Health inspection·October 5, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interviews, the facility failed to honor a resident's request to have a positioning side rail on her bed, to promote the resident's ability to assist with bed mobility. This affected one (#87) of 23 sampled residents for accommodation of needs. The facility census was 96. Residents Affected - Few Findings include: Review of Resident #87's medical record revealed an admission date of 05/20/22, with medical diagnoses including: breast cancer with bone metastasis, muscle weakness, anxiety, and pain. Review of the most recent quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #87 is cognitively intact and required extensive assistance with bed mobility. Review of Resident #87's written plan of care for activities of daily living (ADL's) identified under the section of bed mobility encourage me and assist with repositioning in bed. The plan identified I use rails to reposition and turn in bed. Further review of the medical record revealed no evidence of an assessment of bed rails of any type or documentation of the rails being discussed with the resident. Observation on 10/02/23 at 11:10 A.M., revealed Resident #87 attempted to grab the grab bar and was unable to as her hands have some deformities. The resident was unable to grasp the small area on the bar. Interview with Resident #87, at the time of the observation, stated a few months ago the facility removed her half side rails and replaced them with a grab bar. Resident #87 stated she is not able to grab the bar and assist with her turning. Resident #87 stated she told the facility multiple times before they removed the half rails, she did not want them taken off. Resident #87 stated the Administrator at that time, made the staff removed everyone's side rails. Interview on 10/03/23 at 1:13 P.M., with Maintenance Supervisor (MS) #881 revealed the previous Administrator made the staff remove all resident's half side rails. MS #881 stated the previous Administrator identified all half side rails were restraints. MS #881 stated the facility removed all the M rails (half side rails) and replaced them with U bars (grab bars). MS #881 stated Resident #87 did not want hers removed and MS #881 waited as long as she could to remove Resident #87's. MS #881 stated she was following directions from the previous Administrator, and MS #881was concerned Resident #87 did not want the old bars removed. Page 1 of 12 365976 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

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 record review and staff interview, the facility failed to submit a new Pre-admission Screening and Resident Review (PASARR) when a resident received a new diagnosis of bipolar disorder. This affected one (#71) of two residents reviewed for PASARR. The facility census was 96. Findings include: Review of PASARR results dated 08/02/23, revealed Resident #71 had no indications of serious mental illness. Record review revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease, major depressive disorder, and dementia. Review of physician notes dated 08/10/23 revealed Resident #71 had a family history of schizoaffective disorder. Further review of the medical record revealed a new diagnosis of bipolar disorder was added for Resident #71 on 08/14/21. Review of the electronic and paper medical records revealed no evidence a new PASARR was completed when Resident #71 had a new diagnosis of bipolar disorder. Interview on 10/04/23 at 11:57 A.M., with Social Services Director #821 verified Resident #71 should have had a new PASARR completed upon receiving a new mental health diagnosis and did not. 365976 Page 2 of 12 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, policy review, resident and staff interviews, the facility failed to ensure a daily dressing was completed for a diabetic ulcer. This affected one (#95) of two residents reviewed for skin ulcers. The facility census 96. Residents Affected - Few Findings include: Review of Resident #95's medical record revealed an admission date of 06/23/22, with medical diagnoses including: Diabetes Mellitus (DM) with foot ulcers, severe peripheral vascular disease (PVD) and hypertension. Review of the most recent [NAME] Data Set (MDS) assessment dated [DATE], identified Resident #95 was cognitively intact and able to make his needs known. The assessment revealed Resident #95 is identified with one diabetic ulcer to the outer right foot. Review of physician orders dated 09/01/23 revealed an order for the right outer foot wound to clean ulcer with Vashe (wound solution), apply Santyl and a dry dressing daily on day shift. Interview on 10/02/23 at 9:49 A.M., with Resident #95 stated the staff did not change his foot bandages over the weekend. Observations at the time of the interview revealed Resident #95 pulled up the blankets and the dressings on both feet were noted with dates of 09/29/23 with initials of AV written on the tape securing the dressings. Observation and interview on 10/02/23 at 10:10 A.M., with Licensed Practical