Health inspection·November 21, 2023

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 record review, observations, staff interviews, review of facility policy, and review of online resources from the Centers for Disease Control (CDC), the facility failed to ensure the staff practiced proper hand hygiene during wound care. This affected one (#14) of the three residents reviewed for wound care. The facility census was 103. Residents Affected - Few Findings include: Review of the medical record for Resident #14 revealed the resident was admitted on [DATE]. Diagnoses included multiple sclerosis (MS), depression, anemia, anxiety, and diabetes mellitus. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] for Resident #14, revealed the resident had no cognitive deficits and required extensive assistance with activities of daily living (ADLs). Observation of wound care/dressing change on 11/21/23 at 9:06 A.M. for Resident #14 and being completed by Wound Nurse Practitioner (NP) #51 and Registered Nurse (RN) #66, revealed NP #51 used alcohol-based hand rub (ABHR) and donned gloves. NP #51 removed the old dressing from the resident's right hip, cleansed the wound with gauze moistened with wound cleanser, completed a small amount of wound debridement (process to remove dead or unhealthy tissue from a wound), then used wound cleanser and gauze to clean the wound bed again. NP #51 then applied Santyl (debriding ointment), applied normal saline to four-by-fours and placed them in the wound, and covered the wound with border foam. NP #51 and RN #66 turned Resident #14 over onto her right hip to complete wound care on the resident's sacrum. Observation revealed there was no dressing in place and NP #51 cleaned the two areas on the resident's sacrum and as she noticed a new area on the resident's sacrum, she was touching the wound with her glove. NP #51 measured all three areas and picked up calcium alginate (dressing supply), tore it into four separate pieces and applied the calcium alginate pieces to the wound then covered with a large border foam dressing. During observation, NP #51 never completed any hand hygiene or changed gloves during the two different wound care procedures. An interview on 11/21/23 at 9:34 A.M. with NP #51, verified she never completed any hand hygiene or changed her gloves when going from a dirty wound area to the clean dressing on the resident's wounds. Review of online resources from CDC (https://www.cdc.gov/handhygiene/providers/guideline.html) dated 01/30/20, revealed healthcare personnel should complete hand hygiene before moving from a work area of a soiled body part to a clean body site on the same patient and healthcare personnel were to perform hand hygiene in accordance with the CDC recommendations. (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: 365081 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 365081 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Rivers Healthcare Center 7800 Jandaracres Drive Cincinnati, OH 45248 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)