Health inspection·June 2, 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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Some Based on medical record review, observation, staff interview, review of camera footage, review of facility investigation, and review of facility in-services, the facility failed to ensure staff practiced proper infection control practices. This affected one (#01) of three residents reviewed for infection control. This had the potential to affect six additional residents (#04, #08, #11, #21, #29, and #39) identified as being in Enhanced Barrier Precautions (EBP). The facility census was 40. Findings include: Review of the medical record of Resident #01 revealed an admission date of 12/07/23. Diagnoses include quadriplegia and a history of pressure ulcers to buttocks. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #01 was cognitively intact and dependent on staff for personal hygiene and transfers. Resident #01 was assessed as having an indwelling urinary catheter and incontinence of stool. Review of the physician order dated 06/19/24 revealed Resident #01 was ordered EBP related to wounds. Observation of Resident #01's room revealed a sign for EBP and indicating a gown and gloves were to the donned prior to contact with the resident. Review of five videos date coded as 04/13/25, 04/15/25, 04/17/25, 04/18/25, and 04/21/25 revealed numerous staff members providing direct care to Resident #01. The videos were reviewed on 05/21/25 at 1:00 P.M., along with the Administrator and Director of Nursing (DON) to identify the staff and verify the deficient practice. The video dated 04/13/25, revealed Wound Nurse (WN) #120 and Licensed Practical Nurse (LPN) #121 providing wound care to Resident #01. Both wore gloves but neither had donned a protective gown. The video dated 04/15/25, revealed WN #120 and DON providing direct care without having donned protective gowns. The video dated 04/17/25, revealed Registered Nurse (RN) #122 and Certified Nursing Assistant (CNA) #123 providing direct care to Resident #01 without donning a protective gown. The video dated 04/18/25, revealed RN #100 providing direct care to Resident #01 without donning a protective gown. The video dated 04/21/25, revealed CNAs #105 and #124 providing direct care to Resident #01 without having donned protective gowns. The DON and Administrator verified the findings in the videos. Review of the policy titled, Transmission Based Precautions, dated 05/01/22, revealed Enhanced Page 1 of 2 366033 366033 06/02/2025 Momentous Health at Sidney 510 Buckeye Ave Sidney, OH 45365

F 0880 Barrier Precautions indicated the use of gown and gloves when providing high contact care to residents. Examples of high contact care activities included providing hygiene, changing linens, and wound care. Level of Harm - Minimal harm or potential for actual harm As a result of the incident, the facility took the following actions to correct the deficient practice by 05/13/25: Residents Affected - Some • On 04/17/25, the Quality Improvement Plan started when the DON identified the lack of proper procedure for EBP. • On 04/18/25, the action plan was initiated by instructing all staff to read and sign the EBP policy. By the DON via staff meeting and paper postings. • On 04/30/25, all staff were also instructed to sign and read the policies for contact and droplet precautions. By the DON via staff meeting and paper postings. • On 05/13/25, an all-staff in-service was held and again the EBP procedure was provided to staff. DON and ADON spoke at the all staff and circulated the hand outs with the sign off sheet. • Review of the sign sheets for the training on 04/17/25, 04/18/25, 04/30/25, and 05/13/25, revealed all staff attended the all-staff in-service or indicated they had read the policy. • Random observations on 05/21/25 from 9:00 A.M. to 3:00 P.M., revealed staff to don protective gowns and gloves prior to entering any of the six rooms identified as requiring EBP. • Review of auditing/monitoring dated 04/18/25, 04/21/25, 04/28/25, 04/29/25, 05/05/25, 05/08/25, 05/13/25, and 05/20/25 revealed staff were following the EBP procedure. This deficiency represents the noncompliance discovered during the investigation of Complaint Number OH00165605. 366033 Page 2 of 2