Health inspection·August 7, 2024

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 reviews, observations, staff interviews, and policy review, the facility failed to follow infection control procedures. This affected two (#10 and #13) residents out of the three residents reviewed. The facility census was 58. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 03/20/23 with medical diagnoses of anoxic brain damage, anxiety, dependence on ventilator, tracheostomy, and seizures. Review of the medical record for Resident #10 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #10 was rare/never understood or able to understand others. The MDS indicated Resident #10 was dependent upon staff for all activities of daily living (ADLs). Review the MDS revealed Resident #10 had a gastrointestinal tube (g-tube), tracheostomy, and was on a mechanical ventilator. Review of the medical record for Resident #10 revealed a physician order dated 06/26/24 for Enhanced Barrier Precaution (EBP) related to enteral tube and tracheostomy. Observation on 08/07/24 at 9:47 A.M. revealed upon entering Resident #10's room Registered Nurse (RN) #103 was observed administering Resident #10's medications via g-tube. The observation revealed RN #103 was not wearing a gown but was wearing gloves. The observation revealed Resident #10 had an EBP sign posted on her door and an isolation cart with personal protective equipment (PPE) inside located outside of Resident #13's room. Interview on 08/07/24 at 9:58 A.M. with RN #103 confirmed she had administered Resident #10 rise medications via g-tube. RN #103 confirmed she had not donned a gown prior to administering the medications via g-tube. RN #103 confirmed Resident #10 had an EBP sign posted on her door and an isolation cart located outside of the room. 2. Review of the medical record for Resident #13 revealed an admission date of 07/25/24 with medical diagnoses of acute and chronic respiratory failure with hypoxia, dependence on ventilator, injury of spinal cord, and atrial fibrillation. Review of the medical record for Resident #13 revealed an admission assessment, dated 07/25/24, which indicated Resident #13 was alert and oriented to person, place, time, and situation. The assessment indicated Resident #13 was able to mouth words and required extensive staff assistance with all ADLs. Further review of the assessment revealed Resident #13 had a tracheostomy and was on a Page 1 of 2 365920 365920 08/07/2024 Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036

F 0880 ventilator. Level of Harm - Minimal harm or potential for actual harm Review of the medical record for Resident #13 revealed physician order dated 04/10/24 for EBP related to wound, tracheostomy, catheter, and g-tube and an order dated 06/24/24 to suction tracheostomy as needed. Residents Affected - Few Observation on 08/07/24 at 9:59 A.M. of Resident #13 revealed Respiratory Therapist (RT) #116 performing tracheostomy suctioning. RT #116 was noted to have gloves on but did not have a gown on. The observation revealed an EBP sign posted on Resident #13's door and an isolation cart with PPE inside located outside of Resident #13's room. Interview on 08/07/24 at 10:05 A.M. with RT #116 confirmed she had performed tracheostomy suctioning on Resident #13 and did not wear a gown while performing the task. RT #116 confirmed Resident #13 had an EBP sign posted on her door and an isolation cart located outside of the room. Review of the facility policy titled, EBP, revised 06/01/24 stated EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy stated EBP are only necessary when performing high-contact care activities which included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, wound care, and device care/use such as central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, midlines, and hemodialysis catheters. 365920 Page 2 of 2