PRINTED: 10/23/2020

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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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

A Targeted Infection Control Survey/COVID-10

Focused Survey and Complaint Investigation
#156806 was conducted by the Kansas
Department for Aging and Disability Services
(KDADS), on behalf of the Centers for Medicare
and Medicaid Services (CMS) on 10/19/20. The
facility was found not to be in substantial
compliance with 42 CFR 483 subpart B.

On 10/21/20 at 4:00 PM, The Administrator was

provided the IJ template and informed of the IJ
and notified that on 10/05/20 the facility identified
two residents with symptoms of Covid-19, which
resulted in positive antigen test results (confirmed
on 10/07/20 by a lab test). The facility failed to
enact their "Provisional License - Covid-19
Response" as stated on 06/19/20, which directed
they would move positive residents to a "Special
Care Unit" to decrease the spread of airborne
and droplet based Covid-19. During this time,
Covid-19 positive residents cohorted with
Covid-19 negative roommates, with only a curtain
between them, against CDC guidance and best
practice to prevent the spread of highly
contagious Covid-19.
Based on an interview on 10/20/20 at 10:14 AM
with the Administrator revealed the facility did not
place all residents on quarantine or stop
communal dining until 10/07/20, two days after
residents began showing symptoms of Covid-19
and had positive antigen tests.
An interview with a Consultant on 10/21/20 at
11:15 AM revealed on 10/17/20 between 6-7 PM.
They were at the facility evaluating residents and
observed six different staff at times with their
masks removed. The Consultant further observed
one staff in a resident's room with their mask

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

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: 55EN11 Facility ID: N069001 If continuation sheet Page 1 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 Continued From page 1 F 000

pulled down around their chin, not wearing
goggles in the room and not social distancing.
These failures placed all residents in immediate
jeopardy by the spread of Covid-19 to all
residents in the facility, confirmed by lab testing,
which led to 10 resident deaths.
F 880 Infection Prevention & Control F 880
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:

§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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 2 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 880 Continued From page 2 F 880

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.

§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.
This REQUIREMENT is not met as evidenced
by:
The facility reported a census of 50 residents,
with 50 residents testing positive for Covid-19.
The facility had four hallways and a Special Care
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 3 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 880 Continued From page 3 F 880

Unit (SCU). Based on observation, interview, and
record review the facility failed to follow standards
of practice based on The Centers for Medicare
and Medicaid Services (CMS) and The Centers
for Disease Control and Prevention (CDC) to
reduce the risk and potential for transmission of
infectious diseases, which included the highly
contagious Covid-19 (a potentially fatal
respiratory virus). The facility further failed to
implement a system to prevent transmission of
Covid-19 when two residents started showing
symptoms of the virus on 10/05/20 and had
positive antigen (test that detects Covid-19
proteins) tests, which the lab confirmed on
10/07/20. The facility failed to quarantine the two
positive residents and continued to cohort
Covid-19 positive residents with Covid-19
negative residents. The facility failed to stop
communal dining or place all residents on
quarantine until 10/07/20, two days after the initial
positive results. The facility failed to test all of the
residents in the facility until 10/12/20, 7 days from
the first two resident's positive antigen results to
identify the extent of the outbreak. Ultimately all
61 of the facility residents exposed from 10/05/20
to 10/19/20 tested positive for Covid-19, with 10
residents who died of Covid-19 related
symptoms, one who required hospitalization, and
others who reported various signs/symptoms
related to the virus. This placed all 50 residents in
Immediate Jeopardy.

Findings Included:

- An interview with Administrative Staff A on

10/20/20 at 10:14 AM revealed the facility tested
all residents and staff for Covid-19 from 09/22/20
to 09/24/20 and all the tests came back negative.
On 10/05/20 two residents developed fevers
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 4 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 880 Continued From page 4 F 880

along with other signs and symptoms of
Covid-19. The two residents were tested with the
facility's Antigen Machine (test that detects the
Covid-19 proteins) and both tested positive. The
two residents were then tested by the hospital
and on 10/07/20 the results also came back
positive. On 10/07/20 (two days after the first two
residents started showing symptoms) all
residents were placed in quarantine in their
rooms and the facility stopped communal dining.
On 10/08/20 two more residents tested positive
on the facility Antigen Machine. On 10/09/20 (4
days after the first two resident's tested positive
and the day R1, (a Covid-19 positive resident
died), she talked to Physician JJ regarding the
positive residents and the situation at the facility.
On 10/12/20 (one week after the first two
resident's tested positive) the facility tested
everyone for Covid-19 and on 10/15/20 and
10/16/20 all resident tests came back positive for
the virus. All staff were tested again on 10/19/20,
with 37 testing positive.

