Health inspection·December 9, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based observation and interview the facility failed to maintain comfortable temperature levels. This affected five (Residents #13, #17, #28, #31 and #44) of 15 residents whose rooms were observed for comfortable temperatures. Findings include: Interviews and observations on 12/04/22 from 10:49 A.M. to 11:25 A.M. with Residents #13, #17, #28, #31 and #44 revealed their rooms were cold. Resident #13 was observed lying in bed under the blankets wearing a hoodie and long sleeve shirt. Resident #17 was observed wearing a winter hat, coat and gloves seated in a wheelchair. Resident #28 was observed sitting in wheelchair wearing a long sleeve shirt. Resident #31 was observed lying in bed under the blankets wearing gloves and a winter hat. Resident #44 was observed lying in bed with two blankets covered from his face to toes. All residents stated the rooms were always cold, that staff knew about it but did not do anything about it. Observations and temperature checks on 12/04/22 from 11:28 A.M. to 11:50 A.M. with the Maintenance Director revealed temperatures measured 68 to 70 degrees Fahrenheit (F) in the residents' rooms. Interview on 12/04/22 at 11:50 A.M. with the Maintenance Director revealed facility temperatures should be between 71 and 81 degrees F. The Maintenance Director stated the thermostats were set at 65 degrees F. Page 1 of 18 365784 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on record review and interview, the facility failed to ensure the Long Term Care Ombudsman received copies of hospital transfer notices. This affected two residents (#13 and #66) of two residents reviewed for hospitalizations. The facility census was 65. Findings include: Review of the medical record for Resident #13 revealed an admission date of 06/24/22. Diagnoses included chronic kidney disease, stage 4 (severe), acute kidney failure with tubular necrosis, hydronephrosis with ureteral stricture, major depressive disorder, and stroke. Review of the quarterly minimal data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required limited assistance of one staff for bed mobility, extensive assistance of staff for transfer and toilet use, and supervision with set-up help for eating. Review of the nurses note dated 09/21/22 at 7:58 P.M. revealed Resident #13's labs returned and the physician was notified of the results with critical values. Resident 13's physician gave a new order to send Resident #13 to the emergency room (ER) for evaluation and treatment. Resident #13 transferred to the ER via gurney with emergency medical services (EMS) at 4:00 P.M. Review of the nurses note dated 09/24/22 at 7:21 P.M. revealed Resident #13 was yelling out in pain and grabbing at his groin area. As needed Tylenol was given without effect. Resident #13 continued to yell and grab at his groin region. Resident #13 was asked if he wanted to go to the ER. Resident #13 nodded yes. The nurse then went to gather paperwork and upon return to Resident #13's room he was observed on the floor screaming. Vitals were obtained and an ambulance called. Family and physician notified. Review of the nurses' notes dated 10/01/22 at 10:05 A.M. revealed Resident #13 was found lying on the floor on his right side with blood coming from his forehead. EMS was called to transport resident to the hospital. Resident left for the ER with EMS. The physician, Director of Nursing (DON), and resident's son were notified of the transfer. 2. Review of the medical record for Resident #66 revealed an admission date of 09/09/22 and a discharge date of 10/01/22. Diagnoses included mild cognitive impairment and hypertension. Review of the discharge no return anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had impaired cognition and was independent for bed mobility, required limited assistance for transfers and toilet use, and supervision for eating. Review of the nurses' notes dated 09/29/22 at 5:46 A.M. revealed Resident #66 had an emesis at approximately 1:45 A.M. Abnormal lung sounds were heard and oxygen saturation was at 91 percent. An oder was received for a chest x-ray. Overnight oxygen saturation decreased to 83 percent and oxygen was applied and a new order was obtained to send to the ER for evaluation. Report was called to the hospital. Review of the ombudsman notification revealed an email sent on 10/05/22 for September 2022 discharges and hospital transfers for Resident #13; however, the email was sent to 365784 Page 2 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0623 transferdischargenotices@odh.ohio.gov from Social Services (SS) #438. Level of Harm - Minimal harm or potential for actual harm Review of the email sent on 11/02/22 for the October 2022 discharges and hospital transfers revealed Resident #13 and Resident #66 hospital transfers which was sent to erobinson@dheo.org from SS #438. Residents Affected - Few Interview on 12/06/22 at 11:04 A.M. with SS #438 revealed she started working at the facility in September 2022 and that the local ombudsman had contacted her requesting the discharges and hospital transfers to be sent to them. SS #438 verified she had not sent hospital transfers notices to the State Long Term Care Ombudsman. 