Health inspection·September 12, 2019

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide full visual privacy during the provision of wound care for two (Resident #7 and Resident #51) of two sampled residents observed during the provision of wound care. Residents Affected - Few Findings include: 1. The admission Record documented Resident #7 had been admitted to the facility on [DATE]. The wound assessment, dated 09/10/19, found in the Assessment section of the electronic clinical record (EHR), documented the resident had a stage IV wound to the sacrum. On 09/10/19 at 2:40 P.M., Licensed Practical Nurse (LPN) #47, the facility's wound nurse, was observed as he performed wound care for Resident #7. After he washed his hands and donned gloves, LPN #47 proceeded to expose the resident from the waist down to perform the wound treatment. The window blinds were pulled up and the lower two feet of the window had no covering, allowing exposure of the resident to anyone who would have walked by on the sidewalk in the garden area outside. On 09/10/19 at 3:30 P.M., LPN #47 was asked if he had provided full visual privacy for the resident by not closing the window blinds during the wound treatment. He stated, I didn't. 2. The admission Record documented Resident #51 was admitted to the facility on [DATE]. The wound assessment, dated 09/03/19, found in the Assessment section of the EHR, documented the resident had a healing stage IV wound to the left ischium. On 09/10/19 at 3:01 P.M., LPN #47 was observed as he performed a wound treatment for Resident #51. After he washed his hands and donned gloves, LPN #47 proceeded to pull down the resident's pants and incontinent pad, exposing Resident #51's genitals. He then turned the resident onto his right side, facing the window. The window blinds were wide open, exposing the resident to anyone who might have walked by on the sidewalk in the garden outside. LPN #47 did not pull the privacy curtain to protect the resident from view from the hallway. At 3:08 P.M., LPN #47 left the room to retrieve supplies from the treatment cart in the hallway, leaving the door open approximately two to two- and one-half feet, exposing the resident's naked left hip/buttock to anyone who might have walked by in the hallway. At 3:15 P.M., LPN #47 went back to the treatment cart in the hallway to get a supply, allowing the door to open all the way before closing it. This, again, exposed the resident's naked left hip/buttock to anyone who might have walked by in the hallway. The wound treatment lasted approximately 20 minutes, all of which time the resident's genitals were exposed through the open window blinds. On 09/10/19 at 3:29 P.M., the above observation regarding the exposure of Resident #51 during the Page 1 of 5 365739 365739 09/12/2019 Heather Knoll Retirement Village 1134 North Ave Tallmadge, OH 44278

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wound treatment was reviewed with LPN #47. When asked if he had provided full visual privacy by not closing the blinds and by opening the door to the hallway two times to get supplies, exposing the resident to anyone who might have walked by, he stated, No. On 09/10/19 at 3:49 P.M., the above observations regarding the exposures of Resident #7 and Resident #51 during the provision of wound care were reviewed with the Director on Nursing (DON). When asked if it was facility's policy/procedure to provide full visual privacy during the provision of care, including wound care, she stated, I would assume that we would. On 09/11/19 at 1:37 P.M., the DON stated the facility had no policy/procedure for providing privacy during the provision of wound care. When asked if her expectation would be for staff to provide full visual privacy during a wound treatment, she stated, Yes. 365739 Page 2 of 5 365739 09/12/2019 Heather Knoll Retirement Village 1134 North Ave Tallmadge, OH 44278

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, record review, and interview, the facility failed to provide care in a manner to prevent cross contamination for two (Resident #7 and Resident #30) of four sampled residents for whom the provision of care was observed. Residents Affected - Few Findings include: 1. The admission Record documented Resident #7 had been admitted to the facility on [DATE]. The wound assessment, dated 09/10/19, found in the Assessment section of the electronic health record (EHR), documented the resident had a stage IV wound to the sacrum. On 09/10/19 at 2:40 P.M., Licensed Practical Nurse (LPN) #47, the facility's wound nurse, was observed performing wound care for Resident #7. Upon completion of the wound treatment, LPN #47 repositioned the resident's urine-saturated incontinent brief, rolled the resident onto her back and, without removing his contaminated gloves, proceeded to handle the resident's call light, bed control, and linens and re-applied her pressure-reducing boots. On 09/10/19 at 3:30 P.M., the above observation regarding touching clean items with contaminated gloves was reviewed with LPN #47. He was asked if his failure to remove soiled/contaminated gloves prior to touching clean items in the room was good infection control to prevent cross contamination. He stated, No. On 09/10/19 at 3:49 P.M., the above observation regarding touching clean items with contaminated gloves was reviewed with the Director of Nursing (DON). When asked if touching clean items while wearing soiled gloves was a good infection control practice, the DON stated she agreed it was not good infection control to handle clean items with soiled gloves. On 09/11/19 at 1:37 P.M., the DON stated the facility had no policy/procedure for the performance of wound care. She stated her expectation would be for staff to use proper hand hygiene to prevent cross contamination during the provision of a wound treatment. The facility's Infection Control Policies Transmission-Based Precautions policy, last reviewed 11/2017, documented: Gloves and Hand washing 1) Wear gloves as you would in standard precautions, and during the course of providing direct personal care for a resident. Change gloves after having contact with infective material that may contain high concentrations of microorganisms. 2. Review of Resident #30's Face Sheet located in the resident's paper medical chart indicated Resident #30 had been admitted to the facility on [DATE] with diagnoses including but not limited to quadriplegia and Parkinson's Disease. Review of Resident #30's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/19, documented the resident had been re-admitted from an acute hospital setting. The quarterly resident assessment documented the resident was totally dependent on one person for physical assistance with all personal/hygienic care; had a suprapubic catheter, a neurogenic bladder, Parkinson's Disease, was quadriplegic, and was taking an antibiotic medication. Review of Resident #30's annual MDS assessment, with an ARD of 07/03/19, documented the resident 365739 Page 3 of 5 365739 09/12/2019 Heather Knoll Retirement Village 1134 North Ave Tallmadge, OH 44278

