Health inspection·April 29, 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 review of the medical record, review of facility policy, observation and interview with staff, the facility failed to ensure staff appropriately donned personal protective equipment (PPE)while providing care to Resident #2 who was in isolation for COVID-19 precautions. This had the potential to affect all residents residing in the facility. The facility census was 57. Residents Affected - Many Findings included: Review of the medical record revealed Resident#2 was admitted to the facility on [DATE]. Diagnoses included dementia, thyrotoxicosis, chronic obstructive pulmonary disease, COVID-19, hypertension, Crohn's disease, obstructive sleep apnea, and diabetes. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #2 had moderately impaired cognition. Review of the physician's order revealed Resident #2 had an order to maintain combined droplet/contact precautions and isolation per transmission-based precautions (TBP). All care and services are provided in the resident's room. Do not discontinue isolation until resident has met the criteria for discontinuation of isolation per Centers for Disease Control guidelines using either symptom-based or testing based strategy dated 04/26/23 with an end date of 05/06/23. Review of the progress note dated 04/25/23 at 1:30 P.M. revealed the resident was notified her roommate had teste positive for COVID-19, resident and husband voiced their understanding. The resident will stay in the same room and be placed on precautions due to exposure. Review of the progress note dated 04/28/23 at 1:42 P.M. revealed Resident #2 was in contact/droplet isolation due to being in close proximity to individual who tested positive for COVID. A rapid COVID test was done at bedside and the results were negative. Observations on 04/29/23 at 10:58 A.M. Certified Occupational Therapist Assistant #200 went into room [ROOM NUMBER] with only a surgical mask on to perform occupation therapy exercises on Resident #2 who was in droplet isolation for close contact with her roommate who tested positive for COVID-19. He left the door open to the room so he could be seen in the room without personal protective equipment (PPE) on. At 11:00 A.M. COTA #200 came out of the room of Resident #2 without washing his hands. He verified he had not donned all required (gown, gloves, mask and eye protection) PPE while he was in the room or washed his hands before he exited the room of Resident #2. He stated he was not aware Resident #2 was on isolation. He verified at this time Resident #2 had signage on her door and an isolation cart outside her room indicating she was on isolation. He proceeded to don PPE in the (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: 366237 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 366237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wadsworth Pointe 540 Great Oaks Trail Wadsworth, OH 44281 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)