Health inspection·May 2, 2024

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. Based on record review and staff interview the facility failed to ensure nonpharmacological interventions were attempted and/or behaviors were documented prior to the administration of as needed psychotropic medications. This affected one (Resident #37) of five residents reviewed for unnecessary medications. The facility census was 68. Findings include: Review of the medical record for Resident #37 revealed an admission date of 06/02/21 with diagnoses including unspecified dementia, muscle weakness, depression, unspecified mood disorder, anxiety disorder, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #37 dated 01/30/24 revealed the resident had severely impaired cognition and was coded for receiving antipsychotic, antianxiety, and antidepressant medications. Review of the care plan for Resident #37 revised 02/07/24 revealed the resident had the potential for adverse or less than effective results from psychoactive medications. The resident was on antidepressants and medication for anxiety. Interventions included the following: consult with the physician about reductions and schedule per regulations, document on mood and behavior as needed, monitor for side effects of medication, report to the physician as needed. Review of the physician's orders for Resident #37 revealed orders dated 02/28/24 to 03/12/24, 03/13/24 to 03/26/24, 03/27/24 to 04/09/24, 04/11/24 to 04/24/24, and 04/24/24 to 05/07/24, for Ativan/Benadryl/Haldol (ABH) gel to be applied topically every six hours as needed. Review of the physician's orders for Resident #37 revealed an orders dated 02/28/24 to 03/12/24, 03/13/24 to 03/26/24, 03/27/24 to 04/09/24, 04/11/24 to 04/24/24, and from 04/24/24 to 05/07/24 for Ativan 0.5 milligrams (mg) one tablet every six hours as needed. Review of the Medication Administration Record (MAR) for Resident #37 dated March 2024 revealed ABH gel was administered on 03/06/24 with no nonpharmacological intervention documented prior to administration. ABH gel was also administered on 03/15/24, 03/19/24, and 03/31/24 with no documentation indicating why the drug was needed and no nonpharmacological interventions. Ativan tablets were administered on 03/12/24, 03/18/24, and 03/26/24 with no nonpharmacological interventions documented. Ativan was also administered on 03/02/24, 03/09/24, and 03/16/24 with no documentation indicating why the drug was needed and no nonpharmacological interventions noted. Page 1 of 5 366076 366076 05/02/2024 Ohio Eastern Star Hlth Care Ctr The 1451 Gambier Road Mount Vernon, OH 43050

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress notes for Resident #37 dated 03/02/24 to 03/31/24 revealed they did not include documentation of behaviors or nonpharmacological interventions attempted on 03/02/24, 03/06/24, 03/09/24, 03/12/24, 03/15/24, 03/16/24, 03/18/24, 03/19/24, 03/26/24, and 03/31/24. Review of the MAR for Resident #37 dated April 2024 revealed ABH gel was administered on 04/05/24 with no nonpharmacological intervention documented. ABH gel was also administered on 04/17/24 with no documentation indicating why the drug was needed and no nonpharmacological intervention documented. Ativan tablets were administered on 04/13/24 and 04/16/24 with no nonpharmacological intervention documented. Ativan was also administered on 04/05/24, 04/15/24, and 04/17/24 with no documentation indicating why the drug was needed and no nonpharmacological interventions documented. Review of the progress notes for Resident #37 dated 04/05/24 to 04/17/24 revealed there was no documentation indicating behaviors or nonpharmacological interventions on 04/05/24, 04/13/24, 04/15/24, 04/16/24, and 04/17/24. Review of the care plan for Resident #37 dated 04/22/24 revealed the resident demonstrated behaviors such as agitation and had diagnoses including mood disorder and anxiety. The resident yelled at staff during care and had agitation. Interventions included the following: call the resident's family when resident is anxious, assess and record changes in behaviors, report significant changes to staff and physician, educate and discuss with the family concerns and causal factors of behaviors. Interview on 05/02/24 at 11:06 A.M. with the Director of Nursing (DON) confirmed the facility did not have documentation for behaviors or nonpharmacological interventions in conjunction with administration of as needed ABH gel and Ativan tablets for Resident #37. 366076 Page 2 of 5 366076 05/02/2024 Ohio Eastern Star Hlth Care Ctr The 1451 Gambier Road Mount Vernon, OH 43050