Nurse (LPN) #704 verified the Resident #95's dressings to both feet were dated 09/29/23. LPN #704 confirmed Resident #95's dressing orders included daily dressing changes to both feet. LPN #704 verified there were two different nurses who worked on 09/30/23 and 10/01/23, during the day shift, that should have completed dressing changes for Resident #95's feet and did not. LPN #104 stated on 10/01/23, Agency LPN #728 signed off the Treatment Administration record (TAR), that she had completed the treatment; however, this was not completed on 10/01/23 as signed off. LPN #704 proceeded to change the dressing. Review of Resident #95's most recent wound measurements dated 09/27/23 identified the left heel, identified as a stage 4 wound, measured 1.8-centimeter (cm) by (X) 0.9 cm X 0.2 cm. Interview on 10/04/23 at 11:39 A.M., with Registered Nurse (RN) #990 verified Resident #95 has a stage 4 pressure sore to the left heel and a diabetic ulcer to the right lateral foot. Review of the policy titled, Wound Treatment dated October 2010, identified wound treatments will be provided in accordance with the physician orders, including the cleaning method, type of dressing and frequency of dressing change. 365976 Page 3 of 12 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, policy review, resident and staff interviews, the facility failed to ensure a daily dressing was completed for a pressure ulcer. This affected one (#95) of four residents reviewed for pressure ulcers. The facility census 96. Residents Affected - Few Findings include: Review of Resident #95's medical record revealed an admission date of 06/23/22, with medical diagnoses including: Diabetes Mellitus (DM) with foot ulcers, severe peripheral vascular disease (PVD) and hypertension. Review of the most recent [NAME] Data Set (MDS) assessment dated [DATE], identified Resident #95 was cognitively intact and able to make his needs known. The assessment revealed Resident #95 is identified with one stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) wound to the left heel. Review of physician orders dated 09/01/23 revealed an order for the left heel pressure ulcer wound to clean ulcer with Vashe (wound solution), apply Santyl and a dry dressing daily on day shift. Interview on 10/02/23 at 9:49 A.M., with Resident #95 stated the staff did not change his foot bandages over the weekend. Observations at the time of the interview revealed Resident #95 pulled up the blankets and the dressings on both feet were noted with dates of 09/29/23 with initials of AV written on the tape securing the dressings. Observation and interview on 10/02/23 at 10:10 A.M., with Licensed Practical Nurse (LPN) #704 verified the Resident #95's dressings to both feet were dated 09/29/23. LPN #704 confirmed Resident #95's dressing orders included daily dressing changes to both feet. LPN #704 verified there were two different nurses who worked on 09/30/23 and 10/01/23, during the day shift, that should have completed dressing changes for Resident #95's feet and did not. LPN #104 stated on 10/01/23, Agency LPN #728 signed off the Treatment Administration record (TAR), that she had completed the treatment; however, this was not completed on 10/01/23 as signed off. LPN #704 proceeded to change the dressing. Review of Resident #95's most recent wound measurements dated 09/27/23 identified the left heel, identified as a stage 4 wound, measured 1.8-centimeter (cm) by (X) 0.9 cm X 0.2 cm. Interview on 10/04/23 at 11:39 A.M., with Registered Nurse (RN) #990 verified Resident #95 has a stage 4 pressure sore to the left heel and a diabetic ulcer to the right lateral foot. Review of the policy titled, Wound Treatment dated October 2010, identified wound treatments will be provided in accordance with the physician orders, including the cleaning method, type of dressing and frequency of dressing change. 365976 Page 4 of 12 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of policy, the facility failed to ensure a suprapubic catheter was positioned to allow urine to freely flow. This affected one (#77) of three residents reviewed for catheters. The facility census was 96. Findings include: Review of the medical record revealed Resident #77 was admitted to the facility on [DATE]. Diagnoses included heart failure, hyperlipidemia, mixed receptive-expressive language disorder, gastro-esophageal reflux disease, bladder-neck obstruction, urethral diverticulum, contracture of left hand, and hemiplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/08/23, revealed the resident was severely cognitively impaired. The resident required extensive assistance of two staff for bed mobility, dressing, and personal hygiene. The resident had an indwelling catheter. Review of Resident #77's current plan of care, dated 03/06/23, revealed the resident was at risk for infection due to suprapubic catheter and g-tube placement, with a goal of remaining free of signs and symptoms of infections. Interventions included enhanced barrier precautions and managing indwelling catheters to minimize risk of infection. Review of