Newark Care and Rehab COVID-19 Report

department of health and human services form approved
centers for medicare & medicaid services omb no. 0938-0391
STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

DEFICIENCIES PROVIDER/SUPPLIER/CLIA COMPLETED
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365425 08/10/2020
b. wing
name of provider or supplier street address, city, state, zip code

NEWARK CARE AND REHABILITATION 75 MCMILLEN DRIVE
NEWARK OH, 43055
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICICIENCY MUST BEPRECEDED PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO
TAG BY FULL TAG CROSS-REFERENCED TO THE APPROPRIATE N
F 0000 INITIAL COMMENTS F 0000
COVID 19 FOCUSED INFECTION

CONTROL SURVEY
COMPLAINT INVESTIGATION
MASTER COMPLAINT NUMBER
OH00114661
COMPLAINT NUMBER OH00114591
ADMINISTRATOR: Scott Ratliff, #5282

CERTIFIED BED CAPACITY: 173
CENSUS IN HOUSE: 118
The following deficiency is based on the

complaint investigation completed on
08/10/20.
At the time of the Complaint Investigation,

a COVID 19 Focused Infection Control
Survey was also completed with a related
deficiency.
laboratory director's or provider/supplier representative's signature title (x6) date
WARREN.RATLIFF 09/04/2020
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.
form cms-2567(02-99) previous versions obsolete Event:1VYW11 Facility ID:OH00686 if continuation sheet Page 1 of 39

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F 0880 Continued From page 1 F 0880

F 0880 483.80(a)(1)(2)(4)(e)(f) Infection Prevention F 0880 Newark Care and Rehabilitation – POC 09/02/2020
SS=L & Control
§483.80 Infection Control Newark Care and Rehabilitation wishes to point
The facility must establish and maintain an out to any person who reviews this document
infection prevention and control program that we do not necessarily agree with the
designed to provide a safe, sanitary and citations with which we were cited. However,
comfortable environment and to help the law requires us to prepare a plan of
prevent the development and transmission correction for the citations regardless of
of communicable diseases and infections. whether we agree with them. Thus, we have
prepared such a plan below. Please note,
§483.80(a) Infection prevention and control though, that this plan does not constitute an
program. admission that the citations are either legally
The facility must establish an infection or factually correct. This plan of correction is
prevention and control program (IPCP) that not meant to establish any standard of care,
must include, at a minimum, the following contract, obligation, or position, and Newark
elements: Care and Rehabilitation reserves all rights to
raise all possible contentions and defenses in
§483.80(a)(1) A system for preventing, any civil or criminal claim, action, or
identifying, reporting, investigating, and proceeding.
controlling infections and communicable Please accept September 2, 2020 as the
diseases for all residents, staff, volunteers, facility's allegation of compliance date.
visitors, and other individuals providing
services under a contractual arrangement Facility Position: The reviewer of this citation
based upon the facility assessment should note the following:
conducted according to §483.70(e) and The facility has extensive infection control
following accepted national standards; policies and procedures in place, including
those specifically addressing the care and
§483.80(a)(2) Written standards, policies, monitoring of individuals with COVID-19 and
and procedures for the program, which those who may have been exposed to
must include, but are not limited to: COVID-19. The facility followed CDC Guidance
(i) A system of surveillance designed to on exposure and contact tracing when it
identify possible communicable diseases became aware a former staff member tested
or positive for COVID-19 more than 5 days after
infections before they can spread to other she worked. According to CDC guidance,
persons in the facility; facilities are required to, "Determine which
(ii) When and to whom possible incidents residents received direct care from and which

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of communicable disease or infections health care personnel had unprotected
should be reported; exposure to health care personnel who worked
(iii) Standard and transmission-based with symptoms consistent with COVID-19 or in
precautions to be followed to prevent the 48 hours prior to symptom onset."
spread of infections; Plan of Correction: Although we do not
(iv)When and how isolation should be used necessarily agree with the allegations made in
for a resident; including but not limited to: this citation, we are required by law to provide
(A) The type and duration of the isolation, a plan of correction. Our plan of correction is
depending upon the infectious agent or as follows
organism involved, and F880
(B) A requirement that the isolation should As noted in the 2567, Resident #206 was
be the least restrictive possible for the discharged to her home on 7/7/20. Residents
resident under the circumstances. #70, #202, #207, #208, #49 no longer reside in
(v) The circumstances under which the the facility and did not at that time of the
facility must prohibit employees with a survey. Residents #10 and #29 are both
communicable disease or infected skin recovered and reside in non-covid units.
lesions from direct contact with residents On 07/30/20, the facility developed QIO Action
or their food, if direct contact will transmit Plan focused on testing of residents in a more
the disease; and timely and efficient manner to include test
(vi)The hand hygiene procedures to be frequency, rapid testing, online requisition
followed by staff involved in direct resident processing for faster turnaround times. It will
contact. provide updates to Ohio QIO coordinator.
As of 08/06/20, Units 5, 6, and 7 remain the
§483.80(a)(4) A system for recording COVID-19 unit. It currently has 22 residents
incidents identified under the facility's who remain in transmission-based precautions.
IPCP and the corrective actions taken by The quarantine unit currently has nine (9)
the facility. residents.
As of 08/06/20, the facility has 75 COVID-19
§483.80(e) Linens. tests available in house with an additional 200
Personnel must handle, store, process, tests on order, which will be used for
and transport linens so as to prevent the symptomatic residents and to test residents if
spread of infection. new cases develop in the future.
On 08/07/20, the Director of Nursing (DON),
§483.80(f) Annual review. who is also the facility infection preventionist,
The facility will conduct an annual review of audited all resident rooms to validate isolation
its IPCP and update their program, as procedures were correctly implemented,

