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 Page 1 of 2 365825 365825 09/11/2024 Grande Oaks 24579 Broadway Ave Oakwood Village, OH 44146

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some precautions were required to enter Resident #7's room. Interview with State Tested Nurse Aide (STNA) #455, who was passing by Resident #7's room at the time of the observation, confirmed Resident #7 tested positive for COVID-19 and was in isolation. Further interview with STNA #455 further confirmed staff and visitors were required to wear an N95 mask, a gown, and gloves when entering the room of Resident #7. Interview on 09/11/24 at 9:12 A.M. with Resident #7 confirmed he had COVID-19 with cold-like symptoms and he was supposed to stay in his room. Resident #7 further confirmed staff usually wore the N95 masks, a gown, and gloves when they came into his room, but the nurse did not wear those items when he received his medications during the surveyor's observation. Observation and interview on 09/11/24 at 10:45 A.M. with the Director of Nursing (DON) confirmed there was no signage on Resident #7's door indicating what type of precautions were required and that he was supposed to have a sign indicating he was under contact and droplet isolation precautions. During the interview at 10:45 A.M., the DON confirmed Resident #7 was to remain in isolation for ten days and the nurse who had taken the sign down had been re-educated on the facility's policy and procedure for residents who test positive for COVID-19, but did not verify the sign was replaced. Interview on 09/11/24 at 10:48 A.M. with LPN #443 revealed she was not aware Resident #7 had tested positive for COVID-19. During the interview, LPN #443 confirmed she did not don all the PPE required for entering a COVID-19 positive room and since she was unaware of Resident #7's current COVID-19 positive status, she did not direct anyone else entering the room on the necessary PPE. Review of the policy titled COVID-19 Prevention, Response, and Reporting, last revised 07/01/24, revealed the facility would establish measures to identify and manage residents with suspected or confirmed COVID-19, including communication of the resident's status and visual alerts, such as signs or posters, with instructions about infection control recommendations. The policy further stated the facility was to ensure staff who entered the room of a resident with suspected or confirmed COVID-19 donned a NIOSH-approved respirator with N95 filters or higher, a gown, gloves, and eye protection. The duration of isolation precautions for residents who tested positive and experience mild to moderate symptoms was to be at least 10 days after the symptoms first appeared, at least 24 hours since the last fever without the use of fever-reducing medications, and symptoms had improved. After providing care for a COVID-19 positive individual, staff were to remove and discard the N95 mask and don a new one. Review of the facility census sheet revealed Residents #2, #7, #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 resided on the South unit. 365825 Page 2 of 2