365784 Page 3 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure care plans were developed for hospice and dialysis services. This affected Resident #45 who received hospice services and Resident #63 who received dialysis services. This affected one (Resident #45) of one resident reviewed for hospice and one (Resident #63) of one resident reviewed for dialysis. The facility census was 65. Findings include: 1. Review of the medical record for Resident #45 revealed an initial admission date of 08/26/22. Diagnoses included anxiety disorder, hypertension, hypothyroidism, unspecified, muscle weakness, and vascular dementia with behavioral disturbance. Review of the significant change minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required total dependence for one staff for bed mobility and eating, total dependence of two staff for transfers, and was receiving hospice services. Review of the nurses note dated 10/04/22 at 10:37 A.M. revealed Resident #45 had an increase in lethargy, poor appetite and decreased intake in fluids. Family was contacted to discuss recommendation of hospice services for comfort measures. The family was in agreeance and requested a meeting with hospice. Code status was discussed with family, and they wanted Resident #45 to remain a full code until meeting with hospice. The physician was notified of change in condition with order to consult hospice. Social service contacted hospice and requested information to be sent. Social service would notify family when meeting with hospice was set. Review of the December 2022 physician's orders revealed an order dated 10/06/22 to admit Resident #45 to hospice with diagnoses of vascular dementia with prognosis of six months or less if disease ran normal progression. Review of Resident #45's nurses note dated 10/07/22 at 2:30 P.M. revealed hospice nurse was in to visit. Recommendations given to the nurse and physician was notified. Interview on 12/05/22 at 2:42 P.M. with Regional Nurse #462 verified there was no care plan for Resident #45 in regard to hospice service prior to 12/05/22. Regional Nurse #462 created the hospice care plan for Resident #45 today. Review of the care plan created on 12/05/22 revealed Resident #45 had a terminal prognosis/less than six months to live related to vascular dementia. Review of the facility policy titled, Care Planning-Interdisciplinary Team, revised September 2013 revealed a comprehensive care plan for each resident would be developed within seven days of completion of the resident assessment (MDS). 2: Review of the medical record for Resident #63 revealed an admission date of 09/14/22. Diagnoses included end stage renal disease, moderate protein calorie malnutrition, hypertension, anemia and hepatitis. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. He required limited assistance of one person for bed mobility, transfers, dressing and toilet use and supervision and set up help to eat. Review of the physician orders for November 2022 revealed Resident #63 received dialysis Monday, 365784 Page 4 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0656 Wednesday and Friday. Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 09/21/22 revealed no evidence of a care plan to address Resident #63's dialysis needs. Residents Affected - Few Interview with the acting Director of Nursing (ADON) on 12/06/22 at 8:17 A.M. confirmed there was no care plan for dialysis for Resident #63. Review of the facility policy titled Care planning - Interdisciplinary team dated September 2013 revealed the facility would develop a comprehensive care plan for each resident. 365784 Page 5 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, interview and review of manufacturer instructions the facility failed to ensure Resident #32 was prompted or assisted to rinse mouth with water and expectorate to help reduce the risk of orophayrngeal yeast infection after administration of inhaled medication. This affected one (Resident #32) of five residents observed during medication administration. The census was 65. Residents Affected - Few Findings include: Review of medical record for Resident #32 revealed an admission date of 08/25/20. Diagnoses included bipolar disorder, vascular dementia, chronic obstructive pulmonary disease, and malignant neoplasm of unspecified part of bronchus or lung. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/07/22, Resident #32 had intact cognition and required supervision for locomotion. Review of Resident #32's physician order dated 07/16/22 revealed an order to use a Breo Ellipta inhaler daily for chronic obstructive pulmonary disease. Observation on 12/04/22 at 9:13 A.M., Registered Nurse (RN) #461 administering Breo Ellipta inhaler to Resident #32. Resident #32 took one dose from the inhaler and handed it back to RN #461. RN #461 did not encourage or prompt Resident #32 to rinse mouth after inhalation of the medication. Interview immediately after the observation with RN #32 revealed Resident #32 usually did not rinse her mouth out after inhalation of the medication so RN #32 stopped asking or prompting her to do so. RN #32 confirmed residents were to rinse mouth after taking dose. Review of manufacturer instructions for Breo Ellipta indicated after inhalation, rinse mouth with water and expectorate. 365784 Page 6 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was changed in a timely manner. This affected one resident (#52) of one resident reviewed for respiratory care. The facility census was 65. Residents Affected - Few Findings include: Review of the medical record for Resident #52 revealed an admission date of 10/29/22. Diagnoses included acute respiratory failure with hypoxia, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), and asthma. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition, required limited assistance of one staff for bed mobility and toilet use, total dependence of two staff for transfers, and supervision with set-up help for eating, and used oxygen. Review of Resident #52's December 2022 physician orders revealed orders to change oxygen tubing every week on Sunday on 11:00 P.M. to 7:00 A.M. shift dated 10/30/22. Observation on 12/04/22 at 12:00 P.M. revealed Resident #52 in bed receiving oxygen via a facemask. Observation of the oxygen tubing revealed it was dated 11/14/22. Interview at this time with Resident #52 revealed he could not recall when the oxygen tubing was last changed. Observation on 12/04/22 at approximately 12:05 P.M. with Registered Nurse (RN) #463 verified Resident #52's oxygen tubing was dated 11/14/22. Interview at this time with RN #463 revealed the resident's oxygen tubing should be changed weekly on Sunday evenings and dated. 365784 Page 7 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure pre and post dialysis assessments were completed for one resident (Resident #63). This affected one of one resident (Resident #63) reviewed for dialysis and one of eight resident reviewed for assessments. The facility census was 65. Residents Affected - Few Findings include: Review of the medical record for Resident #63 revealed an admission date of 09/14/22. Diagnoses included end stage renal disease, moderate protein calorie malnutrition, hypertension, anemia and hepatitis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had intact cognition, required limited assistance of one person for bed mobility, transfers, dressing and toilet use and supervision and set up help to eat. Review of the physician orders for November 2022 revealed Resident #63 received dialysis Monday, Wednesday and Friday. Review of the dialysis communication forms from 09/16/22 through 12/05/22 revealed no pre dialysis assessment was completed on 10/28/22, 11/09/22, 11/11/22, 11/14/22, 11/18/22, 11/25/22, 11/30/22 and 12/02/22 and no post dialysis assessment was completed on 10/17/22, 10/19/22, 10/21/22, 10/24/22, 10/26/22, 10/28/22, 10/31/22, 11/02/22, 11/11/22, 11/21/22, 11/23/22, 11/25/22 and 11/28/22. Interview with the Director of Nursing (DON) on 12/06/22 at 8:17 A.M. confirmed dialysis assessments were not completed before and after each dialysis treatment. Review of the contract between the facility and the dialysis center revealed the facility would complete assessments relevant to the resident's care, prior to and after dialysis. Review of the facility policy titled Hemodialysis Access Care dated September 2010 revealed the nurse would document observations pre and post dialysis. 365784 Page 8 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #8 revealed an admission date of 09/06/22. Diagnoses included adjustment disorder with mixed anxiety and depressed mood and dementia with other behavioral disturbance. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required extensive assistance of one staff for bed mobility, transfers, toilet use, limited assistance of one staff for eating, and no behaviors in the seven day look back period. Review of Resident #8's December 2022 physician orders revealed orders for divalproex capsule 125 milligrams (mg), give 125 mg orally two times a day related to adjustment disorder with mixed anxiety and depressed mood dated 05/11/22. An order for Aripiprazole tablet 2 mg, give one tablet by mouth two times a day related to adjustment disorder with mixed anxiety and depressed mood dated 05/24/22. Review of the pharmacy recommendation to physician dated 09/18/22 revealed Resident #8 had been taking divalproex 125 mg twice daily since 05/11/22 without a gradual dose reduction (GDR). The pharmacist asked if a dose reduction could be attempted at this time to verify the resident was on the lowest possible dose. The recommendation indicated, if not, please indicate response below. Below under physician/prescriber