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necessary. including location of residents and
This STANDARD is not met as evidenced implementation of isolation precautions. The
by: audit revealed all isolation precautions were
Based on the unprecedented global correctly implemented.
pandemic that resulted in the Presidential On 08/07/20 the facility implemented a new
declaration of a State of National COVID 19 Testing and Contract Tracing policy.
Emergency dated 03/13/20, Nursing Home The policy identified the facility will determine
Guidance from the Centers for Disease which residents received direct care from and
Control (CDC), review of the facility's which staff had unprotected exposure to staff
policies and procedure, review of the member who worked with symptoms
facility's Coronavirus (COVID-19) outbreak consistent with COVID-19 or in the 48 hours
timeline, review of daily resident census prior to symptom onset, or any staff or
reports, record review, staff and family residents who had exposure to a resident with
interview, the facility failed to perform symptoms of COVID-19. Residents who had
adequate contact tracing to properly exposure to symptomatic resident or were
identify, quarantine, and appropriately test cared for by symptomatic staff will be
all residents with known exposure to a restricted to their room and be cared for using
staff member who had tested positive for all recommended COVID-19 PPE until results
COVID-19. This resulted in Immediate of health care provider (HCP) COVID-19 testing
Jeopardy on 07/01/20 when Licensed are known. If the HCP or resident is diagnosed
Practical Nurse (LPN) #3 notified the with COVID-19, exposed residents will be
facility on 07/01/20 that she tested positive cared for using all recommended COVID-19
for COVID-19. LPN #3 last worked in the PPE until 14 days after last exposure and
facility on their quarantine unit (Units 6 and prioritized for testing if they develop symptoms,
7) on 06/25/20. Residents #10, #202, even if they have previously tested as negative.
#206 and #207 all resided on the Exposed staff will be assessed and evaluated
quarantine unit on 06/25/20 but had been for work exclusion.
moved to other units in the facility between On 8/7/20, the DON began mandatory staff
06/26/20 and 06/30/20. They had been in-service education on COVID-19 procedures
placed in semi-private rooms with four with emphasis on contact tracing, quarantine
other residents (Resident #29, #49, #70, and testing requirements and frequency. All
and #208) resulting in spread of COVID-19 education was completed by 8/10/20 for
and death of residents. This resulted in licensed nurses, nurse aides, dietary and
the likelihood to cause serious harm injury housekeeping, therapists and additional staff.
or death and affected eight residents 8/10/20 will not be permitted to work until the
(Residents #10, #29, #49, #70, #202, in-servicing is completed. As of 08/10/20, 120

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#206, #207, and #208) with the potential to staff had received in-service training. Twenty
affect all the residents in the facility. (20) staff had not received in-service training.
The DON or assistant director of nursing
On 08/06/20 at 9:15 A.M., the (ADON) will call the 20 staff by the end of the
Administrator was notified Immediate day 08/10/20 and provide verbal in service
Jeopardy began on 07/01/20 when the training. These 20 staff will also receive in
facility had been made aware LPN #3 person training when they return to work.
tested positive for COVID-19 after she last On 08/07/20 the DON and Administrator were
worked the facility's quarantine unit on in-serviced by the Chief Clinical Officer on
06/25/20. The facility failed to perform contact tracing guidance and testing of all
adequate contact tracing to identify all residents when an outbreak occurs.
residents who had been exposed to LPN On 08/07/20 the DON began to monitor all
#3 when she worked on 06/25/20. This newly diagnosed residents and newly admitted
resulted in four residents (Resident #10, residents or readmitted residents to ensure
#202, #206, and #207), who had been they are placed in appropriate
moved off the quarantine unit since their transmission-based precautions according to
exposure, not being immediately their diagnosis and contract tracing is
quarantined or tested. All four residents complete where applicable.
were allowed to remain in a semi-private Audits will be completed weekly x 4 weeks or
room with another resident after their until otherwise directed by the QAPI
known exposure had occurred. Resident committee.
#206 moved again and was placed in a On 08/07/20 an ad hoc QAPI committee
new room with another roommate on meeting was held with the medical director to
07/03/20 (two days after the facility had review the
been made aware of her exposure) when preliminary survey findings and internal action
the facility was clearing out a unit to be plan.
used as their new quarantine unit. On 08/10/20 the DON or designee began
Resident #206 was never tested for interview audits of a minimum of 3-5 staff
COVID-19 after she had been exposed and members weekly x 4 weeks to evaluate
was discharged home on 07/07/20 not retention of Inservice content.
knowing if she had COVID-19 or not. On 08/10/20 the facility had 208 COVID-19 test
Residents #10, #202, and #207 were not kits onsite at the facility for needed testing.
immediately tested for COVID-19 when the The Directed Plan of Correction identified by
other residents who resided on the the Ohio Department of Health will be
quarantine unit got tested for COVID-19 on completed by August 28, 2020. (Attachment 1)
07/01/20. Their testing was not completed Beginning 8/10/20, the Administrator and

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until 07/03/20 when the facility started DON/designee will conduct random audits 5x
testing the residents on the remaining weekly for four weeks, then 3 times weekly for
units in the building. The facility's failure to 4 weeks, then weekly for 4 weeks to ensure
immediately quarantine and test those any residents exposed from close contact with
residents likely contributed to the a COVID positive individual starting from 48
COVID-19 outbreak that spread throughout hours before the individual experienced
the facility infecting 71 residents with symptoms of COVID-19 or tested positive for
COVID-19 resulting in 20 deaths. COVID-19 are quarantined with increased
monitoring of signs and symptoms of
The Immediate Jeopardy was removed on COVID-19 and testing, as indicated by the
08/10/20 when the facility implemented the local health department.
following correction actions: Findings will be forwarded to the QAPI
committee for further review and
• On 07/30/20, the facility developed recommendations.
QIO Action Plan focused on testing of
residents in a more timely and efficient
manner to include test frequency, rapid
testing, online requisition processing for
faster turnaround times. It will provide
updates to Ohio QIO coordinator.
• As of 08/06/20, Units 5, 6, and 7

remain the COVID-19 unit. It currently has
22 residents who remain in
transmission-based precautions. The
quarantine unit currently has nine (9)
residents.
• As of 08/06/20, the facility has 75

COVID-19 tests available in house with an
additional 200 tests on order, which will be
used for symptomatic residents and to test
residents if new cases develop in the
future.
• On 08/07/20, the Director of Nursing

