Stearns COVID-19 Inspection Report

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
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STEARNS NURSING & REHAB CENTER
GRANITE CITY, IL 62040
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)
F 000 INITIAL COMMENTS F 000
Complaint #2042514/IL121617: F880

Complaint #2044155/IL123347: F880
Complaint #2044779/IL124018: F880
Complaint #2046532/IL125922: F677, F880
Complaint #2046517/IL125907: F880
Complaint #2046691/IL126111: F580, F677,
F692, F880
Complaint #2046875/IL126323: F677, F692,
F759, F880
Complaint #2046864/IL126317:F580, F684, F880
A COVID-19 Focused Infection Control Survey

was conducted by Illinois Department of Public
Health on September 4, 2020.
Total residents: 81
Sample Size: 44
F 580 Notify of Changes (Injury/Decline/Room, etc.) F 580 9/10/20
SS=E CFR(s): 483.10(g)(14)(i)-(iv)(15)
§483.10(g)(14) Notification of Changes.

(i) A facility must immediately inform the resident;
consult with the resident's physician; and notify,
consistent with his or her authority, the resident
representative(s) when there is-
(A) An accident involving the resident which
results in injury and has the potential for requiring
physician intervention;
(B) A significant change in the resident's physical,
mental, or psychosocial status (that is, a
deterioration in health, mental, or psychosocial
status in either life-threatening conditions or
clinical complications);
(C) A need to alter treatment significantly (that is,
a need to discontinue an existing form of
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Electronically Signed 09/24/2020

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 ID: G9VE11 Facility ID: IL6010441 If continuation sheet Page 1 of 54
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F 580 Continued From page 1 F 580

treatment due to adverse consequences, or to
commence a new form of treatment); or
(D) A decision to transfer or discharge the
resident from the facility as specified in
§483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)
(14)(i) of this section, the facility must ensure that
all pertinent information specified in §483.15(c)(2)
is available and provided upon request to the
physician.
(iii) The facility must also promptly notify the
resident and the resident representative, if any,
when there is-
(A) A change in room or roommate assignment
as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or
State law or regulations as specified in paragraph
(e)(10) of this section.
(iv) The facility must record and periodically
update the address (mailing and email) and
phone number of the resident
representative(s).
§483.10(g)(15)
Admission to a composite distinct part. A facility
that is a composite distinct part (as defined in
§483.5) must disclose in its admission agreement
its physical configuration, including the various
locations that comprise the composite distinct
part, and must specify the policies that apply to
room changes between its different locations
under §483.15(c)(9).
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview and record This Plan of Correction in response to the
review, the facility failed to immediately notify the statement of deficiencies demonstrates
resident, resident's physician and/or the our good faith and desire to continue to
resident's representative of any significant improve the quality of care and services
change in condition, a transfer to the hospital for rendered to our residents. This plan of
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medical treatment, room assignment changes or correction constitutes a written allegation
notification of infection for 6 of 24 residents (R5, of compliance with Federal Medicaid and
R7, R12, R17, R25, R41) reviewed for notification Medicare requirements.
of changes in the sample of 45. F580
1.
Findings include: R5 incident report dated 8/11/20
contained documentation that the
1.On 08/04/20 at 2:29 PM, R41's Nurse's Note, Resident representative was notified of
written by V29, Register Nurse (RN) documented the incident and pending transfer to the
R41 had an oxygen saturation level of 84% emergency room for treatment.
(normal reading is typically between 95% and R7 discharged from the facility on 8/28/20
100% with values under 90% are considered low) and elected not to return.
and was not feeling well or eating. There was no R12 record was reviewed with no new
documentation of physician or family concerns.
representative notification at that time. R17 no longer resides in the facility.
R25 discharged from the facility on
On 08/04/20, R41's Nurse's Note, written by V8, 9/18/20.
Licensed Practical Nurse, with no time, R41 discharged from the facility on
documented R41 had a change in condition 8-4-20.
which included lethargy, malaise (general feeling The Medical records will be reviewed on
of discomfort/illness), diarrhea and poor skin 9-8-20 by Director of Nursing and Nurse
turgor. It documented R41 was alert and oriented Management team. Any concerns
to one and was normally alert and oriented to identified during audit will be discussed
person, place and time. Vital signs were with the attending physician and Resident
documented as blood pressure 152/80, pulse 99, Representative notified regarding their
respirations 26, temperature 101.5 degrees change of condition.
Fahrenheit (F) and oxygen saturation level of 2.
80%. It documented that V28, Advanced Practice All residents have the potential to be
Register Nurse (APRN) was called and R41 was affected.
sent to the hospital for treatment. There was no 3.
documentation that V48, R41's family The Director of Nursing and Nurse
representative was notified of the transfer. Management will review resident changes
in condition in the morning clinical
On 08/25/20 at 7:57 AM, V48, R41's family meeting (HART)meeting. Any changes will
member, stated the family was notified by the be reviewed for documentation of
hospital on 08/05/20 at 2:00 PM that R41 had notification of the attending physician or
been transferred for care. V48 stated she was not nurse Practitioner and authorized resident
notified by the facility of R41's transfer to the representatives. The Director of Nursing
hospital. or Designee completed in-service
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education on or before 9/10/20 with
On 08/25/20 at 2:00 PM, V29, stated she did not licensed staff on the facility policy for
notify the physician or family representative of notification of change of condition and
R41's change in condition on 8/4/20. documenting notification in the medical
record. Any employee who has not
On 08/25/20 at 2:15 PM, V8 stated she did not completed required education will not be
remember if she called the family regarding R41's allowed to work until education completed.
transfer to the hospital. The Director of Nursing or designee will
complete audit tool daily x 14 days then
After multiple attempts to acquire documentation weekly for 2 weeks for compliance with
from the facility staff, there was no documentation notification requirements.
provided that R41 had been tested for COVID-19 4.
while at this facility. The results of the notification audits will
be presented to the Quality
There was no documentation in the medical Assurance/Performance Improvement
record or on the Facility's Line list for COVID-19 Committee for review and further
positive residents, entitled "IDPH Line List for recommendations as deemed necessary.
COVID-19 Outbreaks in Long Term Care
Facilities" provided by the facility on 08/26/20 that Date of Compliance 9/10/20
indicated R41's family representative or physician
was notified that there were positive cases of
COVID-19 in the facility as of July 22, 2020.
2. R5's Hospital Record, dated 8/11/20 at 10:09

AM, documented R5 was admitted from the
facility after falling. The record documented R5
was COVID-19 positive per facility staff. The
Hospital records documented R5 was diagnosed
with Traumatic Subdural Hemorrhage with loss of
consciousness of unspecified duration, large
Hematoma to the forehead and fracture of the
neck. At 11:52 AM, hospital records documented
R5 was transferred to a trauma center for
treatment.
On 08/19/20 at 5:55 AM, during a tour of the

Memory Unit, a name plate for R5 was observed
on a room door. V14, Certified Nursing Assistant
(CNA) stated R5 was on the unit until she had a
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fall. V14 stated after R5 returned from the
hospital, she was placed on the North Hall
(COVID-19 positive unit).
On 8/19/20, at 6:05 AM, V30, LPN stated she

was not working at the time R5 fell and did not
know who the nurse was that sent her out to the
hospital.
On 8/19/20, at 9:00 AM, V8, LPN stated she was

not working when R5 fell and did not know who
the nurse was that sent R5 to the hospital. When
requested, V8, V14 and V30 could not present
any documentation (i.e. nurse's notes or transfer
orders) regarding R5 from that day.
There was no documentation in R5's Facility

medical record that R5's facility physician or
family representative were notified of any
transfer. Multiple attempts were made to facility
staff to present documentation regarding any
transfer notification for R5. There were none
provided.
The Facility's COVID-19 Positive list, entitled

"IDPH (Illinois Department of Public Health) Line
List for COVID-19 Outbreaks for Long Term Care
Facilities" presented on 08/26/20 documented R5
tested positive for COVID-19 infection on
08/07/20.
There was no documentation in R5's medical

record that R5's physician or family
representative was notified of this result.
The Facility's Policy, Notification of Change of

Resident's Status, undated, documented
"Procedure: 1. Guideline for notification of
physician/responsible party (not all inclusive): a.
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Significant change in or unstable vital signs
(temperature, blood pressure, pulse, respiration);
b. emesis/diarrhea; e. symptoms of any infectious
process; i. change in level of consciousness. 2.
Document in the notes: a. resident change in
condition; b. physician notification; c. Notification
of responsible party."
3. On 8/17/2020, R7 was observed on the North

Hall (COVID-19 positive unit). She resided in a
room with R4.
On 8/20/2020, at 12:22 PM, V34, R7's family,

stated R7 had previously been roommates with a
certain resident for a long period of time, but the
facility has moved her twice since then.
On 8/25/2020, staff were in the process of

moving R7 to another room down the same hall.
R4 was also moved to different room.
On 9/1/2020, at 2:15 PM, V34 stated, "No one

ever contacted us about room changes. I had to
find out when I went to visit. I went to visit at her
window (where she had previously been) and
neither her nor her roommate (R4) were in there.
I told my sister, 'Mom is missing again.' It took us
3 or 4 times to get ahold of someone at the
facility."
On 9/3/2020, at 9:51 AM, V46, Social Service

Director stated, "Since the outbreak, we have had
to make a lot of movement. It depends on who is
in the building, but usually it's my job or the
nurses to notify resident's family if they come
back from the hospital or must move to an
isolation room. I give written statements to the
patient or family. I spoke with (R7's) family on the
8th (August 8th, 2020) that was the last
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communication I had with them and that was not
about a room move."
4.R25's Face Sheet, not dated, documents R25

has a Power of Attorney (POA), V52.
R25's Minimum Data Set (MDS), dated

8/21/2020, documents R25 is "severely impaired"
cognitively.
R25's Laboratory Result, dated 8/09/2020,

documents R25 tested positive for COVID-19.
R25's Care Plan, dated 08/10/2020, documented

R25 had a positive COVID-19 test. It documented
an intervention "update/educate
resident/family/responsible party as needed
regarding COVID-19 and condition.
There is no documentation in R25's August 2020

