Health inspection·May 22, 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 record review, observation, interview, and facility policy review, the facility failed to use appropriate infection control precautions while providing wound care to Resident #50 who was in enhanced barrier precautions. This affected one Resident #50 but had the potential to affect all 29 residents who were ordered enhanced barrier precautions, Residents #5, #8, #9, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24, #30, #31, #33, #36, #37, #40, #44, #46, #50, #58, #61, #63, and #64. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Resident #50 revealed an admission date of 06/17/24. Diagnoses included chronic obstructive pulmonary disease, hypertension, and heart failure. Review of the care plan dated 06/17/24 revealed Resident #50 had impaired skin integrity on her left breast and left side of her neck. Interventions included providing wound care as ordered and enhanced barrier precautions. Review of the physician's order dated 09/16/24 revealed an order for enhanced barrier precautions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had moderate cognitive impairment. Resident #50 required extensive assistance for all activities of daily living. Observation and interview on 05/22/25 at 11:15 A.M. of wound care for Resident #50 with Registered Nurse (RN) #502 revealed on the front of Resident #50's door signage that she was in enhanced barrier precautions. The sign stated for staff to wear a gown, gloves, and use hand hygiene when providing personal care including wound care. RN #502 entered the room, set up her area, washed her hands, and began performing the wound care. RN #502 maintained good hand hygiene during the wound care and changed her gloves often using hand sanitizer before applying new gloves. After the procedure was over RN #502 cleaned up her area, removed her gloves and washed her hands. Upon exiting the room, RN #502 confirmed Resident #50 was in enhanced barrier precautions and a gown was not worn during the procedure. RN #502 also confirmed that there was signage on Resident #50's door with personal protective equipment. Review of the facility policy infection prevention and control program policy, revised 02/19/24, revealed it is the policy to maintain an organized, effective facility-wide program designed to systemically prevent, identify, control, and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and contract healthcare workers; to conduct surveillance of Page 1 of 2 365814 365814 05/22/2025 Cortland Center 369 N High Street Cortland, OH 44410

F 0880 communicable disease and infectious outbreaks; and to monitor employee health. Level of Harm - Minimal harm or potential for actual harm This deficiency represents an incidental finding identified during the complaint investigation. Residents Affected - Few 365814 Page 2 of 2