F0880

E

Failure to Timely Report and Communicate COVID-19 Outbreak and Implement Facility-Wide Testing

Cuyahoga Falls, Ohio Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely and accurate documentation and reporting of a COVID-19 outbreak, including delayed notification to residents’ responsible parties and the county health department, and incomplete facility-wide outbreak communication and testing. Three residents residing on the memory care unit, all with dementia or significant cognitive impairment and poor memory, tested positive for COVID-19. One resident tested positive on 01/02/26, and two additional residents tested positive on 01/03/26. Documentation showed that their responsible parties or families were not notified of the COVID-19 outbreak until 01/06/26 by the Social Service Designee, despite the earlier positive test results.

Record review for 24 residents on the Buckeye Trail unit showed no documented evidence that facility-wide COVID-19 testing was implemented following identification of the outbreak, and no documentation that these residents or their responsible parties were notified of the outbreak. The Social Service Designee reported she was informed on 01/06/26 that the facility had determined there was a COVID-19 outbreak and that she notified residents and responsible parties on the Cascade and memory care units, but did not notify residents, responsible parties, or visitors for those on the Buckeye Trail unit. The Infection Control Preventionist stated that after learning of the first positive case, the facility tested residents on the memory care unit and identified two additional positive residents and one LPN, and that testing was conducted on two of the three nursing units, but not on the Buckeye Trail unit.

The Infection Control Preventionist also stated she called the county health department to report the outbreak, while the county health department RN reported that the facility notified her of the outbreak on 01/07/26. The receptionist stated she had not placed any signage at the main entrance and had not been instructed by administrative or supervisory staff to do so, confirming there was no sign on the main entrance door during the outbreak. Two residents interviewed reported they were unaware of a COVID-19 outbreak in the facility and were not offered masks or other PPE, and one resident who frequently used the main entrance stated there were no signs posted to alert visitors or residents of the outbreak. Facility policy required outbreaks of COVID-19 to be reported to the county health department and state LTC bureau by the end of the next business day, and CDC guidance cited in the report called for broad-based testing in nursing homes during outbreaks, rather than limiting testing to close contacts.