Progress Notes or medical record that V52 was
notified of R25 testing positive for COVID-19.

has a POA, V51.

documents Positive for COVID-19.

interventions, in part as, update/educate
R17's MDS, dated 8/21/2020, documents R17 is

severely impaired cognitively.
There is no documentation in R17's medical

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record or August Progress Notes documenting
V51 was notified R17 tested positive for
COVID-19.

has a Guardian, V50.
R12's MDS, dated 8/24/2020, documents R12 is

severely impaired cognitively.

interventions, in part as, update/educate
There is no documentation in R12's August

Progress notes or medical record that V50 was
notified R12 tested positive for COVID-19.
On 8/19/2020 at 11:00 AM V8, Licensed Practical

Nurse (LPN), stated, "We document in the
progress notes in the computer. There are nurses
that don't have computer access. They have to
document on paper. If it is not in the nurses notes
in the computer or on paper, then it wasn't done."
F 677 ADL Care Provided for Dependent Residents F 677 9/10/20
SS=D CFR(s): 483.24(a)(2)
§483.24(a)(2) A resident who is unable to carry

out activities of daily living receives the necessary
services to maintain good nutrition, grooming, and
personal and oral hygiene;
by:
Based on interview, observation and record This Plan of Correction in response to the
review, the facility failed to assist resident with statement of deficiencies demonstrates
dressing for 1 of 4 residents (R7) reviewed for our good faith and desire to continue to
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assistance with Activities of Daily Living (ADLs) in improve the quality of care and services
a sample of 45. rendered to our residents. This plan of
correction constitutes a written allegation
Finding includes: of compliance with Federal Medicaid and
Medicare requirements.
R7's August 2020 Physician's Order Sheet F677
documented she had a diagnosis of Alzheimer's 1.
Disease. R7 discharged from the facility on 8/28/20.
2.
R7's Care Plan Goal, 10/30/20, documented "I Any resident dependent in dressing has
will receive assistance from staff with my ADLs the potential to be at risk for this alleged
(Activities of Daily Living) as needed thru my next deficient practice.
review of 10/30/20." The Care Plan interventions 3.
documented "Observe me frequently to anticipate The Director of Nursing or Designee
and meet my needs. completed in-service education with the
Nursing staff on or before 9/10/20 on
On 8/18/2020, at 9:50 AM, V34, R7 family utilizing the resident's Pocket Care Guide
member, stated her mother (R7) has been to ensure activity of daily living task of
wearing the same outfit and she has pictures of assistance with dressing is completed.
this. V34 stated her mom's new roommate (R4) Any employee who has not completed
has been complaining that staff aren't taking care required education will not be allowed to
of them. work until education completed. The
Director of Nursing or designee will audit 5
On 8/19/2020, at 11:30 AM, R4 stated, "She (R7) rooms per day x 14 days then 5 rooms
is in here because of her memory. She has been per day twice weekly x 2 weeks then
in those clothes since she came to this room from monthly thereafter until resolved through
the other end of the hall, which was 2 days ago. QAPI.
She is not eating." 4.
At, 12:00 PM, R7 was wearing the brownish shirt Results of the audit findings will be
and gray pants with a red stain all down the presented to the Quality Assurance
length of the right pant leg. At this time, R4, R7's Performance Improvement Committee for
roommate stated, "She spilt Kool-Aid on her review and further recommendations as
pants two days ago." deemed necessary until resolved.
R4's Brief Interview for Mental Status (BIMS), Date of Compliance 9/10/20
dated 8/18/2020, indicates R4 is cognitively
intact.
On 8/20/2020, at 12:22 PM, V34, verified that R7

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was wearing the brown shirt and gray pants on
8/18/2020.
On 8/25/2020, at 11:45 AM, R7 was wearing the

same brown shirt and gray pants with the stain
down the pant leg, as she was observed wearing
on 8/19/2020.
F 684 Quality of Care F 684 9/10/20
SS=G CFR(s): 483.25
§ 483.25 Quality of care

Quality of care is a fundamental principle that
applies to all treatment and care provided to
facility residents. Based on the comprehensive
assessment of a resident, the facility must ensure
that residents receive treatment and care in
accordance with professional standards of
practice, the comprehensive person-centered
care plan, and the residents' choices.
by:
Based on observation, interview and record This Plan of Correction in response to the
review, the facility failed to complete timely statement of deficiencies demonstrates
assessments, to notify the physician of a change our good faith and desire to continue to
in condition and to provide medical treatment in a improve the quality of care and services
timely manner for 2 of 2 residents (R17, R41) rendered to our residents. This plan of
reviewed for care and services in the sample of correction constitutes a written allegation
45. This failure resulted in R17 and of compliance with Federal Medicaid and
R41experiencing a medical decline in condition Medicare requirements.
without timely treatment. F684
1.
Findings include: R17 no longer resides in facility as of
8/22/20
1. R17's August 2020 Physician's Order Sheet R41 no longer resides in facility as of
(POS) documented she has diagnoses of Type 2 8/4/20
Diabetes and Chronic Ischemic Heart Disease. 2.
Any resident in the facility has the
R17's Laboratory Result, dated 8/09/2020, potential to be affected by this alleged
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documented she had tested Positive for deficient practice.
COVID-19. 3.
The Director of Nursing or designee
R17's Care Plan, dated 08/10/2020, documented completed in-service training on or before
R17 had a positive COVID-19 test. It documented 9/10/20 with nursing staff regarding
R17 was placed on isolation/droplet precautions, resident assessment including vital signs
staff were to monitor vital signs and oxygen and notifying the physician and resident
saturations levels (SPO2) as ordered. representative of changes in resident
condition and documenting notification in
R17's Nurse's Note, dated 8/13/2020 at 4:07 PM, the medical record. Any non-compliance
documents "Resident decrease SPO2 to 84% will result in 1:1 retraining by the Director
room air. Oxygen applied at 3 liters by nasal of Nursing. Any employee who has not
cannula increased to 98%. Temperature of 99.2 completed required education will not be
at 4:07 PM down to 97.7. Resident fatigued, allowed to work until education completed.
complained of extreme pain to back and all over. The Director of Nursing or designee will
Continue routine pain meds and prn narcotics audit for changes in condition and
slightly effective. No SOB (Shortness of Breath) notification daily times 14 days then
noted. Respirations even non labored at this time. weekly times 2 weeks then monthly for
Added to report sheet, to be monitored every on-going compliance until resolved
shift. POA (Power of Attorney) contacted and through QAPI process.
message left." 4.
The results of the audits will be presented
R17's Departmental Nursing Notes, dated to the Quality Assurance Performance
8/14/2020 at 1:04 AM, documents "T99.7 Improvement Committee by the Director
(temperature)-80 (pulse)-20 of Nursing or designee for review and
(respirations)-106/68(blood pressure). Oxygen further recommendation as deemed
saturation 94% on oxygen at 2 liters. HOB (Head necessary until issue is resolved.
of Bed) elevated-lungs clear with no cough or
SOB." Date of Compliance 9/10/20

records that the facility staff was monitoring R17's
vitals on 8/15, 8/16 and 8/17/20.
R17's Departmental Nursing Notes, dated

8/18/2020 at 12:17 AM, documents "T
(temperature) 99.1-72 (pulse)-20
(respiration)-114/68 (blood pressure). O2 sat 97%
no distress noted."
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records on 8/18/20 for the 6:00 AM-2:00 PM shift
and the 2:00 PM -10:00 PM shift that the facility
was monitoring R17's vital signs.
On 8/19/2020 at 8:40 AM R17 was lying in bed.

V14, Certified Nurse's Aide/CNA, placed R17's
tray on the over bed table. R17's face was red in
color. R17 was taking slow shallow breathes. Her
oxygen tubing was lying on the bed and not on
her face. At 8:43 AM, V14 stated "This is not
normal for her. She has changed. She (R17)
feels hot. She says she doesn't feel good. She
(R17) is positive for COVID 19. This is not like
her. She used to get up out of the bed, transfer
herself to the wheelchair and roll herself out in the
hallway. She would eat pretty good. She has not
been eating at all. She drinks her drinks
sometimes. She has been coughing, sneezing
and has had fever. She hasn't been getting up.
This has been going on about 2 weeks. I have
reported it to the nurse. I tried to get her
temperature, but I was told the thermometer
wasn't working and they would get me a new
one."

Nurse, entered R17's room. V8 applied R17's
oxygen tubing to her nose. V8 did not attempt to
get R17's oxygen saturation level prior to putting
the O2 on R17. V8 then left the room and
proceeded off the unit. V8 returned
approximately 10 minutes later and performed an
oxygen saturation test. R17's results were 92%
with oxygen being delivered per nasal cannula at
2 liters.
On 08/19/20 at 10:10 AM, V14, CNA stated none

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of the residents have had their SPO2 (oxygen
saturation level) levels checked. She stated vital
signs were taken once per shift and normal vital
signs taken are blood pressure, temperature, and
pulse.
On 8/19/20, at 10:12 AM, V30, LPN stated vital

signs are only done once per shift.
On 8/19/20, at 10:15 AM, V14 stated there were

no vitals taken for the day shift. The Vital Sign
sheet had no documentation that R17's vitals
were being monitored.

record on 8/19/20 from 8:40 AM until 4:52 PM the
facility was monitoring R17's vital signs.

