Every finding on record at Vancrest Health Care CTR of Ho

Based on observation, staff interview, and review of facility policy, the facility failed to ensure the snack/nourishment refrigerator for the 300 Hall and 400 Hall nurses' stations was maintained with properly dated and labeled food and beverage items to prevent the potential for foodborne illness. The facility identified thirty-one residents (#1, #4, #9, #14, #16, #17, #18, #19, #20, #23, #24, #26, #27, #28, #29, #30, #31, #32, #33, #36, #39, #40, #42, #44, #46, #48, #50, #55, #57, #59, and #67) who receive nourishments from the refrigerator. The facility census was 56.Findings include:Observation on 02/18/26 at 1:58 P.M. of the 300 Hall and 400 Hall nurses' station refrigeration unit revealed salami and pepperoni stored in unlabeled and undated plastic bags with a visible white film and and mold like substance observed. Further observation revealed outdated yogurt cups; expired fruit cups; expired pudding cups; Mexican food in a leftover container was uncovered and not dated; leftover containers not labeled with a resident name or date; one glass of orange juice was left open to the air with no lid, label, or date; and a bag of shredded cheese that was not labeled or dated and appeared melted inside the bag. An unlabeled and undated frozen dinner meal was stored in the refrigerator drawer. Interview on 02/18/26 at 1:58 P.M. with Social Worker (SW) #237 and the Administrator verified the above observations.Interview on 02/18/26 at 3:43 P.M. with Licensed Practical Nurse (LPN) #280 verified the refrigerator at the nurses' station was used for residents residing on the 300 and 400 hallways. LPN #280 stated there were currently no residents on those hallways who did not consume food orally. LPN #280 further verified all food items should be dated and labeled, including food items used during medication passes.Review of the undated facility policy titled, Food Brought in by Families/Visitors, revealed food requiring refrigeration shall be labeled with the resident's name, contents, and the date received, and stored in a designated refrigerator. The policy further stated unconsumed food would be disposed of according to manufacturer guidelines, expiration dates, food labels, or upon evidence of spoilage.

Based on resident interview, observation, medical record review, the review of dietary meal ticket, staff interview, and review of facility policy, the facility failed to honor residents' food preferences. This affected one (#49) of two residents reviewed for preferences. The facility census was 56. Findings include:Review of the medical record for Resident #49 revealed an admission date of 12/10/25. Diagnoses included fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing, chronic atrial fibrillation, unspecified diastolic (congestive) heart failure, and chronic kidney disease.Review of the Minimum Data Set (MDS) assessment, dated 12/12/25, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Interview with Resident #49 on 02/17/26 at 8:30 A.M. revealed she did not like sausage and the facility kept serving her sausage. Concurrent observation of Resident #49's breakfast meal tray revealed she was served sausage with her breakfast. Resident #49 stated the facility was aware she disliked sausage. Observation of Resident #49's breakfast meal tray on 02/17/26 at 8:30 A.M. revealed the resident was served sausage and gravy over biscuits, half a bowl of cereal, a fried egg, juice, almond milk and hot water for tea. Further observation of Resident #49's dietary meal ticket revealed the resident disliked sausage.Interview with Certified Nursing Assistant (CNA) #272 on 02/17/26 at 8:44 A.M. verified Resident #49 received sausage and gravy for breakfast. Further interview with CNA #272, and concurrent review of Resident #49's dietary meal ticket, confirmed the meal ticket identified the resident did not like sausage. Observation on 02/17/26 at approximately 9:00 A.M. of Resident #49's breakfast meal tray, once the meal was complete, revealed the resident ate the cereal and fried egg; however, Resident #49 did not eat the sausage and gravy. Review of the facility policy titled, Resident Food Preferences, dated July 2017, revealed nursing staff would document the resident's food and eating preferences.

Based on observations, resident interview, staff interviews, and review of facility policy, the facility failed to ensure enteral tube feedings were correctly labeled and dated. This affected one (#20) of one resident reviewed for enteral tube feedings. The facility census was 56.Findings include:Review of the medical record for Resident #20 revealed he was admitted on [DATE]. His diagnoses included dysphagia (difficulty swallowing) following a stroke, right-sided paralysis, aphasia (difficulty speaking), intracerebral hemorrhage, seizures, neurogenic bladder, and protein-calorie malnutrition.Review of the admission Minimum Data Set (MDS) assessment, dated 11/11/25, revealed Resident #20 was cognitively intact and did not display any behaviors at the time of the assessment. Resident #20 received 51% or more of his nutrition from a feeding tube.Review of the physician orders for Resident #20 revealed an order dated 02/09/26 for a puree diet and an order dated 02/11/26 for Jevity 1.5 (nutritional formula) to be administered each night from 9:00 P.M. to 5:00 A.M. at 60 milliliters (mL) per hour with 100 mL water boluses prior to starting and after completing the Jevity 1.5 administration.Observation on 02/17/26 at 9:00 A.M. of Resident #20's enteral tube feeding hanging in his room revealed a tube feeding bag filled with 600 mL of a light brown fluid and a tube feeding bag filled with 1000 mL of a clear liquid hanging from a feeding pump pole. The tube feeding bags were not labeled nor dated.Interview on 02/17/26 at 4:35 P.M. with the Director of Nursing (DON) confirmed Resident #20's tube feeding bags were not labeled to indicate what was contained in the bag, nor dated, and should have been.Interview on 02/18/26 at 2:00 P.M. with Licensed Practical Nurse (LPN) #230 revealed when a tube feeding was administered, it should be labeled with the name of the formula, the date it was hung, and the time it was hung. Further interview revealed once a formula was hung, it must be used or discarded within 24 hours of opening.Review of an undated facility policy titled, Tube Feeding Administration and Hanging Guidelines, revealed enteral tube feedings would be labeled with the date and time they were hung and would be administered or discarded within 24 hours.

Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to obtain an order for oxygen therapy. This affected one (#64) of one resident reviewed for oxygen therapy. The facility identified nine residents (#25, #27, #41, #43, #47, #51, #53, #55, and #64) who received oxygen therapy. The facility census was 56.Findings include:Review of the medical record for Resident #64 revealed an admission date of 02/16/26 with admitting diagnoses of fall with displaced rib fractures of ribs seven through eleven.Review of the hospital Community Referral Form (CRF) dated 02/16/26 for Resident #64 revealed no orders for supplemental oxygen therapy.Review of the admission physician orders for Resident #64 revealed no orders for oxygen therapy.Observation on 02/17/26 at 11:00 A.M. of Resident #64 revealed the resident was resting in bed with oxygen in place and running at three l/m via nasal cannula (NC).Interview on 02/17/26 at 1:54 P.M. with Licensed Practical Nurse (LPN) #230 verified Resident #64 received oxygen therapy at three liters per minute (l/m) and further confirmed the resident did not have a physician order for oxygen therapy. Review of the oxygen order dated 02/17/26 and timed at 5:32 P.M. for Resident #64 revealed oxygen at two l/m. Review on 02/18/26 of the baseline care plan dated 02/16/26 for Resident #64 revealed no baseline care plan was in place for oxygen therapy. Further review on 02/19/26 of the baseline care plan dated 02/16/26 revealed it was updated to include oxygen at three l/m, then changed to two l/m. Interview on 02/19/26 at 10:54 A.M. with LPN #281 revealed she added the documentation related to oxygen therapy to Resident #64's baseline care plan on 02/18/26 to indicate the resident admitted with oxygen in place. LPN #281 confirmed oxygen therapy was not documented upon admission and was added to the baseline care plan two days after admission. Interview on 02/19/2026 at 1:42 P.M. with the Director of Nursing (DON) verified the oxygen order for Resident #64 was not obtained and written until 02/17/26. Review of the facility policy titled, Medication and Treatment Orders, revised July 2016, revealed orders for medication and treatments would be consistent with principles of safe and effective order writing. All drug and biological order shall be written, dated, and signed.

Based on observation, medical record review, staff interview and policy review the facility failed to wear proper personal protective equipment (PPE) upon entry into a contact precautions room. This affected two (#10 and #47) of two residents reviewed for transmission-based precautions (TBP). The facility census was 56.Findings include: 1. Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included sepsis of unspecified organism, muscle weakness, unsteadiness of feet, hypomagnesium, urinary tract infection (UTI), and unspecified dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive deficits. Resident #10 required substantial/maximum assistance with activities of daily living (ADLs). Review of the physician orders revealed an order dated 02/16/26 contact precautions for urine. Observation on 02/17/26 at 9:05 A.M. of signage posted outside of Resident #10's room revealed the resident was in contact precautions. Further observation of the posted signage revealed all providers and staff were to put on gloves and a gown before entry into resident's room. Observation on 02/17/26 at 9:19 A.M. revealed Licensed Practical Nurse (LPN) #291 and LPN #230 entered Resident #10's room without donning a gown. Interview on 02/17/26 at 9:21 A.M. with LPN #230, after exiting Resident #10's room, confirmed a gown was not donned prior to entering the resident's room. LPN #230 stated Resident #10 was on contact precautions for an infection in her urine, so PPE was only needed if coming into contact with the resident's urine. A follow-up interview with LPN #230 and LPN #291 on 02/17/26 at 12:20 P.M. confirmed that neither donned a gown upon entry to Resident #10's room. LPN #230 and LPN #291 confirmed they administered Resident #10's medications, which included intravenous (IV) antibiotics. 2. Review of the medical record for Resident #47 revealed an admission date of 02/28/24 with diagnoses of multiple sclerosis, neuromuscular dysfunction of the bladder, Type II diabetes mellitus, and cellulitis. Review of the MDS assessment, dated 02/05/26, revealed Resident #47 had intact cognition. Review of a physician order dated 02/08/26 revealed Resident #47 was in contact precautions for ESBL (extended-spectrum Beta-Lactamase) (an infection) in urine. Observation on 02/17/26 at 11:15 A.M. revealed signage posted outside of Resident #47's room indicating the resident was on contact precautions. Further obervation of the signage revealed staff must put on gloves and a gown before room entry. No PPE, such as gowns and gloves, was available outside the room. Continued observation revealed Certified Nursing Assistant (CNA) #269 and CNA #242 entered Resident #47's room without donning any PPE. Further observation, upon opening Resident #47's door, revealed both CNAs were wearing gloves and no gowns. Concurrent interview with CNA #269 revealed gowns were located in a bin inside the room near the door to the bathroom. Both CNAs proceeded to don gowns. Interview on 02/17/26 at 11:42 A.M. with the Administrator verified the contact precautions signage outside of Resident #47's room stated PPE should be donned prior to entering the resident's room and further confirmed no PPE was available outside of the room. Interview on 02/17/26 at 11:45 A.M. with Resident #47 revealed staff did not routinely wear gowns when they came in the room. During the interview, LPN #291 entered Resident #47's room not wearing a gown or gloves. LPN #291 explained she planned to check Resident #47's blood sugar. LPN #291 entered the bathroom, obtained a pair of gloves (no gown), and proceeded to check Resident #47's blood sugar. Concurrent interview with LPN #291 confirmed she did not don PPE before entering the room. A follow-up interview on 02/17/26 at approximately 11:55 A.M. with LPN #291 confirmed she should have donned a gown and gloves before entering Resident #47's room to perform a blood sugar check. Review of the facility policy titled, Isolation-Categories of Transmission- Based Precautions, dated January 2012, revealed staff were to wear PPE, specifically disposable gloves and gown, upon entering a contact precautions room.

Based on medical record review, staff interview, and facility policy, the facility failed to ensure treatments were implemented timely for pressure ulcers. This affected one (#46) of three residents reviewed for pressure ulcers. The facility census was 49. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to thrombosis of left middle cerebral artery, hemiplegia right dominant side, spinal stenosis, major depressive disorder recurrent, pressure ulcer of the right heel, gastrostomy status, acute cystitis without hematuria, hyperlipidemia, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired, dependent for all care, and had a stage three pressure ulcer. Review of the admission nursing assessment dated [DATE] revealed Resident #46 readmitted to the facility after a hospital discharge. Review of the skin integrity documented a new unstageable right heel pressure ulcer that measured 3.1 centimeters (cm) in length by 2 cm in width. Review of nursing progress note dated 07/21/24 revealed Resident #46 had an area to the outer right heel 3.0 cm oval shaped black hard area noted with the area around the area blanchable. Blue boots bilateral were on. Review of nursing progress notes dated 07/23/24 revealed Resident #46's outer right heel was assessed. The area was discolored, soft measures 4 cm by 3 cm. Offloading boots and air mattress present on admission when wound noted. The nurse practitioner was aware, skin prep daily, and continue offloading boots. Review of the wound nurse practitioner consultation dated 07/30/24 revealed a new suspected deep tissue injury on the right lateral heel. Measurements were documented as 3 cm in length by 4 cm in width with new treatment orders. Review of the medical record revealed no previous orders provided treatment to the right heel. Interview on 10/17/24 at 8:24 A.M. with Unit Manager Licensed Practical Nurse (LPN) #204 verified Resident #46 had a suspected deep tissue injury upon readmission from the hospital on 07/20/24 and no treatment orders were in place until 07/30/24. Review of the undated policy Pressure Ulcer Risk Assessment and Management verified residents with pressure areas will receive treatment and services to promote healing. Treatment orders will be obtained by the floor nurse utilizing the wound care protocols established by the quality assurance committee.

