Inspection·February 12, 2026

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 medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure proper enhanced barrier precautions were donned when completing a wound treatment. This affected one (Resident #17) of three residents reviewed for infection control. In addition, the facility failed to develop and implement a water management plan to mitigate the risk of Legionella. This had the potential to affect all residents residing in the facility. The facility census was 57.Findings Include:1. Resident #17 was admitted to facility on 04/28/25. Diagnoses included Alzheimer's Disease, infection of the skin, low back pain, depression, anxiety disorder, diabetes, hypertensive retinopathy, dermatochalasis, chronic kidney disease, diabetic retinopathy, and kidney transplant. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #17 was severely cognitively impaired and suffered with moderate depression. Resident #17 had an infected diabetic foot ulcer; treatments included nonsurgical dressing and ointments. Resident #17 received insulin, antianxiety medications, antidepressant medication, an anticoagulant, an antibiotic, and a hypoglycemic medication. Review of the plan of care last revision date revealed Resident #17 had a infected left foot wound, interventions included Enhanced Barrier Precautions (EBP) implemented 11/20/25. Review of the medical record for Resident #17 included an order revised on 02/03/26 for treatment of the ball of the left foot: cleanse with normal saline, apply calcium alginate cut to fit wound, cover with bordered foam dressing daily and as needed (PRN). Assess for Eschar/Black, Dark, Hard Tissue; Any Drainage/Exudate. Observation and interview on 02/11/26 at 4:25 P.M. revealed Registered Nurse #310 gathered supplies for Resident #17's dressing change, took them into the room and placed the wound supplies on the residents' bedside table. RN #310 left the bedside and closed Resident #17's door and returned to the bedside without personal protective equipment (PPE) donned and was ready to unbandage Resident #17's foot wound. RN #310 when asked by the surveyor who was in enhanced barrier precautions RN #310 stated she thought Resident #17 was. RN #310 further stated the only time staff were required to wear PPE were when they were completing direct patient care. RN #310 then asked the surveyor if the wound treatment would be considered direct patient care. RN #310 left the room at that time and returned with donned PPE. Review of facility policy titled Enhanced Barrier Precautions (EBP) dated 04/01/24 revealed EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP is indicated for residents with any wounds and require gown and gloves for high contact resident care (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: 365652 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 365652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241 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)