Health inspection·March 5, 2024

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 policy review the facility failed to ensure staff performed hand hygiene and followed infection control practices when handling soiled linen to prevent cross contamination of germs during Resident #23's tracheostomy care and suctioning procedure. This affected one out of three residents reviewed for tracheostomy care. The facility census was 58. Residents Affected - Few Findings include: Clinical record review revealed Resident #23 was admitted on [DATE] with diagnoses including traumatic brain injury , stroke, high blood pressure, anemia, gastroesophageal reflux disease, kidney disease, hyperlipidemia, depression, and respiratory failure with a tracheostomy. An observation on 03/05/24 at 9:50 A.M. of Respiratory Therapist (RT) #70 perform Resident #23's tracheostomy care and suctioning revealed a concern with performing hand hygiene and following infection control practices. RT #70 gathered the supplies for suctioning the secretions from Resident #23's tracheostomy tube. RT #70 opened the suctioning kit and donned a pair of sterile gloves and proceeded to use the suction catheter to suction Resident #23's secretions via her tracheostomy tube. When RT #70 completed the suctioning task, he wrapped the soiled suction catheter inside his glove and discarded the glove with the catheter in the waste receptacle. RT #70 removed the glove from his other hand and discarded the glove in the waste receptacle. RT #70 did not perform hand hygiene and donned a pair of disposable gloves and then removed them. RT #70 did not perform hand hygiene. RT #70 then exited the room to obtain supplies needed to perform Resident #23's tracheostomy care from the supply cart located in the hallway. RT #70 entered Resident #23's room and donned another pair of gloves and proceeded to perform Resident #23's tracheotomy care. During the tracheostomy care RT #70 noted a wound was present under Resident #23's tracheostomy collar. RT #70 removed the wound dressing (calcium alginate) and obtained a pair of scissors from his shirt pocket and cut the calcium alginate dressing and then placed the scissors back in his shirt pocket without sanitizing/disinfecting the scissors before or after he used the scissors. RT #70 proceeded to apply the calcium alginate to the wound and covered the wound with a split gauze dressing. RT #70 removed the inner tracheostomy cannula and discarded the cannula. RT #70 removed an inner cannula from the packaging and placed the inner cannula inside Resident #23's tracheostomy tube. RT #70 reapplied Resident #23's oxygen mask covering the tracheostomy. RT #70 then removed a towel located under Resident #23's tracheostomy collar soiled with secretions and placed the soiled towel on the floor by the doorway to Resident #23's room. RT #70 used the same gloved hands and touched his cellular phone, pulse oxygenation probe, and television. RT #70 removed his soiled gloves and did not perform hand hygiene and exited Resident #23's room. RT #70 documented Resident #23's tracheostomy care and suctioning procedure in Resident #23's electronic record. RT #70 then gathered supplies to administer Resident #6's respiratory treatment via her tracheostomy tube. RT #70 entered Resident #6's room and donned a pair of disposable gloves. RT #70 was stopped and asked to perform hand hygiene before proceeding to administer Resident #6's respiratory treatment. An interview with RT #70 on 03/05/24 at 10:20 A.M. verified the above findings and confirmed he failed to maintain infection control practices during Resident #23's tracheostomy care and suctioning procedure. Review of the facility policy titled Hand Hygiene dated 2023 indicated staff would perform hand hygiene procedures to prevent the spread of infections to other personnel, residents and visitors. Hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366359 If continuation sheet Page 2 of 3 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 366359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm hygiene was a general term for cleaning hands by handwashing using soap and water or the use of an antiseptic hand rub (alcohol-based hand rub). The facility policy titled Tracheostomy Care dated 2023 indicated the procedure with use of a disposable inner cannula. The procedure included: Residents Affected - Few - Verify the inner cannula is disposable, Verify the correct size. - Explain the procedure to the resident and screen for privacy. - Perform hand hygiene and put on a clean gloves. - Slowly remove the inner cannula from the tracheostomy tube by squeezing the tabs on the connector until both snaps clear the ridged lock on the outer cannula. - Dispose the removed cannula. - Pick up the new inner cannula, touching only the outer locking portion. Insert the and lock the inner cannula into position. - Change the tracheostomy ties/tube holder when soiled or wet. Replace dressing using manufactured split dressing with flaps pointing upward. - Discard gloves and perform hand hygiene. - Make sue oxygen is administered as ordered. - Document the procedure and report any signs/symptoms of infection to the physician. This deficiency represents non-compliance investigated under Complaint Number OH00150890. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366359 If continuation sheet Page 3 of 3