Health inspection·March 28, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the residents code status was consistently documented in the medical record. This affected one (#4) out of 31 residents reviewed for advanced directive in the initial pool. The total facility census was 74. Findings include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include respiratory failure, chest pain, dysphagia, type two diabetes, hypertensive heart disease, peripheral vascular disease, chronic obstructive pulmonary disease, atrial fibrillation, rheumatoid arthritis, spinal stenosis, bradycardia, and edema. Review of the physician orders revealed Resident #4 had an order dated 10/01/21 for Do Not Resuscitate Comfort Care Arrest (DNRCCA) no intubation, no intubation. Review of the paper medical chart for Resident #4 revealed there was a paper in the front of the medical record with a green sticker that stated Full Code. The paper medical chart had a had DNR paperwork present for Resident #4 and the DNR form had the word FULL written diagonally across the form. Review of Resident #4's care plan revealed there was a care plan in place which stated the resident wished to be a DNRCCA with no intubation dated 02/18/22. During an interview on 03/22/22 at 9:00 A.M. with Registered Nurse (RN) #738 revealed if a resident was found without signs of life the chart would be checked, the nurse indicated the paper medical record in the nurses station for DNR status and she would follow what the medical chart identified. RN #738 was asked if the DNR status was indicated on the resident's electronic medication administration record (EMAR) and the nurse stated yes. RN #738 opened Resident #4's EMAR and verified the DNR status indicated DNRCC-A no intubation. RN #738 then opened Resident #4's electronic orders and verified on 10/01/21 there was an order for DNRCCA, no intubation. RN #738 verified the paper medical chart DNR status did not match the DNR status that was in Resident #4's electronic medical record. Page 1 of 15 365997 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interview, review of Safety Data Sheets (SDS) and review of facility policy, the facility failed to secure potentially hazardous chemicals on the the secured memory care unit and C pod. This affected two (#55 and #178) out of two residents reviewed for accident/hazards and had the potential to affect five (#3, #10, #33, #55 #68, and #372) additional residents identified by the facility as cognitively impaired and independently mobile who reside on the secured memory care unit. The facility census was 74. Findings include: 1. Review of the medical record revealed Resident #55 was admitted on [DATE] and a readmission date of 08/25/21. Diagnoses included Alzheimer's disease, osteoporosis, major depressive disorder, anxiety disorder, atrial fibrillation, and hypertension. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was severely cognitively impaired, required supervision for ambulation, and had wandering behavior. Review of the plan of care initiated 03/08/21 revealed Resident #55 had potential mood and behavior problems including restlessness, wandering the secure unit, and going in others spaces. Interventions included redirect as needed. Observation on 03/21/22 at 8:08 A.M. of Resident #38's room revealed the following products sitting on the resident's bedside table: A half-full seven fluid ounce bottle of anti-dandruff shampoo with a label warning to keep out of the reach of children, if swallowed, get medical help or contact poison control center right away; an eleven ounce can of shaving cream with a label warning to keep out of the reach of children; and an unlabeled, half-full medication cup with a thick pink substance. Continued observation of Resident #38's bathroom revealed a half-full medication cup with a peach gel-like substance. Observation on 03/21/22 at 8:11 A.M. of Resident #33's room revealed a full 16 ounce bottle of lotion sitting on the chair next to the Resident's bed. A warning label on the bottle of lotion stated keep out of reach of children, keep out of eyes, and for external use only. Observation on 03/21/22 at 8:21 A.M. of the Parlor A common area revealed a quarter full eight ounce bottle of hand sanitizer, with a warning label to keep out of reach of children. Continued observation of the common area revealed a quarter full aerosol can of disinfectant deodorant, located in an unlocked cabinet above the desk. A warning label on the aerosol can stated hazardous to humans, harmful if absorbed through the skin, take off