Health inspection·September 11, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure appropriate measures were taken which identified Resident #7 as requiring isolation-based precautions for COVID-19 and staff donned appropriate personal protective equipment (PPE) when entering Resident #7's room. This affected 25 residents who resided on the South unit where Resident #7 resided (Residents #2, #9, #10, #12, #15, #16, #18, #19, #20, #21, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, and #41). Residents Affected - Some Facility census was 43. Findings include: Review of the medical record for Resident #7 revealed an admission date of 04/27/23 with diagnoses including acute respiratory failure, dysphagia, right rib fracture, anemia, anxiety, and encounter for surgical aftercare. Further review of the diagnoses revealed a newly added diagnosis of COVID-19 on 09/04/24. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed 06/28/24 revealed Resident #7 had intact cognition, and a primary medical condition listed as debility and cardiorespiratory conditions. Review of the care plan dated 04/27/23 revealed Resident #7 was tested and confirmed to have COVID-19 on 09/04/24 and the facility staff were to follow facility policy and Center for Disease Control and Prevention (CDC) guidelines for isolation precautions related to COVID-19. Review of the physician orders revealed an order dated 09/05/24 timed at 3:00 P.M. stating Resident #7 required isolation and observation due to positive COVID status and that medications and activities were to be completed in the resident's room every shift for COVID until 09/14/24 at 11:59 P.M. Observation on 09/11/24 from 8:39 A.M. to 8:44 A.M. revealed Licensed Practical Nurse (LPN) #443 entered the room of Resident #7 and asked if he had any pain, exited the resident's room, began preparing medications for administration, re-entered Resident #7's room, administered his medication, and returned to the medication cart. LPN #443 was observed wearing a surgical-style mask, no gown, and no gloves. Further observation revealed LPN #443 did not don or doff additional PPE prior to first entry into Resident #7's room, in-between first and second entry, or after exiting Resident #7's room. Observation of Resident #7's room on 09/11/24 at 9:10 A.M. revealed PPE was available in an organizer hanging from the front of Resident #7's closed bedroom door. No sign was posted indicating what (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: 365825 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 365825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Oaks 24579 Broadway Ave Oakwood Village, OH 44146 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)