Health inspection·August 29, 2019

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure water temperatures were maintained at a comfortable level for resident use between 105 - 120 degrees Fahrenheit in resident rooms and shower rooms. This had the potential to affect all 50 residents residing in the facility. Residents Affected - Many Findings include: 1. On 08/26/19 at 10:30 A.M. interview with Resident #6 revealed he wished the water in his room was hotter. Resident #6 explained he often took sponge baths and the water was not as hot as he would like it. On 08/26/19 at 10:36 A.M. interview with Resident #38 revealed she had to let the hot water in her room run a long time before it would get warm. Review of the facility document titled Water Temperatures, dated 06/10/19 to 08/26/19 revealed all water temperatures below 106 or above 119 F would be immediately regulated to be in mid range by the Maintenance Supervisor. The documented water temperatures varied in a range of 112-118 in resident rooms and the shower rooms during this time period. An interview was conducted on 08/27/19 at 2:58 P.M. with Maintenance Supervisor (MS) #800 who stated he checked water temperatures in residents rooms and shower rooms once a week and the temperatures had been right around 116 to 117 degrees Fahrenheit (F). 2. On 08/27/19 from 2:59 P.M. to 3:09 P.M. water temperatures were obtained with MS #800 in resident rooms and shower rooms using a calibrated, digital thermometer. The results were as follows: room [ROOM NUMBER] - 95.5 degrees Fahrenheit (F). room [ROOM NUMBER] - 90.0 degrees F. room [ROOM NUMBER] - 92.0 degrees F. room [ROOM NUMBER] - 114.2 F room [ROOM NUMBER] - 89.2 degrees F. Page 1 of 5 366191 366191 08/29/2019 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0558 The B shower room B - 114 degrees F. Level of Harm - Potential for minimal harm During the above observations MS #800 let each water faucet run for two to four minutes before reading a final temperature. MS #800 revealed he did not know why there was such a difference in the room water temperatures. Residents Affected - Many On 08/29/19 from 8:37 A.M. to 8:55 A.M. additional observations of the water temperatures during a tour with MS #800 of resident rooms and the shower room water temperatures revealed the following: room [ROOM NUMBER] - 95 degrees F. room [ROOM NUMBER] - 95.4 degrees F. Shower room B on 100 hall - 113 F. room [ROOM NUMBER] - 107 degrees F. room [ROOM NUMBER] - 109 degrees F. Shower room C1- 108 degrees F. Shower room C2 - 91.0 degrees F after running the water from 8:53 A.M. to 8:55 A.M. On 08/29/19 at 9:11 A.M. interview with the Administrator revealed the facility was purchasing a circulation pump that would detect water temperatures in the pipes and work to circulate the water supply to keep water temperatures within an acceptable range for the residents. On 08/29/19 at 11:07 A.M. interview with State Tested Nursing Assistant (STNA) #329 revealed she had noticed the hot water temperatures were not consistent and not every resident room had a problem with hot water not being hot enough just some of the rooms. STNA #329 added she did not use shower room C2 because the water does not get hot enough to comfortably shower residents so she used only shower room C1. On 08/29/19 at 2:48 P.M. interview with MS #800 revealed the facility did not have a policy on how to regulate and monitor water temperatures. He added he had the guideline he followed at the bottom of the water temperature logs. 366191 Page 2 of 5 366191 08/29/2019 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to administer pneumococcal vaccines upon informed consent or obtain a signed informed consent. This affected five residents (#10, #14, #20, #42, and #46) of five residents reviewed for pneumococcal vaccines. Residents Affected - Some Findings include: 1. Record review for Resident #20 revealed an admission date of 05/18/16 and diagnoses including chronic kidney disease, and seasonal allergic rhinitis. Resident #20's record did not show any documentation she received the pneumococcal vaccine or any documentation as to the vaccine being medically contraindicated. Review of form titled, Informed Consent for Pneumococcal Vaccine for Resident #20 revealed she signed and dated the informed consent on 08/24/18 stating she gave the facility permission to administer a pneumococcal vaccination unless medically contraindicated. 