Inspection·September 8, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations, staff interviews, review of facility policy, and review of online guidance per the Centers for Disease Control (CDC), the facility failed to ensure staff wore proper personal protective equipment (PPE) to prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected four (#39, #58, #61 and #80) of five residents reviewed for infection control. The facility census was 81. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 09/25/20 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure (CRF) with hypoxia, diabetes mellitus (DM), anxiety disorder, cerebral infarction, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) for Resident #39 dated 08/11/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADL's). Review of the physician orders for Resident #39 revealed an order dated 09/08/23 for strict room isolation with all services provided in the room due to positive COVID-19 infection. Interview on 09/08/23 at 9:26 A.M. during the entrance conference of Licensed Practical Nurse (LPN) #325 confirmed the facility was experiencing a COVID-19 outbreak with 23 COVID-19 positive residents in the facility at the time of the survey. LPN #325 confirmed staff should don the following personal equipment when entering the room or working with a COVID positive resident: gown, gloves, N-95 mask, eye protection (face shield) Observation on 09/08/23 at 9:42 A.M. revealed Resident #39's door was shut and there was a sign on the door indicating the resident was on droplet precautions and there was an isolation cart outside the door. Further observation revealed LPN #585 entered Resident #39's room wearing a cloth mask and carrying a plastic cup of pills and a cup of water. Observation on 09/08/23 at 9:48 A.M. revealed LPN #585 exited the room wearing a cloth mask. Interview on 09/08/23 at 9:48 A.M. of LPN #585 confirmed she was an agency nurse and no one had told her in report that Resident #39 had COVID-19. LPN #585 confirmed she was wearing a cloth mask she brought from home and had not donned PPE prior to entering Resident's #39's room to administer medications. 2. Review of the medical record for Resident #80 revealed an admission date of 06/13/23 with (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 3 Event ID: 365065 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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)