Inspection·July 26, 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, record review and interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented as required for Resident #65. This had the potential to affect ten residents (#55, #56, #57, #58, #59, #60, #61, #62, #63, and #64) that resided on the same hall as Resident #65. Residents Affected - Some Findings include: Review of Resident #65's medical record revealed the resident was admitted on [DATE] with diagnoses that included but not limited to Alzheimer's disease, angina pectoris, major depressive disorder, and atherosclerotic heart disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 was severely cognitively impaired and required maximal assistance with activities of daily living. Review of the physician's orders for July 2024 revealed Resident #65 did not have a urinary catheter. Review of the physician orders dated 07/22/24 revealed that Resident #65 was ordered one gram of ertapenem sodium (antibiotic) for extended spectrum beta-lactamase (ESBL) intramuscularly (IM) once a day for five days. ESBL producing bacteria cannot be killed by many antibiotics used to treat infections making it harder to treat. Review of Resident #65's progress note dated 07/22/24 dated revealed Resident #65 was retested for the COVID-19 virus. Resident #65 was to remain in isolation for the full 10-day period and retest on 07/27/24. The note further indicated all services were rendered in room with no safety concerns at that time. The urine analysis and culture and sensitivity returned indicating positive for ESBL. The physician was notified and opted not to order antibiotic therapy at this time because Resident #65 was on an antiviral for COVID-19. Review of Resident #65's progress note dated 07/23/24 at 5:26 P.M. revealed Resident #65 was retested for the COVID-19 virus. Resident #65 was to remain in isolation for the full 10-day period and retest on 07/27/24. The urine analysis and culture and sensitivity returned positive for ESBL. The physician ordered an IM antibiotic after ensuring there were no interactions with the antiviral that was being administered. Observation and interview on 07/26/24 at 12:42 P.M. with Licensed Practical Nurse (LPN) # 303 revealed Resident #65 was not on isolation precautions or enhanced barrier precautions. LPN #303 verified Resident #65 was not on isolation precautions. LPN #303 stated she took Resident #65 off isolation precautions because the resident had a negative COVID-19 test and did not have to remain on isolation precautions. Interview on 07/26/24 at 1:40 P.M. with the Director of Nursing (DON) revealed although Resident #65 no longer required droplet precautions for COVID-19 the resident should have been on contact precautions because she was newly diagnosed with ESBL. Review of the Centers for Medicare and Medicaid QSO-24-08-NH memo dated 03/20/24 revealed enhanced barrier precautions (EBP) were indicated with any of the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 Infection of colonization with a CDC-targeted MDRO when contact precautions did not apply. • Residents Affected - Some Wounds and/or indwelling medical devices even if resident was not known to be infected or colonized with a multi drug resistant organism (MRDO). Review of the facility census dated 07/26/24 revealed Residents #55, #56, #57, #58, #59, #60, #61, #62, #63, and #64 resided on the same hall as Resident #65. This deficiency represents non-compliance investigated under Complaint Number OH0015586. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 3 of 3