Health inspection·January 29, 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 observation, interview, record review, review of camera video footage and facility policy review, the facility failed to ensure Resident #41 had appropriate transmission-based precautions implemented. This affected one (Resident #41) out of three residents reviewed for infection control. The facility census was 62.Findings include:Review of Resident #41's medical record revealed an admission date of 12/25/25 with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, saddle embolus of pulmonary artery with acute cor pulmonale, urinary tract infection and extended spectrum beta lactamase (ESBL) resistance.Review of Resident #41's physician orders dated 12/25/25 revealed Contact Precautions/Isolation related to ESBL, every day shift and night shift. The orders were active from 12/25/25 through 01/29/26.Review of Resident #41's care plan dated 12/25/25 through 01/28/26 did not reveal evidence Resident #41 had a care plan related to Contact Precautions or Enhanced Barrier Precautions (EBP).Review of Resident #41's care plan dated 12/29/25 included Resident #41 had a problem with skin integrity and had a left elbow skin tear and left FA (forearm) basal cell carcinoma atypical wound. Resident #41's wounds would heal without complications. Interventions included treatment to left elbow per orders; and on 01/29/26 an intervention for EBP's every shift was initiated.Review of Resident #41's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was unable to complete the interview. Resident #41 had impairment on one side of the upper extremity and impairment on both sides of the lower extremities. Resident #41 used a wheelchair and was dependent on staff for toileting and personal hygiene, dressing, bathing and bed mobility. Resident #41 was always incontinent of bowel and bladder. Resident #41 had a PEG (percutaneous endoscopic gastrostomy) feeding tube and received 51 percent or more total calories from tube feeding. Review of Resident #41's urine culture and sensitivity lab report revealed the urine specimen was collected on 01/08/26 and reported on 01/11/26. The report included there were two different groups of GNR (gram-negative rods, the most common cause of bacterial urinary tract infections (UTI's)), and the growth was less than 10,000 CFU (colony forming units) per milliliter, no work up.Review of Resident #41's progress notes dated 01/11/26 at 6:23 P.M. revealed Resident #41's urine culture results were finalized and faxed to Infectious Disease Physician (IDP) #400 and Primary Care Physician (PCP) #401.Review of Resident #41's medical record including physician orders and progress notes dated 01/11/26 through 01/29/26 did not reveal evidence Resident #41 was changed from Contact Precautions to EBP.Review of Resident #41's physician orders dated 01/15/26 revealed enteral-continuous tube feeding: Nutren 2.0 (interchanged with Isosource 1.5 at 40 milliliters per hour for 22 hours (off during ADL care) to provide 880 milliliters in a 24-hour period. Each shift should provide 440 milliliters until 880 total volume reached.Review of Resident #41's video camera footage dated 01/26/26 at about 8:31 A.M. revealed a nurse who appeared to be Licensed Practical Nurse (LPN) #327 was standing next to Resident #41's bed and she was administering medications via Resident #41's PEG tube, and LPN #327 was not Residents Affected - Few Page 1 of 3 365814 365814 01/29/2026 Cortland Center 369 N High Street Cortland, OH 44410

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wearing an isolation gown while she administered the medications.Review of Resident #41's physician orders dated 01/29/26 at 9:15 A.M. revealed Isolation/Transmission-Based Precautions: EBP's, every shift.Observation on 01/29/26 at 11:07 A.M. of Resident #41's room revealed there was a Contact Precaution sign on her door. There was a second sign stating there was a camera located in Resident #41's room. There were two bins inside the door of the room, one red and one yellow. Resident #41's daughter was sitting in the room and Resident #41 was lying in bed with the head of her bed elevated, and her eyes were closed. When asked about the Contact Precaution sign on the door Resident #41's daughter stated the staff did not wear gowns and did not always wear gloves when they provided care for Resident #41. Resident #41's daughter said the bins were brought in the room this morning, were clean, and did not have any personal protective equipment (PPE) in them. Resident #41's daughter lifted the lids to show that there was nothing in either bin, and stated she knew they were clean and that was why she felt comfortable lifting the lid and showing what was inside of them.Interview on 01/29/26 at 11:08 A.M. of LPN #327 and Registered Nurse (RN) #371 revealed Resident #41 had a feeding tube and that was why she was on transmission-based precautions. LPN #327 stated Resident #41 was on EBP, and when asked why there was a Contact Precaution sign on the door, RN #371 stated Resident #41 was on Contact Precautions at the hospital and when she was admitted to the facility but she was now on EBP. LPN #327 stated Resident #41 was on EBP and the staff, including herself, wore appropriate PPE when caring for Resident #41. RN #371 