Every finding on record at Vancrest of Payne

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure newly identified skin impairments were thoroughly evaluated and assessed. This affected one (#24) of one resident reviewed for pressure ulcers. The facility census was 37.Findings include:Review of the medical record revealed Resident #24 was admitted on [DATE] and discharged on 11/22/25. Diagnoses included urinary tract infection, atherosclerotic heart disease of native coronary artery without angina pectoris, cognitive communication deficit, major depressive disorder, essential hypertension, hyperlipidemia, primary osteoarthritis, hypotension, type two diabetes mellitus without complications. Review of the Minimum Data Set (MDS) assessment, dated 09/15/25, revealed the resident was moderately cognitively impaired, dependent for toileting and was always incontinent of bladder. Review of the care plan, dated 04/16/25, revealed the resident was care planned for abrasions and pressure ulcers. Review of the physician orders, dated 08/14/25 to 08/18/25, revealed an order to apply triad paste to coccyx area every shift for a superficial open area, with instructions to apply small amount of paste and gently rub in. Further review of the medical record revealed no assessment of the area identified to the coccyx, including a description of the wound or measurements, was completed until 08/18/25 when wound care assessed the area. Review of the Treatment Administration Record from 08/14/25 through 08/18/25 verified the triad treatment was applied as ordered. Interview on 09/30/25 at 3:00 P.M. with the Director of Nursing (DON) verified Resident #24's coccyx wound was not thoroughly assessed upon identification. The DON confirmed that based on the documentation, the wound was identified on 08/14/25 and not assessed until 08/18/25. Review of the facility policy titled, Pressure Ulcer Risk Assessment and Management, dated 10/25/16, revealed to communicate to the wound care nurse/designee any areas of skin breakdown for continued follow up and obtain measurements, including width, length, and depth.

Based on observation, resident family interview, staff interviews, review of facility self-reported incidents (SRIs), and review of facility policy, the facility failed to report an allegation of injury of unknown origin. This affected one (#35) of two residents reviewed for abuse. The facility census was 37. Findings include:Review of the medical record revealed Resident #35 was admitted on [DATE] and discharged on 11/07/25. Diagnoses included Alzheimer's disease with early onset, age related osteoporosis without current pathological fracture, anxiety disorder, circadian rhythm sleep disorder, and dementia in other diseases classified elsewhere moderate with anxiety.Review of the Minimum Data Set (MDS) assessment, dated 11/07/25, revealed the resident was severely cognitively impaired. The resident was always continent of bowel and bladder. Resident #35 required supervision assistance with toileting and showering and set-up/clean-up assistance with upper and lower body dressing and footwear. Review of a nursing progress note, dated 09/29/25 at 6:27 A.M., revealed Resident #35 had a bruise to the left hand, measuring approximately 5 centimeters (cm) in size, and left shoulder discoloration, approximately 3 cm x 2.5 cm. Observation on 09/29/25 at 10:24 A.M. revealed Resident #35's left hand was swollen and purple in color. Concurrent interview with Resident #35 and her spouse revealed the resident was unable to explain what happened. Resident #35's spouse stated the resident's left hand had a new bruise today and the nurse was aware. Review of the facility submitted SRIs, completed prior to 09/30/25, revealed no SRI was submitted to the state survey agency (SSA) for an injury of unknown origin for Resident #35. Interview on 09/30/25 at 8:24 A.M. with Licensed Practical Nurse (LPN) #171 verified on 09/29/25 Resident #35's hand was swollen and purple and the resident was not able to explain what had occurred. LPN #171 stated she asked some second shift staff and they did not know what happened. Interview on 09/30/25 at 8:35 A.M. with the Director of Nursing (DON) verified it was unknown how the injury to Resident #35's left hand and shoulder had occurred. The DON stated it was reported the resident was unsteady on 09/29/25 and it potentially could have occurred from her running or falling into things. The DON verified not completing a SRI for an injury of unknown origin. A subsequent review of the facility submitted SRIs revealed on 09/30/25 at 11:27 A.M. (after surveyor identification) an SRI was submitted to the SSA for Resident #35's injury of unknown origin.Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 2017, revealed an injury of unknown source was when both of the conditions were met: the source of the injury was not observed by any person or could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. All incidents and allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee. The Administrator or designee will notify the Ohio Department of Health (SSA) of all alleged violations involving the above no later than 24 hours from the time the incident/allegation was made known to the staff member.