Health inspection·February 25, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews the facility failed to ensure Resident's #246 and #250 were provided a dignified dining experience. This affected two (Resident's #246 and #250) of two residents reviewed for dignity. The facility census was 48. Findings include: 1. Review of the medical record revealed Resident #246 was admitted on [DATE] with diagnoses including diabetes mellitus, hypertension, and depression. Interview on 02/14/22 at 9:40 A.M. with Resident #246 revealed he was still waiting on his breakfast tray. He stated his roommate's breakfast tray had been delivered. Resident #246 stated he had asked State Tested Nurse Aide (STNA) #503 three times for his breakfast but had not received it. Interview with STNA #503 on 02/14/22 at 9:42 A.M. verified Resident #246's breakfast tray was not on the cart with the other trays, and she asked the kitchen for his breakfast three times and still had not received his tray. Review of facility mealtimes posted in the 100 Unit hallway revealed the 200 Unit breakfast trays were to be delivered at 8:30 A.M. 2. Review of the medical record revealed Resident #250 was admitted on [DATE] with diagnosis including depression. Observation of the dining room meal service for breakfast on 02/14/22 at 8:17 A.M. revealed Resident #250 to be sitting at a table waiting on his meal. There were two other residents in the dining room at that time. At 8:55 A.M., the two other residents in the dining room were served their breakfast. Resident #250's breakfast was brought to him at 9:15 A.M. Interview on 02/14/22 at 9:05 A.M. with STNA #501 verified Resident #250 waited on his breakfast for an hour. She stated she asked the kitchen for the resident's food many times. Review of facility mealtimes posted in the 100 Unit hallway revealed the dining room breakfast would be served at 8:10 A.M. Page 1 of 26 365831 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

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, and interviews the facility failed to serve meals in a timely manner affecting 47 residents receiving meals from the kitchen except for one (Resident #7) who did not eat by mouth. The facility census was 48. Residents Affected - Many Findings include: Record review was conducted of the facility document titled Meal Times, undated, which was hanging in the main dining room, kitchen and given to the surveyor by Dietary Manager (DM) #508 as the current meal times. The document indicated breakfast service was 8:10 A.M. in the main dining room, 8:20 A.M. to the 300/400 units and 8:30 A.M. to the 100/200 units. Lunch service was 12:10 P.M. in the main dining room, 12:20 P.M. to the 300/400 units, and 12:30 P.M. to the 100/200 units. Dinner service was 4:10 P.M. in the main dining room, 4:20 P.M. to the 300/400 units and 4:30 P.M. to the 100/200 units. Record review of the of the facility document titled Concern Log for the months of September 2021 and October 2021 revealed there had been concerns expressed with breakfast being served late to the residents. Observation was conducted on 02/14/22 from 8:10 A.M. to 9:15 A.M. of the breakfast meal service. The first cart of food was presented to the main dining room at 8:55 A.M., which was 45 minutes late. This affected the timeliness of the remaining meal service. At 9:06 A.M. the cart of meal trays was taken to the 300/400 unit and the 100/200 meal service began at 9:15 A.M. Observation was conducted on 02/15/22 from 8:30 A.M. to 9:37 A.M. of the breakfast meal service. There were nine residents (Resident's #3, #6, #12, #22, #23, #26, #29, #31 and #32) as identified by State Tested Nursing Assistant (STNA) #539 who were sitting in the main dining room without food. STNA #539 verified at 9:16 A.M. they had not received their breakfast from the kitchen. Observation and interview on 02/15/22 at 8:51 A.M. with DM #508 who was inside her office inside the kitchen hand writing tray tickets. DM #508 said her computer had been down since she took over as the DM almost a week prior, so she had to hand write all the resident's tray tickets, and the tray line had not started yet. DM #508 and [NAME] #516 when asked what time the meal service should start both pointed to the Meal Times document hanging on the kitchen wall and verified the meals should be in the dining room by 8:10 A.M. so they normally started tray line between 7:50 A.M. and 8:00 A.M. Observation on 02/15/22 at 9:17 A.M. revealed the first breakfast tray was passed in the main dining room and verified by STNA #539. Observation on 02/15/22 at 12:47 P.M. of the lunch meal service revealed the tray pass did not start until 12:47 P.M. which was 37 minutes past the start of the meal service. This was verified by STNA #527. Interview was conducted on 02/15/22 at 3:28 P.M. with the Administrator who informed the surveyor she was aware DM #508 did not have a way to print tray tickets for the residents because the former dietary manager took the computer with her when she left the job. The Administrator shared DM #508 was new to the job, and she would get the computer fixed for her. 365831 Page 2 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Based on record review and interview the primary care physician/medical director failed to write, sign, and date progress notes at each visit. This affected three (Resident's #19, #39 and #245) of three residents reviewed for physician services as part of the extended survey. The facility census was 48. Findings include: Medical record reviews were conducted for Resident's #19, #39 and #245 and found to be without progress notes from Primary Care Physician/Medical Director (PCP/MD) #552 after 08/24/21. Interview on 02/23/22 at 10:05 A.M. with the Director of Nursing (DON) verified PCP/MD #552, had the resident's progress notes from his visits with the resident. The DON verified the progress notes were not in the resident's medical record. She said this had been ongoing for a while. Interview on 02/24/22 at 9:06 A.M. with PCP/MD #552 verified he did not produce progress notes while at the facility making rounds on his residents. Instead, he would just jot a few notes down then go home and write out a dated and signed progress note. He verified he had his notes at home, and they were not added timely to the medical record. 365831 Page 3 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, interview, and policy review the failed to ensure the disposal of expired medication and supplements. This had the potential to affect all residents in the facility. The facility census was 48. Findings include: Observation of the medication room with Licensed Practical Nurse (LPN) #403, on [DATE] at 1:00 P.M. revealed four boxes of iron supplements with an imprinted use by date of 01/22; one box of Reagent Urinalysis Strips with an expiration date of [DATE] and one bottle of Cherry Sore Throat Spray with an expiration date of 11/21. Interview with LPN #403 at the time of the observation verified the medication was expired and should have been thrown away. Review of the facility's policy Storage of Medication, dated [DATE], indicated the facility shall not use discontinued, outdated, expired, or deteriorated medications/nutritional supplements. All such medications shall be returned to the dispensing pharmacy or destroyed. Nutritional supplements will be discarded. Nurses shall check medications/nutritional supplements to ensure item was not outdated, expired, or deteriorated prior to administering. 