Health inspection·September 23, 2025

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, interview, record review, facility policy review, review of the memorandum from the Department Prevention, the facility failed to ensure staff used appropriate infection control practices using required proper hand hygiene for Residents # 605 and Resident #629 using appropriate standards of practice with use of gloves during incontinence care for Residents #605 and #629 This affected two residents and had the potential to affect all 106 residents residing in the facility.Findings include:1. Review of the medical record revealed Resident #605 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, diverticulosis, collapsed vertebra, unspecified dementia, hydronephrosis, Alzheimer's disease, essential hypertension, and acute kidney failure. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #605 had impaired mental status, she was dependent on staff for activities of daily living (ADL) and was always incontinent of bowel and bladder. Observation on 09/22/25 at 11:55 A.M. revealed Certified Nurse Assistant (CNA) # 294 gathered supplies, provided privacy, washed hands and donned gloves. CNA #294 removed Resident #605 brief that was soiled with light stool and urine. CNA #294 provided peri care from front to back, then with the same gloves on she touched the barrier cream container and put barrier cream on her gloves and applied the cream to Resident #605's peri area. CNA #294 then turned the resident and performed care to her buttocks. CNA #294 then applied a new brief with the same soiled gloves. Once done, CNA #294 removed her gloves and washed her hands and removed all soiled materials. Interview on 09/22/25 at 12:15 P.M. with CNA #294 confirmed she did not was her hands or change her gloves after providing incontinence care before applying a clean brief to Resident #605. 2. Review of the medical record revealed Resident #629 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphagia, type II diabetes, and anxiety disorder. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #629 had severe cognitive impairment and was dependent on staff for all ADL and was always incontinence of bowel and bladder. Observation on 09/22/25 at 12:13 P.M. CNA #306 did not use appropriate hand hygiene during incontinence care for Resident #629, she washed her hands, gathered supplies, applied gloves, removed the brief, washed the resident's peri area and buttocks and applied a clean brief without washing her hands or changing her gloves. She pulled up the covers and lowered the bed to the lowest position with the soiled gloves. Interviews on 09/22/25 at 12:22 P.M. with CNA #306 confirmed she did not wash her hands or change her gloves after providing incontinence care before applying a clean brief and pulling up the covers for Resident #629. Interview on 09/22/25 at 1:03 P.M. with the Director of Nursing (DON) confirmed the facility had a policy in place confirming soiled gloves should be changed and hand hygiene should be performed before placing a clean brief on Resident #605 and Resident #629. Review of the undated facility policy Standard Precautions revealed when to perform hand hygiene to include before Residents Affected - Few Page 1 of 2 365783 365783 09/23/2025 Aventura at Assumption Village 9800 Market Street North Lima, OH 44452

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and after direct contact with a resident's intact skin, after contact with body fluids or excretions, and after glove removal. Review of Hand Hygiene in Healthcare Settings, Healthcare Providers, Glove Use, last reviewed 01/08/21, from the Centers for Disease Control and Prevention, located at https://www.cdc.gov/handhygiene/providers/index.html revealed gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene during patient care if gloves become visibly soiled with blood or body fluids following a task and moving from work on a soiled body site to a clean body site on the same patient. This deficiency was an incidental finding identified during the complaint investigation. 365783 Page 2 of 2