STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2020007964 License No, 1257096 CL GOLDEN, LLC, d/b/a File No. 23301 CROSS LANDINGS HEALTH AND Provider Type: Nursing Home REHABILITATION CENTER, Respondent. / ADMINISTRATIVE COMPLAINT The Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), files this Administrative Complaint against the Respondent, CL Golden, LLC, d/b/a Cross Landings Health and Rehabilitation Center (“the Respondent”), and alleges as follows: NATURE OF THE ACTION This is an action against a nursing home seeking licensure revocation, an administrative fine of $15,000.00, a six-month survey cycle fine of $6,000.00, the assignment of conditional licensure status effective April 20, 2020, and costs of investigation and prosecution, based upon a class I widespread deficiency and the violation of the residents rights. PARTIES 1. The Agency is the licensing and regulatory authority that oversees skilled nursing facilities (also called nursing homes) and enforces the state statutes and rules governing such facilities. Ch. 408, Part IT, Ch. 400, Part II, Fla. Stat.; Ch. 59A-4, Fla. Admin. Code. The Agency is authorized to deny, suspend, or revoke a license, and impose administrative fines pursuant to sections 400.121, 400.23, and 408.815, Florida Statutes, assign a conditional license pursuant to subsection 400.23(7), Florida Statutes, and assess costs related to the investigation and prosecution of this case pursuant to section 400.121, Florida Statutes. 2. The Respondent was issued a license by the Agency to operate a skilled nursing facility (“the Facility”) and was at all times material required to comply with the applicable statutes and rules governing such facilities. BACKGROUND 3. The Novel Coronavirus Disease 2019 (“COVID-19”) is a severe respiratory illness that can spread among humans through respiratory transmission. According to the Centers for Disease Control and Prevention (CDC), people at risk for serious illness from COVID-19 include older adults and people with serious chronic medical conditions. In late 2019, a new and significant outbreak of COVID-19 emerged in China and the World Health Organization declared COVID- 19 a Public Health Emergency of International Concern. The CDC also confirmed instances of community spread of COVID-19 in the United States and has issued extensive written guidance to help control the spread of COVID-19. Individuals who are 65 years and older, those with chronic underlying medical conditions, and those living in nursing homes are at high risk for developing serious complications from COVID-19 illness. Individuals who are infected could develop serious disease with difficulty breathing, and might require intensive care for the treatment of multi-organ failure, respiratory failure, and septic shock. COVID-19 infection can lead to death. COVID-19 is a new disease, caused be a new coronavirus that has not previously been seen in humans. Currently, there is no vaccine and no approved treatment for COVID-19 infection, which is a highly transmissible disease. 4. On March 1, 2020, The Office of the Governor issued Executive Order Number 20- 51 directing the Florida Department of Health (“DOH”) to issue a Public Health Emergency. The Executive Order documented, "Coronavirus Disease 2019 (COVID-19) is a severe acute respiratory illness that can spread among humans through respiratory transmission and presents with symptoms similar to those of influenza." Section 2 directed the State Health Officer to take any action necessary to protect the public health. Section 3 directed the State Health Officer to follow the guidelines established by the CDC in establishing protocols to control the spread of COVID-19. Section 4 designated the Florida the DOH as the lead state agency to coordinate emergency response activities among the various state agencies and local governments. Section 5 specified that all actions taken by the State Health Officer with respect to this emergency before the issuance of this Executive Order are ratified. Section 6 stated that the DOH would actively monitor, at a minimum, all persons meeting the definition of a Person Under Investigation (PUI) as defined by the CDC for COVID-19 for a period of at least 14 days. Active monitoring by the DOH will include at least the following: A. risk assessment with 24 hours of learning an individual meets the criteria for a PUI and B. Twice daily temperature checks. Section 7 directed the DOH, pursuant to its authority in section 381.00315, Florida Statutes, would ensure that all individuals meeting the CDC's definition of a PUI are isolated or quarantined for a period of 14 days or until the person tests negative for COVID-19. Section 8 directed the DOH to make its own determinations as to quarantine, isolation and other necessary public health interventions as permitted under Florida Law. Section 9 directs all state agencies under the direction of the Governor to fully cooperate with the DOH, and any representative thereof in furtherance of this Order. On March 9, 2020, the Office of the Governor issued Executive Order Number 20-52 declaring a state of emergency for the entire State of Florida as a result of COVID-19. 