Health inspection·April 17, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, the facility failed to maintain infection control principles during tracheostomy care. This affected one (Resident #19) of one resident observed for tracheostomy care. The facility identified one resident who currently has a tracheostomy. The facility census was 94. Residents Affected - Few Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of tracheostomy, stenosis of larynx, post-procedural subglottic stenosis, paranoid schizophrenia, drug induced dyskinesia and morbid obesity. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #19 had intact cognition and was always continent of bowel and bladder. The resident required supervision with eating, oral and personal hygiene, toileting, bathing, dressing, bed mobility and transfers. Review of physician orders revealed an order dated 02/22/24 for Resident #19 to have her tracheostomy inner cannula cleansed during tracheostomy care every day and as needed, and to apply a dressing around the tracheostomy to protect the skin. Review of physician orders revealed an order dated 04/17/24 for Resident #19 to have Enhanced Barrier Precautions (EBP) implemented for tracheostomy care, dressing, bathing, showering, transfers in room or therapy gym, personal hygiene, changing linen, providing hygiene, changing briefs or assistance with toileting. Review of physician orders revealed an order dated 02/27/25 for Resident #19 to have tracheostomy care completed every shift and as needed. The nurse is to cleanse the stoma with soap and water, assist the resident with removal of tracheostomy and clean with tracheostomy care cleaning kit solution, reinsert the tracheostomy and apply tracheostomy after care. Ensure tracheostomy ties are secure. During an observation on 04/16/25 at 11:00 A.M., Licensed Practical Nurse (LPN) #46 attempted to provide tracheostomy care to Resident #19 who had Enhanced Barrier Precautions (EBP) in place. Observation revealed that LPN #46 did not perform hand hygiene with alcohol-based hand sanitizer or soap and water prior to entering the resident's room and putting on Personal Protective Equipment (PPE) that included gown, mask and gloves. LPN #46 was observed using her gloved hand to push down overflowing trash in the trash can, then used the same gloved hand to pick up a cup, to be used for saline solution for suctioning, with her thumb inside the cup, and used the same gloved hand to open the tracheostomy care kit, pick up the tracheostomy inner-cannula cleaning brush and place it on the overbed Page 1 of 3 365925 365925 04/17/2025 Brookside Healthcare Center 315 Lilienthal Street Cincinnati, OH 45204

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few table, and picked up the tracheostomy cleaning kit by placing her gloved thumb inside of the area used to hold the tracheostomy cleaning solution. At this point, LPN #46 was asked to stop the tracheostomy care process due to infection control concerns. This was reported to the Director of Nursing (DON). During an interview on 04/16/25 at 11:25 A.M., LPN #46 verified she did not perform hand hygiene upon entering the room of Resident #19 and before putting on PPE. LPN #46 also verified her gloved hand came in contact with trash in the trash can and she then touched the inside of the plastic cup to hold saline for suctioning, and then used the same gloved hand to open the tracheostomy kit, touched the brush used to clean the inner cannula, and then touched the inside of the tracheostomy kit reservoir that was to be used for the tracheostomy inner cannula cleaning solution. During an interview on 04/17/25 at 11:00 A.M. the DON verified LPN #46 did not adhere to EBP guidelines for proper hand hygiene fore entering the room of Resident #19, and did not maintain aseptic technique while attempting to perform tracheostomy care. Review of the policy titled, Enhanced Barrier Precautions (EBP), undated, revealed EBP refer to an infection control intervention designed to reduce transmission of Multi-Drug Resistant Organisms (MDRO) that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care with any skin opening requiring a dressing. Review of the policy titled, Standard Precautions, undated, revealed the facility will adhere to Centers for Disease Control and Prevention (CDC) guidelines and recommendations for hand hygiene unless otherwise explicitly stated. When using soap and water, rub hands vigorously for at least 20 seconds, covering all surfaces of the hands, top of hands and fingers, and wrists. Review of the policy titled, Tracheostomy Care, undated, revealed the purpose of the policy is to provide guidance for tracheostomy care for the licensed and competent nurse or respiratory therapist. Process steps may be performed using a different sequence and does not imply incorrect procedure. Maintaining key areas of aseptic technique and working efficiency to resume oxygenation are the critical components of this process. Maintain an aseptic environment, to the extent possible, to reduce pathogen transmission. Remove gloves and perform hand hygiene prior to opening the sterile tracheostomy kit, set up sterile field, and apply sterile gloves. 365925 Page 2 of 3 365925 04/17/2025 Brookside Healthcare Center 315 Lilienthal Street Cincinnati, OH 45204

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review and interview, the facility failed to ensure portion sizes were served as planned. This had the potential to affect all 94 residents in the facility. Residents Affected - Many Findings include: Review of the dietary spreadsheet for the breakfast meal on 04/17/25 revealed the serving sizes for the scrambled eggs was 1/4 cup, ground ham was a #16 scoop (1/4 cup), pureed ham was a #16 scoop, pureed eggs was a #16 scoop, and pureed muffin was a #16 scoop. During an observation on 04/17/25 at 8:00 A.M., the breakfast tray line revealed [NAME] #24 utilized #8 scoops (1/2 cup) for the ground ham, pureed ham, and pureed eggs and #12 scoops (1/3 cup) were utilized for the scrambled eggs and pureed muffins. During an interview on 04/17/25 at 8:06 A.M., Registered Dietitian (RD) #330 verified [NAME] #24 was not utilizing the correct size scoops for the ground ham, pureed ham, pureed eggs, scrambled eggs, and pureed muffins. During an interview on 04/17/25 at 8:08 A.M., [NAME] #24 stated he utilizes the dietary spread sheets to determine scoop sizes, however got mixed up and was referring to the lunch portions of the spread sheet instead of breakfast. 365925 Page 3 of 3