Inspection·June 9, 2022

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3. The meal delivery was observed for the lunch meal on 3 East beginning on 06/06/22 at 12:32 P.M. STNA #659 was observed delivering room trays. STNA #659 donned disposable gloves and began to deliver trays to Resident's #119, #23 and #11 without removing the gloves or washing her hands. STNA #659 then went to the kitchen to obtain a pitcher of juice and returned wearing the same gloves and proceeded to deliver trays to Resident #52. STNA #659 headed back to the kitchen to obtain milk and continued to pass trays to Resident #103 all wearing the same gloves. Then STNA #659 passed a tray to Resident #188 with the same gloves. STNA #659 moved Resident #103's over bed table closer and raised the head of the bed using the controls. STNA #659 exited the room to obtain help by STNA #788. STNA #788 informed STNA #659 Resident #188 was on contact precautions for Clostridium difficile (C-diff severe diarrhea and inflammation of the colon) bacterium that was highly contagious. STNA #659 said she was not aware the resident was in contact isolation despite the cart with the contact precautions sign posted. STNA #659 was educated by STNA #788 on not wearing gloves when delivering trays to residents and using alcohol based hand rub or washing the hands between trays and to wear the gown and gloves when delivering to residents in rooms while on contact precautions and removing the personal protective equipment prior to leaving the room. Residents Affected - Many Observations on 06/06/22 at 12:04 P.M. revealed Resident #188 was in contact isolation for C-diff. Resident #188's son and daughter in law were in the room only wearing surgical masks. They were sitting down in chairs. Interview with LPN #512 reported the family should have been wearing gowns and gloves when in the room. LPN #512 went down to the room and educated the family. Review of the note dated 06/06/22 indicated LPN #645 was on 3 East and observed family members in Resident #188's room. Resident #188 was on contact precautions. The proper sign was displayed and appropriate personal protective equipment was available for staff and visitors to utilize. The family was observed without PPE on while in Resident #188's room. LPN #645 educated the family on what contact precautions were and what PPE needed to be worn. On 06/07/22 a note to all staff was written by the director of nursing related to personal protective equipment use in isolation rooms. Interview with the director of nursing on 06/07/22 10:50 A.M. reported STNA #659 was educated this morning on appropriate glove use and use of personal protective equipment. 2. Record review of Resident #33 revealed and admission date of 03/15/21. Diagnosis including Chronic Obstructive Pulmonary Disease (COPD). Review of the physician orders for June 2022 revealed an order to change cannula and tubing for oxygen one time a day on Monday. Observation on 06/06/22 at 10:00 A.M. revealed Resident #33's oxygen tubing was not dated. Resident #33 had oxygen in place via nasal cannula. Record review of Resident #67 revealed admission date of 11/01/11. Diagnosis orthopnea (difficulty breathing when lying down) and shortness of breath upon exertion. Review of the physician orders from June 2022 revealed change oxygen tubing very night shift on Mondays. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366071 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 366071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MT Alverna Home Inc 6765 State Road Parma, OH 44134 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 - Many Observation on 06/06/22 at 10:10 A.M. revealed Resident #67's oxygen tubing was not dated. Resident #67 had oxygen in place via nasal cannula. Record review of Resident #79 admission date of 08/12/21. Diagnosis included COPD and emphysema. Review of the physician orders from June 2022 revealed change oxygen tubing every night shift on Mondays. Observation on 06/06/22 at 11:21 A.M. revealed Resident #79's oxygen tubing was not dated. Resident #79 had oxygen in place via nasal cannula. Interview on 06/06/22 at 12:38 P.M. with Director of Nursing (DON) verified Resident #33, #67 and #79 oxygen tubing were not dated. DON verified oxygen tubing was to be changed weekly and dated on Monday night shift. Based on observations, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore eye protection to prevent the spread of Covid-19. This had the potential to affect 135 residents residing at the facility. The facility also failed to ensure oxygen tubing was changed weekly affecting Resident #33, #67 and #79 out of 38 residents receiving oxygen. The facility also failed to ensure the proper use of gloves during meal pass. This affected 135 residents in the facility. 1. Observation on 06/06/22 at 11:30 A.M. of State Tested Nursing Assistant (STNA) #791 walking out of a resident's room revealed STNA #791 was wearing an N95 mask and no eyewear. Interview at this time, with STNA #791 revealed she was an agency nurse and the facility gave her an N95 mask to wear at the start of her shift. Observation and interview on 06/06/22 of STNA #791 at 2:39 P.M., revealed she was wearing an N95 and eye protection. STNA#791 stated at 2:00 P.M. she was given eye protection to wear for the rest of her shift. Observation and interview on 06/06/22 of LPN #714 at 2:41 P.M. revealed she was wearing an N95 and eye protection. Interview at this time with LPN #714 revealed about an hour prior she was given eye protection wear. Interview on 06/06/22 at 3:04 P.M. with the Director of Nursing (DON) verified the findings and stated the facility followed the CDC guidelines and eye protection was required during direct care. Observation and interview on 06/07/22 at 9:57 A M. revealed STNA #707 walking down the 220-hallway wearing an N95 mask with no eye protection. STNA #707 verified the lack of eye protection and said the facility allowed the use of eye protection when needed. Observation and interview at 06/07/22 10:37A.M with Licensed Practical Nurse (LPN) # 714 revealed she was sitting at the nurses' station wearing an N95 mask and no eye protection. Interview at this time with LPN #714 stated she had not worn eye protection in several month. Interview on 06/08/22 at 1:00 P.M. with the facility Infection Control Preventionist (ICP) revealed the facility was in outbreak status due a positive staff on 05/31/22 and 06/06/22 and would continue outbreak status through 06/23/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366071 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 366071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MT Alverna Home Inc 6765 State Road Parma, OH 44134 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 Review of the facility's COVID-19 staff tracking list revealed Occupational Therapist #790 tested positive on 05/31/22 and laundry staff #578 tested positive on 06/06/22. Review of the Cuyahoga County community transmission rate at data.cms.gov on 06/06/22 revealed the county transmission rate for COVID-19 was high for week of 06/01/22 through 06/07/22. Residents Affected - Many Review of the CDC Covid-19 guidance updated 02/02/22 revealed health care providers (HCP) working in facilities located in areas with substantial or high transmission should wear eye protection (goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Review of the facility policy titled COVID-19 infection control in long term care facilities revealed all heath care personnel must wear eye protection when caring for residents in transmission-based precautions (TBP). Fully vaccinated health care personnel may choose not to wear eye-protection regardless of the county positivity rates, unless a resident is in TBP due to symptoms of COVID-19 exposure or positive diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366071 If continuation sheet Page 4 of 4