365831 Page 4 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews the facility did not ensure an effective system was in place to honor resident meal choices and provide therapeutic diets as ordered by the physician. This affected seven (Resident's #10, #19, #25, #26, #33, #246 and #345) of 16 residents reviewed for food. The facility census was 48. Findings include: 1. Record review was conducted of the four-week cycle menu titled Fall/Winter 2021-2022. The menu listed only one meal at breakfast, lunch, and dinner with no second-choice options on the menu. Resident interviews were conducted on 02/14/22 from 9:40 A.M. to 4:48 P.M. with Resident's #19, #25, #26, #33 and #246 who reported they did not get a choice in what meal was served to them and no one came around to their rooms to ask them if they wanted something besides what was on the menu. Observation on 02/15/22 at 8:51 A.M. of the breakfast tray line in the kitchen revealed [NAME] #516 verified she cooked one entree with no alternate choices. The entree she cooked was biscuits with sausage gravy and hard-boiled eggs. She said the residents could have a choice of hot or cold cereal but there was no alternative entree. Resident interviews were conducted on 02/15/22 from 9:05 A.M. to 9:40 A.M. with Resident's #10 and #345. Resident #10 reported there at one time had been a select menu in place so residents could choose what they received at meals but there had not been a select menu for a while. Resident #345 stated there was no choice at the meals. Observation was conducted on 02/16/22 at 12:14 P.M. of the lunch tray line. There were no alternative entree choices on the tray line. The foods on the tray line included pepper steak, noodles, carrots, peas, and mashed potatoes including pureed and mechanical soft variations. Dietary Manager (DM) #508 was present at the time of the observation, verified the findings and said she had no select menu system in place. 2. Record review was conducted for Resident #26 who admitted to the facility on [DATE] with diagnosis including type two diabetes mellitus. A diet order dated 09/28/21 revealed Resident #26 was ordered a CCD diet (carbohydrate-controlled diet) regular texture. A physician order dated 12/30/21 indicated Resident #26 required Synjardy XR Tablet Extended Release 24 Hour 10-1000 milligram once a day for diabetes. A physician order dated 01/14/22 indicated she required insulin glargine 20 units once a day for diabetes. Review of the Nutritional Assessment date 10/06/21 revealed Resident #26 had type two diabetes and required a low concentrated sweets diet. Review of the Medication Administration Record dated 02/01/22 to 02/24/22 revealed Resident #26's blood sugar was tested four times a day ranging anywhere from 128 to 288 indicating her blood sugars were not stable with the reading often being greater than 200. Observation and interview were conducted on 02/14/22 at 11:15 A.M. with Resident #26 who was found 365831 Page 5 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sitting on her bed in her room with an angry look on her face. She explained to the surveyor she was not happy because ever since she came back from the hospital on [DATE] she was getting skipped for meals and would have to go ask for her meals. Resident #26 said she was a diabetic and needed to eat regularly and when they did bring her a tray it was not the food she should be eating for her diabetes. Resident #26 said she had not yet received breakfast and let the staff know. At 11:21 A.M. DM #508 came walking into her room with a meal tray. On the tray was a bowl of sweetened fruity O's type cereal, two cups of milk and two blueberry muffins which was verified by DM #508. Resident #26 was noticeably upset because she said the kitchen knew she ate oatmeal for breakfast, and she would have liked some eggs, but she was going to eat what she got because she was hungry and she proceeded to eat the sweetened cereal. Record review was conducted of a copy of Resident #26's tray ticket the kitchen staff would use to identify her diet order, allergies, dislikes, likes and preferences. The breakfast tray ticket stated she wanted two servings of milk and two servings of oatmeal daily at breakfast. The tray ticket for all three meals stated she was on a regular diet. Record review and interview was conducted on 02/24/22 at approximately 9:30 A.M. with the Director of Nursing (DON) of the physician diet order and tray tickets for Resident #26. The DON verified the diet order on the tray ticket did not match the diet order in the computer and the resident preferred oatmeal at breakfast. This deficiency substantiates Complaint Number OH00112148. 365831 Page 6 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on record review, observation, and interviews the facility did not ensure the Dietary Manager had the appropriate competencies and skill set to effectively run the dietary department to meet the needs of all residents residing in the facility. This had the potential to affect 47 residents receiving meals from the kitchen except for one (Resident #7) who did not eat by mouth. The facility census was 48. Findings include: Record review was conducted of the personnel file for Dietary Manager (DM) #508 whose date of hire was listed as 01/20/22. There was no evidence DM #508 was a certified dietary manager or held an associate degree or higher degree in food service management or hospitality management. Observation was conducted on 02/14/22 at 6:54 A.M. of cases of raisin bread and juice cups sitting directly on the floor near the walk-in cooler. DM #508 revealed the cases were delivered on 02/11/22 and she had not yet been able to put the foods away. When asked if those foods were highly perishable, she said she was not 100 percent sure if they needed to be thrown away or not. Interview was conducted on 02/15/22 at 3:38 P.M. with Dietetic Technician Registered (DTR) #546 who revealed he did not know DM #508 was employed at the facility and he was only at the facility approximately 20 hours a month to focus on the clinical nutrition for the residents. He said his boss was Registered Dietitian (RD) #547 and was available to him by phone if he had any questions but did not make visits in the facility. Interview was conducted on 02/16/22 at 11:20 A.M. with DM #508 who revealed she had never worked in a skilled nursing facility before having worked in a prison kitchen. She shared she had not worked with mechanical soft diets and pureed diets to the extent required in the skilled nursing facility, so she was relying on the cooks in the kitchen to make the correct consistencies for those diets. When asked if the kitchen had a high temperature dish machine or a low temperature dish machine, she said she did not know. Interview was conducted on 02/23/22 at 10:08 A.M. with the Administrator who revealed she did not specifically ask DM #508 when she interviewed her for the job if she had any experience running a kitchen in a skilled nursing facility. Additionally, DM #508 was sent to a sister facility for two to three days to train with another dietary manager per the Administrator but she did not have any evidence of a competency or orientation checklist for DM #508 specific to the needs of the kitchen. 365831 Page 7 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on record review, observation, and interviews the facility did not ensure the dietary staff could demonstrate competency in all aspects of food production, service, and kitchen sanitation. This had the potential to affect all residents receiving meals from the kitchen except for one (Resident #7) who did not eat by mouth. The facility census was 48. Findings include: Record review was conducted of the personnel files for Dietary Manager (DM) #508, [NAME] #507, [NAME] #512, [NAME] #516 and Dietary Aide (DA) #511, DA #513 and DA #517. There was no evidence the employees had initial or annual competency checks related to their job specific duties in kitchen. Observation was conducted on 02/14/22 at 6:54 A.M. of the general kitchen environment. [NAME] #512 was present in the kitchen and identified herself as the person in charge until the dietary manager arrived to work. When the surveyor asked her to explain how she monitored the dish machine to ensure it was functioning properly, [NAME] #512 said she did not do dishes because she was the cook so the surveyor would have to ask an aide. Observation and interview were conducted on 02/15/22 