8/19/2020 at 4:52 PM, documents R17's
temperature was 97.5 degrees F, her respirations
were 20, her blood pressure was 208/92 and her
pulse was 72. The Note documented "resident
resting comfortably in bed with eyes closed.
Medications administered per MAR (Medication
Administration Record) and resident tolerated
meds well. This nurse notified (V28), Nurse
Practitioner, about residents elevated BP (blood
pressure), he stated to recheck in 1 hour after
medications given. NP [sic] 142/78 assessment
complete, lung sounds clear and bowel sounds
present x4. No s/s of distress noted. Will continue
to monitor and observe." The Note did not
document at what time staff rechecked R17's
blood pressure.

record from 8/19/20 at 4:52 PM until 8/20/20 at
5:25 PM regarding if facility staff were monitoring
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R17's condition and her vital signs.
R17's COVID 19 Assessment, dated 8/20/2020 at

5:25 PM, documents "Temperature-Fever-yes
99.5 pulse ox 96%/RA (Room air)."

record from 8/20/20 at 5:25 PM until 8/21/20 at
8:30 PM that facility was monitoring R17 condition
and her vital signs.
R17's COVID 19 Assessment, dated 8/21/2020 at

8:30 PM, documents R17 displayed the following
COVID 19 symptoms: Malaise, loss of appetite
and loss of taste or smell with oxygen in use.
R17's vital signs were documented as follows:
Temperature 96.6 Respiratory Rate 22. Pulse Ox
94% with oxygen at 2 liters per nasal cannula.
R17's heart rate 100 beats per minute. Blood
Pressure 133/73.

record from 8/21/20 at 8:30 PM until 8/22/20
evening shift (2:00 P-10P) that the facility was
monitoring R17's condition and her vital signs.
R17's COVID 19 Assessment, dated 8/22/2020

2-10p, documents R17 displayed the following
COVID 19 symptoms: Malaise, loss of appetite
and aches all over. R17's vital signs were
documented as follows: Temperature 97.3 pulse
ox 94%. R17's heart rate 105 beats per minute.
Blood pressure 124/58.

record from 8/22/20 evening shift until 8/23/20 at
1:39 PM the facility was monitoring R17's
condition and her vital signs. There was no
documentation V28 had been notified of R17's
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condition.

8/23/2020 at 1:39 PM, documents "At
approximately 10:30 A.M. Writer was on hall
passing meds when a member of CNA staff
reported to writer that resident appeared to have
stopped breathing. Writer saw resident at approx.
(approximately) 10am and resident presented
with labored breathing but was still breathing.
Writer contacted POA at 10:35 am. Writer
contacted general medicine at approx 10:40 am
and also writer contacted Madison county coroner
at 10:45A.M. Writer currently awaiting coroner
arrival."
There was no prior documentation of R17's

labored breathing or if the facility contacted the
doctor of this.

Nurse (LPN), stated with regards to where the
nursing staff would have charted/documented
R17's assessments and vital signs "We
document in the progress notes in the computer.
There are nurses that don't have computer
access. They have to document on paper. If it is
not in the nurses notes in the computer or on
paper, then it wasn't done."
On 9/2/2020 at 12:30 PM V13, Infection Control

Nurse, stated "When a resident has a change in
condition, I would expect the resident to be
monitored every shift. The nurses would perform
full assessment on the resident. The physician
would be notified of any changes in the resident's
condition."
On 9/3/2020 at 9:22 AM V28, Advanced Practice

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Registered Nurse, stated "I was not notified of
(R17's) elevated heart rate. With her being
positive for COVID and having changes in
condition, I would expect the staff to monitor and
assess her at least every shift. I would expect the
staff to notify me with changes in R17 condition. It
is possible that she would have been sent to the
hospital. I will send residents to the hospital
unless the family requests them to stay in the
facility."
The Facility's Notification of a Change in a

Resident's Status Policy, dated 1/2015,
documents "The attending physician/responsible
party will be notified of a change in a resident's
condition, per standards of practice and Federal
and/or State Regulations. 1. Guideline for
notification of physician/responsible party (not all
inclusive): a. Significant change in/ or unstable
vital signs (Temperature, B/P, Pulse, Respiration).
e. Symptoms of an infectious disease. 2.
Document in the notes: a. resident's change in
condition. b. Physician notification. c. Notification
of responsible party."
2. R41's Physician's Order Sheet, dated August

2020, documented R41 was admitted to the
facility on 06/23/17 with the following diagnoses,
in part as, Dementia, Rheumatoid Arthritis,
Osteoporosis, Contracture of left lower extremity,
Pain and Herpes Viral Infection.
On 08/04/20 at 2:29 PM, R41's Nurse's Note

written by V29, Registered Nurse (RN)
documented R41 was afebrile (without fever) with
an oxygen saturation of 84% (normal reading is
typically between 95-100 %). It documented R41
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was not feeling well and not eating. There was no
documentation that the physician was notified at
that time.
On 08/05/20 at 2:27 AM, V8, LPN, documented a

late entry for 08/04/20 with no entry time. R41's
Nurse's Notes documented R41 was alert and
oriented x (times) 1 (normal A & O x 2-3), oxygen
saturation 80%, heart rate 99, respirations 26 and
temperature 101.5 (degrees Fahrenheit/F). It
documented R41 was lethargic with malaise
(general feeling of illness/discomfort), diarrhea
and skin turgor poor. It documented V8 called
V28, Advanced Practice Registered Nurse/APRN,
and then sent R41 to the hospital. There was no
documentation of R41 being closely monitored or
additional assessments being done after 2:29 PM
on 8/4/20.
On 08/25/20 at 2:00 PM, V29 stated R41 was not

feeling well the day she went out to the hospital
and had several episodes of diarrhea through the
night and that morning, not eating and just not
wanting to get out of bed much. V29 stated R41's
oxygen saturation levels were low, but after
repositioning her it came up. V29 stated that the
charting entry comes at the end of the shift and
events may have happened earlier in the day.
V29 stated she could not remember the exact
time of day when the above entry happened with
R41 but stated she had been told by staff R41
had not eaten breakfast or lunch. V29 denied
calling the doctor or family at that time, stating
she did not know if these symptoms were from
COVID related infection or not. V29 stated she
thought R41 was COVID-19 positive at the time.
On 08/25/20 at 2:15 PM, V8 stated R41 was

having trouble breathing with episodes of diarrhea
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throughout the day and was not her usual self.
She stated later in the evening (could not
remember exact time of day), R41 had a fever,
was confused and oxygen saturation levels were
low in the 80's. V8 stated she called V28 and was
told to send R41 to the hospital. V8 denied
knowing how long R41 had these symptoms. V8
stated she was not aware if R41 was COVID-19
positive. V8 stated she could not recall if she had
notified the family of R41's change in condition or
transfer to the hospital.
On 09/02/20 at 12:20 PM, V13, LPN/Infection

Preventionist, stated during the months of June
and July 2020, the facility did not have testing
supplies for COVID-19. She stated none of the
residents were tested for COVID-19 until 8/7/20.
V13 stated she would not have known for sure if
R41 was positive or not because she was not in
the facility on 08/07/20 when all were tested.
On 09/03/20 at 8:35 AM, V28, APRN, stated he

recalled being informed that R41 was having
difficulty breathing, but no other details. V28
stated he could not remember what time of day
he was contacted but did recall telling staff to
send R41 to the hospital. V28 stated he thought
R41 was positive for COVID-19. V28 stated he
would have expected the facility staff to notify him
of an oxygen saturation level in the 80's. He
stated he would have expected the facility staff to
monitor R41 more frequently, document any
changes and notify him of a change in condition.
V28 stated he would order to have any resident
that was having difficulty breathing to the hospital
for evaluation. V28 stated he was not sure if a
delay in sending R41 to the hospital contributed
to her death because he did not assess her at
that time.
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On 09/03/20 at 11:52 AM, V48, R41's daughter,

stated the family was not notified of R41's change
in condition or that she had been transferred to
the hospital on 08/04/20. She stated the hospital
notified them on 08/05/20 at 2:00 PM that R41
was admitted on 08/04/20 with a diagnosis of
pneumonia and was COVID-19 positive. V48
stated R41 required assistance with all ADL's due
to her left leg being contracted. R48 stated she
felt like there were so many changes in staffing
that there was no continuity of care for R41 and
that not being notified of changes was part of the
staff not knowing when R41 had a change from
her usual condition.
The State of Illinois Certificate of Death

Worksheet, dated 08/13/20, documented R41's
causes of death as Hypoxemic Respiratory
Failure and Novel Corona Virus Infection.
The CDC website page, "Responding to

Coronavirus (COVID-19) in Nursing Homes,
updated 4/30/2020, documented the facility
should implement the following for residents who
have tested positive for COVID-19 or who are
experiencing symptoms of COVID-19: Increase
monitoring of ill residents, including assessment
of symptoms, vital signs, oxygen saturation via
pulse oximetry, and respiratory exam, to at least
3 times daily to identify and quickly manage
serious infections; and Consider increasing
monitoring of asymptomatic residents from daily
to every shift to more rapidly detect any residents
with new symptoms."
F 692 Nutrition/Hydration Status Maintenance F 692 9/10/20
SS=G CFR(s): 483.25(g)(1)-(3)
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§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes,
both percutaneous endoscopic gastrostomy and
percutaneous endoscopic jejunostomy, and
enteral fluids). Based on a resident's
comprehensive assessment, the facility must
ensure that a resident-
§483.25(g)(1) Maintains acceptable parameters

of nutritional status, such as usual body weight or
desirable body weight range and electrolyte
balance, unless the resident's clinical condition
demonstrates that this is not possible or resident
preferences indicate otherwise;
§483.25(g)(2) Is offered sufficient fluid intake to

maintain proper hydration and health;
§483.25(g)(3) Is offered a therapeutic diet when