response was a handwritten note, No change per VA MH, and verbal was handwritten on the signature line. Under that was the Director of Nursing's signature which was dated 10/01/22. Review of the pharmacy recommendation to physician dated 10/14/22 revealed Resident #8 had been taking divalproex 125 mg twice daily since 05/11/22 without a GDR. The pharmacist asked if a dose reduction could be attempted at this time to verify the resident was on the lowest possible dose. The recommendation indicated, if not, please indicate response below. Below under physician/prescriber response, there was a check in the box next to other, please see doctor's orders/progress notes and written in the lines below was per the physician continue current dose. The signature line was blank but under it, verbal order obtained was handwritten and the date 10/24/22. Review of the pharmacy recommendation to physician/prescriber dated 11/11/22 revealed Resident #8 had been taking divalproex 125 mg twice daily since 05/11/22 without a GDR. The pharmacist asked if a dose reduction could be attempted at this time to verify the resident was on the lowest possible dose. The recommendation indicated, if not, please indicate response below. Below under physician/prescriber response, nothing was checked but there was a handwritten note Has VA mental health apt. 12/22/22. The form had no signature or date. Review of the pharmacy recommendation to physician/prescriber dated 11/11/22 revealed Resident #8 had been taking aripiorazole 2 mg twice daily since 05/24/22 without a GDR. The pharmacist asked if a dose reduction could be attempted at this time to verify the resident was on the lowest possible dose. The recommendation indicated, if not, please indicate response below. Below under physician/prescriber response, nothing was checked but there was a handwritten note Has VA mental health apt. 12/22/22. The form had no signature or date. Further review of Resident #8's medical record revealed no written orders, nurses' notes, or physician notes addressing the pharmacy recommendations to physician/prescriber dated 09/18/22, 10/14/22, and 11/11/22. 365784 Page 9 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the psychiatry psychotherapy notes from Veterans Administration (VA) mental health for Resident #8 dated 10/14/22 and 11/21/22 revealed no documentation addressing the pharmacy recommendation to physician/prescriber dated 09/18/22, 10/14/22, and 11/11/22. Interviews on 12/05/22 at 1:58 P.M. and 2:13 P.M. with the Director of Nursing verified the findings above. The DON stated she called the VA mental health on 10/01/22 for the pharmacy recommendation dated 09/18/22 and received verbal information of no changes. Based on record review and interview, the facility failed to ensure the attending physician documented the rational when pharmacy recommendations were not accepted and no medication changes were made. This affected two out of seven residents reviewed for unnecessary medications (Resident #5 and Resident #8). The facility census was 65. Findings include: Review of the medical record for Resident #5 revealed an admission date of 05/13/22. Diagnoses included schizophrenia, hypothyroidism, anxiety and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #5's physician's orders for December 2022 revealed an order for Ondanestron (Zofran) 4 milligrams (mg), a medication used to prevent nausea, to be given every eight hours as needed, and an order for Miralax 17 grams (gm), a medication to provide relief from constipation, was ordered every 24 hours as needed. Both orders had a start date on 05/13/22. Review of pharmacist recommendations to the physician dated 10/14/22 and 11/11/22 revealed a recommendation to consider discontinuing as needed medications. The response to the recommendation revealed a verbal order by the physician to continue current orders. The verbal order was not signed and provided no rationale. Interview on 12/05/22 at 2:12 P.M. with the Director of Nursing confirmed the pharmacist recommendations were not appropriately addressed by the physician. Review of the policy for Medication Regimen Review dated 11/01/21 revealed pharmacy recommendations would be reviewed within 30 days. 365784 Page 10 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