contaminated clothing, rinse skin immediately with water for 15-20 seconds, call poison control, and keep out of reach of children. Also located in the same unlocked cabinet was a three quarter full eight ounce bottle of hand sanitizer with a warning label to keep out of reach of children. Observation on 03/21/22 at 8:33 A.M. of Resident #55's room revealed a half full, 12 fluid ounce bottle of body lotion and a half full six ounce bottle of baby powder sitting on the resident's bedside table. The baby powder had a warning label stating not for consumption, keep out of reach of children, avoid contact with eyes, external use only, and do not use on broken skin. Sitting on the sink 365997 Page 2 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some counter in Resident #55's bathroom was a full, 21 fluid ounce bottle of body lotion with a warning label to keep out of the reach of children. Interview on 03/21/22 at 8:44 A.M. of Registered Nurse (RN) #848 and Stated Tested Nurse Aide (STNA) #811 revealed all residents residing on the secured unit were cognitively impaired. STNA #811 verified all potentially hazardous items, including hand sanitizer, disinfectant sprays, lotions, powders, soaps, and hair spray, were supposed to be secured and out of reach of the residents. RN #848 stated the pink paste in the unlabeled medication cup in Resident #38's room was butt paste and the peach gel-like substance in the medication cup in the bathroom was body wash. RN #848 and STNA #811 verified the items observed in Residents #38, #33, #55's rooms were not secured and included warning labels to keep out of reach of children. STNA #811 stated they would secure items within reach of residents on the secured memory care unit. Observation on 03/22/22 at 8:48 A.M. of Resident #3's bathroom revealed, sitting on the bathroom sink counter, a three-quarter full, 16 fluid ounce bottle of body lotion and a half-full, 12 fluid ounce pump style bottle of hair spray, which had a warning label to avoid eyes and keep out of the reach of children. Interview on 03/23/22 at 10:48 A.M. of the Administrator verified potentially hazardous materials should be locked and out of reach of residents on the secured memory care unit. The facility confirmed there are six (#3, #10, #33, #55 #68, and #372) residents on the secured memory care unit who are cognitively impaired, independently mobile and who could access unsecured chemicals. Review of the SDS for the disinfectant deodorant spray, revised 01/20/22, revealed the spray caused serious eye irritation, was an extremely flammable aerosol, wear eye/face protectant, store in a well-ventilated place, may be harmful if swallowed, may cause skin irritation, inhalation of vapors or mist may cause respiratory irritation, and keep out of reach of children. Review of the SDS for the hand sanitizer, revised 08/02/20, revealed hazard statements including causes serious eye irritation, if eye contact, immediately flush eyes with water for at least 15 minutes, and seek medical attention. Additionally, if swallowed, do not induce vomiting, rinse mouth with water and obtain medical attention. Review of the SDS for the body wash gel, revised 08/09/17, revealed may be harmful if swallowed. Review of the SDS for the butter paste (butt paste), dated 11/19/15, revealed if eye contact, flush eyes with water, occasionally lifting the upper and lower eyelids and if ingested, wash out mouth with water, if conscious, give small quantities of water, do not induce vomiting unless directed to do so by medical personnel and get medical attention if symptoms occur. Review of the SDS for the body lotion, revised 11/27/19, revealed if ingested, consult a physician, for external use only, avoid contact with eyes, and keep out of reach of children. Review of the SDS for baby powder, revised 05/08/14, revealed for eye contact, rinse eyes immediately with water, also under the eyelids, for at least 15 minutes, obtain medical attention if irritation persists and if ingested, call a physician or poison control center immediately. Review of facility policy titled Locked Cabinet Policy, revised August 2015, revealed upon admission, all items that could be of danger to residents if swallowed, applied, or inhaled (i.e.: 365997 Page 3 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mouthwash, ointment, shampoo, sprays, creams, etc) will be placed in the locked top drawer of the bedside stand or in another secure area. The keys for the drawer will be placed in the nursing station with the resident's name and put on bulletin board. The