Health inspection·June 14, 2025

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure the residents had had access to their personal funds outside of normal business hours and on weekends. This affected one (Resident #9) of one resident reviewed for personal funds. Residents Affected - Few Findings included: Review of Resident #9's admission record revealed Resident #9's admission date was 05/25/23. Review of the annual Minimum Data Set (MDS) assessment date 04/04/25 revealed Resident #9 had intact cognition. During an interview on 06/11/25 at 10:12 A.M., Business Office Manager #100 stated she believed residents went to the front desk during the week from 8:00 A.M. to 8:00 P.M. to request money from their personal funds from either Receptionist #12 or Receptionist #13. During an interview on 06/11/25 at 10:23 A.M., Receptionist #12 stated the hours the residents could receive money from their personal fund was Monday through Friday from 8:00 A.M. to 5:00 P.M. Receptionist #12 stated on the weekends, the residents knew they could not obtain any of their money. During an interview on 06/11/25 at 11:35 A.M., Resident #9 stated they used to have a problem with getting money with Former Administrator #140 and it typically took at least three days to get any of their requested money. Resident #9 stated they had not asked for money outside of business hours because they knew they could not get it if they wanted or needed it. During an interview on 06/13/25 at 11:22 A.M., the Administrator stated she expected the residents to have access to their personal funds seven days a week. Review of the facility policy titled Transactions Involving Resident Funds dated 07/01/23 revealed the Business Office Manager, or his/her designee, is responsible for providing residents with receipts for withdrawals and for requested or needed personal items when such funds are withdrawn from the resident's personal funds account managed by the facility. The policy did not address when residents should have access to their personal funds accounts or how personal funds were made available to residents after hours and on weekends. This deficiency represents non-compliance investigated under Complaint Number OH00162377. Page 1 of 12 365946 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the Resident #176's medical record revealed an admission date of 05/21/25. Diagnoses included rheumatoid arthritis, chronic pain syndrome, and fibromyalgia. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #176 had intact cognition. Review of Resident #176's care plan revealed a focus area initiated 05/21/25, indicating the resident was at risk for alteration in their comfort related to generalized pain, discomfort, fibromyalgia, chronic pain, depression, and rheumatoid arthritis. Interventions directed staff to administer analgesia per orders and to anticipate the resident's need for pain relief and to respond immediately to any complaints of pain. Review of the SRI dated 05/27/25 revealed Resident #176's family expressed to hospital staff that a facility staff member was rough and verbally mean to the resident. The facility notified the State Survey Agency of the allegation of physical and emotional/verbal abuse on 05/27/25 at 3:59 P.M. During an interview on 06/10/25 at 2:50 P.M., the Director of Nursing (DON) stated when she assessed Resident #176's skin on 05/23/25, the resident reported that on the previous night shift, the staff were rough when they repositioned them. The DON stated she treated this allegation more like a grievance rather than an abuse allegation because she thought it was more related to resident care. The DON stated when Resident #176 was at the hospital a few days later, their family member voiced concerns to the hospital case manager related to abuse and care received in the facility on 05/23/25. Per the DON, once the hospital staff notified the facility of the abuse allegation on 05/27/25, the facility reported the allegation of abuse to the State Survey Agency. During a follow-up interview on 06/13/25 at 10:09 A.M., the DON stated she expected staff to report any allegation of abuse immediately. The DON stated she did not feel like Resident #176's concern of staff being too rough with them was an allegation of abuse because of the resident's history having pain. The DON thought it was more of a care concern and that staff needed to take their time when they repositioned the resident. During an interview on 06/13/25 at 10:34 A.M., the Administrator stated she expected all staff to report any allegations of abuse or neglect, then she had two hours to submit the initial report to the State Survey Agency. When Resident #176 reported to the DON that the night shift staff were rough with them, she followed up with the resident and addressed their concerns. The Administrator stated the resident used the key word rough but did not allege abuse the previous night, so they did not report the allegation. The Administrator stated that when the hospital notified her that Resident #176 alleged facility staff were physically rough with them, that was when they submitted the initial report to the State Survey Agency. Review of the facility policy titled Abuse, Neglect and Exploitation with a copyright date of 2025, indicated the facility will have written procedures that included reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than twp hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 365946 Page 2 of 12 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Numbers OH00166090, OH00164707, and OH00162351. Based on staff