at 1:10 P.M. with [NAME] #516 who had not made any mechanical soft meat for the nine residents living in the facility who had physician orders for mechanical soft diet textures. When the cook was asked what meat she prepared for the mechanical soft diets she pointed to the crispy breaded, bone-in, whole chicken legs on the tray line and verified that was what she served them. When asked what the meat consistency should look like for those diets, [NAME] #516 replied it should be chopped up. When asked why she did not chop up any meat for them she replied because she did not have the other kind of chicken without the bone. Observation and interview on 02/16/22 at 11:17 A.M. revealed DA #513 was running dishes through the dish machine. When asked if she had checked the wash and rinse temperatures and recorded those temperatures, DA #513 said she had not done so and had not had a log to record anything for a few months. When asked what the minimum wash temperature and rinse temperature should be, she indicated both should be at 180 degrees Fahrenheit (F). When asked if she had any guidelines she could refer to about what the wash and rinse temperatures should be, DA #513 said she did not, pointed to the two temperature gauges on the dish machine which were clearly marked wash and rinse and said she had a hard time reading them so she did not read them. The wash temperature gauge was reading 134 degrees F, the rinse was reading 188 degrees F and the high-temperature dish machine had a label on it by the gauges clearly indicating what the wash and rinse temperatures needed to be at for the machine. Interview was conducted on 02/16/22 at 11:20 A.M. with DM #508 who said she did not know if the kitchen had a low temperature dish machine or a high temperature dish machine. She said she was not aware the DAs had not been checking the dish machine wash and rinse temperatures. When asked if she had any prior training with texture modified diets, DM #508 explained her dietary management experience was at a prison so the inmates on mechanical soft diets did not get fresh cabbage or fresh salad and there were no ground or pureed meats, so her experience did not match the needs of the residents at the facility. DM #508 said she was relying on the cooks to make the appropriate consistency foods for the residents. Review of the policy titled Consistency Modified Foods, dated January 2019, stated the mechanical 365831 Page 8 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many soft diet included ground moist meats, poultry and fish without bones, canned fruits and vegetables, well cooked vegetables, soft breads, and desserts. Review of the facility policy titled Sanitation, dated October 2008, indicated high-temperature dish machines must be operated with a rinse temperature of at least 150-165 degrees F for at least 45 seconds and a rinse temperature of 165-180 degrees F for at least 12 seconds. 365831 Page 9 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and interviews the facility did not ensure food was served at palatable temperatures. This affected three (Resident's #10, #25 and #33) of nine residents reviewed for food. The facility census was 48. Residents Affected - Few Findings include: Interview was conducted on 02/14/22 at 2:24 P.M. with Resident #25 who stated he did not want to eat the food from the facility anymore because he either did not get what he asked for or it just was not good food. Interview was conducted on 02/14/22 at 4:48 P.M. with Resident #33 who stated a lot of times the food was cold by the time it was served to her in her room. Interview was conducted on 02/15/22 at 9:40 A.M. with Resident #10 who said hot foods are not always hot by the time he gets his room tray. Observation was conducted on 02/17/22 at 12:08 P.M. of the tray line food temperatures and meal service. The food temperatures were taken with a calibrate digital thermometer as followed: BBQ chicken 169 degrees Fahrenheit (F) , sweet potato 203 degrees F, cauliflower 191 degrees F. The tray line started at 12:12 P.M. The system being used to retain hot food temperatures was a plate warmer, thermal base, and thermal dome cover. The test tray was placed on the 300/400-unit cart at 12:22 P.M. and State Tested Nurse Aide (STNA) #520 told the surveyor STNA #520 would pass the trays on the 400 unit then the cart would go to the 300 unit where STNA #527 would finish the tray pass. At 12:42 P.M. the test tray was passed to Dietary Manager (DM) #508 who proceeded to take the food temperatures with the same digital thermometer used on the tray line. The test tray temperatures were as followed: BBQ chicken 132 degrees F, sweet potato 128 degrees F and cauliflower 107 degrees F. The surveyor tasted the foods and found the cauliflower felt barely warm with the sweet potato and chicken just slightly warmer (lukewarm). The overall flavor and portions of the food were appropriate for the meal. 365831 Page 10 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0805 Level of Harm - Immediate jeopardy to resident health or safety 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 medical record review, observations, staff interview, review of the facility menus and spreadsheets for mechanical soft diets, review of facility policy for therapeutic diets, consistency modified diets, and tray card policy, the facility failed to ensure 10 residents on mechanically altered diets were provided food in the correct form assessed to meet their individual needs. This resulted in Immediate Jeopardy for Residents #6, #11, #19, #30, #31, #36, #37, #201 and #345 who were served whole, intact bone-in chicken by the dietary staff and nursing assistants. Residents #6, #27, #30 and #36 also were assessed to need their liquids thickened to nectar consistency and were served the wrong consistency liquids. The noncompliance to the mechanically altered diets placed them at risk for serious harm such as choking which could have resulted in death. The facility identified ten Residents (#6, #11, #19, #27, #30, #31, #36, #37, #201 and #345) who received mechanically altered diets. The facility census was 48. On 02/17/22 at 9:13 A.M. the Administrator and Regional Director of Operations (RDO) #549 were notified Immediate Jeopardy began on 02/15/22 at approximately 1:00 P.M. when Residents #6, #11, #19, #27, #30, #31, #37, #201 and #345 who were ordered mechanical soft diets were observed receiving whole, bone-in regular fried chicken legs. In addition, Residents #6, #27, #30 and #36 were served liquids at the wrong consistency contrary to their assessed needs for nectar thick liquids. Interview with [NAME] #516 and Dietary Manager #508 at 1:10 P.M. revealed [NAME] #516 did not prepare any mechanical soft meat for the meal. The Immediate Jeopardy was removed on 02/16/22 when the facility implemented the following corrective actions: • On 02/15/22 at approximately 2:20 P.M. the Regional Director of Operations (RDO) #549 educated DM #508 on diet spreadsheets including mechanical soft and pureed consistency, the tray ticket program and liquid consistency including nectar and honey thickened liquids and thin liquids. • On 02/15/22 at approximately 3:30 P.M. the Director of Nursing (DON) and Dietetic Technician Registered (DTR) #546 audited 48 of 48 resident diet orders to ensure the ordered diet texture and liquids consistencies matched the resident's assessed needs. • On 02/15/22 at approximately 3:45 P.M. Dietary Manager (DM) #508 educated two of six dietary staff working in the facility on the importance of dietary tray cards, the consistencies of nectar and honey thickened liquids, the consistencies of mechanical soft and pureed modified diets, the therapeutic diet policy, and examples of mechanical soft dietary items. The remaining four dietary staff were educated by DM #508 by 2:00 P.M. on 02/17/22. • 365831 Page 11 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 02/15/22 between 4:30 P.M. and 5:30 P.M. the Administrator and