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure bed hold notices were provided timely. This affected four (#1, #3, #11, and #38) of four residents reviewed for bed hold notices. The facility census was 37.Findings include:1.Review of the medical record for Resident #1 revealed an admission date of 01/16/25 with diagnoses including, but not limited to, atrial fibrillation, major depressive disorder, hydronephrosis with renal and ureteral calculus obstruction, anxiety disorder, and congestive heart failure.Review of Minimum Data Set (MDS) assessment, dated 07/21/25, revealed the resident was cognitively intact.Review of a health status note dated 01/30/25 at 10:41 A.M. revealed Resident #1 was transferred to the emergency room (ER) due to blood in her stool. Review of a Communication - with Family/Next of Kin (NOK)/Power of Attorney (POA) note dated 01/31/25 at 9:23 A.M. revealed the resident's daughter did not want to do a bed hold. The resident's daughter stated they cleared out the resident's room last night. The resident's daughter voiced understanding of not doing the bed hold. A bed hold letter was mailed to the resident's daughter via certified mail.Review of the bed hold notice revealed it was not sent to Resident #1's representative until 01/31/25 (resident transferred to the hospital on [DATE]). Review of a nursing note dated 03/14/25 revealed Resident #1 was transferred to the hospital at 8:53 A.M. Review of a Communication- with Family/NOK/POA note dated 03/17/25 at 11:33 A.M. revealed a voicemail message was left for Resident #1's daughter to return the call. A bed hold letter was mailed via certified mail. Review of the bed hold notice revealed it was not sent to Resident #1's representative until 03/17/25 (three days after transfer to the hospital). Review of nursing note dated 06/02/25 revealed at 9:50 A.M., Resident #1 was transferred to the hospital and the resident's daughter was informed of the transfer at 9:55 A.M. Review of a Communication- with Family/NOK/POA note dated 06/02/25 at 1:55 P.M. revealed Resident #1's daughter was contacted and informed the transfer notice would be sent via certified mail. The resident's daughter was informed the resident had used ten out of thirty days of Medicaid bed hold days. The resident's daughter verbalized understanding.Review of the bed hold notice revealed it was sent to Resident #1's representative on 06/04/25 (two days after transfer to the hospital). Interview on 09/30/25 at 2:16 P.M. with the Administrator revealed bed hold notices were sent via certified mail. The Administrator verified the bed hold notices were not provided until after the resident was admitted to the hospital, adding it was her understanding they did not have to be provided unless a resident was admitted . The Administrator confirmed she was unaware that bed hold notices were to be sent with the resident upon transfer to the hospital, or within 24 hours of the transfer. 2. Review of the medical record for Resident #3 revealed an admission date of 06/09/25 with diagnoses including, but not limited to, unspecified fracture of upper end of left humerus, fracture of right femur, hypertension, dementia, anxiety, and congestive heart failure.Review of the MDS assessment, dated 09/01/25, revealed the resident had severe cognitive impairment.Review of a nursing note dated 08/14/25 revealed Resident #3 was transferred to the ER at 9:43 P.M. Review of communication-with Family/NOK/POA dated 08/15/25 at 1:03 P.M. revealed POA notified regarding bed hold for the resident. Explained that a certified letter would be mailed. Writer sent certified bed hold letter. Review of the bed hold notice revealed it was sent via certified mail to Resident #3's POA on 08/15/25 (one day after transfer). Review of nursing note dated 09/14/25 at 7:29 P.M. revealed on-call notified of the resident's request to be sent to the ER and the resident's condition. Son to send family member over to be with the resident in the ER.Review of a Communication-with Family/NOK/POA note dated 09/15/25 at 1:13 P.M. revealed bed hold discussed with Resident #3's son. Resident #3 had used eight out of thirty bed hold days. Son verbalized understanding and a certified letter was mailed to the son.Review of the bed hold notice revealed it was not sent to Resident #3's POA until 09/15/25 (one day after transfer to the hospital). Interview on 12/22/25 at 3:54 P.M. with the Administrator verified bed hold notices were not provided for Resident #3 until the day after the resident was transferred to the hospital. 