Inspection·November 7, 2018

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dysphagia, respiratory failure, pneumonia, kidney failure, muscle weakness, hyperkalemia, dementia, diarrhea, congestive heart failure. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #68 had severe impaired cognitive skills, required extensive assistance to total dependence for activities of daily living, and always incontinent bowel and bladder. Review of nursing note dated [DATE] revealed Resident #68 was transferred to the hospital for a non-ST Segment Myocardial Infarction (NSTEMI). 4. A chart review completed on [DATE] revealed that Resident #272 was admitted on [DATE] with diagnosis including difficulty in walking, weakness, Alzheimer's, benign prostatic hyperplasia, diarrhea, hyperlipidemia, hypertension, diverticulosis, dehydration, constipation, chronic kidney disease, and left hip fracture. Resident #272 expired on [DATE]. Review of Discharge Return Anticipated MDS dated [DATE] revealed that Resident #272 had severe cognitive deficits, requires extensive to dependent assist, and incontinent of bowel and bladder. Review of nursing note dated [DATE] that Resident #272 was transferred and admitted to the hospital on [DATE]. Interview on [DATE] at 10:30 A.M., with Administrator #8 verified the ombudsman had not been notified of Resident #36, #68, and #272 being discharged from facility to the hospital. 2. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition, Parkinson's, major depressive disorder, anxiety disorder, osteoarthritis, muscle weakness, anorexia, dysphonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment with no acute changes. MDS revealed Resident #36 had rejection to care noted one to three days during seven day look back. Resident #36 required supervision and setup with eating, extensive one person assistance with bed mobility, transfer, locomotion, dressing, toileting, and personal hygiene. Further review of the MDS revealed Resident #36 was wheelchair dependent with a history of falls with no injury and at risk of pressure with no pressure injury. Review of Nursing Progress Notes dated [DATE] and again on [DATE] revealed the resident was sent out, and admitted to the local hospital for a dislocated hip. Further review of the medical record was silent of verification that the ombudsman was ever notified of the hospital transfer. Based on record review and staff interviews, the facility failed to notify the ombudsman of discharges from the facility. This affected four (Resident #36, Resident #68, Resident #100 and Resident #272) reviewed for discharge notification in a facility census of 122. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 2 of 10 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 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. Record review of Resident #100's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; muscle weakness, obstructive hydrocephalus, anemia, osteoarthritis, hyperlipidemia, dysphagia, lack of coordination, depressive disorder, constipation, allergic rhinitis glaucoma and constipation. Review of Resident #100's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed resident had cognitive impairment and required total dependence with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Review of Resident #100's medical record revealed resident was discharged to the hospital on [DATE] with chest pain and readmitted to the facility on [DATE]. The medical record contained no evidence that the resident or resident's representative was provided with an appropriate written transfer/discharge notice at the time of the hospitalizations or that the Office of the State Long Term Care Ombudsman was notified in writing of the resident's hospitalization. Interview with Director of Corporate Compliance (DCC) #17 on [DATE] at 2:33 P.M. verified the facility neither provided the resident or resident's representative with a transfer/discharge notice at the time of the transfers nor notified the Office of the State Long Term Care Ombudsman of the resident's hospitalization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 3 of 10 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 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition, Parkinson's, major depressive disorder, anxiety disorder, osteoarthritis, muscle weakness, anorexia, dysphonia. Review of the MDS assessment dated [DATE] revealed the resident had mild cognitive impairment with no acute changes. The resident was assessed with rejection of care noted one to three days during the seven day look back period. Resident #36 required supervision and setup with eating, extensive one person assistance with bed mobility, transfer, locomotion, dressing, toileting, and personal hygiene. Further review of the MDS revealed Resident #36 was wheelchair dependent with a history of falls with no injury and at risk of pressure with no pressure injury during look back. Review of Nursing Progress Notes dated 05/12/18 and again on 05/30/18 revealed the resident was sent out, and admitted to the local hospital for a dislocated hip. Further review of the medical