Health inspection·October 12, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many building and had to don additional PPE when entering the room of a resident in TBP's for Covid-19. She was asked about the doffing procedures with removing their PPE when leaving the rooms of the residents in TBP's. She mentioned the need to perform hand hygiene and disinfect their face shields with alcohol pads when leaving the room. If they went to a new isolation room, they would have to don new PPE. If going to a non-Covid-19 room, they would just put a surgical mask back on or another N 95 mask, if they felt more comfortable wearing that. She sometimes wore the N 95 mask as part of her source control because she did not want to get Covid-19. She felt she had been adequately trained to protect herself from Covid-19 and to help prevent it from spreading throughout the facility. She acknowledged she was observed not following appropriate infection control practices when doffing and donning PPE between residents rooms. She confirmed she had removed her old N 95 mask and failed to properly disinfect her hands before donning a new N 95 mask, before entering the room of another resident. She also verified she placed her face shield on top of her housekeeping cart, after leaving a resident's room in isolation for Covid-19, without first properly disinfecting it. She acknowledged by doing so she likely contaminated the top of her housekeeping cart, which could possibly contribute to the spread of Covid-19. She also confirmed she did not wash/ sanitizer her hands, after removing her gloves, when she was then observed disinfecting the mop handle before putting it back onto her housekeeping cart. She acknowledged the removal of gloves did not negate the need to perform hand hygiene and failing to do so could contribute to the spread of infections. She further acknowledged she left residents' room (who were in isolation for being Covid-19 positive) without removing all the PPE she was wearing when in that isolation room. She acknowledged all her PPE should be discarded when leaving the isolation room and hand hygiene should be performed upon leaving the room. 1 b.) On 10/10/23 at 12:12 P.M., State Tested Nurse Aide (STNA) #24 was observed to don PPE to deliver a meal tray to Resident #62. Resident #62 was in TBP's for being Covid-19 positive. STNA #24 was noted to don a N 95 mask over top of the surgical mask she was already wearing. The N 95 mask she put over top of the surgical mask was not properly applied as she only used one of the two straps to secure the mask around the back of her head. The second strap hung loosely. Due to the N 95 mask being placed over top of her surgical mask and only one of the two straps to the N 95 mask being used to secure it to her head, a proper seal was not likely to have been achieved while she was in the resident's room. She sat the tray on the resident's bedside table. The resident was observed to be up in his wheelchair in his room and had a moist cough. He had coughed while she was in the room. The aide doffed her PPE while in the room and went into the bathroom to perform hand hygiene. She left the resident's room without donning a new surgical mask before she was observed proceeding down the hall to pass a tray to Resident #44. Resident #44 was in a room mid way down the hall and was not in TBP's for having Covid-19. She then went down to the lounge area to pass meal trays to the five residents sitting in there for lunch. She continued to pass all five trays to those residents at 12:20 P.M. without wearing a surgical mask as part of source control. It was not until 12:23 P.M. that she realized she did not don a new surgical mask, after leaving Resident #62's room. On 10/10/23 at 12:23 P.M., an interview with STNA #24 revealed she had worked at the facility for eight years now. She was asked what PPE she needed to wear when entering a resident's room in isolation for Covid-19. She stated they put on a blue gown, N 95 mask, gloves and a face shield. She was not aware the N 95 mask should not be put on over top of the surgical mask she was already wearing. She confirmed she did put the N 95 mask directly over top of her surgical mask and did not apply both straps around the back of her head to ensure a proper seal. She also confirmed she did not don a new surgical mask, after leaving the room of Resident #62 in isolation for Covid-19, before proceeding to other areas of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 2 of 4 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 facility until 12:23 P.M. Level of Harm - Minimal harm or potential for actual harm 1 c.) On 10/10/23 at 12:14 P.M., an observation of STNA #33 noted her to don PPE before delivering lunch trays to Resident #15 and #16. Both residents resided in the same room and both were in isolation for being Covid-19 positive. She was observed to don a N 95 mask over top of the surgical mask she was already wearing. Residents Affected - Many On 10/10/23 at 12:27 P.M., an interview with STNA #33 revealed she had worked at the facility for five years. She thought it was appropriate to put a N 95 mask over top of the surgical mask she was wearing when she entered the room of Resident #15 and #16. She stated she just thought she would have to change both when leaving the room. She commented that everything changed so much. A review of the facility's policy on Isolation- Categories of Transmission Based Precautions updated November 2020 revealed it was the facility's policy that appropriate precautions shall be used either at all times (standard precautions) or for individuals who were documented or suspected to have infections or communicable diseases that could be transmitted to others (Transmission Based Precautions). TBP's would be used whenever measures more stringent that standard precautions were needed to prevent the spread of infection. PPE use for TBP's included the use of gloves when caring for a resident. The policy instructed them to remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. For gown use, a gown was to be worn when entering the room if there was an anticipation that clothing would have substantial contact with an actively infected resident. The gown was to be removed before leaving the resident's environment. Under droplet precautions, the policy directed the staff to wear a mask when working with the resident. It did not specifically direct them on when and how to remove. The policy provided by the facility did not provide direction on how to don and doff PPE when used for residents in TBP's. A review of Centers for Disease Control's (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 05/08/23 revealed source control was recommended by those residing or working on a unit or area of the facility experiencing a Covid-19 outbreak. Source control referred to use of respirators or well-fitting facemask or cloth masks to cover a person ' s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Healthcare Providers (HCP) who enter the room of a resident with suspected or confirmed Covid-19 (SARS-CoV-2) infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N 95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Use of well-fitting masks in healthcare settings are an important strategy to prevent the spread of respiratory viruses. Well-fitting masks can help block virus particles from reaching the nose and mouth of the wearer (wearer protection) and, if someone is ill, help block virus particles coming out of their nose and mouth from reaching others (source control). Masking by healthcare personnel as part of Standard and Transmission-Based Precautions and by ill individuals as part of respiratory hygiene and cough etiquette (i.e., for people with symptoms) are already well-described. A review of the Sequence for Putting on PPE and How to Safely Remove PPE from the CDC revealed for mask or respirator use, the ties or elastic bands were to be placed at the middle of the head and neck. It did not direct to apply the N 95 mask (respirator) over top of a surgical/ procedure mask. Under How to Safely Remove PPE, the outside of goggles and face shields were considered contaminated. If the hands got contaminated during goggle or face shield removal, they directed the washing of hands immediately. If the item was re-usable, they were to be placed in a designated receptacle for reprocessing or otherwise discarded in a waste container. It did not direct the staff to place them on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 3 of 4 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 365750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Somerset Inc. 411 South Columbus Street Somerset, OH 43783 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 top of a housekeeping cart without disinfecting. Under the removal of a mask or respirator, the front of the mask or respirator was considered contaminated. If your hands get contaminated during removal, they were to wash their hands immediately or use an alcohol based hand sanitizer. They were directed to wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE. Residents Affected - Many This deficiency represents non-compliance investigated under Complaint Number OH00147149. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365750 If continuation sheet Page 4 of 4