Health inspection·May 3, 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, record review, and facility policy review the facility failed to provide wound care and incontinence care to Resident #68 in a manner to promote infection prevention. This affected one resident (#68) of three residents reviewed for wound care and incontinence care. This had the potential to affect all residents in the facility. The facility census was 87. Residents Affected - Few Findings include: Review of the medical record for Resident #68 revealed an admission date of 12/23/22. Diagnoses included respiratory failure with hypoxia, metabolic encephalopathy, atrial fibrillation, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had moderate cognitive impairment. Resident #68 required extensive two-person physical assistance for bed mobility and toilet use; total dependence of two-persons for transfers; extensive one-person assistance for dressing and personal hygiene; and supervision with set-up help only for eating. Resident #68 was always incontinent of urine and bowel. Review of the care plan dated 04/02/23 revealed Resident #68 was incontinent of bowel and bladder. Interventions included checking and changing her every two hours and ensuring her call light was in reach. The care plan also had a focus that Resident #68 had impaired cognitive skills related to metabolic encephalopathy and that Resident #68 was a victim of domestic violence and being left against the wall causes anxiety. Interventions included explaining care before providing it and orienting and reorienting her if it does not upset her. Observation of incontinence care and wound care on 04/25/23 at 2:00 P.M. with State Tested Nurse Aide (STNA) #523 and STNA #530 for Resident #68 revealed they both entered the room with gloves in their hands from their pockets. No hand washing was performed. They transferred Resident #68 into bed in the lift and immediately began incontinence care. Resident #68 had a large bowel movement (BM) and required a new lift pad and pants. STNA #530 removed her gloves went into Resident #68's drawers and removed a new pair of pants while STNA #523 left the room with dirty gloves on and the dirty lift pad and pants not bagged and took them to the dirty linen room, removed her gloves, put on a new pair, grabbed a new lift pad, and returned to the room with no hand hygiene. Licensed Practical Nurse (LPN) #520 then entered the room with gloves on holding wound care supplies. LPN #520 then set her wound care supplies on Resident #68's bedside table with no barrier or precleaning and began performing wound care for Resident #68's buttocks. LPN #520 then removed her gloves after the new dressing was applied and cleaned up her things and left the room. No hand hygiene was performed. STNAs #523 and #530 then began to redress Resident #68 and lifted her into her recliner chair. STNA #530 then (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: 366281 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 366281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483 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)