Clearview Lantern Suites

Based on interview, observation, and record review, the facility failed to ensure the low temperature dishwasher machine was dispensing chlorine sanitizer at a concentration level appropriate to effectively sanitizing kitchenware. and failed to store ready to eat ham inside the walk-in cooler in a manner that prevents cross contamination. The facility also failed to clean the interior walls and ceiling of the walk-in cooler and the shelving inside the cooler at a frequency appropriate to prevent build-up of debris. This had the potential all 51 residents

Findings include:

1. Observations in the main kitchen on 04/19/23 at 8:19 A.M. revealed that the rotor head behind the peristaltic pump cover for the sanitizer and rinse agents located on the top control box attached to the low temperature dishwasher were not spinning during the rinse and sanitize cycles, indicating that the chemical and rinse agents were not being delivered from the chemical storage container to the dishwasher.

Interview with Cook #515 revealed that she did not know how to test the low temp dishwasher. Cook #515 stated I don't really know how to do it and mentioned that Kitchen Supervisor #531 Usually does it, when asked about testing the concentration of the water.

Observations in the main kitchen on 4/19/23 at 8:26 A.M. revealed Kitchen Supervisor #531 was testing the residual water inside the low temperature dishwasher pan after a complete washing cycle with Hydrion Chlorine test strips that had an expiration date of 08/2018. Kitchen Supervisor #531 confirmed a reading of 0 Part per Million (PPM) at the time.

Review of Micro Essential Laboratory, Inc, who is the manufacture of Hydrion Chlroine test strips, Official Quality Control Certification, revealed in the second sentence of the third paragraph from the top under the Certification and Quality Control of Hydrion pH Test papers section, that the Hydrion papers will remain accurate until the expiration date marked on the accompanying color chart.

Interview with Kitchen Supervisor #531 at 8:28 A.M. revealed that the 3-compartment sink was used as a backup when the low temperature dishwasher was not functioning properly.

Observations in the kitchen on 4/19/23 at 8:37 A.M. revealed Kitchen Supervisor #531 was setting up a sanitizing bay of the 3-compartment sink located across with a 1 oz Clean Quick Chlorine package that had a delivery date on the box of 06/25/14.

Interview with Senior Technical Service Agent #222 on 04/19/23 at 11:37 A.M. from Procter & Gamble, who is the manufacture of clean quick chlorine packages, revealed that packages expire one year after the manufacture date. Agent #222 was provided production number 323517402 from packages and confirmed a production date of 365 th day of 2013.

2. Observations inside the walk-in cooler on 04/19/23 at 8:11 A.M. revealed one 10 pounds (LBS) ground beef (raw) and a fully cooked delicatessen ham stored together on a yellow plastic tray located on bottom shelf of the 5-tier storage shelf that's located directly across from the entrance door.

Interview with Kitchen Supervisor #531 on 04/19/23 at 8:13 A.M. confirmed that the 10 LBS ground beef (raw) and a fully cooked delicatessen ham were stored together on the yellow plastic tray.

3. Observations on 04/19/23 at 8:09 A.M. inside the walk-in cooler revealed build-up around the four-to-five-inch enclosed fluorescent light bulb attached to the ceiling. Observations on 04/19/23 at 8:14 A.M. revealed build-up on the wire storage shelves inside the cooler's three section hinged door, reach in refrigerator, located outside of the walk-in cooler.

Interview on 04/19/23 at 8:15 A.M. with Kitchen Supervisor #531 confirmed observations of build-up in walk-in cooler and inside TRUE reach-in unit.

These violations represents non-compliance investigated under Complaint Number OH00141332