interview, record review, review of the facilities Self-Reported Incidents (SRI), and facility policy review, the facility failed to timely report allegations of physical and/or emotional abuse to the State Survey Agency. This affected three (Residents #7, #176, and #276) of five residents reviewed for abuse. The facility census was 80. Findings included: 1. Review of Resident #7's medical record revealed an admission date of 04/21/23. Diagnoses included Alzheimer's disease, dementia with agitation, dementia with psychotic disturbance, and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was independent in cognitive skills for daily decision making. and dated 03/04/25 at 7:38 A.M., indicated the resident was attacked by another resident (Resident #276) with an eye glass case on the right side of their head. Resident #7 was heard screaming and stated, I just got hit with eye glasses by this [man/woman] (Resident #276) standing next to me. Resident #7 was immediately assessed and no injury was noted, but the resident complained of pain to the right side of their head and as needed Tylenol (treats mild pain) was administered as requested. The physician, resident family, and management were made aware. Review of Resident #276's medical record revealed an admission date of 03/08/24 with a diagnosis of chronic obstructive pulmonary disease. The quarterly MDS assessment dated [DATE] revealed Resident #276 had severe cognitive impairment. #276 walked to another resident (Resident #7) and attacked them with an eye glass case in the head. LPN #5 immediately assisted Resident #276 to a different location and educated the resident not to hit other residents with an eye glass case. The physician, resident family, and management were made aware. Review of the facility's SRI from 03/04/25 to 06/11/25 revealed the facility did not report the physical abuse allegation between Resident #276 and Resident #7 to the State Survey Agency. During an interview on 06/12/25 at 9:36 A.M., LPN #5 stated that on the day of the incident (03/04/25), Resident #7 sat in the television room and yelled at Resident #276. Resident #276 responded to Resident #7 by hitting them on their head with their eyeglasses case. LPN #5 stated she reported the incident to risk management immediately after the incident occurred. During an interview on 06/12/25 at 1:25 P.M., Former Administrator #140 stated he did remember the incident between Resident #276 and Resident #7. Former Administrator #140 stated Resident #7 was very territorial and always had to feel in charge. Former Administrator #140 stated he believed the incident had been reported to the State Survey Agency. During an interview on 06/12/25 at 10:38 A.M., the Administrator verified the facility had not submitted a facility-reported incident to the State Survey Agency following the incident between Resident #276 and Resident #7 on 03/04/2025. 365946 Page 3 of 12 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/13/25 at 10:10 A.M., the Director of Nursing (DON) stated the management team was initially told that if two cognitively impaired residents did not know what they were doing and had an altercation, the facility could just separate the residents involved and do nothing further. The DON stated she learned any time there was a physical altercation between two residents even if the residents were cognitive impaired, the altercation had to be reported. The DON stated her expectation was any sort of perception of abuse by a staff member or resident-to-resident, no matter how big or small, the allegation would be reported immediately. During a follow-up interview on 06/13/25 at 10:36 A.M., the Administrator stated the time frame to report an allegation of abuse was immediately or within two hours. 365946 Page 4 of 12 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, review of Self-Reported Incidents (SRI) and time cards, and facility policy review, the facility failed to immediately protect the resident(s) from the alleged perpetrator(s) when a resident reported an allegation of staff-to-resident physical abuse. This affected one (Resident #176) of five residents reviewed for abuse. Residents Affected - Few Findings included: Review of the Resident #176's medical record revealed an admission date of 05/21/25. Diagnoses included rheumatoid arthritis, chronic pain syndrome, and fibromyalgia. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #176 had intact cognition. Review of Resident #176's care plan revealed a focus area initiated 05/21/25, indicating the resident was at risk for alteration in their comfort related to generalized pain, discomfort, fibromyalgia, chronic pain, depression, and rheumatoid arthritis. Interventions directed staff to administer analgesia per orders and to anticipate the resident's need for pain relief and to respond immediately to any complaints of pain. Review of the SRI dated 05/27/25 revealed Resident #176's family expressed to hospital staff that a facility staff member was rough and verbally mean to the resident. Review of time cards for the timeframe 05/22/25 to 05/27/25 revealed Certified Nursing Assistant (CNA) #3 worked in the facility from 7:14 P.M. on 05/22/25 to 7:19 A.M., on 05/23/25, from 8:05 P.M. on 05/23/25 to 7:16 A.M. on 05/24/25, and from 6:51 P.M. on 05/24/25 to 7:00 A.M. on 05/25/25. Registered Nurse (RN) #4's time cards for the timeframe 05/22/25 to 05/27/25 revealed RN #4 worked in the facility from 6:55 P.M. on 05/22/25 to 7:21 A.M. on 05/23/25 and from 7:09 P.M. on 05/24/25 to 7:18 A.M. on 05/25/25. During an interview on 06/10/25 at 