Review of the "Covid-19 Adult Care Home

Checklist Form" dated 06/19/20 revealed in the
event of a Covid-19 positive resident the facility
would initiate a plan to move residents currently
residing in the facility "Special Care Unit" (SCU)
to the nursing home part of the facility. Resident's
who were positive for Covid-19 would then be
moved to the SCU where "the best isolation can
take place." The residents would be quarantined
to their room and staff would use isolation
Personal Protective Equipment (PPE - mask,
gloves, gown, face shield or goggles, shoe
protection). Staff would be dedicated to care for
only the Covid-19 positive residents and would
enter the building through the SCU back door, so
they did not have to enter the nursing home. The
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 5 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 880 Continued From page 5 F 880

facility failed to initiate their plan when two
residents in the facility started showing symptoms
of Covid-19 and tested positive for the highly
contagious virus.

Review of the CDC guidance "Responding to

Covid-19 in Nursing Homes" revised 04/30/20
revealed the facility would isolate a newly
diagnosed Covid-19 positive resident and care
for using all recommended PPE. Staff would
place the positive/suspected resident in a single
room, if possible. The document stated "cohorting
residents on the same unit based on symptoms
alone could result in inadvertent mixing of
infected and non-infected residents." If a resident
had confirmation of Covid-19, regardless of
symptoms they were to be transferred to a
designated Covid-19 care area. Roommates of
the positive resident would be considered
exposed, should remain on quarantine for 14
days, and could only cohort with other exposed
(not positive) residents if no other rooms were
available.

Review of facility documentation from 10/05/20 to

10/20/20 lacked evidence the facility isolated the
first two Covid-19 positive residents, only
cohorted residents who were Covid-19 positive
with each other, and/or made arrangements for
Covid-19 positive resident's roommates who were
negative to be moved into a separate room.

A follow up interview with Administrative Staff A

on 10/20/20 at 6:33 PM revealed the facility had
two residents who were at a high risk for
elopement and the only place she had to secure
them was on the SCU. Administrative Staff A
decided not to utilize the SCU (as stated in the
facility plan), left the Covid-19 positive residents
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 6 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 880 Continued From page 6 F 880

in their rooms, and if they had a roommate they
would try to keep them each quarantined to their
side of the room.

Observation of the facility on 10/19/20 revealed

shared rooms were only separated by a privacy
curtain.

Review of the facility "Electronic Health Record"

(EHR) on 10/20/20 revealed the following:

1. R12 and R1 cohorted in the same room. On

10/15/20 R12 received a positive Covid-19 test
result. R1 admitted to the hospital on 10/08/20
and died in the hospital on 10/09/20, where she
tested positive for Covid-19.

2. R13 died on 10/13/20 at 04:45 PM and had a

positive Covid-19 test result.

3. R14 died on 10/15/20 at 01:12 PM and had a

positive Covid-19 test result.

4. R8 and R9 cohorted in the same room and on

10/18/20 both received positive Covid-19 test
results. R9 died on 10/16/20.

5. R4 and R5 cohorted in the same room and on

10/18/20 both received positive Covid-19 test
results. R5 died on 10/16/20.

6. R6 and R7 cohorted in the same room. R6

tested positive for Covid-19 on 10/05/20. R7
tested positive for Covid-19 on 10/16/20 and died
on 10/16/20.

7. R15 died on 10/17/20 at 08:06 PM and had a

positive Covid-19 test result

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 7 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 880 Continued From page 7 F 880

8. R10 and R11 cohorted in the same room. On
10/15/20 R10 and received positive Covid -19 test
results. R11's record lacked a positive test result,
although the facility reported all resident tested
positive for Covid-19. R11 died 10/18/20.

9. R2 and R3 cohorted in the same room and on

10/18/20 both received positive Covid-19 test
results. R3 died on 10/18/20.

10. R16 died on 10/19/20 at 09:50 AM and had a

positive Covid-19 test result.

Further review of the facility EHR on 10/20/20

revealed residents with various symptoms of
Covid-19 ranging from asymptomatic to severe
symptoms (pain, difficulty breathing, weakness),
which led to resident deaths.

Review of the "Staff Testing Document" provided

by the facility revealed out of 70 staff tested as of
10/20/20, 55 staff had tested positive for
Covid-19.

An observation provided during an interview with

Consultant GG on 10/21/20 at 11:15 AM revealed
she entered the facility on 10/17/20 with Physician
JJ to evaluate residents who were positive with
Covid-19 and had a full code status (a technique
of basic life support for the purpose of
oxygenating the brain and heart until appropriate
medical treatment can restore normal heart and
ventilation action) to see if they needed
hospitalization or other interventions. During her
visit to the facility she observed six different
(unidentified) staff at various times with their
masks removed. Consultant GG further observed
one unidentified staff in a resident's room with her
mask pulled down around her chin, not wearing
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 8 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 880 Continued From page 8 F 880

goggles, and sitting next to the resident (failed to
social distance) discussing getting the resident
ready for bed.

