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
record review, interviews, Centers for Disease Control and Prevention (CDC) guidance, and facility policy
review, the facility failed to ensure timely and accurate documentation of COVID-19 outbreak identification
and reporting. Residents tested positive for COVID-19 between 01/02/26 and 01/03/26; however,
documentation reflected delays in notifying residents' responsible parties until 01/06/26 and the county
health department until 01/07/26. This affected three residents (#11, #60 and #64) who tested positive for
COVID-19 and were not timely notified, 24 residents (#1, #6, #7, #9, #12, #14, #17, #19, #20, #22, #26,
#27, #31, #34, #37, #38, #43, #45, #48, #53, #55, #59, #62, #63) who were neither tested nor had
documented outbreak notification. The facility census was 63.Findings include: A review of Resident #60's
clinical record revealed an admission date of 09/12/25 with diagnoses including dementia with psychotic
disturbance, restlessness, agitation, schizophrenia, malnutrition, anxiety, delusional disorder, conversion
disorder with seizures and paranoid personality disorder. Resident #60 resided on the memory care unit
and had impaired cognition with poor memory.A review of Resident #11's clinical record revealed an
admission date of 12/19/25 with diagnoses including Alsheimer's disease, malnutrition, depression, high
blood pressure and cholesterol, peripheral vascular disease, chronic kidney disease, and gastroesophageal
reflux disease. Resident #11 resided on the memory care unit and had poor cognition with poor memory.A
review of Resident #64's clinical record revealed an admission date of 09/08/25 and re-admission on
[DATE] with diagnoses including dementia, adult failure to thrive, psychosis, depression and malnutrition.
Resident #64 resided on the memory care unit and had poor cognition and poor memory.A review of
Resident #60's clinical record revealed he had tested positive for COVID-19 on 01/02/26 and Resident
#11's and Resident #64's clinical record revealed they had tested positive for COVID-19 infection on
01/03/25. A review of the three residents' clinical record revealed their responsible party and/or family were
notified on 01/06/26 of the outbreak of COVID-19 infections by Social Service Designee (SSD) #65.Review
of the medical records for 24 residents (#1, #6, #7, #9, #12, #14, #17, #19, #20, #22, #26, #27, #31, #34,
#37, #38, #43, #45, #48, #53, #55, #59, #62, #63) on the Buckeye Trail unit revealed no documented
evidence that the facility failed to implement and document facility-wide COVID-19 testing following
identification of an outbreak, no documented evidence the residents or responsible parties were notified of
the outbreak of COVID-10 infections in the facility. An interview with SSD #65 on 01/21/26 at 8:41 A.M.
revealed she was informed on 01/06/26 that the facility had determined they had an outbreak of COVID-19
infections in the facility. SSD #65 stated she notified the residents' responsible parties of the COVID-19
outbreak of infections in the facility on 01/06/26. SSD #65 stated she notified the residents and residents'
responsible parties of the residents who resided on the Cascade and [NAME] nursing units but didn't notify
the residents or the responsible parties or visitors of the residents who resided on the Buckeye Trail unit.An
interview on 01/21/26 from 9:45 A.M. and 10:30 A.M. with Infection Control Preventionist (ICP) #66
revealed
Residents Affected - Some
(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:
365826
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
365826
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/22/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Continuing Healthcare of Cuyahoga Falls
300 East Bath Road
Cuyahoga Falls, OH 44223
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 - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Resident #60 tested positive for COVID-19 infection on 01/02/25. ICP #66 stated the hospital had
determined Resident #60 had contracted the infection in the facility and notified the facility on 01/03/25 that
he had tested positive for COVID-19 infection on 01/02/25. ICP #66 stated the facility tested all the
residents who resided in the memory care unit and found Resident #11 and Resident #64 had also tested
positive for COVID-19 along with one staff member, Licensed Practical Nurse (LPN) #67. ICP #66 stated
the facility had performed COVID-19 testing on two (Cascade and [NAME] nursing units) out of the three
nursing units ([NAME], Cascade and Buckeye nursing units) in the facility. ICP #66 stated the facility tested
the employees who worked on the memory care unit ([NAME]) and other employees who came in contact
with LPN #67. Signs were placed outside of the memory care unit with personal protective equipment and
stated the receptionist placed a sign outside the main entrance for visitors in the facility to alert them that
the facility had an outbreak of COVID-19 infections. ICP #66 stated she called the county health
department and notified them of the outbreak of COVID-19 infections in the facility. ICP #66 stated the
facility had identified six residents (#11, #60, #64, #56, #3, and #13) and one staff member (LPN #67) who
had tested positive for COVID-19 infection between 01/02/26 to 01/07/26.An interview with County Health
Department Registered Nurse (CHDRN) #69 on 01/21/26 at 9:52 A.M. revealed the facility had notified her
of the outbreak of COVID-19 infections on 01/07/26. CHDRN #69 provided guidance to minimize the spread
of the COVID-19 infections in the facility via email.An interview with Receptionist #68 on 01/21/26 at 10:33
A.M. revealed she had not placed signage on the doors of the main entrance. Receptionist #68 stated she
was not told to place signs outside of the main entrance by the administrative staff or other supervisory
staff and verified there was no sign placed outside the main entrance door during the COVID-19
outbreak.Interviews with Resident #9 and Resident #38 on 01/21/26 between 10:45 A.M. and 11:00 A.M.
revealed they were unaware the facility had an outbreak of COVID-19 and were not offered a mask or other
personal protective equipment. Resident #38 stated he was in and out of the main entrance doors several
times a day and stated there were no signs placed on the door to alert visitors and/or residents of an
outbreak of COVID-19 infections in the facility.The facility policy titled Report a Facility Outbreak (Including
COVID-19) dated 10/08/25 indicated outbreaks of COVID-19 infections should be reported by the end of
the next business day to the county health department and Long-Term Care Bureau of Ohio.The CDC
guidance titled Viral Pathogens Toolkit for Nursing Homes dated 01/09/26 indicated to control the spread of
COVID-19 infections in the facility implement broad-based testing in nursing homes as opposed to only
testing close contacts to identify asymptomatic infection.This deficiency represents non-compliance
investigated under Complaint Number 2711895 and is a recite to the surveys completed on 11/19/25 and
12/08/25.
Event ID:
Facility ID:
365826
If continuation sheet
Page 2 of 2