2:50 P.M., the Director of Nursing (DON) stated when she assessed Resident #176's skin on 05/23/25, the resident reported that on the previous night shift, the staff were rough when they repositioned them. The DON stated she treated this allegation more like a grievance rather than an abuse allegation because she thought it was more related to resident care. The DON stated when Resident #176 was at the hospital a few days later, their family member voiced concerns to the hospital case manager related to abuse and care received in the facility on 05/23/25. Per the DON, once the hospital staff notified the facility of the abuse allegation on 05/27/25, the facility reported the allegation of abuse to the State Survey Agency, suspended CNA #3 and RN #4 and began an investigation. During a follow-up interview on 06/13/25 at 10:09 A.M., the DON stated she expected staff to report any allegation of abuse immediately. The DON stated the facility should protect the resident following an allegation of abuse, and the facility should immediately suspend the alleged perpetrator pending investigation. The DON verified CNA #3 and RN #4 were not immediately suspended following the initial allegation on 05/23/25 but were suspended once the facility was notified by the hospital of the allegation on 05/27/25. The DON verified CNA #3 and RN #4 worked in the facility between 05/23/25 and 05/27/25 but did not work with Resident #176. 365946 Page 5 of 12 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/13/25 at 10:34 A.M., the Administrator stated she expected all staff to report any allegations of abuse or neglect. When Resident #176 reported to the DON that the night shift staff were rough with them, she followed up with the resident and addressed their concerns. The Administrator stated the resident used the key word rough but did not allege abuse the previous night, so they did not report the allegation. The Administrator stated that when the hospital notified her that Resident #176 alleged facility staff were physically rough with them, that was when they suspended CNA #3 and RN #4 and started the investigation. Review of the facility policy titled Abuse, Neglect and Exploitation, with a copyright date of 2025, under Protection of Resident, the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to responding immediately to protect the alleged victim and integrity of the investigation and make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. This deficiency represents non-compliance investigated under Complaint Numbers OH00166090 and OH00162351. 365946 Page 6 of 12 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to refer to the appropriate state-designated authority for a level II pre-admission screening and resident review (PASARR) when residents were diagnosed with a new mental illness diagnosis. This affected one (Resident #21) of five residents reviewed for PASARR. Findings included: Review of Resident #21's medical record revealed an admission date of 04/20/24 with a diagnosis of paranoid schizophrenia. Resident #21 received a diagnosis of anxiety disorder on 02/21/25. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 had severe cognitive impairment. Resident #21 had active diagnoses to include anxiety disorder and schizophrenia. Review of Resident #21's care plan revealed a focus area initiated 10/10/24, which indicated the resident was prescribed psychotropic medication, was at risk for adverse reactions, and had a diagnosis of paranoid schizophrenia. Interventions directed the staff to administer psychotropic medications as ordered by the physician and observe for side effective and effectiveness every shift. Resident #21's medial record revealed no evidence the resident was referred to the appropriate state-designated authority for a level II PASARR once the resident was diagnosed with a new mental illness diagnosis on 02/21/25. During an interview on 06/10/25 at 1:31 P.M., the Social Services Director (SSD) #105 stated she was responsible for the residents' PASSARRs in the facility. SSD #105 stated if a resident developed a new mental illness diagnosis after admission, she was responsible for submitting a new PASARR. During an interview on 06/13/25 at 10:19 A.M., the Director of Nursing (DON) stated all she knew about a PASARR was that it was needed upon a resident admission to the facility and related to a mental illness diagnosis. The DON stated the PASARR needed to be updated if a resident received a new mental illness diagnosis. During an interview on 06/13/25 tat 10:43 A.M., the Administrator stated social services should update a resident's PASARR when a resident had a new mental illness diagnosis. Review of the facility policy titled Resident Assessment-Coordination with PASARR Program dated 07/01/23 revealed any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 365946 Page 7 of 12 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #21's medical record revealed an admission date of 04/29/24 with a diagnosis of paranoid schizophrenia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had severe cognitive impairment and had an active diagnosis of schizophrenia. Residents Affected - Few Resident #21's Preadmission Screening and Resident Review Result Notice dated 05/03/24, indicated the resident had no indications of a serious mental illness and/or developmental disability. During an interview on 06/10/25 at 1:31 P.M., Social Services Director (SSD) #105 stated she was responsible for the residents' PASARRs in the facility, but she did not know who was responsible to ensure the accuracy of the