Based on observation, interview, record review, and facility policy review the facility failed to ensure food was stored, served, and prepared in a manner that prevents food borne illness and contamination. This had the potential to affect all 47 residents residing in the facility. Findings include: Observation of the kitchen on 12/29/22 at 10:07 A.M. revealed countertops with food debris on them, a trash can in front of the handwashing sink with brown streaks running down the lid, coffee grounds in a coffee filter, uncovered, six coffee pots sitting on the counter with coffee grounds in them, streaks of liquid down the side of the stove, and scrambled eggs on the steam table. The cooler in the dry storage area had streaks of liquid running down the front doors, a box with approximately 20 bottles of beverage labeled Ensure sitting on the floor, a bag of onions on the floor with a second bag of onions sitting on top of a box of bottled water which sat on the floor. The large refrigerator had a bag of sliced cheese opened and undated, 20 cups identified as fruit crisp dated 12/20/22 open to air, 13 cups of fruit undated and open to air, a large tray of Salisbury steak open to air, six boxes of unopened juice on the floor, nine boxes of miscellaneous product unopened sitting on the floor, a red diced product identified as beets in bin unlabeled, a bin of diced potatoes undated, a bag of frosting opened and undated, multiple cups of prepared diced onions and relish dated 11/17/22 and a jar of garlic opened and undated. Interview on 12/29/22 at the time of the observation with Cook #204 confirmed the items identified above were unlabeled or undated as described. She confirmed refrigerated items should be used within three days once opened; she could not confirm if items could be placed directly on the floor. She also confirmed the kitchen was to be cleaned after each meal, and it was not cleaned today after breakfast. Review of the document titled Job description outline signed by Cook #204 revealed maintaining a sanitary kitchen was a requirement of the job. Review of the facility policy titled Kitchen Cleanliness and Food Prep and StorageBased on observation, interview, record review, and facility policy review the facility failed to ensure food was stored, served, and prepared in a manner that prevents food borne illness and contamination. This had the potential to affect all 47 residents residing in the facility.

Findings include:

Observation of the kitchen on 12/29/22 at 10:07 A.M. revealed countertops with food debris on them, a trash can in front of the handwashing sink with brown streaks running down the lid, coffee grounds in a coffee filter, uncovered, six coffee pots sitting on the counter with coffee grounds in them, streaks of liquid down the side of the stove, and scrambled eggs on the steam table.

The cooler in the dry storage area had streaks of liquid running down the front doors, a box with approximately 20 bottles of beverage labeled Ensure sitting on the floor, a bag of onions on the floor with a second bag of onions sitting on top of a box of bottled water which sat on the floor. The large refrigerator had a bag of sliced cheese opened and undated, 20 cups identified as fruit crisp dated 12/20/22 open to air, 13 cups of fruit undated and open to air, a large tray of Salisbury steak open to air, six boxes of unopened juice on the floor, nine boxes of miscellaneous product unopened sitting on the floor, a red diced product identified as beets in bin unlabeled, a bin of diced potatoes undated, a bag of frosting opened and undated, multiple cups of prepared diced onions and relish dated 11/17/22 and a jar of garlic opened and undated.

Interview on 12/29/22 at the time of the observation with Cook #204 confirmed the items identified above were unlabeled or undated as described. She confirmed refrigerated items should be used within three days once opened; she could not confirm if items could be placed directly on the floor. She also confirmed the kitchen was to be cleaned after each meal, and it was not cleaned today after breakfast.

Review of the document titled Job description outline signed by Cook #204 revealed maintaining a sanitary kitchen was a requirement of the job.

Review of the facility policy titled Kitchen Cleanliness and Food Prep and Storage

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #35 was free from an incident of verbal abuse during the dinner meal on 09/02/22. This affected one resident (#35) of three residents reviewed for abuse.

Findings include:

Review of the medical record for Resident #35 revealed the resident had diagnoses including anxiety disorder, asthma and chronic obstructive pulmonary disease.

Review of an assessment, dated 11/26/19 revealed Resident #35 was independent for eating and had no cognitive impairment.

On 09/16/22 at 9:07 A.M. interview with Resident #9 revealed sometimes she does talk too loud because she can not hear very well. Resident #9 revealed she did not remember the events of 09/02/22 but did remember another resident asking her to keep it down at dinner. Resident #9 reported she thanked the woman because she stated sometimes she did not even know she was talking loudly.

On 09/16/22 at 9:21 A.M. interview with Resident #35 revealed on 09/02/22 she was eating dinner when Resident #9 kept talking loudly and disrupting the meal. Resident #35 revealed after she was done eating, she approached Resident #9 to let her know her loud voice was disrupting her dinner. Resident #35 reported as soon as she approached Resident #9, Cook #517 came out of the kitchen screaming at her to quit talking to her, to shut up, to go back to her room and remember who cooks her food. Resident #35 revealed she was very disturbed by the situation and felt Cook #517 was verbally threatening her. At the time of the interview, Resident #35 was observed to become tearful while explaining the events.

On 09/16/22 at 9:38 A.M. interview with Cook #535 revealed she had not been working on 09/02/22 but when she returned to work, Cook #517 reported to her, she had put Resident #35 in her place. She reported Resident #35 had a history of causing trouble with other residents and Cook #517 had finally said something to her.