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(DON), who is also the facility infection
preventionist, audited all resident rooms to
validate isolation procedures were correctly
implemented, including location of
residents and implementation of isolation
precautions. The audit revealed all
isolation precautions were correctly
implemented.
• On 08/07/20 the facility implemented a

new COVID 19 Testing and Contract
Tracing policy. The policy identified the
facility will determine which residents
received direct care from and which staff
had unprotected exposure to staff member
who worked with symptoms consistent
with COVID-19 or in the 48 hours prior to
symptom onset, or any staff or residents
who had exposure to a resident with
symptoms of COVID-19. Residents who
had exposure to symptomatic resident or
were cared for by symptomatic staff will be
restricted to their room and be cared for
using all recommended COVID-19 PPE
until results of health care provider (HCP)
COVID-19 testing are known. If the HCP or
resident is diagnosed with COVID-19,
exposed residents will be cared for using
all recommended COVID-19 PPE until 14
days after last exposure and prioritized for
testing if they develop symptoms, even if
they have previously tested as negative.
Exposed staff will be assessed and
evaluated for work exclusion.
• On 8/7/20, the DON began mandatory

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staff in-service education on COVID-19
procedures with emphasis on contact
tracing, quarantine and testing
requirements and frequency. All education
will be completed by 8/10/20 for licensed
nurses, nurse aides, dietary and
housekeeping, therapists and additional
staff. Staff not educated by 8/10/20 will
not be permitted to work until the
in-servicing is completed. As of 08/10/20,
120 staff had received in-service training.
Twenty (20) staff had not received
in-service training. The DON or assistant
director of nursing (ADON) will call the 20
staff by the end of the day 08/10/20 and
provide verbal in-service training. These 20
staff will also receive in person training
when they return to work.
• On 08/07/20 the DON and

Administrator were in-serviced by the Chief
Clinical Officer on contact tracing guidance
and testing of all residents when an
outbreak occurs.
• On 08/07/20 the DON will begin to

monitor all newly diagnosed residents and
newly admitted residents or readmitted
residents to ensure they are placed in
appropriate transmission-based
precautions according to their diagnosis
and contract tracing is complete where
applicable. Audits will be completed
weekly x 4 weeks or until otherwise
directed by the QAPI committee.

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• On 08/07/20 an ad hoc QAPI
committee meeting was held with the
medical director to review the preliminary
survey findings and internal action plan.
• On 08/10/20 the DON or designee will

conduct interview audits of a minimum of 3
-5 staff members weekly x 4 weeks to
evaluate retention of Inservice content.
• On 08/10/20 between 10:55 A.M. and

12:10 P.M. twelve (12) staff were
interviewed and verified they had received
in-service training in the areas of contact
tracing, quarantine and testing
requirements and frequency. All staff
interviewed were knowledgeable on the
in-service training.
• On 08/10/20 the facility had 208

COVID-19 test kits onsite at the facility for
needed testing.
• Onsite observations on 08/10/20

revealed all staff were wearing appropriate
PPE including N95 face masks and face
shields.
Although the Immediate Jeopardy was

removed on 08/10/20, the facility remained
out of compliance at Severity Level 2 (no
actual harm with potential for more than
minimal harm that is not Immediate
Jeopardy) as the facility was still in the
process of implementing their corrective
actions and monitoring to ensure on-going

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compliance.
Findings include:
Review of the Department of Health and

Human Services, Centers for Medicare and
Medicaid (CMS) Memo QSO 20-20-ALL
dated 03/03/20 revealed CMS is
committed to taking critical steps to
ensure America ' s healthcare facilities are
prepared to respond to the threat of
disease caused by the 2019 Novel
Coronavirus (COVID-19). As part of CMS
guidance, the Focused Infection Control
Survey was made available to every
provider in the country to make them
aware of infection control priorities during
this time of crisis, and providers may
perform a voluntary self-assessment of
their ability to meet these priorities. The
QSO Memo included additional
instructions to nursing homes.
"We are disseminating the Infection

Control survey developed by CMS and
CDC so facilities can educate themselves
on the latest practices and expectations.
We expect facilities to use this new
process, in conjunction with the latest
guidance from CDC, to perform a voluntary
self-assessment of their ability to prevent
the transmission of COVID-19. We also
encourage nursing homes to voluntarily
share the results of this assessment with
their state or local health department
Healthcare-Associated Infections (HAI)

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Program".
"Furthermore, we remind facilities that they

are required to have a system of
surveillance designed to identify possible
communicable diseases or infections
before they can spread to other persons in
the facility, and when and whom possible
incidents of communicable diseases or
infections should be reported (42 CFR
483.80 (a) (2) (i) and (ii)".
1. Review of the facility's timeline of their

COVID-19 outbreak confirmed they were
first notified by LPN #3 on 07/01/20 that
she had been tested for COVID-19 the day
before and her test results came back
positive. LPN #3 was indicated to have
been a nurse who worked Units 6 and 7
(quarantine unit) on an as needed basis
(prn). The facility started their timeline on
06/25/20, as that was the date LPN #3 last
worked. The facility started COVID-19
testing for the residents who currently
resided on Units 6 and 7 on 07/01/20. On
07/03/20, six of those residents had tested
positive for COVID-19 after their exposure
to LPN #3 occurred. The timeline
indicated on 07/03/20 room changes were
made on Unit 5. Unit 5 was cleared out to
allow the facility to utilize it as their new
COVID-19 unit. Those residents who
resided on the quarantine unit that were
tested on 07/01/20 and found to be
negative for COVID-19 were moved to Unit
5. The facility designated Units 6 and 7 as

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their COVID-19 units when the first six
residents tested positive for COVID-19.
Those on Units 6 and 7 that tested
negative for COVID-19 and still had
quarantine days remaining were moved to
Unit 5 when it was made the new
quarantine unit.
The timeline also reflected those residents,

who had resided on Units 6 and 7 on
06/25/20 but had been moved to other
units within the facility between 06/26/20
and 06/30/20. There was a total of four
residents (Residents #10, #202, #206 and
#207) who were identified as having been
moved off Units 6 and 7 between that time.
A focused review of those four residents

(Residents #10, #202, #206, and #207)
was completed as there was no indication
on the facility's timeline of those residents
being placed back onto the quarantine unit
after their known exposure had occurred.
The facility also was not able to provide
any COVID-19 test results to show those
residents were included within the initial
testing that had been done on those
residents that resided on Unit 6 and 7.
1(a). A review of Resident #206's

electronic health record (EHR) revealed
she was originally admitted to the facility
on 12/20/17. Her most recent admission
date was 06/17/20. Her diagnoses
included Type II Diabetes Mellitus (Adult
onset), asthma, chronic kidney disease-

