Health inspection·May 6, 2025

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, staff interview, record review, document review, and policy review the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infections when they failed to follow droplet precautions for Resident #90 and failed to properly clean a blood glucose monitoring machine for Resident #3. This had the potential to affect four (Resident #3, #76, #78, and #79) Residents who received blood glucose monitoring on the two East hallway The facility census was 106. Residents Affected - Few Findings include: 1. Record review of Resident #90 revealed an admission date of [DATE] with pertinent diagnoses of: congestive heart failure, hypothyroidism, atherosclerotic heart disease, atrail fibrillation, and hypertension. Review of the [DATE] admission Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and uses a walker and wheelchair to aid in mobility. Review of a Physician Order dated [DATE] revealed Isolation Precautions: Droplet, for possible exposure to whooping cough every day and night shift droplet precautions. Observation on [DATE] at 8:38 A.M. revealed Licenses Practical Nurse #20 (LPN) went into Resident #90 room to take his blood pressure. There was a sign on the door stating droplet precautions and LPN #20 did not wear any eye, nose or mouth protection. Interview with LPN #20 on [DATE] at 8:40 A.M. revealed the surveyor asked why Resident #90 was on precautions and LPN #20 looked up the information in the computer and stated that Resident #90 was on droplet precautions due to possible exposure to whooping cough. Observation on [DATE] at 8:50 A.M. revealed LPN #20 walked back into Resident #90 room without eye, nose, or mouth protection to administer Resident #90 medications. Interview with LPN #20 on [DATE] at 8:56 A.M. verified he walked into the room and did not wear eye, nose, or mouth protection to administer Resident #90 medications. LPN #20 stated he forgot and he should have wore eye, nose, and mouth protection when going into the room. Interview with the Director of Nursing (DON) on [DATE] at 9:20 A.M. revealed Resident #90 had an exposure to whooping cough on [DATE] during a family gathering in the facility. The family notified the facility on [DATE] and they started Resident #90 on a prophylactic antibiotic, put him on droplet (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: 365436 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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)