drawer may be opened by staff for the resident's use. 2. Medical record review of Resident #178 admission date 03/17/22. Diagnoses included cholelithiasis without obstruction, dehydration, and hypotension. Observation on 03/21/22 at 9:14 A.M. of Resident #178's bathroom with a spray bottle of Shurgard (use to clean and disinfect) sitting on the bathroom sink. Interview on 03/21/22 at 9:15 A.M. with Resident #178 stated the staff left the cleaning supplies in the bathroom after cleaning the sink and toilet yesterday. Interview on 03/21/22 at 09:18 AM with Registered Nurse (RN) #738 stated the cleaning produces are not to be in the resident rooms. RN #738 verified the spray bottle with chemical disinfectant left on the bathroom sink. Interview on 03/24/22 at 8:05 A.M. with Housekeeping Supervisor (HS) #846 stated the cleaning supplies are always to be in sight of the housekeeping personnel at all times and they are not to leave cleaning supplies in resident rooms. Review of the SDS revealed for Shurguard germicidal disinfectant caution keep out of reach of children. Review of facility policy titled Locked Cabinet Policy, revised August 2015, revealed upon admission, all items that could be of danger to residents if swallowed, applied, or inhaled (i.e.: mouthwash, ointment, shampoo, sprays, creams, etc) will be placed in the locked top drawer of the bedside stand or in another secure area. The keys for the drawer will be placed in the nursing station with the resident's name and put on bulletin board. The drawer may be opened by staff for the resident's use. Review of the facility policy dated titled Hazardous Chemical Security dated 06/2015, revealed hazardous chemicals and supplies will be used and stored in a safe manner. All hazardous chemicals and materials will be stored in a locked area when not in use. When using hazardous chemicals or materials, they must remain within sight of the staff member using them at all times to prevent access by resident. 365997 Page 4 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident and staff interview, the facility failed to monitor a residents dialysis catheter access site and failed to monitor the resident upon return to the facility after dialysis treatment. This affected one (#273) of one residents reviewed for dialysis. The total facility census was 74. Residents Affected - Few Findings include: Review of Resident #273's medical record revealed the resident was admitted to the facility on [DATE] with diagnosis that include but are not limited to chronic kidney disease stage IV, morbid obesity, bradycardia, and fluid overload. Review of Resident #273 physician orders revealed the resident had an order to check dialysis line every shift for signs and symptoms of infection or bleeding with a start date of 03/20/22. Review of Resident #273's care plan revealed the resident had a care plan initiated on 03/20/20 stating I utilize HEMO dialysis related to end stage renal disease. The care plan contained an intervention to clinically assess the resident upon return to the facility from dialysis center dated 03/20/20. Review of Resident #273's progress notes revealed progress note 03/17/22 at 4:52 P.M. revealed the resident returned from having dialysis catheter placed. Review of Resident #273's Treatment Administration Record (TAR) for March 2022 revealed the record contained no documentation to the resident having her dialysis access site checked on 03/17/22, 03/18/22, or 03/19/22. Resident #273 did not have her dialysis access site monitored every shift until 03/20/22. Review of progress note dated 03/18/22 at 10:32 P.M. revealed Resident #273 requested her dialysis catheter to be checked as she felt it was pulling and the nurse charted the Registered Nurse (RN) supervisor assessed the area and reinforced the dressing. The progress notes contained no documentation regarding any other assessment or monitoring of the dialysis access catheter. Review of progress note dated 03/19/22 at 10 :54 P.M. revealed Resident #273 had her first dialysis today reports being tired no other issue. Review of progress note on 03/19/22 at 11:25 P.M. revealed the note was a skilled progress note with no mention of the resident return from dialysis clinical assessment. Review of Resident #273's hard medical record revealed post dialysis clinical assessment documentation was complete for dialysis services on 03/21/22; however, the post dialysis clinical assessment documentation was not completed after the first dialysis treatment on 03/19/22. During an interview with Resident #273 on 03/21/22 at 1:24 P.M. revealed the facility staff have not been assessing her dialysis catheter. During an interview with Licensed Practical Nurse (LPN) #704 on 03/23/22 at 10:00 A.M. revealed if a resident at the facility has dialysis services the dialysis access would be monitored and assessed every shift. 