3. Review of the medical record for Resident #11 revealed an admission date of 02/24/25 with diagnoses including, but not limited to, heart failure, angioneurotic edema, depression, anxiety, constipation, insomnia, presence of left artificial should joint, and hypertension.Review of the MDS assessment, dated 10/10/25, revealed the resident had severe cognitive impairment.Review of a nursing note dated 05/30/25 at 10:05 P.M. revealed Resident #11 was in much discomfort and had blood in his brief, with a history of hemorrhoids. Resident #11 requested to go the the hospital and POA agreed.Review of a Communication-with Family/NOK/POA note dated 06/03/25 at 1:04 P.M. revealed the writer spoke with Resident #11's POA regarding bed hold. POA stated the resident should be returning in the next few days, so they wanted to do the bed hold. A certified bed hold letter was sent to the POA.Review of the bed hold notice revealed it was mailed on 06/03/25 (four days after transfer to the hospital). Interview on 12/23/25 at 11:24 A.M. with the Administrator verified the bed hold notice for Resident #11 was not provided until four days after transfer to the hospital.4. Review of the medical record for Resident #38 revealed an admission date of 05/10/25 with diagnoses including, but not limited to, atherosclerotic heart disease of native coronary artery, cerebral infarction, type two diabetes, hypertension, and heart failure.Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact.Review of a nursing note dated 06/05/25 at 1:28 A.M. revealed at approximately 12:45 A.M. staff were conducting rounds and the resident was groaning out and not following commands. Updated on-call and a new order was received to send to the ER. Review of a Communication/NOK/POA note dated 06/06/25 at 10:05 A.M. revealed the resident's son was updated regarding bed hold for the resident. The son stated the hospital made it seem like the resident would possibly return to the facility either today or tomorrow. Son stated that if this was the case, they would want to hold the bed. Son stated he would call back in the afternoon to let the writer know for sure. The resident is still in observation for now.Review of the bed hold notice revealed it was mailed on 06/09/25 (four days after the resident transferred to the hospital). Interview on 12/23/25 at 11:24 A.M. with the Administrator verified Resident #38's bed hold notice was not provided until four days after transfer to the hospital. Review of the facility policy titled, Bed-Holds and Returns, revised October 2022, revealed all residents/representatives were provided written information regarding the facility and state bed hold policies, which addressed holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, were provided with written notice about these policies at least twice: notice one well in advance of any transfer (admission packet) and notice two at the time of the transfer (or, if the transfer was an emergency, within 24 hours).

Based on medical record review, staff interview, physician interview, and review of medication information from Medscape, the facility failed to administer seizure medications for a resident who was admitted to the facility from the hospital with a new onset of seizure disorder resulting in significant medication errors. This affected one (Resident #30) of three residents reviewed for medication administration. The facility census was 29. Findings include: Review of the medical record of Resident #30 revealed an admitted [DATE], a transfer to the hospital on 09/25/24 and then discharged home on 09/25/2024, with a return to the facility on [DATE] after retruning to the hosptial on 09/29/2024. Diagnoses included unspecified convulsions, Parkinson's disease with dyskinesia without mention of fluctuations, repeated falls, wedge compression fracture of T5-T6 vertebra (on admission), and type II diabetes mellitus. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #30 was cognitively intact and required supervision assistance for toileting, bathing, and dressing. Review of the progress note dated 09/25/24 at 8:21 A.M. LPN #100 documented Resident #30 was nonresponsive and shaking all over with seizure-like activity. Resident #30 was sent to the emergency room . Further review of the medical record revealed Resident #30 returned to the facility from the hospital on 10/10/24 at approximately 4:15 P.M. with a new diagnosis of new onset seizures. Review of the hospital discharge paperwork dated 10/10/24 revealed new orders for Keppra (anticonvulsant medication) 1000 milligrams by mouth twice daily for convulsions and Vimpat (anticonvulsant medication) 100 mg by mouth twice daily for convulsions. Review of the document titled, Electronically Transmitted Prescription, dated 10/10/24 at 8:19 P.M. revealed the pharmacy was advised of the admission medications for Resident #30. The form did not indicate if the medications were ordered as stat. Review of the Medication Administration Record (MAR) revealed the Keppra and Vimpat were not administered on 10/10/24. Further review of the medical record revealed no documentation the physician was notified Keppra and