record revealed there was no documented evidence the resident and/or representative was provided the required notice of bed hold when she was sent out of the facility to the hospital. Interview via email on 11/07/18 at 12:50 P.M. DCC #17 verified the facility did not have a provide verification Resident #36 or her representative was provided the required bed hold notices when she was transferred to the hospital. Based on record review and staff interview, the facility failed to provide residents or their representatives with written bed hold notices during absences from the facility. This affected two (Resident #36 and Resident #100) of four residents reviewed for hospitalizations. The facility census was 122. Findings include: 1. Review of Resident #100's medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses; muscle weakness, obstructive hydrocephalus, anemia, osteoarthritis, hyperlipidemia, dysphagia, lack of coordination, depressive disorder, constipation, allergic rhinitis glaucoma and constipation. Review of Resident #100's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident had cognitive impairment and required total dependence with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Review of Resident #100's medical record revealed the resident was discharged to the hospital on [DATE] with chest pain and readmitted to the facility on [DATE]. The medical record contained no documented evidence the resident or resident's representative was provided with a written bed hold notice at the time of the leave or hospitalization. Interview with Director of Corporate Compliance (DCC) #17 on 11/06/18 at 2:33 P.M., verified a written bed hold notice was not provided to Resident #100 or their representative at the time of leave or hospitalization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 4 of 10 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 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident's code status was accurately documented in the electronic medical record. This affected one (Resident #100) of 32 residents reviewed for accurate advanced directives. The facility census was 122. Findings include: Review of Resident #100's medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses; muscle weakness, obstructive hydrocephalus, anemia, osteoarthritis, hyperlipidemia, dysphagia, lack of coordination, depressive disorder, constipation, allergic rhinitis glaucoma and constipation. Review of Resident #100's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident had cognitive impairment and required total dependence with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Review of Resident #100's paper chart revealed the resident had a Do Not Resuscitate (DNR) form indicating resident's code status to be Do Not Resuscitate Comfort Care (DNRCC). Resident #100's representative and physician signed the DNR form on 10/30/18. Review of Resident #100's code status in his electronic record revealed resident's code status to be listed as a full code. Interview with Director of Corporate Compliance (DCC) #17 on 11/05/18 at 3:30 P.M. verified Resident #100's code status in the electronic chart was not accurate prior to surveyor intervention. Review of the facility's undated Advanced Directives policy revealed the physician's order regarding a resident's code status should be entered into the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 5 of 10 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 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 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 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 observations, record review, staff interviews and policy review, the facility failed to ensure narcotic medications were signed out immediately upon administration. This affected three residents (#42, #108, #322) of 15 residents (#68, #27, #83, #92, #48, #62, #85, #36, #322, #42, #70, #12, #18, #105, and #108) receiving narcotic medications on floors two and three of the facility. The facility census was 122. Findings include: 1. Review of Resident #42's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, major depressive disorder, anxiety disorder, psychosis, cirrhosis of the liver, neck fracture, and dysphagia. Observation on 11/06/18 at 12:50 P.M. revealed Licensed Practical Nurse (LPN) #54 revealed the nurse signing out a Lorazepam for Resident #42 with a time of administration at 8:00 A.M. Interview of LPN #54 on 11/06/18 at 12:50 P.M. verified she had not signed out a Lorazepam on Resident #42's record upon administration at 8:00 A.M. because she had another patient actively dying. 2. Review of Resident #108's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of fractured femur, hypertension, lumbago, asthma, chronic obstructive pulmonary disease, anxiety, osteoarthritis, depressive disorder, and colostomy. Observation of medication cart #201 on 11/06/18 at 3:04 P.M. with LPN #83 revealed a scheduled drug count sheet for resident #108 revealed there should have been a quantity of 12 hydrocodone 5/325 pills but only 11 pills were located in the locked cart. LPN #83 stated she did not document a dose of the medication given approximately 30 minutes prior due to an acute situation with another resident. Interview of Infection Preventionist #303 on 11/06/18 at 3:06 P.M. verified the incorrect count sheet and number of pills for Resident #42. 