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stage 4 (severe), and hypertension.
A review of Resident #206's census report

revealed she resided on Unit 6/7 on
06/25/20 when LPN #3 last worked and
potentially exposed all the residents on
that unit to COVID-19. She remained on
that unit until 06/30/20 when she was
moved to Unit 5 (a rehabilitation/ long term
care unit at that time). There was no
evidence of any room changes occurring
on 07/01/20 when it had been known by
the facility the resident had been possibly
exposed to COVID-19 through LPN #3.
She was moved again on 07/03/20 from
Unit 5 when the facility was clearing that
unit off to make room for their new
quarantine unit. Review of the resident's
record revealed Resident #206 was not
retained on Unit 5 despite her having had a
potential exposure from a staff member
that tested positive for COVID-19 that
should have required her to have a
quarantine period of 14 days after the last
date of her exposure.
Resident #206's medical record provided

no evidence of her being tested for
COVID-19 after her known exposure on
06/25/20. She did not get tested when the
other residents who resided on Unit 6 and
7 with her were tested after their known
exposure.
A review of Resident #206's progress notes

provided no documentation about her being

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tested for COVID-19 or an explanation as
to why testing had not been completed.
She was discharged home from the facility
on 07/07/20 never being tested to know
whether she contracted COVID-19 from her
exposure.
On 08/04/20 at 8:49 A.M., the surveyor

received an email response from the
Administrator with a follow up phone call
confirming they did not have any evidence
of a COVID-19 test being completed on
Resident #206. He acknowledged she
was one of the 23 residents that resided
on Units 6 and 7 on 06/25/20 when LPN #3
worked shortly before she tested positive
for COVID-19, potentially exposing all the
residents on that unit. The Administrator
stated the resident was abruptly
discharged to home on 07/07/20 before
they could test her. He was not able to
explain why she could not have been
tested on 07/01/20 when the other
residents who resided on Units 6 and 7
were tested.
On 08/05/20 at 12:46 P.M., a phone

interview with LPN #12 revealed the facility
tested the residents that still resided on
Units 6 and 7 first, before testing other
residents on other units. She denied
Resident #206 was included in the testing
of those residents on 07/01/20 despite her
being one of the residents who resided on
Units 6 and 7 on 06/25/20 when LPN #3
last worked and possibly exposed them to

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COVID-19. She stated if the residents had
been moved off those units between
06/26/20 and 06/30/20, they would have
been tested when their respective units
were tested. When asked why those
residents were not put back into
quarantine after their known exposure, she
replied they were following protocol and
CDC guidelines. She indicated those
residents that were taken off Units 6 and 7
between 06/26/20 and 06/30/20 completed
their initial 14-day quarantine period and
were not having symptoms at the time
they were moved. She did not feel their
exposure to LPN #3 on 06/25/20 and risk
they may contract COVID-19 warranted
the need for them to be placed back into
quarantine for another 14 days. When
asked why Resident #206 would have been
taken off Unit 5 on 07/03/20 when the
facility was making that their new
quarantine unit and her having her recent
exposure to a positive staff member with
COVID-19 she again stated they were
following CDC guidelines on what they
recommend them to do. She was not able
to give any specific information on what
CDC guidelines they were following.
On 08/05/20 at 10:30 A.M. a call was

placed to Resident #206's son. He
reported Resident #206 came home after
being discharged from the facility on
07/07/20 and passed out a day or two after
her discharge. He stated they sent her to
the local hospital, and she tested positive

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for COVID-19. He confirmed she had
passed away on 07/25/20 as a result of
her COVID-19 infection.
On 08/05/20 at 10:32 A.M., a return call

was received by Resident #206's daughter.
She stated she was not informed the
facility had a COVID-19 outbreak nor was
she aware the resident had been exposed
to a staff member who had tested positive
for COVID-19. She did not know whether
the resident had been tested while in the
facility. She assumed she had been as
she had not been told otherwise. She
confirmed the resident was discharged
from the facility on 07/07/20 but denied it
was at the request of the family. She
stated her brother called her on that date
and told her they were discharging the
resident. Her brother was working and
was not able to go pick her up. They
arranged for a granddaughter to go get her
and bring her home. She stated the
resident was so weak she had a fall earlier
that morning while still in the nursing home
and fell again when she got home. The
family sent her to the hospital on 07/08/20
because she was so weak, she could not
stand. The hospital immediately tested
her for COVID-19, and she tested positive.
She stated she felt they had poor
communication at the facility, and she did
not feel they kept them aware of the
resident's change in condition. She
reported the resident was placed on
BIPAP at the hospital and was admitted to

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the critical care unit (CCU), but she never
recovered. She confirmed her mother
passed away on 07/25/20.
1(b). A review of Resident #49's medical

record revealed she was admitted to the
facility on 10/16/19. Her diagnoses
included seizures, a history of a stroke,
chronic obstructive pulmonary disease,
emphysema, Alzheimer's disease,
congestive heart failure, dementia and
unspecified psychosis.
A review of Resident #49's census report

revealed she resided on Unit 4 in room
471-A from 10/16/19 through 07/14/20.
She shared a room with Resident #206
between 07/03/20 and 07/07/20. Resident
#206 was brought to her room after the
resident had been exposed to LPN #3 on
06/25/20. LPN #3 later tested positive for
COVID-19 when she was tested at a
hospital on 06/30/20.
A review of Resident #49's Coronavirus

report for July 2020 revealed the facility
was monitoring her temperature and
oxygen saturation (level of oxygen in the
blood measured by a pulse oximeter
placed on the finger) four times a day.
She was noted to start having a fever
beginning 07/13/20. Her temperature was
recorded as having been between 99.2
degrees F. and 100.4 degrees F. She had
one episode of her oxygen saturation level
being low (less than 90%) on 07/22/20

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when her reading was 89%.
A review of Resident #49's COVID-19