Based on medical record review, resident interview, staff interview, and facility policy, the facility failed to ensure communication with dialysis treatment center and and failed to provide ongoing monitoring/assessment of the dialysis access site. This affected one (#150) of one resident reviewed for dialysis. The census was 49. Findings include: Review of the medical record revealed Resident #150 was admitted on [DATE]. Diagnoses included abscess of liver, acute kidney failure, cognitive communication deficit, chronic kidney disease stage 3, vascular dementia, major depressive disorder, type two diabetes mellitus with hyperglycemia, and hyperlipidemia. Review of physician orders dated 10/07/24 revealed Resident #150 received outpatient dialysis on Monday, Wednesday, and Fridays. Review of the most recent care plan dated 10/16/24 revealed Resident #150 was care planned for dialysis with interventions. None of the interventions included monitoring of the dialysis access site. Interview on 10/16/24 at 11:12 A.M. with Resident #150 revealed no paper work has been provided to bring to dialysis. Interview on 10/16/24 at 12:49 P.M. with Licensed Practical Nurse (LPN) #264 verified no communication is sent to the dialysis center for Resident #150. Interview on 10/16/24 at approximately 3:00 P.M. with the Director of Nursing (DON) verified there was no physician order for monitoring Resident #150's dialysis access site. Review of the undated policy, Dialysis, verified the facility will complete ongoing assessment and oversight of the resident before and after dialysis treatments, including monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices. In addition, the facility will provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and service as outlined in the agreement.

Based on observation, staff interview, and review of the menu spreadsheet, review of recipe, review of resident diet list, the facility failed to ensure pureed protein was prepared following the recipe to ensure adequate protein was provided. This affected one (#19) of one resident identified on a pureed diet. Additionally, the facility failed to ensure appropriate scoop sizes were used to serve protein portions to Resident #19 on a pureed diet, and to 11 (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) residents identified on a mechanical soft diet. The facility census was 44. Findings include: 1. Review of Resident #19's medical record revealed an admitted [DATE]. Diagnoses included dementia with psychotic disturbance and hemiplegia and hemiparesis following a cerebral vascular accident. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a low cognitive function. Review of a physician order dated 12/20/21 revealed Resident #19 received a no-added-salt diet with pureed texture and thin liquids. Observation on 09/20/23 at 10:52 A.M., revealed Cook #301 preparing the pureed protein using a food processor. Observed inside the food processor was noodles, two veal parmesan patties and marinara sauce. Continued observation revealed Cook #301 added an unmeasured amount of hot water at two intervals during the preparation of the puree. Interview on 09/20/23 at approximately 10:54 A.M., with Dietary Manager #307 revealed the food processor contained two veal parmesan patties, one cup of noodles, and eight ounces of marinara sauce. Further interview revealed a double portion was made because the size of the machine made it difficult to make a single portion of puree. Interview on 09/20/23 at approximately 12:40 P.M., with Dietary Manager #307 while reviewing the recipe for pureed veal parmesan, revealed only the veal patty should be pureed and served with a three-ounce scoop. No additional menu items, such as noodles or sauce, should have been included in the protein serving. Further review revealed a nutritive liquid, such as broth or milk, should be used to thin the protein, as needed. Continued interview with Dietary Manager #307 confirmed Cook #301 used only water to thin the pureed protein. Review of the recipe for Veal Parmesan, dated 09/25/17, revealed puree instructions: remove desired number of servings and add nutritive liquid, milk, broth, etc. Blend until desired consistency. 2. Review of the menu spreadsheet for the noon meal on 09/20/23 revealed residents on a pureed diet should receive three ounces of pureed veal parmesan. Further review revealed residents on a mechanical soft diet should receive three ounces of ground veal parmesan. Observations beginning on 09/20/23 at 12:00 P.M., revealed Cook #301 serving lunch using a green handled scoop to serve the pureed protein and to serve the mechanical soft protein. Interview on 09/20/23 at approximately 12:15 P.M., with Dietary Manager #307 stated the green handled scoop portions provided three-ounce servings. Review of a facility provided diet list revealed one resident (#19) was on a pureed diet, and 11 (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) residents identified on a mechanical soft diet. Follow up interview on 09/21/23 at 9:32 A.M., with Dietary Manager #307 confirmed the green handle scoops provided only two and two-third (2 2/3) ounce portions and further confirmed residents who received the puree portion of protein and mechanical soft portion of protein did not receive the required amount of protein for the meal.

Based on observation, staff interview, review of resident diet list, and review of policy, the facility failed to ensure hand hygiene was practiced during the preparation of mechanical soft food. This had the potential to affect 11 residents (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) identified on a mechanical soft diet. The facility census was 44. Findings include: Observations on 09/20/23 beginning at 11:03 A.M., revealed Cook #301 wearing gloves and handling tongs to pick up patties of veal parmesan to prepare mechanical soft textured food. Interview at that time with Cook #301 stated there were 11 residents on a mechanical soft diet, and she prepared the patties of veal parmesan in batches to not overload the food processor. Continued observation revealed Cook #301 placing four patties in the food processor, closing the lid, pressing the start button, pressing the stop button, opening the lid, using a spatula lying on the countertop to push the food lower into the food processor, picking up a carafe of hot water and pouring the water into the food processor, replacing the lid of the food processor, and continuing to process the patties. Continued observation revealed Cook #301 retrieved a pan for the final product, stopped the food processor, opened the lid, tapped the stirring arm of the food processor with her right index finger to allow the food to drop back into the machine, then picked up the food processor and spatula and scooped the processed patties into the pan. Cook #301 repeated this process two more times, each time tapping the stirring arm of the food processor with her right finger, and also wiping food from the blade with her finger, into the processor before removing the blade. Interview on 09/20/23 at 11:11 A.M., with Cook #301 confirmed she touched multiple non-food items and also touched ready-to-eat mechanical soft veal parmesan patties. Review of a facility provided diet list revealed 11 (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) residents identified on a mechanical soft diet. Review of the undated policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices revealed employees must wash their hands during food preparation to prevent cross contamination.