5. On March 11, 2020, the Florida Division of Emergency Management (“DEM”) issued Emergency Order No. 20-002 restricting entrance into residential health care facilities including nursing homes. On March 15, 2020, the DEM issued Emergency Order No. 20-006 further restricting entrance into residential health care facilities including nursing homes. The Emergency Order limited persons who were allowed to enter a facility and directed screening of all individuals seeking entry. The order documented, “Individuals seeking entry to the facility under the above section 1 (includes staff) will not be allowed to enter if they meet any of the screening criteria listed below”: a. Any person infected with COVID-19 who has not had 2 consecutive negative test results separated by 24 hours; b. Any person showing, presenting signs or symptoms of, or disclosing the presence of a respiratory infection, including cough, fever, shortness of breath or sore throat; c. Any person who has been in contact with any person(s) known to be infected with COVID-19, who has not yet tested negative for COVID-19 within the past 14 days; d. Any person who traveled through any airport within the past 14 days; or e. Any person who traveled on a cruise ship within the past 14 days. Part 5 of the Order stated, "The following documentation must be kept for visitation within a facility: a. Individuals entering a facility subject to the screening criteria above may be screened using a standardized questionnaire or other form of documentation. b. The facility is required to maintain documentation of all non-resident individuals entering the facility. Documentation must include: 1. Name of the individual; 2. Date and time of entry; and 3. The documentation used by the facility to screen the individual showing the individual did not meet any of the enumerated screening criteria, including the screening employee's printed name and signature. 6. On March 18, 2020, the Agency issued an alert entitled, “Residential and Long- Term Care Facilities to Implement Universal Use of Facial Masks.” The alert stated, “Effective immediately staff of residential and long-term care facilities are to implement universal use of facial masks while in the facility. All staff, essential healthcare visitors and anyone entering the facility are to don a facemask upon the start of their shift or visit and only change it once it becomes moist. It is important to keep hands away from the facemask and only touch the straps of the facemask. Gloves are to be worn when providing care to the resident. Continue to perform hand hygiene prior to donning gloves, after removing gloves, and anytime there is contact with the resident environment. Staff in a room with a patient with respiratory symptoms of unknown cause or a patient with known or suspected COVID-19 should adhere to Standard, Contact, and Droplet Precautions with eye protection. This includes wearing gown, gloves, N95 facemask (as fitted and available - if not available, at least a facial mask), and eye protection such as face shields or goggles. In addition to securing more gowns, gloves, and facemasks, facilities will need to immediately order the appropriate eye protection (i.e. face shields) since many do not have this on hand. In the event you are unable to acquire the necessary PPE, please notify your local emergency management agency. Facilities will need to educate their staff on the proper donning (putting on), doffing (taking off), and disposal of any PPE. Information about the recommended duration of Transmission-Based Precautions is available in the Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19.” 7. On April 5, 2020, an unannounced joint Focused Infection Control survey due to the pandemic Coronavirus disease 2019 (COVID-19) was conducted with representatives from the DOH. Additional joint Focused Infection Control surveys were conducted by the Agency and representatives from the DOH on April 8, 2020, April 10, 2020, April 11, 2020, and April 13, 2020. Representatives from the DOH also conducted separate visits to evaluate and provide infection control training and education. On April 6, 2020, an onsite visit was made by the DOH epidemiology team. The DOH contracted a specialized infection control team (“strike team”) consisting of four registered nurses who made both joint and independent visits to the Facility on April 9, 10, 11, and 13, 2020. 8. On April 14, 2020, the DOH issued Quarantine/Isolation Orders on the Facility, which called for the immediate transfer of five residents who were either confirmed or suspected of being infected with COVID-19. On April 16, 2020, the DOH issued Quarantine/Isolation Orders on the Facility, which called for the immediate transfer of eight additional residents who were found to be infected with COVID-19 on April 15, 2020. Additional evidence gathering (documentation and interviews) continued offsite through April 20, 2020. 