365997 Page 5 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0698 Level of Harm - Minimal harm or potential for actual harm During an interview with RN #752 on 03/23/22 at 10:57 A.M. confirmed Resident #273 did not have documentation of the dialysis catheter being ordered to be monitored until 03/20/22 and the record contained no documentation to the resident's catheter being monitored from 03/17/22 when it was inserted until 03/20/22 with the exception of one time on 03/18/22 when the resident requested to have the catheter assessed. Residents Affected - Few During an interview with RN #738 on 03/23/22 at 9:40 A.M. revealed Resident #273 leaves for dialysis early before her shift starts at 7:00 A.M. and returns around 11:00 A.M. During an interview with LPN #704 on 03/23/22 at 10:00 A.M. revealed if a resident at the facility has dialysis services it is the standard to assess the resident upon return to the facility after dialysis treatment. LPN #704 revealed the assessment would include obtaining the resident's vital signs and checking the access site. During an interview with RN #738 on 03/23/22 at 11:05 A.M. confirmed the post dialysis clinical assessment was not completed on 03/19/22 after the resident returned to the facility from dialysis treatment. RN #738 also confirmed the dialysis treatment time for 03/19/22 was at 6:00 A.M. During an interview with RN #801 on 03/24/22 at 3:30 P.M. revealed the facility does not have a policy for dialysis. 365997 Page 6 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on review of personnel files and staff interview, the facility failed to ensure one State Tested Nurse Aide (STNA) received training and competencies when caring for residents with dementia. This affected one (STNA #759) out of eight personnel files reviewed and had the potential to affect 40 (#372, #28, #55, #3, #59, #27, #68, #47, #11, #6, #38, #8, #33, #14, #35, #43, #53, #39, #17, #34, #20, #5, #60, #24, #61, #64, #2, #63, #69, #54, #31, #19, #36, #71, #49, #7, #57, #1, #16 and #62) residents in the facility diagnosed with dementia who STNA #759 provided care. The facility census was 74. Findings include: Review of the personnel file for STNA #759 revealed a hire date of 03/23/20. Further review revealed STNA #759 completed training for the care of residents with dementia on 04/25/20. Review of STNA #759's personnel file revealed there was no further training or competencies on the care of residents with dementia was documented. Interview on 03/24/22 at approximately 3:15 P.M. with the Human Resources Manager #773 confirmed STNA #759 did not complete any training or competencies on the care of residents with dementia since 04/25/20. Further interview revealed STNA #773 was a current employee and did not have any gaps in his employment since his hire date. The facility confirmed STNA #759 provided care to residents with dementia which included a total of 40 (#372, #28, #55, #3, #59, #27, #68, #47, #11, #6, #38, #8, #33, #14, #35, #43, #53, #39, #17, #34, #20, #5, #60, #24, #61, #64, #2, #63, #69, #54, #31, #19, #36, #71, #49, #7, #57, #1, #16 and #62) residents. 365997 Page 7 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on personnel files review and staff interview, the facility failed to ensure one State Tested Nurse Aide (STNA) received 12 hours of annual training. This affected one (#759) out of five STNA personnel files reviewed and had the potential to affect all 74 residents residing in the facility. The facility census was 74. Residents Affected - Many Findings include: Review of the personnel file for STNA #759 revealed a hire date of 03/25/20. Continued review revealed STNA #759 completed eight hours of continuing education in 2021. Further review revealed STNA #759 completed five hours of continuing education in the last 12 months. Interview on 03/24/22 at 1:45 P.M. with the Human Resource Manager #773 confirmed STNA #759 did not complete 12 hours of annual training. Further interview revealed STNA #759 was a current employee and had no gaps in his employment since his hire date. 365997 Page 8 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During on observation on 03/21/22 at 8:55 A.M. of the refrigerator which was located in the Olganz dining area, outside