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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** Based on observation, staff interview, review of an owner's manual, and review of the facility policy, the facility failed to maintain the kitchen in a clean condition and failed to maintain kitchen equipment in proper working condition to prevent contamination and/or food borne illness. The had the potential to affect all residents in the facility. The facility census was 68. Findings include: 1.Observation on 04/29/24 at 10:47 A.M. with [NAME] #169 revealed the bottom of two hot holding units were covered in food debris. Interview on 04/29/24 at 10:47 A.M. with [NAME] #169 confirmed the bottoms of both units were not clean and they should be cleaned every two to three weeks. Observation on 04/29/24 at 10:53 A.M. with [NAME] #169 and Dietary Manager (DM) #170 revealed there was a large thick frozen puddle of a dark brown and red substance on floor of walk-in freezer. Interview on 04/29/24 10:53 A.M. with [NAME] #169 confirmed the substance on the floor of the walk-in freezer was a puddle of corned beef juice frozen to the ground. Observation on 04/29/24 at 11:13 A.M. with [NAME] #169 and DM #170 revealed there was a sticky residue and sticker paper on plastic containers on the clean drying rack. Interview on 04/29/24 at 11:13 A.M. with [NAME] #169 confirmed the presence of the sticky residue on the plastic containers and immediately took four small square containers to the dishwasher. Review of the facility policy titled Main Kitchen Cleaning Checklist undated revealed staff tasks included detailed cleaning of the warming boxes, inside and out, and detailed cleaning of the coolers and freezers to be completed monthly. 2. Interview on 04/29/24 at 11:04 A.M. with DM #170 confirmed the facility had high temperature sanitizing dishwashers and the rinse water temperature to reach was 180 degrees Fahrenheit (F) when staff completed temperature checks. DM #170 also confirmed the facility had five satellite kitchens within the neighborhoods of the facility. Observation on 04/29/24 at 12:10 P.M. of the [NAME] neighborhood dishwasher revealed DM #170 used a temperature strip to test the dishwasher hot rinse temperature. The strip was supposed to turn black when it reached 180 degrees F, but it only turned white and gray. Observation on 04/29/24 12:15 P.M. revealed DM #170 used a thermometer to test the [NAME] neighborhood dishwasher hot rinse temperature again and the high temperature measured 162 degrees F. Interview on 04/29/24 at 12:15 P.M. with DM #170 again confirmed the hot rinse temperature of the dishwasher should be 180 degrees F. Observation on 04/29/24 at 12:17 P.M. revealed DM #170 tested the temperature of the [NAME] 366076 Page 3 of 5 366076 05/02/2024 Ohio Eastern Star Hlth Care Ctr The 1451 Gambier Road Mount Vernon, OH 43050

F 0812 neighborhood dishwasher hot rinse a third time using a thermometer and it tested 152 degrees F. Level of Harm - Minimal harm or potential for actual harm Observation on 04/29/24 at 12:28 P.M. of the Lilly Neighborhood dishwasher revealed DM #170 tested the dishwasher hot rinse temperature with a thermometer and the high temperature read 163 degrees F. Residents Affected - Many Observation on 04/29/24 at 12:31 P.M. revealed DM #170 ran the Lilly neighborhood dishwasher a second time. Server #343 read the thermometer for the dishwasher hot rinse temperature and said it tested at 156 degrees F. Observation on 04/29/24 12:36 P.M. revealed DM #170 ran the Lilly neighborhood dishwasher a third time. Server #343 read the thermometer for dishwasher hot rinse and said it tested at 147.6 degrees F. Observation on 04/29/24 at 12:39 P.M. revealed DM #170 tested the [NAME] neighborhood dishwasher hot rinse temperature with a thermometer. When DM#170 attempted to read the thermometer, it was turned off. Observation on 04/29/24 at 12:44 P.M. revealed DM #170 ran the [NAME] neighborhood dishwasher a second time. Server #341 read the thermometer and said the hot rinse temperature was 147 degrees F. Observation on 04/29/24 at 12:47 P.M. revealed DM #170 ran the [NAME] neighborhood dishwasher a third time using a heat strip which did not turn black to indicate it was heated to 180 degrees F. Interview on 04/29/24 at 12:53 P.M. with DM #170 confirmed it was the normal practice of the facility to test the dishwasher temperatures with heat strips and a thermometer. Observation on 04/29/24 at 01:03 P.M. revealed DM #170 tested the dishwasher rinse temperature of the [NAME] neighborhood with a temperature strip. The temperature did not turn a different color which meant the rinse water did not reach 180 degrees F. Observation on 04/29/24 at 01:06 P.M. revealed DM #170 ran the [NAME] neighborhood dishwasher a second time and tested the hot rinse water using a heat strip and a thermometer. The heat strip didn't change color and the thermometer read 147 degrees F. Observation on 04/29/24 at 01:08 P.M. revealed DM #170 ran the [NAME] neighborhood dishwasher a third and tested the hot rinse water using a heat strip and a thermometer. The heat strip didn't change color and the thermometer read 148 degrees F. Observation on 04/29/24 at 01:11 P.M. revealed DM #170 ran the [NAME] neighborhood dishwasher a fourth time and tested the hot rinse water using a heat strip and a thermometer. The heat strip didn't change color and the thermometer read 150 degrees F. Observation on 05/01/24 at 12:10 P.M. of the [NAME] neighborhood dishwasher with DM #170 revealed the dishwasher hot rinse temperature was checked with a thermometer and it was 170 degrees F. Observation on 05/01/24 at 12:16 P.M. of the [NAME] neighborhood dishwasher with DM #170 revealed the dishwasher hot rinse temperature was checked with a temperature heat strip and the dishwasher did not get to 180 degrees Fahrenheit. 366076 Page 4 of 5 366076 05/02/2024 Ohio Eastern Star Hlth Care Ctr The 1451 Gambier Road Mount Vernon, OH 43050

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 05/01/24 at 12:43 P.M. of the [NAME] neighborhood dishwasher with DM #170 revealed the dishwasher temperature was checked with a thermometer and it was 170 degrees F. Review of the poster hanging on the wall of the [NAME] neighborhood kitchen regarding dishwasher temperature checks revealed employees should power on the thermometer, set to Fahrenheit and obtain water temperatures. Review of the owner's manual for the dishwasher dated 03/01/22 revealed the wash temperature must be 155 degrees F minimum and the rinse temperature must be 180 degrees F minimum. Review of the facility policy titled Culinary-Dishes dated March 2020 revealed the facility staff should operate dishwashers and related machinery in accordance with all manufacturers' guidelines. 366076 Page 5 of 5