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 observation and interview the facility failed to ensure medications were labeled with name of medication, expiration date, and cautionary instructions as applicable. This had the potential to affect 34 (Resident #2, #4, #5, #6, #7, #10, #11, #15, #16, #17, #18, #19, #20, #22, #25, #26, #27, #29, #30, #34, #35, #37, #41, #45, #46, #49, #51, #54, #55, #57, #58, #61, #63, and Resident #219) of 34 residents residing on the [NAME] unit. The census was 65. Findings include: Observations of medication administration on 11/04/22 at 8:59 A.M. revealed a medication cup filled with 12 medications inside the medication cart for the [NAME] unit. Interview at time of observation with Registered Nurse (RN) #458 revealed she could not identify the medications in the cup or who the medications were for. RN #458 stated the cup was in the top drawer from the night before. Interview on 12/05/22 at 3:22 P.M. with the Director of Nursing (DON) stated she looked up the medication based on the numbers printed on the medications and identified the medications as over the counter. The DON stated the medications were not stored correctly. 365784 Page 11 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to ensure menus included a variety of food and failed to ensure menus and recipes were followed. This affected all residents except Resident #35 who received nothing by mouth. The facility census was 65. Finding include: 1. Review of the menu for week two revealed chicken for dinner on Sunday and Monday and for lunch on Tuesday. Review of the renal menu for week two revealed turkey sandwiches for lunch on Sunday and Thursday and for dinner on Tuesday and Wednesday. Interview on 12/06/22 at 12:00 P.M. with Dietary Manager (DM) #451 verified the main menu had chicken for three consecutive days. DM #451 stated that was why she switched today's lunch to Sloppy joes. DM #451 verified the renal menu had turkey sandwiches repeatedly on the menu. DM #451 stated she had heard residents complain of the lack of variety on the menu. 2. Observation of tray line on 12/06/22 at 12:08 P.M. revealed the regular Sloppy [NAME] was served using a green handled scoop; the pureed Sloppy [NAME] was served using a blue handled scoop; the mashed potatoes using a green handled scoop; and the pureed using a green handled scoop. Interview on 12/06/22 at 12:27 P.M. with Dietary Manager (DM) #451 revealed she did not provide Dietary Staff (DS) #410 with a menu with the serving sizes for each meal item but told DS #410 what the serving sizes were. DM #451 stated she did not have a menu for today's meal, but the recipe indicated what the serving sizes were. Review of the recipe revealed for the pureed Sloppy [NAME] on bun a #8 scoop portioned onto two #20 scoops of pureed bun. DM #451 indicated the bread was pureed with the Sloppy [NAME]. Review of the recipe for the regular Sloppy job revealed a #8 scoop portioned onto the hamburger bun. DM #451 stated the vegetables and mashed potatoes were generally four ounce servings. Review of the disher capacity sheet revealed the serving sizes and color of the disher which indicated the #8 scoop was grey handled and provided 3.64 ounces; the #12 scoop was green handled and provided 3.19 ounces. DM #451 verified DS #410 used the incorrect serving utensils which provided less then what the recipes indicated. 365784 Page 12 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the pureed sloppy joe was properly prepared and of the correct consistency. This had the potential to affect 13 residents (#4, #6, #10, #20, #22, #26, #29, #39, #41, #46, #52, #74, and #119) of 13 residents who received a pureed diet. The facility census was 65. Findings include: Observation on 12/06/22 at 11:31 A.M. revealed Dietary Staff (DS) #410 wash her hands and obtain the temperature of the cooked, Sloppy [NAME]. Observation of the robot coupe (food processor) revealed it was clean and dry. DS #410 poured the Sloppy [NAME] into the robot coupe, added hot water and six slices of bread then blended the mixture. At 11:35 A.M., DS #410 stopped the robot coupe and stated the it was done. DS #410 poured the finished Sloppy [NAME] into a small steam table pan. The Sloppy [NAME] appeared chunky, and a taste test revealed the Sloppy [NAME] was chunky with bites of meat. At this time Dietary Manager (DM) #451 tasted the sloppy joe and informed DS #410 to put it back in the robot coupe and blend it longer. DS #410 poured the Sloppy [NAME] back into the robot coupe, added hot water, and blended it again. DS #410 stopped to check the Sloppy [NAME] consistency and asked if it was done. DM #451 looked at it and stated to add thickener. DM #451 added thickener to the Sloppy [NAME] mixture and blended it further. DS #410 stopped the robot coupe and at this time the Sloppy [NAME] pureed mixture appeared smoother and a taste test revealed very minimal grit. DS #410 poured the mixture back into the same small steam table pan. Observation along the inside of the small steam table pan revealed some of the chunky Sloppy [NAME]. Interview at this time with DS #410 verified the observation and stated she was going to switch out the pans. Review of the recipe for pureed Sloppy [NAME] on bun revealed: 1. Refer to regular recipe instructions; 2. measure desired number of servings of sandwich filling into food processor. Blend until smooth. Add broth or gravy if product needs thinning. Add commercial thickener if product needs thickening; 3. Measure desired numbers of servings of bread/bun into food processor. Blend until smooth. Add milk if product needs thinning. Add commercial thickener if product needs thickening; 4. Portion a #8 scoop of sandwich filling and two #20 scoops of bread. Note: Liquid measure is approximate and slightly more or less may be required to achieve desired pureed consistency. Interview on 12/06/22 at 12:27 P.M. with DM #451 verified that DS #410 did not follow the recipe for the pureed Sloppy [NAME]. 