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Based on observation and interview, the facility failed to ensure a damaged exit door was repaired. The census at the time of the survey was 19.

Findings include:

The facility's COVID unit was toured with Staff F beginning at approximately 12:16 PM on 01/12/21. Staff F demonstrated how one patient was discharged from the COVID unit earlier that morning. Staff F used her badge to unlock a door at the opposite end of the unit. That door lead to the base of a stairwell, beyond which was a second door that led directly outside. A gap wide enough for rodents and other animals to fit through was observed at the top of the door. Staff F confirmed this observation.

Staff A was made aware of the above finding on 01/12/21 at 1:28 PM.

Based on observations, interviews, and review of policy, the facility failed to ensure all staff adhered to infection prevention and control policies and procedures related to the use of N95 respirators. This affected two of two male staff members observed. The census at the time of the survey was 19.

Findings include:

Facility document N-95 Respirator Use (undated) was reviewed and revealed "employees with extensive facial hair cannot use N-95 due to inability to create seal between mask and skin."

Facility policy N95 Respirators (effective 03/17/20) was reviewed and revealed "N95 respirators are not designed for children or people with facial hair. Because a proper cannot be achieved on children and people with facial hair, the N95 respirator may not provide full protection."

Staff G was interviewed beginning at 11:04 AM on 01/12/21. Staff G was wearing a KN95 mask and a face shield. Facial hair could be seen protruding out from under Staff G's mask. Staff G confirmed this observation and stated he and other male coworkers refused to shave. Staff G also stated he was told during the fit test that the N95 could not be worn with facial hair.

The facility's COVID unit was toured beginning at approximately 12:16 PM on 01/12/21. Immediately upon entering the unit, a male staff member identified as a MHT (mental health technician) was observed. The MHT confirmed through interview he was assigned to work on the COVID unit. Facial hair was seen protruding out from under the N95 respirator the MHT was wearing. The COVID unit currently had two positive patients.

Review of documentation revealed neither staff member was exempt from wearing an N95 respirator.

Staff A was made aware of these findings on 01/14/21 at 1:28 PM.

This deficency substantitates Substantial Allegation OH00118883.