Twinsburg Post Acute

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to obtain additional information about the incident involving Resident #1 on 07/06/25. Interview on 07/08/25 at 3:11 P.M. with Administrator confirmed Resident #1's representative was never notified of the incident on 07/06/25 due to there was no telephone number for her. Review of the facility policy titled Change in a Resident's Condition or Status revised February 2021 revealed the facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. This deficiency represents non-compliance investigated under Complaint Number 2574277 and Complaint Number OH00167210 (138517).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Twinsburg Post Acute

8551 Darrow Road Twinsburg, OH 44087

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 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

screaming in pain. Resident #2's daughter reported she went to the nurse and reported her mom was unable to get up and walk and just moving made her scream in pain. Resident #2's daughter reported she insisted her mom be sent to the hospital and reported she thought her mom must have had a fall because there was also a dressing on her left arm dated 05/20/25 (There was no documentation of a dressing).

Resident #2's daughter revealed the staff told her later (unable to recall when) that her mom had wandered into someone's room, fell down, broke her hip, walked on it, and then they assisted her back to bed.

Resident #2's daughter revealed There was no way my mom could have walked on it, just moving it made her scream in pain. The resident's daughter revealed it was then another 45 minutes to an hour before the facility transferred the resident to the hospital. Review of the sign in visitor log dated 05/20/25 revealed Resident #2's daughter arrived on 05/20/25 at 2:55 P.M. This shows evidence of the time the daughter arrived, she was sent to the hospital after that. A telephone interview on 08/06/25 at 6:33 P.M. with LPN #277 revealed she was Resident #2's primary charge nurse on 05/20/25 during the day shift. LPN #277 revealed she was on her lunch break (did not recall the time) when she received a call from UM #293 indicating Resident 2's daughter was there and Resident #2 was in pain. LPN #277 stated she gave Resident #2 her medications that morning when the resident was in bed. LPN #277 didn't know how CNA #211 changed her, but Resident #2 did not get out of the bed. UM #293 wanted LPN #277 to write a statement saying she fell on her day shift and the LPN refused to write one. LPN #277 revealed Resident #2 did not appear to be in pain that morning, but she did not have to move her. Interview on 08/07/25 at 8:22 A.M. with Resident #36 revealed she recalled a resident coming into her room. Resident #36 stated a female resident fell, didn't know who the female resident was, it had occurred a couple months ago around twilight time, before morning. Resident #36 stated it looked like the resident was dancing, fell, the man picked her up, she walked out, then she didn't know what happened. Resident #36 confirmed when she saw the resident in her room, she turned her call light on and yelled for help. The man that came in was staff. Interview on 08/07/25 at 8:45 A.M. with CNA #211 revealed she was Resident #2's primary CNA on 05/20/25. CNA #211 stated on the morning of 05/20/25, CNA #211 fed Resident #2 in bed. Resident #2 was usually up wandering but did lay down for naps throughout the day. However, Resident #2 did not get up at all on that day. CNA #211 stated she was on lunch break when Resident #2 was transferred to the hospital. CNA #211 stated she changed Resident #2 that morning, and she did not seem like she was in pain, she was lying in a fetal position, which was not her usual as she would wander typically, and was on her side. CNA #211 stated she didn't have to straighten Resident #2's legs out to provide incontinence care.

CNA #211 confirmed she provided incontinence care that morning only and confirmed she was Resident #2's primary CNA on that day. CNA #211 revealed Resident #2 didn't scream until her daughter straightened her legs out. Resident #2 did not get up at all that day. CNA #211 stated Resident #2 did usually get up on night shift and walked around during the day but didn't on 05/20/25. Review of the facility policy titled, Change in a Resident's Condition or Status revised February 2021 revealed the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in

the resident's medical/mental condition and or status. The nurse would notify the resident's attending physician or physician on call when there had been a (an) accident or incident involving the resident; discovery of injuries of an unknown source; significant change in the resident's physical/emotional/mental condition. This deficiency represents non-compliance investigated under Complaint Number 2581344. This is an example of continued non-compliance from the survey dated 06/25/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Twinsburg Post Acute