the kitchen serverery revealed in the freezer there was a Styrofoam container with a utensil handle sticking out of the foil that was covering the container. The observations revealed a paper napkin on top of the Styrofoam container which read 109. No thermometer was visualized in the freezer. Observation of the refrigerator revealed multiple food items in the refrigerator which included a 13 by nine inch glass dish with a brown cookie like substance that was 3/4 the way full, aluminum foil was attached to one end of the dish with the other end sticking straight up half way down the length of the dish, leaving the substance uncovered there was no label on the aluminum foil to indicate the date the food was placed in the refrigerator or what the dish contained. There was a 32 ounce container of great value low fat peach yogurt that was 3/4 empty with a manufacture use by date of 04/14/22, and no other label on the container indicating when the item was placed in the refrigerator or which resident the item belonged to. There was a clear plastic food container with a red lid inside a a plastic zip gallon bag labeled 110, two servings of lasagna, there was no date indicating when the food item was placed in the refrigerator. There was a full 32 ounce plastic container with a label reading Berard's seafood bisque in a brown paper sack labeled room [ROOM NUMBER], there was no date on the soup container or the bag to indicate when the soup was placed in the refrigerator. There were two pitchers of red liquid, that were approximately 1/4 full, one was dated 03/13/22, and the other was undated. There was one 7-Up, 16 oz bottle with no labeling on the bottle. There was no thermometer visualized in the refrigerator. During an observation of the refrigerator with the Director of Nursing (DON) 03/21/22 at 9:15 A.M. revealed the refrigerator was for employee use. When the contents of the refrigerator and freezer were observed with the DON, the DON identified the item in the freezer was a partial bowl of ice cream. The DON verified there were items in the refrigerator that appeared to be for both staff and resident use. The DON also verified the items lacked the proper labeling and there were not thermometers present in the either the freezer or refrigerator to know if the food was being kept at the correct temperature. The facility confirmed 72 out of 74 residents receive meals from the facility kitchen and there are two (#21 and #70) residents who received no food by mouth. During an observation of the Olganz kitchen serverery refrigerator with Dietary Worker #849 on 03/21/22 at 12:30 P.M. revealed there was a plastic container with a label that read chicken noodle soup dated 03/17/22. Dietary Worker #849 revealed the soup is made up in advance and kept in the refrigerator and served to residents on the hall as they request. Dietary Worker #849 verified the soup was out of date. Review of undated Sanitation Policy revealed the food service areas shall be maintained in a clean and sanitary manner. Further stating under policy interpretation and implementation all kitchens, kitchen areas, dining areas shall be kept clean and free from litter and rubbish with equipment maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. Review of Food Storage Policy dated 2019 revealed food will be stored in areas that are clean, dry and free of contaminants. Stock must be rotated with each new order, old stock out first (first in, first out). Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 365997 Page 9 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0812 seven days or discarded. Level of Harm - Minimal harm or potential for actual harm Review of the Leftovers Policy dated 2019 states leftovers will be covered, labeled and dated; then stored appropriately. Leftovers that have not been properly stored will be discarded. Additionally, leftovers can be used within seven days with the day of preparation is counted as day one. Residents Affected - Some Review of the Labeling, Dating and Covering Foods with a revision date of 05/2000 revealed food shall be stored in such a manner to prevent contamination. Open food shall be stored in an appropriate container and covered with plastic wrap or a lid that fits the container. The wrap or lid must be airtight. All foods and containers must be labeled and dated. Based on observations, staff interviews, and review of facility policies, the facility failed to ensure kitchen areas were maintained in a clean and sanitary condition and failed to ensure food was labeled/dated appropriately. This