On 09/16/22 at 9:51 A.M. interview with the Director revealed she was not made aware of the incident involving Resident #35 and Cook #517 on 09/02/22 until 09/06/22 when she checked her voicemail. She reported Resident #35's daughter had called in on 09/05/22 (a holiday) and left a message explaining the incident. She reported Resident #35's daughter was very upset and threatening to call the police. The Director reported she immediately began an investigation. The Director revealed she believed there was not enough evidence to support the resident had been verbally abused.

On 09/16/22 at 10:38 A.M. interview with Resident #1 revealed she was leaving the dining room on 09/02/22 when she heard Cook #517 scream at Resident #35 telling her to leave Resident #9 alone, to shut up, go back to her room, and remember who cooks your food. She reported this bothered her and she felt it was a threat. She reported following the incident, residents were afraid to eat in the dining area.

On 09/16/22 at 10:48 A.M. interview with Resident #21 revealed she was in the dining room on 09/02/22 and reported she saw Resident #35 go over to Resident #9 to ask her to talk quieter. She reported then Cook #517 began screaming at Resident #35 to leave Resident #9 alone, shut up, go back to her room, and remember who cooks your food. Resident #21 reported she perceived the incident as a threat toward Resident #35.

On 09/16/22 at 10:58 A.M. a telephone interview with Cook #517 revealed she did holler at Resident #35. She reported in her opinion, Resident #35 liked to cause trouble with all the other residents. She reported that day (09/02/22) when she saw Resident #35 walk up to Resident #9, she told her to leave her alone. She then reported Resident #35 said to her, who do you think you are the cook, to which she responded, yes, I am the cook and I cook your food. Cook #517 revealed she then told Resident #35 to go back to her room.

On 09/16/22 at 12:40 P.M. interview with Licensed Practical Nurse (LPN) #524 revealed she was the nurse on duty during the dinner shift on 09/02/22. She revealed she was aware of the incident when Cook #517 began screaming at Resident #35. She stated she entered the dining room to de-escalate the situation and Cook #517 just began screaming at her too. She reported Cook #517 did tell Resident #35 yes, I do cook your food remember that. The LPN revealed after the incident she followed Resident #35 back to her room to make sure the resident was OK. LPN #524 indicated she felt Resident #35 was threatened by the cook. The LPN denied immediately reporting the incident to the Director or to the Director of Nursing.

Review of the facility undated policy titled Resident Rights revealed all staff should be trained in and knowledgeable about resident rights. Residents have the right to be free from physical, verbal, mental, and emotional abuse and to be treated at all times with courtesy, respect, and full recognition of dignity and individuality.

Review of facility policy titled Abuse Reporting and Investigation, dated 08/10/21 revealed the definition of abuse included but was not limited to the willful inflection of physical pain, injury, or mental anguish, sexual statements, inappropriate touching, forced sexual activity, harassment, threatening statements, yelling derogatory or racial statements, unexplained bruises, welts, burns, or fractures or lacerations. The policy revealed the Director of Health and Wellness or Executive Director shall be notified immediately. The Director of Health and Wellness or Executive Director would immediately remove the employee from duties for suspension, pending an investigation of the allegation.

This violation substantiates Complaint Number OH00135667.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure food was stored, prepared and served in a sanitary manner. This had the potential to affect all 44 residents residing in the facility.

Findings include:

On 08/21/22 at 2:16 P.M. observation of the kitchen revealed Styrofoam cups were in the corn flakes, rice krispies, frosted mini wheat's, fruit loops, cheerios and bran flakes bins. There was a metal spoon in the brown sugar and a scoop in the flour.

The shelf above the grill and cook top was dusty, sticky, and had dried noodles on it. There was a pot of milk and butter cooking on the stove top and a pot of water boiling for the mashed potatoes.

There were no current food temperature logs, dishwasher water temperature, sanitation testing logs or refrigerator and freezer temperature logs. Review of the food temperature logs revealed there were no food temperatures recorded since 06/07/22. Review of the dishwasher temperature log, three door cooler, activity freezer, dining room refrigerator, walk in refrigerator, walk in freezer temperature logs and dishwasher sanitation logs revealed the last time temperatures and sanitation levels were recorded was 03/14/22.

On 08/21/22 at 2:22 P.M. interview with Dishwashers #67 and #83 revealed they did not know if they were operating a low or hot temperature dishwasher. Neither staff member indicated they had to test the sanitation of the dish machine or knew how to test sanitation.

On 08/21/22 at 2:32 P.M. interview with Cook #74 verified the scoops were left in the cereal, flour, brown sugar and dirty shelf above the cooking surface. Cook #74 verified staff did not know if the dishes the meals were served on met sanitation standards due to water temperatures and sanitation levels not being obtained.

