Health inspection·September 5, 2019

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of the Quality Assessment and Assurance meeting sign-in sheets and staff interview, the facility failed to ensure the medical director attended the Quality Assessment and Assurance meeting on a quarterly basis. This had the potential to effect all 44 residents residing in the facility. Residents Affected - Few Findings include: Review of the Quality Assessment and Assurance meeting sign-in sheets for July, August, September, November, and December 2019 revealed no medical director signature. The October 2019 meeting was not held due to Administrator illness. Interview on 09/05/19 at 11:00 A.M., the Administrator verified the Medical Director had not attended the required quarterly meetings. Page 1 of 2 365680 365680 09/05/2019 Vancrest of Hicksville 601 Defiance Avenue Hicksville, OH 43526

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of a facility policy and staff interview, the facility failed to implement a risk assessment and water management program for the prevention and spread of Legionella. This had the potential to affect all residents. The facility census was 44. Residents Affected - Few Findings include: Review of the facility policy titled Water Management Program, dated 11/17, revealed the facility water management program will include, at a minimum, an initial evaluation of the building water system, and based on that analysis, will complete a water system infection control risk assessment. The program may include disinfectant level controls and specify testing protocols and acceptable ranges for control measures. The facility failed to provide evidence of a risk assessment or water management program. Interview on 09/05/19 at 11:00 A.M. with the Administrator revealed the facility did not have a water management program in place to monitor for Legionella. He further verified the facility did not have a risk assessment completed. He verified the facility did not have a flow sheet to identify potential areas of concern and the facility and was not completing any water testing protocols. 365680 Page 2 of 2