Health inspection·October 24, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, review of safety data sheets, and review of the facility policy, the facility failed to ensure harmful cleaning chemicals were not accessible to severely cognitively impaired residents. This had the potential to affect 36 residents (#1, #7, #8,#11, #13, #12, #14, #19, #20, #21, #22, #25, #26, #34, #35, #39, #40, #41, #44, #45, #47, #49, #51, #52, #54, #58, #59, #60, #63, #64, #65, #67, #69, #74, #76, #180) identified by the facility as being both mobile and severely impaired cognitively. The facility census was 76. Findings include: Observation on 10/23/24 from 10:53 A.M. to 10:57 A.M. revealed there were four spray bottles of chemicals sitting in an open pocket of a floor technician's cart sitting unattended in the hallway as Floor Technician #431 was cleaning resident room [ROOM NUMBER]. Observation on 10/23/24 at 10:59 A.M of the floor technician's cart with Floor Technician #431 confirmed there was one spray bottle labeled Crew Restroom & Surface SC Non-Acid Disinfectant Cleaner, one spray bottle labeled Virex two 256 One-Step Disinfectant Cleaner, one spray bottle labeled Fantasik, and one spray labeled Clorox Germicidal Bleach in the open pocket of the floor technician cart he had been using. At the time of the observation, Housekeeper #431 confirmed he had just finished cleaning resident rooms numbered 11 and 14 and left his cart in the hallway as he cleaned the rooms. Interview on 10/23/24 at 11:29 A.M. with Housekeeping/Laundry Supervisor #429 revealed the floor technician's cart should not have had the chemical cleaners on it, and all chemicals should be locked. Review of the safety data sheet for Virex two 256 One-Step Disinfectant Cleaner and Deodorant; Quat Based Disinfectant, revised on 04/30/20, revealed the product caused severe skin burns and serious eye damage, was harmful if swallowed, and may cause damage to organs through prolong or repeated exposure. The product should be stored locked up. Review of the safety data sheet for Crew Restroom & Surface SC Non-Acid Disinfectant Cleaner, revised 07/31/24, revealed the product caused severe skin burns and serious eye damage, was harmful if swallowed, and may cause damage to organs through prolonged or repeated exposure. The product should be stored locked up. Review of the safety data sheet for Fantasik Multi-Surface Disinfectant Degreaser, revised 10/02/19, revealed the product should be stored out of reach of children and pets and contact with skin, (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 2 Event ID: 365715 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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)