reviewed Resident #41's physician orders and stated RN/Wound Care Nurse/MDS Nurse (RN/WCN/MDS) #373 placed Resident #41 on EBP today.Interview on 01/29/26 at 11:14 A.M. of RN/WCN/MDS #373 revealed Resident #41 was on EBP, she wrote the order today (01/29/26), and she did not put a Contact Precaution sign on Resident #41's door today (01/29/26). RN/WCN/MDS #373 stated she was double-checking residents' orders for residents receiving wound care, and Resident #41 was not changed from Contact to EBP precautions. RN/WCN/MDS #373 stated Resident #41 had a feeding tube and chronic basal cell carcinoma on her arm and that was why she was placed on EBP. Resident #41 was on Contact Precautions for ESBL in her urine when she was admitted to the facility, but her urine was rechecked on 01/11/26, it was negative for ESBL and both IDP #400 and PCP #401 were notified.Interview on 01/29/26 at 11:23 A.M. of the Director of Nursing (DON) revealed she was filling in for the Infection Preventionist because the Infection Preventionist was newly hired, had just finished her Infection Prevention training, and had not taken over the role of Infection Prevention yet. The DON stated she was also newly hired and was still learning Infection Prevention. Interview on 01/29/26 at 11:47 A.M. of LPN #327 revealed Resident #41 was on Contact Precautions when she was admitted to the facility and stayed on the Contact Precautions until her antibiotic for the ESBL in her urine was completed around the end of December, then she was changed to EBP. LPN #327 confirmed when she reviewed Resident #41's physician orders there were no orders to discontinue Contact Precautions and place Resident #41 on EBP. LPN #327 confirmed on 01/29/26 orders were written to place Resident #41 on EBP.Observation on 01/29/26 at 11:56 A.M. revealed Resident #41 was lying in bed with her eyes closed and the head of her bed was raised about thirty degrees. Resident #41's daughter was sitting in a chair by the end of the bed. When asked if staff wore gowns and gloves when caring for Resident #41, Resident #41's daughter stated yesterday was the first day the nurses and aides used gowns when providing Resident #41's care. When asked if she had video camera footage showing the nurses and aides did not wear gowns and gloves Resident #41's daughter provided camera footage showing a nurse did not wear an isolation gown when providing care.Interview on 01/29/26 at 12:29 P.M. of Maintenance and Housekeeping Supervisor (MHS) #336 revealed today (01/29/26) he was told Resident #41's room needed PPE bins and he brought a red bin and a yellow bin. MHS #336 stated Resident #41's room 365814 Page 2 of 3 365814 01/29/2026 Cortland Center 369 N High Street Cortland, OH 44410

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had bins when she was admitted , but he had not brought any bins for at least one week and it might be two weeks. MHS #336 stated he always provided the red and yellow bins to resident rooms who were on precautions. MHS #336 stated the reason he was not told Resident #41 needed the red and yellow bins in her room might be because the housekeeping staff thought she was no longer on transmission-based precautions. The housekeeping staff rely on the nurses to tell them a resident is on transmission-based precautions.Interview on 01/29/26 at 3:00 P.M of the DON confirmed there was no evidence in Resident #41's care plan dated 12/25/25 through 01/28/26 that she had a care plan initiated for Contact Precautions or EBP. The DON stated an intervention for EBP was initiated on 01/29/26. The DON stated she told RN/WCN/MDS #373 to make sure care plans were updated for transmission-based precautions today (01/29/26). Review of the facility policy titled Enhanced Barrier Precaution Policy, revised 05/19/25, included EBP were intended to prevent the transmission of multi-drug-resistant organisms (MDRO) via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. EBP were indicated for high contact care activities for high-risk residents and for all those colonized or infected with a MDRO currently targeted by the CDC. Other MDRO's may be included at the discretion of the facility Infection Control Committee unless required by state guidance. High-risk residents include those with chronic wounds and indwelling devices such as central lines, urinary catheters and trachs and for all those colonized or infected with an MDRO currently targeted by the CDC. High contact care activities that may result in transfer of MDRO's to hands and clothing of healthcare personnel, even when blood and body fluid exposure was not anticipated. These included dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use, and wound care. Staff engaging in high-contact activities would don both gloves and gown before initiating the activity and remove PPE before exiting the room or area where the activity occurred. Signage indicating the appropriate type of precautions and indicating that visitors should stop at the Nurse's Station before entering would be placed on the resident's door. Staff would educate visitors regarding donning appropriate Personal Protective Equipment while adhering to the resident's right for privacy protection. This deficiency represents noncompliance investigated under Master Complaint Number 2728869. 365814 Page 3 of 3