Health inspection·October 21, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital documents, observation, Local Health Department (LHD) interview, staff interview, and review of facility policy, the facility failed to have an effective water management and legionella prevention plan and further failed to implement recommended legionella mitigation strategies to prevent the potential spread of Legionella pneumonia. This had the potential to affect all 94 residents residing in the facility. The facility census was 94. Findings include:Review of the medical record for Resident #88 (SR) revealed an admission date of 09/23/21. Diagnoses included cerebral infarct (stroke), diabetes, hemiplegia and hemiparesis, anxiety, cardiac arrhythmia, dysphagia, and weakness. Further review of the medical record revealed the resident was treated for pneumonia at the facility and sent to the hospital on [DATE] for further evaluation and treatment.Review of the hospital lab results, dated 10/03/25, revealed Resident #88 tested positive from a urinalysis test for legionella (bacteria that can cause a severe form of pneumonia). Further review of a hospital note dated 10/14/25 revealed Resident #88 was admitted with altered mental status and found to have acute respiratory failure and sepsis secondary to Legionella pneumonia. The note stated septic shock developed after admission and the hospital stay had been complicated with a diagnosis of atrial fibrillation (a-fib) with rapid ventricular response (RVR) and continued diuresis (increase production and excretion of urine) for pulmonary edema. Review of the facility policy and procedure titled, Reducing Legionella Risk and Transmission, dated June 2017, revealed legionella could cause pneumonia. It was the policy to reduce the risk of growth and spread of legionella through assessment identification, prevention, monitoring, reporting, investigating, and controlling infections and communicable diseases. The policy stated the facility should analyze and assess areas of risk with considerations of water temperatures, stagnation, no usage of disinfectants and conditions for bacteria spread. Prevention and monitoring mechanisms could include periodic disinfectants through usage of chemicals and consider testing residents for legionella when they develop pneumonia. If an infection was confirmed, the facility should complete an investigation including auditing and identification of the potential origin for the legionella. The facility should consider restricting water in the facility or other immediate control measures. Review of the Legionella Risk Assessment, dated November 2017, revealed the document was completed to reduce the growth and spread of legionella. The action plan included the weekly flushing of all faucets not in frequent use, all eye wash stations, all shower heads, and all bathtub faucets; all hot water tanks should be flushed bi-monthly; and the ice machine filter should be changed every six months. The risk assessment tool included no ranges or instructions of what to do if the measures were out of appropriate ranges. Review of the facility's Water Management Plan, undated, revealed a diagram of the water system. It stated, The diagram below shows which types of monitoring could occur at different locations within the facility water system to reduce spread of legionella. The diagram included upon entrance to the facility from [NAME] Avenue, a visual inspection and disinfectant Residents Affected - Many Page 1 of 3 366313 366313 10/21/2025 Scioto Pointe 740 Canonby Place Columbus, OH 43223

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many levels should be completed; the ice machine in the dining room should have visual inspections; the water heaters for the resident rooms, the water heater for the kitchen, laundry and mechanical rooms, sinks and showers for the resident rooms and kitchen and laundry appliances should have temperature checks completed and sinks and showers should have disinfectant levels checked. Review of electronic mail (e-mail) communication between the facility Assistant Administrator (AA) #200 and the LHD revealed the facility notified the LHD on 10/06/25 of a resident with a positive legionella result. From 10/06/25 to 10/07/25, the e-mails discussed testing samples of the facility water sources. On 10/08/25, the LHD asked if facility had initiated water restrictions and asked, If yes, what specifically are you doing? The facility had no evidence this was responded to via e-mail. On 10/10/25, the LHD informed the facility they would be onsite for a consultation, stating the first priority was to protect current residents by restricting water usage or installing point of use filters. Interview on 10/14/25 at 2:20 P.M. with AA #200 revealed facility had a resident (#88) test positive for legionella while at the hospital. She reported the positive case was reported to both the LHD and the state health department (SHD). AA #200 stated the facility collected 13 samples from different areas of the facility and