Health inspection·October 15, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident representative interview, review of video footage,staff interview, observation, and review of the facility policy, the facility failed to ensure staff performed proper hand hygiene and follow appropriate infection control practices for discarding soiled items when providing incontinence care. This affected two (Residents #51 and #81) of three residents reviewed for incontinence care. The facility census was 85 residents. Residents Affected - Few Findings include: 1.Review of the medical record for Resident #81 revealed an admission date of 11/22 with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, diabetes mellitus, obstructive uropathy, and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #81 dated 08/16/24 revealed the resident had severely impaired cognition, had an indwelling urinary catheter, was incontinent of bowel, and needed assistance with toileting. Interview on 10/15/24 at 8:05 A.M. with Resident #81's representative confirmed she had installed a camera in the resident's room to ensure Resident #81's care needs were met. Resident #81's representative further confirmed she had multiple video recordings of facility staff failing to perform hand hygiene during incontinence care to the resident and the representative provided the video footage of the improper hand hygiene practices. Review of the video footage dated 08/16/24 at 4:13 P.M. with the Administrator and the Director of Nursing (DON) revealed State Tested Nursing Assistant (STNA) #90 performed Resident #81's incontinence care with gloved hands. STNA #90 removed Resident #81's incontinence brief and cleaned the perineal area, applied powder and cream to the resident's perineum, and placed a clean incontinence brief on the resident. Using the same gloved hands used for incontinence care STNA #90 arranged the resident's bed linens and touched various items in the resident's room including the bed remote, the over-the-bed table and cups of water on the table. STNA #90 also wiped Resident #81's face with the same soiled gloved hand and then opened a straw and placed the straw in a cup located on the over-the-bed table and assisted the resident with drinking the beverage. STNA #90 then gathered the soiled linen and trash bag and left the room still wearing her soiled gloves and did not perform hand hygiene. Review of the video footage dated 08/22/24 at 11:54 P.M. with the Administrator and the DON revealed STNA #92 performed Resident #81's incontinence care with gloved hands, and then used the soiled gloved hands to handle the resident's bed linens, the bed remote, the over-the-bed table, and a package of incontinence wipes. STNA #92 then gathered the soiled trash bag and left Resident #81's room without performing hand hygiene or removing his gloves. Page 1 of 3 366487 366487 10/15/2024 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the video footage dated 08/31/24 at 5:24 P.M. with the Administrator and the DON revealed STNA # 98 performed Resident #81's incontinence care with gloved hands. During the task STNA #98 placed the soiled incontinence brief and soiled wipes on the floor. STNA #98 did not remove her gloves or perform hand hygiene and then repositioned Resident #81's legs on a pillow, covered her with clean linens, and used the bed remote to adjust the position and height. The video ended before STNA #98 exited the room. Review of the video footage dated 09/01/24 at 8:45 P.M. with the Administrator and the DON revealed STNA #91 performed incontinence care for Resident #81 with gloved hands. STNA #91 adjusted Resident #81's bed linens with the same soiled gloved hands and also handled a package of incontinence wipes. STNA #91 then removed the soiled gloves, donned a second pair of gloves without washing her hands, and then gathered the soiled trash and left the room without performing hand hygiene. Review of the video footage dated 09/02/24 at 4:38 P.M. with the Administrator and the DON revealed STNA #95 performed Resident #81's incontinence care with gloved hands. During the task STNA #95 placed the soiled incontinence brief and soiled incontinence wipes on the floor. STNA #95 then touched Resident #81's bed linens, the bed remote, placed a package of incontinence wipes in the drawer, and assisted the resident with drinking water using the same soiled gloved hands. Review of the video footage dated 09/10/24 at 5:06 A.M. with the Administrator and the DON revealed STNA #96 performed incontinence care for Resident #81 with gloved hands. During incontinence care STNA #96 placed the soiled incontinence brief on the floor. Upon completion of incontinence care STNA #96 used the same soiled gloved hands to reposition the resident's head and pillow and covered the resident with clean linens. STNA #96 then picked up the soiled