Based on observation, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living were provided with nail care. This affected three (#4, 19 and #26) of three residents reviewed for assistance with activities of daily living. The facility census was 44. Findings include: 1. Review of Resident #4's medical record revealed an admitted [DATE], with diagnosis including dementia with mood disturbance, cerebral infarction, psychosis, and macular degeneration. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a cognitive deficit and required extensive assistance for personal hygiene. Review of Resident #4's most recent care plan revealed the resident had an activity of daily living (ADL) self-care performance deficit related to decreased strength and endurance, impaired cognition related to dementia. Interventions were to provide limited to extensive assistance with personal hygiene. Review of Resident #4's medical record revealed he was to receive a shower/bath every Wednesday and Saturday. Observation of Resident #4 on 09/18/23 at 10:02 A.M., revealed the resident's fingernails were long and unkept. Observation of Resident #4 was observed eating breakfast on 09/21/23 at 7:55 A.M., and his fingernails remained long and failed to be cut on his shower day. 2. Review of Resident #19's medical record revealed an admitted [DATE], with diagnosis including dementia with psychotic disturbance, hemiplegia and hemiparesis following a cerebral vascular accident, glaucoma, and congestive heart failure. Review of Resident #19's quarterly MDS assessment dated [DATE] revealed had a low cognitive function and required extensive assistance for personal hygiene. Review of Resident #19's more recent care plan revealed he had an ADL self-care deficit related to hemiplegia affecting the left non-dominant side and cognitive deficit. Interventions included providing extensive assistance with personal hygiene. Observation on 09/18/23 at 10:22 A.M., revealed Resident #19 was sitting in his wheelchair in a common area with his blanket over his head. He was not able to be interviewed due to low cognitive function. His fingernails were noted to be long and unkept. Two nails were seen to be jagged. Observation on 09/21/23 at 8:23 A.M., revealed the resident was in the dining room eating breakfast. The resident's fingernails continued to be long and unkept. 3. Review of Resident #26's medical record revealed an admitted [DATE], with diagnosis including dementia, Alzheimer's, ischemic cardiomyopathy, diabetes mellitus, acute renal failure, and congestive heart failure. Review of Resident #26's quarterly MDS assessment dated [DATE] revealed the resident had a low cognitive function. He required personal assistance from two staff for dressing and personal hygiene. Review of Resident #26's shower and bath schedule revealed he was to receive a shower every Monday and Thursday. Review of Resident #26's most recent care plan revealed he had an ADL self-care performance deficit related to hemiplegia following an old cerebral vascular accident., neuropathy, dementia, weakness, arthritis, anxiety, tremor, health/functional decline. Resident #26 was noted to have bilateral lower extremity contracture's and required an extensive need of one to two staff for personal hygiene. Review of Resident #26's medical record revealed he was to have a bath/shower every Monday and Thursday. Observations on 09/18/23 at 1:08 P.M. revealed Resident #26 was lying in bed. His fingernails were noted to be long and unkept. Further observation of Resident #26 on 09/20/23 at 11:01 A.M., revealed the resident's fingernails continued to be long and jagged. Interview with Resident #26 on 09/18/23 at 9:52 A.M., revealed he would like to have his nails trimmed. Interview with Licensed Practical Nurse (LPN) #305, on 09/20/23 at 1:12 P.M., revealed nails were to be trimmed and filed/checked at each shower twice weekly. If a resident refused nail care, it should be reported to the nurse and the nurse would then attempt. If the resident refused care, it would be documented in the medical record. The nurses were also responsible for diabetic resident's nail care. Interview with State tested Nursing Aide (STNA) #306, on 09/20/23 at 1:12 P.M., revealed all residents nails were to be trimmed/checked after every shower which would be twice weekly. Interview with LPN #305, on 09/21/23 at 7:59 A.M., verified Residents #4, #19, and #26's nails were long and in need of trimming and nail care should have been completed on their shower day. Review of the policy titled Activities of Daily Living dated September 2018 revealed the facility will provide care and services for the following activities of daily living: hygiene which included bathing, dressing, grooming, oral care, and nail care.

Based on staff interview, record review, and review of the facility's Hospice Agreement, the facility failed to ensure coordination of care between the facility and Hospice provider. This affected one (#43) of one resident reviewed for Hospice care. The facility identified one resident in the facility was under Hospice care. The facility census was 44. Findings include: Review of the medical record for Resident #43 revealed an admitted [DATE], with diagnoses of dementia, hemiplegia, and hemiparesis. Review of the modified quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and required extensive assistance of two people for bed mobility, dressing, was totally dependent on two people for transfers, and required extensive assistance of one person for eating. Review of a physician order dated 05/26/23 revealed Resident #43 was admitted to hospice. Review of the facility's current care plan for Resident #43 revealed she received Hospice services. Interventions included Hospice aide to provide care and Hospice Registered Nurse to provide care. The care plan provided no guidance regarding the tasks to be completed by Hospice and the tasks to be completed by the facility when providing care to Resident #43. Interview on 09/19/23 at 4:47 P.M., with Unit Manger (UM) #309 revealed a Hospice care plan was not in Resident #43's medical record. Further interview confirmed a Hospice care plan should be in the paper chart for each resident under Hospice care. Interview on 09/21/23 at 12:21 P.M., with UM #309 revealed she called Hospice and a care plan for Resident #43 was faxed to the facility on [DATE]. UM #309 confirmed the care plan began 05/26/23. UM #309 further confirmed the facility's Hospice care plan for Resident #43 provided no guidance regarding the coordination of care between the facility and the Hospice staff. Review of the facility's Hospice agreement, initiated 10/20/14, revealed responsibilities of the facility included coordinating with Hospice in developing a plan of care for each Hospice patient.

