Health inspection·October 5, 2023

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, personal funds review, and staff interview, and review of a facility policy, the facility failed to return and complete final accounting of resident funds in a timely manner after a resident death. This affected one (#281) of one residents reviewed for discharged resident funds. The census was 78. Residents Affected - Few Findings include: Review of the medical record for Resident #281 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included cerebral atherosclerosis, dementia, embolism, cerebrovascular disease, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #281 was assessed with cognitive impairment and required extensive assistance of two staff members for transfers and mobility. Review of the resident funds authorization form dated [DATE] revealed Resident #281 opened a resident fund account at the facility. Review of the resident fund statement dated [DATE] revealed Resident #281's account was closed on this date. Review of the undated Ohio Department of Medicaid Personal Needs Allowance Account Remittance Notice revealed Resident #281 died on [DATE]. The notice included information on timeliness and expectations for return of resident monies. For residents without estate and when monies are to be returned to the State of Ohio, funds are to be returned no later than 90 days after the date of death . Review of the copy of the return check dated [DATE] revealed a check was made out to the Ohio Treasury Department and Ohio Attorney General Office in the amount of $1,854.56. Interview on [DATE] at 3:06 P.M. with Business Office Manager (BOM) #160 and Corporate Business Office Manager (CBOM) #251 confirmed Resident #281 died on [DATE], and the funds were not returned until [DATE]. BOM #160 revealed she was waiting on family to reach out about funeral arrangements, and revealed she thought she had three to six months to return funds to resident, family, or State of Ohio. Review of facility policy titled, Resident Trust, dated [DATE], revealed residents discharging from the facility, or who expire while in the facility shall have account balances closed in five Page 1 of 14 365994 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0569 business days and a full accounting is provided. To ensure timely closure, business office will provide Administrator the balance report every Monday, Wednesday, and Friday for discharged residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365994 Page 2 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence that pre-admission screening and resident review (PASARR) assessments were completed and failed to follow up on PASARR level II determinations. This affected two (#24 and #32) of two resident reviewed for PASARR assessments. The census was 78. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 05/03/22. Diagnoses included hemiplegia and hemiparesis, chronic obstructive pulmonary disease, dementia, anxiety, bipolar disorder, depression, and psychotic disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively impaired and required extensive assistance of one to two staff members for transfers and mobility. Review of the medical record found no evidence of Resident #24 having any PASARR assessment completed. 2. Review of the medical record for Resident #32 revealed an admission date of 11/03/18. Diagnoses included paranoid schizophrenia, anxiety, and depression. Review of the MDS assessment dated [DATE] revealed Resident #32 had moderate cognitive impairment and required extensive assistance of one to two staff members for transfers and mobility. Review of the Agency on Aging Pre-admission Screening (PAS) determination letter dated 10/19/18 revealed Resident #32 required level II services for further evaluation. Review of the medical record revealed no evidence Resident #32 had any PASARR assessment completed. Interviews on 09/27/23 from 4:15 P.M. to 4:45 P.M. with Social Services (SS) #115 revealed medical records staff should get a copy of the PASARR assessments and will inform her if changes are needed. SS #115 verified the facility did not have a copy of PASARR assessments for Resident #24 or Resident #32. SS #115 revealed they were able to get an older copy of the PASARR assessment for Resident #24, and confirmed it did not contain any mental health diagnoses and also was marked no when asking if Resident #24 had a diagnosis of dementia. Interview on 09/28/23 4:07 P.M. with SS #115 revealed Resident #32 previously was at another facility, and a request was made to get a copy of the PASARR assessment from that other facility. SS #115 verified she was unable to locate any copy of the PASARR assessment in facility records. SS #115 confirmed facility did not have any evidence of level II services being followed up for Resident #32. 