Inspection·February 22, 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 observations, staff interviews, medical record reviews, and policy reviews, the facility failed to implement their infection control policies when they allowed a resident positive with Coronavirus Disease 2019 (COVID-19) to share a room with a non-COVID-19 positive resident. This affected one (#59) out of five residents reviewed for infection control procedures related to COVID-19. Additionally, the facility failed to follow infection control guidelines when performing incontinence care. This affected one (#1) out of the three resident reviewed for incontinence care. Facility census was 108. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #60 revealed an admission date of 09/05/19 with medical diagnoses of asthma, hypertension (HTN), cystic disease of the liver, rheumatoid arthritis, and hyperlipidemia. Review of the medical record for Resident #60 revealed an annual Minimum Data Set (MDS), dated [DATE], which indicated Resident #60 had moderate cognitive impairment and was dependent upon staff for eating, toileting, bathing, bed mobility, and transfers. Review of the medical record for Resident #60 revealed a physician order dated 02/21/24 for contact and droplet precautions for COVID-19. Review of the medical record revealed Resident #60 shared a room with Resident #59. Observation on 02/22/23 at 11:07 A.M. of Resident #60 revealed a personal protective equipment (PPE) cart and droplet isolation sign located outside of Resident #60's room. Resident #60 was observed lying in bed sleeping. Observation of Resident #60's room revealed the bed was located on the right side of the room and there was a wall that went from ceiling to floor and was half the length of the room as a divide between Resident #60's side of the room and roommates' side of the room. Resident #60's roommate, Resident #59, was observed wheeling herself around the room, to the bathroom and to the door of the room to the hallway. The door to the room was observed to be open at all times during the investigation. Resident #60 was unable to answer questions due to impaired cognition. Review of the medical record for Resident #59 revealed an admission date of 01/11/22 with medical diagnoses of chronic obstructive pulmonary disease (COPD), heart failure, schizoaffective disorder, Alzheimer's disease, and anxiety. Review of the medial record for Resident #59 revealed a significant change MDS, dated [DATE], which indicated Resident #59 had short- and long-term memory loss and was independent with eating and bed mobility, required supervision for toilet hygiene and transfers, and was dependent for bathing. Review of the medical record for Resident #59 revealed Resident #59 was up to date on influenza and pneumococcal vaccinations but had refused a COVID-19 booster vaccination. Review of the medical record for Resident #59 revealed she shared a room with Resident #60. Review of the medical record did not contain documentation to support Resident #59 was COVID-19 positive or that Resident #59's representative was notified Resident #59 was sharing a room with a resident who was COVID-19 positive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366466 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 366466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Trace Health and Rehabilitation 250 West Social Row Road Centerville, OH 45458 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 Residents Affected - Few Observation on 02/22/23 at 11:07 A.M. of Resident #59 shared a room with Resident #60. The observation revealed Resident #59 was in her wheelchair wheeling herself to the door to the room. Resident #59 was not able to answer questions due to impaired cognition. Interview on 02/22/24 at 2:05 P.M. with Administrator confirmed the facility had private rooms available to move residents who were COVID-19 positive into so they did not have to share rooms with a resident who was not COVID-19 positive. Administrator confirmed Resident #60 tested positive for COVID-19 and shared a room with Resident #59 who was not COVID-19 positive. Administrator confirmed Resident #60 and Resident #59's room had a wall that was in the middle of the room to divide the space but confirmed Resident #59 had the ability to wheel herself over to Resident #60's side of the room and be exposed to COVID-19. Review of facility policy titled COVID-19, dated 05/11/23, stated residents with symptoms of COVID-19 should not be cohorted with residents with confirmed COVID-19 unless they are confirmed to have COVID-19 through testing. 2. Review of the medical record for Resident #1 revealed an admission date of 09/12/22 with medical diagnoses of respiratory failure, anxiety, diabetes mellitus, HTN, paraplegia, and atrial fibrillation. Review of the medical record for Resident #1 revealed a quarterly MDS, dated [DATE], which indicated Resident #1 was cognitively intact and was dependent for toilet hygiene, bathing, bed mobility, and transfers. The MDS indicated Resident #1 was always incontinent of bladder and had a colostomy. Review of the medical record for Resident #1 revealed a physician order dated 09/14/23 to apply versetime to right gluteus and sacrum every shift and with incontinence cares and an order dated 02/22/24 for contact precautions for carbapenem-resistant enterobacterales (CRE) in the urine. Observation on 02/22/4 at 10:43 A.M. of State Tested Nursing Assistant (STNA) #237 providing incontinence care for Resident #1. The observation revealed STNA #237 cleansed Resident #1 with cleansing wipes, removed the soiled depends and pad from underneath Resident #1 and discarded the items in the trash. STNA #237 was observed applying protective skin barrier cream to Resident #1 and then applied clean depends. STNA #237 was observed to reposition Resident #1 in bed and then removed her gloves and washed her hands. During the observation, STNA #327 did not change her gloves or perform hand hygiene after they became soiled. Interview on 02/22/24 at 10:55 A.M. with STNA #237 confirmed she did not change her gloves or perform hand hygiene after she cleansed Resident #1's peri area and removed the soiled items or prior to applying the protective skin barrier or applying clean depends. Review of the facility policy titled, Infection Control, dated 11/28/17 stated all staff are to perform hand hygiene between resident contact, after handling contaminated objects, after PPE removal and before and after performing resident care procedures. This deficiency represents non-compliance investigated under Complaint Number OH00151260. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366466 If continuation sheet Page 3 of 3