Based on record review, resident interview, staff interview, Certified Nurse Practitioner interview, and review of the policy, the facility failed to ensure behavior interventions of non pharmacological interventions were implemented prior to increasing antipsychotic medication doses. This affected one (#18) of five residents reviewed for psychotropic medications. The facility census was 44. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE], with diagnoses of schizoaffective disorder and traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition and required supervision with one person assistance for transfers and locomotion. Further review revealed no physical or verbal behaviors towards others or not toward others, no rejection of care. Review of the behavior care plan initiated 05/19/18 revealed Resident #18 had a traumatic brain injury, schizoaffective disorder, impaired decision making, and short term memory loss, and may exhibit episodes of being short tempered, cursing, or giving gestures. Resident #18 had a tendency to overreact to situations and could become agitated and aggressive and not easily redirected by staff. Resident #18 needed supervision with group activity and meals when other residents were around. Interventions included an update 09/12/23 for Resident #18 to avoid group settings. Meals to be provided in room instead of dining room. Resident to not attend group activities with other residents in the facility. Review of a discontinued physician order for Resident #18 revealed an order dated 02/24/22 through 07/25/23 for Risperdal (an antipsychotic medication) 0.5 milligrams (mg) by mouth twice daily. Review of a nursing progress note dated 06/25/23 revealed Resident #18 was in the dining room for the evening meal at a table with another resident (Resident #38) who accidentally spilled his water on the table. The water spilled onto Resident #18 who became upset and threw his own water cup, with water in it, at Resident #38. Resident #18 was sent to the emergency roiagnom on [DATE] and returned to the facility the same day with no new orders. The facility initiated a self-reported incident with the State of Ohio on 06/25/23. Review of a nursing progress note dated 07/24/23 revealed Resident #18 was agitated when another resident called him [NAME]. Review of a nursing progress note dated 07/25/23 revealed the behavioral and mental health Nurse Practitioner (NP) (Certified Nurse Practitioner #308) was aware of Resident #18's increased agitation and outbursts. The NP ordered an increase in the Risperdal to 1.0 mg twice daily. Review of the current physician order dated 07/25/23 revealed Resident #18 received Risperdal 1.0 mg by mouth twice daily. Interview on 09/18/23 at 4:36 P.M., with Resident #18 revealed he was not allowed to participate in activities such as bingo and wished he could eat in the dining room. Resident #18 stated he had not recently asked to eat in the dining room or participate in activities. Interview on 09/18/23 at approximately 5:10 P.M., with the Administrator and Director of Nursing (DON) revealed Resident #18 demonstrated behaviors that were disruptive to other residents and therefore was permitted to attend only supervised activities such as bingo. Resident #18 would not be permitted to attend unsupervised activities such as watching a movie. Further interview revealed Resident #18 was offered a choice between eating in his room or eating in the dining room at his own table, and Resident #18 chose to eat in his room. Interview on 09/19/23 at approximately 10:00 A.M., with Unit Manager #309 confirmed behavioral health had not seen Resident #18 since 06/28/23 because the Nurse Practitioner rounded on Monday when Resident #18 was at day-work. Interview on 09/20/23 at 10:09 A.M., with the DON revealed Resident #18 had an outburst in June 2023 and remained angry after that, so the facility began at that time to separate Resident #18 from other residents to keep from triggering his behaviors. The DON stated Resident #18 was disruptive to other residents and used foul language in the facility. The DON stated Resident #18's guardian regularly visited and provided diet Pepsi, but when Resident #18 used foul language and was disruptive, Resident #18's guardian withheld the visits and diet Pepsi. The DON stated Resident #18 would fixate on his desire for diet Pepsi, and when the facility offered an off-brand of soda to Resident #18, he refused because he preferred only diet Pepsi. Further interview revealed staff would occasionally purchase a diet Pepsi with their own money to calm Resident #18 down. However, the DON stated Resident #18 would continue to request more diet Pepsi and was not calmed with only one. The facility did not purchase diet Pepsi for Resident #18. The DON, verified there was no other interventions attempted. Continued interview at that time, with the DON revealed the facility did not speak with Resident #18's guardian to advise her of Resident #18's increased behaviors due to the lack of visits and diet Pepsi. Interview on 09/20/23 at 4:09 P.M., with the Administrator revealed Resident #18 was unable to de-escalate himself once he became upset. The Administrator stated Resident #18 was upset since the interaction in June when Resident #38 accidentally spilled water on Resident #18. Further interview revealed Resident #18's guardian, shortly after that time, began withholding visits, snacks and drinks from Resident #18 which increased his behaviors. The Administrator stated the facility did not consider purchasing Resident #18 diet Pepsi. Telephone interview on 09/21/23 at 12:25 P.M., with Certified Nurse Practitioner (CNP) #308 for the behavioral and mental health company, who provided services to Resident #18 revealed she recalled the conversation from July 2023 regarding the increase in Risperdal for Resident #18. CNP #308 stated she only met Resident #18 once, but as yet had not conducted a face-to-face session with him since she began with the facility in July 2023. CNP #308 stated when she visited in the facility in July and August 2023, Resident #18 was out of the facility at a day-work. CNP #308 recalled the conversation from July 2023 wherein the facility advised her Resident #18 was having behaviors and threw a cup at another resident. Further interview revealed she was aware Resident #18's guardian was not visiting or providing snacks, and was also aware Resident #18 was restricted from activities and the dining room. CNP #308 stated diet Pepsi was not mentioned specifically. CNP #308 restated she was new to the facility in July 2023 and had not had a session with Resident #18 at that time and relied on the facility's perspective at that point. Further interview revealed CNP #308 and the facility staff did not discuss alternative behavioral interventions before doubling the Risperdal dose on 07/25/23. Telephone interview on 09/21/23 at 1:58 P.M., with Resident #18's Case Manager #312 revealed Resident #18 had no negative behaviors or outbursts at workshop. Resident #18 attended workshop three days per week. The facility had given the Resident #18 a 30 day notice to discharge and his guardian was upset as to where Resident #18 would go because she was unable to care for him at home. Case Manager #312 stated Resident #18's guardian, as a result of the 30-day notice, told Resident #18 he had to behave and stopped buying his diet Pepsi. Case Manager #312 stated she arranged for Resident #18 to attend many shows and outings paid for by his guardian. Resident #18 never had any issues with behaviors at these outings. Review of the policy Psychotropic Medications, revised 09/14/23, revealed it is the intent of the policy that a resident's mood, mental status, or behavior may be appropriately managed without antipsychotic drugs through the use of non-drug interventions to manage resident behavior.

Based on medical record review, observation, staff interview, and facility policy review, the facility staff failed to follow their policy to complete hand sanitizing to prevent the spread of infection. This failed practice had the potential to affect 45 of 45 residents residing in the facility. The census was 45. Findings include: Review of the medical record for Resident #147 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/12/21 at 12:02 P.M. revealed State tested Nurse Aid (STNA) #112 was passing lunch trays on the 200-Hall. STNA #112 left one resident room and without sanitizer her hands. She went to the tray cart, obtained a meal tray and entered the isolation room of Resident #147. STNA #112 could be heard asking Resident #147 if she wanted tarter sauce. STNA #112 then exited the isolation room without hand sanitizing, walked down the hall toward the kitchen and returned to the isolation room with tarter sauce. STNA #112 did not sanitizer her hands prior to reentering the room. Interview with STNA #112 on 04/12/21 at 12:06 P.M. she stated she was not aware Resident #147 was in isolation. STNA #112 verified there was a Contact Precautions isolation sign on the wall beside the door and there was a supply of personal protective equipment on the door. STNA #112 verified she did not apply hand sanitizer prior to entering the room, after exiting the room, or upon re-entering the room. Observation of the signage beside the room door revealed Contact Precautions with instructions to clean hands when entering and exiting the room. Interview on 04/12/21 at 12:11 P.M. with Registered Nurse (RN) #124 verified Resident #147 was on contact precautions for bacteria in her urine. Review of the undated facility policy titled Procedure for Handwashing revealed when to wash hands included before and after resident contact.

