Health inspection·April 16, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to complete comprehensive care plans on residents. This affected two (#14 and #15) residents of the four residents reviewed for care plans. The facility census was 39. Findings include: 1) Review of medical record for Resident #14 revealed the resident was admitted on [DATE] with diagnoses including, but not limited to, breast cancer, kidney failure, atrial fibrillation, and acute cystitis. Review of the care plan for Resident #14 revealed there was no care plan related to the resident's skin integrity and the Stage II pressure injury. Observation of wound care for Resident #14 on 04/15/24 11:34 A.M. provided by Wound Care Physician #53, revealed the resident had a stage two pressure ulcer on the right buttock that was being debrided. Interview with Wound Care Doctor #53 at the same time, verified the resident had a stage two pressure ulcer on her right buttock. Interview with Minimum Data Set (MDS) Coordinator #51 on 04/16/24 at 11:15 A.M. verified there were care plans that addressed Resident #14's skin integrity or the presence of a pressure ulcer. MDS #51 reported the care plan should address the resident's skin concerns. 2) Review of medical record for Resident #15 revealed the resident was admitted on [DATE] with diagnoses including, but not limited to, depression, pain, chronic kidney disease, anxiety, and history of skin cancer. Review of care plan for Resident #15, revealed there was no care plan related to the resident's skin integrity. Review of a physician's order dated 03/24/24 for Resident #15 revealed the resident was ordered to have moisture barrier cream applied to coccyx/peri area after each incontinent episode. Interview with MDS Coordinator #51 on 04/16/24 at 11:15 A.M. verified there were care plans that addressed Resident #15's skin integrity. MDS #51 reported the care plan should address the resident's skin integrity and being at risk for skin integrity concerns. Page 1 of 2 365462 365462 04/16/2024 Bridgetown Nursing and Rehabilitation Centre 4307 Bridgetown Road Cheviot, OH 45211

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, observation, staff interview, review of online resources from the Centers for Disease Control (CDC) and review of facility policy, the facility failed to follow infection control procedures during dressing changes. This affected one (#14) resident of the three residents reviewed for wound care. The facility census was 39. Residents Affected - Few Findings include: Record review for Resident #14 revealed the resident was admitted on [DATE] with diagnoses including but not limited to breast cancer, kidney failure, atrial fibrillation, and acute cystitis. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had moderately impaired cognition. Observation of would care/dressing change for Resident #14 on 04/15/24 11:34 A.M. with Licensed Practical Nurse (LPN) #54 and State Tested Nursing Assistant (STNA) #55 revealed LPN #54 removed a soiled incontinence brief and replaced it with a clean one. LPN #54 then cleansed the open wound on Resident #14's right buttock with saline and gauze. LPN #54 then placed a new wound dressing without completing any hand hygiene and changing her gloves. Interview with LPN #54 on 04/15/24 at approximately 11:40 A.M. verified that she never completed any hand hygiene and changed her gloves when going from a dirty wound area to a 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. Review of the Infection Prevention and Control Program (dated 10/01/23) revealed hand hygiene shall be performed in accordance with facility's established hand hygiene procedures. This deficiency represents non-compliance investigated under Complaint Number OH00152359. 365462 Page 2 of 2