9. On April 17, 2020, the Agency imposed an Immediate Moratorium on Admissions on the Facility. The Facility census was 42 on April 5, 2020, 41 on April 14, 2020 and 28 on April 16, 2020. Also, on April 17, 2020, the DOH issued an Order of Emergency Suspension of License on the Facility’s administrator and regional nursing home administrator. COUNT I Resident Rights 10. Under Florida law, all licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: (c) Any entity or individual that provides health, social, legal, or other services to a resident has the right to have reasonable access to the resident. The resident has the right to deny or withdraw consent to access at any time by any entity or individual. Notwithstanding the visiting policy of the facility, the following individuals must be permitted immediate access to the resident: 1. Any representative of the federal or state government, including, but not limited to, representatives of the Department of Children and Families, the Department of Health, the Agency for Health Care Administration, the Office of the Attorney General, and the Department of Elderly Affairs; any law enforcement officer; any representative of the State Long-Term Care Ombudsman Program; and the resident’s individual physician. 2. Subject to the resident’s right to deny or withdraw consent, immediate family or other relatives of the resident. The facility must allow representatives of the State Long-Term Care Ombudsman Program to examine a resident’s clinical records with the permission of the resident or the resident’s legal representative and consistent with state law. ()) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. (n) The right to be treated courteously, fairly, and with the fullest measure of dignity and to receive a written statement and an oral explanation of the services provided by the licensee, including those required to be offered on an as-needed basis. § 400.022(1)(c), (1), (n), Fla. Stat. (2019). 11. Under Florida law, any violation of the resident’s rights set forth in this section constitutes grounds for action by the agency under section 400.102, 400.121, or part II of chapter 408, Florida Statutes. § 400.022(3), Fla. Stat. (2019). Survey Findings 12. Based upon observations, interviews with representatives from the State of Florida public health authority (Florida Department of Health/ (DOH)), facility staff interviews, record reviews, and review of infection control orders, directives, recommendations and guidelines from the Centers for Disease Control and Prevention (CDC), the State Survey Agency (Agency for Health Care Administration), and the Florida Division of Emergency Management (DEM), the Facility failed to ensure residents’ rights to adequate and appropriate health care services for the Coronavirus Disease 2019 (COVID-19) pandemic. The Facility failed to: (a) implement droplet isolation precautions for both COV1D-19 infected residents and Persons Under Investigation (PUIs) to control or prevent the potential spread of COVID-19, (b) ensure that staff were consistently screened prior to facility entry, (c) consistently deny entry to staffmembers with sore throats, coughs, and/or other possible COVID-19 symptoms, (d) fully, completely and timely cooperate with the DOH regarding their mission as the public health authority resulting in a decreased ability for DOH to timely mitigate potential COVID-19 disease transmission, (e) store housekeeping chemicals in properly labeled containers with clear instructions for use, and (f) implement mandates and directives issued by the DEM, the Agency and the DOH related to the COVID-19 pandemic. 13. These failures directly affected all forty-two (42) of the residents residing in the Facility on April 5, 2020, plus one (1) additional COVID-19 infected resident who had been hospitalized. During this period, at least fifteen (15) residents, which included every wing in the Facility, became infected or possibly infected with COVID-19 as of April 15, 2020 (Residents #1 through #3 and #7 through #18). 14. A DOH Epidemiologist reported that the Jefferson County Health Department (CHD) was contacted on April 4, 2020, by a local hospital, then by the Facility, to report that one of the Facility's residents (Resident #1) tested positive for COVID-19 upon transfer to the hospital. 15. The DOH Epidemiologist opened an epidemiological investigation, to include a review of infection control practices, upon notification of the positive test result. 16. | The Epidemiologist called the Facility on April 4, 2020 and spoke to the Director of Nursing (DON). The Epidemiologist asked the DON if there were any other residents exhibiting respiratory symptoms and the DON replied that there were six others. The Epidemiologist informed the DON that the six residents were now Persons Under Investigation (PUIs), as defined by the CDC, and must be placed on droplet isolation precautions per CDC recommendations. 