365994 Page 3 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, medical record review, and review of a facility policy, the facility failed to ensure residents received hearing supports and devices in a timely manner. This affected one (#2) of one residents reviewed for hearing ancillary services. The census was 78. Residents Affected - Few Findings include: Review of the medical record for the Resident #2 revealed a re-admission date of 08/29/23. Diagnoses included diabetes mellitus type II, chronic obstructive pulmonary disease, heart failure, vascular dementia, schizophrenia unspecified. Review of an audiology evaluation dated 10/14/22 revealed Resident #2 was seen for a hearing test on 07/11/22 in which bilateral hearing loss was found. The resident voiced interest in hearing aides at that time. Further review of the report revealed facility staff agreed hearing aides were appropriate for the resident and bilateral earmold impressions were completed. The hearing test found severe to profound mixed hearing loss in the right ear and a moderately severe sensorineural hearing loss in the left ear. The plan included the resident's desire to proceed with amplification. The resident reported she previously was evaluated, and told she was getting hearing aides and impressions were taken at this time. The audiology providers gave facility the order for two hearing aides with a plan for follow up for hearing aide fitting. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact, required extensive assistance of two staff members for transfers and mobility, and assessed Resident #2 with moderate difficulty with hearing with no hear aides or appliances. Review of the plan of care dated 08/22/23 revealed Resident #2 had a hearing impairment with no care plan interventions to assess for hearing aides or order hearing aides as requested. Review of current physician orders revealed no current or past orders for Resident #2's hearing aides. Interview and observation on 09/25/23 at 10:20 A.M. with Resident #2 revealed she had difficulty hearing. Observation at that time revealed Resident #2 did not have hearing aides in her ears. Resident #2 revealed she was waiting on hearing aides, and was told by the audiologist it would take about five weeks for them to be delivered. Resident #2 voiced concern as she had been waiting several months, but could not remember exactly how long. Interview on 09/27/23 at 4:15 P.M. with Social Services (SS) #115 revealed she was not aware Resident #2 was waiting on hearing aides. SS #115 confirmed Resident #2's audiology visit dated 10/14/22 revealed hearing aides were ordered by the ancillary service provider. Interview on 09/27/23 at 4:45 P.M. with Social Services (SS) #115 revealed she never received the hearing aide order information, they were not signed by the facility physician, and the hearing aides not subsequently ordered for Resident #2. SS #115 revealed the ancillary services typically would provide this information to nursing and they were supposed to then provide it to her for follow up. SS #115 confirmed she never received the information. SS #115 revealed she got a new form, and would be providing it to the physician for their signature to get the hearing aides ordered for Resident 365994 Page 4 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0685 #2. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled, Social Services Referral to Outside Providers, dated 09/26/23, revealed a report from the provider visit should be maintained in the resident's medical record and service providers recommendations were to be integrated into the resident's care plan if adopted. Recommendations shall be communicated to direct staff and follow up visits and services shall be scheduled as needed. If/when new inventory appliance were received a inventory list shall be updated. Residents Affected - Few 365994 Page 5 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review staff interview, and review of Food and Drug Administration (FDA) medication information, the facility failed to provide an appropriate diagnosis for the use of psychotropic medications. This affected one (#22) of five residents reviewed for unnecessary medications. The census was 78. Findings include: Record review of Resident #22 revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, urinary tract infection, hypertension, depression, anxiety, diabetes mellitus type II, anemia, and insomnia. Review of the most recent Minimum Data Set (MDS) assessment completed 09/12/23 revealed Resident #22 was assessed with severe cognitive impairment. Review of current physician orders revealed Resident #22 received the anticonvulsant and mood stabilizer Depakote Sprinkles 125 milligrams (mg), one capsule by mouth every eight hours related to unspecified dementia, the antipsychotic medication Seroquel 25 mg, one tablet by mouth daily related to unspecified dementia, Seroquel 25 mg two tablets by mouth daily at bedtime related to unspecified dementia, and Seroquel 25mg, one-half tablet by mouth once daily related to unspecified dementia. Review of the FDA Black Box Warning for Seroquel revealed elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk for death. Seroquel was not approved for the treatment of patients with dementia-related psychosis. Interview with the Director of Nursing and the Administrator on 09/29/23 at 09:34 A.M. verified Resident #22 received Depakote and Seroquel, and confirmed unspecified dementia was not an acceptable diagnosis for the use of Seroquel and Depakote. 365994 Page 6 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, medical record review, staff and resident interviews, review of meal tickets, and review of a facility policy, the facility failed to ensure resident food preferences were honored. This affected two (#6 and #18) of two residents reviewed for food preferences. The census was 78. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 04/13/19. Diagnoses included dementia, asthma, cerebral infarct, pain syndrome, and COVID-19. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired and was totally dependent for transfers. Review of the plan of care dated 08/10/23 revealed Resident #6 was at nutritional and/or dehydration risk with interventions to provide diet preferences and substitutes as ordered. Review of Resident #6's meal ticket dated 09/26/23 revealed the resident dislike of cheese. Observation on 09/26/23 from 4:50 P.M. to 5:00 P.M. revealed Resident #6 had No cheese printed on her meal ticket and was given cheese on her burger. Observation and interview on 09/26/23 at 5:22 P.M. with Licensed Practical Nurse (LPN) #187 confirmed Resident #6 received a burger with cheese. LPN #187 verified the meal ticket on Resident #6's meal tray did not match what was delivered. 2. Review of the medical record for Resident #18 revealed an admission date of 07/30/19. Diagnoses included chronic kidney disease stage four, dementia, heart failure, and vascular disease. Review of the MDS assessment dated [DATE] revealed Resident #18 was cognitively intact, and required extensive assistance of two staff members for mobility and transfers. Review of the plan of care dated 08/11/23 revealed Resident #18 was at nutritional and/or dehydration risk with interventions to provide diet preferences and substitutes as ordered. Review of Resident #18's meal ticket dated 09/26/23 revealed the resident disliked raw vegetables with a note of them being difficult to chew. Observation on 09/26/23 from 4:50 P.M. to 5:00 P.M. revealed Resident #18 had No raw veggies due to chewing difficulties on her ticket, and was given the raw vegetable toppings of lettuce and tomato for the burger. Observation and interview on 09/26/23 at 5:18 P.M. with State Tested Nurse Aide (STNA) #214 confirmed Resident #18 received raw vegetables (lettuce and tomato) for her burger. Interview on 09/26/23 at 5:25 P.M. with Dietary Manager (DM) #237 confirmed resident preferences should be honored. DM #237 revealed she interpreted the statement for no raw vegetables on Resident 365994 Page 7 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0800 #18's meal ticket to mean no hard raw vegetables such as carrots. Level of Harm - Minimal harm or potential for actual harm Interview on 09/26/23 at 6:00 P.M. with Resident #18 revealed she had difficulty chewing raw vegetables, and confirmed her meal ticket requested no raw vegetables. Residents Affected - Few Review of the undated facility policy titled, Food preference assessment, revealed each resident can make note of preferences in several categories including cereal, starches, bread, fruits, vegetables, and meats. 365994 Page 8 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of open and closed medical records, staff interviews, review of a death certificate, review of water sample testing reports, review of weekly water temperature and chlorine level logs, review of water sample testing kit manufacturer's instructions, review of the facility's water management plan, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure the water system was accurately tested for chlorine levels and maintained in a safe manner which resulted in elevated levels of Legionella bacteria in the facility's water system and exposure to the residents. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when one resident (#100) was found to have altered mental status and abnormal vital signs on [DATE], was sent to the emergency room (ER) for evaluation, tested positive for Legionella pneumonia in the hospital on [DATE], and subsequently died on [DATE]. The facility's failure to have an effective water management program in place to monitor control measures to prevent the growth of potential Legionella in the water system placed all 78 residents at potential risk for Legionella bacteria exposure. Additionally, the facility failed to ensure staff members wore appropriate personal protective equipment (PPE) while in the rooms of three (#06, #22, #51) residents who had tested positive for COVID-19 infection, in accordance with CDC recommendations, to prevent further transmission of COVID-19 to residents who were not infected with the virus. This affected three (#06, #22, #51) of eight residents reviewed during the survey for implementation of appropriate infection prevention and control practices. The census was 78. Residents Affected - Many On [DATE] at 5:05 P.M., the Administrator, Director of Nursing (DON), Maintenance Director #122, Regional Clinical Consultant Coordinator (RCCC) #555, Regional Clinical Consultant #444, and Contracted Corporate Employee #333 were notified that Immediate Jeopardy began on [DATE] when the facility was notified by the hospital Resident #100 tested positive for Legionella Pneumonia. Review of Resident #100's change in condition evaluation dated [DATE] revealed the resident was documented to have altered mental status, abnormal vital signs, elevated white blood count, pneumonia, and jaundice. The physician was documented as being notified on [DATE] at 2:33 P.M. and the resident was transferred to the hospital for evaluation. Review of the Resident #100's death certificate dated [DATE] revealed the resident died on [DATE] at 10:50 A.M. with an immediate cause of death as drug induced liver injury due to Legionella pneumonia, chronic obstructive pulmonary disorder, and liver cirrhosis. Review of the Legionella bacteria test result report dated [DATE], and finalized on [DATE], revealed 30 out of the 33 water samples taken from the facility on [DATE] tested positive for the presence of Legionella pneumophilia, serogroup one. Resident #100 had resided in one of the identified positive Legionella rooms. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], Resident #100 was transferred to the hospital. On [DATE], upon notification of the positive urine antigen test regarding Resident #100, all facility residents were reviewed by the DON/designee to ensure no additional residents were exhibiting symptoms consistent with Legionella infection. Medical Director #500, the Local County Health Department (LCHD), and the corporate office were notified by the DON of Resident #100's positive diagnostic test results for Legionella Pneumonia. On [DATE], the facility contracted with Industrial Water Management (IWM) to assist in testing and 365994 Page 9 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0880 remediation if any Legionella bacteria was discovered. Level of Harm - Immediate jeopardy to resident health or safety On [DATE], a meeting was held with IWM, the Ohio Department of Health (ODH), and the LCHD where the water system process flow and schematics were reviewed, and target areas were identified on the 100 and 200 hallways where Legionella bacteria could potentially grow. Residents Affected - Many On [DATE], biologic Point of Use ([NAME]) filters were installed on all water outlets (showers, sinks, and beauty shop hair sink) by IWM contractors. These filters were rated for 90-day efficacy from the date of installment. On [DATE], the Administrator directed tap water to be restricted from use for drinking and cooking, and bottled water was to be used for hydration and cooking for residents and staff. The ice and juice machines were also instructed to be taken out of use. On [DATE], the facility continued daily review by the DON/designee of all resident clinical changes in condition to ensure appropriate follow-up with the physician. Since [DATE], all facility residents positive for pneumonia were tested for Legionnaire's disease (pneumonia caused by Legionella bacteria) and all tested negative. On [DATE], Dietary Manager #237 disposed of all ice in the ice machine and thoroughly disinfected the ice machine. On [DATE], the DON/designee provided in-services to all staff, residents, and residents responsible parties regarding the water management program, Legionella screening symptoms, facility remediation measures, and the plan for continued water management. On [DATE], the installation of the in-line ice filter was completed by Maintenance Director #122 using the connection kit supplied with the in-line filter provided by IWM. The ice machine was then put back into service. On [DATE], the installation of an in-line filter for the juice machine was completed by Maintenance Director #122 at which time the juice machine was put back into service. On [DATE], the facility established a water management program team to include the Administrator, Maintenance Director #122, Regional Maintenance Director #222, the DON, Health Division Risk Officer #790 from IWM, and the Environmental Consultant #898 from IWM. On [DATE], a monochloramine remediation process was completed with 2.0 to 3.0 parts per million (PPM) of monochloramine introduced paired with a contact time of 21 days. A daily flushing regime was completed following this process to ensure introduction and reintroduction of the disinfecting agent on all pipework throughout the remediation event. On [DATE], Maintenance Director #122 and all maintenance staff, Infection Control Preventionist (ICP) #200, and the Administrator were educated on the water management program policy with a focus on controls, documentation, and validation by Corporate Infection Preventionist #932. This education was provided again on [DATE]. On [DATE], IWM Employee #777 reported it would be necessary to suspend the plumbing project at the 365994 Page 10 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many facility related to Legionella bacteria due to positive COVID-19 virus in the facility. IWM's policy indicated the company did not risk their employees' exposure to the virus. IWM Employee #777 stated the monochloramine treatment would be extended in the facility, if needed. Upon IWM resumption of the plumbing project, the dead legs would be removed or reactivated with the installation of a valve allowing for water flow so that it could be routinely flushed. On [DATE], chlorine levels of the facility water were tested and retested in the facility. IWM Employee #777 verified with facility management and ODH surveyors the current filters applied to all faucets provided adequate protection against Legionella bacteria. A retest of the facility water system will be scheduled 72 hours post-remediation. A sample set will be collected at that time, repeating the exact sample set as initially tested. Two weeks following that test, a third test will be completed. Both post-remediation water sample testing results will be submitted to the LCHD and the ODH for review. The investigation will not conclude until there is an agreement by the local and state health departments. The Administrator/designee will complete random audits weekly for eight weeks, then monthly for four months, to ensure the facility water management program is implemented and effective, controls/tasks are completed and documented, and resident review for symptoms of Legionella infection are completed during the morning clinical meeting with appropriate follow-up with the physician. Additional education and monitoring will be initiated for any identified concerns. Corrective actions will be completed as needed with additional audits to ensure corrective action was effective. Interview on [DATE] at 10:35 A.M. with Maintenance Director #122, at 2:32 P.M. with Maintenance Assistant #232, and at 2:41 P.M. with Maintenance Employee #180 all verified they were educated about water management procedures and Legionella bacteria testing. All staff members interviewed were knowledgeable regarding the content of the education. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the closed medical record for Resident #100 revealed the resident was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE], transferred to the hospital on [DATE], and discharged on [DATE]. This resident had diagnoses including chronic obstructive pulmonary disease, dependence on supplemental oxygen, hypertension, and heart failure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was assessed with intact cognition as evidence by a Brief Interview for Mental Status (BIMS) assessment score of 13. The resident was assessed to require supervision with bed mobility, transfers, toileting, and eating. Review of Resident #100's change in condition evaluation dated [DATE] revealed the resident was documented to have altered mental status, abnormal vital signs, elevated white blood count, pneumonia, and jaundice. The physician was documented as being notified on [DATE] at 2:33 P.M. and the resident was transferred to the hospital for evaluation. 365994 Page 11 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of the Resident #100's death certificate dated [DATE] revealed the resident died on [DATE] at 10:50 A.M. with an immediate cause of death as drug induced liver injury due to Legionella pneumonia, chronic obstructive pulmonary disorder, and liver cirrhosis. During an interview on [DATE] at 2:35 P.M. with the Administrator confirmed Resident #100 was diagnosed with Legionella Pneumonia and verified this diagnosis was a contributing factor to the resident's death on the death certificate. Review of the facility water temperature log as part of the facility's Legionella bacteria prevention plan revealed water was tested weekly from four random resident rooms to measure temperature and chlorine levels. Review of the weekly logs dated [DATE] through [DATE] revealed no measurements of chlorine levels present in the water. Further review of the weekly logs dated [DATE] through [DATE] revealed all chlorine level results were documented as being 0.5 PPM or higher. Review of the Legionella bacteria test result report dated [DATE], and finalized on [DATE], revealed 30 out of the 33 water samples taken from the facility on [DATE] tested positive for the presence of Legionella pneumophilia, serogroup one. Observation on [DATE] at 9:35 A.M. revealed there were specialized water filters in place on all the facility faucets and shower heads. Interview with Maintenance Director #122 on [DATE] at 3:20 P.M. revealed the facility conducted testing for Legionella bacteria annually in January and obtained water temperatures and chlorine levels in water samples weekly. Maintenance Director #122 verified there was no evidence Legionella bacteria testing was completed on facility water samples in January of 2023 as the previous maintenance director was thought to have disposed of all maintenance records prior to being walked out of the facility at the end of [DATE]. Observation on [DATE] at 1:45 P.M. revealed Maintenance Assistant #232 obtained a water sample from the bathroom sink in the conference room and tested the water sample using the WaterWorks 5-WAY Water Check testing strip. Maintenance Assistant #232 then held the testing strip bottle vertically with the cap upward and attempted to read the results by holding the testing strip vertically against the vertical bottle where the results reference was located, when he should have been reading the results horizontally due to the orientation of the bottle. Further observation revealed the testing strip had an indicator that contained five blocks per strip to test for free chlorine, total chlorine, potential of hydrogen (pH), total alkaline, and total hardness. Each block per strip was specific to each of the testing methods. The strip must be aligned across all five testing blocks for each one of the testing components with the color chart results printed on the testing strip bottle to obtain a proper reading. Interview at the time of the observation with Maintenance Assistant #232 verified he attempted to read the results in the wrong direction which would result in inaccurate readings. Maintenance Assistant #232 verified he was performing the weekly sampling of chlorine levels present in the facility water supply and may have documented inaccurate results due to reading chlorine results incorrectly. Observation on [DATE] at 3:44 P.M. revealed Maintenance Director #122 obtained a water sample from the bathroom sink in the conference room and tested the water sample using the WaterWorks 5-WAY Water Check testing strip. Maintenance Director #122 then attempted to read the results by holding the testing strip bottle vertically with the cap upward and read the results by holding the testing strip vertically against the vertical bottle where the results reference was located, when he should have 365994 Page 12 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many been reading the results horizontally due to the orientation of the bottle. At the time of the observation, Maintenance Director #122 verified he was reading the results in the wrong direction which would result in inaccurate readings. Review of the undated WaterWorks 5-Way Water Check manufacturer's instructions revealed