Review of the facility Kitchen Cleanliness and Food Prep and Storage policy, last reviewed 04/21/21 included the kitchen was to remain clean everyday. Clean as you go, if you see anything that needs clean you must clean it. There should be a master clean list placed behind the door for everyone to follow.

Review of the monthly cleaning list for the kitchen, last reviewed 08/21/22 included to make sure all shelves above the steam table were clean.

Review of the facility Daily Temperature Logs policy, last reviewed 08/21/22 revealed temperatures for all freezers and coolers must be taken three times a day. The dishwasher temperatures should be taken three times a day as well as the parts per million sanitation.

This violation substantiates Complaint Number OH00134845. This violation is also an example of continued non-compliance from the survey dated 08/25/21.

Based on observation and interview the facility failed to maintain an adequate supply of bowls, dessert plates and drinking glasses for resident meal service. This had the potential to affect all 44 residents residing in the facility.

Findings include:

On 08/21/22 at 11:54 A.M. observation of the lunch meal revealed the residents were served salad in styrofoam bowls. At 12:04 P.M. lemonade was served in styrofoam cups. At 12:12 P.M. the aides brought the meals around on an open shelf cart. They had plastic covers over them. The meal was either a cold submarine sandwich on a plate with chips or chicken noodle soup served in a styrofoam bowl. At 12:21 P.M. cake was served on a small thin paper plate.

On 08/21/22 at 12:22 P.M. interview with Personal Care Aide (PCA) #70 revealed staff had to hold the plate by both sides, because the plate was so thin, if it was held on one end only the weight of the cake would push the paper plate down and drop the cake to the floor.

On 08/21/22 at 12:15 P.M. interviews with Resident #1, #22 and #35 revealed at times they also get their coffee in a styrofoam cup and their hot food on styrofoam plates. The residents indicated when cutting food, they would cut through the styrofoam plates.

On 08/21/22 at 12:21 P.M. interview with Resident #32 revealed at supper the meals were mainly served on styrofoam.

On 08/21/22 at 2:31 P.M. interview with Cook #81 revealed they serve in styrofoam bowls because they do not have enough regular bowls. Staff pre-pour cereal in bowls for morning and do not have them for the other meals. She said the cups they have were plastic and get cloudy from lemonade so lemonade is served in styrofoam. She said she had never used dessert plates at the facility, only paper plates for dessert.

Observation of the kitchen at the time of the interview revealed there were 50 dark red plastic bowls in the kitchen. There were not any glass glasses, just the plastic glasses the cook said were unsuitable for lemonade. There was a bin with assorted small vegetable bowls and small plates that would not amount to the 44 residents in the facility.

On 08/21/22 at 2:58 P.M. interview with the Administrator revealed no one ever told her the facility did not have enough dishware for meal service for all residents to be served resulting in the routine use of styrofoam.

This violation substantiates Complaint Number OH00134845.

Based on record review and staff interview the facility failed to establish a grievance committee comprised of home staff and residents, sponsors, or outside representatives in a ratio of not more than one staff member to every two residents, sponsors, or outside representatives. This had the potential to affect all 44 residents residing in the facility.

Findings include:

The facility's grievance committee was reviewed while investigating an allegation of unresolved resident concerns.

The committee was comprised of Licensed Practical Nurse/Director of Nursing (DON) #51 and Resident #32. The last time the committee was comprised of a two to one ratio, two residents, sponsors or outside representative to one staff was in 2019.

On 08/21/22 at 2:47 P.M. interview with DON #51 verified the grievance committee was herself and the resident council president without a second non-staff participant.

Review of the facility General Policy Agreement, updated 06/01/20 revealed the Grievance Committee would consist of at least three members and no more than five.

This violation substantiates Complaint Number OH00134845.

Based on observation, record review and interview the facility failed to ensure residents requests and inquires were responded to promptly related to meal service. This had the potential to affect all 44 residents residing in the facility.

Findings include:

Review of the resident council meeting minutes from the meeting held on 06/08/21 revealed residents complained of the use of styrofoam plates for meals. The facility response was staff was short in the kitchen and if it was a meal that needed to be cut, it needed to be served on regular plates.

Review of the 10/07/21 resident council meeting minutes revealed the kitchen used paper plates last night. The action taken noted the dishwasher was broke and water turned off to fix.

Review of the 04/05/22 resident council meeting minutes revealed concerns aides were clearing the table before everyone leaves the dining area. The action taken noted staff could clean around residents but if the resident was not finished staff shouldn't be removing anything they were still using or eating. Staff education was completed.

