of Harm - Actual harm Review of the quarterly MDS dated [DATE] revealed Resident #26 had cognitive impairment. Residents Affected - Some Review of August 2023 Physician Orders and TAR revealed no evidence Resident #26 was placed on contact isolation after she was found to have a rash on 08/13/23 and was ordered to be treated with permethrin cream. Review of a nursing note dated 08/13/23 at 12:37 P.M. with LPN #377 revealed Resident #26 was complaining of itching and the nurse examined noting a rash to her torso and extremities. PCP #400 was notified and ordered permethrin cream and repeat the cream in seven days. Observation on 08/22/23 at 7:36 P.M. revealed Resident #26 was in her room without a shirt on attempting to make her bed. She was observed with a red rash covering her back, chest, abdomen, and bilateral arms and had multiple scratch marks that were scabbed from previous scratching. She was observed to intensely dig at her back making red marks and removing previous scabbed scratches causing areas to bleed. While scratching she was observed making facial grimaces as she was trying to reach the middle of her back. She was unable to be interviewed due to cognitive ability. Interview on 08/24/23 at 9:45 A.M. with Administrator and Interim Director of Nursing verified no evidence Resident #26 was placed on transmission-based precautions. 8. Interview on 08/24/23 at 3:35 P.M. and 4:18 P.M. with STNA #373 revealed she worked 5:00 P.M. to 5:00 A.M. usually on the secured unit but floated to other units in the facility. She revealed approximately one week ago she got a rash to her arms, legs, and abdomen that looked like what the residents had on the secured unit. She revealed she told a nurse (but did not want to get the nurse in trouble so would not provide her name) about her rash and the nurse gave her permethrin cream to apply to the rash and the nurse had stated the rash was scabies. She revealed she remained on duty and worked having direct contact with the residents despite having the rash, as the nurse did not send her home. She revealed she was upset as she felt the facility should have told the staff the rash was contagious and what should have been done to prevent the rash from spreading amongst the staff. She revealed she was concerned bringing the contagious rash home to her family. She revealed she felt this was a contamination issue especially because she worked on other units and with how many residents had the rash on the secured unit, she was concerned about spreading to the other units. She revealed she did not tell the interim DON instead she told the nurse on duty. STNA #373 explained she knew the interim DON was aware, as the interim DON had contacted her today (08/24/23) and told her she needed to repeat the permethrin treatment. STNA #373 revealed she was not sure how the interim DON thought she would get the cream but probably the interim DON assumed she would get it from the nurse who gave it to her the first time. She then revealed the interim DON called her back later and told her she was being removed from the schedule until she got a doctor's release. Interview on 08/25/23 at 3:56 P.M. with STNA #373 revealed she went to Physician #901 today (08/25/23) and she was diagnosed with scabies. She revealed the physician had told her she had burrowing to her skin which was a classic sign of scabies. She revealed she was ordered permethrin cream to be applied and was to remain off work until 08/27/23. She revealed she was notifying the facility. Review of the staffing schedule and interview on 08/24/23 at 8:31 A.M. with Scheduler/ STNA #372 revealed the following staff from 08/07/23 to 08/20/23 had worked the secured unit as well as other 365290 Page 9 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 units in the facility during this time frame including STNA #373 as well as LPN #377, STNA #319, #322, #335, #340, #349, #351, #358, #365, #367, and #375. Level of Harm - Actual harm Residents Affected - Some 9. Interview on 08/22/23 at 7:22 P.M. with STNA #351 revealed on the secured unit there was tons of residents with rashes. She revealed she usually worked on the secured unit but today, 08/22/23, she was on a different unit. She revealed just more and more residents keep getting it and nobody seems to be doing anything about it. She revealed she felt bad as the residents constantly are itching and scratching at their skin and seemed to be uncomfortable. She revealed she was concerned about what the rashes were as she had heard it was scabies, but that management was not telling the staff. She revealed she had never received any in services regarding the rashes and precautions to take. Interview on 08/22/23 at 7:39 P.M. with STNA #375 revealed he routinely worked the secured unit and there were several residents with rashes on the unit. He revealed the rashes were bad as residents were itching so bad it felt like they cannot take it anymore as the residents had the rashes a long time approximately two months it seemed. He revealed management had not communicated what the rashes were and/ or given any training regarding precautions they should be doing. Interview on 08/22/23 at 7:42 P.M. with STNA #402 revealed she routinely worked the secured unit and was upset as nobody had told the staff what the rashes were, and she felt the staff had a right to know especially that so many residents had rashes and that more keep on getting a rash. She revealed she was giving Resident #62 a shower recently and during the shower Resident #62 