Health inspection·January 15, 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 medical records review, staff interview, observation, review of facility policy, and review of Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) while caring for a resident who was positive with Coronavirus Disease 2019 (COVID-19). This affected one (#1) out of three residents reviewed for infection control. The census was 90. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed an admission date of 07/24/24. Diagnoses listed included cerebral atherosclerosis, hypertension, vascular dementia, and chronic kidney disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitive impaired and receiving Hospice services. Review of physician orders revealed an order dated 01/13/25 for contact and droplet precautions due to COVID-19. Review of progress notes dated 01/13/25 at 12:36 P.M. revealed Resident #1 tested positive for COVID-19 with a rapid test nasal swab. Observation on 01/15/25 at 11:06 A.M. revealed Certified Nursing Assistant (CNA) #100 in Resident #1's room standing at the right side of her bed. CNA #1 was gathering bed linens and repositioning Resident #1's bedding. CNA #100 was not wearing a gown, faceshield or goggles. CNA #100 was wearing a surgical style face mask. Observation of Resident 1's room entry revealed a sign stating to use contact and droplet precautions. A bin outside the door contained PPE. Interview with CNA #100 on 01/15/25 at 11:09 A.M. confirmed Resident #1 was in contact and droplet precautions due to being COVID-19 positive. CNA #100 confirmed she did no wear a gown, faceshield or goggles, or N95 (respirator) while in Resident #1's room providing care. Review of the facility's Covid QAPI Plan dated revised August 2024 revealed all staff must use PPE when going into a COVID-19 positive resident room- N95, eyewear, gown, and gloves. Review of the CDC Infection Control Guidance: SARS-CoV-2 revealed healthcare personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face (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: 365821 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 365821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439 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)