Health inspection·December 7, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and procedure, observation, review of facility documentation and clinical records, and staff interviews, it was determined that the facility failed to ensure infection control and prevention was implemented during a COVID-19 outbreak on two of two units observed (First and Second Floor Unit). Residents Affected - Some Findings include: Review of facility policy and procedure titled Response to an Outbreak of COVID-19, revised November 20, 2023, revealed Identification of a single new case (resident or staff) 14 days after the last known case would meet the criteria for a new outbreak and prompt the need for an outbreak response. Further review of this policy revealed Managing exposed residents and employees as part of the unit-based or facility-wide response: Employees working in COVID rooms/areas must wear full PPE, including a full-face shield (goggles are not acceptable) gown, gloves and N-95. Further review of this policy revealed For full outbreak, on day 1-10, staff caring for residents in the yellow zone should use full PPE (gloves, gowns, eye protection using a full-face shield, and N-95. The facility experienced a COVID-19 outbreak beginning on November 20, 2023 and continuing through December 7, 2023. This outbreak consisted of a total of thirty-three (33) residents. Interview with Nursing Home Administrator and Director of Nursing on December 4, 2023, at 9:00 a.m. revealed that all staff and visitors must wear full PPE (personal protective equipment) on both the first floor and second floor nursing units due to the COVID-19 outbreak. This interview further revealed that staff were to remove PPE prior to leaving a COVID-19 positive resident's room and wash the face shield for reuse. Observation on December 4, 2023, at 11:17 a.m. on the second-floor nursing unit revealed a dietary aide preparing meal trays with a face shield pulled to the top of the staff person's head. Observation on December 4, 2023, at 11:24 a.m. on the second-floor nursing unit revealed Employee E4 exit a COVID-19 positive resident room and enter a resident room with COVID-19 negative residents without changing any PPE. This observation further revealed Employee E4 exit the COVID-19 negative room, remove the PPE gown and walk up the hallway to dispose of the gown without donning another gown. Observation on December 4, 2023, at 11:27 a.m. revealed Physical Therapist Employee E5 exit a COVID-19 positive resident room without removing PPE and walked in the hallway to the elevator area and removed the PPE at the elevator area. Observation on December 4, 2023, at 11:33 a.m. on the second-floor nursing unit revealed housekeeping Employee E7 remove PPE gown after cleaning a COVID-19 positive room, don a new gown at the housekeeping cart without washing hands or face shield. Housekeeping Employee E7 returned to the housekeeping cart and proceeded to continue to empty trash in the spa room without washing hands and/or washing face shield or changing mask or face shield. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395806 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 395806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anne's Retirement Community 3952 Columbia Avenue Columbia, PA 17512 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 Observation on December 4, 2023, at 12:04 p.m. in the second-floor elevator revealed CNA Employee E6 enter the elevator wearing a gown and proceed to the first floor and exit the elevator on the first floor wearing the PPE gown that was worn on the second floor. Interview with CNA Employee E6 revealed employee was going to lunch. Observation on December 5, 2023, at 8:54 a.m. revealed facility physician sitting at the nurses' station desk wearing N-95 mask and goggles but no face shield. Observation on December 5, 2023, at 11:38 a.m. revealed a visitor at the second-floor elevator entrance preparing to exit the unit wearing a surgical mask and no other PPE, Visitor stated I didn't know there was COVID here. Observation on December 5, 2023, at 11:42 a.m. revealed a staff member returning from lunch; walked to the nurses' station in a surgical mask, no N-95 mask and no face shield. Employee donned N95 at the nurses' station. Observation on December 5, 2023, at 11:49 a.m. revealed staff member arrive on the second-floor nursing unit with no PPE Staff person entered the assisted dining room with no PPE then walked down the hall to the linen cart for a gown; re-entered the assisted dining room with mask and gown but no face shield. Staff person then exited the assisted dining room and walked down a second hallway and returned to the dining room without wearing the required face shield. Observation on December 5, 2023, at 11:55 a.m. revealed a staff person assisting a resident to eat in the assisted dining room without wearing the required face shield. Observation on all days of the survey revealed donning and doffing of all PPE occurring in the same location at the entrance to the second-floor elevator area. Interview with Licensed Employee E8, infection preventionist on December 6, 2023, at 1:30 p.m. revealed the facility was aware of breaches in infection control protocol due to low staffing. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on December 7, 2023, at 10:00 a.m. Review of Resident 53's clinical records revealed resident tested positive for COVID (An infectious disease caused by a virus named SARS-CoV-2) on November 26, 2023, and was on contact isolation (Used when a patient has an infectious disease that may be spread by touching either the patient or other objects that patient has handled). In addition to standard precautions Observation of Resident 53's door revealed signage indicating as follows: For all staff - Contact and Droplet Precaution in addition to standard precautions. The same signage also revealed Before entering the room, perform hand hygiene, put on a gown, put on a mask, put on protective eyewear, perform hand hygiene, and put on gloves. On leaving the room, dispose of gloves, dispose of gown, perform hand hygiene, remove protective eyewear, dispose of the mask, and perform hand hygiene. Observation was conducted on December 4, 2023, at 12:08 p.m of meal service. Unlicensed employee E3 was observed entering Resident 53's room with a gown, mask, and face shield. Employee E3 assisted the resident with setting up meals and touching the resident and the table. Employee E3 was observed leaving Resident 53's room and then went to assist another resident who was negative for COVID (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395806 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 395806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anne's Retirement Community 3952 Columbia Avenue Columbia, PA 17512 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 without changing their gown and performing hand hygiene. Employee E3 was observed leaving the room and assisted two other residents on the same unit without changing gowns. At 12:14 p.m., Employee E3 was observed leaving the C- Unit with the same gown then came back at 12:16 p.m. and proceeded to assist two other residents. Interview with Employee E3 was conducted on December 4, 2023, at 12:18 p.m. Employee E3 confirmed not changing PPE (Personal Protective Equipment) after assisting Resident 53, a positive COVID resident before leaving the room and assisting other residents who were negative for COVID. Employee E3 stated, I forgot [resident name] was COVID-positive. The above information was discussed with the Nursing Home Administrator on December 7, 2023, at 9:45 a.m. The facility failed to ensure, that infection control and prevention were practiced on the First floor Unit. 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 2/10/23. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 2/10/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395806 If continuation sheet Page 4 of 4