Health inspection·May 22, 2024

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 observation, interview, record review, and policy review the facility failed to ensure a comprehensive water management plan which had the potential to affect all residents; ensure staff were alerted Resident #5, #19, and #53 were on Enhanced Barrier Precautions (EBP), and failed to ensure appropriate infection control practices were maintained during medication administration affecting Residents #16 and #72. The facility census was 88. Residents Affected - Many Findings include: 1. Review of the facility's undated policy Identifying Building at at an Increased Risk Assessment revealed the facility was to have a water management program in place. Review of the facility's policy Legionella Water Management Program Policy, dated 08/08/18 revealed the facility was to appoint a water program committee responsible for developing and implementing a risk management plan for water systems. Review of the facility's Legionella monitoring documentation revealed the facility did not a have comprehensive water management plan. The facility was assessing water temperatures in resident rooms and monitoring chorine levels. The facility had not established a water management team, developed a water system diagram identifying showers, ice machines, water fountains, or identified high risk area where Legionella could grow. Interview on 05/22/24 at 1:45 P.M. the facility's Administrator confirmed the facility did not have a comprehensive water management plan in place. The Administrator stated the facility recently had a change in the maintenance department possibly resulting in the loss of the plan. 2. Review of the medical record for Resident #5 revealed and admission date of 09/27/19 and diagnoses including but not limited to anxiety disorder, chronic kidney disease, and gastroparesis. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition and was dependent for activities of daily living. Review of the physician's orders for May 2024 revealed that EBP was ordered because the resident had a urinary catheter. A gown and gloves were to be worn for all high contact resident care activities. Review of the medical record for Resident #19 revealed and admission date of 11/13/20 and a readmission date of 12/11/20. Diagnoses included but were not limited to diabetes mellitus, syncope and Page 1 of 5 365927 365927 05/22/2024 Regina Health Center 5232 Broadview Rd Richfield, OH 44286

F 0880 collapse, depression, and dementia. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #19 was severely cognitively impaired and was dependent for activities of daily living. Residents Affected - Many Review of the physician's orders for May 2024 revealed that EBP was ordered because the resident had a urinary catheter. A gown and gloves were to be worn for all high contact resident care activities. Review of the medical record for Resident #53 revealed and admission date of 02/08/24 and a readmission date of 03/13/24. Diagnoses included but were not limited to sepsis, unspecified psychosis not due to a known substance or known physiological condition, major depressive disorder, and bipolar disorder. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact, required partial to moderate assistance activities of daily living and was receiving chemotherapy. Review of the physician's orders for May 2024 revealed that EBP was ordered because Resident #53 had to be straight cathed every six hours for urinary retention. A gown and gloves were to be worn for all high contact resident care activities. Observation on 05/19/24 from 3:00 through 3:30 P.M. revealed that Residents #5, #19, #53, who were ordered barrier precautions, had no signs on the door to alert staff and no personal protective equipment (PPE) was located near their rooms. This was verified by Infection Control Preventionist (ICP) #52 at time of observation. ICP #52 stated that she wasn't sure why PPE and the enhance barrier signs were not on the door of the first-floor residents when the second floor had signs and PPE. Review of the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group reference QSO-24-08-NH revealed EBP recommendations included use of EBP for residents with chronic wounds or indwelling medical devices during high contact resident care activities regardless of their multidrug-resistant organism status. Review of the undated facility policy Enhanced Barrier Precautions, revealed the facility would identify residents with central lines, urinary catheters, feeding tubes, hemodialysis catheters and tracheotomy/ventilator status regardless of Multi drug-resistant Organisms (MDRO) colonization status. High contact resident care activities requiring gown and glove use included but were not limited to tracheotomy/ventilator care. Residents identified with MDRO, wound, and or indwelling medical devices would have an EBP sign noting the PPE needed and the high contact care activities placed on the door or wall outside of the resident room. 3. An observation of on 05/21/24 at 8:10 A.M. revealed Registered Nurse (RN) #86 preparing medications for Resident #16. RN #86 removed losartan 25 milligram (mg) from its packaging and placed the medication into her hand. RN #86 then placed the losartan 25 mg tablet into a medication cup. RN #86 verified touching the medication directly with her hand and placing it in the medication cup. RN #86 then continued to prepare the medications for Resident #16 by removing them directly from the packaging and placing them in the cup without touching them. RN #86 then gave Resident #16 the medications she prepared including the losartan 25 mg touched with her hand. 365927 Page 2 of 5 365927 05/22/2024 Regina Health Center 5232 Broadview Rd Richfield, OH 44286