there is a nutritional problem and the health care
provider orders a therapeutic diet.
by:
Based on observation, interview, and record This Plan of Correction in response to the
review, the facility failed to monitor, assess and statement of deficiencies demonstrates
implement intervention to prevent weight loss for our good faith and desire to continue to
1 of 3 residents (R7) reviewed for nutritional improve the quality of care and services
status in a sample of 45. This failure resulted in rendered to our residents. This plan of
R7 experiencing a 16-pound weight loss in one correction constitutes a written allegation
month and hospitalization for dehydration. of compliance with Federal Medicaid and
Findings include: F692
1.
R7's Dietary Notes, dated 7/28/2020 documents R7 no longer resides in the facility.
R7's weight on 7/3/2020 was 153 pounds with no 2.
significant weight loss. Any resident in the facility has the
potential risk to be affected by this alleged
R7's Minimum Data Set (MDS), dated 9/1/2020, deficient practice.
documents that R7 is independent with eating; 3.
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requiring no encouragement or cues. The MDS The Registered dietitian has reviewed all
documented she is cognitively impaired. residents with weight loss and made
appropriate recommendations. The
R7's current Care Plan, documented "I am at risk Director of Nursing has followed up on
for weight loss due to my diagnosis of recommendations. The Registered
Alzheimer's" with an onset date of 1/2017. R7's Dietitian or Designee completed
care plan lists the goal as, "I will have no education with certified nursing assistants
complications in my nutritional status and and licensed staff on or before 9/10/20
maintain a stable weight thru my next review: offering residents who consume less that
10/30/20." The approaches include, "Offer me a 50% alternate food items to maintain
substitute if you notice I am not eating what is intake and avoid weight loss. Any
served." and "Weigh me monthly and PRN (As employee who has not completed
needed)." required education will not be allowed to
work until education completed. The
R7's Physician's Order, dated, 8/3/2020, Director of Nursing /Designee will audit
documents, "D/C (discontinue) weekly/monthly meal service for offering alternates daily x
weights." 14 days then twice weekly times 2 weeks
for on-going compliance.
R7's Nurse's Notes, dated 8/11/20, documented 4.
that R7 was complaining of an upset stomach Results of audits will be presented to the
which she associated with a stomach ulcer. Quality Assurance Performance
Improvement Committee for review and
R7's Nursing Notes document that on 8/18/2020, further recommendations as deemed
at 7:12 PM, R7 was repeatedly complaining of necessary.
stomach pain and refused dinner. There was
nothing documented as to what interventions Date of Compliance 9/10/20
were attempted such as offering a substitute or
providing encouragement.
On 8/19/2020, at 12:00 PM, R4, R7's roommate,

stated "She (R7) has not been eating."
R7's Nurse's Notes, dated 8/21/20 at 12:46 PM

documented R7 continued to complain of upset
stomach.
On 8/25/2020, at approximately 12:00 PM, R7

had her lunch tray in front of her, untouched. At
this time, R7 stated, "I can't eat. I think my ulcer is
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back. I haven't eaten in 3 or 4 days." V49,
Licensed Practical Nurse/ LPN provided R7 a
supplement drink. R7 took one sip out of it.

record regarding if the facility assessed R7's
continued refusal of food and stomach pain. R7's
Care Plan was not updated to address R7's
refusal of food and stomach pain.
On 8/25/2020, at 2:00 PM, V5, Licensed Practical

Nurse (LPN) stated that the medical director had
written an order to discontinue weights due to the
scale being located off the isolation hall.
On 8/27/2020, at 2:17 PM, V36, Medical Director,

stated that he did not write the order to
discontinue the weights, nor was he aware they
had been.
R7's Nursing Notes document that on 8/28/2020,

R7 experience nausea, vomiting and stomach
pain. R7's POA (Power of Attorney) was
contacted and requested R7 be sent to the
Emergency Room for evaluation.
On 9/1/2020, at 2:15 PM, V34, R7's family

member, stated R7 had been admitted to the
hospital and was severely dehydrated.
R7's Dietary Notes, dated 8/28/2020 documents

R7's current weight was 137 and that R7 had
experienced a significant weight loss of 10.46%.
The Dietary Note documented recommendations
to add to weekly weight and begin health shake
three times daily with meals.
On 9/3/2020, at 1:20 PM, V36, stated, "A 10%

weight loss from not eating is harmful to the
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patient and could have potentially been the cause
of her (R7's) hospitalization. Some residents
require a lot more cueing in order to eat."
As of 9/3/2020 at 3:51 PM, after multiple request,

the facility had still not provided an appetite log
for R7.
F 759 Free of Medication Error Rts 5 Prcnt or More F 759 9/10/20
SS=D CFR(s): 483.45(f)(1)
§483.45(f) Medication Errors.

The facility must ensure that its-
§483.45(f)(1) Medication error rates are not 5

percent or greater;
by:
Based on interview, observation and record This Plan of Correction in response to the
review, the facility failed to administer statement of deficiencies demonstrates
medications as ordered. There were 26 our good faith and desire to continue to
opportunities with 2 errors resulting in a 7.69 % improve the quality of care and services
medication error rate. The errors involved (R6, rendered to our residents. This plan of
R39) in the sample of 45 out of 12 residents correction constitutes a written allegation
observed during medication administration. of compliance with Federal Medicaid and
Findings include: F759
1.
1. On 8/25/2020 at 12:45 PM, V3, Licensed Attending physician was notified of
Practical Nurse (LPN), was administering medication error and order obtained to
medications to R39. V3 stated, "(R39) takes his change to liquid form. After further
meds crushed." V3 crushed all of R39's investigation, the resident can swallow
medications including Potassium Chloride ER meds whole and the potassium changed
(Extended Release) 10 MEQ (milliequivalents) back to pill form. There were no adverse
and gave them to him in yogurt. reactions as a result of this error. A
clarification order was obtained on 8/27/20
R39's Physician's Order Sheet (POS), dated for R6 for administration times for Xanax.
August 2020, documents "Potassium Chloride ER Attending physician was notified of
10 MEQ: give 1 tablet by mouth TID (Three times medication error. No new orders were
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a day)." It also documents that Potassium given and no adverse outcome as a
Chloride ER are not to be crushed. result.
2.
On 8/27/2020 at 2:00 PM, V37, Nurse Any resident residing in the facility
Practitioner, stated, "Technically not supposed to receiving medications have a potential
give Potassium crushed. It can be dissolved in risk to be affected by this alleged deficient
water. They need to let us know so we can give practice.
an alternative form if the patient cannot swallow 3.
pills." The Director of Nursing or Designee will
completed education with licensed staff
On 8/27/2020, at 2:17 PM, V36, Medical Director, regarding medication administration on or
stated, "They are not supposed to crush extended before 9/10/20. Any employee who has
release pills." not completed required education will not
be allowed to work until education
An Article from "Medical News Today" completed. A 100% audit was completed
documents, "Many pills have special coatings on by the Director of Nursing or unit
them to regulate their rate of release when they managers to reconcile physician orders
enter the body. Crushing them can change the with medication administration records for
rate of release and lead to temporary overdose." accuracy. 1:1 retraining was completed
with V3 regarding correct medication
administration on 9/7/20 and a medication
2. R6's POS, dated August 2020, documents, error report completed. Audits of
"Xanax 0.25 mg (Milligrams) TID." The POS does medication pass will be completed daily
not specify the times to administer. for 14 days then weekly times 2 weeks by
the Director of Nursing. Any
R6's POS, dated July 2020, documents, "Xanax non-compliance identified through audits
0.25 mg TID at 8 AM, 12 PM, and 8 PM. will result in 1:1 retraining.
4.
R6's Medication Administration Record (MAR), The Director of Nursing or designee will
dated August 2020, documents, "Xanax 0.25 mg present results of audits to the Quality
at 8 AM, 12 PM, and 4 PM." Assurance Performance Improvement
Committee for review and further
On 8/25/2020, at 3:06 PM, V8, LPN, administered recommendations as deemed necessary.
4 PM meds, including Xanax 0.25 mg to R6.
Date of Compliance 9/10/20
On 8/27/2020 at 2:00 PM, V37 stated, "Every 8
hours would be my preference for scheduling
Xanax. (They) should be verifying the MAR with
the POS."
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On 8/27/2020, at 2:17 PM, V36 stated, "It sounds

like they gave it (Xanax) early."
On 9/3/2020 at 2:03 PM, V2, Director of Nursing

(DON), stated, if the times of the order had been
changed per patients request, there would have
been a telephone order written.
The facility's Medication Administration- General

Guidelines policy and procedure, undated,
documents, Procedure: "2. Medications are
administered in accordance with written orders of
attending physicians, taking into consideration
manufacturer's specifications, and professional
standards of practice." It continues, "20. If safe to
do so, medication tablets may be crushed or
capsules emptied out when resident has difficulty
swallowing. A. Sustained release or enteric
coated dosage forms should generally not be
crushed and require a specific physicians order to
do so."
F 880 Infection Prevention & Control F 880 9/10/20
SS=L CFR(s): 483.80(a)(1)(2)(4)(e)(f)
§483.80 Infection Control

The facility must establish and maintain an
infection prevention and control program
designed to provide a safe, sanitary and
comfortable environment and to help prevent the
development and transmission of communicable
diseases and infections.
§483.80(a) Infection prevention and control

program.
The facility must establish an infection prevention
and control program (IPCP) that must include, at
a minimum, the following elements:
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§483.80(a)(1) A system for preventing, identifying,

reporting, investigating, and controlling infections
and communicable diseases for all residents,
staff, volunteers, visitors, and other individuals
providing services under a contractual
arrangement based upon the facility assessment
conducted according to §483.70(e) and following
accepted national standards;
§483.80(a)(2) Written standards, policies, and

procedures for the program, which must include,
but are not limited to:
(i) A system of surveillance designed to identify
possible communicable diseases or
infections before they can spread to other
persons in the facility;
(ii) When and to whom possible incidents of
communicable disease or infections should be
reported;
(iii) Standard and transmission-based precautions
to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a
resident; including but not limited to:
(A) The type and duration of the isolation,
depending upon the infectious agent or organism
involved, and
(B) A requirement that the isolation should be the
least restrictive possible for the resident under the
circumstances.
(v) The circumstances under which the facility
must prohibit employees with a communicable
disease or infected skin lesions from direct
contact with residents or their food, if direct
contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed
by staff involved in direct resident contact.
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§483.80(a)(4) A system for recording incidents
identified under the facility's IPCP and the
corrective actions taken by the facility.
§483.80(e) Linens.
Personnel must handle, store, process, and
transport linens so as to prevent the spread of
infection.
§483.80(f) Annual review.