DON rounded the floor during dinner and observed all meal trays being delivered with correct diet consistency including 10 of 10 mechanical soft diets and four of four nectar consistency liquids. • On 02/15/22 from 6:30 P.M. to 7:30 P.M. 10 of 10 residents ordered a mechanically altered diet and nectar thickened liquids had respiratory assessments completed by the DON and RN #537. There were no signs or symptoms of respiratory compromise. • On 02/15/22 between 7:30 P.M. and 8:00 P.M. the DON reviewed 10 of 10 mechanically altered and nectar thickened liquid diet orders with Medical Director (MD) #552 and verified the diet orders being implemented for the residents were accurate compared to the physician orders. • On 2/16/2022 beginning at 6:00 A.M. the DON and Administrator began to educate all available staff on shift on the meal tray preparation, meal tray service, the importance of checking dietary tray cards, proper consistency of thin, nectar and honey consistency thickened liquids, consistency of modified diets, the therapeutic diet policy, and examples of mechanical soft dietary items. All staff (42 out of 42 staff including 16 out of 16 STNA's, 4 out of 4 RN's, 3 out of 3 LPN's, 5 out of 5 housekeeping/laundry employees, 1 out of 1 activities aid, 6 out of 6 dietary staff, 7 out of 7 department heads) education was completed on 02/17/22 by 2:00 P.M. when DM #508 completed the education with the remaining four of six dietary department employees. • On 02/16/22 beginning at approximately 8:30 A.M. RDO #549 again reviewed for competency with DM #508 the importance of dietary tray cards, consistency of thickened liquids, consistency of modified diets, therapeutic diet policy and examples of mechanical soft items. RDO #549 monitored breakfast and lunch meal service to ensure compliance. • On 02/16/22 at 12:08 P.M. RDO #549 communicated with the contracted Registered Dietitian (RD) #547 to inform her of the recent review of dietary spreadsheets and mechanically altered diet extensions with related staff education. RDO #549 observed the lunch meal service. • The facility administrator or designee ( which may include the DON, ADON, RDO #549, DTR #546, DM #508 or RD #547) will continue to audit/observe the meal tray service line to ensure all tray items match the resident diet order/food consistency/liquid consistency all 3 meals for the next 3 days and then 1 random tray line service daily (5 days per week) x 4 weeks and then as determined by QAPI committee comprised of the administrator, DON, dietary manager, maintenance director, social service director, activity director, BOM/HR director, admissions director. 365831 Page 12 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0805 • Level of Harm - Immediate jeopardy to resident health or safety The facility DON or designee which may include the ADON, Charge Nurse, Administrator, RDO #549, Regional Clinical Nurse (RCN) #553, DTR #546 and RD #547 will observe meal tray delivery service to the rooms to ensure all tray items match the resident diet order/food consistency/liquid consistency all 3 meals for the next 3 days and then 1 random tray line service daily (5 days per week) x 4 weeks and then as determined by QAPI committee comprised of the administrator, DON, dietary manager, maintenance director, social service director, activity director, BOM/HR director, admissions director. Residents Affected - Some Although the Immediate Jeopardy was removed on 02/16/22 the facility remained out of compliance at a severity level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) as the facility was still in the process of implementing their corrective action, monitoring to ensure on-going compliance, and evaluating their corrective action for further recommendations. Findings include: 1. Record review was conducted for Resident #6 who was admitted to the facility on [DATE] with diagnoses including stroke, multiple sclerosis, and oropharyngeal dysphagia (difficulty chewing and swallowing). The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had no cognitive impairment, required extensive assistance of two staff for bed mobility and transfers and required set-up and one-staff physical assistance with eating. A physician order dated 07/21/21 indicted Resident #6 was to receive a mechanical soft diet with nectar consistency liquids. The plan of care with a revision date of 12/06/21 revealed the care plan indicated Resident #6 required a mechanically altered diet with nectar consistency liquids. The interventions included dietary staff and nursing staff would provide the diet as ordered and monitor the consistency of the diet served to the resident. Observation of and interview with Resident #6 in the dining room on 02/15/22 at 12:47 P.M. presented as dependent on a custom wheelchair with a head rest for mobility and positioning. Resident #6 required staff assistance to put his food on the table, set-up the meal and prepare his nectar consistency liquids. Resident #6 was alert and oriented to person, place, time, and conversation and had little eye contact with the surveyor during conversation. Resident #6 was able to verbally make his needs known to staff. 2. Record review was conducted for Resident #11 who was admitted to the facility on [DATE] with diagnosis including Alzheimer's dementia with behavioral disturbance. The MDS 3.0 assessment dated [DATE] revealed Resident #11 had severe cognitive impairment, required extensive assistance of one staff for bed mobility, extensive assistance of two staff for transfers and set-up help only and supervision for eating. A physician order dated 01/07/21 indicated Resident #11 required a mechanical soft diet with thin consistency liquids. The plan of care with a revision date of 07/15/19 revealed Resident #11 was edentulous (no teeth) by choice and required a mechanically altered diet texture. The interventions included for dietary and nursing staff to provide the ordered diet. Observation and interview were conducted 02/14/22 at 11:00 A.M. in the Resident #11's room. He presented as alert with disorientation to time, place and was not able to provide reciprocal conversation with the surveyor often making limited comments of no relevance to the questions. 3. Record review was conducted for Resident #19 who was admitted to the facility on [DATE] with 365831 Page 13 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some diagnoses including stroke, hemiparalysis of right side and dementia. The MDS 3.0 assessment dated [DATE] revealed Resident #19 had no cognitive impairment and required limited assistance of one staff to provide physical assistance for eating, extensive assistance of two staff for transfers and extensive assistance of one staff for bed mobility. A physician order dated 06/23/21 indicated Resident #19 required a mechanical soft diet with thin consistency liquids. The plan of care with a revision date of 02/15/22 revealed Resident #19 required a mechanically altered diet and the diet should be provided to him as ordered by the dietary and nursing staff. Observation and interview of Resident #19 in his room on 02/15/22 at approximately 6:00 P.M. revealed he was unable to use his paralyzed right arm to eat his meal, but he could feed himself with his left hand. Resident #19 was alert and oriented to person, place and conversation and was able to verbally make his needs known to staff. 4. Record review was conducted for Resident #30 who was admitted to the facility on [DATE] with diagnoses including stroke, right sided paralysis, and oropharyngeal dysphagia. The MDS 3.0 assessment dated [DATE] revealed Resident #30 had severe cognitive impairment, required extensive assistance of two staff for bed mobility, total assistance by two staff for transfers and extensive assistance with one-staff physical assistance for eating. A physician order dated 07/07/21 revealed Resident #30 required a mechanical soft diet with nectar consistency liquids and low concentrated sweets. The plan of care with a revision date of 04/25/19 revealed dietary staff and nursing staff should provide the diet as ordered. Observation was conducted of Resident #30 on 02/15/22 at approximately 5:59 P.M. revealing a vulnerable man with paralysis in need of extensive assistance by staff to ensure he ate his meal. Resident #30 was alert but unable to carry a conversation nor answer questions from the surveyor. 