Review of the 05/11/22 resident council meeting minutes revealed concerns the kitchen used paper plates all weekend. The action taken revealed staff would be talked to and styrofoam items would be locked up. The Ombudsman was present at this meeting.

Review of Resident #35's medical record revealed a progress note, dated 05/30/22 that included the resident did not come to dinner due to how the kitchen staff had been acting with the music being very loud, dancing around and the way they talked to residents and other staff.

Review of Resident #32's medical record revealed a progress note, dated 05/29/22 the resident was very upset at dinner as to how he was spoken to by the male kitchen employee. The employee went back into the kitchen and was yelling about the incident that took place. All employees walked away except for his sister who was here at the time in the kitchen picking him up. On 05/31/22 the resident refused to stay and eat dinner because they still served on paper plates. The resident went back to his apartment.

On 08/21/22 at 11:54 A.M. observation of the lunch meal revealed the residents were served salad in styrofoam bowls. At 12:04 P.M. lemonade was served in styrofoam cups. At 12:12 P.M. the aides brought the meals around on an open shelf cart with plastic covers over them. The meal was either a cold submarine sandwich on a plate with chips or chicken noodle soup served in a styrofoam bowl. At 12:21 P.M. cake was served on a small thin paper plate.

On 08/21/22 at 12:22 P.M. interview with Personal Care Aide #70 revealed staff had to hold the plate by both sides, because the plate was so thin, if it was held on one end only the weight of the cake would push the paper plate down and drop the cake to the floor.

On 08/21/22 at 12:15 P.M. interviews with Resident #1, #22 and #35 revealed at times they also get their coffee in a styrofoam cup and their hot food on styrofoam plates. The residents indicated they cut through the styrofoam plates when they cut their food. The residents reported they were told the lemonade comes in styrofoam because it stains the glasses. Resident #35 revealed this felt degrading. The residents indicated when one particular cook was one duty she wanted to get out in a hurry she used styrofoam. Residents were still eating and this cook would have the aides start cleaning off tables, asking residents if they were finished with this or that in order to take the items away. The residents indicated this made their dining experience feel rushed. Staff bring the big garbage cans around and throw trash in them at each table while residents are still eating. During the interview, the residents also voiced concerns about food temperatures and indicated hot foods were often not hot enough when served with styrofoam. Residents cut through the styrofoam plates when cutting up our food. The residents revealed these concerns were brought up at every resident council meeting, had been occurring for at least a year and about a month ago the residents indicated they spoke to the Ombudsman about it.

On 08/21/22 at 12:21 P.M. interview with Resident #32 revealed at supper the meals were mainly served on styrofoam; out of nine meals, eight were served using styrofoam. The resident revealed the last time he went and spoke to the Administrator about serving meals on paper and styrofoam, the Administrator said she had to keep the kitchen happy and wanted to have a cook to cook for the residents. Resident #32 revealed he was tired of talking to the Administrator about it as it had been a problem and talked about for at least a year. The resident reported he had hoped alerting the Ombudsman to the concern would resolve it before a formal grievance had to be filed. The resident revealed the facility resident council generally met quarterly.

On 08/21/22 at 1:01 P.M. interview with the Administrator revealed she did not think there were any outstanding concerns from the resident council meetings.

On 08/21/22 at 2:47 P.M. interview with the Director of Nursing (DON) revealed she knew the Administrator spoke to the kitchen about the use of styrofoam and paper plates.

On 08/21/22 at 2:58 P.M. interview with the Administrator revealed she was unaware the staff had used styrofoam for meals on this date. The Administrator revealed she had not locked up the styrofoam and paper dishes because she thought the issue had been previously. The Administrator revealed staff had been serving lemonade and desserts using styrofoam for eight years. The Administrator failed to acknowledge the residents had a right for a request for a home-like environment for dining and their desire not to eat off of styrofoam and paper plates honored.

On 08/22/22 at 8:51 A.M. interview with the Ombudsman verified she had attended the recent resident council meeting and had attempted to intervene and advocate for the residents to get real dishes for meals as they preferred. However, the Ombudsman indicated the Administrator was difficult to work with and she could see why the residents had been dealing with this same issue for over a year.

Review of the facility admission packet revealed under Resident Rights the resident had the right to voice and recommend changes in policies and services to the homes staff, to employees of the department of health or to other persons not associated with the operation of the home free of restraint, interference, coercion, discrimination, or reprisal. The right included access to a resident rights advocate and the right to a member of to be active in and to associate with persons who were active in organizations of relatives and friends of nursing home residents and other organizations engaged in assisting residence.

This violation substantiates Complaint Number OH00134845.