2. Record review for Resident #42 revealed an admission date of 08/17/17 and diagnoses including Parkinson's disease, hypertension, and Alzheimer's disease. Resident #42's record did not show any documentation he received the pneumococcal vaccine or any documentation as to the vaccine being medically contraindicated. Review of form titled, Informed Consent for Pneumococcal Vaccine for Resident #42 revealed the facility received a telephone consent on 10/19/18 from Resident #42's wife stating she gave the facility permission to administer a pneumococcal vaccination unless medically contraindicated. 3. Record review for Resident #10 revealed an admission date of 12/20/17 and diagnoses including hypertension, diabetes, and asthma. Resident #10's record did not show any documentation she received the pneumococcal vaccine or any documentation as to the vaccine being medically contraindicated. Review of form titled, Informed consent for Pneumococcal Vaccine for Resident #10 revealed she signed stating she gave the facility permission to administer a pneumococcal vaccination unless medically contraindicated. 4. Record review for Resident #14 revealed an admission date of 06/01/18 and diagnoses including heart failure and chronic atrial fibrillation. Review of Resident #14's record did not show any documentation she received the pneumococcal vaccine or any documentation as to the vaccine being medically contraindicated. Review of form titled, Informed consent for Pneumococcal Vaccine for Resident #14 revealed she signed stating she gave the facility permission to administer a pneumococcal vaccine unless medically contraindicated. The informed consent was not dated. 5. Record review for Resident #46 revealed an admission date of 02/19/18 and diagnoses including hypertension and asthma with acute exacerbation. Resident #46's record did not show any documentation she received the pneumococcal vaccine or any documentation as to the vaccine being medically contraindicated. Review of form titled, Informed consent for Pneumococcal Vaccine for Resident #46 revealed the box 366191 Page 3 of 5 366191 08/29/2019 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was marked with a X giving the facility permission to administer a pneumococcal vaccination unless medically contraindicated. The informed consent was not signed or dated. Interview on 08/29/19 at 1:23 P.M. with the Director of Nursing and Assistant Director of Nursing (ADON) #328 verified they received signed consents from Resident #10, #14, #20, and #42 but had no documentation the pneumococcal vaccine was administered or any documentation the vaccine was medically contraindicated from being administered. They verified Resident #46's consent was marked with an X to receive the vaccine but was not signed or dated. They had no other documentation regarding Resident #46 consenting or refusing the pneumococcal vaccine or any documentation she received the vaccine or that the vaccine was medically contraindicated. Interview on 08/29/19 at 2:34 P.M. with the Director of Nursing revealed the facility did not have a policy regarding Pneumococcal vaccines. 366191 Page 4 of 5 366191 08/29/2019 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide single rooms with at least 100 square feet of living space in each room. This affected six residents (#49, #48, #5, #7, #39, and #41) of 50 residents residing in the facility. Findings include: Interview on 08/28/19 at 9:42 A.M. with the Administrator revealed the facility had six single rooms with less than the required 100 square footage of living space. Six of the six rooms were occupied by residents at the time of the survey. Review of the space/occupancy certification waiver applications revealed Resident #49, #48, #5, #7, #39, and #41 were in single rooms that measured less than the required 100 square feet of living space. The room measurements and residents affected were as follows: room [ROOM NUMBER] (Resident #49) 96.47 square feet. room [ROOM NUMBER] (Resident #48) 93.15 square feet. room [ROOM NUMBER] (Resident #5) 96.46 square feet. room [ROOM NUMBER] (Resident #7) 93.55 square feet. room [ROOM NUMBER] (Resident #39) 97.75 square feet. room [ROOM NUMBER] (Resident #41) 91.50 square feet. 366191 Page 5 of 5