5. Record review was conducted for Resident #31 who was admitted to the facility on [DATE] with diagnosis including Alzheimer dementia. The MDS 3.0 assessment dated [DATE] revealed Resident #31 had severe cognitive impairment, required limited assistance of one staff for bed mobility and transfer and set-up with supervision for meals. A physician order dated 07/06/2020 revealed Resident #31 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 12/11/21 revealed Resident #31 had the potential for alteration in nutrition and hydration status due to a poor appetite and need for supplements. Interventions included for dietary and nursing staff to provide the diet as ordered and monitor diet consistency. Observation was conducted on 02/15/22 at 12:49 P.M. of Resident #31 sitting in her wheelchair in the main dining room. She was alert, able to state her name but disoriented to place and time. Resident #31 could answer simple questions with a one word reply with limited ability to express her wants and needs. Resident #31 was unable to verbalize understanding of her mechanical soft diet. 6. Record review was conducted for Resident #36 who was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance and schizophrenia. The MDS 3.0 assessment dated [DATE] revealed severe cognitive impairment, extensive assistance of two staff for bed mobility and transfers and set-up with supervision for eating. A physician order dated 12/10/2020 indicated Resident #36 required a mechanical soft diet with nectar thick liquids. The plan of care with a revision date of 12/11/21 revealed Resident #36 required mechanical soft texture with nectar thick liquids and interventions included to give the diet as ordered and monitor the consistency of the diet. 365831 Page 14 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Observation was conducted on 02/14/22 at approximately 11:00 A.M. of Resident #36 in his bed. He was alert but completely disoriented. When asked if the staff provided good care to him, Resident #36 gave unrelated comments about catching a bus. 7. Record review was conducted for Resident #27 who was admitted to the facility with diagnosis including dysphagia. The MDS 3.0 assessment dated [DATE] revealed severe cognitive impairment, and Resident #27 was totally dependent on two staff for bed mobility, transfers and needed extensive assistance of one staff for eating. A physician order dated 06/08/21 revealed Resident #27 was receiving palliative care services from hospice. On 10/24/21 her diet order was mechanical soft with pureed meats and nectar thick liquids. On 02/08/22 she was ordered a chest x-ray to rule out cough and aspiration. On 02/15/22 she was ordered speech therapy for dysphagia. Review of the chest x-ray revealed Resident #27's lungs were clear. Review of the Speech Therapy Evaluation and Treatment Plan dated 02/15/22 authored by Speech Therapist (ST) #545 revealed Resident #27's current diet texture was appropriate, and she was able to feed herself without staff assistance and with proper positioning for the meal. Observation and interview were conducted on 02/15/22 at 5:57 P.M. of Resident #27 sitting upright in her bed with her tray table at breast level and within her reach. Resident #27 presented with good positioning and demonstrated an ability to feed herself using a divided plate, double handled, lidded sip cup and built-up handled utensils. Resident #27 was alert and oriented to herself, the meal and conversation capable of giving appropriate answers to simple questions by the surveyor. Resident #27 smiled, made good eye contact with the staff and was able to verbally make her needs known to staff when they asked her what she would like to drink. 8. Record review was conducted for Resident #201 who was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance and unspecified psychosis. The MDS 3.0 assessment dated [DATE] revealed Resident #201 was cognitively impaired, needed limited assistance of one staff for bed mobility and transfers and supervision and set-up for meals. A physician order dated 10/10/2018 indicted Resident #201 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 06/11/21 revealed Resident #201 required mechanical soft consistency due to difficulty chewing with an intervention for dietary and nursing staff to monitor the consistency served to him and provide the ordered diet. Observation was conducted on 02/15/22 at 1:10 P.M. of Resident #201 sitting up on the side of his bed with his meal tray in front of him. He presented as alert and oriented to person, place, and conversation. Resident #201 was visually impaired but able to point to the food on his plate, identify it and feed himself with standard utensils. He could carry on reciprocal conversation and verbally make his wants and needs known to staff. 9. Record review was conducted for Resident #345 who was admitted to the facility on [DATE] with diagnoses including quadriplegia. The MDS 3.0 assessment dated [DATE] revealed he had no cognitive impairment, was totally dependent on two staff for bed mobility and transfers and totally dependent on one staff for eating. A physician order dated 12/12/19 indicated Resident #345 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 01/08/22 indicted Resident #345 was edentulous, required a mechanical soft diet and dietary and nursing staff should offer diet as ordered. Observation was conducted on 02/15/22 at approximately 6:00 P.M. of Resident #345 who presented as highly vulnerable with limited body movement. He needed the staff to feed him and was alert and 365831 Page 15 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0805 oriented to the meal. Resident #345 was able to verbally make his wants and needs known to the staff. Level of Harm - Immediate jeopardy to resident health or safety 10. Record review was conducted for Resident #37 who was admitted to the facility on [DATE] with diagnoses including moderate intellectual disability, dysphagia, and dementia with behavioral disturbances. The MDS 3.0 assessment dated [DATE] revealed Resident #37 had cognitive impairment, required extensive assistance of one staff for bed mobility, transfers and supervision and set-up for meals. A physician order dated 02/14/22 and revised on 02/16/22 revealed Resident #37 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 06/12/19 indicated Resident #37 had dysphagia. The nutrition risk portion of the care plan with a revision date of 01/23/22 revealed Resident #37 required a mechanical soft diet due to dysphagia and thickened liquids. The interventions were to provide the diet as ordered and monitor the consistency of the diet served to him. Residents Affected - Some Observation was conducted on 02/14/22 at approximately 11:00 A.M. of Resident #37 in his bed. He was alert with disorientation and unable to answer simple questions from the surveyor. Record review was conducted of the menu for 02/15/22 and 02/16/22 along with the mechanical soft spreadsheets, therapeutic diets policy, and consistency modified diets policy. The mechanical soft spreadsheet for 02/15/22 revealed ground pork loin, diced oven potato, and green beans should have been served for lunch. Dinner was garden vegetable soup, three packs of saltines, ground turkey for the sandwich and pineapple chunks. The therapeutic diet policy stated crackers were allowed if softened in soups. Observation and interview were conducted on 02/15/22 at 8:51 A.M. with DM #508 who was sitting in her office writing diet orders and resident names on white pieces of paper. She informed the surveyor it was her first week