Resident #77's current plan of care, revised 05/15/23, revealed the resident had a suprapubic catheter placed with a goal of remaining free from catheter-related trauma. Interventions included checking tubing for kinks as needed; keeping the bag lower than bladder; positioning catheter bag and tubing below the level of the bladder. Review of current physician orders for October 2023, identified orders for a urinary catheter nursing measure to change collection bag with sediment or as needed, and change suprapubic catheter and drainage bag monthly and as needed. Observation on 10/04/23 at approximately 10:32 A.M., revealed Resident #77 was in his room and sitting up in his wheelchair with a mechanical lift sling underneath him. Resident #77's catheter tubing was going down through his right pant leg, came out of the bottom of his pant leg, and was looped upward. Resident #77 was sitting on top of the urinary catheter drainage bag and part of the urinary catheter tubing. Interview at the time of observation, with Licensed Practical Nurse (LPN) #839, verified Resident #77's catheter tubing was looped upward and Resident #77 was sitting on his urinary catheter drainage bag and part of his tubing. LPN #839 verified urine was unable to flow through the tubing and into the drainage bag. Review of the CDC guidance for Catheter-Associated Urinary Tract Infections (CAUTI), revised February 2017, revealed proper techniques for urinary catheter maintenance included maintaining unobstructed urine flow, keeping the catheter, and collecting tube free from kinking, and using standard precautions including the use of gloves and gown as appropriate during any manipulation of the catheter 365976 Page 5 of 12 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0690 or collecting system. Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Catheter Care, revised 05/10/23, revealed the policy was to ensure that residents with indwelling catheters received appropriate catheter care. Residents Affected - Few 365976 Page 6 of 12 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, the facility failed to ensure residents received medications as ordered. This affected three (#31, #48, and #87) of 21 residents on the Cederview hallway. The facility census was 96. Findings include: 1. Review of Resident #31's medical record revealed an admission date of 12/10/17, with medical diagnoses including: chronic kidney disease (CKD), major depression, anemia, delusional disorder, paranoid schizophrenia, chronic pain, and obsessive-compulsive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] identified the resident was cognitively intact. Review of Resident #31's Medication Administration records (MAR) dated 10/02/23, for medications scheduled upon rising, included Cymbalta 60 milligram (mg), Gabapentin 400 mg and Oxcarbazepine 600 mg, contained no evidence of initials listed to indicate Resident #31's medications were administered. Interview on 10/02/23 at 8:11 A.M., with Resident #31 stated she did not receive any of her early morning medications. Resident #31 stated the nurse just did not come in and give me any medications. Resident #31 stated she reported this to a nursing assistant; however, the nurse never did come in. Interview on 10/02/23 at 8:15 A.M., with State Tested Nursing Assistant (STNA) #888 verified there were three residents (#31, #48, and #87) complaining of not receiving their medications this morning from the night shift nurse. STNA #888 stated she has not had a chance to report this information to her supervisor at this time. STNA #888 stated the night shift nurse, Licensed Practical Nurse (LPN) #728, was from a staffing agency and the day shift nurse today, LPN #713, is also from a staffing agency. Interview on 10/02/23 at 10:28 A.M., with LPN #713 stated she relieved LPN #728 this morning and received verbal report from her. LPN #713 stated LPN #728 seemed in a hurry during the report and did not let me know any residents did not receive medications. LPN #713 stated she was not aware three residents have stated they did not receive medications this morning. LPN #713 verified the MARS do not indicate the residents received their medications. 2. Review of Resident #48's medical record revealed an admission date of 09/18/18, with medical diagnoses including: trigeminal neuralgia, insomnia, cardiomegaly, weakness, and morbid obesity. Interview on 10/02/23 at 10:31 A.M., with Resident #48 stated she never received her morning medications this morning. Resident #48 stated she has trigeminal neuralgia and if she does not receive her medications on time, it can cause pain. Resident #48 stated thank goodness I am not in pain at this time. Review of Resident #48's MAR for 10/02/23, for upon rising, revealed nine medications including: levothroxine 50 micrograms (mcg), linzess 290 mg, Protonix 40 mg, Cymbalta 30 mg, Tylenol 650 mg, Gabapentin 800 mg, Lactaid, Midodrin 5 mg and Xanax 0.25 mg, contained no evidence of initials listed to indicate Resident #48's medications were administered. 