Inspection·December 18, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interview, review of information from Center for Disease Control and Prevention (CDC) and policy review, the facility failed to ensure proper personal protective equipment (PPE) was worn in residents room who was positive for Coronavirus Disease 2109 (COVID-19). This affected one (#129) out of three residents sampled for infection control practices and had the potential to affect nine (#121, #122, #123, #124, #125, #126, #127, #128, and #130) additional residents who reside on the transitional care unit three. The facility census was 140. Residents Affected - Some Findings include: Review of medical record for Resident #129 revealed the resident was admitted to the facility on [DATE]. Diagnoses include epilepsy, COVID-19, chronic obstructive pulmonary disease, type two diabetes, need for assistance with personal care, chronic kidney disease stage three, anxiety, major depressive disorder, polymyalgia, intellectual disabilities, and constipation. Review of Resident #129's minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of 14 which indicated cognitively intact. Resident #129 required extensive assistance for activities of daily living with the exception of eating which required supervision. Review of care plan for Resident #129 revealed resident has an infection as evidence by urinary tract infection and was currently COVID-19 positive. Interventions included strict single room droplet and respiratory isolation. All services to be provided in room, and administer medications and treatments to treat infection and or symptoms as ordered. Review of Resident #129's medical record revealed the resident tested positive for COVID-19 on 12/07/23. Further review of Resident #129's physician orders revealed an order for strict single room droplet and respiratory isolation related to signs and symptoms of COVID-19. All services are to be provided in room from from 12/08/23 to 12/18/23. Observation on 12/14/23 at 2:14 P.M. of State Tested Nursing Assistant (STNA) #639 entering Resident #129's room revealed STNA #369 donned an N95 respirator (respiratory protective device designed to achieve a very close fit and very efficient filtration of airborne particles) and gloves prior to entering room. Observations revealed STNA #639 did not don a gown or eye protection before entering Resident #129's room. Signage on door required staff to don N95 respirator, gown, face shield, and gloves prior to entering room. Interview on 12/14/23 at 2:19 P.M. with Licensed Practical Nurse (LPN) #602 verified STNA #639 did not don a gown or faceshield/goggles prior to entering Resident #129's room who was COVID positive. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365278 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)