Health inspection·April 20, 2023

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, facility policy review, and review of the Centers for Disease Control (CDC) guidance, the facility failed to maintain proper infection control procedures to prevent the spread of COVID-19 infection. This affected two residents (Resident #14 and #23) but had the potential to affect all 51 residents residing in the facility. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/08/21. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed resident had impaired cognition and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #14 medical record reviewed they were diagnosed with COVID-19 on 04/07/23. Review of physician orders dated 04/07/23 revealed the resident was to be on transmission based precautions (TBP) for ten days duration. Interview on 04/17/23 at 8:39 A.M. with Infection Preventionist (IP) #150 revealed the facility was in a COVID-19 outbreak status. IP #150 reported staff were to wear N95 masks, surgical mask over top of N95 mask, eye protection, gown, and gloves to enter in the COVID-19 rooms. IP #150 reported before exiting the COVID-19 rooms staff were to doff (take off) surgical mask, gown, gloves, and then upon exit disinfect their goggles or face shields and perform hand hygiene. Observation on 04/17/23 at 9:31 A.M. revealed STNA #103 donned (put on) personal protective equipment (PPE) to enter Resident #14's room with her goggles on her head. Resident #14 was observed to be on TBP. STNA #103 exited the room at 9:36 A.M. and her goggles still on her head. STNA #103 preceded to go down the hall. STNA #103 did not disinfect her goggles as required due to COVID-19 outbreak status at the facility. Interview on 04/17/23 at 9:37 A.M. with STNA #103 revealed she forgot to wear the goggles correctly as she entered Resident #14's COVID-19 positive room room to perform personal care and exited the room with the goggles remaining on her head. STNA #103 proceeded to head down the hall without disinfecting her goggles. She reported I just forgot. STNA #103 confirmed she did not wear her goggles correctly and did not clean goggles after exiting the room. Interview on 04/17/23 at 10:08 A.M. with IP #150 confirmed staff were to disinfect goggles or face shields upon exiting room and hand hygiene is to be performed upon exiting resident rooms. Page 1 of 2 365855 365855 04/20/2023 Laurie Ann Nursing Home 2200 Milton Boulevard Newton Falls, OH 44444

F 0880 Level of Harm - Minimal harm or potential for actual harm Interview on 04/17/23 at 12:15 P.M. with Director of Nursing (DON) regarding observation of STNA #103 revealed staff were to wear a N95 mask, surgical mask over N95 mask, gown, gloves, and eye protection to inter a COVID-19 positive room and upon exit remove the surgical mask gown, and gloves. DON reported upon exit staff are to clean their goggles or face shield and perform hand hygiene. Residents Affected - Many 2. Review of the medical record for Resident #23 revealed an admission date of 01/20/23. Review of MDS dated [DATE] revealed resident had intact cognition and required extensive assistance for bed mobility, transfers, dressing and was dependent for toileting and bathing. Resident #23's medical record revealed the resident was diagnoses with COVID-19 on 04/10/23. Review of physician orders dated 04/10/23 revealed Resident #23 was to be in TBP for ten days duration. Observation on 04/17/23 at 9:41 A.M. of Housekeeping Supervisor (HKS) #119 revealed she had donned PPE to enter Resident #23 to answer a call light. Resident #23 was observed to be in TBP. Upon exiting the room at 9:44 A.M. after deactivating the call light (HKS) #119 did not disinfect her goggles or perform hand hygiene. Interview on 04/17/23 at 9:45 A.M. with (HKS) #119 revealed she didn't know how to clean her goggles and was going to use the hand sanitizer at the end of the hall. (HKS) #119 was asking this surveyor what she was supposed to do and how to clean the goggles. HKS #110 reported I was going to use the hand sanitizer at the end of the hall. HKS #110 confirmed she did not clean her goggles and did not perform hand hygiene after exiting the room. Interview on 04/17/23 at 10:08 A.M. with IP #150 confirmed staff were to disinfect goggles or face shields upon exiting room and hand hygiene is to be performed upon exiting resident rooms. Interview on 04/17/23 at 12:15 P.M. with DON regarding observation of HKS #119 revealed staff are to wear N95 mask, surgical mask over N95 mask, gown, gloves, and eye protection to inter a COVID-19 positive room and before exit remove the surgical mask gown, and gloves. DON reported upon exit staff are to clean their goggles or face shield and perform hand hygiene. Review of facility policy, Novel Coronavirus Prevention and Response, revised 07/24/22, revealed N95 mask, eye protection, gloves and gown to be worn and hand hygiene performed. Review of the CDC guidance updated 09/27/22 titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed health care personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 365855 Page 2 of 2