Health inspection·January 19, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and policy review, the facility failed to ensure a dependent resident received timely personal hygiene care. This affected one resident (#11) out of two residents reviewed for activities of daily living (ADL). The facility identified all 24 residents required assistance from staff with bathing and dressing. The facility census was 24. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed an admission date of 01/31/20. Diagnoses included Alzheimer's disease, restlessness and agitation, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition and required extensive assistance of one person for personal hygiene. Review of the current care plan for Resident #11 revealed an ADL self-care deficit related to chronic pain, osteoarthritis, Alzheimer's, dementia, and need for limited assistance in ADL function. Interventions included extensive assistance of one person for personal hygiene. Review of the bathing schedule revealed Resident #11 received a shower on 01/16/23. Observations on 01/17/23 at 9:45 A.M. revealed Resident #11 was dressed and sitting on her bed playing cards. Resident #11 had several long, white hairs coming from her chin. Subsequent observation on 01/18/23 at 8:54 A.M. revealed Resident #11 sitting in her recliner and playing cards. Resident #11 remained with several long, white hairs coming from her chin. Observation and interview on 01/19/23 at 8:08 A.M. with the Director of Nursing (DON) revealed Resident #11 was in her room and Resident #11 had long white hairs coming from her chin. The DON verified the hairs were present and visible. The DON said the State Tested Nurse Aides (STNAs) were expected to provide shaving for residents. Interview on 01/19/23 at 8:12 A.M., with STNA #342 verified she had shaved Resident #11 in the past and Resident #11 had not resisted care. Interview on 01/19/23 at 10:44 A.M., with STNA #358 verified Resident #11 had some hairs coming from her chin which were long enough to shave. Review of the facility policy titled Activities of Daily Living AM/PM Care, undated revealed residents were assisted at appropriate level for mouth care, hair care, and shaving, etc. Page 1 of 2 366468 366468 01/19/2023 Vancrest of Payne 650 North Main Street Payne, OH 45880

F 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Potential for minimal harm Based on staff interview, review of the staffing schedule, review of the Staff Coronavirus Disease 2019 (COVID-19) Vaccination Matrix, review of the facility policy, and review of the Centers of Medicare and Medicaid Services (CMS) memorandum QSO-23-02-ALL, the facility failed to ensure staff were COVID-19 vaccinated, had an approved exemption, or had been identified as appropriate for a temporary delay per Center for Disease Control and Prevention (CDC) guidance. The vaccination rate for the facility was calculated at 98.8%. This had the potential to affect all 24 residents currently residing in the facility. Residents Affected - Many Findings include: Review of the Staff Vaccination COVID-19 log, provided on 01/17/23, revealed the facility had 82 employees with 47 employees vaccinated, 34 employees with granted exemptions, and one employee (State Tested Nursing Aide #346) who was partially vaccinated. Interview on 01/17/23 at 12:29 P.M. with the Administrator revealed State Tested Nurse Aide (STNA) #346 was hired on 05/09/22 and received the first dose of a two-dose COVID-19 vaccination on 06/21/22 and had not received the second COVID-19 vaccination dose. Subsequent interview with the Administrator on 01/18/23 at 4:14 P.M. revealed STNA #346 never tested positive for COVID-19 since his hire date on 05/09/22. The Administrator confirmed on 01/19/23 at 8:41 A.M. that STNA #346 did not receive his first COVID-19 vaccination dose prior to his hire date. Interview with the Director of Nursing (DON) on 01/19/23 at 2:39 P.M., verified STNA #346 worked consistently at the facility since he was hired, and worked throughout the facility. Review of the staff schedule for December 2022 and January 2023 revealed STNA #346 worked throughout the facility on multiple days monthly. COVID-19 health care staff vaccination, dated 10/26/22, revealed CMS expects all providers' and suppliers' staff to have received the appropriate number of doses of the primary vaccine series unless exempted as required by law, or delayed as recommended by the Centers for Disease Control and Prevention (CDC). Facility staff vaccination rates under 100% constitute noncompliance under the rule. Review of the facility policy titled COVID-19 Vaccine Mandate Policy, dated November 2021 revealed all facility staff are required to have received at least one dose of a Food and Drug Administration (FDA)-authorized COVID-19 vaccine by the first day of employment. 366468 Page 2 of 2