Based on medical record review, staff interview, and policy review, the facility failed to send notification of a resident transfer and discharge from the facility to the Office of the State Long-Term Care Ombudsman. This affected one (#43) of two residents who were transferred or discharged from the facility. The facility identified five residents who were transferred or discharged from the facility since 01/01/21. The census was 45. Findings include: Review of Resident #43's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #43 was discharged from the facility on 01/21/21. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing progress notes dated between 01/20/21 and 02/01/21 revealed Resident #43 was discharged to another skilled nursing facility; however, the medical record contained no documentation of the long-term care ombudsman being notified of the discharge. Interview on 04/15/21 at 8:51 A.M. with the Administrator verified the Office of the State Long-Term Care Ombudsman was not notified of Resident #43's discharge from the facility.

Based on medical record review, staff interview, and resident interview, the facility failed to ensure residents and resident representatives were provided a copy of the bed hold notice upon discharge when the resident was transferred to the hospital. This affected one resident (#40) of one resident reviewed for hospitalization . The facility identified five residents were transferred/discharged to the hospital since 01/02/21. The census was 45. Findings include: Review of the medical record for Resident #40 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes for Resident #40 dated 03/14/21 at 5:31 A.M. revealed the resident had an emergent transfer to the hospital for evaluation. An attempt was made to notify family and a message was left for the family to return their call. Review of progress notes dated 03/15/21 at 10:57 A.M. revealed the family was notified of the transfer. There was no documentation of any bed hold policy being provided to the family. Interview with Resident #40 on 04/12/21 at 3:00 P.M. revealed the resident did not receive a copy of the bed hold notice at the time of her transfer to the hospital or at anytime after her transfer to the hospital. Interview with Social Worker #130 on 04/14/21 at 3:30 P.M. verified no bed hold notice was provided to the resident or resident representative upon the resident's transfer to the hospital.

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure side rails were applied to a resident bed to assist with bed mobility. This affected one (#12) of one residents reviewed for activities of daily living (ADLs). The facility identified 15 residents with orders for side rails used to assist with bed mobility. The census was 45. Findings include: Review of Resident #12's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact and was assessed to require extensive two-plus person physical assistance with bed mobility. Review of the Care Area Assessment (CAA) for ADL Functional/Rehabilitation Potential revealed Resident #12 required extensive staff assistance for bed mobility and her goal was to maintain her current level of function with ADLs or have a slow decline. Review of an ADL self care performance deficit care plan, dated 02/15/21, revealed Resident #12 required extensive assistance of one to two staff members for bed mobility and had an intervention for bilateral half side enablers to her bed to improve bed mobility. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February, March, and April 2021 treatment administration record (TAR) revealed Resident #12's bilateral half side enablers were documented as in place to her bed every shift during these months. Observation on 04/12/21 at 2:19 P.M., 3:04 P.M., and 3:56 P.M. revealed Resident #12 was laying in bed in her room. Further observation of Resident #12's bed frame revealed no side rails were installed to her bed. Review of Resident #12's census information revealed she was moved to her current room on 04/01/21. Observation on 04/13/21 at 7:27 A.M. revealed Resident #12 laying in bed with no side rails installed on her bed. A subsequent observation was made on 04/13/21 at 10:28 A.M. and revealed Resident #12 was sitting in a chair in her room and her bed continued to have no side rails installed. Interview on 04/13/21 at 10:40 A.M. with Resident #12 stated she was not able to fully turn and reposition herself in bed and required staff assistance with this task. Resident #12 stated she was not aware if she was supposed to have bilateral half side rails on her bed. Interview on 04/13/21 at 2:29 P.M. with Stated tested Nurse Aide (STNA) #258 stated Resident #12 did assist with some ADLs and stated it was often difficult to turn and reposition Resident #12 in bed due to her inability to fully assist. STNA #258 verified Resident #12 did not have side rails on her bed to assist with bed mobility. Interview on 04/13/21 at 2:50 P.M. with Maintenance Assistant (MA) #460 stated Resident #12 was getting a different bed because the one she was currently in did not have side rails and Resident #12 needed them.

Based on medical record review, staff interview, and facility policy review, the facility failed to complete pressure wound assessments at least once every seven days. This failed practice affected one (#20) of three residents reviewed for pressure wounds. The facility identified four residents with pressure ulcers. The census was 45. Findings include: Review of the medical record for Resident #20 revealed an admitted d of 02/23/21, discharged [DATE] and re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . ,, Review of the pressure wound assessments revealed assessments were completed on 02/23/21, 03/05/21, 03/12/21, 03/19/21, 03/22/21, 04/02/21, and 04/09/21. The weekly assessment was not completed for 11 days from 02/23/21 to 03/05/21 and not completed for eight days from 03/22/21 to 04/02/21. Interview on 04/13/21 at 3:28 P.M. with the wound nurse, Licensed Practical Nurse (LPN) #109, verified a minimum of every seven wound assessments was not completed for Resident #20. Review of the facility policy titled Pressure Ulcer Risk Assessment and Management, revised 10/25/16, revealed all skin conditions and pressure areas will be treated according to physician's orders, monitored on a regular basis and documented according to facility procedures. A facility nurse will be responsible for measurement and treatment evaluation of pressure areas during weekly rounds. The wound care nurse or designee will measure each pressure area weekly.