Person Under Investigation (PUI) Case
Report dated 07/14/20 revealed her
symptoms of COVID-19 included a fever
with a date of onset being 07/14/20. Her
exposure history was marked as having
been unknown. The course of treatment at
that time was to move her to a private
room. An updated COVID-19 PUI Case
Report dated 07/16/20 revealed the
resident was moved to the COVID-19 unit.
Full barrier precautions were in place. The
resident was indicated to previously have
been on droplet precautions. The
physician declined any further interventions
at that time.
A review of Resident #49's COVID-19 test

done on 07/14/20 revealed the results
came back on 07/16/20 showing she
tested positive for COVID-19 (11 days after
Resident #206 had been moved into her
room).
A review of Resident #49's nurses'

progress notes revealed a note dated
07/22/20 that indicated the resident was in
the active dying phase. She expired in the
facility with her family at her bedside on
07/23/20.
2 (a). A review of Resident #202's medical

record revealed she was originally admitted
to the facility on 02/07/20. Her most

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recent admission was on 06/11/20. Her
diagnoses included dementia, congestive
heart failure, chronic kidney disease- stage
4 (severe), mitral valve prolapse,
atherosclerotic heart disease, and chronic
obstructive pulmonary disease.
Review of Resident #202's census report

revealed she resided on the facility's
quarantine unit on 06/25/20 when LPN #3
(who was the first person in the facility
known to test positive for COVID-19 on
07/01/20) last worked on 06/25/20. The
census report showed she was moved
from the quarantine unit to Unit 2 in Room
224- A on 06/26/20. She was placed in
the same room as Resident #208, who
resided in room 224- B. She remained in
that room even after 07/01/20 when the
facility had known on that date that she
was potentially exposed to COVID-19 by
LPN #3 on 06/25/20.
Resident #202 was tested for COVID-19 on

07/03/20 when the residents on Unit 2
were being tested. She was tested as part
of the facility's facility wide testing after
LPN #3 was known to have tested positive
for COVID-19. Her specimen was
collected on 07/03/20. The lab received
the specimen on 07/06/20 and the results
were reported back to the facility as being
positive on 07/07/20.
While her COVID-19 test was still pending,

Resident #202 was moved onto the

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COVID-19 unit on 07/03/20 before it was
known whether she was positive for
COVID-19 and asymptomatic at that time.
She was then moved the very next day on
07/04/20 off the COVID-19 unit onto the
quarantine unit in room 514- A. On
07/07/20, they moved her again and back
on the COVID-19 unit when her COVID-19
test results were received, and she was
positive for COVID-19.
Review of a COVID-19 PUI Case Report

dated 07/07/20 revealed Resident #202
was asymptomatic, but the date of
symptom onset was listed as 07/07/20.
The course of treatment indicated the
resident had a positive COVID-19 test
come back and was moving to the
COVID-19 positive unit. She was placed in
full barrier precautions.
Resident #202's Coronavirus report for July

2020 revealed she started to have
temperatures recorded that were above 99
degrees F. on 07/08/20. On 07/09/20, her
SPO2 began to drop below 90 as well.
Her highest temperature between 07/08/20
and 07/20/20 was 99.8 degrees F. On
07/17/20, her SPO2 was recorded as
being 79%.
Review of her progress notes revealed she

had a seizure the morning of 07/08/20 with
no prior history. The physician was
notified, and new orders were received for
Keppra (anti-seizure medication) and stat

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labs. Her condition continued to decline
and on 07/13/20 she had crackles and
wheezes in her lungs and low oxygen
saturation despite being on oxygen at 5
LPM. The physician was updated, and
new orders were received for her to receive
Morphine prn. The family was updated on
her condition. She continued to decline
and started refusing everything orally. She
expired in the facility on 07/20/20.
On 08/05/20 at 12:46 P.M., an interview

with LPN #12, who was standing in for the
DON during her absence, was conducted.
She was asked why Resident #202 was
not placed back into quarantine when she
had a known exposure to LPN #3 on
06/25/20, who tested positive for COVID-19
on 06/30/20. She confirmed the facility
was aware of LPN #3 ' s positive COVID-19
status on 07/01/20. She stated they were
following CDC guidelines and protocols.
She did not feel leaving Resident #202 in
Resident #208's room after 07/01/20 (when
Resident #202 was exposed to LPN #3)
put Resident #208 at risk of getting
COVID-19 herself. She was then asked
why Resident #202 was not tested for
COVID-19 on 07/01/20 when the other
residents on Units 6 and 7 that were also
exposed to LPN #3 were tested. She
stated the resident graduated from
quarantine and they did not consider her
exposure on 06/25/20 to require a new
quarantine period. She was not able to
explain why the census in the resident's

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EHR showed she had been moved to the
COVID-19 unit without her being
symptomatic at that time and before her
test results came back. She was then
asked why Resident #202 was moved to
the quarantine unit on 07/04/20 the day
after. She thought maybe the resident had
an appointment outside the building that
would require her to be quarantined but the
nurses' progress notes did not support
that she had been out of the facility.
2 (b). A review of Resident #208's medical

record revealed her most recent admission
to the facility was on 01/13/16. Her
diagnoses included Type 2 diabetes
mellitus, hyperlipidemia, chronic kidney
disease- stage 3 (moderate), and
schizophrenia.

confirmed she shared a room with
Resident #202 between 06/26/20 and
07/03/20, after Resident #202 had been
exposed to LPN #3 on 06/25/20. She
remained in Room 224- B even after
07/01/20 when the facility had known of
Resident #202's potential exposure to
COVID-19. Resident #202 subsequently
tested positive for COVID-19 on 07/03/20
when she was tested as part of the
facility's facility wide testing.
Review of Resident #208's COVID-19

report for July 2020 revealed the facility
was checking her temperature and SPO2

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four times a day. She was noted to start
having an elevated temperature above 99.4
degrees F. when her temperature was
101.5 degrees F. on 07/02/20 (six days
after Resident #202 had moved into her
room). On 07/03/20 her temperature was
elevated three different times that day
when checked. The temperatures
recorded for that day was 101.7 degrees
F., 102.9 degrees F., and 103.2 degrees
F. On 07/04/20, her temperature was 99.5
degrees F. There were no abnormal SPO2
readings recorded.
Review of Resident #208's COVID-19 test

completed on 07/02/20 revealed she was
positive for COVID-19 and her results were
reported to the facility on 07/04/20.
Review of Resident #208's COVID-19 PUI