17. The Epidemiologist asked the DON if there were any symptomatic staff who were in close contact with Resident #1 during the two days prior to his hospital transfer. The DON responded that she, as well as three Licensed Practical Nurses (LPNs) (LPN G, LPN H and LPN I), were in close contact with Resident #1. When the DON was asked if she had any respiratory symptoms, she stated that she did not. 18. The Epidemiologist requested a complete list of staff with contact information, a line list (list of ill residents including name, date of birth, and onset dates of symptoms), the Facility's infection prevention and control policy, as well as staff education related to infection control and COVID-19. 19. The Epidemiologist informed the Facility that the information was required for the underlying goal of mitigating the transmission of the virus. The purpose of requesting staff contact information was to first. to notify them of possible exposure to COVID-19, and second, to determine if they were a close contact to the COVID-19 positive resident and if they had any symptoms. 20. The Epidemiologist then instructed the DON, despite not reporting any symptoms, and three other nurses to go home to self-isolate and not to work. 21. The Epidemiologist called the Facility again on April 4, 2020, to follow-up on the documents requested and obtain clarification on the number of tests that needed to be delivered to the Facility. 22. This time, she spoke to the Regional Nursing Home Administrator (Regional NHA), who stated that there were only four residents with symptoms and not six as previously stated by the DON (Resident # 2, #3, #4 and #5). 23. The DOH delivered approximately nine (9) tests to the Facility on April 4, 2020, and the Facility staff determined that four residents (Resident #2, #3, #4 and #5) and three health care staff would be tested. 24, The CHD utilized the triage line and contacted the Agency to request that a joint on-site facility visit be conducted on April 5, 2020, to complete an infection contro] assessment and epidemiological investigation. 25. | Onthe evening of April 5, 2020, the CHD was notified that two of the four residents (Resident # 2 and #3) and one of the three health care staff tested on April 4, 2020, showed positive results for COVID-19 infection. 26. Based upon the new cases and the findings of the triage team comprised of the Jefferson & Madison County Health Administrator (“CHA”), the Epidemiologist, and Agency surveyor on April 5, 2020, a Level I response was enacted as outlined in the CHD's “COVID-19 Long Term Care Response Plan” in which a team is deployed to assess resident safety and infection control practices. Therefore, another visit was made to the Facility on April 6, 2020, by a CHD epidemiology team. 27. Based upon the findings of the CHD Registered Nurse (RN), CHA and Epidemiologist that determined the Facility was at an increased risk for an outbreak, an escalation to a Level II response was enacted in which an infection control expert is deployed and a mass casualty response with triage, treatment, safety and transport capabilities was invoked. Therefore, a subsequent visit was made to the Facility on April 8, 2020, this time by a Florida Hospital Association Infection Preventionist (FHA IP) and Agency surveyor. 28. Based on the FHA IP and surveyor's findings from the April 8, 2020, visit and the DOH Epidemiologist's confirmation of a Facility outbreak, a further escalated Level III response was enacted in which a response team grounded in infection control principles was deployed to support the facility over two to four days. Therefore, a DOH contracted Strike Team, a specialized infection control team consisting of four registered nurses, Strike RN A, Strike RN B, Strike RN C and Strike RN D, was sent to the Facility on April 9, 10, 11, 13, of 2020. The Agency provided 10 additional on-site monitoring on April 10, 11, and 13, 2020. 29, On April 5, 2020, at approximately 12:30 PM a joint visit was conducted at the facility with the CHD Jefferson and Madison CHA and DOH Epidemiologist. 30. On April 5, 2020, at approximately 12:30 PM, prior to Facility entry, the team approached the Facility's main entrance and through the window observed Resident #22 sitting in his wheelchair in the main lobby with no facemask. The surveyor referred to the following resources: CDC guidance (referenced below) and CMS COVID-19 Long-Term Care Facility Guidance, pg. 2, April 2, 2020, which stated that patients should be offered a facemask or cloth face covering as supply allows and that patients may remove their cloth face covering when in their rooms, but should put them back on when leaving their room. 31. The main entrance door was locked, and signs were posted related to screening procedures and suspended visitation. 