365976 Page 7 of 12 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of Resident #87's medical record revealed an admission date of 05/20/22, with medical diagnoses including: breast cancer with bone metastasis, muscle weakness, Diabetes, anxiety, constipation, and high blood pressure. Review of Resident #87's MDS revealed the resident was cognitively intact. Interview on 10/02/23 at 11:10 A.M., with Resident #87 stated she did not receive her morning medications this morning from the agency nurse. Resident #87 stated she also did not have her blood sugar checked. Resident #87 stated she has muscle spasms and chronic pain and those are the medications that were not given this morning. Resident #87 stated this does not occur often, however, the staff told the nurse night nurse, and she did nothing. Review of Resident #87's MAR revealed Baclofen 10 mg and Percocet 5/325 mg medications were not initialed as being administered. The MAR listed a blood sugar level was listed. Interview on 10/02/23 at 3:50 P.M., with the Director of Nursing (DON) and Administrator stated the facility has started an investigation this morning (10/02/23) into allegations from three residents regarding not receiving their morning medications. The interview confirmed LPN #728 worked the overnight shift from 10/01/23 through 10/02/23, and this was her first shift in the facility. DON stated the facility interviewed LPN #728 as part of their investigation, and LPN #728 confirmed she does not remember giving Resident #31 or Resident #87 their medications. LPN #728 told the DON, that she reported to LPN #713 (day shift nurse) of not administering medications to those residents. The DON stated LPN #713 denied being told anyone did not receive their medications. The DON stated the facility is not going to have LPN #728 return to work at the facility. 365976 Page 8 of 12 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

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** 3. Review of Resident #87's medical record revealed an admission date of 05/20/22, with medical diagnoses including: breast cancer with bone metastasis, muscle weakness, anxiety, and pain. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #87 is cognitively intact and had a long standing indwelling urinary Catheter. Residents Affected - Some Review of Resident #87's physician orders for October 2023 revealed an order for Enhanced Barrier Precautions (EBP). Observation on 10/03/23 at 1:11 P.M., of Resident #87 receiving catheter care from State Tested Nursing Assistants (STNA) #811 and #859 revealed the staff had gloves on and was not utilizing gowns. Observations of the room revealed there was no signage to indicate the resident required EBP. Interview on 10/03/23 at 1:11 P.M., with STNA #811 and #859 verified the staff was not aware Resident #87 should be on Enhanced Barrier Precautions (EBP), which should including wearing a gown when providing care of her urinary catheter. STNA #811 and #859 verifed there was not a sign on the door to alert staff of the need to provide Resident #87 with precautions. Observation and interview on 10/03/23 at 1:23 P.M., with Registered Nurse (RN)/Unit Manager #831, verified Resident #87's room had no signage on the door to alert staff of the need for her to be on EBP. RN #831 verified Resident #87's physician orders included the barrier precautions. RN #831 stated all residents whom have a urinary catheter, wound and tube feeding should be in the EBP. 4. Review of Resident #95's medical record revealed an admission date of 06/23/22, with medical diagnoses including: Diabetes Mellitus (DM) with foot ulcers, Severe Peripheral Vascular Disease (PVD) and High blood pressure. The most recent assessment (MDS) dated [DATE] identified Resident #95, BIM score is 14, which identifies he is completely cognitively intact and able to make his needs known. The assessment revealed Resident #95 is identified with one stage 4 wound to the left heel. Review of physician orders dated 09/01/23 identified the left heel pressure ulcer wound; clean ulcer with Vashe, apply Santyl and a dry dressing daily on day shift. Observation of Licensed Practicing Nurse (LPN #704) changing Resident #95's wound dressings was completed on 10/02/23 at 10:10 A.M. LPN #704 was observed with gloves on, however no gown. LPN #704 confirmed Resident #95 should be on EBP, which includes the need for her to wear a gown when changing his dressings to the wounds on his feet. The observation confirmed there was a sign posted on the outside of Resident #95's room, which is a private room. The sign identified enhanced barrier precautions; Provider and staff must also wear gloved and gown for the following high contact resident care activities; dressing, bathing/showering, changing linens, providing hygiene; changing briefs' or assisting with toileting. Device care or use central line, urinary catheter, feeding tube, tracheostomy; wound care; anu skin opening requiring a dressing Review of the facilities Enhanced Barrier Precautions (EBP), Policy dated 10/24/22 was completed. It is the Policy of this facility to implement enhanced barrier precautions for the preventions of transmission of multi-resistant organisms. Enhanced barrier precautions refer to the use of gown, gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition. 