Health inspection·May 11, 2023

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, review of Centers for Medicare and Medicaid Services (CMS) guidance and interview, the facility failed to ensure it was administered in a manner which enabled it to use its resources effectively and efficiently when they did not terminate the use of a temporarily certified Health Care Isolation Center (HCIC) area per CMS waiver guidelines as required. This affected 11 residents (#13, #52, #54, #55, #56, #57, #58, #59, #60, #61 and #64) of 11 residents residing in HCIC rooms. The facility census was 64. Residents Affected - Some Findings include: Review of a facility application and survey history, revealed on 02/01/21, the facility was approved to operate as a HCIC with an In-House Surge Facility. The location of the HCIC was the first floor, Rooms 111 through 134. The approval allowed a surge in capacity of 24 for the facility to operate 128 certified beds. Review of CMS MEMO, QSO-22-15-NH & NLTC & LSC, dated 04/07/22 and revised 08/29/22, revealed the following Emergency Declaration Blanket Waivers for Various Provider-Types Ending 60 Days from Publication of this Memorandum included: Physical Environment for SNF/NFs - CMS waived requirements to temporarily allow for rooms in a long-term care facility not normally used as a resident's room, to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity. Certain conditions of participation and certification requirements for opening a NF if the state determines there is a need to quickly stand up a temporary COVID-19 isolation and treatment location. Requirements to temporarily allow for rooms in long-term care facility not normally used as a resident's room, to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity. Review of an Enhanced Information Dissemination Collection (EIDC) electronic reporting system Memo, dated 05/09/22, revealed facilities with Health Care Isolation Centers (HCIC) were further informed of the reference to end COVID-19 Emergency Declaration Blanket Waivers and HCIC Program. CMS waived requirements to allow for a non-SNF building to be temporarily certified and available for use by a SNF in the event there were needs for isolation processes for COVID-19 positive residents. The memo included this may not have been feasible in the existing SNF structure to ensure care and services during treatment for COVID-19, provided that the state approved the location as one that sufficiently addresses the safety and comfort for patients and staff. The waiver also included the requirements to temporarily allow for rooms in a long-term care facility not normally used as a resident's room to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity. (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: 366222 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 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)