Health inspection·December 11, 2025

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 observation, interviews, record review and facility policy, the facility failed to ensure neutropenic guidelines and isolation were maintained for Resident #36 and the provider order was followed by staff to prevent the development and transmission of communicable diseases and infections to the immunocompromised resident. This affected one resident out of five reviewed for infection control. The census was 85.Review of the medical record for Resident #36 revealed an admission date of 10/27/25 with a diagnoses of Cauda Equina Syndrome (spinal cord injury of lower back), myeloblastic leukemia (a blood cancer), epileptic syndrome, diastolic heart failure, adult failure to thrive, depression, venous thrombosis and embolism (blood clots), and depression.Review of the physician's orders dated 10/27/25 revealed Resident #36 was ordered to have neutropenic transmission-based precautions due to being an immunocompromised resident with myeloblastic leukemia. Immunocompromised residents are at increased risk for numerous types of infections while receiving healthcare, specifically, fungal and bacterial infections. This included: signage outside of the room, wear N95 mask, shield, gloves and gown when entering the room. Removal of personal protective equipment (PPE) prior to leaving room and hand hygiene before and after entering room. Sanitize shared equipment between uses.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated Resident #36 was cognitively intact. The functional assessment revealed Resident #36 required maximum assistance with showering and personal hygiene and was dependent on staff for toileting and mobility using a manual wheelchair. Resident #36 was also incontinent of bowel and bladder.Observation on 12/08/25 10:36 A.M. of Resident #36 sitting comfortably in a chair in her room. PPE was hanging on the outside of the door for staff and included an ample supply of surgical masks, gowns, gloves, and hand sanitizer. No N95 masks were available for staff.Observation on 12/08/2025 1:10 P.M. revealed Resident #36 was outside of the room in the common area not wearing any mask and in close contact with other residents and staff.Observation on 12/08/25 at 2:11 P.M. of Licensed Practical Nurse (LPN) #413 entering Resident #36's room wearing a surgical mask only.Interview with LPN #413 on 12/08/25 at 2:20 P.M. revealed Resident #36 does not wear a mask outside of her room. LPN #413 also stated that staff do wear surgical masks when entering Resident #36's room but do not don all the PPE unless providing care to resident. LPN #413 also verified the provider order indicated anyone entering resident's room would wear an N95 mask, gown and gloves and perform hand hygiene upon entering and exiting the room, and the resident would wear a mask outside of her room.Interview with the Director of Nursing (DON) on 12/08/25 at 2:30 P.M. verified Resident #36's order and stated they have not been using N95 masks per the order. The DON also stated the provider should have been contacted after placing the order in October 2025 to change to surgical masks and not N95 masks.Interview with Resident #36 on 12/09/25 at 2:45 P.M. revealed she only wears a mask when in physical therapy and does not wear a mask in any other area of facility including common areas such as dining room and activities room.Review Residents Affected - Few Page 1 of 2 365947 365947 12/11/2025 Ohman Family Living at Holly 10190 Fairmount Rd Newbury, OH 44065

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Resident #36's labs dated 12/08/25 revealed a [NAME] Sedimentation Rate of 46 millimeters per hours (mm/hr.) (reference range 0-20 mm/hr.) which indicates chronic inflammation due to active leukemia.Review of the facility policy titled, Isolation: Transmission -Based Precautions, dated 01/04/25, revealed Reverse Isolation (Neutropenic) is for compromised residents and should include signage on door, protecting resident from everyone else; and in addition to standard precaution to wear a gown when coming into contact with resident; wear a mask when coming within six feet of resident; and place a mask on resident when outside of their room.Review of the Center for Disease Control (CDC) Guidelines for Infectious Disease, dated 2007, revealed for neutropenic precautions, healthcare staff typically wear gloves, gowns, and masks (surgical or N95), along with meticulous hand hygiene, to protect immunocompromised patients from germs by creating a barrier against blood, body fluids, and respiratory secretions, especially when entering the patient's room for direct care. Patients themselves often wear masks in public to protect their weakened immune systems from others' germs. 365947 Page 2 of 2