Health inspection·October 5, 2023

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 and record review the facility failed to ensure personal protective equipment (PPE) was worn while providing care to a resident on contact precautions. This affected 10 of 10 residents who received care provided by State Tested Nurse Aide (STNA) #209, Residents #5, #24, #37, #48, #54, #57, #63, #69, #76 and #77. Residents Affected - Some Findings include: Review of Resident #5's medical records revealed an admission date of 08/30/23. Diagnoses included muscle weakness, falls and cellulitis (bacterial infection involving the inner layers of the skin). Review of Resident #5's Minimum Data Set assessment dated [DATE] revealed Resident #5 had intact cognition, required extensive assistance with bed mobility, toileting and personal hygiene. Resident #5 was incontinent of bowel and bladder. Review of the care plan dated 09/20/23 revealed Resident #5 had a Clostridium Difficile (C-diff) infection (bacterial infection that causes diarrhea and inflammation of the colon) and was on isolation precautions. Interventions included implement isolation precautions. Review of current physician orders dated 09/26/23 revealed an order to place Resident #5 in isolation precautions. Review of progress note dated 09/27/23 revealed Resident #5's stool sample tested positive for C-diff. Observation on 10/03/23 at 11:40 A.M. revealed a sign posted outside of Resident #5's room indicating contact precautions and an isolation bin that included gowns, gloves and masks. Further observation revealed STNA #209 exiting Resident #5's room without PPE and immediately entered another resident's room. Continued observation revealed STNA #245 exiting Resident #5's room at 11:42 A.M. and doffing a gown and gloves. Interview with STNA #245, at time of observation, revealed Resident #5 was on contact precautions for C-diff. STNA #245 stated she was required to don PPE including a gown and gloves prior to entering Resident #5's room. STNA #245 stated she had assisted STNA #209 with providing Resident #5 with a bed bath and incontinence care. Interview on 10/03/23 at 12:07 P.M. with STNA #209 revealed he was aware Resident #5 was on contact precautions for C-diff. STNA #209 confirmed he had not worn PPE while in Resident #5's room providing care and was unable to provide an explanation as to why he had not worn PPE while providing Resident #5's care. Page 1 of 2 366111 366111 10/05/2023 Falling Water Healthcare Center 18840 Falling Water Strongsville, OH 44136

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 10/04/23 at 1:55 P.M. with the Director of Nursing (DON) revealed she had been made aware of STNA #209 not wearing appropriate PPE while providing care for Resident #5 who was on contact precautions. The DON stated she had immediately educated STNA #209 regarding proper PPE usage and stated STNA #209 was unable to provide an explanation regarding why PPE was not utilized as required. Review of STNA #209's assignment for 10/03/23 revealed STNA was assigned to care for Residents #5, #24, #37, #48, #54, #57, #63, #69, #76 and #77. Review of facility informational handout (undated) revealed healthcare providers were to wear gown and gloves while providing care to residents with C-diff infections. This deficiency represents non-compliance investigated under Complaint Number OH00146583. 366111 Page 2 of 2