8551 Darrow Road Twinsburg, OH 44087

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 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, record review, and review of the facility policy, the facility failed to ensure wound care was completed as per the physician orders for one resident, Resident #57 of three residents reviewed for wound care. The facility census was 70.Findings include:Record review for Resident #57 revealed an admission date of 10/23/23. Diagnoses included multiple sclerosis, sepsis, chronic osteomyelitis, colostomy, neuromuscular disfunction of the bladder, pressure ulcer stage IV (Full thickness loss with exposed bone, tendon or muscle), and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #57 was severely cognitively impaired. Resident #57 had impairment on one side of the upper extremity and both sides of the lower. Resident #57 was dependent on staff for all activities of daily living (ADL). Resident #57 was at risk for pressure ulcers, had one stage IV pressure ulcer and one unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). Review of the physician orders for Resident #57 revealed on 05/23/25, an order for the right dorsum foot to cleanse right dorsum foot with Dakin's 0.25% solution, blot dry, apply calcium alginate with silver, ABD and kerlix. Change daily and as needed every day shift for wound management.

Observation 07/08/25 at 4:30 P.M. revealed Wound Care Nurse (WCN) #292 and Unit Manager (UM) #293 were going to provide wound care for Resident #57. WCN #292 and UM #293 confirmed the date on the dressing to Resident #57's wound on the right foot was dated 07/06/25 the initials were [Licensed Practical Nurse (LPN) #283]. Observation after removal of the dressing revealed the old dressing had a heavy drainage and foul odor. The tissue surrounding the edges of the wound bed was white/emaciated. The appearance and odor was verified by WCN #292. Record review of the nursing staff assignment sheets and timecards and interview on 07/09/25 at 9:00 A.M. with the Administrator and UM #293 confirmed LPN #283 worked at the facility on 07/06/25. LPN #283 did not work on 07/07/25 or 07/08/25. The Administrator and UM #293 confirmed LPN #283 completed the dressing change on 07/06/25 and the dressing change was not completed again until 07/08/25. Review of the facility's undated policy titled Wound Care revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Dress the wound and mark tape with initials, time, and date and apply to dressing. This deficiency represents non-compliance investigated under Complaint Number OH00167210 (1381513).

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Twinsburg Post Acute

8551 Darrow Road Twinsburg, OH 44087

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 0689 Level of Harm - Minimal harm or potential for actual harm

#238, #216 and Activity Director #203 revealed Resident #1 never required supervision. The facility identified Residents #23, #41, and #70 who resided on the same hall as Resident #1 and were independently mobile and had cognitive impairments. This deficiency represents non-compliance investigated under Control Number OH00167346 (1381517). This is an example of continued non-compliance from the survey dated 06/25/25.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Twinsburg Post Acute

8551 Darrow Road Twinsburg, OH 44087

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 0690 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

do it. Interview on 08/07/25 at 11:04 A.M. with LPN #518 confirmed CNP #514 requested a urinalysis be obtained for Resident #20. Observation on 08/07/25 at 11:38 A.M. revealed Licensed Practical Nurse (LPN) #518 and Unit Manager (UM) #350 straight catheterized Resident #20. LPN #518 straight catheterized Resident #20 for a residual of 1,300 cubic centimeters (cc) during the second attempt. Record review and

interview on 08/11/25 at 3:00 P.M. with DON confirmed there were no urinalysis results in the medical

record for Resident #20 for the urinalysis ordered 08/07/25. The DON confirmed the urine was obtained on 08/07/25 and the urine was never sent to the laboratory. The DON stated she did not know why the urine was never sent and confirmed it should have been obtained and sent per the CNP orders. Telephone

interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she ordered a urinalysis on 08/07/25 for Resident #20 and revealed she was never notified the urinalysis was not completed as ordered. Review of

the facility policy titled, Catheter Care Urinary revised August 2022 revealed the purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician. This deficiency represents non-compliance investigated under Complaint Number 2581344 and Complaint Number 2574277.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Twinsburg Post Acute