Based on observation, staff interview, and medical record review, the facility failed to ensure hand positioning devices for contractures were applied as ordered by a physician. This affected one (#19) of two reviewed for positioning and mobility. The facility identified four residents with orders for positioning devices. The census was 45. Findings include: Review of Resident #19's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 02/17/21, revealed Resident #19 had severely impaired cognitive skills for daily decision making. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an activities of daily living (ADL) self care performance deficit care plan, dated 01/04/21, revealed Resident #19 required extensive assistance from staff for dressing, using between one and two staff members. An intervention was added on 02/03/21 which revealed Resident #19 had bilateral hand rolls to be applied in the morning and taken off at night. Review of a splint and brace program care plan, dated 02/24/21, revealed Resident #19 was dependent with splint and brace application and removal and had contractures to bilateral hands. An intervention as part of the care plan revealed Resident #19's bilateral hand rolls should be on when he was up for the day and off at night with the wide end of the roll applied toward the thumb. Observation on 04/12/21 at 2:23 P.M. and 3:16 P.M. revealed Resident #19 laying in bed with no hand rolls in place. The resident's fingers on bilateral hands were observed to be flexed over his palms in a fixed position, with the pads of his fingers lying against the palm of his hands. One blue padded hand roll was observed on top of the dresser in Resident #19's bedroom. Observation on 04/13/21 at 7:31 A.M., 8:07 A.M., 9:07 A.M., and 10:25 A.M. revealed Resident #19 was laying in bed with no hand roll placed in either hand. A blue padded hand roll was observed on the over-bed table in Resident #19's bedroom. Observation on 04/13/21 at 11:23 A.M. revealed Resident #19 was sitting in his reclining chair with no hand rolls in place. At 2:32 P.M. Resident #19 was laying back in bed with no hands rolls placed in his hands. The blue padded hand roll remained on the over-bed table. Review of Resident #19's April 2021 treatment administration record (TAR) on 04/13/21 at 2:35 P.M. revealed documentation to indicate Resident #19's hand roll was applied on the day shift on 04/13/21. Interview on 04/13/21 at 2:48 P.M., Registered Nurse (RN) #124 stated Resident #19 was dependent on staff for dressing and verified Resident #19's hand rolls were to be placed on during the day and taken of at night. RN #124 stated none of the nurse aides informed her Resident #19 refused to wear his hand rolls on 04/13/21. Observation on 04/13/21 at 2:54 P.M. of Resident #19 in his bedroom, with RN #124, revealed Resident #19 was laying in bed with no hand rolls in place, which RN #124 verified. RN #124 located the blue hand roll laying on his over-bed table, but after searching in Resident #19's dresser, closet, bathroom, chair, and bed, a second hand roll was not located. Interview on 04/13/21 at 3:07 P.M. with State tested Nurse Aide (STNA) #136 and at 3:15 P.M. with STNA #137 both stated they were not told by the off-going nurse aides that Resident #19 refused any of his care on their shift.

Based on observations, staff interview, review of Center for Disease Control (CDC) guidance, review of facility training and education information, review of staffing schedules, and review of facility policy, the facility failed to implement infection control practices to prevent the potential spread of COVID-19. This had the potential to affect the twenty two residents (#20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, and #41) who were COVID-19 negative in the facility. The facility census was 39. Findings include: 1. Observation on 11/19/20 from 8:24 A.M. to 9:29 A.M. found all staff including nursing staff, dietary staff, and housekeeping staff were wearing N95 respirators and face shields. Interview on 11/19/20 at 9:05 A.M. with State tested Nursing Assistant (STNA) #141 revealed she was an STNA on the COVID-19 positive hall. STNA #141 reported N95 masks were stored in the back barn in paper bags when not in use. STNA #141 reported the N95 masks were rotated and replaced if soiled or dirty. Interview on 11/19/20 at 10:23 A.M. with Licensed Practical Nurse (LPN) #290 revealed she wore the same N95 mask she was wearing on the non-COVID unit on the COVID-19 positive unit. Interview on 11/19/20 at 12:09 P.M. with LPN #290 revealed she had one N95 mask that she stored in a container in the back barn. LPN #290 reported she used the same N95 for the three days in a row she worked in a week. LPN #290 stated she would get a fresh mask if hers was soiled or sweaty. LPN #290 stated she knew where the supply was and would get a new mask every couple weeks or so. Interview on 11/19/20 at 12:17 P.M. with LPN #292 revealed N95 masks were stored in the red barn and stored in brown paper bags with their names on them when not in use. LPN #292 reported they were issued one N95 mask per month unless they were damaged or malfunctioned. Observation on 11/19/20 at 1:20 P.M. of the red barn storage area found brown paper bags labeled with staff names and organized by department. Observation of LPN #290 and LPN #292's brown paper bags revealed each had one bag containing a surgical mask and the remaining bags were empty. Interview at the time of the observation on 11/19/20 at 1:20 P.M. with the Administrator verified staff were only getting one N95 mask and they were flip flopped every two weeks or if they were broken or soiled. Review of the undated facility policy titled Vancrest Emergency Operations Plan revealed a section titled, Respirator or Simple Facemask. This section stated staff should put on a respirator or facemask before entry into the patient room or care area. The type of mask will be determined upon exposure risk. Guidance on extended use of respirators was required due to limited supply and the facility followed the CDC's Strategies to Optimize the Current Supply of N95 Respirators. Review of the CDC guidance Optimizing N95 Respirator Supplies, updated 06/28/20, revealed to mitigate the contact transfer of pathogens from the respirator to the wearer could be to issue each healthcare personnel who may be exposed to COVID-19 patients a minimum of five respirators. Each respirator will be used on a particular day and stored in a breathable paper bag until the next week. This will result in each worker requiring a minimum of five N95 respirators if they put on, take off, care for them, and store them properly each day. This amount of time in between uses should exceed the 72 hour expected survival time for [DIAGNOSES REDACTED]-CoV2. 2. Observation on 11/19/20 at 9:38 A.M. of the non-COVID wing found Housekeeping Supervisor (HS) #282 cleaning room [ROOM NUMBER]. HS #282 was observed adjusting her N95 respirator under her face shield by cupping the outer surface of the N95 and pushing the N95 up higher over her nose. HS #282 was then observed touching the doorknob of the bathroom in room [ROOM NUMBER]. HS #282 did not complete hand hygiene after adjusting her mask. Observation on 11/19/20 at 9:59 A.M. of HS #282 found the straps of her N95 respirator at the bottom of her hairline and gapping open at the bottom under her chin. The elastic appeared to be loose and unable to secure the N95 properly. HS #282 was observed again using her bare hand under her shield to adjust her N95 mask. HS #282 did not complete hand hygiene after adjusting her N95. Coinciding interview with HS #282 verified she was touching the outside of her N95 with her hands. HS #282 stated her N95 needed fixed and wasn't fitting properly. Review of the facility's training information and CDC reminder postings titled Sequence for Putting on and Removing Personal Protective Equipment, revealed the staff were to wear their respirator at all times and the respirators were to be secured with ties or elastic bands at the middle of the head and neck. The respirators were to fit snug to the face and below the chin. Staff were instructed to keep their hands away from their face and perform hand hygiene. Review of the facility policy titled COVID-19 Procedure: Outbreak Response, dated March 2020, revealed Personal Protective Equipment (PPE) guidance included all PPE types must be consistently and properly worn when required. Regularly inspected, maintained and replaced as necessary. Properly removed, cleaned, and stored or disposed of as applicable to avoid contamination of self, others, or the environment. Review of the CDC guidance Optimizing N95 Respirator Supplies, updated 06/28/20, revealed Healthcare Providers re-using an N95 respirator should use a clean pair of gloves when donning or adjusting a previously worn N95 respirator. It was important to discard gloves and perform hand hygiene after the N95 respirator was donned or adjusted. 3. Interview on 11/19/20 at 10:23 A.M. with LPN #290 revealed there was no dedicated staff assigned to the COVID-19 positive unit. LPN #290 reported the nurses were rotated between the COVID-19 negative and monitoring hall and the COVID-19 positive hall. LPN #290 pointed to the schedule and said she was assigned three days on the COVID-19 negative and monitoring hall this week and in a couple days she will be on the COVID-19 positive hall. LPN #290 reported the same N95 mask she was wearing she also wore on the COVID-19 positive unit. Observation on 11/19/20 at 12:04 P.M. found Housekeeper #140 wiping down the handrails on the non-COVID hall. Interview on 11/19/20 at 12:17 P.M. with LPN #292 revealed there was no dedicated staff assigned to the COVID-19 unit. LPN #292 reported the nurses were split between the COVID-19 positive hall and the COVID-19 monitoring or negative hall. LPN #292 reported it could switch each day and it just depended on how they were scheduled. Observation 11/19/20 at 12:58 P.M. found Housekeeper #140 cleaning a resident room on COVID-Positive hall. Review of the POS [REDACTED]. Some nurses were rotated weekly and others worked on the East and West halls within the same week. No designated nursing staff for the COVID-19 unit was found. Review of the staffing schedule for the housekeeping staff for 11/15/20 through 11/28/20 revealed on 11/20/20 and 11/21/20 it was found Housekeeper #140 was the only housekeeper on the schedule and worked 6:00 A.M. to 2:00 P.M. covering all halls. On 11/15/20 and 11/26/20 Housekeeper #146 was the only housekeeper scheduled for the building, worked from 6:00 A.M. to 2:00 P.M. and covered all halls. No dedicated staff was found. Interview on 11/24/20 at 10:38 A.M. with the Director of Nursing (DON) verified the numbers listed on the schedule indicated the shifts the housekeeping staff worked. The DON reported hall designations for housekeeping staff were verbally made when there was more than one staff assigned to the schedule during the day. One staff assigned indicated they were responsible for all housekeeping tasks. Review of the undated policy titled Emergency Operations Plan under the section titled, Environmental Services revealed workers within the unit of suspected or confirmed COVID cases should don PPE as instructed based off of exposure to keep general spaces as clean as possible with focus on surfaces and high-touch areas. Dedicated staffing was required with no shared assignments to a non-affected unit. High touched areas were to be cleaned every 2 hours between the hours of 4:00 A.M.-8:00 P.M. Review of the CDC Guidance titled Responding to COVID-19 in Nursing Homes, dated 04/30/20, revealed the facility was to determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP with COVID-19 were identified in the facility. This would allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit. Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. Assign environmental services staff to work only on the unit. 4. Interview on 11/19/20 at 8:57 A.M with Housekeeper #140 revealed the facility used Lysol, Clorox spray, and Sanicare spray when cleaning resident rooms and common areas. Housekeeper #140 reported there was one housekeeping cart per wing. Observation on 11/19/20 at 12:04 P.M. found Housekeeper #140 wiping down the handrails on the non-COVID hall. Housekeeper sprayed Sanicare Disinfectant on a cloth and wiped the cloth on handrails. The handrails were observed to be dry after immediate wiping. No sit time for sanitization and disinfection was observed. Observation on 11/19/20 at 12:51 P.M. found Housekeeper #140 spraying Sanicare Disinfectant on a rag and wiped the rag on the handrails and telephone. Coinciding interview with Housekeeper #140 verified she was wiping down the handrails with the rag. She stated she was working to keep everyone safe by disinfecting touched surfaces. Observation of wiped surfaces revealed the surfaces were dry and the disinfectant was not applied and allowed to sit to be effective. Review of the manufactures directions for usage of Sanicare TBX Disinfectant revealed the directions for use included holding the container six to eight inches from surface to be treated, spraying the area until it was covered with the product/solution, allow product to penetrate and the surface to remain wet for three minutes. Wipe off with a clean cloth, mop, or sponge. The facility identified twenty two residents (#20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, and #41) who were COVID-19 negative in the facility.