The facility will conduct an annual review of its
IPCP and update their program, as necessary.
by:
Based on observation interview and record This Plan of Correction in response to the
review, the facility failed to develop and statement of deficiencies demonstrates
implement infection control procedures to prevent our good faith and desire to continue to
the spread of COVID-19 infection by: failing to improve the quality of care and services
implement transmission based precautions, rendered to our residents. This plan of
implementing procedures for COVID -19 positive correction constitutes a written allegation
staff and/or symptomatic staff; encouraging of compliance with Federal Medicaid and
residents to wear masks and socially distance Medicare requirements.
from others, utilizing personal protective F880
equipment and perform hand-hygiene and 1.
ensuring the environment is clean and sanitary. The facility is followed CDC guidance for
This failure has the potential to affect all 81 managing COVID-19 virus and for
residents living in the facility. cohorting residents based on results of
resident testing. Currently, there are no
This failure resulted in an Immediate Jeopardy facility onset positive residents or any
(IJ) which began on 8/9/20 when 11 residents, positive staff.
R13, R15, R17, R18, R20, R21, R23, R24, R25, 2.
R26 and R28 who resided on the Memory Care Any resident residing in the facility has the
unit, tested positive for COVID-19 and the facility potential to be affected by this alleged
failed to implement transmission-based deficient practice.
precautions and isolate these resident from 3.
residents without COVID-19. Subsequently on the The facility has implemented it's allegation
Memory Care Unit, three additional residents, R9, of compliance plan as follows:
R16 and R27 tested positive for COVID-19. Due A. The facility created an additional
to these residents' comorbidities and designated unit for a total of 3. General
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vulnerabilities, this failure increases their risk for population without symptoms or positive
severe illness from COVID-19 and possible results DU-2 for new Admissions or
death. readmissions and DU-3 for residents
tested as positive.
The Immediate Jeopardy was identified on B. Residents returning from the hospital
8/26/20. On 8/26/20 at 2:13 PM, V1, and new admissions are placed on the
Administrator, V2, Director of Nurse, V35, DU-2 unit for 14 day observation.
Director of Clinical Operations and V12, Clinical C. Residents will transfer from DU-2 to
Operations Consultant were notified of the DU-1 upon completion of their 14 day
Immediate Jeopardy. The surveyors confirmed by observation and remain asymptomatic or
observations, record review and interview that the test negative per CDC guidelines.
Immediate Jeopardy was removed on 8/27/20 but D. Previous positive residents will be
non-compliance remains at Level Two because moved from DU-3 to DU-1 upon recovery
additional time is needed to evaluate the using symptom based method.
implementation and effectiveness of in-service E. Rooms have been allocated on the
training. Memory unit as a DU-2 observation area
for newly admitted or readmitted residents
Findings include: and a DU-3 area for anyone testing
positive in that area. Residents who are
1.On 8/17/2020 at 11:10 AM, V1, Administrator, recovered or testing negative are placed
stated "The COVID-19 positive residents are on DU-1.
located on the COVID-19 Unit (100-hall). But we F. Signage has been posted at each
do have a couple of residents that came back designated unit describing appropriate
positive over the weekend that are on the PPE usage and precautions to be used.
Memory Unit." Residents on droplet precautions also
have sign to alert staff and direct PPE
The facility provided a list on 8/17/20 of residents required.
on the Memory Unit who currently tested positive G. The facility floor plan has been made
for COVID-19. The following 15 residents were on to identify designated units will be updated
this list: R9, R12, R13, R15, R16, R17, R18, R20, daily by the admission director and the
R21, R23, R24, R25, R26, R27, and R28. Executive Director.
H. The facility has a designated clean
On 8/26/20, the facility provided the Line List for room for donning PPE and a dirty room
COVID-19 Outbreaks in Long Term Care for doffing PPE prior to entering and when
Facilities. The Line List documented that 2 leaving the unit.
residents, R42 and R6 tested positive for I. Resident testing positive were place on
COVID-19 on 7/27/20. The last documented Droplet precautions per physician orders
resident on the line list, R44, was noted to be for the duration of their contagion period.
positive on 8/15/20. At that time, the line list J. The facility is following the CDC
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documented 60 residents had tested positive for guidance and currently conducting weekly
COVID-19. testing of Resident s and Staff. The
county positivity rate will be checked
On 9/2/20, at 11:45 AM, V39, Local County weekly to direct the frequency of staff
Health Department (LCHD) Staff Nurse, stated testing.
that the facility was required to notify the Local K. The facility has been and continues to
County Health Department the total number of be current in reporting line list to the
residents and staff who tested positive for county health department for all positive
COVID-19 and the total number of deaths which cases.
were related to COVID-19. V39 stated that on L. All employees are screened prior to
8/31/20, the facility had reported to the LCHD 76 starting work and no one is allowed to
residents and 35 staff persons had tested positive work if symptomatic.
for COVID-19. V39 stated the facility reported 19 M. The facility staff completed in-service
deaths related to COVID-19. education on Transmission based
precautions, the different designated units
2. The following observations were conducted on and the proper PPE utilization on 8/27/20
the Memory Unit on 8/17/20 and 8/19/20: by the RN charge nurse and MDS nurse.
Any employee who has not completed
On 8/17/2020 at 11:15 AM when entering the required education will not be allowed to
Memory Care unit, there were residents in the work until education completed. In
dining room, without masks and without addition, education has also been
maintaining social distancing. There were no provided on hand hygiene, social
signs on the residents' rooms' doors indicating distancing and use of mask for residents
any of the residents were on transmission-based and the facility Abuse policy on or before
precautions. All the residents' room doors were 9/10/20. Any employee who has not
opened to the hallway. V14 and V15, Certified completed required education will not be
Nurse's Assistants were working on the Memory allowed to work until education completed.
Unit. N. There is no group congregating or
dining in the Memories unit as of 8/27/20.
On 8/17/20, from 11:20 AM through 11:38 AM, Currently there are no facility onset
V14 and V15 identified the residents in each of COVID-19 positive residents in the facility,
the rooms and if they had tested positive or nor are there any COVID-19 positive staff
negative for COVID-19. V14 and V15 stated that members.
many of the residents who had tested positive 4.
with COVID-19 were still residing with roommates Observation monitoring by the director of
who had tested negative for COVID-19. V14 and Nursing/Designees were completed daily
V15 stated the following residents had tested x 14 days then weekly x 2 weeks then
positive for COVID-19: R9, R12, R13, R15, R16, monthly until resolved by the QAPI
R17, R18, R20, R21, R23, R24, R26 and R28. committee. Results of the audits will be
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V14 and V15 stated those positive residents are presented to the Quality Assurance
roommates with the following residents who had Performance Improvement committee for
tested negative for COVID-19: R10, R11, R14, review and further recommendations as
R19, R22, R27 and R29. deemed necessary until concern resolved.
On 8/17/20 at 11:37 AM, R21, who was identified Date of Compliance 9/10/20
as testing positive for COVID-19, was ambulating
in the hallway. At that time, R21 was not wearing
a mask and was walking by other residents and
staff without socially distancing. None of the staff
attempted to redirect R21 at that time.
On 8/17/2020 from 11:40 AM through 1:16 PM,

during the mealtime, residents were gathered in
the dining room/activity area for lunch. None of
these residents were wearing masks. Residents
were sitting at square tables that sat four
residents each. The tables were approximately
three feet apart. While residents were seated at
these tables, these residents could not socially
distance 6 feet apart. R25, R16, R27, R26, R13,
R18, R28 were all identified as residents who
tested positive for COVID-19. These residents
were seated at tables with R14, R30, R22, R19,
R29 and R31 who had all tested COVID-19
negative.
On 8/17/2020 at 11:43 AM and throughout the

mealtime, R27, who has been identified as
COVID negative, was ambulating in the dining
room and up and down the hall without wearing a
mask. R27 was not socially distancing from other
residents and staff did not intervene or provide
redirection. At 1:16 PM R27 was walking in the
dining room and the hallway, coughing. R27 was
not wearing a mask. V14, V15, and V16 did not
intervene or redirect. The staff did not encourage
R27 to perform hand hygiene.
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On 8/17/2020 at 11:50 AM R12, who has been
identified as testing positive for COVID-19, was
ambulating in the dining room and in the hallway
without a mask. At no time did staff, including
V14 and V15, provide redirection or attempt to
cue R12 to wear a mask.
On 8/17/2020 at 12:00 PM, in the dining area,

R22, who has been identified as COVID negative,
was sitting at a table with R26, and R13, who
have been identified as testing positive for
COVID-19. R22 coughed and sneezed in her
hand. R22 did not cover her mouth or nose when
she sneezed. R22 was not wearing a mask. V14,
V15, and V16, Licensed Practical Nurse did not
attempt to cue or assist R22 with hand hygiene
after she coughed.
On 8/17/2020 at 12:06 PM R23, who has been

identified as COVID-19 positive, was sitting at
table in the dining room, coughing without a face
mask. R23 did not cover his mouth when
coughing. V14, V15, and V16 did not encourage
or cue R23 when he was coughing to cover his
mouth.
On 8/19/20, at 5:50 AM, on the Memory Care

Unit, none of the residents' rooms' doors had
signage that any of the residents were on
transmission-based contact-droplet precautions.
At that time, V14 and V30, Licensed Practical
Nurse/LPN were working on the Unit. V14 stated
that those residents who tested positive for
COVID-19 were located from rooms 309 to 316.
At that time, R43 and R13 were standing in the
hall outside their rooms with no masks on. V14
provided no redirection to go back to their rooms.
V14 stated R43 did not have COVID-19 but R13
was positive for COVID-19. V14 and V30 stated
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the residents were all moved on 08/17/20 and
again on 08/18/20 due to some of the residents
sharing rooms with positive residents. V14 and
V30 stated they were not sure why the negative
residents were still sharing the same hall,
especially since they have many that wander the
halls all day. V14 and V30 stated they did not
know if they were supposed to use new PPE
when going in and out of positive resident rooms
and stated they wear the same gowns unless
they leave the unit.
On 08/19/20 at 6:30 AM, V26, CNA came onto

the Memory Care unit to work. V14 stated to her
"Why are you on this unit, because you're positive
(tested positive for COVID-19) and we still have
negative residents?" V26 told her she was told to
come to this hall to work. V26 went into every
room on the hall with the same gown, gloves,
mask and face shield to check on residents. V26
took R13 by the arm and walk her back into her
room from the hallway. V26 then went into R17's
room and reposition R17 in bed. Both residents in
this room, have COVID-19 infection. V26
continued up and down the hall in and out of
resident rooms. At 7:25 AM, V26 was informed by
V15, CNA she needed to be on the North hall to
work. V26 exited the Memory Care hall through
the 200-hall then went directly to the North hall
double doors. V26 did not doff her PPE when
leaving the Memory Care unit.
The facility's undated Line List for COVID-19