8551 Darrow Road Twinsburg, OH 44087

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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interviews with staff and pharmacy, the facility failed timely respond and act upon the pharmacy's notification regarding irregularity with a new order to start an antibiotic. This affected one (#20) of one resident reviewed for pharmacy services.Findings included: Record review revealed Resident #20 was admitted to the facility on [DATE REDACTED] with diagnoses including urinary tract infection (UTI) and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #20 was cognitively intact. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days. A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions. Interview on 08/06/25 at 3:40 P.M. with the Director of Nursing (DON) revealed the DON reviewed Resident #20's Medication Administration Record (MAR) and confirmed Cipro was ordered on 08/01/25 and was scheduled to start on 08/02/25 at 9:00 P.M. The DON confirmed from 08/02/25 through 08/06/25 for the scheduled doses at 9:00 P.M. the boxes all had a number nine; and documented Resident #20 received Cipro three of 10 doses on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only. Telephone interview on 08/06/25 at 4:55 P.M. with Certified Pharmacy Technician (CPHT) #515 with the DON present revealed the Cipro for Resident #20 was never sent because the pharmacist reached out for a drug interaction. CPHT #515 revealed the note stated an RN would clarify. The pharmacy never received the response, so they never sent the Cipro. The DON verified LPN #275 documented on the MAR

she gave Resident #20 the Cipro from the prepackaged medications this A.M. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. On 08/07/25 there was an order by CNP #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days. Flush peripherally inserted central catheter (PICC) line/midline/central line with 10 cubic centimeters (cc) normal saline (NS) before and after medication administration. Interview on 08/07/25 at 10:39 A.M. with the DON and record review of the Pharmacy Communication request received 08/04/25 at 11:54 A.M. revealed the request stated to Please Respond. Medication Cipro had a drug interaction with (medication) tizanidine. Please consider changing the antibiotic to something else or hold all tizanidine while on this antibiotic. The DON revealed she also gets emails from the pharmacy, but the recommendations also come through the fax. The pharmacy also calls the nurses who need to update the physician with the pharmacy information. The DON confirmed the pharmacy recommendation was not completed and revealed any nurse could do it. This was an incidental finding discovered during the course of the complaint investigation.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Twinsburg Post Acute

8551 Darrow Road Twinsburg, OH 44087

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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #7 already ate her breakfast and said that was important information to know. CNP #514 verified UM #293 never notified her Resident #7 ate her breakfast prior to the blood sugar results. CNP 3514 stated

she didn't want a hypoglycemic reaction so she needed to know information to give correct orders. 4.

Record review for Resident #68 revealed an admission date of 04/10/23. Diagnoses included chronic atrial fibrillation and hypertension (HTN). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #68 was cognitively intact and had hypertension. Review of the physician orders for Resident #68 revealed an order dated 07/28/25 for metoprolol succinate extended release 24 hour 25 milligrams (mg) give one tablet by mouth one time a day for HTN hold for a heart rate of less than 60 beats per minute or a systolic blood pressure of less than 100. The order under status revealed pending order signature. Review of the Medication Administration Record (MAR) for Resident #68 revealed the metoprolol was not administered in July 2025 or 08/01/25 to 08/11/25. Resident #68's last blood pressure documented

in the medical record was dated 07/28/25 at 9:54 A.M. and was 140/88. The last pulse documented was 06/03/25 and was 72. Interview with the Director of Nursing (DON) on 08/11/25 at 3:25 P.M. confirmed staff did not monitor Resident #68's blood pressure or pulse and she was also unable to find the documentation for the pulse and blood pressure daily for Resident #68. DON confirmed the medication metoprolol was not administered to Resident #68 per the order. Telephone interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she wrote the order on 07/28/25 for Resident #68 to receive metoprolol succinate extended release 25 mg one time a day. CNP #514 revealed the medication should have started after she ordered it and she was never notified by any staff the medication was never initiated. The medication had a dual purpose for the blood pressure and the heart rate so both the heart rate and blood pressure needed monitored prior to medication administration. Review of the facility policy titled Medication Administration dated 11/2017 revealed to administer the medications as ordered; the physician shall be notified of held medications. This deficiency represents non-compliance investigated under Complaint Number 2574277 and Complaint Number 1381508 (OH00167560).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Twinsburg Post Acute

8551 Darrow Road Twinsburg, OH 44087

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 0770

Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interviews with staff, the facility failed to timely obtain a urinalysis ordered by the physician/certified nurse practitioner (CNP). This affected one (#20) of one resident reviewed for laboratory services.Findings included: Record review revealed Resident #20 was admitted to the facility on [DATE REDACTED] with diagnoses including urinary tract infection (UTI) during stay, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #20 was cognitively intact.

