Health inspection·September 4, 2024

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 medical record review, observation, staff interview and review of facility policy, the facility failed to ensure staff followed infection control procedures including the proper use of personal protective equipment (PPE) to prevent transmission of COVID 19. This had the potential to affect all thirteen residents (Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, and Resident #26) residing in Resident #26's assigned care area. Residents Affected - Some Findings include: Resident #26 was admitted on [DATE] with diagnoses that included Parkinson's disease without dyskinesia, dysphasia following cerebral infarction, chronic kidney disease, congestive heart failure, atrial fibrillation, cardiomyopathy, gastro-esophageal reflux disease without esophagitis, and depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact with minimal depression. Resident #26 had no impairment of range of motion in upper or lower extremities and uses a walker. Resident #26 was independent for eating and oral hygiene. Resident #26 required set-up/clean-up assistance for toileting, personal hygiene, and dressing and required partial/moderate assistance for showering. Resident #26 had a care plan that addressed transmission-based precautions for a positive COVID 19 test. The care plan also addressed Resident #26's preference for door to room to be open at all times due to the fear Resident #26 has when the door is closed. 09/03/24 10:30 A.M. interview with Licensed Practical Nurse (LPN) #460 confirmed Resident #26 was placed in airborne isolation on 08/31/24 after becoming symptomatic and then testing positive for COVID 19. 09/03/24 at 12:33 P.M. observation of Resident #26's door revealed it was wide open with the resident in bed watching TV. Observed State Tested Nursing Assistant (STNA) #410 walk into Resident #26's room with only a surgical face mask on. STNA #410 then left the room and went into Resident #24 and #25's room asking if the residents were done with their trays. STNA #410 did not change her mask or perform any hand hygiene. Interview on 09/03/24 at 12:42 P.M. with STNA #400 confirmed Resident #26's door was open. STNA #400 stated Resident #26 doesn't like his door closed; he was afraid when it was closed, and he opens it back up. STNA #400 confirmed STNA #410 went into Resident #26's with just a surgical face mask 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: 366196 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 366196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark South Inc. 17 Forry Street Newark, OH 43055 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)