Health inspection·July 6, 2021

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based only record review, observation, interview, review and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to resume communal dining as per CMS and CDC guidelines. This had the potential to affect all residents of the facility with the exception of one (Resident #5) who received no food by mouth and three (Residents #25, #108, #420) who are on transmission-based precautions and isolated to their rooms. The facility census was 113. Findings include: Review of the CDC COVID-19 county positivity rate dated 06/28/21 revealed Wyandot county had a positivity rate of 2.2 percent. During observation on 06/28/21 at 11:38 A.M., the main dining room on the first floor had ten residents, seated one resident per table. No residents were observed seated together. During observation on 06/28/21 from 11:53 A.M. to 12:32 P.M., the second floor dining room had eight residents, seated one resident per table. No residents were observed seated together. During observation on 06/29/21 at 12:00 P.M., Resident #4 was eating lunch in her room. During interview on 06/29/21 at 2:36 P.M., State Tested Nursing Assistant (STNA) #602 stated Resident #4 has been eating in her room. The resident used to eat in the dining room with other residents, but since the facility is only allowing one resident per table, she now prefers to eat in her room. STNA stated the resident enjoyed sitting with other residents. STNA stated she believed all but one resident on the floor is vaccinated. During observation on 06/30/21 at 11:37 A.M., the first floor dining room revealed residents eating at separate individual tables for social distancing. During interview on 06/30/21 at 12:16 P.M., STNA #604 stated residents eat at separate individual tables for social distancing. During interview on 07/01/21 at 10:32 A.M., Residents #114, #36, #99, #71, #2, #66, and #88 stated they were not allowed to sit together in the dining room during meals. Residents #114 and #71 reported they had tried to sit together for meals on multiple occasions and staff tell them they need to separate. Review of the CDC website titled Updated Healthcare Infection Prevention and Control Page 1 of 3 365478 365478 07/06/2021 Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351

F 0561 Level of Harm - Minimal harm or potential for actual harm Recommendations in Response to COVID-19 vaccination dated 04/27/21 revealed, fully vaccinated residents can participate in communal dining without use of source control or physical distancing. Unvaccinated residents in communal area should use source control when not eating and unvaccinated residents should continue to remain at least six feet from others. Residents Affected - Some 365478 Page 2 of 3 365478 07/06/2021 Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, record review and policy review, the facility failed to ensure residents were served the correct altered texture diet. This affected two (Residents #9 and #102) of two residents reviewed for altered diets. The facility census was 113. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #9, dated 03/31/21 revealed the resident required total dependence for eating with one person physical assistance, was cognitively impaired and rarely understood. The resident's diet order was a regular diet, pureed texture, nectar consistency. 2. Review of the MDS assessment for Resident #102, dated 05/31/21, revealed the resident required extensive assistance of one person for eating, was cognitively impaired and rarely understood. The resident's diet order was a regular diet, blended texture, thin consistency. 3. During observation on 06/28/21 between 12:24 P.M. and 12:32 P.M. Resident #102 was served Resident #9's meal tray and Resident #9 was served Resident #102's meal tray. Resident #102 had a tray with pureed roast beef, mashed potatoes, carrots, pudding, chocolate magic cup and thickened cranberry juice. The meal ticket had Resident #9's name printed on the top. Resident #9 had a tray with pureed roast beef, mashed potatoes, carrots, pudding, magic cup (thickened nutritional supplement ice cream) and ensure plus (nutritional supplement drink) and thinned juice. The meal ticket had Resident #102's name printed at the top. Both residents were ordered a pureed texture diet, however Resident #9 was supposed to have nectar thickened liquids and Resident #102 was supposed to have thin liquids. Resident #102 received Resident #9's thickened liquids and Resident #9 received Resident #102's thin liquids. State Tested Nursing Assistant (STNA) #616 was observed feeding Resident #9's meal to Resident #102, including Resident #9's thickened liquids. Registered Nurse (RN) #614 was assisting Resident #9 with eating Resident #102's meal. RN #614 offered thinned juice to Resident #9. Resident #9 proceeded to drink the thinned juice. During interview on 06/28/21 at 12:32 P.M., STNA #616 reported it was her second day and she was unaware of which resident she was assisting. She identified Resident #102 by reviewing the resident's sock label. STNA #616 verified Resident #102 was served and being fed Resident #9's meal, but it was okay because both residents had the same diet. STNA #616 did not attempt to stop feeding Resident #102, even after realizing she was feeding Resident #102 the wrong meal tray. RN #614 verified Resident #102 and Resident #9 were served each other's meal trays. RN #614 further verified Resident #102 received and consumed Resident #9's thickened juice and Resident #9 received and consumed Resident #102's thinned juice. Review of facility policy titled Therapeutic Diets, revised 12/11/19 revealed the facility had a policy in place for assuring a resident receives and consumes foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his/her goals and preferences. 365478 Page 3 of 3