had the potential to affect 72 out of 74 residents who received meals from the facility kitchen, the facility identified two (#21 and #70) residents who received no food by mouth. The facility census was 74. Findings include: 1. The following concerns were noted during the initial kitchen tour conducted on 03/21/22 between 7:25 A.M. and 7:55 A.M. Observation at 7:25 a.m. a black substance on the ceiling, air vents and light fixtures over the preparation tables Interview with the Dining Services Assistant (DSA) #739 at 11:10 A.M. revealed cooks were responsible for cleaning the kitchen. DSA #739 verified the black substance on ceiling and light fixtures stating she did not know what the substance was but that it looked like duct. 2. The following concerns were noted during the initial unit kitchen tours conducted on 03/21/22 between 8:55 A.M. and 9:50 A.M. At 8:55 A.M. the tour of [NAME] Court kitchen revealed an unlabeled and undated clear plastic container with a white lid containing a pink substance sitting to the right on the first shelf of the refrigerator and an undated, open plastic bag of yellow cheese slices on the second shelf of the refrigerator. At the time of the observation, Dining Service Assistant #839 identified the pink substance as thickener, further adding the pink liquid should have been labeled and dated when it came from the main kitchen. Dining Service Assistant #839 verified the plastic bag holding the yellow cheese was open and should be sealed, labeled and dated. At 9:30 A.M. the tour of Boeckling Court revealed a half full, partially covered white cup with a white plastic spoon sticking out above the rim of the cup containing a white and black substance. The cup was not dated and labeled with a illegible name. Interview with the Director of Dining Services #711 verified this is not the way resident food is to be stored. Further adding facility policy states resident food should be labeled and dated. 365997 Page 10 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some At 9:50 A.M. the tour of [NAME] kitchen revealed a stainless steel refrigerator in the service kitchen with drip marks down the exterior front and unknown white substance on the ice maker dispenser tray which left residue on finger when rubbed. Inside the refrigerator an opened undated and unlabeled minute maid cranberry apple raspberry juice in left drawer. Additionally, on the right middle shelf an open undated half empty container of broccoli cheddar soup labeled with Resident #55's first name. On the bottom of the open soup container with a use by date of 02/18/22. Interview at the time of the observation, Dining Service Assistant #771 verified the minute maid cranberry apple raspberry juice was open, undated and not labeled, further stating the open juice container should be labeled and dated. Dining Service Assistant #771 verified the use by date of 02/18/22, further stating the soup should have been disposed of. Observation on 03/21/22 at 11:51 A.M. of the [NAME] kitchen ceiling revealed a brown color mark with cracked, peeling paint in a circular pattern to the right of the ceiling light in middle of kitchen above the refrigerator. Interview at the time of the observation with Dining Service Assistant #771 revealed she was unaware of the brown mark with cracked, peeling paint, claiming she has never noticed it. Interview on 03/23/22 at 10:48 A.M. with Maintenance Director #900 and the Administrator revealed there had been a pipe leak a couple [NAME] ago which likely resulted in the ceiling damage to the [NAME] kitchen. The Administrator stated he was unaware of the damage and is not sure why it had not been taken care. 365997 Page 11 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to offer pneumococcal vaccinations to residents. This affected one (#16) of five residents reviewed for pneumococcal vaccinations. The facility census was 74. Residents Affected - Few Findings include: Review of the medical record revealed Resident #16 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), pressure ulcer of sacral region, vascular dementia, chronic kidney disease, cerebral infarction (stroke), pleural effusion (excessive fluid in spaces surrounding the lungs), heart failure, major depressive disorder, Coronavirus Disease 2019 (COVID-19), and malignant neoplasm of unspecified ovary. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/06/22 revealed Resident #16 was moderately cognitively impaired and up to date on her pneumococcal vaccine. Review of Resident #16's pneumococcal vaccination record, dated 11/01/19, revealed the resident received a single vaccination of Prevnar 13 (PCV13). The record contained no documentation for vaccination with Pneumovax 23 (PPSV23). Interview on 03/23/22 at 3:00 P.M. of Infection Preventionist (IP) #822 revealed pneumococcal vaccination included both a dose of PCV13 and PPSV23. IP #822 stated Resident #16 would have been due for PPSV23 in the fall of 2020, but the resident had COVID-19 in September 2020 and she believed there was a delay in administration of PPSV23 because of that. IP #822 stated she would have to look into whether Resident #16 had been offered PPSV23. Interview on 03/24/22 at 9:44 A.M. of IP #822 verified Resident #16 had not been offered the PPSV23 vaccination. Interview on 03/24/22 at 1:33 P.M. of the Director of Nursing (DON) revealed the admitting nurse verified a resident's vaccination status. The DON stated this was sometimes difficult to do because the resident, family, and physician did not always know the information. The DON stated the facility was working on gaining access to the state's vaccination reporting system to assist with vaccination verification. While the MDS nurse reviewed vaccination status during assessment periods, the DON verified the facility did not have a process in place to monitor and track vaccinations to ensure any additional pneumococcal doses were offered. The DON stated the MDS nurse must have missed Resident #16 had not been offered or received the PPSV23 vaccine. Review of facility policy titled Pneumococcal Immunizations, revised 09/01/21, revealed the DON or designee would coordinate and implement all activities. Additionally, residents age [AGE] years or older would receive PCV13 followed in one year by by PPSV23. 365997 Page 12 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of Nation Emergency dated 03/13/20, review of the Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL, review of the staff Coronavirus Disease 2019 (COVID-19) vaccination list, review of staff personnel records, review of staff timecards, review of facility policy, and staff interview, the facility failed to implement their vaccination policy and monitor staff members to ensure that 100 percent (%) of staff have received the COVID-19 vaccine, have an approved exception, or have been identified as appropriate temporary delay per Centers for Disease Control (CDC) guidance. The vaccination rate for the facility was calculated at 96.8%. The facility census was 74. Residents Affected - Few Findings included: Review of the facility staff COVID-19 vaccination list, undated, revealed the facility had a total of 127 employees. There were 102 employees fully vaccinated for COVID-19, two employees partially vaccinated for COVID-19 and 18 employees had granted exemptions. Three, State Tested Nursing Assistants (STNA's), #720, #772 and #828, and one, Dietary Services Aide (DSA) #737 were identified as not having been vaccinated, having an exemption or a temporary delay per CDC guidance. This indicated a staff vaccination rate of 96.8%. Interview on 03/22/22 at 10:15 A.M. of Human Resources (HR) #773 verified STNA's #772 and #828 and DSA #737 were not vaccinated for COVID-19 and had not requested an exemption. HR #773 stated STNA #720 was a recent rehire and had no evidence of a COVID-19 vaccination, had not requested an exemption and had no delay per CDC guidance. HR #773 verified STNA's #772, #828, #720, and DSA #737 had been working and providing resident care. HR #773 stated the facility thought they had until April 13, 2022 to be in compliance with the regulation but recently learned they were required to be at 100% staff vaccination rate. HR #773 verified the facility policy indicated all staff employed prior to 12/06/21 had to be fully vaccinated for COVID-19 prior to 01/04/22 and staff hired after 12/06/21 must have received at least one dose of a COVID-19 vaccine prior to providing any care to residents. The facility confirmed there have been no new COVID-19 cases within the past four weeks. Review of STNA #720's personnel file revealed a hire date of 03/11/22. Review of STNA #720's timecard report from 03/11/22 through 03/23/22 revealed she worked on 03/11/22, 03/19/22, and 03/20/22. Review of STNA #772's personnel file revealed a hire date of 09/13/21. Review of STNA #772's timecard report from 02/13/21 through 03/23/22 revealed the STNA worked 02/18/22, 02/21/22, 02/26/22, 02/27/22, 03/04/22, 03/07/22, 03/12/22, 03/13/22, 03/18/22, and 03/21/22. Review of STNA #828's personnel file revealed a hire date of 10/15/03. Review of a