An interview with Resident Representative KK on

10/21/20 at 2:45 PM revealed he/she and two
other family members went to the facility on Labor
Day (09/07/20) weekend to visit their family
member during the afternoon. The facility had a
table set up in the entry way for screening but
there were no staff available to assist the visitors .
After waiting quite some time, they walked down
a hall to find someone to help them.
Representative KK stated they had to go quite a
ways, but found a staff member and when they
asked about screening and what they needed to
do, the staff member said "I don't know the
policy." He/she was not sure what department the
staff member worked in, but the staff member
wore a mask. They went on down to the nurse's
station where there were three staff sitting, none
wearing masks, but did put them on when he/she
asked questions about visiting her family
member. Representative KK stated they all
looked at each other and one said she wasn't
sure what they needed to do, and she would have
to ask the nurse. The nurse said she wasn't sure,
but thought they were to check their
temperatures. Representative KK asked all three
of the staff members if they could go to the
resident's room and the staff member said she
did not know, but the week before it was just one
visitor allowed. The nurse then said it would be ok
if they all went to the resident's room. When they
got to the resident's room, his roommate was
present. Neither the resident nor his roommate
wore masks. They did not stay in the room, but
went to the activity room to visit. Representative
KK stated her family member did not wear a
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 9 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 880 Continued From page 9 F 880

mask when he left the room and went to the
activity room. The resident told Representative
KK wearing a mask did not really matter because
most of the nursing staff did not wear them all of
the time, and he had mentioned that to other
family members several times before.

An interview on 10/21/20 at 8:31 AM with R17

revealed staff wore masks when they came into
her room, but moved the mask around at times.
R17 stated she did not wear a mask at any time,
and no one ever told her she should.

An interview on 10/21/20 at 8:40 AM with R12

revealed he thought he felt better from having
Covid-19, but still felt a little weak. R12 reported
he did not wear a mask and the facility never
offered him one. The resident reported his wife
passed away at the hospital and tested positive
for Covid-19.

An interview with Certified Nurse Aide (CNA) M

on 10/21/20 at 08:05 AM revealed if a Covid-19
positive resident had a roommate the facility did
not move either resident, both residents stayed in
the room.

An interview with CNA N on 10/21/20 at 08:10 AM

revealed residents did not wear masks or cover
their face with a tissue when staff provided cares .
If a Covid-19 positive resident had a roommate
the facility did not move either resident, they both
quarantined in their room.

An interview with Licensed Nurse (LN) G on

10/21/20 at 7:55 AM revealed if a resident had
signs or symptoms of Covid-19 and had a
roommate the facility did not move the roommate
they just kept them to their side of the room,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 10 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 880 Continued From page 10 F 880

divided by a curtain.

An interview with LN H revealed staff only wore

N-95 masks when they gave nebulizer
treatments, otherwise they wore surgical masks
when working with Covid-19 positive residents.
Covid-19 positive residents who had a roommate
were not moved, they both quarantined in their
rooms and had a curtain to divide them.

Review of the unsigned policy "Covid-19 Policy

and Procedure" dated 05/20/20 revealed elderly
and those with chronic medical conditions
demonstrated more severe illnesses than other
populations at this time. The facility would
implement surveillance, and infection control and
prevention strategies to reduce the risk of
transmission of Covid-19. The facility would
implement their actions according to the CDC,
State, County and local Health Departments,
State Survey Agencies and the World Health
Organizations recommendations. The policy
further described the plan to move SCU residents
to the nursing home part of the facility and to
isolate Covid-19 positive residents in the SCU.

Review of the undated "Covid-19 Surveillance

Policy" revealed residents would be tested for
Covid-19 with the facility Antigen Machine and
positive residents would be retested through the
local hospital and placed in quarantine. If the
facility had an outbreak (2 residents or more) all
residents would be tested through the local
hospital and put on quarantine.

The facility failed to follow standards of practice to

reduce the risk and potential for transmission of
Covid-19. On 10/19/20, the facility reported all 50
residents tested positive for Covid-19. The facility
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 11 of 12
 PRINTED: 10/23/2020
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
A. BUILDING ______________________

175506 B. WING _____________________________

10/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

201 W CRANE STREET

ANDBE HOME, INC
NORTON, KS 67654

(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 880 Continued From page 11 F 880

further failed to implement a system to prevent
transmission of Covid-19 when two residents
started showing symptoms of the virus on
10/05/20 and had positive antigen tests, which
the lab confirmed on 10/07/20. The facility failed
to quarantine the two positive residents and
continued to cohort Covid-19 positive residents
with Covid-19 negative residents. The facility
failed to stop communal dining or place all
resident's on quarantine until 10/07/20, two days
after the initial positive results. The facility did not
test all residents until 10/12/20, 7 days after the
first two residents showed signs/symptoms of the
virus. The facility further failed to properly utilize
PPE and screen all visitors before entering the
building. Ultimately all 61 of the residents
exposed from 10/05/20 to 10/19/20 tested
positive for Covid-19, with 10 residents who died
of Covid-19 related symptoms, one who required
hospitalization, and many others who reported
various signs/symptoms related to the virus. This
placed all 50 residents in Immediate Jeopardy.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 55EN11 Facility ID: N069001 If continuation sheet Page 12 of 12