Health inspection·April 9, 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 record review, observations, interviews with staff and Environmental Specialist, review of the facilities approved water management plan and timeline and policy review, the facility failed to timely implement their approved water management plan to potentially prevent a Legionella outbreak. This affected one (#84) out of three residents reviewed for Legionella and had the potential to affect all 68 residents residing in the facility. The facility census was 68. Residents Affected - Many Findings include: Review of the medical record for Resident #84 revealed the resident was originally admitted to the facility on [DATE] and was readmitted following a hospital stay on 10/24/23. Resident #84 left the faciity on [DATE], against medical advice. Diagnoses included diabetes mellitus, illicit drug use, history of respiratory failure, and pneumonia. Review of Resident #84's quarterly Minimum Data Set (MDS) assessment, dated 10/31/23, revealed the resident had intact cognition. Review of Resident #84's medical record revealed the resident went to the emergency room on [DATE] due to an issue that was not respiratory related and was admitted . Resident #84 was readmitted to the facility on [DATE]. Further review of the hospital documentation from the hospital stay from 10/12/23 to 10/24/23 revealed Resident #84 was diagnosed with Legionella pneumonia while at the hospital. Orders for treatment included an oral antibiotic. Review of Resident #84's nurses notes dated 10/24/23 revealed the hospital notes reflected the resident tested positive for Legionella while at the hospital. The facility called the facility physician, local health department and the Ohio Department of Health. Observation on 03/26/24 from 10:30 A.M. until 11:00 A.M. revealed 64 shower filters are in place throughout the facility. The observations revealed there were no sink filters noted. Interview on 03/26/24 at 11:00 A.M. with the Administrator revealed Resident #84 returned after a two week stay in the hospital and it was discovered the resident had a diagnoses of Legionella pneumonia. The Administrator stated the hospital did not inform the facility of Resident #84's positive Legionella test results. The Administrator stated Resident #84's Legionella test results were noted in the hospital records by the facility staff. The Administrator noted the facility immediately reported Resident #84's positive Legionella results to the local health department and the state agency. The facility began testing at the facility. The Administrator confirmed the facility submitted a plan to the Ohio Department of Health on 12/15/23 regarding the Legionella/water management plan. The Page 1 of 2 365946 365946 04/09/2024 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Administrator confirmed there was a delay in installing filters on the showers per their Legionella/water management plan and these filters were not installed until 03/09/24. The Administrator further confirmed filters still have not been installed on the sinks per the approved water management plan. The Administrator confirmed no other residents have tested positive for Legionella. Interview with Environmental Specialist #202 via telephone on 03/26/24 at 1:45 P.M. revealed the facility water management plan was approved by the Ohio Department of Health and the Local Health Department (LHD) at the end of 12/23. Environmental Specialist #202 stated part of the facilities approved water management plan included installing filters on showers and sinks and as far as he knew none of the filters were in place. Environmental Specialist #202 stated the water should not be used in those areas if no filters are in place due to the risk of spreading Legionella. Review of the facility approved water management plan and timeline revealed testing for Legionella began on 11/01/23 and an outside consultant was hired. On 12/15/23, Ohio Department of Health approved the facility water management plan sent by the consultant. The approved water management plan indicated the facility was to put filters on showers and sinks in the positive areas. Shower heads were applied to sixty four showers on 03/09/24 which was three months after the recommendations. No filters were placed on the sinks and the staff and residents used the sinks. Filters were applied to the sinks on 04/04/24. Review of facility policy titled Water Management dated 05/17 revealed the facility will have a water management plan to reduce the risk of Legionella in the facility water system. The facility will work to inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. This deficiency represents non-compliance investigated under Complaint Number OH00152311. 365946 Page 2 of 2