Inspection·June 13, 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 record review, interview, observation, and review of the facility policy, the facility failed to ensure proper Personal Protective Equipment (PPE) was used for Enhanced Barrier Precautions (EBP). This affected one resident (Resident #49) out of three residents reviewed for infection control. The facility census was 58. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #49 revealed an admission date of 06/15/23 with diagnoses including but not limited to dementia, peripheral vascular disease, and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had intact cognition. Review of the physician orders revealed an order for catheter care every shift and as needed and staff to use Enhanced Barrier Precautions during high contact resident care activities due to chronic Foley every shift. Observation made on 06/13/24 at 1:09 P.M. of catheter care for Resident #49 by State Tested Nursing Assistant (STNA) #707 revealed the resident was in enhanced barrier precautions (EBP), STNA #707 did not wear proper Personal Protective Equipment (PPE) including a gown. STNA #707 set up and covered the over bed table with a towel, water basin, and wash cloths. He then washed his hands, applied gloves, explained what was happening, prepared the towels and wash cloths, provided appropriate catheter care with no concerns. STNA #707 changed Resident #49's brief, bed linen, and assisted with reposition in the resident. Interview on 06/13/24 at 1:32 P.M. with STNA #707 revealed he confirmed Resident #49 was EBP and he was to wear a gown when performing catheter care and he did not. Review of the facility policy titled Enhanced Barrier Precautions dated August 2022, revealed under the section titled Policy Interpretation and Implementation number two EBPs employ the use of gown and glove during high contact resident care activities when contact precautions do not otherwise apply. Under letter A. Gloves and gown are applied prior to performing high contact resident care activity (as opposed to before entering the room) Under number three Examples of high-contact resident care activities requires the use of gown and gloves for EBPs include: d. providing hygiene (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: 366425 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 366425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Village Skilled Nursing & Rehabilitation Ltd 708 Moore Road Akron, OH 44319 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)