stated, her skin was on fire, she felt she was dying. She revealed all the residents scratch all the time and cannot get a good night sleep. She revealed Resident #61 always complained and appeared in a lot of discomfort. She revealed she had not received any training regarding the rashes and/ or precautions to take. She revealed staff member, STNA #373, now had the rash and stated most likely because nobody was telling them what the rashes really were and any special instructions that they should be taking to prevent the spread. Interview on 08/22/23 at 8:25 P.M. with Agency STNA #403 revealed several residents had rashes on the secured unit. She revealed she had not received any in-services regarding the rashes and/ or precautions to take. Interview on 08/23/23 at 9:37 A.M. with the Interim DON verified per the list the facility submitted there were 17 residents currently with rashes on the secured unit. She verified all 17 residents appeared to have the same type of rash and revealed I am assuming it is contagious because one person is getting it then the next person also getting it. She revealed the facility could not state the rash was scabies but verified PCP #400 was ordering permethrin cream which was a treatment to treat scabies. She was asked what infection control plan the facility had initiated, and she revealed once the rash was found on a resident, the resident was placed on contact isolation and permethrin cream was ordered and applied and then washed off after 12 hours. When the Interim DON was asked if any further plans regarding the outbreak, she stated why would I have to have any other plan or such, we see the rash, we call the doctor, we get the cream, and they wash it off. She verified the facility had not contacted the local health department regarding the outbreak of rashes. She was asked if she felt the facility was having an outbreak of rashes and she stated yes. She verified the facility did not have any formal training of staff regarding infection control measures regarding the outbreak of rashes and then asked, what am I supposed to educate on a rash?. She verified the facility completed only one skin sweep on 07/26/23 and revealed if the staff find a rash, they already know they were to report it but verified she had no education evidence she educated the staff regarding reporting of rashes. 365290 Page 10 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 Level of Harm - Actual harm Residents Affected - Some Interview on 08/23/23 at 10:38 A.M. with Local Health Department Epidemiologist #405 revealed they had not been contacted by the facility regarding the outbreak of rashes that potentially may be scabies since the physician was treating the rashes with permethrin cream. He revealed anytime there was two or more cases including rashes that they needed to be reported by the facility. He revealed if they have 17 rashes or possibly more confined to one unit this was a contagious outbreak and needed to be reported. He revealed the local health department would try to figure out the exact diagnosis and/ or confirm if it was scabies, work with the medical team at the facility, implement isolation exposure guidelines as usually they would send the facility immediate guidelines to implement and coordinate a host of infection control measures to stop and prevent further spread/ outbreak. Interview on 08/23/23 at 12:03 P.M. with Activities Director #342 revealed she was upset as the facility does not share anything about what the rashes were and what the staff should do. She revealed the facility had not in serviced and/ or provided any education regarding precautions to take. She revealed she was concerned as she did not want to take anything home to her kids so felt the facility should educate especially since almost all the residents on the secured unit have the rash. Interview on 08/23/23 at 3:38 P.M. with PCP #400 revealed about a month ago Resident #61 started to have a rash as she felt he was the first resident on the secured unit to have. She revealed at first, she treated with triamcinolone cream as she felt it was allergic dermatitis. She revealed the rash did not improve and the rash looked like possibly scabies. She revealed she ordered him to be treated with permethrin cream and had referred him to a dermatologist. She revealed she seen him recently and felt his rash had improved and felt it was because he had received permethrin cream for the scabies. She revealed she had received further calls regarding other residents having the same type of rash, so she instructed them to treat as well with permethrin cream and repeat the cream in one week. She revealed she also ordered the facility to treat the resident's roommate as well as precaution. She revealed she did not realize there was currently 17 total residents with rashes as she stated, not aware of 17 did not think that many but that she received a lot of calls so could be that many as she did not keep track. She revealed there were only a few contagious rashes with severe itching with scabies being one of them and that was why she treated the rashes with permethrin cream. Review of a list provided by the facility on 08/22/23 of residents with current rashes on the secured unit included 17 residents: Resident #9, #12, #17, #19, #26, #36, #42, #45, #48, #54, #61, #62, #63, #69, #96, #103, and #104. Review of Infection Control Log from 07/01/23 to 08/22/23 revealed the following 20 residents on the secured unit currently or had rashes and/ or were treated with permethrin