The assessment revealed Resident #20 required supervision or touch assistance with toileting hygiene.

Resident #20 had no indwelling catheter or intermittent catheter noted on the MDS assessment. On 08/04/25 an order was obtained to remove indwelling catheter today (08/04/25) and straight catheterize every four to six hours. On 08/07/25 there was an order by Certified Nurse Practitioner (CNP) #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days and a urinalysis. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. CNP #514 stated, the facility never told her that Resident #20 not getting straight catheterized as physician ordered. And when they do straight catheterization, the staff were obtaining more than 250 cc of urine left in the bladder and this was retention. CNP #514 confirmed retention (a condition in which a person is unable to empty their bladder completely) can cause a UTI. CNP #514 stated she was going to order an intravenous (IV) antibiotic now and more laboratory values including a urinalysis because Resident #20 did not receive the Cipro that was ordered. CNP #514 stated she was not happy with the facility and stated she had received a call from the hospital, and the urinalysis results returned from when

she went to the ER on [DATE REDACTED] and showed she had a UTI, that was why the Cipro was ordered. Interview

on 08/07/25 at 11:04 A.M. with Licensed Practical Nurse (LPN) #518 confirmed CNP #514 requested a urinalysis be obtained for Resident #20. Record review and interview on 08/11/25 at 3:00 P.M. with Director of Nursing (DON) confirmed there were no urinalysis results in the medical record for Resident #20 for the urinalysis ordered 08/07/25. The DON confirmed the urine was obtained on 08/07/25 and the urine was never sent to the laboratory. The DON stated she did not know why the urine was never sent and confirmed

it should have been obtained and sent per the CNP orders. Telephone interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she ordered a urinalysis on 08/07/25 for Resident #20 and revealed she was never notified the urinalysis was not completed as ordered. This was an incidental finding discovered during

the course of the complaint investigation.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Twinsburg Post Acute

8551 Darrow Road Twinsburg, OH 44087

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

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, resident and staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure staff wore personal protective equipment (PPE) for a resident on Enhanced Barrier Protection (EBP). This affected one (#20) of one resident reviewed for infection control. The facility census was 70. Findings include: Record review for Resident #20 revealed an admission date of 07/20/24. Diagnoses included Parkinson's disease and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #20 was cognitively intact. Resident #20 had no indwelling catheter or intermittent catheter.

Review of the physician orders for Resident #20 revealed an order dated 03/31/25 to straight catheterize every six hours or urinary retention four times a day for urinary retention; an order dated 08/01/25 for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a urinary tract infection (UTI) for seven days; and an order dated 08/04/25 for EBP use gown and gloves for high contact resident care including dressing,, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes and care of any device including trach, central line, tube feeding and catheter. Observation on 08/07/25 at 11:38 A.M. revealed Licensed Practical Nurse (LPN) #518 and Unit Manager (UM) #350 straight catheterized Resident #20. UM #350 assisted Resident #20 back to bed and repositioned her legs. Neither LPN #518 nor UM #350 donned an isolation gown. LPN #518 straight catheterized Resident #20 for a residual of 1,300 cubic centimeters (cc) during the second attempt.

LPN #518 then provided peri care for Resident #20. Resident #20 stated when staff straight catheterized her, they never wear isolation gowns. UM #350 stated nurses would only wear an isolation gown if the resident had an infection Interview on 08/07/25 at 12:21 P.M. with DON revealed staff should wear Personal Protective Equipment (PPE) for wound care, peri care, indwelling catheter, or when providing care for a specific reason. DON confirmed staff should wear an isolation gown when providing hands on care for Resident #20. Review of the facility policy titled, Enhanced Barrier Precautions (EBP) revised February 2021 revealed EBP are utilized to prevent the spread of multi-drug resistant organisms (MDRO's) to residents. EBP refers to an infection control intervention designed to reduce the transmission of MDRO's

during high contact resident care activities. EBP apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and has secretions or excretions that are unable to be covered or contained. Indwelling medical devices include urinary catheters. EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. This was an incidental finding discovered during the course of the complaint investigation.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet