Health inspection·October 10, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medical record review observation, staff interview, and review of the facility policy, the facility failed to ensure proper hand hygiene and enhanced barrier precautions were followed during incontinence care. This affected one (Resident #28) of three residents reviewed for incontinence care. The facility census was 93 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 09/13/24 with diagnoses including chronic bronchitis, depression, and traumatic ischemia of muscle. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 09/19/24 revealed the resident had intact cognition and required setup assistance with eating, was dependent with toileting and bathing, had a urinary catheter and was always incontinent of bowel. Review of the care plan for Resident #28 dated 09/13/24 revealed the resident had an indwelling catheter related to obstructive uropathy. Interventions included the following: perform catheter care every shift and as needed, empty catheter bag every shift and as needed, maintain enhanced barrier precautions (EBP) due to indwelling catheter, staff to check catheter tubing for kinks. Observation on 10/09/24 at 11:33 A.M. of incontinence care for Resident #28 per State Tested Nurse Aide (STNA) #10 revealed the resident was in EBP related to the urinary catheter. STNA #10 did not don a gown before or during care. STNA #10 performed hand hygiene and applied gloves. Resident #28 had a large bowel movement which STNA #10 cleaned with gloved hands. STNA #10 then applied clean linens and a dry incontinence brief and adjust the resident's bed wearing the same soiled gloves. Interview on 10/09/24 at 11:55 A.M. with STNA #10 confirmed Resident #28 was in EBP due to having an indwelling urinary catheter but he did not don a gown before or during care. Further interview with STNA #10 confirmed he cleaned bowel movement from Resident #28 with his gloved hands and then applied clean linens to the bed and a dry incontinence brief to the resident and adjust the resident's bed wearing the same soiled gloves. Review of the facility policy titled Hand Hygiene dated August 2024 revealed all team members of the facility would follow hand hygiene guidelines to reduce the incidence of health care associated infections. Staff should wear gloves when contact with blood or other potentially infectious materials (body fluids, secretions, and excretions) was likely. Staff should change gloves during patient care if moving from a contaminated body site to a clean body site. Staff should remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366000 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)