Health inspection·September 29, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care for a resident who was positive for COVID-19, and failed to complete proper hand hygiene prior to exiting the room. This affected one (#24) of five residents reviewed for infection control. The facility identified there were five residents who were positive for COVID-19 (and resided on the dementia care unit) during the survey. This had the potential to affect 10 residents who resided on the dementia care unit who were not positive for COVID-19. Findings include: Medical record review for Resident #55 revealed an admission of 02/14/22. Review of the physician orders dated 09/28/25 revealed Resident #55 was placed in droplet precautions due to a positive testing for COVID-19. Observation on 09/29/25 at 8:27 A.M. revealed Certified Nursing Aide (CNA) #170 obtained Resident #55's breakfast tray off the cart in the hallway and placed a gown and gloves on, and was wearing a surgical mask, and went into Resident #55's room who was on droplet precautions. CNA #170 did not put on eye protection or a N-95 mask. CNA #170 attempted to feed Resident #55 and the resident refused to eat, CNA #170 took the tray with her, set it on the bathroom sink, removed her gown and gloves, and placed the tray on the cart of empty trays. CNA #170 took a trash container and emptied in another empty room's trash can. CNA #170 went down the hall and took off her mask outside of the restroom and went into the bathroom and washed her hands and exited the bathroom. Interview with CNA #170 on 09/29/25 at 8:35 A.M. confirmed she didn't wash her hands before leaving Resident #55's room who was on droplet precautions. CNA #170 reported she didn't have any hand sanitizer on the dining cart or on the PPE cart outside of the door of the resident's room. CNA #170 confirmed she didn't have an eye protection or an N-95 mask on in Resident #55's room and stated she did not know she was supposed to wear one. Interview with the Director of Nursing (DON) on 09/29/25 at 10:02 A.M. revealed Resident #55 tested positive yesterday (09/28/25) and she didn't think the staff were supposed to be wearing a face shield but later found out they should be for droplet precautions. The DON confirmed the staff should be hand washing or utilizing hand sanitizer when leaving the rooms. The DON confirmed the facility policy for droplet precautions was for a surgical mask but didn't know about if N-95 mask should be worn if the resident was positive for COVID-19. Review of the policy titled COVID Prevention and Management dated 09/01/23 revealed it is the policy of the facility to minimize exposures to respiratory pathogens and prompt identification of residents, staff and visitors with clinical features and an epidemiologic risk for COVID-19. It was the facilities policy to promote easy and correct use of PPE by making PPE, including eye protection, face masks, gowns and gloves readily available. Educate staff on proper use of PPE and application droplet precautions including eye protection. Review of the policy titled Droplet Precautions dated 12/19/20 revealed hand hygiene included to wash hands immediately after gloves are removed and in between dirty and clean tasks; alcohol based hand rub may be used immediately after contact or touching contaminated items, and perform hand hygiene Residents Affected - Some Page 1 of 2 365899 365899 09/29/2025 Oak Creek Terrace Inc 2316 Springmill Road Kettering, OH 45440

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some before leaving the resident room. Regarding masks, eye protection, and face shields, the facilities Droplet Precautions policy stated to wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and resident-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Review of the the CDC guidance titled Infection Control Guidance: SARS-CoV-2 dated 06/24/24 and found at https://www.cdc.gov/covid/hcp/infection-control/index.html revealed a health care professional who enters the room of a resident 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), This deficiency represents non-compliance investigated under Complaint Number 2619457. 365899 Page 2 of 2