PASARR. SSD #105 stated she assumed the PASARR should be accurate when the resident admitted to the facility from a hospital. SSD #105 stated she should have submitted a new PASARR for Resident #21 since it appeared the one that came from the hospital was inaccurate. During an interview on 06/13/25 at 10:19 A.M., the Director of Nursing (DON) stated all she knew about a PASARR was that it was needed upon a resident admission to the facility and related to a mental illness diagnosis. The DON stated if the facility needed the PASARR, social services and admissions should work closely together to ensure the PASARR was in place. During an interview on 06/13/25 at 10:43 A.M., the Administrator stated the social worker should review a resident's PASARR to make sure it was correct. The Administrator stated she expected a resident's PASARR to be 100% accurate. 3. Review of Resident #24's medical record revealed an admission date of 05/25/23. Diagnoses included generalized anxiety disorder, schizoaffective disorder, bipolar type, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had severe cognitive impairment and had active diagnoses including anxiety disorder, depression, bipolar disorder, and schizophrenia. Resident #24's Hospital Exemption from Preadmission Screening Notification dated 07/20/24, indicated the resident did not have a mental illness diagnosis. During an interview on 06/10/25 at 1:31 P.M., Social Services Director (SSD) #105 stated she was responsible for the residents' PASARRs in the facility, but she did not know who was responsible to ensure the accuracy of the PASARR. SSD #105 stated she assumed the PASARR should be accurate when the resident admitted to the facility from a hospital. During a follow-up interview on 06/10/25 at 1:40 P.M., SSD #95 stated Resident #24's PASARR was inaccurate and it should have been resubmitted to include the resident's new mental diagnosis. During an interview on 06/13/25 at 10:19 A.M., the Director of Nursing (DON) stated all she knew about a PASARR was that it was needed upon a resident admission to the facility and related to a mental illness diagnosis. The DON stated if the facility needed the PASARR, social services and admissions should work closely together to ensure the PASARR was in place. During an interview on 06/13/25 tat 10:43 A.M., the Administrator stated the social worker should review a resident's PASARR to make sure it was correct. The Administrator stated she expected a 365946 Page 8 of 12 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0645 resident's PASSAR to be 100% accurate. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Resident Assessment-Coordination with PASARR Program, dated 07/01/23, revealed all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Residents Affected - Few Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the pre-admission screening and resident review (PASARR) for the residents and failed to ensure the PASARR was completed on or before admission to the facility. This affected three (Residents #21, #24, and #38) of five residents reviewed for PASARR. Findings included: 1. Review of Resident #38's medical record revealed an admission date of 12/26/24. Diagnoses included dementia with other behavioral disturbance, psychosis, major depressive disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 had moderate cognitive impairment and active diagnoses which included anxiety disorder, depression, and psychotic disorder. Resident #38's Preadmission Screening and Resident Review Identification Screen dated 12/26/24, indicated the resident did not have a mental illness diagnosis. During an interview on 06/10/25 at 1:31 P.M., the Social Services Director (SSD) #105 stated she was responsible for the residents' PASARRs in the facility, but she did not know who was responsible to ensure the accuracy of the PASARR. SSD #105 stated she assumed the PASARR should be accurate when the resident admitted to the facility from a hospital. During a follow-up interview on 06/10/25 at 2:06 P.M., SSD #105 stated admissions was responsible for ensuring the PASARR was correct. SSD #105 agreed Resident #38's PASARR was not correct. During an interview on 06/10/25 at 2:00 P.M., Admissions/Marketing Director #110 stated social services was responsible for ensuring a resident's PASARR was correct. Admissions/Marketing Director #110 agreed Resident #38's PASARR was not correct. During an interview on 06/13/25 at 10:19 A.M., the Director of Nursing (DON) stated all she knew about a PASARR was that it was needed upon a resident admission to the facility and related to a mental illness diagnosis. The DON stated if the facility needed the PASARR, social services and admissions should work closely together to ensure the PASARR was in place. During an interview on 06/13/25 tat 10:43 A.M., the Administrator stated the social worker should review a resident's PASARR to make sure it was correct. The Administrator stated she expected a resident's PASARR to be 100% accurate. 365946 Page 9 of 12 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to ensure the medications were securely stored. This affected one of five medications carts. Findings included: During an observation on 06/12/25 at 6:08 A.M., the surveyor noted an unlocked medication cart parked in the doorway facing a resident's room. Licensed Practical Nurse (LPN) #10 was inside a different resident's room, and the unlocked medication cart was not within her line of sight. During an interview on 06/12/25 at 6:10 A.M., LPN #10 stated medication carts should be locked when not in the line of sight of the nurse, because someone could access the medications stored inside the cart. During an interview on 06/12/25 at 7:03 A.M., the Director of Nursing stated she expected medication carts to be locked when not within the line of sight of the nurse. During an interview on 06/13/25 at 11:19 A.M., the Administrator stated she expected medication carts to be locked any time they were not within the nurse's line of sight to prevent residents from being able to access medications stored inside the carts. 365946 Page 10 of 12 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

