Health inspection·October 3, 2019

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews and record review, the facility failed to ensure the smoking area held ashtrays for disposal of ashes and failed to maintain a clean environment free of cigarette butts. This affected twenty-four (Resident #28, #19, #31, #39, #33, #8, #42, #15, #1, #24, #27, #29, #30, #18, #38, #36, #40, #22, #20, #32, #14, #9, #3 and #34) of thirty-two residents who smoke. Findings include: An observation on 09/30/19 at 3:08 P.M. of the smoking area revealed there were twenty-four residents (Resident #28, #19, #31, #39, #33, #8, #42, #15, #1, #24, #27, #29, #30, #18, #38, #36, #40, #22, #20, #32, #14, #9, #3 and #34) smoking in the outdoor designated area. There were two metal pails with lids in the area, one was in the center of the outdoor canopied space with twelve surrounding small benches placed in a square. Each bench was approximately four feet from the metal pail. The other pail was near the entrance door on the right side of the door as you would exit. There were no ashtrays present in this designated smoking area. The pails were used to dispose of used cigarette butts. There were nineteen residents on the benches and five residents sitting on the concrete ground of the area leaning against the fence. The fence was a chain link, and there was grass surrounding the enclosed area for smoking. All twenty-four residents dropped their cigarette ashes to the concrete ground near them. Two residents (Resident #42 and Resident #20)flicked their ashes through the chain link fence to the outside grassy area. There were used cigarette butts just outside of the fenced area around the smoking space on all sides of the enclosure and there were approximately 60 to 100 used butts under the benches and on the concrete floor. The two metal pails were each half full of cigarette butts. This was verified by State Tested Nursing Assistant (STNA) #118 who revealed they would usually clean up the area after each break. There were eight cigarette breaks each day. During this cigarette break, neither STNA who had supervised smoking reminded residents to use the pails and not the ground or floor area for ashes. An interview on 09/30/19 at 3:29 P.M. with STNA #118 revealed during each cigarette break, each resident was given one cigarette only and they were supervised by two STNAs. All residents required some level of supervision for smoking. An interview and observation on 10/02/19 at 10:06 A.M. of the smoking area with Maintenance Supervisor #155 revealed and confirmed there were no ashtrays in the smoking area. He agreed there were ash marks on the concrete and fifteen cigarette butts still on the ground. An interview on 10/02/19 at 10:11 A.M. with Licensed Practical Nurse (LPN) #101 revealed the STNAs were supposed to pick up cigarette butts at the end of each shift. She had no information regarding ash trays. (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: 366230 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 366230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Pointe 2765 North Elyria Road Wooster, OH 44691 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)