sent them to the lab for legionella testing. Interview on 10/14/25 at 3:00 P.M. with the Administrator revealed the facility completed flushes, monitored water temperatures, and changed the ice machine filter as outlined in the risk assessment, but they did not do chemical testing as the facility utilized city water. He also reported the facility had no bathtubs and no eye wash stations. Interview on 10/14/25 at 3:25 P.M. with the Administrator, AA #200 and the Director of Nursing (DON) revealed their contacts at the LHD requested they do a two-month look back for positive cases of pneumonia, test those residents for legionella, and send them their plan and auditing materials. The Administrator stated the facility had a good water management plan that was used by several other facilities. They reported they did everything they could think of and were waiting for final lab results. They acknowledged the emails on 10/08/25 and 10/10/25 with the LHD mentioned restricting water usage and using point of contact filters and verified neither of the recommended mitigation strategies were implemented. Interview on 10/14/25 at 3:40 P.M. with Maintenance Director (MD) #300 revealed he completed water temperature checks weekly and stated he attempted to keep the temperature between 110- and 120-degrees F. He also reported flushing the plumbing fixtures and the water heaters and conducted chlorine testing at the entry point of the building. He reported he was looking for chlorine levels between 0.5 parts per million (ppm) and 1.0 ppm and confirmed a few had been outside those levels at the beginning of the year. He reported the facility had no documentation of what steps were taken to address this but stated he called the city water department and retested after about one to two weeks. MD #300 had no evidence of any retesting being completed. MD #300 verified the facility did not restrict water usage in the facility following Resident #88's positive legionella test result and he was unaware of any plans to use filtration devices. Interview on 10/15/25 at 10:47 A.M. with LHD Staff (LHDS) #500 revealed they had spoken with facility staff and reviewed their overall water management plan. LHDS #500 stated if a facility had one positive legionella case, they should take water samples for testing. While waiting for the water testing results, the facility should restrict water usage for the water sources the affected resident had access to. LHDS #500 stated the facility should close the shower area and bathroom the affected resident had access to, especially if there was a roommate involved, or place filters on the water spickets. LHDS #500 stated the facility's legionella prevention plan was not thorough and did not include basic items such as visual inspections, chemical testing, taking temperatures and doing routine testing. They revealed they had planned to meet with facility later in the week and would be working with facility to improve 366313 Page 2 of 3 366313 10/21/2025 Scioto Pointe 740 Canonby Place Columbus, OH 43223

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many their plan. LHDS #500 stated they recommended the facility work with a consultant. Observation on 10/15/25 at 10:55 A.M. of Resident #88's room confirmed the resident had a roommate who used the same bathroom, which was still in full use, without the installation of any filters. Concurrent interview with Certified Nurse Aide (CNA) #75 verified Resident #88 had a roommate and the bathroom remained operational, without the use of any filters. Additionally, CNA #75 confirmed the shower room used by Resident #88 was still in full use, without the use of filters on the water faucets. Continued observation of the shower room revealed the shower room floor was wet, as if a shower had recently been completed. No filters were observed on the shower faucet. Further observation revealed the shower room sink had an eye wash device on the faucet, with no filters observed. Observation on 10/15/25 at 11:47 A.M. revealed MD #300 completed a chlorine test of a water sample from the staff bathroom. MD #300 stated he was looking for a result of 0.5 ppm to 1.0 ppm. The result was 0.23 ppm. MD #300 stated he completed a test earlier to make sure it was in normal range and the chlorine level result at that time was 0.46 ppm. MD #300 redid the testing, shook the solution more vigorously, and confirmed the result was in the normal range. MD #300 stated there was an issue with the testing system as it did not instruct on a standard amount of time or how long to shake the solution prior to reading the result. Further interview with MD #300 verified the shower room had a functional eye wash station, although the facility stopped using them and used water bottles instead. Interview on 10/15/25 at 2:00 P.M. with the Administrator confirmed the facility's water management plan could have been more robust to address the legionella concerns. This deficiency represents non-compliance investigated under Complaint Number 2638537. 366313 Page 3 of 3