cream: on 07/26/23 Residents #12, #17, #31, #54, #96, on 07/27/23 Resident #36, #42, #50, #62, on 08/08/23 Resident #19, #27, #48, #102, on 08/09/23 Resident #63, #69, #118, on 08/10/23 Resident #103, on 08/13/23 Resident #26, and on 08/20/23 Resident #45, and #104. Review of Know Your ABC's: A Quick Guide to Reportable Infectious Disease in Ohio dated 08/01/19 included the facility would report an outbreak, unusual incident, or epidemic of other disease such as histoplasmosis (fungal infection, pediculosis (lice), scabies) by the end of the next business day to the local health department. Review of facility policy labeled, Scabies identification, Treatment and Environmental Cleaning dated August 2016 revealed the purpose of this procedure was to treat residents infected with and sensitized to scabies and to prevent the spread of scabies to other residents and staff. The policy revealed scabies was an itching skin irritation caused by a microscopic human mite which burrows into the 365290 Page 11 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 Level of Harm - Actual harm Residents Affected - Some skin's upper layers and eventually causes itching, tiny red lines just above the skin and an allergic rash. The incubation period was two to six weeks and persons who had been previously infected develop more rapid symptoms one to four days after re-exposure. The policy revealed symptoms include severe itching which worsens at night and spreads by skin-to-skin contact or through contact with bedding, clothing, privacy curtains and furniture. Residents should remain on contact precaution 24 hours after the treatment and any staff members should report any rashes that developed on their bodies to the Infection Preventionist or Director of Nursing. The policy revealed during a scabies outbreak the Infection Preventionist or committee would coordinate an effective treatment program. The policy revealed infected employees can return to work after treatment was completed but should use gowns and gloves for direct resident care to prevent reinfestation until all control measures for affected areas have been completed. This deficiency represents non-compliance investigated under MASTER Complaint Number OH0000145650, Complaint Number OH00145621, OH00145594, OH00145593, OH00145536, OH00145524, and OH00145303 and is an example of continued noncompliance from the survey dated 07/20/23. 365290 Page 12 of 13 365290 08/28/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review and policy review, the facility failed to keep the facility reasonably free from insects and pests with the potential to affect all 117 residents. The facility census was 117 . Residents Affected - Many Findings include: Review of a service report from the pest control company, dated 03/22/23, contained special instructions at the bottom of the report that stated Employee sanitation practices need improvement. Please ensure employees are following the proper sanitation guidelines mandated by your facility. Mop sink and buckets should be emptied after use to help prevent pests. Observation on 08/21/23 from 8:41 A.M. to 9:28 A.M. of the resident common areas, hallways, dining areas and laundry rooms revealed evidence of living and dead pests in the facility. The floors in the main dining and activity room had food residue, dead flies and spider webs with eggs by the baseboards and behind the piano. The laundry room had moist walls with black staining. There was dirty trash piled high and used dirty gloves scattered on the floor. Laundry aid #405 verified about seventy-five dead flies scattered on the floor and the break room table, and Assistant Housekeeping Manager # 606 verified the bugs during the observations. Observation on 08/21/23 from 9:51 A.M. to 10:20 A.M. revealed the restorative room for resident's therapy had a dead wasp in the kitchen area with multiple spider webs and dead insects in the room. The memory care unit hallway had multiple dead bugs in the activity room with liquid spilled and bugs pooled in the liquids. The memory care hall ceiling light fixtures had multiple dead bugs laying in the light fixtures. The administrator was present during the tour with STNA #300 both verifying the findings. Observation on 08/21/23 at 10:22 A.M. of the main kitchen revealed sticky wet floors with dried food debris, various dead bugs on the floor and two large trash cans in the dish machine room with food piled up with gnats and flies flying around the trash. The trash can lids were ajar exposing the food for the knats and flies to land on. The mop room revealed a dirty, musty smelling mop head with multiple flies and gnats flying and landing on the mop head. An interview on 08/21/23 from 3:17 P.M. to 3:25 P.M. with Residents #104 and #38 revealed there were bugs and flies in their rooms and they were not satisfied with housekeeping. Interview with resident #71 on 08/23/23 at 11:30 A.M. revealed the flies bother him and he wanted the flies out. Observed three flies land on the resident during the interview. An interview on 08/21/23 with RN #363 and Laundry Aide (LA) #405 revealed RN #363 stated housekeeping could use more staff and LA #405 stated every day is a bug problem. An interview on 08/23/23 at 11:35 A.M. with LPN #335 revealed many residents had bugs in their rooms. This deficiency represents non-compliance identified during the investigation of Master Complaint Number OH00145650 and Complaint Numbers OH00145621, OH00145594, OH00145593, OH00145536 and OH00145524. 365290 Page 13 of 13