Outbreaks in LTC Facilities, undated, was
provided on 8/26/20. The Line list documented
V26 had an onset of COVID-19 on 8/14/20.
On 08/19/20 at 7:45 AM, on the Memory Unit,

V25, Maintenance and V32, Housekeeping,
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began hanging a plastic sheet-like barrier with a
zipper in the middle. The plastic sheet was
hanging from the ceiling to the floor starting at
resident rooms 309 and 310. The plastic was
attached from the ceiling to the floor around two
small poles attached to either wall. There was an
approximate 1-1.5-inch gap between the wall and
the poles on either side. The plastic was not
secured to the ceiling, floor or walls for an airtight
seal. V32 stated he was told to come assist V25
and assumed it was to separate the positive
(tested positive for COVID-19) residents from the
negative ones. While V25 and V37 were putting
up the plastic, R27 was wandering the hall
between the positive and negative side.
On 8/19/2020 at 8:10 AM R12, who has been

identified as testing positive for COVID-19 with
symptoms of fever, was walking up and down the
hallway coughing and made no attempt to cover
her mouth. R12 was not wearing a mask. R12 did
not maintain social distancing as she walked pass
R33, who has been identified as COVID negative.
On 8/19/2020 at 8:15 AM R27, who was identified

as newly COVID positive, was walking in the
hallway coughing, and was not wearing a mask.
R27 walked through the zipper area of the plastic
and opened the fire doors into the common area.
R27 did not maintain social distancing as she
walked past R33, who has been identified as
COVID negative, sitting in the hallway. V15
redirected R27 and walked with R27 through the
hall, again walking pass R33, to her room. At 8:17
AM, V15 stated "(R27) is confused and will not
remember or understand the redirection." At 9:00
AM, again, R27 came through the plastic
sheeting from the positive side to the negative.
V14 was in another resident's room passing
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breakfast tray and was informed by V31 that R27
had come through the plastic barrier. V14 then
retrieved R27 and returned her to her room.
On 8/19/2020 at 8:35 AM R7 was walking in the

hall coughing in her hand with a runny nose. R7
did not have a mask on. R7 did not maintain
social distancing when walking pass R21, who
has been identified as positive, who was standing
in the hallway.
On 08/19/20 from 5:50 AM to 11:20 AM, R43 was

wandering in the hall of the Memory Care unit.
Staff were observed to redirect R43 multiple
times back into her room, but she would stay for
a short time and would come back out into the
hall. R43 did not wear a mask and was not asked
by any staff to wear one. At 6:15 AM, V14 stated
they do not have masks for the residents.
On 8/17/2020 at 11:40 AM V14, CNA was working

on the Memory Unit. V14 stated "We do have
multiple residents that are positive for COVID.
The positive and negative residents are in the
same room. The positive residents do wander in
rooms of negative residents or vice versa. In and
out of each other's room. We try to redirect but
with only 2 CNAs it can be difficult. They
(residents) don't understand and will do it again.
The residents eat in dining room. I don't know
what precautions were put in place for the COVID
positive residents. No one is on droplet isolation."
On 8/17/2020 at 11:50 AM V15, CNA working on

the Memory Unit, stated "The residents wander in
and out of each other's room. You will find them
laying in each other's beds. If the 2 CNAs are in
the rooms no one is here to watch the others. We
do have positive residents on the hall. The
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residents are not separated. They (positive) are in
the rooms with the negative residents. Not sure of
any precautions put in place. No isolation. If there
was isolation there would be a sign on the door.
The residents with the infection would be moved
and separated from the other residents. We have
not done that. All the residents do wander in and
out of the rooms and up and down the hall."
On 8/17/2020 at 11:57 AM V27, Housekeeper,

was working the Memory Unit.V27 stated "I don't
know of any residents on isolation. I know there
are residents that are positive but don't know who
they are."
On 8/17/2020 at 1:30 PM V16, Licensed Practical

Nurse (LPN), was questioned regarding how she
knows who is positive for COVID-19. V16 stated
"I go and ask. They (Administration) get the
results and then will tell us. But I don't wait. I go to
them and ask. I need to know. Currently do not
have any residents on droplet isolation or
precautions. If they were there would be a sign on
the door to report to the nurse. Biohazard
containers would be in the room and supplies
outside the door. Residents that are positive are
in the rooms with negatives. No separation has
been done. And we have residents with
symptoms."
On 8/17/2020 at 2:45 PM V17, Agency CNA, was

working on the evening shift on the Memory unit.
V17 stated "I don't know of any residents on any
isolation. I assume the nurse would tell us, but
the nurse is not back here. If there were residents
on isolation there would be barrels in the hallway
and signs would be outside the door. But none
are down here."
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On 8/17/2020 at 2:48 PM V18, CNA, was working
the evening shift on the Memory unit. V18 stated
"It's my first day down here. I have not received
report of residents on precautions. I'm not aware
of any droplet precautions."
On 8/17/2020 at 2:49 PM V19 CNA, was working

the evening shift on the Memory unit. V19 stated
"If any residents were on precautions, we would
be told that by the nurse. I have not received that
information. There would be supplies and signs
outside doors."
On 8/17/2020 at 2:50 PM V20, Laundry Aide, was

entering and exiting rooms, delivering residents'
laundry on the unit and stated "I don't know
anyone on any isolation or precautions. I don't
know anyone with COVID 19. I come in, do my
job and go home."
On 8/17/2020 at 3:00 PM V5, Minimum Data

Set/Care Plan Coordinator, stated "The process
for residents that are positive for COVID is those
residents are placed on precautions standard and
droplet precautions and in isolation. We do have
residents with positive results on the unit. The
COVID positive residents and the negative
residents should not be in the same room. The
rooms don't allow for 6 feet, social distancing and
if both residents were not positive then 1 resident
would have to be moved. The residents should
have been moved immediately. None of the
residents should be eating in the dining room.
Each resident should have a mask on. The
COVID 19 results came back Saturday (8/15) and
we are starting to make some room changes.
There were residents with results on 8/10 and
symptoms that should have had room changes
and placed on droplet isolation before today."
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On 8/19/2020 at 9:36 AM V28, Nurse Practitioner,

FNP, stated "When resident test positive for
COVID I would expect the resident to be placed
on droplet isolation immediately. I would expect
the residents that are negative and the residents
that are positive to be separated.
On 8/19/2020 at 11:40 AM V1, Administrator
stated "If a resident's COVID 19 results were
positive. Droplet precautions are to be put into
place immediately upon receiving results. Not a
week later. The residents should wear face mask
and the staff should encourage them."
On 8/24/2020 at 4:34 PM, when asked if a

resident tested positive for COVID 19 what would
be your expectation of the facility, V36, Medical
Director, stated "I would expect the positive
residents to be separated from the negative
residents and placed on Contact and Droplet
isolation immediately. The residents on the
memory unit have memory issues with other
comorbidities. Having the negative and the
positives together puts the negative residents at
risk for getting the virus. Each resident responds
differently. Due to the residents' vulnerability this
could be life threatening."
The following residents are located on the

Memory Care Unit and have tested positive for
COVID-19:
R13's August 2020 POS documented she has

diagnoses of Dementia, Paranoid Personality
Disorder and Atherosclerotic heart disease of
native coronary artery.

documented she had tested positive for
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COVID-19.

diagnoses of Dementia, cognitive communication
deficit,

COVID-19.
R17's August 2020 Physician's Order Sheet

(POS) documented she has diagnoses of Type 2
Diabetes and Chronic Ischemic Heart Disease.

COVID-19.
R18's August 2020 POS documented she has a

diagnosis of Dementia. Malnutrition.

COVID-19.
R20's August 2020 POS documented he has

diagnoses of Unspecified Dementia with
behavioral disturbances and Chronic Obstructive
Pulmonary Disease.
His Laboratory Result, dated 8/09/2020,

documented he had tested positive for
COVID-19.

diagnoses Alzheimer's disease, Dementia.

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COVID-19.
R23's August 2020 POS documented he has a

diagnosis of Dementia.

COVID-19.
R24's August 2020 POS documented he has

diagnoses of Dementia, Heart Failure, and
COVID-19.

COVID-19.

diagnoses Alzheimer's disease and
Atherosclerotic Heart Disease.

COVID-19.

diagnoses of Type 2 Diabetes, Atherosclerotic
heart disease of native coronary artery and
Dementia.

COVID-19.
R28's Face Sheet, not dated, documented she

has diagnoses of Schizoaffective Disorder,
Alzheimer's Disease, Hypertension and GERD.

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documented she had tested Positive for
COVID-19.
R9's August 2020 Physician's Order Sheet (POS)

documented she has diagnoses of Dementia,
Hypertension, Hypothyroidism and
Hyperlipidemia.

COVID-19.
R16's August Physician's Order Sheet

documented she has a diagnosis of Toxic
Encephalopathy, Dementia and Heart Failure.

documented she had tested Positive for
COVID-19.

diagnoses of dementia, abdominal aortic
aneurysm atrial fibrillation and hypertension.