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** 2. During a concurrent interview and medication administration observation on 06/12/25 at 6:39 A.M., Licensed Practical Nurse (LPN) #10 removed a Prilosec (reduces the amount of acid produced in the stomach) and vitamin B-12 (vitamin) tablet from a bottle, placed them in her bare hand before she placed the tablets in a medication cup, and proceeded to administer the medications to Resident #72. LPN #10 verified she touched the two medications with her bare hands and stated she should never touch the medications with her hands, the medication should be dispensed directly into a medication cup to prevent cross contamination. Residents Affected - Few During an interview on 06/12/25 at 7:03 A.M., the Director of Nursing stated she expected when nurses dispensed medications, they should dispense the medications directly into medication cups without touching the medications. During an interview on 06/13/25 at 11:20 A.M., the Administrator stated she expected the nurses to follow their policy during medication administration to ensure medications were not handled prior to administering them to the residents to prevent the possibility of cross contamination. Review of the facility policy titled Medication Administration, with a copyright date of 2025, revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy included to remove medication from source, taking care not to touch medication with bare hand. Based on observation, interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to ensure staff performed hand hygiene during the provision of wound care for a resident and failed to ensure staff did not touch medications with their bare hands during medication administration. This affected one (Resident #36) of three residents reviewed for pressure ulcers and one (Resident #72) of six residents observed for medication administration. Findings included: 1. Medical record review revealed Resident #36 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #36 had intact cognition. Resident #36 had two stage IV pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) that were present on admission/reentry. During a concurrent interview and wound care observation on 06/11/25 at 10:42 A.M., Assistant Director of Nursing (ADON) #150 performed wound care treatment on Resident #36's sacral wound. ADON #150 was assisted by Licensed Practical Nurse (LPN) #2. ADON #150 cleansed the resident's wound, performed the treatment, and dressed the resident's wound without ever changing his gloves. While still wearing the same gloves, ADON #150 wore when he cleansed the resident's round, ADON #150 touched the resident's bed sheets, bed rails, over-the-bed table, eye glasses, cellular phone and pillow. ADON #150 was noted to remove his personal protective equipment, a gown and gloves, then he brought the contaminated items used during wound care up to his chest and pressed them up against his shirt and proceeded to walk through the resident's room with these items in contact with his person. When asked 365946 Page 11 of 12 365946 06/14/2025 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few about the break in infection control, ADON #150 replied, What, what was the problem. My gloves are clean. When asked about holding the soiled supplied to his chest, ADON #150 shook his head and had no response. During an interview on 06/13/25 at 10:00 A.M., the Director of Nursing stated she could not believe ADON #150 had such trouble with wound care and commented ADON #150 must have been nervous. During an interview on 06/13/25 at 11:00 A.M., the Administrator stated that was not ADON #150's usual standard, he ADON knew the correct procedure. Review of the facility policy titled Clean Dressing Change, dated 07/01/23, revealed it is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Wash hands and put on clean gloves. Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound. Measure wound using disposable measuring guide. Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. Secure dressing. Discard disposable items and gloves into appropriate trash receptacle and wash hands. Review of CDC guidance titled Clinical Safety: Hand Hygiene for Healthcare Workers found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html and dated 02/27/24 revealed hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of deadly germs to patients. Recommendations included on know when to wear (and change) gloves stated gloves are not a substitute for hand hygiene. If your tasks requires gloves, perform hand hygiene before donning gloves and touching the patient or the patients surroundings; always clean your hands after removing gloves. When to change gloves and clean hands included if gloves become soiled with blood or body fluids after a task, if moving from work on a soiled body site to a clean body site on the same patient or if clinical indication for hand hygiene occurs, and before exiting a patient room. 365946 Page 12 of 12