Inspection·February 13, 2020

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, record review, policy review, personnel file review, review of Isolation guidelines from the Center for Disease Control (CDC), review of a self-learning orientation packet for volunteers, and interview, the facility failed to ensure isolation precautions were adhered to by a volunteer. This involved one (Resident #9) resident of two residents reviewed for respiratory care/infections. This had the potential to affect all 20 residents. Residents Affected - Many Findings include: Review of Resident #9's medical record revealed an admission date of 02/04/20. Diagnoses included acute respiratory failure with hypoxia and acute bronchiolitis (inflammation of the bronchioles caused by a viral infection) due to respiratory syncytial virus (RSV). Laboratory results from the hospital dated 01/30/20 revealed Resident #9 tested positive for RSV prior to her admission to the nursing facility. A safety assessment dated [DATE] indicated Resident #9 was placed on contact and droplet isolation precautions. On 02/10/20 at 9:15 A.M., personal protective equipment (PPE) was observed hanging from Resident #9's door to the hallway with signs on the door frame indicating droplet precautions and contact precautions. The signs indicated visitors were to wear gowns, gloves, and masks. The signs instructed visitors to wash hands before entering the room and to wash hands before leaving the room. At the time of the observation, Registered Nurse (RN) #40 reported Resident #9 was on isolation for RSV-A and people entering her room needed to wear gown, gloves and mask. On 02/10/20 at 11:47 A.M., State Tested Nursing Assistant (STNA) #52 was observed taking a tray from the meal cart to the doorway of Resident #9's room and asking if she could hand the tray to Volunteer #210 who was already in the room. Volunteer #210 was observed standing in the room handling objects in the room (especially on the overbed table sitting in front of Resident #9), picking the food tray up off the bed and placing it on the over bed table. Volunteer #210 was not wearing PPE and left the room without washing her hands or using hand sanitizer. On 02/10/20 at 11:52 A.M., during interview,Volunteer #210 (who was wearing a smock with a name tag identifying her as a volunteer) verified she did not wear PPE while in Resident #9's room and stated she had never been told anything about PPE use. Volunteer #210 acknowledged the lack of hand hygiene being performed. Volunteer #210 stated she delivered mail throughout the facility and adjoining hospital. On 02/10/20 at 11:55 A.M., during interview, RN #40 stated volunteers should use the same isolation precautions as other staff and she was uncertain what kind of training volunteers received. (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: 366405 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 366405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooster Community Hospital Snf 1761 Beall Avenue 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)