COVID-19.
R27's current Care Plan did not have

documentation that R27 was positive for
COVID-19 infection or interventions in place.

diagnoses of Chronic Obstructive Pulmonary
Disease, Unspecified dementia with behavior
disturbances and Alzheimer's disease.
R12's Care Plan, dated 8/8/20 documented she

had tested positive for COVID-19 and should be
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placed on Isolation Droplet precautions.
After multiple request, the facility was unable to

provide a laboratory test result confirming R12
had COVID-19.
The Facility's Coronavirus (COVID-19) Policy,

revised 7/7/20, documented "Any resident
suspected of having Coronavirus will be placed
on Standard, Contact and Droplet Precautions as
per CDC guidelines." The Policy documents "The
infected resident will remain in his/her room on
precautions with the door closed, if possible. The
asymptomatic roommate will be moved to a
private room, if available or to the Designated
Unit, for observation pending consultation with the
local health department."
The Centers for Disease Control (CDC) website

page, "Responding to Coronavirus (COVID-19) in
Nursing Homes, updated 4/30/2020, documented
the facility should implement the following for
residents who have tested positive for COVID-19:
"Ensure the resident is isolated and cared for
using all recommended 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 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
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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)."
The CDC website page, Interim Infection

Prevention and Control Recommendations for
Healthcare Personnel During the Coronavirus
Disease 2019 (COVID-19) Pandemic, updated on
July 15, 2020, documents "Source control refers
to use of cloth face coverings or facemasks to
cover a person's mouth and nose to prevent
spread of respiratory secretions when they are
talking, sneezing, or coughing. Because of the
potential for asymptomatic and pre-symptomatic
transmission, source control measures are
recommended for everyone in a healthcare
facility, even if they do not have symptoms of
COVID-19." The website page documents
"Patients and visitors should, ideally, wear their
own cloth face covering (if tolerated) upon arrival
to and throughout their stay in the facility. If they
do not have a face covering, they should be
offered a facemask or cloth face covering, as
supplies allow. Patients may remove their cloth
face covering when in their rooms but should put
it back on when around others (e.g., when visitors
enter their room) or leaving their room."
3. R5's POS, dated August 2020, documented R5

was admitted to the facility on 7/27/20 and had
diagnoses of Alzheimer's Disease, Diabetes
Mellitus Type II, Subarachnoid Hemorrhage and
Scalp Hematoma (08/11/20) and Gastrostomy
Tube placement (08/15/20).
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The Facility's Line List for COVID-19 Outbreaks

in Long Term Care Facilities, undated,
documented R5 had the onset of COVID-19 on
8/7/20. The Line list documented she had tested
positive for COVID-19 but did not document when
the positive laboratory results were received.
On 08/17/20, R5 was in a room located on the

positive COVID-19 unit on the 100-hall.
R5's Nurse's Notes and Daily Care Guide, both

dated 8/20/20, documented she resided on the
100-hall, the COVID-19 positive unit.
On 08 25/20, at 11:30 AM, R5 was observed in a

room on the Memory unit (300 hall). There was
no signage on her room door indicating she was
on any type of transmission-based precautions.
On 08/25/20, 12:30 PM V16, LPN stated R5 was

just moved to the Memory unit on 08/24/20. V16
stated she was not sure if R5 had COVID-19 or
not.
On 08/19/20 at 12:45 PM, V1, Administrator, was

asked for vital signs, nurse's notes for August
2020 and any information on when R5 was tested
for COVID-19 and the results. As of 08/28/20 at
3:00 PM, there was no additional documentation
given by the facility.
4. On 8/17/2020, at 11:45 AM, V7, LPN, "I found

out yesterday (8/16/2020) I was positive. I was
sick all last week and I worked." V7 stated "(V1)
knew I was sick with cough, no taste/smell, low
grade temp, and a headache too. She (V1) told
me to come to work even when I had symptoms."
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On 8/17/2020, throughout the day shift on the
COVID-19 positive unit, V7 was coughing often
and her eyes were blood shot. V7 appeared very
fatigued and winded.
V7's lab report documents the specimen was

collected on 8/14/2020. The laboratory results
dated 8/15/20 documents V7 is positive for
COVID-19.
On 8/26/2020, at 8:30 AM, a telephone interview

was conducted with V7. V7 stated she was at
home quarantining with symptoms of a cough,
shortness of breath, loss of taste/smell as well as
extreme fatigue. V7 could be heard coughing
during the conversation. V7 also stated, "The last
day I worked was 8/18/2020. I worked a double
on the memory care unit. As a nurse manager, I
am not on the "staffing pattern" but I fill in when
staffing is low. I help answer call lights and pass
trays every day I work."
5. On 8/19/20 at 7:25 AM, V29, Registered Nurse

(RN) was passing medication on the COVID-19
positive hallway (North Hall). V29 stated she had
just come back today after being off due to having
positive COVID-19. V29 stated she had been
symptomatic during her time off. V29 stated she
had not been feeling well for a few days prior to
being tested but continued to come to work. V29
stated her symptoms started on 08/06/20 and
she was not tested until 08/08/20. V29 stated she
was at work on 08/10/20 when she was informed,
she had tested positive for COVID-19. She stated
she was told to finish her shift and go home. She
stated she then was off from 08/11/20 to 08/18/20
and returned 08/19/20. She stated she will be
retested 08/19/20 by facility staff.
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The facility's Line List for COVID-19 Outbreaks in
Long-term Care Facilities documented V29 had
onset of COVID-19 symptoms on 8/7/20 and had
tested positive for COVID-19.
The CDC website page, "Preparing for COVID-19

in Nursing Homes" updated on 6/25/20,
documents "As part of routine practice, ask HCP
(including consultant personnel and ancillary staff
such as environmental and dietary services) to
regularly monitor themselves for fever and
symptoms consistent with COVID-19; Remind
HCP to stay home when they are ill; if HCP
develop fever (T100.0F) or symptoms consistent
with COVID-19 while at work they should inform
their supervisor and leave the workplace. Have a
plan for how to respond to HCP with COVID-19
who worked while ill (e.g., identifying and
performing a risk assessment for exposed
residents and co-workers)." The website page
document "Screen all HCP at the beginning of
their shift for fever and symptoms of COVID-19;
Actively take their temperature and document
absence of symptoms consistent with COVID-19;
and if they are ill, have them keep their cloth face
covering or facemask on and leave the
workplace."
The CDC website page, "Criteria for Return to

Work for Healthcare Personnel with SARS-CoV-2
-Infection (interim Guidance), updated on 8/10/20,
documents Healthcare Personnel (HCP) with
mild to moderate illness who are not severely
immunocompromised can return to work when at
least 10 days have passed since symptoms first
appeared, at least 24 hours have passed since
last fever without the use of fever-reducing
medications and symptoms (e.g., cough,
shortness of breath) have improved. The website
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page documents "Note: HCP who are not
severely immunocompromised and were
asymptomatic throughout their infection may
return to work when at least 10 days have passed
since the date of their first positive viral diagnostic
test."
The facility's policy, titled, "Coronavirus" dated

5/29/2020, documents, "Staff members who have
signs and symptoms of respiratory infection while
on the job should: immediately stop work and
self-isolate at home."
6. On 8/17/2020, at 10:45, V1 stated, "All

residents who have tested positive for COVID-19
reside on the North Hall in the facility. We are
wearing the yellow reusable gowns until they
enter the (COVID isolation) unit. When staff enter
the unit, they are to use the blue disposable
gowns." V1 stated that all residents on the
COVID-19 unit are on droplet contact
precautions. V1 stated that all staff are expected
to wear blue disposable gowns, gloves,
goggles/and or face shields.
On 8/19/2020, V25, Maintenance, entered the

double doors to the North COVID isolation hall in
a reusable cloth yellow gown and proceeded past
the shower curtain that was being used as a
plastic barrier to the rest of the hall. At that time,
V35, Director of Clinical Operations, stated, "You
need to put on a blue gown before entering this
area." V25 stated, "Oh, that's new today."
On 8/19/2020, at 12:25 PM, V25, was in the

hallway of North hall and stated he was just
checking the rooms, and it was his first time
wearing the blue isolation gowns. V25 continued
to state, "I had just been wearing the yellow
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(gown)."
On 8/17/2020, at 11:11 AM, V5, MDS

Coordinator, exited the North COVID isolation hall
through the double doors wearing a blue
disposable gown over a yellow reusable gown. V1
instructed V5 that she was to doff the blue gown
before exiting the isolation hall. At this time, V1
stated, "She should have removed the blue gown
before exiting the unit."

5/29/2020, documents, "Preventing Illness: 1.
The best way to prevent the illness is to avoid
being exposed to the virus and properly
using/wearing PPE when needed."
7. On 8/17/2020, at approximately 11:45 AM, V7,

LPN/Unit Manager, stated, "We have no
housekeeping staff back here (on the COVID-19
unit). It doesn't help prevent the spread of
infection."
On 8/17/2020, at 11:55 AM, the floors were visibly

soiled and sticky throughout the North COVID
isolation hall. At this time, V5, LPN stated, "We
haven't had housekeeping back here in over a
week."
On 8/17/2020, at 12:30 PM, R1, who resides on

the COVID-19 unit, stated, "They do not clean my
room."
On 8/17/2020, at 1:00 PM, V1 stated, "Honestly, I

don't know when the last time it (the COVID
Isolation hall) was cleaned. Housekeeping called
off today. We will call in evening shift to do
housekeeping. We should be cleaning high touch
surfaces 4 times a day."
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On 8/19/2020, at 8:45 AM, R1 stated, ""They still

have not cleaned my room since we talked about
it the other day (8/17/2020) and the bathroom
stinks."

revised 7/7/20, documents, "Environmental
Cleaning with an approved disinfectant should be
completed daily, or when visibly soiled and for
terminal cleaning after infection has resolved.
Clean all high touch point areas." The Policy
documents "An approved disinfectant will be used
for cleaning the rooms of residents with
Coronavirus. Attention should be given ro bedside
tables, handrails, call buttons, windowsills, and
toilets."
8. On 08/19/20 at 5:45 AM, upon arrival to the

front door to the facility, V30, Licensed Practical
Nurse (LPN) was standing and smoking in front
of the entrance. V30 gave this surveyor the code
to get into the building and stated no one was
available to do any screening at this hour. There
was no one at the front desk or in the lobby area.
V30 did not attempt to screen the surveyor.
The CDC website page, "Interim Infection