Vimpat were not administered. Review of the progress note dated 10/10/24 at 11:23 P.M. documented by Licensed Practical Nurse (LPN) #106, revealed Resident #30 was alert and oriented to person, place, time, and event, pleasant and cooperative. Her speech was clear. Focal seizure-like activity had been noted during supper lasting 10 minutes. Seizure precautions were in place and Resident #30 had been able to answer questions during the active episode. Blood pressure, heart rate, and respiratory rate were within normal limits. Resident #30 remained continent of bowel and bladder with minimal intermittent urinary incontinence. The documentation is absent of any family or physician notification. Review of the progress note dated 10/11/24 at 9:01 A.M. documented by Registered Nurse (RN) #128, revealed the nurse was alerted to Resident #30's room by son-in-law. Upon entry to the room, RN #128 noted Resident #30 lying in bed, her body was shaking, her eyes were fixed open and pupils dilated. Resident #30 was not responsive to verbal or tactile stimuli. Resident #30's respirations varied but the partial oxygen saturation remained between 89 to 97% (percent) on room air. The episode occurred for an extended period with the convulsions slowly subsiding. The Director of Nursing (DON) arrived at the room and the son-in-law refused to have Resident #30 transported to the emergency room stating ,what good would it do? She will end back up in a larger hospital and she does not want to be there. The DON notified the physician of the interaction. Review of the progress note at 9:45 A.M., documented by RN #166, revealed a late entry: received orders from Nurse Practitioner to administer two mg of Ativan twice to help control the seizures and a one time dose to administer Keppra 1000 mg liquid orally. A progress note, on 10/11/24 at 4:21 P.M. documented by RN #128 revealed an order to begin Diastat (anticonvulsant) rectally as needed. Review of the MAR revealed Levetiracetam (Keppra) 100 mg per milliliters (ml), 10 ml was administered 10/11/24 at 9:34 A.M. Review of the pharmacy, Delivery Sheet, dated 10/11/24 and time stamped 12:22 P.M. revealed six tablets of Keppra 1000 mg was delivered, along with 11 other medications for Resident #30. Interview on 10/22/24 at 8:40 A.M. with the Director of Nursing (DON) revealed Resident #30 arrived at the facility on 10/10/24 at a little after 4:00 P.M. without the transferring hospital having given any report. The facility did not have some of her medications. Interview on 10/22/24 at 3:00 P.M. with Pharmacist #500 revealed medications were delivered on 10/11/24 between 1:00 P.M. and 1:30 P.M. which included Keppra 1000 mg six tablets, among others. Interview on 10/31/24 at 9:34 A.M. with LPN #101 revealed she had been on duty when Resident #30 arrived back to the facility from the hospital on 10/10/24. LPN #101 stated she had put the medication orders into the computer. She stated she normally will also print out a copy of the orders and fax them to the pharmacy but could not be certain she had done that. The facility does not keep a record of fax transactions. Telephone interview on 10/31/24 at 9:39 A.M. with Certified Nurse Practitioner (CNP) #500 revealed she had not been contacted related to the unavailability of the Keppra and Vimpat. CNP #500 stated if she would have been notified, she would have called the pharmacy herself or called a local pharmacy to have an emergency supply drop shipped and also given an order for an as needed medication the facility does have in the emergency box. She further reported having been called on 10/11/24 of the active seizure occurring and had given the Ativan order and added the Diastat order. CNP #500 stated she had attempted to have Resident #30 returned to the hospital numerous times and the family refused. Interview on 10/31/24 at 10:30 A.M. with the DON revealed the Keppra liquid was borrowed from another resident. Telephone interview on 10/31/24 at 11:02 A.M. with RN #128 revealed she guessed Resident #30's seizure began on 10/11/24 a little after 8:00 A.M. RN #128 stated she remained with Resident #30 for the duration and had sent a State tested Nursing Assistant (STNA) to get another nurse. RN #128 stated the DON came and assisted and got the order for the Ativan. Interview on 10/31/24 at 11:54 A.M. with the DON revealed there was no documentation in the medical record indicating the physician was made aware of Keppra and Vimpat not being available for Resident #30. The DON further verified the medications were not administered timely. Review of medication information from Medscape at https://reference.medscape.com/drug/keppra-spritam-levetiracetam-343013#91 revealed Vimpat and Keppra are used for seizure disorder. Further review revealed, Do not stop taking this medication without consulting your doctor. Your seizures may become worse when the drug is suddenly stopped. This deficiency represents non-compliance investigated under Complaint Number OH00159061.