Case Report dated 07/02/20 revealed the
resident had a cough and fever with date of
onset of 07/02/20. Her exposure to
COVID-19 was indicated to be unknown.
The course of treatment indicated was an
x-ray along with stat labs. She was
indicated to be in isolation at that time, but
her census report showed she shared a
room with Resident #202 through 07/03/20.
The COVID-19 PUI Case Report for
07/04/20 again documented her symptoms
as an elevated temperature above 99.4 and
a cough. The course of treatment was to
send her to the local hospital.
Review of Resident #208's progress notes

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confirmed she became symptomatic of
COVID-19 on 07/02/20. The physician
was notified, and the note indicated in
addition to an x-ray and stat labs she was
placed in isolation. Her chest x-ray came
back negative. The resident's family was
updated on her condition and the plan of
action. She continued to have a fever
through 07/04/20 being medicated with
Acetaminophen. She was increasingly
weak, was having more confusion and her
SPO2 was noted to be 78%. The
physician was notified, and she was
transferred to the hospital on 07/04/20.
She was admitted to the hospital with
COVID-19 and did not return to the facility.
The resident expired on 07/05/20 as noted
by a Google search for her obituary. She
was also included on the list the facility
provided of those residents who had
COVID-19 and died.

DON in her absence, was conducted.
LPN #12 was asked why they continued to
allow Resident #208 share a room with
Resident #202, after it had been known on
07/01/20, that Resident #202 had been
exposed to a staff member that tested
positive for COVID-19. She stated they
were following guidelines and protocols
provided by CDC. She was asked to
clarify why Resident #208's COVID-19 PUI
Case Report dated 07/02/20 indicated she
was placed on isolation when there was no

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evidence in her census report showing a
room change had taken place. She was
supposed to check into that but did not
provide any additional information to
support she had a room change on
07/02/20 and it was known Resident #208
still resided in room 224 until 07/03/20.
3 (a). A review of Resident #207's medical

record revealed he was admitted to the
facility on 12/15/18. His diagnoses
included morbid obesity, atherosclerotic
heart disease, congestive heart failure,
chronic kidney disease- stage 3
(moderate), obstructive sleep apnea, Type
2 Diabetes Mellitus, hypercholesterolemia,
hypertension, and atrial fibrillation.

revealed he resided on the facility's
quarantine unit on 06/25/20 when he was
exposed to a staff member that later
tested positive for COVID-19. He was
moved to Unit 1 and placed in Room 102-
A on 06/30/20. He shared a room with
Resident #70 who was in room 102- B.
There was no evidence of Resident #207
being placed on the facility's quarantine
unit after the facility had been made aware
of Resident #207's exposure to a staff
member who tested positive for COVID-19.
The daily census report for Unit 1 on
07/02/20 confirmed they remained in the
same room with one another after 07/01/20
until Resident #207 was placed on the
facility's quarantine unit.

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Review of Resident #207's COVID-19 tests

revealed he was not tested for COVID-19
until 07/03/20 when the residents on Unit 1
were tested as part of the facility's facility
wide testing of residents. The specimen
was collected on 07/03/20 but the lab did
not receive the specimen to process it until
07/07/20 (4 days after it had been
obtained). The results were reported back
to the facility on 07/08/20 as being
negative. He was tested and positive
results were reported to the facility on
07/11/20. Resident #207 was placed on
droplet precautions on 07/10/20 as a result
of his positive COVID-19 test.

Case Report dated 07/08/20 revealed he
was noted to have a fever greater than 99.4
degrees F. The date of onset for his
symptoms was 07/08/20. His exposure
was marked as having been unknown. His
course of treatment indicated he was to be
put on droplet isolation precautions and in
a private room.
His COVID-19 report for July 2020 that

documented his temperature and SPO2
levels revealed they were being checked
four times a day. He started having a
temperature above 99 degrees F. on
07/07/20 when it was noted to be 99.3. It
was elevated again on 07/09/20 three
different times when it was recorded as
being 99 degrees F., 99.3 degrees F., and

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99.4 degrees F. His temperature was
elevated again on 07/10/20 with
temperature of 99.1 degrees F. and 99.3
degrees F. His SPO2 was low on
07/10/20 when it was recorded as being
88% when checked at 5:00 P.M. with his
oxygen at 5 liters per minute (LPM). No
additional checks were done.
A review of Resident #207's progress notes

revealed he was transferred to the hospital
on 07/10/20 and admitted. He did not
return to the facility and the facility had
him on their list of residents that died as a
result of COVID-19.

DON during her absence, was conducted.
She was asked why Resident #207 was
not placed in quarantine when it had been
known by the facility that he had
potentially been exposed to COVID-19
through LPN #3. She stated they were
following the guidelines and protocols of
the CDC. She stated he graduated from
quarantine after he completed his initial
14-day quarantine period. She did not see
the reason for him to be put back into
quarantine for 14 more days after his
known exposure to LPN #3. She was
asked why he was not tested when all the
other exposed residents that resided on
the quarantine unit were tested on
07/01/20. She stated they tested those
residents who were exposed and still on

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the quarantine unit first as they felt they
were a priority. She did not see the
importance in testing him at the same time
as the other residents despite him being
exposed at the same time. She stated
they tested all residents on the other units
throughout the facility when they got to
them. She was then asked why it took
four days after the specimen had been
collected for the lab to receive it. She
stated it was a holiday weekend and was
collected on Thursday but not picked up
until the following Monday. She was not
sure if the delay in delivery had any impact
in his results as those came back negative
and the COVID-19 test done the following
day was positive for COVID-19. She
stated the specimen was just sent in a
Fed-Ex bag that was provided by the lab.
She denied they had any instructions to
store or deliver the specimen packaged in
ice. She did not know it was
recommended to deliver it in dry ice or
other means to keep it in a temperature of
minus 94 degrees F. or below if the
delivery was going to be delayed for more
than 72 hours. She was not concerned
the resident was exposed on 06/25/20 and
his first COVID-19 test results were not
received until 07/08/20. She did not feel
leaving Resident #207 in Resident #70's
room, after he had been known to be
exposed to a staff member that tested
positive for COVID-19, put Resident #70 at
an increased risk of getting COVID-19.