incontinence brief from the floor and placed it on the floor outside of doorway to Resident #81's room. STNA #96 then placed the package of incontinence wipes in the resident's drawer and exited the room without removing the soiled gloves or performing hand hygiene. Review of the video footage dated 09/12/24 at 2:28 P.M. with the Administrator and the DON revealed STNA #94 performed incontinence care for Resident #81 with gloved hands. During the incontinence care STNA #94 placed the soiled linens and soiled incontinence brief directly on the floor. Upon completion of the task STNA #94 continued to use the same soiled gloved hands to apply lotion to Resident #81's back and buttocks and placed the lotion container on Resident #81's bedside table. STNA #94 then assisted Resident #94 with donning a gown and covered the resident with the clean linens. STNA #94 then exited the room wearing the same soiled gloves used for the incontinence care. Review of the video footage dated 09/19/24 at 10:57 A.M. with the Administrator and the DON revealed STNA #93 performed incontinence care for Resident #81 using gloved hands. STNA #93 completed the task and then used the same gloved hands soiled from incontinence care to place the package of incontinence wipes in Resident #81's drawer with her other personal items and assisted the resident with dressing and adjusted the resident's bed linens. Review of the video footage dated 09/20/24 at 5:06 A.M. with the Administrator and the DON revealed STNA #97 performed incontinence care for Resident #81 using gloved hands. Upon completion of the task STNA #97 used the same soiled gloved hands to reposition the resident, adjust the bed linens, and handled the bed remote to adjust the height of the bed. The video ended before STNA #97 exited the room. Interview on 10/15/24 at 10:55 A.M. with the Director of Nursing (DON) and the Administrator 366487 Page 2 of 3 366487 10/15/2024 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confirmed Resident #81's representative had installed a video camera in the resident's room to monitor care. Interview with the Administrator and DON confirmed the nine videos viewed with the Surveyor which ranged in dates from 08/16/24 to 09/20/24 showed STNAs #90, # 91, 92, #93, #94, #95, #96, #97, and #98 providing incontinence care to Resident #81. Further interview confirmed none of the STNAs observed in the video performed appropriate hand hygiene following the provision of incontinence care. Interview confirmed all nine STNAs touched the resident and/or resident items using soiled gloves. Interview confirmed STNAs #94, #95, #96, and #98 did not properly dispose of soiled linen and infectious waste but instead dropped the soiled items on the floor. 2. Review of the medical record for Resident #52 revealed an admission date of 04/25/24 with diagnoses including diabetes mellitus, hypertensive heart disease with heart failure, urinary retention, and post-traumatic stress disorder. Review of the functional assessment for Resident #52 dated 08/27/24 revealed the resident needed staff assistance with toileting and hygiene. Observation on 10/15/24 at 10:05 A.M. of incontinence care for Resident #52 per STNA #98 revealed staff performed incontinence care with gloved hands. Resident #52 had a large bowel movement and STNA #98 assisted the resident onto her side and cleaned the resident's perineal area using disposable incontinence wipes and applied moisture barrier cream. Using the same gloved hands STNA #98 adjusted Resident #52's bed remote, cover the resident with bed linens, and placed the resident's call light within reach, and then exited the room. Interview on 10/15/24 at 10:15 A.M. with STNA #98 confirmed she failed to remove her soiled gloves and perform hand hygiene following incontinence care for Resident #52. STNA #98 confirmed following incontinence care she then handled Resident #52's items with soiled gloved hands. Review of the facility policy titled Hand Hygiene/Handwashing dated 02/21/24 revealed hand hygiene was the most important component for preventing the spread of infection. Use of gloves did not replace the need for hand cleaning by either hand rubbing or hand washing. The procedure indicated alcohol-based hand sanitizer was the preferred method of hand hygiene unless the hands were visibly soiled. Hand hygiene should be performed in the following clinical indications: immediately before touching a resident, before performing an aseptic techniques or handling invasive devices, before moving from a soiled body site to a clean body site on the same resident, after touching a resident or the resident's immediate environment, after contact with blood, body fluids, or contaminated surfaces, immediately after glove removal. This deficiency represents noncompliance investigated under Complaint Number OH00158188. 366487 Page 3 of 3