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure a dependent resident received timely personal hygiene care. This affected one resident (#11) out of two residents reviewed for activities of daily living (ADL). The facility identified all 24 residents required assistance from staff with bathing and dressing. The facility census was 24. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, restlessness and agitation, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition and required extensive assistance of one person for personal hygiene. Review of the current care plan for Resident #11 revealed an ADL self-care deficit related to chronic pain, osteoarthritis, Alzheimer's, dementia, and need for limited assistance in ADL function. Interventions included extensive assistance of one person for personal hygiene. Review of the bathing schedule revealed Resident #11 received a shower on 01/16/23. Observations on 01/17/23 at 9:45 A.M. revealed Resident #11 was dressed and sitting on her bed playing cards. Resident #11 had several long, white hairs coming from her chin. Subsequent observation on 01/18/23 at 8:54 A.M. revealed Resident #11 sitting in her recliner and playing cards. Resident #11 remained with several long, white hairs coming from her chin. Observation and interview on 01/19/23 at 8:08 A.M. with the Director of Nursing (DON) revealed Resident #11 was in her room and Resident #11 had long white hairs coming from her chin. The DON verified the hairs were present and visible. The DON said the State tested Nurse Aides (STNAs) were expected to provide shaving for residents. Interview on 01/19/23 at 8:12 A.M., with STNA #342 verified she had shaved Resident #11 in the past and Resident #11 had not resisted care. Interview on 01/19/23 at 10:44 A.M., with STNA #358 verified Resident #11 had some hairs coming from her chin which were long enough to shave. Review of the facility policy titled Activities of Daily Living AM/PM Care, undated revealed residents were assisted at appropriate level for mouth care, hair care, and shaving, etc.

Based on staff interview, review of the staffing schedule, review of the Staff Coronavirus Disease 2019 (COVID-19) Vaccination Matrix, review of the facility policy, and review of the Centers of Medicare and Medicaid Services (CMS) memorandum QSO-23-02-ALL, the facility failed to ensure staff were COVID-19 vaccinated, had an approved exemption, or had been identified as appropriate for a temporary delay per Center for Disease Control and Prevention (CDC) guidance. The vaccination rate for the facility was calculated at 98.8%. This had the potential to affect all 24 residents currently residing in the facility. Findings include: Review of the Staff Vaccination COVID-19 log, provided on 01/17/23, revealed the facility had 82 employees with 47 employees vaccinated, 34 employees with granted exemptions, and one employee (State tested Nursing Aide #346) who was partially vaccinated. Interview on 01/17/23 at 12:29 P.M. with the Administrator revealed State tested Nurse Aide (STNA) #346 was hired on 05/09/22 and received the first dose of a two-dose COVID-19 vaccination on 06/21/22 and had not received the second COVID-19 vaccination dose. Subsequent interview with the Administrator on 01/18/23 at 4:14 P.M. revealed STNA #346 never tested positive for COVID-19 since his hire date on 05/09/22. The Administrator confirmed on 01/19/23 at 8:41 A.M. that STNA #346 did not receive his first COVID-19 vaccination dose prior to his hire date. Interview with the Director of Nursing (DON) on 01/19/23 at 2:39 P.M., verified STNA #346 worked consistently at the facility since he was hired, and worked throughout the facility. Review of the staff schedule for December 2022 and January 2023 revealed STNA #346 worked throughout the facility on multiple days monthly. Review of the Centers for Medicare & Medicaid Services (CMS) memorandum, QSO-23-02-ALL regarding COVID-19 health care staff vaccination, dated 10/26/22, revealed CMS expects all providers' and suppliers' staff to have received the appropriate number of doses of the primary vaccine series unless exempted as required by law, or delayed as recommended by the Centers for Disease Control and Prevention (CDC). Facility staff vaccination rates under 100% constitute noncompliance under the rule. Review of the facility policy titled COVID-19 Vaccine Mandate Policy, dated November 2021 revealed all facility staff are required to have received at least one dose of a Food and Drug Administration (FDA)-authorized COVID-19 vaccine by the first day of employment.

