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 Page 1 of 4 365894 365894 11/03/2023 MCV Health Care Facilities, Inc 411 Western Row Road Mason, OH 45040

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dry. Use lotions on dry skin as indicated. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration to physician. Staff to observe enhanced barrier precaution: gown and glove use during high-contact resident care activities. Review of Resident #3's physician order dated 10/31/23 at 6:30 P.M. revealed Enhanced Barrier Precautions for (wound) every shift. Orders dated 10/19/23 at 4:15 P.M. revealed Triad Hydrophilic Wound Dress External Paste (wound dressings), apply to buttocks topically every day and night shift for wound care and apply to buttocks topically as needed for wound care. Review of the medical record for Resident #59 revealed admission date 10/17/23. Diagnoses include non-pressure chronic ulcer of left lower leg, cellulitis of left lower leg, atrial fibrillation, chronic pulmonary obstructive disease, asthma, Parkinson's Disease and history of venous thrombosis and embolism. Review of the admission MDS assessment dated [DATE] revealed Resident #59 had intact cognition. Resident #59 was at risk for pressure injury, with skin and ulcer/injury treatments, and application of nonsurgical dressings (with or without topical medications) other than to feet. Review of the nursing assessment/baseline care plan dated 10/17/23 revealed Resident #59 had multiple skin concerns to his coccyx, right and left hand, left and right lower leg, and bilateral feet. Resident #59 was at high risk for skin breakdown and required barrier cream with goal for alterations to heal without signs or symptoms of infection. Review of Resident #59's physician orders dated 10/31/23 at 6:30 P.M. revealed Enhanced Barrier Precautions for (wound) every shift. Order dated 10/19/23 at 2:45 P.M. revealed cleanse left lower extremity with normal saline. Pat dry, cover with layer of Adaptec followed by calcium alginate. Cover with abdominal pad, wrap with Kerlix. Change Monday, Wednesday, Saturday night and as needed for saturation. Observation on 10/31/23 from 8:47 A.M. through 9:07 A.M. with the Director of Nursing (DON) verified that all residents who were on enhanced barrier precautions were to have a personal protective equipment box outside their rooms with signs and supplies. The DON confirmed Resident #3, and Resident #59 were to be in enhanced barrier precautions but neither resident had signage, and/or personal protective equipment outside their rooms. Interview on 10/31/23 at 4:14 P.M. Resident #59 stated some staff wore gowns while providing care and completing wound dressing changes and some staff did not wear the gowns. 3. Review of medical record revealed Resident #13 had an admission date 08/17/23. Diagnosis included dementia, type two diabetes, and cognitive communication. Review of MDS assessment dated [DATE] revealed Resident #13 BIMS was 13 out of 15 that indicated she was cognitively intact. Resident #13 required for assistance extensive two-person physical assist for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Resident #13 used a wheelchair for mobility. Observation on 11/02/23 from 9:45 A.M. through 10:12 A.M. with Resident #13 receiving a bed bath from Licensed Practical Nurse (LPN) #97 and LPN #550. 365894 Page 2 of 4 365894 11/03/2023 MCV Health Care Facilities, Inc 411 Western Row Road Mason, OH 45040

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 11/02/23 at 10:00 A.M. LPN #97 had been assisting in giving bed bath to Resident #13 and stated she would get more linens on linen cart. LPN #97 took off her surgical gloves but did not perform hand hygiene. LPN #97 left the room, then returned with clean linens. LPN #97 applied new surgical gloves to assist with the bed bath again. Observation on 11/02/23 at 10:08 A.M. with LPN #550 had performed incontinence care with her gloves on cleaning bowel movement up. LPN #550 then proceeded to wash up Resident #13, then applying lotion to Resident #13's back with the same gloves on. Interview on 11/02/23 at 10:12 A.M. with LPN #550 verified she did not change her gloves or hand hygiene, after cleaning bowel movement with Resident #13, before apply lotion to Resident #13 back. LPN #97 verified she had never hand hygiene when leaving, and returning bringing back the clean linens. 4. Review of the medical record for Resident #2 revealed he was admitted to the facility on [DATE], transferred to the hospital on [DATE], and re-admitted on [DATE]. Diagnoses included acute respiratory failure with hypoxia, congestive heart failure, acute pulmonary edema, atrial fibrillation, type two diabetes mellitus and hyperlipidemia. Review of the quarterly MDS assessment, dated 09/14/23, revealed this resident had severe cognitive impairment Resident #2 was assessed to require extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene as well as supervision for eating. Review of the active physician orders revealed an order dated 10/12/23 to cleanse area of left buttock with normal saline apply alginate and mepilex during day shift on Tuesday, Thursday, and Saturday for wound care. Observation on 11/02/23 at 10:31 A.M. with Registered Nurse (RN) #120 and RN #72 who placed personal protective equipment: gown and surgical gloves on before entering Resident #2's room. Neither nurse (RN #120 or RN #72) performed hand hygiene before donning personal protective equipment (PPE) to enter Resident #2's room. Observation on 11/02/23 at 10:32 A.M. with RN #120, and RN #72 who performed a skin observation/assessment of Resident #2. Interview on 11/02/23 at 10:39 A.M. RN #120 confirmed he did not perform hand hygiene before entering Resident #2's room and stated hand hygiene should have been performed. Review of facility policy titled Enhanced Barrier Precautions dated 2023, revealed that all nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. Review of facility policy titled Hand Hygiene Policy dated June 2023, revealed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Review of the facility policy titled Infection Prevention and Control Program dated 2023 revealed that all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during providing resident care services. Hand hygiene shall be performed 365894 Page 3 of 4 365894 11/03/2023 MCV Health Care Facilities, Inc 411 Western Row Road Mason, OH 45040

F 0880 in accordance with our facility's established hand hygiene procedures. All staff shall use personal protective equipment according to the established facility policy governing the use of personal protective equipment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365894 Page 4 of 4