Health inspection·April 17, 2025

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, interviews, and facility policy, the facility failed to ensure infection control was maintained during incontinence care. This affected one resident (#32) of three residents reviewed for incontinence care. The facility census was 85. Residents Affected - Few Findings included: Review of the medical record for Resident #32 revealed an admission date of 04/28/21. Diagnosis included type 2 diabetes mellitus with diabetic neuropathy, chronic kidney disease, difficulty walking, and hallucinations. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #32 had intact cognition. Review of the bladder and bowel revealed Resident #32 was always incontinent of bladder and bowel. Review of the Care Plan dated 03/09/25 revealed Resident #32 had bladder incontinence related to history of urinary tract infection (UTI) and impaired mobility and bowel incontinence related to immobility. Interventions included clean peri-area with each incontinence episode. Cleanse peri-anal area with warm soap and water, check resident every two hours and assist with toileting as needed (PRN). Observation on 04/16/25 at 12:35 P.M. of incontinence care for Resident #32 revealed Certified Nursing Assistant (CNA) #319 gathered supplies, knocked on door, provided privacy, and explained the procedure to resident. CNA #319 did not wash hands or use hand sanitizer and donned gloves. CNA #319 placed two washcloths in the sink in the resident's bathroom and turned on the water. CNA #319 removed Resident #32's brief soiled with medium amount of urine. CNA #319 removed her gloves and donned new gloves without performing hand hygiene. CNA #319 went to bathroom sink where the two washcloths were sitting in the bottom of the sink, picked up one washcloth and applied soap to the washcloth and then picked up the other washcloth and carried over to Resident #32's bed. At this time CNA #259 and Registered Nurse (RN) # 270 came into the room to assist. CNA #319 provided peri care with the soapy washcloth first, then with the rinse wash cloth, and then patted dry with a towel. CNA #319 removed her gloves and donned new gloves without performing hand hygiene. CNA #319 went to resident bathroom and placed two more washcloths in the bottom of resident sink and turned the water on. CNA #319 grabbed one washcloth and applied soap and grabbed the other washcloth and went to resident bed. CNA #319 performed care on buttocks first with soapy washcloth, then rinse washcloth, then patted dry. CNA #319 removed gloves and applied new gloves without performing hand hygiene. CNA #319 applied barrier cream and then removed gloves, applied new gloves without performing hand hygiene. CNA #319 with the help of CNA #259 and RN #270 assisted resident with pillows, call light in reach and asked if she needed anything else. CNA #19 removed her gloves, didn't perform hand hygiene, and exited the room Page 1 of 2 366431 366431 04/17/2025 Avenue at Aurora 425 South Chillicothe Road Aurora, OH 44202

F 0880 with the dirty linens. Level of Harm - Minimal harm or potential for actual harm Interview on 04/16/25 at 3:06 P.M. with CNA #319 revealed she did not maintain infection control during incontinence care. CNA #319 verified she did not perform hand hygiene before entering the resident room, after changing gloves, during the incontinence care procedure and before exiting room. CNA #319 revealed she should not have placed the washcloths in the sink and should have used a basin instead. Residents Affected - Few Interview on 04/16/25 at :09 P.M. with CNA #259 revealed hand hygiene was to be performed before and after glove usage and before and after exiting resident room. CNA #259 verified during incontinence care you are to use a basin with water and not place washcloths in the bottom of resident sink due to infection control. Interview on 04/17/25 at 6:29 A.M. with RN/Unit Manager #266 revealed hand hygiene was to be performed before and after glove usage and before and after exiting resident room. RN/Unit Manager # 266 revealed during incontinence care you are to use a basin and not place washcloths in the bottom of resident sink due to infection control. Interview on 04/1725 at 12:19 P.M. with Director of Nursing (DON) confirmed CNA #319 did not maintain infection control during incontinence care as hand hygiene is performed before and after donning/doffing gloves and before and after entering and exiting resident room. DON verified for incontinence care you are to use a clean basin and to not put washcloths in the resident sink and run water due to to the sink being dirty. Review of facility policy titles, Incontinence Care, revised December 2022, revealed the purpose of the policy was to ensure a resident who is incontinent of bowel and/or bladder receives appropriate treatment and services to prevent urinary tract infections. The procedure for incontinence care is to perform hand hygiene, apply clean gloves, fill a basin with warm water, perform peri care, dispose of gloves and perform hand hygiene. Review of facility policy, Handwashing, revised July 2022, revealed the purpose of the policy is to maintain the highest standard of hygiene in patient care through thorough handwashing procedures. These evidence-based practices are designed to protect healthcare staff and residents by preventing the spread of infections among residents, staff, and visitors and to ensure staff do not carry infectious pathogens on their hands or via equipment during resident care. Staff involved in direct resident contact must perform hand hygiene (even if gloves are used): before and after contact with the resident, before donning and after doffing personal protective equipment (PPE), examples, gloves, and after contact with body fluid. Gloves should be changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care. 366431 Page 2 of 2