Inspection·September 6, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations and interviews, the facility failed to follow infection control protocols. This affected 18 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18) of 26 residents residing on the memory care unit. The facility census was 95. Residents Affected - Some Findings included: Review of the incident log revealed the facility had 33 residents with COVID-19. Review of current census revealed 19 residents still remained COVID positive with 18 of those residents residing on the memory care unit. During the initial tour on 09/03/24 between 7:46 A.M. and 7:58 A.M., revealed one room was identified on the memory care unit to have droplet precautions in place. Interview on 09/03/24 at 10:31 A.M. with Licensed Practical Nurse (LPN) #176 revealed the memory care unit has quite a few COVID positive residents. Residents who wander are encouraged to stay in their room, but they do not because they are confused so they are then encouraged to wear a mask and they are also noncompliant with that. LPN #176 stated the staff just try to keep the residents separated from each other as much as possible. LPN #176 stated when interacting with residents who have COVID, droplet precautions are in place which include gown, gloves, an N-95 mask, and a face shield. A KN-94 mask is acceptable if staff are not in a room with a COVID positive resident. During the interview, LPN #176 was observed to be wearing a KN-95 mask in common areas where several residents identified as having COVID were located. She was not wearing eye protection, gloves, or a gown. Interview on 09/03/24 at 11:15 A.M. with Director of Nursing (DON) revealed she did not have an infection control log, map, or trend tracking worksheet. The DON stated her previous Assistant DON was the infection preventionist and quit without notice over the weekend and took all the infection control information with her. The DON stated she would continue to attempt to reach previous Assistant DON but she declined to provide contact information because she was more worried about what ADON would say than about the current concerns with the survey. The DON stated she would be able to put a new infection control log together before the end of the survey. Observations were made continuously of the memory care unit on 09/03/24 from 12:25 P.M. to 12:40 P.M. Twelve (12) residents were in the common area of the facility for meals. Some residents were observed coughing or sneezing. Staff were noted to only be wearing masks but no additional personal protective equipment (PPE). There was still only one resident room door with the droplet precautions on the door indicating COVID positive residents. Staff were observed throughout this timeframe assisting residents back to their rooms in close proximity. Interview on 09/03/24 at 12:57 P.M. with State Tested Nursing Assistant (STNA) #190 revealed it was her first time working the memory care unit so she was unable to identify the residents who did or did not have COVID. During interview, STNA #190 was noted to only be utilizing one strap of her N-95 mask. Interview and observation on 09/03/24 at 3:12 P.M. with the DON on the memory care unit confirmed 18 residents were positive for COVID. Confirmed sign postings were visible on one resident door and one was found on a cart outside of another door. The DON confirmed staff should be wearing N-95 masks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 2 of 3 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in high risk areas and none of the staff on memory care should be wearing a KN-95 mask. The DON confirmed staff should be wearing additional PPE given the population they work with are noncompliant with isolation and wearing masks. Review of a facility policy titled COVID-19 Prevention and Management (dated 09/27/22) revealed N-95 respirators are mandated to be worn while in droplet isolation or quarantine rooms. Disciplinary actions could be taken if staff are observed not wearing a mask, wearing a mask inappropriately, not wearing eye protection on a residential unit, not wearing all required PPE while entering an isolation room. The resident's door should be kept closed at all times, contact and droplet precautions should be maintained, if a resident must leave their room they must wear a face mask, perform hand hygiene, limit their movement in the facility and utilize social distancing. The policy did not identify how to proceed in the case of a memory care unit. This deficiency represents non-compliance investigated under Master Complaint Number OH00157064 and Complaint Number OH00157037. This deficiency is evidence of continued non-compliance from the survey dated 08/06/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 3 of 3