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An observation on 05/21/24 at 8:25 A.M. revealed RN #86 preparing medications for Resident #72. RN #86 removed a docusate sodium 100 mg from a stock bottle and placed the medication into her hand. RN #86 then placed the docusate sodium 100 mg tablet into a medication cup. RN #86 verified touching the medication directly with her hand and placing it in the medication cup. RN #86 then continued to prepare the medications for Resident #72 by removing them directly from the packaging and placing them in the cup without touching them. RN #86 then gave Resident #72 the medications she prepared including the docusate sodium 100 mg touched with her hand. On 05/21/24 at 10:00 A.M. an interview RN #164 revealed RN #86 should not have touched the medications for Residents #16 and #72 with her hands. RN #164 also stated the medications for Residents #16 and #72 should have been discarded once they were contaminated with RN #86 hands. A review of the policy titled, Medication Administration Policy dated 01/03/23 revealed in point 5, Health care staff may administer medications consistent with applicable Ohio State law and the rules and regulations that apply to their profession, including Registered Nurses and Licensed Practical Nurses. 365927 Page 3 of 5 365927 05/22/2024 Regina Health Center 5232 Broadview Rd Richfield, OH 44286

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review and policy review the facility failed to ensure Resident #9 was offered and received education regarding the influenza and pneumonia vaccines. This affected one of five residents reviewed for immunizations (Residents #26, #32, #27, #79, and #9). The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #9 revealed an admission date of 03/12/21. Diagnoses included dementia, diabetes mellitus, and chronic kidney disease. The record indicated the resident had a responsible party. Review of the resident immunizations in the online medical record revealed refused next to both influenza and pneumonia vaccines. Further review of the medical record revealed no evidence that the facility offered the vaccines or provided education to the resident or her representative. Interview on 05/22/24 at 11:14 A.M. with Registered Nurse (RN) #52 revealed she was responsible for obtaining vaccine consents and providing education. RN #52 reported the facility did not obtain a written refusal for Resident #9's influenza and pneumonia vaccines or have evidence that education was provided to the resident or the resident's responsible party regarding the vaccines. Review of the facility policy, Resident Influenza/COVID 19/Pneumonia/RSV vaccination Program dated 09/2023 revealed vaccines were offered annually to all residents. The Infection Preventionist was responsible to coordinate the vaccination program. 365927 Page 4 of 5 365927 05/22/2024 Regina Health Center 5232 Broadview Rd Richfield, OH 44286

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview, record review and policy review the facility failed to ensure Resident #9 was offered and received education on the Covid-19 vaccine. This affected one of five residents reviewed for immunizations (Residents #26, #32, #27, #79, and #9). The facility census was 88. Findings include: Review of the medical record for Resident #9 revealed an admission date of 03/12/21. Diagnoses included dementia, diabetes mellitus, and chronic kidney disease. The record indicated the resident had a responsible party. Review of the resident immunizations in the online medical record revealed refused the Covid-19 vaccine. Further review of the medical record revealed no evidence that the facility offered the vaccine or provided education to the resident or her representative. Interview on 05/22/24 at 11:14 A.M. with Registered Nurse (RN) #52 confirmed she was responsible for obtaining vaccine consents and providing education. RN #52 reported the facility did not obtain a written refusal for Resident #9's Covid-19 vaccine or have evidence that education was provided to the resident or the resident's responsible party regarding the vaccine. Review of the facility policy, Resident Influenza/COVID 19/Pneumonia/RSV vaccination Program dated 09/2023 revealed vaccines were offered annually to all residents. The Infection Preventionist was responsible to coordinate the vaccination program. 365927 Page 5 of 5