Inspection·October 17, 2019

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure appropriate interventions to prevent potential for urinary contamination of an indwelling urinary catheter for one (#65) of one residents reviewed for indwelling urinary catheter. The facility identified four residents with an indwelling urinary catheter. The facility census was 69. Findings include; Review of the medical record revealed Resident #65 admitted to the facility on [DATE]. Diagnoses included dementia with behavior disturbance, chronic kidney disease, obstructive and reflux uropathy, neuromuscular bladder dysfunction, urinary retention, benign prostatic hyperplasia (BPH), gross hematuria, and history of urinary tract infections. Review of the Minimum Data Set (MDS) assessment, dated 09/25/19, the resident was identified with severe cognitive impairment and required extensive physical assistance with activities of daily living, including hygiene. The resident utilized an indwelling urinary catheter and was incontinent of bowel. Review of the physician order dated 08/28/18 revealed Resident #65 was to have catheter care every shift to prevent infection. On 12/13/18 the physician ordered the placement of a leg bag in the morning. On 07/21/19 a revised physician order presented for the use of a french coude indwelling catheter to be used and changed every 30 days due to BPH. Review of the plan of care, revised 06/19/19, addressed the indwelling catheter due to the diagnosis of urinary retention, BPH, obstructive and reflux uropathy, neuromuscular dysfunction of bladder, and history of chronic urinary tract infections with gross hematuria. Interventions included: changing catheter bag as ordered, keep drainage bag lower then bladder level, monitor urine characteristics, provide catheter care routinely, and use leg bag during the day. Observation's on 10/15/19 at 9:54 A.M. and on 10/16/19 at 6:42 A.M. and 8:28 A.M. noted a strong urine odor detected inside Resident #65's room. On 10/16/19 at 6:42 A.M. and 8:28 A.M. the indwelling catheter drainage bag was observed hanging from the side of a trash can at the resident's bedside. The trash can contained discarded rubbish. Observation on 10/16/19 at 8:28 A.M. revealed State Tested Nurse Aide (STNA) #400 and Registered Nurse (RN) #500 entered Resident #65's room to complete catheter care and change the catheter bag to a leg bag. STNA#400 washed hands and donned plastic gloves. STNA #400 proceeded to unfasten Resident #65's adult brief and cleansed the insertion site of the catheter with a provodone-iodine solution swab. STNA #400 did not cleanse the catheter tubing or surrounding perineal area. After changing gloves and washing hands, STNA #400 changed the gravity drainage catheter bag to a leg bag. STNA #400 then placed a single layer paper towel on the floor next to the resident's bed with a graduated cylinder on top and drained 400 cubic centimeters(cc) of cloudy urine to the cylinder. While the urine was draining, droplets of urine were observed on the surface of the paper towel and falling on the carpet. STNA #400 then disposed of the urine in the toilet and rinsed the graduated cylinder with tap water only. No type of disinfectant solution was utilized. The cylinder was placed in a clear tote on the floor of the bathroom next to the toilet. The tote contatined the drainage bag which was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 contained inside a clear plastic bag with an open top. The tote was not covered. Level of Harm - Minimal harm or potential for actual harm Interview on 10/16/19 at 8:46 A.M., RN #500 and STNA #400 verified the urinary catheter drainage bag was hanging on the trash can and the spillage of urine to the floor while emptying the catheter bag. STNA #400 confirmed the resident's catheter was not thoroughly cleansed during care and the drainage bag was not covered in the plastic bag and neither the catheter drainage bag not the graduated cylinder were covered in the tote. Residents Affected - Few Review of the facility policy titled Daily Catheter Care Policy, dated 02/01/2001, identified the definition as cleansing the catheter and area around the catheter with a cleansing solution. The procedure indicated for a male resident to expose and cleanse the perineal meatus, take a applicator and wipe using a circular motion around the penis. With another applicator, wipe around the catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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, staff interview, review of facility policy, and review of manufacturer instructions for use, the facility failed to ensure the appropriate concentration of sanitizer was utilized during cleansing of kitchen equipment. This deficient practice had the potential to affect 69 residents identified by the facility to receive food from the facility kitchen in a facility census of 69. Findings include; Observation on 10/15/19 at 8:45 A.M. of the facility kitchen with Food Service Manager (FSM) #1 revealed a bucket of sanitizer next to the steam kettles in the kitchen. FSM #1 obtained solution test strips and proceeded to test the contents contained in the bucket identified as quaternary sanitizer. The result of the test indicated no sanitizer solution was contained in the bucket. Interview with FSM #1 at the time revealed sanitizer solution was to test at 200 parts per million (ppm) to be effective and as indicated by the manufacturer. Additional observation on 10/16/19 at 10:45 A.M. with FSM #1 noted a bucket identified as sanitizer located next to the two steam kettles in the kitchen. FSM #1 proceeded to test the contents of the bucket and the result indicated the sanitizer was at 50 ppm. Interview at the time of the observation with [NAME] #10 revealed she just cleaned and sanitized the two steam kettles using the same bucket of sanitizer. At 11:52 A.M. second check of the sanitizer bucket with FSM #1 noted the sanitizer at 150 ppm. Interview at this time with FSM #1 revealed he was contacting the sanitizer vendor for repair. Review of the facility policy titled Sanitation Bucket Policy, dated July 2018, revealed staff are to test sanitation buckets using test strips each time a bucket is filled. The solution is to test at 200 ppm. If the solution is too high or too low staff is to inform a supervisor. Review of the quaternary sanitizer manufacturer instructions identified the sanitizer solution concentration was to be tested at 200 ppm for effective sanitizing. Interview on 10/17/19 at 10:55 A.M., FSM #1 revealed the chemical vendor inspected the sanitizer dispenser and found debris inside the hose. Once the debris was removed the sanitizer dispenser was found to be at the appropriate 200 ppm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 4 of 4