PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ F 000 INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 000 This report is the result of an unannounced Abbreviated Survey conducted off site at Enumclaw Health and Rehabilitation Center on 03/23/2020, with an onsite visit of 03/26/2020. A sample of 15 residents was selected from a census of 57. The sample included ten current residents and five discharged residents. On 03/27/2020, the facility was notified of an IJ related to Infection Control. The IJ was not removed before exit. The following were complaints investigated as part of this survey: #3699402 #3699510 #3699523 The survey was conducted by: Susan Lee Loewen MSN, BSN, RN, Investigator Lisa Foster, MN, RN, NH Surveyor The survey team is from: Department of Social & Health Services Aging & Long Term Support Administration Residential Care Services, Region 2, Unit F 20425 72nd Avenue South, Suite 400 Kent, Washington 98032-2388 Telephone: (253) 234-6000 Fax: (253) 395-5070 . LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE Electronically Signed (X6) DATE 04/15/2020 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: 61WI11 Facility ID: WA11700 If continuation sheet Page 1 of 11 PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Infection Prevention & Control SS=K CFR(s): 483.80(a)(1)(2)(4)(e)(f) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG F 880 (X5) COMPLETION DATE 5/19/20 §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 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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 61WI11 Facility ID: WA11700 If continuation sheet Page 2 of 11 PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 2 (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. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 §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: Based on observation, interviews and record reviews the facility failed to take appropriate actions related to a COVID-19 outbreak. These failed practices may have contributed to multiple residents and staff contracting COVID-19. As of 03/26/2020, based upon the facility's incomplete LTC (Long Term Care) Respiratory Surveillance Line List, and multiple staff interviews, 15 residents tested positive for Coronavirus disease (COVID-19) and 9 residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 61WI11 Please see attached informal dispute resolution request. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of federal Facility ID: WA11700 If continuation sheet Page 3 of 11 PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 3 had pending lab results. Three residents who tested positive for COVID-19 remained at the local hospital. As of 04/02/2020 38 residents and 10 staff tested positive for COVID-19. Five residents expired. Additionally the facility failed to operationalize their infection prevention and control program to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections, in particular COVID-19. These failed practices resulted in an immediate jeopardy on 03/27/2020. Findings included... On March 4th CMS (Center for Medicare & Medicaid Services) released a transmittal to nursing homes that directed nursing homes to monitor the CDC (Center for Disease Control) website which included a link to CDC. Upon clicking on the link it directs the facility to a Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term Care Settings This checklist should be used as one tool in developing a comprehensive COVID-19 response plan. The checklist did not describe mandatory requirements or standards; rather, it highlights important areas to review to prepare for the possibility of residents with COVID-19. In general, when caring for residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless the suspected diagnosis FORM CMS-2567(02-99) Previous Versions Obsolete C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ Event ID: 61WI11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 and state law. Identified residents Resident #1, # 2 and # 4 no longer reside in the facility. Resident # 3, #5 and # 6 care plans have been update and continue in isolation. Resident #7: staff are wearing goggles when entering the room and are being cleaned in doorway prior to placing on isolation cart. Identification of others Residents at the facility who have been in contact with another resident or staff member with symptoms or became symptomatic are in isolation. systematic changes ED has been educated on having staff member screen staff or visitor at point of entry. Facility has limited access to the building and thermometer is placed at the entrance to facility. Staff have been educated to place residents in droplet precautions if they become symptomatic. Nurse Managers have been educated on the COVID-19 Tool Kit sent by DOH. Staff have been educated on donning and doffing isolation PPE and competencies have been completed. They have been educated to have N95 mask on during resident care. SDC has been educated on reporting 2 residents or staff with respiratory symptoms to Health Department. SDC is in contact with the DOH Facility ID: WA11700 If continuation sheet Page 4 of 11 PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 4 requires Airborne Precautions (e.g., tuberculosis). This includes restricting residents with respiratory infection to their rooms. If they leave the room, residents should wear a facemask (if tolerated) or use tissues to cover their mouth and nose. Continue to assess the need for Transmission-Based Precautions as more information about the resident's suspected diagnosis becomes available. Observations were conducted on 03/26/2020 from 1:41 PM until 2:46 PM. VISITOR ENTRY Review of the facility February 2020 Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease (COVID-19) or Persons Under Investigation for COVID-19 policy, showed the procedure directed staff to manage visitor access and movement within the facility. The Centers of Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings recommended, "Limit points of entry to the facility." The back door was posted