on the job and the former dietary manager took the computer, so she had no computer program to print tray tickets for the residents. Observation was conducted on 02/15/22 from 12:47 P.M. to 1:13 P.M. of the lunch meal service. State Tested Nurse Aide (STNA) #527 was passing trays in the main dining room. The resident tray tickets had been handwritten on approximately four-inch-wide by eight-inch-long white paper. The residents name and diet type were written in red ink on the tickets. The tray tickets for Residents #6 and #31 stated mech soft on the ticket in red ink. The ticket gave no specific instructions on the types or portions of food to be served for the meal. The meal served to both residents was diced potato, cooked green beans and a whole, regular texture, bone-in, breaded, fried chicken leg. Resident #31's lips were sunken around her gum lines presenting as edentulous and when asked by the surveyor if she could eat the chicken, she said she did not know if she could. Resident #6 said he wanted to eat the chicken. The surveyor intervened and brought the concern to the attention of STNA #527 who had been passing trays to other residents. She verified the findings. She did not attempt to offer them any alternative foods of mechanical soft consistency instead she began trying to cut the meat off the bone for Resident #31 saying the meat was dry and hard to cut up. She shredded the meat into large stringy pieces and the resident declined to eat it. In addition, Resident #6 required drinks thickened to nectar consistency. The only drink on his tray appeared too thick. STNA #527 verified the finding as she stirred his drink to check the consistency, she said it was too thick more like honey not nectar. Observation and interview on 02/15/22 at 1:10 P.M. of the kitchen tray line with [NAME] #516 and DM #508 revealed she did not make any mechanical soft chicken or other mechanical soft meat for the 365831 Page 16 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some lunch meal. When asked what she served the 10 mechanical soft diets in the facility she pointed to the bone-in fried chicken pieces in the steam table pan and said that was what she served. When asked what mechanical soft consistency chicken should look like she replied it was chopped meat and she was not able to make it that way because she did not have any other chicken without bones. The surveyor proceeded to the 100 unit to check other mechanical soft meal trays and encountered the same concerns. Observation on 02/15/22 at 1:13 P.M. of Resident #36 was found sitting on the side of his bed taking a bite out of the bone-in fried chicken leg. He was unable to verbalize understanding he was ordered a mechanical soft diet and said he wanted to eat the chicken leg. STNA #541 appeared in the doorway after the surveyor had entered the room and verified the findings including the cranberry juice on his meal tray was not thickened at all but should have been thickened to nectar consistency. STNA #541 said Resident #36 did not need supervision with eating, so she had just set up his tray and he ate alone in his room. She verified the paper on his tray said mech soft nectar liquids. Interview was conducted on 02/15/22 at 3:38 P.M. with DTR #546 who revealed he was contracted to come to the facility every other week and meal rounds were not part of his contract. He verified a bone-in, regular consistency chicken leg should never be served to any resident who needed a mechanical soft diet. He said he had not done any staff education on therapeutic diets within the last year because the former dietary manager was a seasoned dietary manager and he had never noticed any problems in the facility when she worked there. He said his supervisor was RD #547 who did not come to the facility but reviewed his work with him via telephone. Interview was conducted on 02/15/22 at 4:47 P.M. with ST #545 who said she worked at the facility per diem. Her only resident on case load was Resident #27 who she was seeing because the staff told her she was having some coughing episodes. When asked what her expectation was for any resident in need of a mechanical soft diet, she explained the meat should be ground or at least chopped into small, bite sized pieces. She said she had not provided any diet guidance for mechanical soft diets to the facility, nor had she been asked to provide any. She verified Resident #27 had not aspirated and her current diet texture of mechanical soft with pureed meat and nectar thickened liquids was appropriate for her. She stated with proper positioning Resident #27 did not need to be supervised or assisted with eating her meals. Observation was conducted with the DON on 02/15/22 from 5:57 P.M. to 6:15 P.M. of the dinner trays for Residents ##6, #11, #19, #30, #31, #36, #37, #201 and #345. All residents except Resident #27 where served a ground turkey sandwich on white bread, tomato soup with three packs of whole saltine crackers and canned pineapple. None of the resident's saltine crackers had been added to their soup. Resident #27 was served pureed turkey sandwich, mashed potato, and applesauce even though her diet was mechanical soft with pureed meat and nectar thick liquids. STNA #527 brought her in a cup of red drink and said it was not thick enough because the thickener had settled to the bottom. She proceeded to add 2 scoops of thickener to the cup which made it present as more of a honey thick liquid. When asked if she followed the recipe on the can for thickening liquids, she said she does it all the time so she knew how much to add without looking. When asked if a staff member would stay with Resident #27 throughout the meal, STNA #527 expressed she did not need to be fed because she could feed herself, so they just check on her a few times. Interviews were conducted on 02/17/22 from 9:45 A.M. to 10:00 A.M. with Occupational Therapy Assistant (OTA) #548, Licensed Practical Nurse (LPN) #518, STNA #526, STNA #527, STNA #515 and STNA #506 who reported the kitchen occasionally sends out the wrong texture foods, but it did not happen often. 365831 Page 17 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0805 They offered no specific dates on when wrong textured foods were sent from the kitchen. Level of Harm - Immediate jeopardy to resident health or safety Review of the policy titled Consistency Modified Foods, dated January 2019, stated the mechanical soft diet included ground moist meats, poultry and fish without bones, canned fruits and vegetables, well cooked vegetables, soft breads, and desserts. Residents Affected - Some Review of the policy titled The Importance of Dietary Tray Cards, dated 2009, indicated the tray card must be completely accurate to ensure the correct diet was served to each resident. The tray card should include the residents name, room number, diet type, portions, likes/dislikes, supplements, allergies, beverage preferences, adaptive devices, and thickened liquids order. Review of the policy titled Therapeutic Diets, dated October 2017, indicated hard crackers are to be served softened in soup or liquid. 365831 Page 18 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