365784 Page 13 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure resident meal choices were obtained consistently. This affected 13 residents (#11, #14, #17, #18, #23, #32, #36, #42, #58, #59, #61, #63, and #76) and had the potential to affect all residents except Resident #35 who received nothing by mouth. Findings include: Observation of the lunch meal on 12/04/22 between 12:35 P.M. and 12:38 P.M. revealed Residents #14, #17, #23, #32, #36, #42, #59, and #76 were served chips, deli sandwich, and fruit cup. Interviews during this time with the residents revealed sometimes they received a menu and could choose between the main meal and an alternate. All stated they did not get that option on this date. They also complained there was a lack of food variety. Resident #17 stated he was not happy with what he received to eat for lunch. Interview on 12/04/22 at 3:32 P.M. with Dietary Staff (DS) #450 revealed residents usually received a menu for lunch and dinner with their breakfast trays so they could choose between the main meal or the alternate. DS #450 stated the residents did not receive the menus today and to follow-up with Dietary Manager (DM) #451. Interview on 12/04/22 at 3:36 P.M. with DM #451 revealed she created and sent out menus for residents to choose between the main meal and the alternate. DM #451 stated she did not create or send out menus for the weekends and on days they had sandwiches as the main entree. DM #451 stated she had heard complaints from the residents regarding the menus with one of the complaints being repetitive menu choices. 2. Review of the medical record for Resident #11 revealed an admission date of 08/02/10. Diagnoses included Multiple sclerosis, anxiety, arthritis and gout. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, was independent requiring only set up help to eat. Review of the medical record for Resident #18 revealed an admission date of 11/04/18. Diagnoses included Alzheimer's disease, anxiety, depression and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognition and required supervision and set up help to eat. Review of the medical record for Resident #58 revealed an admission date of 04/26/22. Diagnoses included diabetes, anemia, fibromyalgia and constipation. Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and was independent in eating. Review of the medical record for Resident #61 revealed an admission date of 06/07/22. Diagnoses included dementia, depression, insomnia and dry skin. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognition and was independent in eating. Review of the medical record for Resident #63 revealed an admission date of 09/14/22. Diagnoses included end stage renal disease, hypertension and hepatitis. Review of the comprehensive MDS assessment dated [DATE] revealed the resident was cognitively intact and required supervision and set up help 365784 Page 14 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0806 to eat. Level of Harm - Minimal harm or potential for actual harm Interview on 12/04/22 at 10:43 A.M. with Resident #58 revealed she never had a choice of what she wanted to eat, she ate whatever was given to her. Residents Affected - Some Observation of lunch on 12/05/22 at 12:12 P.M. revealed all residents in the [NAME] dining room were served a turkey sandwich, a bag of potato chips or cheese curls, peaches, sliced tomatoes and coleslaw. Interview with Residents #11, #18 and #61, at the time of the observation, revealed they were not given a choice of what they wanted for lunch. Interview on 12/05/22 at 12:45 P.M. with State Tested Nurse Aide (STNA) #404 revealed residents were seldom given a choice of what they would like to eat, they ate whatever was served. Interview on 12/06/22 at 9:54 A.M. with Resident #63 revealed he was given a choice of what he would like to eat an average of once per week. 365784 Page 15 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure meals were served in a sanitary manner. This had the potential to affect all residents except Residents #4, #6, #10, #20, #22, #26, #29, #39, #41, #46, #52, #74, and #119 who received a pureed diet and Resident #35 who received nothing by mouth. The facility census was 65. Findings include: Observation of tray line on 12/06/22 at 12:12 P.M. revealed Dietary Staff (DS) #410 with gloved hands use a red and black plunger to pick up a metal hot pellet, place the pellet on an insulated bottom, then place a plate on top. DS #410 then opened the steamer with the same gloved hands, picked up a scoop to scoop a serving of pureed carrots that was in the steamer, and then finished making the pureed plate. Continued observation revealed DS #410 with the same gloved hands take a bun from a bag of buns and make a Sloppy [NAME] sandwich for a regular diet plate. DS #410 continued to prepare plates in the same manner without changing gloves or washing hands. Interview at 12:23 P.M. with DS #410 verified the observation and stated she had no other way to prepare the plates. 365784 Page 16 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