with the following signs; "No Admittance - Use front door only", "Attention: Due to recent outbreak of COVID-19 in our nation we are trying to minimize all-essential access to the center" and a second posting to those with questions, regarding the facility's management of Corono Virus, to call Staff C with a listed phone number. FORM CMS-2567(02-99) Previous Versions Obsolete C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ Event ID: 61WI11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 routinely as needed and are sending LTC facility COVID-19 Updating Report form every 3 days and complete line listing every 7 days. DSHS is sent a weekly line listing with staff and resident on separated line listing per DSHS request. DNS/Designee has been educated to complete COVID-19 focused survey for nursing homes on a daily basis. Staff monitoring door for screening have been educated on surveillance results out of normal baseline and when not to allow persons into building. If staff are symptomatic they are turned away at the door, recommend to get tested for COVID-19, and added to line listing. Staff will report to ED/DNS findings daily. MONITORING Dns/Designee to complete the Daily COVID-19 Focus Survey audit daily x 4 weeks then 3 x week x 4 weeks then weekly x 4 weeks. SDC/Designee to review screening to validate completion SDC to complete random donning and doffing competencies including cleaning and drying of goggles. ED to validate point of entry that staff are checking results before allowing into the building including temperatures. Findings from audit to be brought to QAPI for further evaluation Person Responsible Executive Director Facility ID: WA11700 If continuation sheet Page 5 of 11 PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 5 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 The front door had one sign posted directing those with questions, regarding the facility's management of Corono Virus, to call Staff C with a listed phone number. On 03/26/2020 Staff G, Housekeeping, was observed walking down the hallway, carrying a mask, looking for assistance as they were told to spray with disinfectant and bag the mask before going home. Administrative Staff assisted Staff G, who then exited the facility out the back door. Later on, during the onsite visit, Staff G was observed in the facility without wearing a protective facial mask. Staff G was not observed to have come into the facility by either the front or back entrance, nor observed to have been screened for symptoms of COVID-19. During an interview on 03/27/2020 at 1:04 PM, Staff D stated that she did not know how staff G re-entered the facility, but she re-educated Staff G on the process. According to Staff D, the facility doors are locked but staff have a code to unlock the door and enter the facility. When asked why Staff G returned, Staff D stated that Staff G went to get a Burrito or Taco out of the break room. The Centers of Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings recommended, "All visitors should be actively assessed for fever and respiratory symptoms upon entry to the facility. If fever or respiratory symptoms are present, visitor should not be allowed entry into the facility." Upon entrance to the facility, on 03/26/2020 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 61WI11 Facility ID: WA11700 If continuation sheet Page 6 of 11 PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 6 1:41 PM, the facility requested the surveyor to complete a health screening form at the reception desk, located in the foyer, directly to the right of the front entrance. Located at reception was a sign in sheet with visitors listed. During an interview with Staff A, the visitors listed included two plumbers on 03/25/2020 and a hospice staff member on 03/26/2020. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 Staff A, Administrator, then escorted the surveyor, down the hallways, past ten resident rooms,and through resident care areas, to Nursing Station #2 located in the 500 unit the epicenter of the facility's COVID-19 outbreak, to be screened for the presence of a fever. The only thermometer available, at the nurse's station, was an oral thermometer, so the surveyor had to remove their face mask to be screened for the presence of a temperature. When questioned regarding the use of an oral thermometer, Staff A stated, "That's all we have." INFECTION SURVEILLANCE HealthCare Workers A March 10, 2020 letter to Long-Term Care Facility Director, from WA (Washington) State DOH (Department of Health), instructed the facility to "Immediately notify the health department about anyone with COVID-19 or if you identify two or more residents or healthcare providers who develop respiratory infections within a week. Review of the facility COVID-19 Timeline showed that on 03/17/2020 three staff (Staff H, I, J) were identified as symptomatic. The facility failed to notify the Department or DOH of healthcare workers with symptoms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 61WI11 Facility ID: WA11700 If continuation sheet Page 7 of 11 PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 7 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 According to the facility provided Timeline, on 03/20/2020 Staff K exhibited symptoms of a fever and cough. Review of the line listing provided by the facility on 03/25/2020 at 9:03 AM showed, Staff K was not entered on the line list. Further review of the facility Timeline showed on 03/23/2020 Resident L, M, B, D and N were symptomatic. Review of the line listing, provided by the facility on 03/25/2020 at 9:03 AM, showed the results of testing conducted were not noted for Staff L, M and N. Residents On 03/19/2020 at 4:01 PM the Department received an anonymous Report that: "Supposedly the facility is in lockdown yet they are admitting patients from St. Elizabeth Hospital in Enumclaw where the coronavirus has affected a patient." According to the facility Timeline, On 03/13/2020 Resident #14 and #15 were admitted to the facility. On 03/17/2020 Resident #13 was readmitted to the facility from