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 record review, observation, and interview the facility failed to ensure food was prepared, stored, and served under sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen except for Resident #7 who did not eat by mouth. The census was 48. Findings include: Observation on 02/14/22 at 7:05 A.M. in the kitchen dry storage room revealed one open, undated carrot cake mix with a use by date of 11/11/21, four 16-ounce containers of medium barley with a use by 12/17/21, an open, undated five-pound bag of blueberry muffin mix with a use by date of 10/26/21, and an open undated gallon Ziploc bag with four tortilla shells. Sitting directly on the floor were two cases of 48, four-ounce 100% orange juice and one case vegetable oil. The entire perimeter of the dry storage room floor where the floor met the wall was heavily covered in crumbs and a buildup of dirt. Outside the dry storage room by the walk-in cooler sat a case of raisin bread on top two cases of 48, four-ounce juice cups. These findings were confirmed at the time of the observation by Dietary Manager (DM) #508 who said the stock came in on Friday 02/11/22; she was the person responsible to put it away, but she had not had a chance to do it. Observation inside the walk-in cooler at 7:15 A.M. on 02/14/22 with DM #508 revealed the staff were putting pans of food in the cooler without labeling and dating the foods. There were multiple pans of food identified by DM #508 as chicken gravy, beef gravy, mashed potatoes, pureed peas, an unknown type of pureed meat, shredded pot roast, chopped carrots, and three bowls of fruit salad which had no dates or labels to identify what it was and when it had been prepared. Over 40 bags of bread/buns/rolls were in the cooler without dates. There were three, gallon bags of raw chicken and a five-pound bag of opened, shredded cheddar cheese with no dates. DM #508 said she would throw out all the food without dates. Observation and interview on 02/16/22 at 11:17 A.M. revealed Dietary Aide (DA) #513 was running dishes through the dish machine. When asked if she had checked the wash and rinse temperatures and recorded those temperatures, DA #513 said she had not done so and had not had a log to record anything for a few months. When asked what the minimum wash temperature and rinse temperature should be, DA #513 indicated both should be at 180 degrees Fahrenheit (F). When asked if she had any guidelines she could refer to about what the wash and rinse temperatures should be, DA #513 said she did not, pointed to the two temperature gauges on the dish machine which were clearly marked wash and rinse and said she had a hard time reading them so she did not read them. The wash temperature gauge was reading 134 degrees F, the rinse was reading 188 degrees F and the high temperature dish machine had a label on it by the gauges clearly indicating what the wash and rinse temperatures needed to be at for the machine. Observation on 02/17/22 at 12:25 P.M. revealed Dish Machine Repair Person (DRP) #500 was working on the dish machine. He explained a corroded float was sticking which did not allow the heating element to consistently heat to the desired temperature each time staff ran the dish machine. He stated the dish machine would be cleaned and fixed prior to him leaving. Observation on 02/17/22 at 12:12 P.M. with the Administrator of the tray line for lunch meal service. [NAME] #507 with the same gloved hands she was using to pick up utensils and move pans around on the tray line was making direct contact with mechanical soft meats, cauliflower, and pieces of corn 365831 Page 19 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many bread to position the food on the meal plates. [NAME] #507 at no time changed gloves or washed her hands in between tasks. This was verified with the Administrator during the observation. Observation on 02/17/22 at 12:28 P.M. revealed a dish machine temperature log sheet for the month of February 2022 with only two entries listed, both for 02/17/22. The entries indicted the wash temperature was at 150 degrees F and the rinse temperature at 180 degrees F for the breakfast meal. Record review and interview were conducted on 02/17/22 at 2:11 P.M. with Dietetic Technician Registered (DTR) #546 who verified the findings on the dish machine log. He stated he did not provide any oversight regarding kitchen sanitation except for a quarterly sanitation audit but would be willing to do some training with the staff. He said the former dietary manager was seasoned and he had not had any concerns brought to his attention when the former dietary manager was working in the kitchen. 365831 Page 20 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations, and interviews the facility administration failed to ensure its resources were effectively and efficiently managed to attain and maintain the highest practicable physical, mental, and psychosocial well-being of all 48 residents residing in the facility. The facility census was 48. Residents Affected - Many Findings include: The following concerns were identified throughout the duration of the annual survey: 1. The breakfast and/or lunch meal service was running between 37 to 45 minutes late at breakfast and/or lunch on 02/14/22 and 02/15/22. On 02/15/22 at 8:51 A.M. Dietary Manager (DM) #508 informed the surveyor she had to hand write tray tickets for 47 residents (Resident #7 did not eat by mouth) since she started her job there almost a week prior because the former dietary manager had taken the computer with the tray ticket program on it. She said the Administrator was aware of it. Interview was conducted on 02/15/22 at 3:28 P.M. with the Administrator who verified she was aware the former dietary manager took the computer with her, and a replacement had not been installed for DM #508. 2. As part of the extended survey conducted at the facility three medical records were selected for Resident's #19, #39 and #245 to ensure physician visits were timely and physician notes were signed, dated, and placed in the medical records at the time of the visits. The review revealed there were no dated and signed progress notes in the records from Primary Care Physician/Medical Director (PCP/MD) #552 with notes missing as far back as August 2021. Interview on 02/23/22 at 10:05 A.M. with the Director of Nursing (DON) verified PCP/MD #552, had the resident's progress notes from his visits with the resident with him and not at the facility. The DON verified the progress notes were not in the resident's medical records and it had been an ongoing problem for a while. Interview on 02/24/22 at 9:06 A.M. with the PCP/MD #552 verified he did not produce progress notes while at the facility making rounds on his residents. Instead, he would just jot a few notes down then go home and write out a dated and signed progress note. He verified he had his notes at home, and they were not added timely to the medical records. Interview with the Administrator on 02/23/22 at 10:08 A.M. revealed the Administrator was not aware PCP/MD #552 was not leaving his resident assessment progress notes at the facility. 3. Record review was conducted of the personnel file for DM #508 whose date of hire was listed as 01/20/2022. There was no documented evidence DM #508 was a certified dietary manager or held an associate degree or higher degree in food service management or hospitality management. Interview was conducted on 02/16/22 at 11:20 A.M. with DM #508 who revealed she had never worked in a skilled nursing facility before having worked in a prison kitchen. DM #508 shared she had not worked with mechanical soft diets and pureed diets to the extent required in the skilled nursing facility, so she was relying on the cooks in the kitchen to make the correct consistencies for those 365831 Page 21 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many diets. When asked if the kitchen had a high temperature dish machine or a low temperature dish machine, DM #508 said she did not know. Interview with the Administrator on 02/23/22 at 10:20 A.M. revealed the Administrator interviewed DM #508 for the dietary manager position and she did not inquire if she had experience with therapeutic diets in skilled nursing facilities. She added the prior dietary manager was supposed to provide DM #508 training but did not work out her notice of resignation, so the training ended early than planned for DM #508. When asked how she ensured DM #508 was competent to run the dietary department, she said she sent her to work with another dietary manager at a sister facility for two to three days but had no evidence of competency checklists or competency testing for DM #508. 