Health inspection·June 5, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to maintain privacy for the medical records of Residents #26 and #46. This affected two residents (#26 and #46) of three residents reviewed for confidentiality of records. This had the potential to affect all 99 residents residing in the facility. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 12/12/23. Diagnoses included obstructive and reflux uropathy, secondary malignant neoplasm of the bone, malignant neoplasm of the prostrate, and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Resident #26 required extensive/substantial assistance for all activities of daily living. Resident #26 had an indwelling catheter for urine and was frequently incontinent of bowel. Review of the care plan dated 03/29/24 for Resident #26 revealed he would receive personalized care. Interventions included allowing the resident to choose a type of bath, bed bath, or shower, and to let him choose what he wants to wear. 2. Review of the medical record for Resident #46 revealed an admission date of 02/22/24. Diagnoses included peripheral vascular disease, hyperlipidemia, and end stage renal disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 had intact cognition. Resident #46 required assistance with all activities of daily living. Resident #46 had an indwelling catheter for urine and an ostomy for bowel. Review of the care plan dated 04/05/24 for Resident #46 revealed he was able to make his own leisure and lifestyle choices. Interventions included encouraging Resident #46 to participate in activities, and to provide Resident #46 with a monthly activities calendar. Observation on 06/04/24 at 8:12 A.M. revealed a medication cart in front of Resident #49's room with the laptop open and the medication list for Resident #26 exposed as well as his diagnosis and demographic information. Licensed Practical Nurse (LPN) #603 then exited Resident #49's room at 8:14 A.M. and immediately went to the computer screen. Interview during the observation with LPN #604 confirmed she did leave Resident #26's medical information exposed on the laptop while she was in Resident #49's room. She was not sure how long she was in there but reported she heard Resident #49 coughing, so she just went in. Page 1 of 4 366195 366195 06/05/2024 Beeghly Oaks Center for Rehabilitation & Healing 6505 Market Street Youngstown, OH 44512

F 0583 Level of Harm - Minimal harm or potential for actual harm Observation on 06/04/24 at 8:16 A.M. revealed a medication cart in front of Resident #67's room with the laptop open and the screen exposing Resident #46's medication list and demographic information. LPN #565 was heard laughing in Resident #67's room with the door closed. LPN #565 then exited Resident #67's room at 8:18 A.M. Interview during the observation with LPN #565 confirmed she left the information exposed and knew she was not supposed to do that. Residents Affected - Few Review of the facility policy titled Confidentiality of Information and Personal Privacy, revised October 2017, revealed the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. This deficiency represents noncompliance investigated under Master Complaint Number OH00154250. 366195 Page 2 of 4 366195 06/05/2024 Beeghly Oaks Center for Rehabilitation & Healing 6505 Market Street Youngstown, OH 44512

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. Based on observation, interview, record review, and facility policy review the facility failed to ensure food was stored and prepared in a sanitary manner and failed to ensure a sanitary environment. This had the potential to affect all 98 residents in the facility who receive food from the kitchen. The facility identified one resident (#16) who received nothing by mouth. The facility census was 99. Findings include: Tour of the kitchen on 06/05/25 at 9:10 A.M. with Dietary Manager #602 revealed the dishwasher was not reaching appropriate temperatures for the rinse cycle. It had not reached the appropriate temperature since the end of March 2024. Dietary Manager #602 reported that a repair man was there in March 2024, and he reported the dishwasher needed a bolster that was on backorder. The maintenance man was aware of it, and it had not come in. She reported that the staff was running dishes through the dishwasher twice and rinsing them in the sanitizer in the three sinks. She confirmed that no formal in-service was completed regarding the emergency dishwasher procedures, but the staff was informed. Dietary Manager #602 reported that staff were testing the water in the sanitizer sinks but they do not have plugs for the sinks, so they used clean dish towels to fill the sinks. Observation of the sanitizer sink revealed it tested 280 parts per million. Observation of the dishwasher revealed the wash cycle hit 152 degrees Fahrenheit and the rinse hit 81 degrees Fahrenheit. Subsequent observation of the dishwasher revealed the wash cycle hit 158 degrees Fahrenheit and the rinse hit 88 degrees Fahrenheit. Dietary Aide #601 was observed in the kitchen near the food preparation area with no hair net on. Observation of the walk-in cooler revealed an unsealed and undated open bag of bacon bits. Interview with Dietary Manager #602 confirmed she placed the bag of bacon bits in the walk-in cooler yesterday and did not date or seal it. Interview on 06/05/24 at 9:30 A.M. with Dietary Aide #601 confirmed she was not wearing a hair net and reported she just got to the kitchen and forgot. Interview on 06/05/24 at 9:35 A.M. with Dietary Aide #550 and Dietary Aide #569, as they were washing dishes, confirmed since the dishwasher was not reaching the appropriate temperatures, they have been running the dishes twice through the dishwasher and rinsing them in the three-sink sanitizer. They confirmed they tested the water in the three-sink system and documented it along with the dishwasher temperatures. No concerns with the dishwashing observations. Interview on 06/05/24 at 9:53 with the Administrator confirmed that he was not aware the dishwasher was not reaching appropriate temperatures. He reported he had just learned of it from Dietary Manager #602, and the company was called back out to the facility today. Interview on 06/05/24 at 9:55 A.M. with Maintenance Director #561 confirmed the dishwasher did stop reaching appropriate temperatures in March of 2024. He reported the company came out that day and recommended the bolster be replaced, but it was on backorder at that time. When they came to the facility in March 2024, the machine was fixed by changing a limit and it was functioning. He was not aware it was still not functioning, and he lost communication with the company. Maintenance Director #561 confirmed he just called the company, and they would be out to the facility today. Tour of the kitchen on 06/05/24 at 11:30 A.M. revealed Dietary Aide #550 prepping deserts with no 366195 Page 3 of 4 366195 06/05/2024 Beeghly Oaks Center for Rehabilitation & Healing 6505 Market Street Youngstown, OH 44512

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hair net on. Interview during the observation with Dietary Aide #550 confirmed he was not wearing a hair net. Review of the dishwasher invoice dated 03/22/24 revealed that the technician arrived on site and operated the unit. The final rinse temperature was 77 degrees Fahrenheit. The high limit sensor had been tripped. The technician reset the limit and watched the unit heat up. The final rinse temperature went to 212 degrees Fahrenheit. The technician then adjusted the temperature to get it back to 189 degrees Fahrenheit. The technician recommended that the contactor and the thermostat be replaced. The customer requested a quote, and a quote was issued. Review of the facility policy preventing foodborne illness, food handling, revised July 2014, revealed all food service equipment and utensils will be sanitized according to the current guidelines and manufacturers' recommendations. Review of the facility policy titled Preventing Foodborne Illness, Employee Hygiene and Sanitary Practices, revised October 2017, revealed hair nets or caps and/or beard restraints must be worn to keep hair from contacted exposed food, clean equipment, utensils, and linens. This deficiency was an incidental finding identified during the complaint investigation. 366195 Page 4 of 4