Health inspection·December 11, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to failed to suspend staff pending an abuse investigation. This affected one (Resident #41) of three residents reviewed for abuse. The facility census was 50. Residents Affected - Few Findings include: Record review for Resident #41 revealed she was admitted to the facility on [DATE]. She was under the care of hospice services. Her diagnoses included, heart failure, diabetes mellitus (DM), pruritus, gastro esophageal reflux disease (GERD), dementia, and anxiety disorder. Review of Resident #41's Minimum Data Set (MDS) assessment, dated 09/16/24, revealed she was severely cognitively impaired. Resident #41 was dependent on staff for medication administration. Resident #41 required maximum assistance from staff with eating, oral hygiene, toilet use, bathing, dressing, and personal hygiene. Resident #41 had an indwelling catheter and required hospice services. Review of the Self Reported Incident (SRI) dated 11/11/24 at 12:44 P.M. revealed Resident #41's daughter reported an allegation of neglect that occurred on 11/09/24. Resident #41's daughter alleged Registered Nurse (RN) #81 refused to give Resident #41 her medications. Resident #41's daughter called Emergency Medical Transport (EMT) and had her mother transferred to the hospital. Further review of the SRI investigation stated Assistant Director of Nursing (ADON) #89 interviewed Resident #41 and she stated she felt safe. The report stated RN #81 will no longer provide care to Resident #41. Further review revealed no indication RN #81 was suspended pending an investigation. Interview on 12/05/24 at 2:40 P.M. with the Administrator confirmed the incident of alleged abuse from RN #81 to Resident #41 was not reported until 11/11/24. The Administrator confirmed the facility began a facility investigation of alleged abuse. The Administrator confirmed RN #81 continued to work through the entire investigation and was never suspended pending the outcome of the investigation. The Administrator confirmed the investigation began on 11/11/24 at 12:44 P.M. and was closed on 11/15/24 at 11:28 A.M. Interview on 12/09/24 at 9:59 A.M. with RN #81 confirmed the facility never suspended her at any time from the date of the alleged incident 11/09/24 throughout the conclusion of the investigation 11/15/24. Review of RN #81's time card confirmed RN #81 worked full shifts on 11/11/24 and 11/15/24. Review of the facility policy titled, Abuse, Neglect, Exploitation, Mistreatment, Misappropriation Page 1 of 4 365652 365652 12/11/2024 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0610 Level of Harm - Minimal harm or potential for actual harm of Resident Property, undated, confirmed employees accused of alleged abuse/neglect will be immediately removed from the facility and will remain removed pending the results of a thorough investigation. This was an incidental finding found during the course of the complaint investigation. Residents Affected - Few 365652 Page 2 of 4 365652 12/11/2024 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

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 observations, interviews, and policy review, the facility failed to ensure proper infection control measures were maintained during resident care. This affected two (#37 and #41) residents reviewed for incontinence care. The facility census was 50. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 08/01/24. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes mellitus (DM II), and congestive heart failure (CHF). Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, substantial assistance with toileting, dressing, and transfers, and dependent with bathing. Review of section H for bowel and bladder revealed Resident #37 was always incontinent of bladder and frequently incontinent of bowel. Observation on 12/11/24 at 9:55 A.M. revealed Certified Nursing Assistant (CNA) #100 completed incontinence care to Resident #37. CNA #100 performed hand hygiene and applied gloves prior to providing care. During care, CNA #100 failed to change gloves and perform hand hygiene until after procedure was finished. CNA #100 cleaned Resident #37's perineal area, which was soiled with urine and feces. CNA #100 cleaned Resident #37's backside with the same gloves. After CNA #100 cleaned Resident #37, she placed a new depend on her, covered her with her blanket, and adjusted Resident #37 in bed with soiled gloves. CNA #100 cleaned her working area, removed her gloves, and performed hand hygiene. Interview on 12/11/24 at 10:04 A.M. with CNA #100 verified she did not change her gloves during incontinence care to Resident #37. Review of the facility policy titled, Hand Hygiene, dated 2022 revealed all staff were to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves did not replace hand hygiene. If your task required gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. 2. Review of the medical record for Resident #41 revealed an admission date of 09/09/24. Diagnoses included anxiety disorder, DM II, neuromuscular dysfunction of bladder, and heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of five. This resident was assessed to require substantial assistance with eating, toileting, bathing, dressing, and transfers. Review of section H for bowel and bladder revealed Resident #41 had an indwelling catheter and always incontinent of bowel. Review of the physician order dated 09/17/24 revealed Resident #41 was ordered foley catheter care every day and night shift. Observation on 12/11/24 at 9:47 A.M. revealed Certified Nursing Assistant (CNA) #100 performed catheter care to Resident #41. During care, Resident #41 was in Enhanced Barrier Precautions (EBP) 365652 Page 3 of 4 365652 12/11/2024 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0880 Level of Harm - Minimal harm or potential for actual harm related to catheter, which required staff to wear a gown and gloves during hands on care. CNA #100 did not apply a gown when providing care to Resident #41. Interview on 12/11/24 at 10:04 A.M. with CNA #100 verified she did not wear a gown when providing catheter care to Resident #41. Residents Affected - Few Review of the facility policy titled, Enhanced Barrier Precautions, dated 04/01/24 revealed enhanced barrier precautions referred to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employed targeted gown and glove use during high contact resident care activities. For residents for whom EBP are indicated, EBP was employed when performing the following high-contact resident care activities including hygiene, bathing, shower, and urinary catheter care. This was an incidental finding found during the course of the complaint investigation. 365652 Page 4 of 4