timecard report from 02/13/22 through 03/23/22 revealed STNA #828 worked 02/16/22, 02/17/22, 02/18/22, 02/21/22, 02/22/22, 02/23/22, 02/24/22, 02/26/22, 02/27/22, 03/02/22, 03/03/22, 03/04/22, 03/07/22, 03/08/22, 03/09/22, 03/10/22, 03/12/22, 03/13/22, 03/16/22, 03/17/22, 03/18/22, and 03/21/22. Review of DSA #737's personnel file revealed a hire date of 11/29/21. Review of a timecard report from 02/13/22 through 03/23/22 revealed DSA #737 worked 02/16/22, 02/17/22, 02/18/22, 02/23/22, 02/24/22, 02/25/22, 02/26/22, 02/27/22, 03/02/22, 03/03/22, 03/04/22, 03/09/22, 03/10/22, 03/12/22, 03/13/22, 03/16/22, 03/17/22, and 03/18/22. Review of facility policy titled COVID-19 Staff Vaccine Policy, dated 11/16/21, revealed all staff 365997 Page 13 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0888 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hired or engaged before 12/06/21 must have received, at a minimum, the first dose of a primary series or a single dose COVID-19 vaccine by 12/05/21. All staff hired or engaged before 12/06/21 must be fully vaccinated against COVID-19 by 01/04/22. Additionally, all staff hired or engaged after 12/06/21 must have received, at a minimum, the first dose of a two dose COVID-19 vaccine or a one-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the community and/or its residents. Further review revealed exemptions would be made under certain circumstances and staff requesting an exemption should contact human resources. COVID-19 health care staff vaccination, dated 01/14/22, revealed CMS expected all providers' and suppliers' staff to have received the appropriate number of doses by the time frames specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by the Centers for Disease Control (CDC). Facility staff vaccination rates under 100% constitute non-compliance under this rule. Within 30 days after issuance of this memorandum, less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule. Within 60 days after issuance of this memorandum, 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple-dose vaccine series), or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule. 365997 Page 14 of 15 365997 03/28/2022 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview, the facility failed to ensure resident rooms and bathrooms were maintained in good repair. This had the potential to affect 15 (#20, #53, #60, #43, #33, #38, #24, #55, #49, #10, #3, #68, #2, #61, and #372) residents residing on the secured memory care unit. The facility census was 74. Findings include: Observation on 03/21/22 at 8:08 A.M. of Resident #38's room on the secured memory care unit revealed several quarter sized areas on the wall near the closet door with chipped paint and drywall and scrape marks along the walls. Observation on 03/21/22 at 8:31 A.M. of the Parlor B shower room on the secured memory care unit revealed cracked and peeling paint on the ceiling, near the vent. The paint was hanging from the ceiling. Interview on 03/21/22 at 8:44 A.M. of State Tested Nurse Aide (STNA) #811 verified the chipped paint and drywall and scrape marks on Resident #38's walls. STNA #811 stated the resident utilized a wheelchair and a hoyer lift and the damage was likely the result of the walls being hit. STNA #811 stated maintenance was generally good about making any needed repairs, if they were aware of the need. STNA #811 was uncertain if any work orders had been submitted for the repairs. Interview on 03/23/22 at 10:48 A.M. of the Administrator, Maintenance Director (MD) #900, and Maintenance Technician (MT) #707 verified the damage to Resident #38's walls and the ceiling in the Parlor B shower room. MT #707 stated the peeling paint on the ceiling in the Parlor B shower room was likely due to hot showers causing condensation resulting in the peeling paint. MD #900 stated the current process was for staff to complete a work order, but staff would sometimes stop MT #707 in the hall and make him aware of any maintenance needs. MT #707 verified maintenance had not received any work orders for Resident #38's room or the Parlor B shower room and he was unaware of any maintenance needs. The Administrator stated the facility would be outsourcing maintenance beginning in April 2022 and he felt this was going to help with addressing any issues and maintaining the facility. The facility confirmed the identified areas of concern had the potential to affect 15 (#20, #53, #60, #43, #33, #38, #24, #55, #49, #10, #3, #68, #2, #61, and #372) residents residing on the secured memory care unit. 365997 Page 15 of 15