Based on medical record review, review of the facility policy for bed-hold, and staff interview, the facility failed to ensure resident or resident representative receive the bed-hold policy upon discharge from the facility. This affected one (Resident #34) of three residents reviewed for discharge. The facility census was 32. Findings included: Review of medical record for Resident #34 revealed admitted [DATE]. The resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE] to the hospital. Review of the minimum data set (MDS) revealed she was assessed as being severely impaired cognition. A review of the progress notes dated 07/25/22 revealed Resident #34 was taken to an appointment at a behavioral consult and was admitted to the hospital. At this time, the representative was ensured of bed hold while resident was away. Further review on 07/29/22, the resident's representative was called, advised that we were not aware the Managed Medicaid does not do bed holds. The facility would cover the cost of 07/25/22 to 07/29/22. Family would be responsible for bed hold starting 07/30/22. Family declined bed hold. Interview on 08/22/22 at 12:06 P. M. with the Resident #34 representative revealed he was told on the phone they could hold her bed, then a few days later he was informed her insurance did not pay for it. He was going to have to pay for the bed hold out of pocket. He did not want them to hold the bed for her. Interview with the Administrator on 08/22/22 at 12:30 P.M. verified Resident #34 did not have the discharge bed hold paperwork filled out upon admission to the hospital. This was done all verbally and was incorrect information. Review of a policy titled, Bed-Holds and Returns, dated 03/17, revealed prior to transfer and therapeutic leaves, residents and resident representatives will be informed in writing of the bed-hold and return policy. This deficiency substantiates Complaint Number OH 711.

Based on observation, interview, policy review and Center for Disease Control (CDC) recommendations, the facility failed to implement effective and recommended infection control practices to prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect 23 of 23 residents residing in the facility. Findings include: Review of the Medical Record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 had positive COVID-19 test results on 11/25/20 and was placed in droplet isolation for COVID-19. Resident #1 was still in isolation in her room on 12/03/20. Observation on 12/03/20 at 9:08 A.M. revealed State tested Nursing Assistant (STNA) #98 was standing in the hall outside of Resident #1's isolation room removing items from an isolation cart by the door. The cart had three drawers containing personal protective equipment (PPE). On top of the cart there was hand sanitizer, alcohol wipes and three face shields. Interview with STNA #98 on 12/03/20 at 9:11 A.M. she stated she was cleaning up the isolation cart. STNA #98 verified there were three face shields on top of the cart, not in any protective package of any kind and they had no staff identification as to who they belonged to. STNA #98 stated the face shields were for use by staff entering the isolation room of Resident #1. Staff apply these face shields prior to going into the the isolation room, then remove the face shield after exiting the isolation room, clean it with the alcohol wipes, then leave them on top of the isolation cart to dry. STNA #98 stated she did not know how long the face shields were allowed to be reused. STNA #98 verified the face shields did not have any identifying information to ensure they would not be used by more than one staff person. STNA #98 stated we were told to clean them and then grab one when going into the isolation room. STNA #98 verified the face shields were used by all staff entering the isolation room and not maintained for individual use and verified that had been the on-going practices since the first resident tested positive for COVID-19 on 11/15/20. Interview with STNA #74 on 12/03/20 at 9:37 A.M. verified she was the designated STNA for isolation today. STNA #74 stated she changes PPE when entering the isolation room and wears a gown, N-95 mask, face shield and gloves when in the isolation room. She verified she gets her PPE from the isolation cart outside the room and uses one of the face shields from the top of the cart. When exiting the isolation room, her gown and gloves are removed while inside the room. Outside the room, she removes the face shield, cleans it with the alcohol wipes and lays it on the top of the cart to dry, then removes the N-95 mask and puts it in a bag identified with her name and keeps it in the drawer of the cart. STNA #74 verified she did not have a personal face shield for in the isolation room and just used one from the top of the cart. Interview on 12/03/20 at 9:48 A.M. with Licensed Practical Nurse (LPN) #86 verified staff were sharing face shields used in the isolation room. Staff obtain any face shield from the top of the isolation cart for use in the isolation room, clean the face shield after exiting