365831 Page 22 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on record review and interviews the facility did not ensure agency nursing service providers, dietary department staff competencies, a governing body representative and dietary staff representative were included in the Facility Assessment. This had the potential to affect all 48 residents living in the home. The census was 48. Findings include: Interview was conducted on 02/16/22 at 4:43 P.M. with the Director of Nursing who indicated the facility utilized a contracted nursing services staffing agency to help staff the facility. A record review was conducted of the Facility Assessment with a review and approval date of 02/22/21 revealed the contracted nursing services staffing agency was not identified within the Facility Assessment. There were also no dietary department specific annual competencies listed on the assessment. Per the signature page of who attended the meeting to approve the assessment, there was no one from the governing body or dietary department present at the approval meeting. Interview was conducted on 02/23/22 at 10:03 A.M. with the Administrator who verified the findings on the assessment and said she had planned to update it soon because it had not been updated since she became the new Administrator at the facility on 08/03/21. 365831 Page 23 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure physician progress notes were made available in the medical record for Resident's #19, #39 and #245. This affected three of three residents reviewed as part of the extended survey. The facility census was 48. Findings include: 1. Record review was conducted for Resident #39 who was admitted to the facility on [DATE] with diagnoses including major depression, chronic pain, contractures, paraplegia, anemia, and heart disease. There were no primary care physician progress notes or visits dated after 08/24/21 in the resident's medical record. Interview with the Director on Nursing (DON) on 02/23/22 at 2:12 P.M. revealed she had been having problems getting the progress notes from Primary Care Physician/Medical Director (PCP/MD) #552 because PCP/MD #552 had the notes with him instead of leaving the notes at the facility or in the medical record. 2. Review of the medical record revealed Resident #19 was admitted on [DATE] with diagnoses including dementia, congestive heart failure, diabetes mellitus and depression. There were no primary care physician progress notes or visits dated after 08/24/21 in the resident's medical record. Interview on 02/23/22 at 10:05 A.M. with the DON verified PCP/MD #552 had the resident's progress notes from his visits with the resident. The DON verified the progress notes were not in the resident's medical record and it had been an ongoing problem for a while. Interview on 02/24/22 at 9:06 A.M. with the PCP/MD #552 verified he did not produce progress notes while at the facility making rounds on his residents. Instead, he would just jot a few notes down then go home and write out a dated and signed progress note. He verified he had his notes at home, and they were not added timely to the medical record. 3. Review of the medical record revealed Resident #245 was admitted on [DATE] with diagnoses including malignant neoplasm of the colon (cancer), heart failure, and diabetes mellitus. There were no primary care physician progress notes or visits dated after 08/10/21 in the resident's medical record. Interview on 02/23/22 at 10:05 A.M. with the DON verified PCP/MD #552 had the resident's progress notes from his visits with the resident. The DON verified the progress notes were not in the resident's medical record and it had been an ongoing problem for a while. Interview on 02/24/22 at 9:06 A.M. with the PCP/MD #552 verified he did not produce progress notes while at the facility making rounds on his residents. Instead, he would just jot a few notes down then go home and write out a dated and signed progress note. He verified he had his notes at home, and they were not added timely to the medical record. 365831 Page 24 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control recommendations for Healthcare Personnel (HCP), the facility failed to follow acceptable infection control practices, including the proper use of personal protective equipment (PPE) to prevent the potential spread of COVID-19. This had the potential to affect all 48 residents residing in the facility. Residents Affected - Some Findings include: Observation on 02/14/22 at 6:23 A.M. revealed State Tested Nurse Aide (STNA) #534 coming out of room [ROOM NUMBER] not wearing proper PPE (no eye protection or N95 respirator mask). STNA #534 verified she was not wearing proper PPE as she only had a surgical mask on. She stated she had been in-serviced on COVID-19 and there was an adequate supply of PPE including eye protection and N95 respirator masks. Observation on 02/14/22 at 6:24 A.M. revealed STNA #532 coming out of room [ROOM NUMBER] not wearing proper PPE (no eye protection). STNA #532 verified she was not wearing proper PPE as she did not have eye protection on, and her N95 respirator mask's bottom strap was hanging below her chin. She stated she did not have a face shield yet but was educated on COVID-19. STNA #532 stated the facility had an adequate supply of PPE. Observation on 02/14/22 at 6:57 A.M. revealed STNA #501 screened in at the entrance. After screening, STNA #501 placed a surgical mask on. She stated she had just started with the facility four days prior and was educated to wear a mask and gloves. Observation on 02/14/22 at 6:50 A.M. revealed American Health Associates Laboratory Technician (AHA Lab Tech) #554 at the nurse's station not wearing proper PPE (no eye protection or N95 respiratory mask). AHA Lab Tech #554 stated the staff updated her on what PPE she should be wearing, and they had instructed her to wear a surgical mask. She stated she could not wear a face shield as she cannot see to draw resident's blood with it on. She verified she had been in resident rooms [ROOM NUMBER]. Observation on 02/14/22 at 7:30 A.M. revealed Maintenance Director #542 at the nurse's station not wearing proper PPE (no N95 respirator mask). Maintenance Director #542 verified he was wearing a surgical mask but should be wearing a N95 and eye protection as the facility had a COVID positive resident in the building. He stated he had been educated on COVID-19, and there was an adequate supply of PPE. Interview on 02/14/22 at 9:26 A.M. with the Director of Nursing (DON) verified staff should be wearing N95 respirator masks and eye protection in resident rooms and common areas. She confirmed they did have a COVID positive resident, unvaccinated residents, and the facility county level was red (requiring eye protection). Review of the CDC's Data Tracker County Positive Rate, dated 02/07/22, revealed Mahoning County's positivity rate was 16.8% and the county was identified as red, a high community transmission rate for COVID-19. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare 365831 Page 25 of 26 365831 02/25/2022 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/02/22, stated if COVID is not suspected in a patient, HCP working in facilities located in counties with substantial or high transmission should also use PPE including N95 respirator masks when working in situations where multiple risk factors for transmission are present including a patient is unvaccinated and unable to use source control. Eye protection should be worn during all patient care encounters. Also, source control is recommended for everyone in a healthcare setting regardless of vaccination status for those who live or work in counties with substantial or high community transmission. Source control options for HCP include a NIOSH-approved N95 respirator, respirators that have been approved and are similar to NIOSH-approved N95 masks or a well-fitted facemask. A fully vaccinated HCP should wear source control when they are in areas of the healthcare facility where they could encounter patients. 365831 Page 26 of 26