Health inspection·June 30, 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, interview, record review, and facility policy review, the facility failed to maintain infection control procedures while administering medications. This affected two residents (#26 and #53) of four residents observed for medication administration. Residents Affected - Few Findings include: 1. Review of Resident #53's medical records revealed an admission date of 07/17/24 with diagnosis of cerebral infarction and chronic pain syndrome. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had intact cognition. Observation on 06/25/25 at 9:39 A.M. of Licensed Practical Nurse (LPN) #286 revealed she did not perform hand hygiene before preparing nine medications for Resident #53. LPN #286 placed all medications in the medicine cup and at 9:44 A.M. applied gloves without performing hand hygiene. LPN #286 then entered the resident room and removed the Lidocaine patch from Resident #53's left shoulder area and applied a new Lidocaine patch. LPN #286 at 9:47 A.M. removed her gloves and did not perform hand hygiene. LPN #286 at 9:48 A.M. checked the computer on the medication cart and typed on the key board. LPN #286 at 9:50 A.M. opened the medication cart with her keys and pulled out the Tylenol container and placed two Tylenol in a medicine cup for Resident #53 without performing hand hygiene. LPN #286 at 9:51 A.M. administered two Tylenol to Resident #53 without performing hand hygiene. LPN #286 returned to her cart without performing hand hygiene. Interview on 06/15/25 at 9:51 A.M. with LPN #286 verified she did not perform hand hygiene before or after interaction with resident during medication administration with Resident #286 and verified she did not perform hand hygiene before and after glove usage. Interview on 06/25/25 at 1:55 P.M. with Director of Nursing (DON) confirmed hand hygiene was to be performed before and after each resident during medications administrations, and before donning gloves and after doffing gloves. 2. Review of Resident #26's medical records revealed an admission date of 06/02/25 with diagnosis of metabolic encephalopathy. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had intact cognition. Observation of medication administration on 06/25/25 at 12:20 P.M. with LPN #280 revealed he washed his hands before administering medications to Resident #26. LPN #280 put two medications in the Page 1 of 2 366095 366095 06/30/2025 Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medicine cup and administered to Resident #26. Upon exiting Resident #26's room LPN #286 did not perform hand hygiene after medication administration was completed. Interview on 06/25/25 at 1:53 P.M. with LPN #280 verified he did not perform hand hygiene after administering Resident #26's medication. LPN #280 reported he got busy and forgot and knows he is supposed to. Interview on 06/25/25 at 1:55 P.M. with Director of Nursing (DON) confirmed hand hygiene is to be performed before and after each resident during medications administrations, and before donning gloves and after doffing gloves. Review of the facility policy, Handwashing/Hand Hygiene, dated 2001, revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Further states, indications for hand hygiene included immediately before touching a resident; after touching a resident; after touching a resident's environment; immediately after glove removal and perform hand hygiene before applying non-sterile gloves. Gloves do not replace hand washing/hand hygiene. Review of the facility policy, Personal Protective Equipment - Gloves, dated 2001, revealed gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non intact skin. Further states to wash your hands after removing gloves or use hand sanitizer. 366095 Page 2 of 2