Inspection·June 27, 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 observation, interview, record review and facility policy review the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when caring for a resident on the South unit who had orders for Enhanced Barrier Precautions (EBP). This affected one Resident (Resident #51) of three residents reviewed for infection control, and had the potential to affect an additional 23 residents (#33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55 and #56) living on the South unit. The facility identified 24 residents in EBP (Residents #4, #10, #11, #14, #20, #27, #30, #31, #33, #41, #47, #48, #50, #51, #52, #54, #58, #75, #81, #86, #87, #88, #97, and #103). The facility census was 106. Residents Affected - Some Findings include: Review of the medical record for Resident #51 revealed an admission date of 02/23/24. Diagnosis included type two diabetes mellitus, anoxic brain damage, urinary tract infection, acute respiratory failure with hypoxia, infection and inflammatory reaction due to indwelling urethral catheter, and a personal history of other infectious and parasitic disease sepsis due to staph Aureus. Review of Resident #51's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and was dependent on staff for all Activities of Daily Living (ADLs). Review of Resident #51's physician orders dated June 2024 revealed she was in Enhanced Barrier Precautions (EBP) and staff were to use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device (trach, central line, tube feeding, and catheter) every shift for reducing the chance of spreading infection. Further review of Resident #51's physicians orders revealed she had a foley catheter, tube feedings, and wound care. Observation on 06/27/24 at 11:45 A.M. of Resident #51 revealed she was to be in Enhanced Barrier Precautions related to her heel wound, and lines and tubes such as foley catheter and tube feeding. Observation on 06/27/24 at 11:47 A.M. of wound care for Resident #51 by Registered Nurse (RN) #705 revealed she cleansed the left heal with saline soaked gauze, painted with betadine then applied Adaptic, then applied a clean dry dressing and reapplied the residents heel boots. Hand hygiene was completed appropriately with no concerns identified related to the wound care. While RN #705 performed wound care she was not wearing the proper Personal Protective Equipment (PPE) as required including (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365033 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)