365976 Page 9 of 12 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Based on observation, resident interview, staff interview, record review, review of the policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when performing high-risk resident care activities for residents on Enhanced Barrier Precautions (EBP). In addition, the facility failed to implement EBP per physician order for Resident #87. This affected four (#37, #77, #87, and #95) of 25 residents identified on EBP. Findings included: 1. Record review revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included cardiomyopathy, respiratory disorders, lack of coordination, asthma, hyperlipidemia, retention of urine, and hypothyroidism. Review of Resident #37's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/10/23, revealed the resident was cognitively intact. The resident required extensive assistance of two staff for bed mobility, dressing, and toileting. The resident required extensive assistance of one staff member for personal hygiene and had an indwelling catheter. Review of Resident #37's current physician orders for October 2023, identified an order for urinary catheter care every shift. Further review of Resident #37's physician orders identified an order for enhanced barrier precautions in place outside of room for staff and resident protection. The order was dated 01/29/23 through 10/04/23. The order was discontinued during the survey on 10/04/23 and a new order dated 10/04/23 was implemented for enhanced barrier precautions as indicated every shift for isolation precautions. Observation on 10/02/23 at 10:35 A.M., revealed signage was posted on the exterior doorframe of Resident #37's room which identified the resident was on EBP. The signage stated everyone must clean their hands, including before entering and when leaving the room, and providers and staff must also wear gloves and a gown for high-contact resident care activities including but not limited to dressing, changing linens, wound care including any skin opening requiring a dressing, and device care or use including urinary catheters, feeding tubes, central lines, and tracheostomies. Resident #37 was sitting in the doorway leading to her room and asked State Tested Nurse Aide (STNA) #854 to fix her sweater and also stated she dropped some blankets. STNA #854 assisted Resident #37 in adjusting her sweater and then went into the resident's room, picked up and folder blankets which had been lying on the floor, and made the resident's bed. STNA #854 was not wearing a gown or gloves during any of these activities. Interview on 10/02/23 at 10:58 A.M., with STNA #886 revealed Resident #37 did not have any active infections and staff never wore a gown when going into the room or providing care to the resident. STNA #886 reported staff did not wear gowns for any of the residents on EBP and that Resident #37 should not have signage posted since she did not have an infection. Interview on 10/02/23 at 11:24 A.M., with STNA #854 verified STNA #854 had assisted Resident #37 with her sweater, blankets, and bed linens without gloves or a gown. STNA #854 verified staff were supposed to wear gloves and a gown anytime they touched a resident or assisted with changing/adjusting bed linens. Review of the facility policy titled Enhanced Barrier Precautions, dated 10/24/22, revealed the facility's policy was to implement enhanced barrier precautions for the prevention of transmission of 365976 Page 10 of 12 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Multidrug-Resistant Organisms (MDRO). The policy stated enhanced barrier precautions referred to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition. The policy also stated clear signage would be posted on the door or wall outside of the resident room indicating type of precautions, required personal protective equipment, and the high-contact resident care activities that require the use of gown and gloves. The policy further stated high-contact resident care activities included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use including central lines, urinary catheters, feeding tubes, and tracheostomy/ventilator tubes. Review of the CDC guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), reviewed 08/01/23, revealed EBP expanded the use of PPE and referred to the use of gown and gloves during high contact resident care activities that provided opportunities for transfer of MDROs to staff hands and clothing. Nursing home residents with wounds and indwelling medical devices were at especially high risk of both acquisition of and colonization with MDROs. Examples of high-contact resident care activities requiring gown and glove use for EBP included dressing, providing hygiene, changing linens, wound care, and device care. 2. Review of the medical record revealed resident #77 was admitted to the facility