Based on record review, resident and staff interviews, facility documents, and Centers for Disease Control (CDC) guidelines, the facility failed to isolate one (#127) resident, when the resident's roommate became positive for Coronavirus Disease 2019 (COVID-19). The facility census was 36. Findings include: Review of the record for Resident #127 revealed an initial admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #127's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of six, indicating the resident was severely cognitively impaired. Review of Resident Infection Line List for positive COVID-19 results revealed Resident #133 was on isolation beginning 08/29/20, tested positive on 09/03/20, and had symptoms of shortness of breath, fever, and cough. Review of the census on 09/03/20, verified Resident #127 and Resident #133 shared the same room on the west hall. The census also verified an empty resident room in the east hall and 10 additional empty beds also on the east hall. In addition, two empty resident rooms were being utilized for a temporary COVID staff area. Interview on 09/08/20 at approximately 12:30 P.M. with Resident #127, verified moving to the new room last Friday, 09/04/20. Resident #127 reported her roommate had been coughing and added that she was not sure if that was normal or not. Interview on 09/09/20 at 10:00 A.M. with the Administrator and Director of Nursing (DON), revealed all residents were tested on Monday, 08/31/20, which resulted in Resident #133 testing positive with COVID-19 on 09/03/20. The DON reported receiving the results on 09/03/20, at approximately 6:30 A.M. Resident #133 had a roommate, Resident #127. Resident #127 had been previously exposed but tested negative for COVID-19 and had not developed symptoms. The Administrator and DON verified the facility did not immediately separate Resident #127 and Resident #133. On 09/04/20, prior to lunchtime, the facility moved unexposed Resident #117, who was in a single room with unexposed Resident #118. On 09/04/20, the facility verified moving Resident #127 to a private room, separating the resident from a COVID-19 positive roommate. Resident #127 remained in the room with a COVID positive roommate for more than 24 hours. Interview by telephone on 09/09/20 at 8:44 A.M. and email on 09/09/20 at 1:23 P.M., with the County Health Department Registered Nurse (RN), revealed instructing the facility to isolate the COVID-19 positive resident and to separate the roommate was best practice and would align with isolation procedures. Review of Centers for Disease Control and Prevention (CDC) guidance for Responding to COVID-19 in Nursing Homes, updated 04/30/20, verified if a resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. In addition, roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure. This deficiency substantiates Complaint Number OH 591.