3. Resident #332 was admitted to the facility on [DATE] with diagnoses include acute kidney failure, type two diabetes, primary osteoarthritis left knee, segmental and somatic dysfunction of lower extremity, presence of left artificial knee joint. Review of Resident #332's narcotic count sheet on 11/06/18 at 3:06 P.M. revealed oxycontin 10 milligrams (mg) with a quantity of four should be in the narcotic box. A narcotic count performed with LPN #83 revealed there were only three oxycontin 10 milligram pills in the drawer. LPN #83 stated she gave Resident #332 one pill at 9:00 A.M. but did not document it. Review of undated facility policy, Managing Controlled Substances, revealed Immediately after a dose of a controlled drug is administered, the licensed nurse administering the drug is to enter all of the following information on the proof-of-use record: date and time of administration, dose administered, signature of the nurse administering the dose, remaining doses, the controlled substance administration must also be recorded on the Medication Administration Record (MAR). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 6 of 10 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 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews and facility policy review, the facility failed to ensure vials of insulin were disposed of after 28 days of being accessed for resident use. This affected one resident (#52) of one resident receiving novolog insulin from one (Medication cart #302) of five medications carts observed. The facility census was 122. Findings include: Review of Resident #52's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes, diabetic polyneuropathy and hyperlipidemia. Observation of medication cart #302 on 11/06/18 at 12:43 P.M. revealed an open vial of Resident #52's Humalog insulin dated as opened on 10/07/18 and a manufacturer expiration date of 03/2021. Interview with Licensed Practical Nurse (LPN) #54 on 11/06/18 at 12:43 P.M., verified Resident #52's Humalog insulin was opened on 10/07/18. LPN #54 also stated accessed insulins are good for 30 days. Interview with Infection Preventionist (IP) #303 on 11/06/18 at 12:45 P.M., indicated opened vials of insulin are good for 30 days. Review of the facility policy, Administration of Injectable Medications, (undated) revealed multi-dose injectable vials must be discarded after 28 days or according to manufacturer instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 7 of 10 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 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 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 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. 4. Observation on 11/06/18 at 11:48 A.M. Dining Services(DS) #32 was observed checking temperatures of food prior to distribution on the fourth floor. DS #32 was noted to wash hands and apply gloves while checking each food item. While temping food, DS #32 was observed touching her face and glasses with gloved hands then taking the same gloved hand with the thermometer, putting it into the tomato soup, and touching the soup with dirty gloved hands. Interview immediately following the observation with DS #32 verified they touched their face and glasses and then putting their hands in the soup, touching soup with the same gloved hand. 5. Observation on 11/06/18 at 12:15 P.M. revealed Chef #136 was noted assisting food service for residents on the fourth floor kitchenette area. A small refrigerator was observed with cups of milk, juice, fruit bowls, and plates containing chicken salad sandwiches with the door kept open during the entire food service prep observation. Temperatures taken on food inside of the refrigerator prior to serving to residents. Chef #136 temped cups of milk at 55 degrees and chicken salad sandwiches at 50 degrees. Interview on 11/06/18 immediately following the observation with Chef #136 verified the increased temperatures and also verified the cold foods should be maintained at/or below 40 degrees. Review of the facility's Food Storage policy dated 09/2004 revealed food items are to be kept out of the 40 degrees to 140 degrees danger zone. Further review of the policy revealed gloves are to be changed by staff every time they go from one task to another. The policy did not provide any information regarding food being protected from ice build up. Based on observation, record review, staff interview and policy review, the facility failed to ensure food temperatures, the handling of food, sanitizer buckets, food items in a reach in freezer, and pest control in the kitchen were maintained in a manner to prevent and protect food against contamination and spoilage. This affected all 122 residents residing who receive meals from the kitchen. The facility census was 122. Findings include: 1. Observation of the facility's kitchen on 11/04/18 at 8:43 A.M. revealed a reach in freezer to include a ham in the manufactures plastic packaging that had approximately 1 inch of ice build-up around the ham. There was also a box of food items in the reach in freezer that had approximately one inch of ice build-up on the box. Observation of the reach in refrigerator revealed three pans of red jello dated 10/21/18 that were not covered. Interview with Chef #137 on 11/04/18 at 8:43 A.M. verified the ice build-up on the ham and on the box in the reach in freezer. Chef #137 reported the freezer probably had a leak. Chef #137 also confirmed the three pans of red jello in the reach in refrigerator were dated 10/21/18 and were not covered. Review of the facility's Dates and Labels policy dated February 2010 revealed ready to eat products must be used within seven days from opening. Opened products must be stored in an air tight container if the original container does not reseal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 8 of 10 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 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 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 0812 Level of Harm - Minimal harm or potential for actual harm 2. Observation of the dishwasher on 11/04/18 at 9:00 A.M. revealed a red insect about one half inch long to crawl out from underneath the dishwasher and returned under the dishwasher. Interview with Kitchen Attendant #44 on 11/04/18 at 9:00 A.M. verified the insect crawled out from underneath the dishwasher. Residents Affected - Many Review of the facility's work orders revealed two roaches were seen in the facility near the kitchen on 10/03/18. Review of the facility's undated pest control scope of service contract revealed the main kitchen is inspected by the pest control company weekly. Interview with Director of Environmental Services (DES) #300 on 11/06/18 at 3:00 P.M. revealed the facility's kitchen is inspected weekly and sprayed as needed for pests. 3. Observation of the kitchen sanitizer buckets on 11/04/18 at 9:10 A.M. revealed two sanitizer buckets in active use in the kitchen. The sanitizer bucket located on the preparation table near the stove was 400 parts per million (ppm). The sanitizer bucket located in the sink near the walk-in refrigerators revealed the sanitizer to be zero ppm. Interview with Director of Food Services (DFS) #305 on 11/04/18 at 9:05 A.M. verified sanitizer buckets in the kitchen did not contain the appropriate ppm of sanitizer. Review of the facility's undated Red Sanitizer Bucket revealed the sanitizer buckets should be between 300 to 400 ppm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 9 of 10 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 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record reviews, staff interviews and facility policy review, the facility failed to ensure individually used glucometers were cleaned appropriately. This affected six residents (#29, #76, #96, #50, #60, #59) the facility identified as using glucometers. The facility census was 122. Residents Affected - Some Findings include: Interview on 11/05/18 at 8:10 A.M., with Licensed Practical Nurse (LPN) #89 revealed she cleans resident glucometers with alcohol wipes between uses. Interview on 11/06/18 at 8:16 A.M., with LPN #96 revealed she cleans resident glucometers with alcohol pads between uses. Interview on 11/05/18 at 8:39 A.M., with Infection Preventionist (IP) #303 revealed each resident have their own glucometer and staff should be cleaning glucometers with Sani-Wipes between each use, as stated in the facility policy. Interview on 11/06/18 at 9:00 A.M., with IP #303 revealed he had been told LPN #96 was cleaning glucometers with alcohol swabs between each use and had already provided LPN #89 and LPN #96 with education regarding the cleaning of glucometers. Observation of multiple medication carts during medication administration observation revealed each cart contained a container of Sani-Wipes are located in the left bottom drawer. Review of the Assure Prism Glucometer User Instruction Manual revealed, The meter should be cleaned and disinfected after use on each patient. We have validated PDI Super Sani-Cloth wipes for disinfecting the Assure Prism multi-meter. Review of the facility policy, Cleaning Glucometers Policy and Procedure, dated 11/08/17 revealed, glucometers are disinfected to help prevent the spread of infection. All glucometers will be disinfected between uses for residents with an approved surface disinfectant or per manufacturer's recommendations. All glucometers are to be cleaned with an approved surface disinfectant or per manufacturers recommendations prior to and after each resident use. Wipe all hard, non-porous environmental surfaces of glucometer with disinfecting wipe or per manufacturers recommendations Allow all surfaces to remain wet and air dry for at least one minute to kill HBV, HCV, HIV-1 and other bacteria/viruses. Five minutes for suspected TB. Lancets are to be for single use only and disposed of properly after use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 10 of 10