Health inspection·September 4, 2024

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 medical record review, observation, staff interview and review of facility policy, the facility failed to ensure staff followed infection control procedures including the proper use of personal protective equipment (PPE) to prevent transmission of COVID 19. This had the potential to affect all thirteen residents (Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, and Resident #26) residing in Resident #26's assigned care area. Residents Affected - Some Findings include: Resident #26 was admitted on [DATE] with diagnoses that included Parkinson's disease without dyskinesia, dysphasia following cerebral infarction, chronic kidney disease, congestive heart failure, atrial fibrillation, cardiomyopathy, gastro-esophageal reflux disease without esophagitis, and depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact with minimal depression. Resident #26 had no impairment of range of motion in upper or lower extremities and uses a walker. Resident #26 was independent for eating and oral hygiene. Resident #26 required set-up/clean-up assistance for toileting, personal hygiene, and dressing and required partial/moderate assistance for showering. Resident #26 had a care plan that addressed transmission-based precautions for a positive COVID 19 test. The care plan also addressed Resident #26's preference for door to room to be open at all times due to the fear Resident #26 has when the door is closed. 09/03/24 10:30 A.M. interview with Licensed Practical Nurse (LPN) #460 confirmed Resident #26 was placed in airborne isolation on 08/31/24 after becoming symptomatic and then testing positive for COVID 19. 09/03/24 at 12:33 P.M. observation of Resident #26's door revealed it was wide open with the resident in bed watching TV. Observed State Tested Nursing Assistant (STNA) #410 walk into Resident #26's room with only a surgical face mask on. STNA #410 then left the room and went into Resident #24 and #25's room asking if the residents were done with their trays. STNA #410 did not change her mask or perform any hand hygiene. Interview on 09/03/24 at 12:42 P.M. with STNA #400 confirmed Resident #26's door was open. STNA #400 stated Resident #26 doesn't like his door closed; he was afraid when it was closed, and he opens it back up. STNA #400 confirmed STNA #410 went into Resident #26's with just a surgical face mask and Page 1 of 2 366196 366196 09/04/2024 Altercare Newark South Inc. 17 Forry Street Newark, OH 43055

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when there was no tray to remove, she left and went into Resident #24 and #25's room with the same mask and no hand hygiene to collect meal trays. Interview on 09/03/24 at 12:44 P.M. with STNA #410 confirmed she went into Resident #26's with just a surgical face mask. STNA #410 stated they were told they only had to wear the PPE for direct patient care, if they were just delivering or picking up trays, a mask was okay. Interview on 09/03/24 at 3:30 P.M. with Resident #26 confirmed Resident #26 preferred to have his door open, at least far enough to see what is going on in the hallway. Interview on 09/03/24 at 4:00 P.M. with the Administrator confirmed the goal was to keep the door shut with airborne isolation if the resident can tolerate the door shut if but it is okay to have the door open. Administrator was told when the STNA's were asked about wearing PPE, they stated they were told they only had to wear PPE if they were doing direct care, and the Administrator stated the STNA's were confusing enhanced barrier precautions with isolation precautions. Interview on 09/03/24 at 3:45 P.M. with the Administrator confirmed the STNAs were assigned a specific group of rooms at the beginning of each shift. Resident #26 was included in the room [ROOM NUMBER] through 318 assignment (Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, and Resident #26). Review of policy Infection Control Guidelines for All Nursing Procedures, undated, revealed an outline of education provided to all nursing staff, general guidelines for the difference between Standard Precautions and Transmission - Based Precautions. The policy addresses appropriate hand hygiene and use of personal protective equipment. These are considered general guidelines and refers readers to procedures for any specific infection control precautions. Review of Policy Coronavirus (COVID 19) Protocol, undated, specified staff would wear a N95 mask, eye protection, and gowns in quarantine/isolation rooms. 366196 Page 2 of 2