Inspection·April 11, 2024

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, medical record review, staff interview, and clean dressing change policy review, the facility failed to prevent cross- contamination between soiled elimination containers, clean wound dressings, food, and beverages. This affected one (#1) of three residents reviewed for infection control interventions in a facility census of 80. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed an admit date of 10/29/23, with the diagnoses including: type II diabetes mellitus with foot ulcer, urinary tract infection, non-pressure chronic ulcer of right heel and midfoot, atrial fibrillation, hemiplegia, aortocoronary bypass graph, heart failure, hypertension, benign prostatic hyperplasia, and major depression. Review of the most current minimum data set assessment dated [DATE], revealed Resident #1 was assessed with intact cognition (BIMS-15), ability to make needs known, required substantial to maximal assistance with activities of daily living, incontinent of bowel and bladder, at risk for pressure ulcer development with presence of diabetic foot ulcer and associated application of wound treatment (dressing). Review of the medical record noted on 03/18/24, a physician orders were implemented for the treatment of diabetic ulcers to Resident #1 right plantar heel and right posterior heel. Treatments were ordered as follows: Right plantar heel, cleanse with wound cleanser. Pat dry. Pack collagen in area at 10 o'clock and place on wound bed. Cover with abdominal dressing (ABD) pad. Wrap with kerlix. Secure with tape. Complete every day shift for diabetic ulcer and as needed for Diabetic ulcer. Right posterior heel, cleanse with wound cleanser. Pat dry. Apply Collagen to wound bed. Cover with ABD pad. Wrap with kerlix. Secure with tape. Complete every day shift for Diabetic ulcer and as needed for diabetic ulcer. Observation on 04/11/24 at 7:11 A.M., noted Resident #1 resting in bed. A urinal was placed on the overbed table and located four inches from an empty cup and water pitcher. At 7:17 A.M., a State Tested Nurse Aide (STNA) #200 was observed to place the residents breakfast tray on the overbed table and proceeded to empty the urinal. No cleansing of the overbed table occurred. At 10:26 A.M., Registered Nurse (RN) #300 placed clean dressing supplies on the overbed table within one inch of a soiled urinal. RN #300 proceeded to open and apply the dressing to the residents wound. No cleansing of the table or clean field was attempted. Interview on 04/11/24 at 10:40 A.M., with RN #300 confirmed the soiled urinal was setting on the bedside table next to clean dressing supplies. RN #300 stated the overbed table was not cleaned or (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: 365756 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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)