Health inspection·October 10, 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 observation, record review and review of the Centers for Disease Control and Prevention (CDC) Infection Control Guidance, the facility failed to implement the appropriate personal protective equipment when entering and leaving a resident's room who was confirmed COVID-19 positive. This finding affected two residents (Residents #7 and #48) who reside on the South 2 hall and had the potential to affect an additional 44 residents residing on the South 2 and South 3 halls including Residents #2, #3, #5, #8, #9, #11, #13, #16, #18, #20, #21, #26, #28, #30, #33, #36, #38, #40, #41, #42, #47, #49, #50, #51, #56, #57, #61, #62, #66, #67, #69, #70, #71, #74, #77, #81, #83, #84, #90, #91, #92, #95, #97 and #100. The facility census was 97. Residents Affected - Some Findings include: Review of Resident #7's medical record revealed the resident was readmitted on [DATE] with diagnoses including cognitive communication deficit, dementia in other diseases and major depressive disorder. Review of Resident 7's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of the facility infection control documentation revealed Resident #7 tested positive for COVID-19 on 10/01/23 and 10/06/23. The documentation indicated the resident was off COVID-19 precautions on 10/12/23. Review of Resident #7's physician orders revealed an order dated 10/09/23 for droplet precautions maintained during all encounters while in COVID isolation. All services to be provided in the room. Review of Resident #48's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, hyperlipidemia and major depressive disorder. Review of Resident #48's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of the facility infection control documentation revealed Resident #48 tested positive for COVID-19 on 09/30/23 and 10/05/23. The documentation indicated the resident was off COVID-19 precautions on 10/11/23. Review of Resident #48's physician orders revealed an order dated 10/01/23 to maintain droplet precautions due to COVID positive. The resident to receive all services including meals, treatments 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: 366428 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 366428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Fairview Park 20770 Lorain Road Fairview Park, OH 44126 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)