Health inspection·April 17, 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 record review, staff interview, review of facility policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to timely cohort COVID-19 positive residents. This affected four (Residents #39, #11, #29, and #34) of four residents reviewed for COVID-19 isolation. The facility census was 42. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #39 was admitted on [DATE]. Diagnoses included cerebral palsy, contracture of muscle multiple sites, hyperlipidemia, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 02/18/25, revealed the resident is rarely understood. Review of census data revealed Resident #39 has not experienced a room move since 03/14/25. Review of nursing progress notes, dated 04/11/25, revealed the resident tested positive for COVID-19. The resident was symptomatic and was sent to the emergency room for further evaluation due to risk factors for respiratory disease. Review of nursing progress notes, dated 04/11/25, revealed the resident returned from the hospital with a new prednisone order. Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included Alzheimer's disease, dysphagia, cognitive communication deficit, major depressive disorder recurrent, unspecified dementia, hyperlipidemia, and pressure ulcer of the sacral region stage 3. Review of the MDS assessment, dated 03/06/25, revealed the resident is rarely understood. Review of census data revealed Resident #11 shared a room with Resident #39 since 03/14/25. Review of nursing progress notes, dated 04/13/25, revealed the resident tested positive for COVID-19. Interview on 04/17/25 at 8:41 A.M. with the Director of Nursing (DON) verified Resident #39 tested positive on 04/11/25, was sent to the hospital, and returned the facility the same day. The DON verified upon returning, Resident #39 was placed in a room with two negative residents (#11 and #19) and (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: 366171 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 366171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cridersville Nursing and Rehab 603 East Main Street Cridersville, OH 45806 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)