Health inspection·March 9, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure notices of Medicare non-coverage (NOMNC) contained all required information. This affected two of two residents (Residents #133 and #134) reviewed for beneficiary notices. The facility census was 30. Residents Affected - Some Findings Include: Medical record review revealed Resident #133 was admitted to the facility [DATE] with diagnoses that included heart failure and high blood pressure. Resident #133 discharged home [DATE]. Review of the NOMNC given to Resident #133 on [DATE] prior to his discharge revealed the notice stated Your Medicare provider and/or health plan have determined that Medicare with not pay for your current {insert type} services after the effective date indicated above. Medical record review revealed Resident #134 was admitted to the facility on [DATE] with diagnoses that included left femur fracture, anxiety disorder and depression. Resident #134 expired at the facility on [DATE]. Review of the NOMNC given to Resident #134 on [DATE] prior to ending skilled services and electing hospice services revealed the notice stated Your Medicare provider and/or health plan have determined that Medicare with not pay for your current {insert type} services after the effective date indicated above. Interview with Social Worker (SW) #998 on [DATE] at 3:30 P.M. verified the notices given to Residents #133 and #134 did not contain what service type was ending. Page 1 of 5 365533 365533 03/09/2023 Joshua Tree Care Center 27500 Mill Rd North Olmsted, OH 44070

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and staff interview the facility failed to ensure the service of a Registered Nurse (RN) for at least eight hours a day seven days a week as required. This had the potential to affect all residents. The facility census was 30. Findings Include: Review of facility staffing schedules revealed on 04/02/22, 04/03/22, 04/16/22, 04/17/22, 04/30/22, 05/01/22, 05/14/22, 05/28/22, 05/29/22, 06/12/22, and 06/25/22 the facility did not have the services of an RN for eight consecutive hours as required. Interview with the Administrator on 03/07/23 at 5:00 P.M. verified the lack of RN hours on the dates listed above. 365533 Page 2 of 5 365533 03/09/2023 Joshua Tree Care Center 27500 Mill Rd North Olmsted, OH 44070

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 staff interview the facility failed to ensure food was labeled and dated properly and the walk in freezer was maintained in good working condition. This had the potential to affect all residents. The facility census was 30. Findings Include: Observation during tour of the kitchen on 03/06/23 between 7:15 A.M. and 7:33 A.M. revealed the following. 1. The walk in in freezer had significant ice build up. Multiple chunks of ice more then six inches in diameter with ice crystals formed were stuck to the freezer shelves. One of the chunks of ice had engulfed a box of tater tots and the box of tater tots was stuck to the ice block and immovable. Hanging from the top of freezer were over ten, six inch long icicles. In addition, there was an undated and opened bag chicken patties, an undated and opened bag of chicken tenders, an undated unlabeled and opened bag of cheese omelettes, an undated and opened box of pork egg rolls, and two undated and opened packages of ham. 2. In the dry storage area there was a dented can of sweet peas, an undated and opened bag of elbow macaroni, an undated and opened bag of rainbow rotini, an undated and opened bag of rigatoni, and an undated and open container of liquid butter. Interview with Dietary Manager (DM) #800 at the time of the discovery, on 03/06/23 between 7:15 A.M. and 7:33 A.M., confirmed the observations. 365533 Page 3 of 5 365533 03/09/2023 Joshua Tree Care Center 27500 Mill Rd North Olmsted, OH 44070

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to implement and maintain a comprehensive Quality Assurance Performance and Improvement (QAPI) plan. This had the potential to affect all 30 residents residing at the facility. Residents Affected - Many Findings Include: Review of the QAPI program documentation revealed no evidence the plan addressed the full range of care and services provided by the facility which was comprehensive, data driven and ongoing. There were no indicators focusing on outcomes of care, quality of life or resident rights. Interview with Director of Nursing (DON) on 03/09/23 at 2:10 P.M. revealed the facility did not have a plan to provide the survey team. The last QAPI plan was completed on 03/16/21. Interview with the Administrator on 03/09/23 at 2:15 P.M. verified the facility was not participating in any data driven ongoing QAPI programs. Several weeks ago she started considering programs for participation. Review of the facility's policy titled Quality Assurance Program, undated revealed the facility would have a program in effect, in order to continue to identify, monitor, evaluate and promote the maintenance and enhancement of every resident's quality of life and quality of care. 365533 Page 4 of 5 365533 03/09/2023 Joshua Tree Care Center 27500 Mill Rd North Olmsted, OH 44070

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to implement and monitor measures to prevent the potential spread of Legionella. This had the potential to affect all 30 residents residing at the facility. Residents Affected - Many Findings include: Review of the facility's policy titled Legionella Prevention Program dated November 2017, revealed control measures including physical control measures, water temperature management, disinfectant level controls, visual inspections, environmental testing for pathogens and specific testing protocols with acceptable ranges for control measures. Parameters included: • Hot water to be maintained above a temperature of 122 degrees Fahrenheit (F). • Cold water temperatures to be maintained below 77 degrees F. • Maintain chlorine residual levels at Center of Diseases Control and Prevention (CDC) recommended levels. • Maintain chlorine residual logs to ensure safe levels. Review of the Legionella water testing log from 03/01/22 through 03/01/23 revealed one entry indicating on 05/12/22 the water from the faucet at the eye wash station located in the kitchen was tested and negative for Legionella. There was no documented evidence the other control measures listed in the facility's legionella prevention program were implemented/monitored. Interview with the Administrator on 03/09/23 at 11:00 A.M. revealed the facility had no additional documentation to support the facility's legionella prevention program was implemented/monitored. Review of CMS Survey and Certification letter 17-30-All, dated 06/02/17, revealed facilities were to implement a water management program that considered the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) industry standard and the Center of Disease Control and Prevention (CDC) toolkit, and included control measures such as physical controls, temperature management, disinfection level control, visual inspections, and environmental testing for pathogens. 365533 Page 5 of 5