Health inspection·July 6, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to ensure the air conditioning units were working properly and temperatures were monitored to keep comfortable air temperatures for the residents. This affected four residents (Resident's #2, #11, #25, #31) who resided in the older section of the facility, ten residents (Resident's #6, #10, #13, #16, #19, #22, #24, #27, #29, #30) who resided in the secured memory nursing unit in the old area of the facility, and had the potential to affect ten residents (Resident's #1, #2, #5, #7, #9, #15, #17, #21, #23, #31) who ate in the dining area. The facility census was 33. Findings include: Review of the facility census revealed Resident #2, #11, #25, and #31 resided on the facility's older section of the facility. Resident #6, #10, #13, #16, #19, #22, #27, #29, and #30 resided on the secured memory care unit. Review of a list of residents that use the facility front dining room revealed Resident #1, #2, #5, #7, #9, #15, #17, #21, #23, #31 used the dining room. Review of Resident #2's medical record revealed an admission date of 11/06/21 and diagnoses included Huntington's Disease, major depressive disorder, and anxiety disorder. Review of Resident #2's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had severe cognitive impairment. Review of Resident #25's medical record revealed an admission date of 05/09/23 and diagnoses included congestive heart failure, type two diabetes mellitus, and hypertensive heart disease with heart failure. Review of Resident #25's admission MDS 3.0 assessment dated [DATE] revealed Resident #25's Brief Interview for Mental Status was not assessed. Review of Resident #31's medical record revealed an admission date of 01/14/22 and diagnoses included fracture of left femur, anxiety disorder, and type two diabetes with diabetic polyneuropathy. Review of Resident #31's admission MDS 3.0 assessment dated [DATE] revealed Resident #31's Brief Interview for Mental Status was not assessed. Page 1 of 4 366036 366036 07/06/2023 Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/06/23 at 8:23 A.M. of State Tested Nursing Assistant (STNA) #231 revealed she was assisting residents in the dining area. STNA #231 stated there was no air conditioning in the facility. STNA #231 stated for the past month and probably longer the air conditioning in the facility did not work. Observation on 07/06/23 at 8:23 A.M. of the dining area revealed it felt very warm and humid while standing still. Interview on 07/06/23 at 8:24 A.M. of Resident #25 revealed he was sitting in his room in the nursing unit close to the dining area. Resident #5 stated this whole section of the facility was too hot, it is the old section of the facility and he was told the air conditioning was being worked on. Resident #25 stated it was terrible the last few days because it was so hot. Resident #25 stated he told Maintenance Director (MD) #204 the facility was too hot, and did not understand why he was not given a window air conditioning unit. Resident #25 indicated he felt sick from the heat, and laid down because he had no energy. Resident #25 stated he was not eating his normal portions of food due to the heat. Observation on 07/06/23 at 8:24 A.M. of Resident #25 revealed he had a fan turned on in his room. Resident #25 indicated he kept the door closed and the fan on to help with the heat. Interview on 07/06/23 at 8:26 A.M. of STNA #221 revealed it had been horribly hot on the old side of the building for a few days and we felt like we were going to pass out. STNA #221 stated the thermometer read 90 degrees Fahrenheit in the dining area one of the days. STNA #221 stated the air conditioning was totally out since 06/30/23. STNA #221 stated she passed extra water with ice to help keep the residents hydrated and cool. Interview on 07/06/23 at 8:27 A.M. of Resident #31 revealed she resided in the old part of the facility and was sitting in her room with a fan on. Resident #31 stated it was really hot in the facility the past few days, she could not sleep, she did not feel well, she felt like she had no energy and could not do anything because of it. Interview on 07/06/23 at 8:34 A.M. of MD #204 revealed the air conditioning was turned off this morning because the air conditioners were getting worked on. MD #204 stated the workers took the air conditioner apart and left to get a needed part. Interview on 07/06/23 at 9:20 A.M. of the Director of Nursing (DON) revealed the older side of the facility had a different air conditioning system than the newer side of the facility. The DON stated she noticed it was warm on the old side of the building, and stated I say that every day. The DON stated the old part of the facility always had a temperature difference from the new area. The DON indicated she was not aware the air conditioning was not working. Observation on 07/06/23 at 10:10 A.M. of the outside area of the facility revealed two air conditioning unit with rust on some of the panels and other panels laying on the ground in front of the air conditioner. Observation of the inside area of the air conditioners revealed the air conditioners were not working. Observation on 07/06/23 at 10:18 A.M. of Resident #2 revealed he was lying on his bed, and his room felt very warm and humid. Resident #2 confirmed it was hot in his room, and stated it is always hot. 366036 Page 2 of 4 366036 07/06/2023 Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/06/23 at 10:51 A.M. of Registered Nurse (RN) #219 revealed she was assigned to the secured memory care nursing unit, which was located on the old side of the facility, and another nursing unit located on the old side of the facility. RN #219 stated it was very hot over the weekend, and she was dripping sweat she was so hot. RN #219 stated the air conditioner had not worked since 04/2023 and probably did not work before that. RN #219 stated Resident's #10, #11 and #31 absolutely complained about it being so hot. RN #219 stated the front room common area and dining area were very hot and had been for about a week. RN #219 stated she told