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, interview, policy and procedure review, and review of the Centers for Disease Control guidelines, the facility failed to ensure all employees were administered a baseline Tuberculosis (TB) test on hire. This had the potential to affect all 65 residents in the facility. Residents Affected - Many Findings include: Review of the facility's TB risk assessment revealed the facility was a low risk classification. Review of the personnel file for the Administrator revealed a hire date of 08/10/22. There was no evidence a tuberculosis test was administered prior to starting work. Review of the personnel file for Dietary Manager #451 revealed a hire date of 06/21/22. There was no evidence a tuberculosis test was administered prior to starting work. Review of the personnel file for Admissions Director #445 revealed a hire date of 04/25/22. There was no evidence a tuberculosis test was administered prior to starting work. Review of the personnel file for Social Service Designee #438 revealed a hire date of 09/23/22. There was no evidence a tuberculosis test was administered prior to starting work. Review of the personnel file for speech and language therapist #430 revealed a hire date of 05/04/22. There was no evidence a tuberculosis test was administered prior to starting work. Review of the personnel file for Dietary aide #415 revealed a hire date of 08/22/22. There was no evidence a tuberculosis test was administered prior to starting work. Review of the personnel file for State Tested Nurses Aide (STNA) #407 revealed a hire date of 01/20/22. There was no evidence a tuberculosis test was administered prior to starting work. Interview with the Administrator on 12/07/22 at 1:28 P.M. confirmed TB tests were not administered on hire. Review of the facility policy titled Tuberculosis Infection Control Program dated August 2019, revealed screening of employees for TB infection would occur. Review of the Centers for Disease Control TB guidelines revealed the following. TB Screening Procedures for Settings (or HCWs) Classified as Low Risk o All HCWs should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. tuberculosis. o After baseline testing for infection with M. tuberculosis, additional TB screening is not necessary unless an exposure to M. tuberculosis occurs. o HCWs with a baseline positive or newly positive test result for M. tuberculosis infection (i.e., TST or BAMT) or documentation of treatment for LTBI or TB disease should receive one chest 365784 Page 17 of 18 365784 12/09/2022 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0880 Level of Harm - Minimal harm or potential for actual harm radiograph result to exclude TB disease (or an interpretable copy within a reasonable time frame, such as 6 months). Repeat radiographs are not needed unless symptoms or signs of TB disease develop or unless recommended by a clinician (39,116). TB Screening Procedures for Settings (or HCWs) Classified as Medium Risk Residents Affected - Many o All HCWs should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. tuberculosis. o After baseline testing for infection with M. tuberculosis, HCWs should receive TB screening annually (i.e., symptom screen for all HCWs and testing for infection with M. tuberculosis for HCWs with baseline negative test results). o HCWs with a baseline positive or newly positive test result for M. tuberculosis infection or documentation of previous treatment for LTBI or TB disease should receive one chest radiograph result to exclude TB disease. Instead of participating in serial testing, HCWs should receive a symptom screen annually. This screen should be accomplished by educating the HCW about symptoms of TB disease and instructing the HCW to report any such Vol. 54 / RR-17 Recommendations and Reports 11 symptoms immediately to the occupational health unit. Treatment for LTBI should be considered in accordance with CDC guidelines (39). TB Screening Procedures for Settings (or HCWs) Classified as Potential Ongoing Transmission o Testing for infection with M. tuberculosis might need to be performed every 8-10 weeks until lapses in infection control have been corrected, and no additional evidence of ongoing transmission is apparent. o The classification of potential ongoing transmission should be used as a temporary classification only. It warrants immediate investigation and corrective steps. After a determination that ongoing transmission has ceased, the setting should be reclassified as medium risk. Maintaining the classification of medium risk for at least 1 year is recommended. 365784 Page 18 of 18