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3 (b). A review of Resident #70's medical
included chronic kidney disease- stage 3
(moderate), chronic obstructive pulmonary
disease, heart failure, Type 2 Diabetes
Mellitus, hyperlipidemia, and atrial
fibrillation.

revealed he resided on Unit 1 in Room 102-
B. He remained in that room with
Resident #207 until 07/08/20 when
Resident #207 had been moved to the
quarantine unit after he developed
symptoms of COVID-19 and eventually
tested positive for COVID-19.
Review of Resident #70's COVID-19 report

for July 2020 revealed the facility was
checking his temperature and SPO2 four
times a day. He was noted to start
showing symptoms of COVID-19 on
07/12/20 as his oxygen saturation dropped
to 67%. He became symptomatic 12 days
after he started sharing a room with
Resident #207, who had been known to be
exposed to an employee who tested
positive with COVID-19. He was sent to
the hospital on 07/12/20 where he too
tested positive for COVID-19. Upon his
return from the hospital on 07/14/20, his
temperature and SPO2 continued to be
monitored daily. On 07/17/20, he was
noted to have an elevated temperature of
100.3, F. There were no other elevated

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temperatures or decreased oxygen
saturation levels before he was transferred
out to the hospital again on 07/19/20.

Case Report dated 07/04/20 revealed he
was symptomatic with a cough. His date
of onset of the symptoms was 07/04/20.
He was not known to have had any known
exposures in the past 14 days. His
course of treatment indicated he was
placed on droplet precautions and
COVID-19 testing was done. He continued
to share a room with Resident #207 from
06/30/20 until 07/08/20. An additional
COVID-19 PUI Case Report dated
07/14/20 indicated his symptoms
continued to be a cough. His onset of
symptoms was indicated to be 07/12/20.
The course of treatment indicated he
returned from the hospital and was placed
on COVID-19 unit. Full barrier precautions
were in place. He was indicated to have
previously been on droplet precautions.
The physician declined further intervention
at that time.
Review of Resident #70 ' s nurses'

progress notes revealed the resident had a
decline in his condition. His medications
had been discontinued on 07/18/20 and his
code status was changed from a full code
to a Do Not Resuscitate Comfort Care. He
was started on Levaquin for pneumonia
and COVID-19. They attempted to start an
intravenous line for hydration, but they

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were unsuccessful with starting it. The
family was updated on his condition and
wanted him sent to the hospital. He was
sent on 07/19/20 and was admitted for
pneumonia and an altered mental status.
He did not return to the facility.
4 (a.) A review of Resident #10's medical

included Parkinson's disease, difficulty
walking and malaise.

revealed he resided on the facility's
quarantine unit on 06/25/20 when LPN #3
last worked potentially exposing the
residents on that unit to COVID-19. She
had tested positive on 06/30/20 and
reported it to the facility on 07/01/20. On
06/29/20, Resident #10 was moved to Unit
1 in a semi-private room (103-B) sharing it
with Resident #29. There was no evidence
of Resident #10 being placed on the
quarantine unit after it had been known by
the facility that he had a positive exposure
to the staff member that tested positive for
COVID-19.

Case Report dated 07/03/20 showed he
started showing symptoms of COVID-19
that included a cough and shortness of
breath. The date of onset was 07/03/20.
He was marked as having an unknown
exposure risk in the past 14 days under

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the social history section of the report.
The treatment indicated included
COVID-19 testing and him being placed on
droplet precautions.
Review of Resident #10's Coronavirus

reports for July 2020 revealed he started
having elevated temperatures greater than
99 degrees F. on 07/03/20 when his
temperature was 100.9 degrees F. He
continued to run a fever off and on for the
next several days. His highest
temperature was 101.1 degrees F. on
07/07/20.

revealed he was not tested for COVID-19
until 07/03/20. He did not get tested on
07/01/20 when the initial group of residents
that had been exposed and still resided on
the quarantine unit had been tested. The
specimen was collected on 07/03/20 but
was not received by the lab until 07/07/20
(4 days after it had been obtained). The
results were reported to the facility on
07/08/20 as being positive.
Review of Resident #10's nurse's progress

notes revealed he sustained a fall on
07/08/20 and was sent to the hospital. He
was reported to be positive for COVID-19
and he was admitted to the hospital. The
facility received their COVID-19 results
when he was already at the hospital. A
nurse's progress note dated 07/11/20
revealed the resident returned to the facility

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and was placed on the COVID-19 unit in
room 710- A. He remained in the facility at
the time the complaint investigation was
completed.
4 (b.) A review of Resident #29's medical

included atherosclerotic heart disease,
hyperlipidemia and hypertension.

revealed he was on Unit 1 Room 103-A
sharing a room with Resident #10. They
shared that room together between
06/29/20 and 07/03/20 even after it had
been known on 07/01/20 that Resident #10
had an exposure to a staff member that
tested positive for COVID-19. Resident
#29 was moved to a private room on
07/03/20 after a hospital visit. He was
then placed on the COVID-19 unit
beginning 07/08/20.
Review of Resident #29's COVID-19 report

for July 2020 revealed the resident started
with an elevated temperature above 99.4
degrees F. beginning on 07/03/20 when it
was recorded as being 101.4 (four days
after Resident #10 had been placed in his
room). He continued to have elevated
temperatures between 99.1 degrees F. and
100.2 degrees F. between 07/07/20 and
07/31/20.

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Case Report dated 07/03/20 revealed his
symptoms of COVID-19 included a
temperature over 99.4 degrees F. The
onset date of his symptoms was 07/03/20.
The course of treatment included
COVID-19 testing and placing the resident
in droplet isolation at that time. A
COVID-19 PUI Case Report dated
07/08/20 reporting same symptoms of an
elevated temperature specifying he had an
elevated temperature on 07/03/20 x 1.
Between 07/03/20 and 07/08/20 his
temperature only exceeded 99.4 degrees
F. x 1. The course of treatment indicated
he had no active symptoms and COVID-19
test results. He was moved to the
COVID-19 unit for further testing.

revealed he had a COVID-19 test done on
07/03/20. It was not received by the lab for
processing until 07/07/20. His COVID-19
test results came back positive on
07/08/20
Review of Resident #29's nurses' progress

notes revealed he was sent out to the
hospital on 07/03/20 after falling out of bed.
The fall was unwitnessed, and he
complained of a headache which is why he
was sent to the emergency room to be
evaluated. He returned to the facility on
the same day. A progress note dated
07/08/20 indicated his COVID-19 test was
positive. A nurse's progress note dated

