Inspection·August 24, 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 observation, staff interviews and catheter procedure review, the facility failed to maintain infection control procedures during incontinence care for residents. This affected two (#11 and #12) of three reviewed for incontinence care. The facility census was 34. Residents Affected - Few Findings include: 1. Review of medical record for Resident #11 revealed an admission date of 09/01/22 and admitted to Hospice on 10/05/22. Medical diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was significantly impaired cognition and required extensive two-person assistance for bed mobility, total dependence for transfer, toileting and independent for eating. Documentation revealed she was always incontinent of urine and stool. 2. Review of medical record for Resident #12 revealed admission date of 02/04/21 and admitted to hospice on 10/08/22. Medical diagnoses included Alzheimer's Disease, depression, and lung cancer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely impaired cognition and required total dependence for bed mobility, transfers, eating and toileting. Documentation revealed she was always incontinent of urine and bowel. Observation on 08/24/23 at 5:25 A.M., revealed State Tested Nurse Assistant (STNA) #20 provided incontinence care for Residents #11 and #12 without providing privacy by shutting the door or pulling the privacy curtain in between them. STNA #20 was observed to provide urine incontinence care for Resident #11, while the resident was in bed. The privacy curtain was not drawn and the door to the room was left open. Resident #11's genital areas were exposed. STNA #20 was observed to bring to bedside one soapy and one wet wash cloth, and one towel. The same part of the soapy washcloth was used to cleanse the entire vaginal area. The soapy cloth was then placed on one end of the towel and the second wet wash cloth was used to rinse in the same manner then placed on the same end of the towel as the other washcloth. The opposite end of the towel was used to dry the perineal area. Resident #11 was then assisted onto her right side and the same cloths were used to cleanse her buttocks. The used clothes were place in a bag on the floor. Without removing her soiled gloves, STNA #20 repositioned Resident #11, covered her with a sheet and used the bed remote to adjust the bed and turned out the light. STNA #20 then removed her gloves and washed her hands and proceeded to prepare to provide incontinence care for Resident #12, who resided in the same room. Observation continued at 5:32 A.M., for Resident #12 who was incontinent of urine. The door and curtain remained open, while STNA #20 provided care. STNA #20 was observed to repeat the same procedure of using the washcloths to clean the entire vaginal area and then laying the used washcloths on the towel. STNA #20 used the opposite end of the towel to dry the resident. Then proceeded to use the soiled washcloths to clean the buttocks. However, the incontinence product for Resident #12 ripped and STNA #20 removed her gloves and without providing hand hygiene, reached into a drawer to grab a replacement incontinent product, applying new gloves before finishing care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 2 of 3 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 365527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Springfield 1600 Saint Paris Pike Springfield, OH 45504 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/24/23 at 5:42 A.M., STNA #20 verified she provided incontinence care for both Resident #11 and #12 and reused linens during peri care. STNA #20 verified she did not remove gloves after providing incontinence care for Resident #11 prior to repositioning the resident. STNA #20 verified she did not perform hand hygiene after removing gloves during Resident #12's care. Interview on 08/24/23 at 9:02 A.M., with the Administrator revealed the facility had no policy for incontinence care. However, the Administrator did supply an undated catheter care procedure provided to staff during orientation. Which documented privacy and dignity would be provided by closing the door, privacy curtain and blinds. The task in step three documented to wash the outer peri area moving front to back and use new area of cloth as many times as necessary to remove urine and use new cloth to wash inner labia. The Administrator verified what the procedure indicated what staff were to do during incontinence care. This was an incidental finding discovered during the investigation of Complaint Number OH00145298. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 3 of 3