Health inspection·November 30, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility failed to notify resident physicians and responsible parties when residents tested positive for COVID-19. This affected 11 residents (#2, #22, #27, #33, #40, #44, #66, #69, #77, #89, and #99 ) of 19 residents reviewed for COVID-19. The facility census was 40. Findings included: 1. Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, type II diabetes, asthma, and major depression. Review of nursing note from 11/16/23 revealed Resident #66 tested positive for COVID-19, and the resident's physician was not notified. 2. Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, and hypertension. Review of nursing note from 11/17/23 revealed Resident #40 tested positive for COVID-19, but the resident's physician was not notified. 3. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and hypertension. Review of nursing note from 11/20/23 revealed Resident #27 tested positive for COVID-19, but the resident's physician was not notified. 4. Record review revealed Resident #89 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, hypertension, and sleep apnea. Review of nursing note from 11/20/23 revealed Resident #89 tested positive for COVID-19, but the resident's physician was not notified. 5. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, muscle wasting and atrophy, hypokalemia, and hypertension. Review of nursing note from 11/20/23 revealed Resident #44 tested positive for COVID-19, but the resident's physician and responsible party were not made aware. Page 1 of 3 365588 365588 11/30/2023 Arcadia Valley Skilled Nursing and Rehabilitation 25675 East Main Street Coolville, OH 45723

F 0580 Level of Harm - Minimal harm or potential for actual harm 6. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including pulmonary embolism, pneumothorax, and hypothyroidism. Review of infection control log from 11/23/23 revealed Resident #22 tested positive for COVID-19, but there was no note in her medical record, and no evidence the physician or responsible party was made aware. Residents Affected - Some 7. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including transient ischemic attack, dementia, and heart disease. Review of nursing note from 11/24/23 revealed Resident #33 tested positive for COVID-19, but the resident's physician was not notified. 8. Record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dementia, and hypertension. Review of nursing note from 11/24/23 revealed Resident #99 tested positive for COVID-19, but the resident's physician was not notified. 9. Record review revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including dementia, type II diabetes, hemiplegia and hemiparesis following cerebral infarction, and hypertension. Review of nursing note from 11/24/23 revealed Resident #77 tested positive for COVID-19, but her responsible party was not notified. 10. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, chronic kidney disease, and hypertension. Review of infection control log from 11/24/23 revealed Resident #2 tested positive for COVID-19, but there was no note and no evidence the physician or responsible party were made aware. 11. Record review revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including dementia, heart disease, hypertension, and syncope and collapse. Review of nursing note from 11/25/23 revealed Resident #69 tested positive for COVID, but the resident's physician was not notified. Interview on 11/30/23 at 3:34 P.M. with the Director of Nursing confirmed all above findings. This deficiency is cited as an incidental finding to Complaint Number OH00148658. 365588 Page 2 of 3 365588 11/30/2023 Arcadia Valley Skilled Nursing and Rehabilitation 25675 East Main Street Coolville, OH 45723

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 observation and interview, facility failed to wear personal protection equipment (PPE) including N-95 respirator masks appropriately in isolation rooms. This had the potential to affect all 40 residents residing in the facility. The facility census was 40. Residents Affected - Few Findings included: Observation on 11/30/23 at 7:51 A.M. revealed State Tested Nursing Assistant (STNA) #133 entering room [ROOM NUMBER], which was a COVID isolation room, wearing a surgical mask underneath an N-95 respirator mask. This breaks the seal of the N-95 respirator mask. Interview on 11/30/23 at 8:01 A.M. with STNA #133 confirmed she was wearing a surgical mask under her N-95 respirator and she was unaware it could cause the seal of the N-95 to break. Observation on 11/30/23 at 9:00 A.M. revealed Housekeeper #199 entering room [ROOM NUMBER], which was a COVID isolation room, wearing a surgical mask underneath an N-95 respirator mask. This breaks the seal of the N-95 respirator mask. Interview on 11/30/23 at 3:34 P.M. with Director of Nursing confirmed Housekeeper #199 had been wearing a surgical mask underneath her N-95 respirator before entering a COVID isolation room. Review of the facility policy titled Transmission Based Precautions revealed healthcare staff will provide care to residents with COVID while wearing an N-95 respirator, eye protection, gloves, and a gown. This deficiency represents non-compliance investigated under Complaint Number OH00148658. 365588 Page 3 of 3