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was totally dependent on staff for all her care needs; had a suprapubic catheter, a neurogenic bladder, Parkinson's Disease, was quadriplegic; and had a urinary tract infection (UTI) within the last 30 days. Review of Resident #30's plan of care, revised on 07/17/19, documented a potential for complications related to an indwelling catheter; had bladder spasms, chronic UTI, and had a very malodorous urine. The goal was for Resident #30 to remain free of signs and symptoms (s/s) of UTI's and avoid complications. Interventions included: catheter care per the facility's policy and after each incontinent episode of bowel; assess patency of elimination equipment; observe drainage; assess urine color; observe and record output every shift; urinary assessment as needed; administer medications as ordered; observe for side effects and effectiveness; monitor labs; obtain urine analysis (U/A) and culture and sensitivity (C&S) per medical doctor (MD) if s/s of UTI occur; report results to MD and initiate treatment as ordered. Review of Resident #30's recent lab results revealed on 06/21/19, a urine sample was obtained for a UA and C&S. Results were positive for a UTI. On 07/10/19, a urine sample was obtained for a UA and C&S. Results were positive for a UTI with a culture of Acinetobacter Baumanni/Haemolyticus, a multidrug-resistant [superbug], emerging pathogen in the healthcare system commonly found on the skin. On 08/02/19, a urine sample was obtained for a UA and C&S. Results were positive for a UTI. Lab was reported critical and was positive for Ecoli, a type of bacteria that normally lives in the intestine, and ESBL (extended spectrum beta lactamase) positive, an enzyme that causes some antibiotics not to work for treating bacterial infections [superbug]. Observation on 09/09/19 at 2:37 P.M. revealed Resident #30 lying in her bed. Attached on the side of the resident's bed was a catheter bag draining per gravity. The catheter bag was approximately half full of pale-yellow urine with white colored mucus and sediment. On 09/11/19 at 2:20 P.M. State Tested Nursing Assistant (STNA) #81 was observed performing suprapubic care for Resident #30. STNA #81 washed her hands, put on disposable gloves, filled two plastic pans with warm water, and placed a washcloth in each pan of warm water. STNA #81 took a bottle of cleansing body soap and squirted the soap out of the bottle onto one washcloth. STNA #81 then took the soapy washcloth and cleaned around Resident #30's suprapubic catheter site. STNA #81 then returned the soapy washcloth back into the pan. Without changing the gloves STNA #81 had just cleaned the catheter site with, STNA #81 took the clean, unused washcloth and wiped the soap off from around the suprapubic catheter site. The catheter bag at that time remained draining per gravity from the side of the resident's bed. The urine was light yellow and slightly cloudy. Following the observation, STNA #81 was asked why she did not change her gloves after cleaning the suprapubic catheter with the soapy washcloth and before cleansing the soap off the catheter site (dirty to clean). STNA #81 replied, I was not taught that way. I understand what you are saying though. During an interview, regarding the suprapubic catheter care performed on Resident #30 by STNA #81 on 09/11/19 at 3:00 P.M., the DON was explained how everything had been set up and then explained how the care had been performed step by step. The DON was then asked if she had noticed anything performed incorrectly by STNA #81. The DON stated, She (STNA #81) didn't change gloves between dirty and clean. On 09/12/19 at 9:15 A.M., LPN #14 who worked on Resident #30's unit was asked if Resident #30 365739 Page 4 of 5 365739 09/12/2019 Heather Knoll Retirement Village 1134 North Ave Tallmadge, OH 44278

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few experienced frequent UTI's. She stated, Yes, she does. She was asked who performed the care to Resident #30's suprapubic catheter site. LPN #14 said the assistants did the care every shift. Review of the facility's policy titled, Catheter Care undated, indicated, Policy: It is the policy of [name deleted] that catheter care will be provided as ordered. Protocol: A. Gather soap and water. B. Wash hands, put on gloves. C. Wash around catheter site, monitor for drainage or bleeding from site. D. Remove gloves and wash hands. E. Notify nurse of any abnormal findings. F. Catheter Care to be prepared Q [every] shift and PRN [as needed]. 365739 Page 5 of 5