St. Elizabeth Hospital. Staff B, interviewed on 03/23/2020 at 10:00 AM, stated that the facility stopped admitting residents on 03/20/2020 because residents exhibited symptoms of suspected COVID-19. On 03/20/2020 at 7:18 PM the Department received notification from the facility of seven Residents (#s 8, 9, 10, 11, 12, 13 & 14) who presented with acute fever and/or respiratory symptoms. According to the report, Per Medical Director, all symptomatic residents were placed on Droplet/Contact isolation and sent to the Emergency Department for COVID testing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 61WI11 Facility ID: WA11700 If continuation sheet Page 8 of 11 PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 8 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 Review of the line listing showed Resident's #s 12, 13 & 14 first exhibited symptoms on 03/20/2020, but review of the resident's clinical records showed elevated temperatures and other reported symptoms were present on 03/19/2020. During an interview on 03/27/2020 at 1:04 PM Staff D stated that she and Staff B called the DOH on 03/22/2020 after they received a resident's COVID-19 positive test result. The DOH representative sent the facility the Long Term Care (LTC) Tool Kit to use and said if the facility had questions or needed help to call. Staff D stated that she had been emailing the line lists, but the facility had not called and requested assistance, and had not spoken with a DOH representative since 03/22/2020. During an interview on 03/23/2020 at 10:00 AM, Staff B stated that DOH called the facility back and said they wouldn't go out to the facility because there were only three COVID-19 positive residents of seven tested. Review of the documents provided by Staff C on 03/26/2020 included the LTC [Long Term Care] Tool Kit included "Aggressive Infection Prevention and Control Actions for Facilities with Suspected or Confirmed Cases of COVID-19, which directed the facility to "Treat all other residents in that same section or unit as if they have been exposed and implement Droplet and Contact Precautions with eye protection in the entire unit." Review of facility Infection Control [IC] documentation showed Resident #1 was in room 503, bed B on 03/21/2020. On 03/21/2020 Resident #2 was also in room 503, bed A. On FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 61WI11 Facility ID: WA11700 If continuation sheet Page 9 of 11 PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 9 03/22/2020 Resident #2 was symptomatic for COVID-19, and moved to room 203A on the 200 unit, which the facility dedicated to the care of COVID-19 positive residents. Resident #2 tested positive for COVID-19 on 03/26/2020. Resident #1 remained in room 503, and was not placed on precautions until Resident #1 exhibited symptoms on 03/24/2020. Resident #1 tested positive on 03/26/2020. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 On 03/21/2020 Resident #3 and Resident #4 were roommates in room 522. On 03/22/2020 Resident #3 exhibited symptoms, was moved to the 200 unit and tested positive for COVID-19. On 03/26/2020 Resident #4 was not observed on precautions. During an interview on 03/27/2020 Staff B stated that Resident #4 was exhibiting symptoms and was "placed on isolation this morning." On 03/21/2020 Resident #5 and Resident #6 were roommates in room 110. On 03/26/2020 Resident #5 was observed in room 501, on precautions, pending COVID-19 test results. On 03/27/2020 Resident #5's COVID-19 test results were positive. On 03/26/2020 Resident #6 was observed in room 110 still not on any isolation precautions. During an interview on 03/27/2020 at 1:04 PM when asked why roommates of symptomatic residents were not placed on precautions until symptomatic, Staff D stated that they were told by corporate not to start the roommate on isolation, and continue with surveillance to conserve PPE [Personal Protective Equipment]. Corporate Nurse, Staff C, interviewed on 03/27/2020 at 1:45 PM, stated that roommates, of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 61WI11 Facility ID: WA11700 If continuation sheet Page 10 of 11 PRINTED: 04/16/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 505400 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 03/26/2020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2323 JENSEN STREET ENUMCLAW HEALTH & REHAB CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ ENUMCLAW, WA 98022 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 10 residents who were positive for the COVID-19 virus, were not placed on any isolation precautions unless the roommates presented with symptoms of COVID-19, to conserve PPE's. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 On 03/26/2020 all staff were observed wearing masks. Review of documents "Covid-19 Timeline" provided by the facility showed that on 03/20/2020 all staff that had contact with positive residents were issued a facemask to be worn, and education was provided. In an email on 03/30/2020 at 3:11 PM, when asked when the facility implemented universal face masks were to be worn by all staff, Staff A replied, 03/24/2020. STANDARD and TRANSMISSION-BASED PRECAUTIONS On 03/26/2020 Resident #7's room was observed with posted precautions, and an infection control (IC) cart outside the room. Staff F, Lead Aide was observed to donn and doff Personal Protective Equipment (PPE) to respond to Resident #7's request for potato chips. Staff F was wearing a N95 mask, donned disposable gown and gloves but there was no eye protection in the IC cart. Staff D went down the hallway and retrieved goggles, which Staff F donned over N95 mask. Staff F entered the resident's room, provided the potato chips, and removed the gown and gloves prior to exiting the room. Outside the room, Staff F removed the goggles, and disinfected them. Staff D cued Staff F that the removal and cleaning of goggles should have been conducted before leaving the room. Refer to WAC 388-97-1320(1)(a)(2)(a)(b)(c) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 61WI11 Facility ID: WA11700 If continuation sheet Page 11 of 11