someone about the heat in the facility but she could not remember who. Interview on 07/06/23 at 11:21 A.M. of Activities Director (AD) #228 revealed she conducted activities in the front room common area and the dining room, and both rooms were very warm. AD #228 stated she moved activities from the dining room to the front room because of the heat on 07/05/23 and today (07/06/23). AD #228 stated she did not notice what the temperature in the facility was, but it felt very warm. Interview on 07/06/23 at 11:27 A.M. of MD #204 revealed the air conditioning company conducted routine inspections of the heating and cooling systems of the facility twice a year. MD #204 stated during the spring inspection one of the air conditioners needed an igniter replaced. MD #204 indicated the humidity was really bad the past week and made it feel even warmer in the facility. MD #204 stated he did not monitor the temperature of the facility and document the temperatures on paper or in the electronic system. MD #204 stated he did not notice what the temperature on the thermometer was. MD #204 stated he monitored the temperature by walking around and feeling how warm it was, and staff made him aware of issues quickly. MD #204 stated on 07/03/23 he arrived at the facility and was told it was hot on the old side of the facility, he went to the old side, it felt warm and humid and he called the air conditioning company and set up service for 07/05/23 or 07/06/23. MD #204 stated residents told him it was hot and humid in the facility, but he did not remember which residents. MD #204 stated he installed a window air conditioning unit in Resident #11's room on 07/03/23 because her visitor said her room was really hot. MD #204 stated Resident #32 told him it was hot the same day he made the service call (07/03/23), but she already had a fan and did not install a window air conditioning unit. Interview on 07/06/23 at 12:29 P. M of RN #219 revealed she provided extra fluids, juice, popsicles, and frozen treats for the residents to help keep them hydrated and cool. Interview on 07/06/23 at 12:29 P.M. of Dietary Aide (DA) #230 revealed she was given permission to give the residents popsicles, ice cream, juice, ice to help keep them cool and hydrated. Observation on 07/06/23 at 12:35 P.M. of MD #204 revealed he checked the temperatures of the old side of the facility with a temperature device gun. MD #204 checked the temperature in the dining room and the exterior wall area was 83 degrees. Interview on 07/06/23 at 1:32 P.M. of Air Conditioning Rep (ACR) #246 revealed the air conditioning units were very old and had to be recharged because there was a micro leak in the system. ACR #246 stated when the air conditioners stopped blowing cold air they needed recharged. ACR #246 stated the air conditioning unit for the secured nursing unit needed replaced because it needed a part that was not manufactured anymore. ACR #246 stated the facility would need to use supplemental air like window air conditioning units in the secured memory care unit in the old area of the facility. Observation on 07/06/23 at 1:44 P.M. of MD #204 revealed he checked the temperature in the dining 366036 Page 3 of 4 366036 07/06/2023 Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691

F 0584 room with a temperature device gun and the temperature in the exterior wall area was 82. Level of Harm - Minimal harm or potential for actual harm Interview on 07/06/23 at 2:56 P.M. with Air Conditioning Company Service Rep (ACCSR) #247 revealed MD #204 called on 07/05/23 to set up appointment to have the air conditioners checked in the old side of the facility. ACCSR #247 stated they were too busy on 07/05/23 to come to facility but arrived on 07/06/23. Residents Affected - Some Interview on 07/06/23 at 3:27 P.M. of the DON and the Administrator revealed today was when the DON found out about the air conditioning not working. The DON stated yesterday MD #204 told her he called the air conditioning company to come to the facility to check the air conditioning units. The DON stated she received a text from STNA #221 on 07/01/23 about the old area of the facility being really hot. The DON stated she contacted MD #204 on 07/01/23 at 2:30 P.M. to look into the heat issue. The DON stated she did not work the weekend but worked on 07/01/23 and she did not feel the facility was excessively hot. The DON stated no one said anything to her about the old area of the facility being very hot. The DON stated she did not follow up with MD #204 about the reported heat level in the old area of the facility because she did not hear anything else from him and she did not think it was a problem. The DON stated if there was an issue MD #204 would bring it up in the morning meeting on 07/01/23, and he did not mention anything in the meeting about the heat level in the old area of the facility. The Administrator stated she had been helping another facility out and this was her first day in the facility this week. Interview on 07/06/23 at 3:42 P.M. of MD #204 revealed he got a text on Saturday 07/02/23 from the DON stating that it might be hot in the facility, and for him to check out the situation. MD #204 stated he installed a window air conditioning unit by the secured memory unit nursing station due to the heat level on the unit. MD #204 stated he reported that he installed window air conditioning units during the Monday (07/01/23) morning meeting, and he called the air conditioning company Monday morning and spoke with the service department to have someone come to facility to check out the air conditioning units. MD #204 stated this was done by phone call, he did not send any emails, and there was no documentation of the call. Review of the facility policy titled Safe and Homelike Environment undated included in accordance with residents' rights, the facility would provide a safe, clean, comfortable and homelike environment. The facility would maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. This deficiency represents non-compliance investigated under Complaint Number OH00144257. 366036 Page 4 of 4