Health inspection·November 3, 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 medical record review, observations, staff and resident interviews and review of facility policies, the facility failed to ensure staff implemented infection control protocols when providing care to residents. This affected 10 (#52, #51, #31, #29, #41, #46, #3, #59, #13 and #2) out of 17 residents sampled for infection control. Facility census was 67. Residents Affected - Some Findings included: 1. Observation on 10/31/23 from 11:55 A.M. through 12:05 P.M. with State Tested Nursing Assistant (STNA) #171 revealed the staff assisted Resident #52 with the lunch meal while wearing gloves. After assisting Resident #52, STNA #171 assisted Resident #51 with the same pair of gloves. STNA #171 then got up out of her chair and went to Resident #31 and picked up her pizza and handed it to the resident by using the same glove. Then STNA #171 went to Resident #29 to give him a bite of his pizza by using the same surgical gloves and feeding him at the mouth with her hands. STNA #171 then went to Resident #41 to give her pizza in her hand with the same surgical gloves on. STNA #171 then went to the pizza box with the same surgical gloves to take a new piece of pizza to give to Resident #46, that laid pizza on his plate. STNA #171 then took off her pair of surgical gloves and hand hygiene with alcohol sanitizer. Interview on 10/31/23 at 12:05 P.M. with STNA #171 confirmed she had the same pair of gloves and did not perform hand hygiene while assisting Resident #29, #31, #41, #46, #51, and #52 with their lunch meals. 2. Review of the medical record for Resident #3 revealed admission date 10/05/23. Diagnoses include traumatic subdural hemorrhage, compression fracture of second thoracic vertebra, diabetes mellitus type two, congestive heart failure and atherosclerotic heart disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #3 was at risk for pressure ulcers with three deep tissue injuries and moisture associated skin damage. Resident #3 had pressure reduction devices for the chair and bed. Resident #3 had pressure ulcer/injury care. Review of the plan of care dated 10/24/23 revealed Resident #3 has pressure ulcers to right buttock and coccyx, related to decreased mobility, incontinence, and malnutrition, prefers to sit in chair and will decline at times to lay down and reposition between mealtimes. Goal for pressure ulcers to be healed with no signs/symptoms of infection and no further pressure ulcers. Interventions include, but not limited to, encourage good nutrition and hydration to promote healthier skin. Encourage house supplement as ordered. Follow facility protocols for treatment of injury. Keep skin clean and (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 4 Event ID: 365894 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 365894 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MCV Health Care Facilities, Inc 411 Western Row Road Mason, OH 45040 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)