dip one test strip into a [NAME] sample for five seconds with a constant, gentle back and forth motion, remove the strip and shake once briskly to remove excess water, wait 25 seconds and then match pH, total alkalinity, free chlorine, total chlorine, and total hardness, in that order, to the color chart. Complete color matching within 30 seconds. Review of the facility policy titled, Water Management Plan, dated [DATE], revealed seven key activities were routinely performed in a Legionella water management program including deciding where control measures should be applied and how to monitor them and establish ways to intervene when control limits are not met. Control measures may include visible inspections, use of disinfectant, and temperature (that may require mixing valves to prevent scalding). Monitoring such control includes testing protocols for control measures, acceptable ranges, and documenting the results of testing. Review of the CDC website at, https://www.cdc.gov/legionella/wmp/healthcare-facilities/water-mgmt-validation.html, revealed according to the CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC), healthcare facilities have two options for confirming that their water management program is working as intended including performing environmental sampling for Legionella and performing active clinical surveillance for infections due to Legionella. 2) Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, hypertension, constipation, depression, anxiety, diabetes mellitus type II, and COVID-19. Review of the most recent MDS assessment completed on [DATE] revealed Resident #22 was assessed with severe cognitive impairment. Review of Resident #22's physician orders revealed the resident was on isolation precautions (contact and droplet) since [DATE] when the resident tested positive for COVID-19. Observation of Resident #22 on [DATE] at 9:15 A.M. revealed the resident was lying in bed with no roommate noted. There was an isolation cart located outside of the room at the door and was stocked with N-95 face masks, gowns, face shields, and gloves for staff and visitors to put on prior to entry of the room. There was a sign posted on the door which indicated the resident was on isolation precautions. Observation of State Tested Nurse Aide (STNA) #175 on [DATE] at 9:17 A.M. revealed this staff member entered Resident #22's room without wearing proper PPE as STNA #175 did not put on an N-95 face mask, gown, gloves, or a face shield prior to entering the room. Interview on [DATE] at 9:22 A.M. with Licensed Practical Nurse (LPN) #135 verified STNA #175 was in Resident #22's room while on isolation precautions without wearing proper PPE. 3) Review of the medical record for Resident #51 revealed an admission date of [DATE]. Diagnoses included cerebral atherosclerosis, dementia, dysphagia, metabolic disorder, and COVID-19. 365994 Page 13 of 14 365994 10/05/2023 Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Review of the MDS assessment dated [DATE] revealed Resident #51 was rarely or never understood and required extensive assistance of two staff members for transfers and mobility. Review of the nursing progress notes dated [DATE] at 1:15 A.M. revealed Resident #51 was tested for COVID-19 after signs of a non-productive cough, and the test result was positive for COVID-19. Resident #51 was started on the COVID-19 treatment medication Paxlovid. Residents Affected - Many Review of physician orders dated [DATE] revealed Resident #51 was started on contact and droplet isolation for a COVID-19 positive test result. Observation and interview on [DATE] at 10:40 A.M. to 11:00 A.M. revealed Maintenance Employee #170 was observed in Resident #51's room wearing a surgical mask. Resident #51's door had a sign posted indicating the resident was in droplet and contact isolation. Interview with Maintenance Employee #170 at the time of the observation stated he was packing up a closet full of belongings from a previous resident, and confirmed he should be wearing an N-95 face mask due to Resident #51's COVID-19 isolation status. 4) Review of the medical record for Resident #06 revealed an admission date of [DATE]. Diagnoses included dementia, asthma, cerebral infarct, pain syndrome, and COVID-19. Review of the MDS assessment dated [DATE] revealed Resident #06 was cognitively impaired and was totally dependent for transfers. Review of the nursing progress notes dated [DATE] revealed Resident #06 tested positive for COVID-19. Review of physician orders dated [DATE] revealed Resident #06 was started on contact and droplet isolation for a COVID-19 positive test result. Observation on [DATE] at 12:06 P.M. revealed STNA #252 and STNA #253 were passing out lunch trays to residents on the hall. Further observation revealed STNA #252 entered Resident #06's room wearing a surgical mask. Interview with STNA #252, on [DATE] at the time of the observation, confirmed Resident #06 was COVID-19 positive and N-95 face masks were to be worn when in COVID-19 isolation areas. STNA #252 stated the reason she did not wear proper PPE while in Resident #06's room was due to the facility not having enough PPE carts. Review of the CDC website at, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, last updated [DATE], revealed healthcare professionals (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This deficiency represents non-compliance investigated under Master Complaint Number OH00146830, Complaint Number OH00146579, and Complaint Number OH00146062. 365994 Page 14 of 14