Prevention and Control Recommendations for
Healthcare Personnel During the Coronavirus
Disease 2019 (COVID-19) Pandemic, updated on
July 15, 2020, documents to "Screen everyone
(patients, HCP (Healthcare Personnel, visitors)
entering the healthcare facility for symptoms
consistent with COVID-19 or exposure to others
with SARS-CoV-2 infection and ensure they are
practicing source control." The website
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documents "Actively take their temperature and
document absence of symptoms consistent with
COVID-19. Fever is either measured temperature
100.0°F or subjective fever; and ask them if they
have been advised to self-quarantine because of
exposure to someone with SARS-CoV-2
infection."
9. On 8/19/20, at 5:50 AM, V30 walked through

the double doors of the COVID-19 unit with a
mask on only and without hand sanitizing or
donning a gown, gloves or face shield/goggles.
Multiple signs on the double doors documented
full PPE required past this point including gown,
mask, face shield or goggles and gloves.
On 8/19/20 at 5:47 AM, V14, Certified Nurse's

Aide/CNA then came through the double doors
onto the COVID-19 unit, fully donned in PPE,
gown, gloves, mask and face shield. V14 stated
she was looking for someone to help her and no
one had shown up for the shift on her unit. V14
then stated she worked on the Memory Unit. V14
went back through the double doors through
another set of double doors that entered the 200
Hall and through a locked set of double doors that
led into the Memory Unit. V14 then went through
the four set of double doors to the hall that
housed the Memory Care residents. V14 did not
remove her gloves or gown while touching these
doors and going from one unit to the other.
10. Throughout the survey, surveyors requested

from V1, Administration, documentation of how
the facility was trending/tracking the COVID-19
infections throughout the facility. The facility did
not produce this documentation prior to exit on
9/4/20.
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11. On 8/17/20, at 10:45 AM, V1 stated the
current census in the facility was 81.
The Immediate Jeopardy that began on 8/9/20

was removed on 8/27/20 when the facility took
following actions to remove the Immediacy:
1. The facility has three designated units as

follows: D-1 General Population, D-2 Admissions,
readmits, and Tested Negative, and D-3 Positive
Residents:
a)Resident Testing positive for COVID-19 are
placed in the D-3 unit. Completed 8/27/20 and
ongoing.
b) Resident returning from hospital, admission or
new admission and readmission will be placed on
the D-2 unit for 14-days. Completed 8/27/20 and
ongoing.
c)Resident will transfer from D-2 unit to D-1 unit if
negative or asymptomatic per CDC guidelines.
Date completed 8/27/20 and ongoing.
d) Those residents on the Memory Unit that are
positive have been placed on the D3 unit and
those residents that are negative and recovered
have been placed on D1 unit. Date completed
8/27/20 and ongoing.
e) Rooms have been allocated for those
residents who have admitted/readmitted to the
facility will be placed on the D2 unit per CDC
guidelines. Date Completed 8/27/20 and ongoing.
f) Signage will be posted at each designated unit
describing appropriate PPE usage and
Precautions that are used. Date completed
h) Designated units have been revamped where
this is a designated clean room for donning and a
dirty room for doffing PPE prior to and when
leaving the unit. The Designated units will be
monitored by the Director of Nursing Services
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(DNS)/Designee throughout the shifts.
i) Those positive residents have been placed on
Droplet Precautions per Physician's Orders.
j) Those positive residents have been placed on
isolation by Executive Director/Director of Nurse
and her designees. Date completed 8/27/20 and
ongoing.
2). Inservice staff on type of transmission-based
precautions and how to identify the different units
by area, proper PPE usage to prevent the spread
of COVID-19 was completed on 8/26/20 by
Minimum Data Set/Care Plan Nurse and RN
Charge Nurse prior to working the floor. Date
completed 8/27/20.
3). Staff will be observed daily by nurse
manager/Director Nursing Services/Designee
throughout the shift to ensure compliance and
proper PPE. Any non-compliance will result in 1:1
retraining and disciplinary action by the DNS or
ED.
Regarding Failed to Implement Procedures when
staff test positive for COVID-19 and have
COVID-19 symptoms
1).All entry to the facility will come through the
front entrance for screening prior to proceeding o
their workplace. Area will be monitored 24 hours
daily. Complete dated 8/27/20 and ongoing.
2). Those staff that are identified as positive from
COVID-19 Testing will be notified by Infection
Control Preventionist or Designee and Follow the
CDC Criteria for Return to Work for Healthcare
Personnel with COVID-19. Ongoing
3). In-serviced staff on screening checklist for
employee/visitors was on 8/26/20 by MDS nurse
prior to working. Any employee that has not
completed the in-service will not work until their
in-services are completed. Ongoing.
4) DNS/Designee will review Screening Checklist
for Employee/Visitor Daily for accuracy and
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chances in staff condition. Ongoing.
5) Monitor compliance to be presented to QAPI to
ensure policies and procedures are in alignment
with CDC guidance for COVID-19. QAPI Meeting
was performed on 8/27/20 by ED and Medical
Director to review Root Cause Analysis and
Implement Performance Improvement Plan
based on the findings of the review on 8/27/20 for
F880). Date completed 8/27/20.
Regarding issue of failing to encourage masking
and social distancing of residents:
1). Resident will be care planned for
non-compliance with face mask and social
distancing.
2) In-serviced staff on observing and intervening
when necessary with residents to wear mask and
practice social distancing was completed by
social services and activity staff on 8/26/20 prior
to working the floor. Date completed on 8/26/20
and ongoing.
3) Social Service to inform those family members
who are resident representative for their love
ones regarding wearing of mask and social
distancing when non-compliant.
4) Masks were given to resident and staff to
observe and intervene at any point they observe
resident being non-compliant. The resident with
BIMS of 13 or higher will be educated and advise
of the consequences of not wearing mask and
will be asked to remain in their rooms. Those
residents with BIM score of below 13, staff will
assist resident with proper placement of mask
and social distancing. Completed on 8/27/20 and
ongoing.
5) Social Services and Activity staff will perform
observation rounds to ensure residents are
wearing their mask and practicing social
distances. Monitor compliance to be presented to
QA to ensure policies and procedures are in
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alignment with CDC guidance for COVID-19.
6) Staff will observe at all times when insight of
residents that masks are properly in place and
residents are social distancing. Staff will intervene
at any point they observe when residents are
noncompliant. Ongoing.
7) QAPI Meeting was performed on 8/27/20 by
ED and Medical Director to review Root Cause
Analysis and Implement Performance
Improvement Plan based on the findings of the
review on 8/27/20 for F880. Dated completed
8/27/20.
Regarding Failing to Utilize Appropriate PPE
1) Staff has been retrained and completed
competencies on proper PPE usage on 8/26/20
by MDS Coordinator and RN charge Nurse prior
to working floor. Date completed 8/27/20 and
ongoing.
2) Observation rounds to be performed by Nurse
Manager/DNS/Ed daily throughout the day to
ensure proper wearing of PPE. Any
non-compliance will result in 1:1 retraining and
disciplinary action by ED. Any staff not in the
facility during the time of the in-service will be
unable to work until training has been completed.
Ongoing.
3) QAPI meeting was performed on 8/27/20 by
ED and Medical Director to review Root Cause
Analysis and Implement Performance
review on 8/27/20 for F880. Date completed
Regarding failed to utilize appropriate Hand
washing
1) Competencies of hand washing techniques
and utilization of ABHR and hand hygiene
performed with returned demonstration by
DNS/MDS coordinator and Designee with return
demonstration. Any staff not in the facility at the
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time of retraining and competencies will be
re-inserviced prior to working. Training and
competencies were completed on 8/27/20 /and
ongoing.
2) staff in-serviced on appropriate hand hygiene
by MDS and Charge Nurse on 8/26/20.
Manager/DNS/Designee on appropriate hand
hygiene daily.
3) Observation rounds to be performed by Nurse
Manager/DNS/Designee on appropriate hand
hygiene daily.
4) Monitor compliance to be presented to QAPI
by ED and Medical Director on 8/27/20/ to ensure
policies and procedure are in alignment with CDC
guidance for COVID-19. QUAP review Root
Cause Analysis and implement Performance
review on 8/27/20 for F880. Date completed
8/27/20.
Regarding Failed to Implement Infection Control
procedure on the Memory Unit
1) The facility is following CDC guidelines for
cohorting based on the results of the resident's
testing. Date completed 8/27/20 and ongoing.
2) The facility had 3 designated units as follows:
a) Resident testing positive results are placed on
the DU-3 unit.
b) Resident Returning from Hospital, or new
admission and readmission will be placed on
DU-2 unit or 14 days observation. Date
completed 81720 and ongoing.

Stearns COVID-19 Inspection Report

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PRINTED: 10/08/2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

F 000 INITIAL COMMENTS F 000

Complaint #2042514/IL121617: F880

A COVID-19 Focused Infection Control Survey

§483.10(g)(14) Notification of Changes.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Electronically Signed 09/24/2020

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

F 580 Continued From page 1 F 580

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

F 580 Continued From page 2 F 580

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

F 580 Continued From page 3 F 580

2. R5's Hospital Record, dated 8/11/20 at 10:09

On 08/19/20 at 5:55 AM, during a tour of the

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

F 580 Continued From page 4 F 580

On 8/19/20, at 6:05 AM, V30, LPN stated she

On 8/19/20, at 9:00 AM, V8, LPN stated she was

There was no documentation in R5's Facility

The Facility's COVID-19 Positive list, entitled

There was no documentation in R5's medical

The Facility's Policy, Notification of Change of

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

F 580 Continued From page 5 F 580

3. On 8/17/2020, R7 was observed on the North

On 8/20/2020, at 12:22 PM, V34, R7's family,

On 8/25/2020, staff were in the process of

On 9/1/2020, at 2:15 PM, V34 stated, "No one

On 9/3/2020, at 9:51 AM, V46, Social Service

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

F 580 Continued From page 6 F 580

4.R25's Face Sheet, not dated, documents R25

R25's Minimum Data Set (MDS), dated

R25's Laboratory Result, dated 8/09/2020,

R25's Care Plan, dated 08/10/2020, documented

There is no documentation in R25's August 2020

5.R17's Face Sheet, not dated, documents R17

R17's Laboratory Result, dated 8/09/2020,

R17's Care Plan, dated 08/10/2020, documented

R17's MDS, dated 8/21/2020, documents R17 is

There is no documentation in R17's medical

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

F 580 Continued From page 7 F 580

6.R12's Face Sheet, not dated, documents R12