on [DATE]. Diagnoses included heart failure, hyperlipidemia, mixed receptive-expressive language disorder, gastro-esophageal reflux disease, bladder-neck obstruction, urethral diverticulum, contracture of left hand, and hemiplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/08/23, revealed the resident was with severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, dressing, and personal hygiene. The resident had an indwelling catheter. Review of current physician orders for October 2023, identified orders for urinary catheter nursing measure, change collection bag with sediment or as needed, and change suprapubic catheter and drainage bag monthly and as needed, and enhanced barrier precautions. Review of Resident #77's current plan of care, dated 03/06/23, revealed the resident was at risk for infection due to suprapubic catheter and g-tube placement, with a goal of remaining free of signs and symptoms of infections. Interventions included enhanced barrier precautions and managing indwelling catheters to minimize risk of infection. Observation on 10/02/23 at 10:55 A.M., revealed signage was posted on the exterior doorframe of Resident #37's room which identified the resident was on EBP. The signage stated everyone must clean their hands, including before entering and when leaving the room, and providers and staff must also wear gloves and a gown for high-contact resident care activities including but not limited to dressing, changing linens, wound care including any skin opening requiring a dressing, and device care or use including urinary catheters, feeding tubes, central lines, and tracheostomies. Interview on 10/02/23 at 10:58 A.M., with STNA #886 revealed Resident #77 did not have any active infections and staff never wore a gown when going into the room or providing care to the resident. STNA #886 reported staff did not wear gowns for any of the residents on EBP and that Resident #77 should not have signage posted since he did not have an infection. 365976 Page 11 of 12 365976 10/05/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 10/04/23 at approximately 10:32 A.M., revealed Resident #77 was in his room and sitting up in his wheelchair with a mechanical lift sling underneath him. The resident's catheter tubing was going down through his right pantleg, came out of the bottom of his pantleg, and was looped upward. The resident was sitting on top of the urinary catheter drainage bag and part of the urinary catheter tubing. Interview at the time of observation, with Licensed Practical Nurse (LPN) #839, verified the resident's catheter tubing was looped upward and the resident was sitting on his urinary catheter drainage bag and part of his tubing. LPN #839 verified urine was unable to flow through the tubing and into the drainage bag. LPN #839 washed her hands upon entering the room, donned gloves, and rearranged the suprapubic catheter tubing and drainage bag. LPN #839 was not wearing a gown during this time. LPN #839 doffed their gloves. LPN #839 was asked about the suprapubic catheter and proceeded to move the catheter drainage bag with their bare hands. LPN #839 verified she did not don proper PPE prior to moving and touching Resident #839's suprapubic catheter tubing and drainage bag. Review of the CDC guidance for Catheter-Associated Urinary Tract Infections (CAUTI), revised February 2017, revealed proper techniques for urinary catheter maintenance included maintaining unobstructed urine flow, keeping the catheter, and collecting tube free from kinking, and using standard precautions including the use of gloves and gown as appropriate during any manipulation of the catheter or collecting system. Review of the facility policy titled Enhanced Barrier Precautions, dated 10/24/22, revealed the facility's policy was to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). The policy stated enhanced barrier precautions referred to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition. The policy also stated clear signage would be posted on the door or wall outside of the resident room indicating type of precautions, required personal protective equipment, and the high-contact resident care activities that require the use of gown and gloves. The policy further stated high-contact resident care activities included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use including central lines, urinary catheters, feeding tubes, and tracheostomy/ventilator tubes. Review of the CDC guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), reviewed 08/01/23, revealed EBP expanded the use of PPE and referred to the use of gown and gloves during high contact resident care activities that provided opportunities for transfer of MDROs to staff hands and clothing. Nursing home residents with wounds and indwelling medical devices were at especially high risk of both acquisition of and colonization with MDROs. Examples of high-contact resident care activities requiring gown and glove use for EBP included dressing, providing hygiene, changing linens, wound care, and device care. 365976 Page 12 of 12