the isolation room and leave it to dry on top of the isolation cart to be used by any staff. LPN #86 verified the face shields are not stored in a bag and are not designated to any certain employee. During observation on 12/03/20 at 12:41 P.M., Registered Nurse (RN) #62 arrived at the isolation room for Resident #1. RN #62 was observed donning PPE in preparation for entering the isolation room and applied a face shield which she obtained from the top of the isolation cart. RN #62 verified she was using a random face shield from the top of the cart which was not identified as belonging to any particular person and was not her designated face shield. She then entered the isolation room. Observation at 12:50 P.M. revealed RN #62 exited the isolation room. She discarded her N-95 mask into the biohazard trash. RN #62 then cleaned the face shield with an alcohol wipe and placed it back on the cart to dry. Regarding the reuse of face shields, RN #62 stated staff use the face shields from the top of the isolation cart only in the isolation room. They are cleaned with alcohol and left to dry on the cart for any staff you may enter the isolation room. RN #62 verified the face shields are not designated to any one staff and are shared by the staff. Review of the facility policy titled COVID-19 Procedure: Outbreak Response dated March 2020 revealed during a COVID-19 outbreak the most effective protection measures are Engineering controls, administrative controls, safe work practices and PPE. Examples of PPE include gown, gloves, goggles, face shields, face masks and respiratory protection. All types of PPE must be consistently and properly worn when required. regularly inspect, maintain and replace PPE as necessary. properly remove, clean and store or dispose of PPE, as applicable, to avoid contamination of self, others or the environment. Review of the CDC recommendations for extended use of eye protection (found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html) revealed extended use of eye protection is the practice of wearing the same eye protection for repeated close contact encounters with several different patients, without removing eye protection between patient encounters. Extended use of eye protection can be applied to disposable and reusable devices. Eye protection should be removed and reprocessed if it becomes visibly soiled or difficult to see through. If a disposable face shield is reprocessed, it should be dedicated to one health care provider and reprocessed whenever it is visibly soiled or removed (for example when leaving the isolation area) prior to putting it back on.

Based on medical record review, policy review and staff interview, the facility failed to issue written notice of the bed hold policy to a resident's representative. This affected one (#21) of one resident reviewed for hospitalization s. The total facility census was 22. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the medical record for Resident #21 revealed the resident was transferred to the hospital by ambulance on 07/15/19 at 12:14 P.M. Additional review of Resident #21's medical record revealed the resident was also transferred to the hospital by ambulance on 07/23/19 at 2:37 P.M. The medical record had no evidence of the resident representative being notified of the bed hold policy or bed hold days for the 07/15/19 and 07/23/19 transfers. Interview with Social Services Manager (SSM) #100 on 08/20/19 on 2:27 P.M. confirmed the facility did not issue a written notice of the bed hold policy to the resident or representative related to the resident's discharges to the hospital on [DATE] and 07/23/19. SSM #100 confirmed the facility was only providing the bed hold policy upon initial admission to the facility.

Based on medical record review, staff interview and policy review, the facility failed to issue written notice of the reasoning for transfer to the hospital to the resident and/or resident representative. This affected one (#21) of one resident reviewed for hospitalization s. The facility census was 22. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the medical record for Resident #21 revealed the resident was transferred to the hospital by ambulance on 07/15/19 at 12:14 P.M. Resiident #21 returned to the facility on [DATE] at 4:32 P.M. Additional review of Resident #21's medical record revealed the resident was also transferred to the hospital by ambulance on 07/23/19 at 2:37 P.M. Resident #21 had not returned to the facility as of 08/20/19. The medical record had no evidence of the written notifications being provided to the resident and/or resident representative at the 07/15/19 or 07/23/19 discharge. Interview on 08/20/19 at 2:27 P.M. with Social Services Manager (SSM) #100 confirmed Resident #21's medical record had no documented written notifications being provided to the resident and/or resident representative. Review of a facility policy titled Transfer and Discharge, dated 11/2017, revealed notice will be provided to the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing in a language and manner they understand.