Health inspection·March 20, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and review of facility policy, the facility failed to ensure staff implemented proper infection control practices related to hand hygiene. This affected two residents (Resident #14 and Resident #28) who were reviewed for incontinence care. The facility census was 84. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 07/08/21 with diagnoses including atherosclerotic heart disease, dementia, wheezing, benign prostatic hyperplasia with urinary tract symptoms, and contractures of bilateral hip, knees, and ankles. Review of the quarterly Minimum Data Set (MDS) assessment completed on 01/02/24 revealed Resident #14 had moderately impaired cognition. Further review revealed Resident #14 was always incontinent of bowel and bladder and was dependent on staff for toileting and bathing. Review of the current care plan revealed Resident #14 needed assistance with activities of daily living (ADLs). Interventions included assisting with ADLs as needed and reporting decline in ability to the physician and therapy department. Observation on 03/19/24 at 8:20 A.M. of Resident #14 revealed he was receiving personal care from State Tested Nurse Aide (STNA) #411. Further observation revealed STNA #411 was not wearing gloves while performing a bed bath and incontinence care. STNA #411 was observed removing an incontinence brief containing a small amount of smeared stool from under Resident #14 as she proceeded to wash his rectal area, then genitalia and groin area with ungloved hands. Continued observation revealed STNA #411 donned gloves and applied barrier cream without first performing hand hygiene. STNA #411 then removed her gloves and continued putting on a clean incontinence brief and dressing Resident #14's upper body with no hand hygiene after glove removal or before dressing the resident. Interview on 03/19/24 at 8:45 A.M. with STNA #411 confirmed she did not don gloves to provide the bed bath or incontinence care. Further interview confirmed STNA #411 did not perform hand hygiene before donning gloves prior to the application of barrier cream, dressing Resident #14, or between glove changes. Review of facility policy titled Perineal Care, dated 04/30/19, revealed gloves were to be worn when perineal care was performed. Gloves were to be removed after completing perineal care, and then staff were to perform hand hygiene prior to repositioning the resident and replacing the bed covers. Review of the policy titled Hand Washing/Hand Hygiene, dated 08/30/19, revealed hand hygiene was to Page 1 of 2 366152 366152 03/20/2024 West View Healthy Living 1715 Mechanicsburg Road Wooster, OH 44691

F 0880 Level of Harm - Minimal harm or potential for actual harm be performed before moving from a contaminated area to a clean area during resident care, after potential contact with bodily fluids, and after removing gloves. 2. Review of the medical record for Resident #28 revealed an admission date of 03/04/22 with diagnoses including dementia, hypertension, dysphagia, overactive bladder, and functional urinary incontinence. Residents Affected - Few Review of the annual Minimum Data Set (MDS) assessment completed on 03/06/24 revealed Resident #28 had severely impaired cognition. Further review of the annual MDS assessment revealed Resident #28 was always incontinent of bladder and bowel and was dependent on staff for all aspects of personal care. Review of the current care plan revealed Resident #28 had functional urinary incontinence related to dementia, communication deficits, and overactive bladder. Interventions included providing incontinence care as needed, application of moisture barrier to the skin, and reporting signs or symptoms of urinary tract infection or skin breakdown. Observation on 03/20/24 at 9:35 A.M. revealed Resident #28 received incontinence care from STNA #427. The observation revealed STNA #427 did not discard gloves or perform hand hygiene after cleansing loose stool from Resident #28's groin, perineal area, rectal area, buttocks, and coccyx area. Further observation revealed STNA #427 opening the drawer from Resident #28's bedside table, rummaging through the drawer to search for barrier cream and powder, then handling and applying the barrier cream to Resident #28's buttocks with the same soiled gloves used to provide the incontinence care. STNA #427 was observed removing the gloves prior to removing Resident #28's pants (per resident preference), repositioning Resident #28, and applying bed covers. No hand hygiene was performed after glove removal, prior to completing resident care. Interview on 03/20/24 at 9:45 A.M. with STNA #427 confirmed she did not remove her gloves or perform hand hygiene between cleaning Resident #28's bowel movement, obtaining items from her bedside dresser, applying barrier cream, and putting on a clean incontinence brief. Further interview confirmed no hand hygiene was performed after she removed the soiled gloves and proceeded with resident care. STNA #427 further revealed her typical process included wearing the same gloves throughout incontinence care, including applying ordered barrier creams after cleaning the resident's urine and/or stool. Review of facility policy titled Perineal Care, dated 04/30/19, revealed gloves were to be worn when perineal care was performed. Further review revealed gloves were to be removed after completing perineal care, and then staff were to perform hand hygiene prior to repositioning the resident and replacing the bed covers. Review of the policy titled Hand Washing/Hand Hygiene, dated 08/30/19, revealed hand hygiene was to be performed before moving from a contaminated area to a clean area during resident care, after potential contact with bodily fluids, and after removing gloves. 366152 Page 2 of 2