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08/01/20 revealed a hospice consult was
obtained per the resident's request
because of a decline in his condition. He
remained in the facility as of 08/05/20 with
hospice services pending.
On 08/06/20 at 1:30 P.M., a phone

interview with LPN #3 revealed she first
became symptomatic on 06/27/20. She
stated she started with body aches and
was fatigued but thought she just had the
flu. She reported she developed a high
fever on 06/28/20 and 06/29/20. She
confirmed she went to the hospital on
06/30/20 and was tested for COVID-19.
Her COVID-19 test came back positive and
she notified the facility on 07/01/20. She
denied she reported her positive symptoms
to the facility when they were first
appeared on 06/27/20. She stated she
was hospitalized between 06/30/20 and
07/03/20 and was still testing positive
showing she still had it.
Review of CDC's Coronavirus Disease 2019

(COVID-19) Preparing for COVID-19 in
Nursing Homes and Long Term Care
Facilities updated 06/25/20 indicated given
their congregate nature and residents
population served (e.g., older adults often
with underlying chronic medical
conditions), nursing home populations are
at a high risk of being affected by
respiratory pathogens like COVID-19. As
demonstrated by the COVID-19 pandemic,
a strong infection prevention and control

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(IPC) program is critical to protect both
residents and healthcare personnel (HCP).
They were to create a plan for testing
residents for COVID-19 that addressed
triggers for performing testing (e.g., a
response to a resident or HCP with
COVID-19 in the facility). They were also
to have a plan for how roommates, other
residents and HCP who may have been
exposed to an individual with COVID-19
will be handled (e.g., avoid placing
unexposed residents into a shared space
with them).
Review of the Department of Health and

Human Services, CMS Memo QSO
20-30-NH dated 05/18/20 revealed CMS
was committed to taking critical steps to
ensure America's nursing homes are
prepared to respond to the Coronavirus
Disease 2019 Public Health Emergency.
Nursing homes have been severely
impacted by COVID-19, with outbreaks
causing high rates of infections, morbidity
and mortality. The vulnerable nature of the
nursing home population combined with
the inherent risk of congregate living in the
healthcare setting, requires aggressive
efforts to limit COVID-19 exposure and to
prevent the spread of COVID-19 within the
nursing homes. The Memo provided
information regarding testing in the nursing
homes. The facility was to have the
capacity for all residents to be tested if a
staff member tests positive for COVID-19.
They were to have an arrangement with

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laboratories to process tests with results
obtained rapidly (e.g., within 48 hours).
Review of the CDC's Testing Guidelines for

Nursing Homes: Interim SARS-CoV-2
Testing Guidelines for Nursing Home
Residents and Healthcare Personnel
updated 07/21/20 revealed nursing home
residents are at high risk for infection,
serious illness and death from COVID-19.
Testing practices should aim for rapid
turnaround times (e.g., less than 24 hours)
in order to facilitate effective interventions.
Testing asymptomatic residents with
known or suspected exposure to an
individual infected with COVID-19 including
close and expanded contacts (e.g., there
is an outbreak in the facility). If viral
testing capacity is limited, CDC suggests
first directing testing to residents who are
close contact.
Review of the CDC residents with

new-onset suspected or confirmed
COVID-19 revealed the facility should:
• Ensure the resident is isolated and

cared for using all recommend COVID-19
PPE. Place the resident in a single room
if possible pending results of SARS-CoV-2
testing.
• Cohorting residents on the same unit

based on symptoms alone could result in
inadvertent mixing of infected and
non-infected residents (e.g., residents who

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have fever, for example, due to a
non-COVID-19 illness could be put at risk
if moved to a COVID-19 unit).
• If cohorting symptomatic residents,

care should be taken to ensure infection
prevention and control interventions are in
place to decrease the risk of
cross-transmission.
• If the resident is confirmed to have

COVID-19, regardless of symptoms, they
should be transferred to the designated
COVID-19 care unit.
• Roommates of residents with COVID-

19 should be considered exposed and
potentially infected and, if at all possible,
should not share rooms with other
residents unless they remain
asymptomatic and/or have tested negative
for SARS-CoV-2 14 days after their last
exposure (e.g., date their roommate was
moved to the COVID-19 care unit).
• Exposed residents may be permitted

to room share with other exposed
residents if space is not available for them
to remain in a single room.
This deficiency substantiates Master

Complaint Number OH00114661,
Complaint Number OH00114591,
Complaint Number OH00114590,Complaint
Number OH00114531, and Complaint
Number OH00114417.

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department of health and human services form approved

centers for medicare & medicaid services omb no. 0938-0391

STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

name of provider or supplier street address, city, state, zip code

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 0000 INITIAL COMMENTS F 0000

COVID 19 FOCUSED INFECTION

ADMINISTRATOR: Scott Ratliff, #5282

The following deficiency is based on the

At the time of the Complaint Investigation,

laboratory director's or provider/supplier representative's signature title (x6) date

STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

name of provider or supplier street address, city, state, zip code

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 0880 Continued From page 1 F 0880

STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

name of provider or supplier street address, city, state, zip code

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 0880 Continued From page 2 F 0880

STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

name of provider or supplier street address, city, state, zip code

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 0880 Continued From page 3 F 0880

STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

name of provider or supplier street address, city, state, zip code

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 0880 Continued From page 4 F 0880

STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

name of provider or supplier street address, city, state, zip code

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 0880 Continued From page 5 F 0880

• As of 08/06/20, Units 5, 6, and 7

• As of 08/06/20, the facility has 75

• On 08/07/20, the Director of Nursing

STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

name of provider or supplier street address, city, state, zip code

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 0880 Continued From page 6 F 0880

• On 08/07/20 the facility implemented a

• On 8/7/20, the DON began mandatory

STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

name of provider or supplier street address, city, state, zip code

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 0880 Continued From page 7 F 0880

• On 08/07/20 the DON and

• On 08/07/20 the DON will begin to

STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

name of provider or supplier street address, city, state, zip code

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 0880 Continued From page 8 F 0880

• On 08/10/20 the DON or designee will

• On 08/10/20 between 10:55 A.M. and

• On 08/10/20 the facility had 208

• Onsite observations on 08/10/20

Although the Immediate Jeopardy was

STATEMENT OF (X1) (x2) multiple construction (X3) DATE SURVEY

name of provider or supplier street address, city, state, zip code

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)