Health inspection·April 20, 2023

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, interview, facility policy review, and review of the Centers for Disease Control (CDC) guidance, the facility failed to maintain proper infection control procedures to prevent the spread of COVID-19 infection. This affected two residents (Resident #14 and #23) but had the potential to affect all 51 residents residing in the facility. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/08/21. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed resident had impaired cognition and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #14 medical record reviewed they were diagnosed with COVID-19 on 04/07/23. Review of physician orders dated 04/07/23 revealed the resident was to be on transmission based precautions (TBP) for ten days duration. Interview on 04/17/23 at 8:39 A.M. with Infection Preventionist (IP) #150 revealed the facility was in a COVID-19 outbreak status. IP #150 reported staff were to wear N95 masks, surgical mask over top of N95 mask, eye protection, gown, and gloves to enter in the COVID-19 rooms. IP #150 reported before exiting the COVID-19 rooms staff were to doff (take off) surgical mask, gown, gloves, and then upon exit disinfect their goggles or face shields and perform hand hygiene. Observation on 04/17/23 at 9:31 A.M. revealed STNA #103 donned (put on) personal protective equipment (PPE) to enter Resident #14's room with her goggles on her head. Resident #14 was observed to be on TBP. STNA #103 exited the room at 9:36 A.M. and her goggles still on her head. STNA #103 preceded to go down the hall. STNA #103 did not disinfect her goggles as required due to COVID-19 outbreak status at the facility. Interview on 04/17/23 at 9:37 A.M. with STNA #103 revealed she forgot to wear the goggles correctly as she entered Resident #14's COVID-19 positive room room to perform personal care and exited the room with the goggles remaining on her head. STNA #103 proceeded to head down the hall without disinfecting her goggles. She reported I just forgot. STNA #103 confirmed she did not wear her goggles correctly and did not clean goggles after exiting the room. Interview on 04/17/23 at 10:08 A.M. with IP #150 confirmed staff were to disinfect goggles or face shields upon exiting room and hand hygiene is to be performed upon exiting resident rooms. (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: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurie Ann Nursing Home 2200 Milton Boulevard Newton Falls, OH 44444 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)