32. | The NHA answered the door. The CHA, Epidemiologist, and surveyor identified themselves and the purpose of the visit. The NHA stated that he could not allow the team in without calling the owner and getting permission first. The CHA informed the NHA that he was welcome to call the owner, but could not deny the team immediate entry. The NHA complied and screened each team member at the door, then led the team to the conference room. 33. OnApril 5, 2020, at approximately 12:45 PM, an interview was conducted with the NHA. The Epidemiologist again requested the above information, and asked the NHA if any of the staff were also employed by other health care facilities. The NHA confirmed that some staff were dually employed. 34. The Epidemiologist requested that the names of those facilities also be included with the staff contact information. The NHA stated the Facility's designated infection preventionist 11 is the DON, but she was sent home to self-isolate. The NHA stated that he was now serving as the interim infection preventionist. 35. The NHA stated that 280 N95 facemasks were received in the evening on April 3, 2020, so most staff did not receive them until yesterday (April 4, 2020). 36. | When asked if the Facility had received any new admissions recently, he replied “no” and that the Facility had only received readmissions from the hospital. 37. The surveyor asked the NHA to describe the policy in place for residents returning from the hospital. He replied, “to isolate them for seven days,” which he defined as “placing them in private rooms.” 38. On April 5, 2020, at approximately 01:20 PM, the team initiated a Facility tour. The team did not observe any signs or posters with information pertaining to COVID-19, such as how to identify it or prevent its spread, were observed anywhere throughout the building other than the exterior of the main entrance. 39. The team did not observe any of the PUIs identified by the Epidemiologist to be placed on droplet isolation precautions, as instructed. 40. The residents who were PUIs were in various rooms throughout the Facility, and not in a separate unit from residents who did not have COVID-19. 41. _—_ Resident #3, an active PUI, was sharing a room with Resident #7, who was not an active PUI. 42. Although the three remaining PUIs were observed in private rooms, none of the four rooms had droplet isolation precaution signs posted or Personal Protective Equipment (PPE) readily accessible outside the residents’ rooms. 43. When the team brought this to the attention of the NHA and RNHA, they stated 12 that they had isolated the residents as they were, for the most part, all in private rooms. 44. The team educated the NHA and Regional NHA that this measure was insufficient as without additional droplet isolation precautions in place and increased awareness among staff; there was nothing to keep staff from spreading the virus from one room to the next. 45. | The team shared the CDC's recommendation to have a designated unit to house confirmed or suspected residents within the Facility. 46. The surveyor asked the NHA if designated staff would be caring for the residents on the soon-to-be isolation unit. 47. The NHA stated that it would really depend on whichever staff happened to be assigned those rooms on each shift. 48. The team then also shared that the CDC recommended having dedicated staff assigned to care for residents with known or suspected COVID-19, and that ideally, a nurse would be the dedicated caretaker, to further reduce the number of health care staff having to enter the rooms. 49. The surveyor asked the NHA ifhe had seen the CDC's guidance related to strategies to optimize the supply of PPE and equipment to which he shook his head no. The surveyor shared this resource with the NHA by e-mail. 50. On April 5, 2020, at approximately 02:15 PM, the surveyor observed the Regional NHA carrying a plastic bin of PPE to begin setup of droplet precaution isolation rooms. 51. On April 5, 2020, by approximately 03:15 PM, the four PUIs had been consolidated at the front of the building on the East Hall. 52. The first six rooms beyond the main lobby now served as the newly established isolation unit and consisted of rooms 1, 2, 3, 27, 28 and 29. 13 53. All persons proceeding to resident rooms would first have to pass through this isolation area. 54. On April 5, 2020, at approximately 03:30 PM, the surveyor asked the NHA what he planned to do with Resident #7 who was not a known PU] at the time of entrance, but became one because he was sharing a room with Resident #3, who was a PUI. 55. | The NHA responded, “I probably need to have him tested.” 56. | The NHA was advised that Resident #7 must also be suspected positive until proven otherwise. 57. The surveyor asked the NHA why the location of the current isolation unit was selected. 58. | The NHA stated that having it at the front of the building would prevent residents being transferred in from the hospital from having to go through the whole building. 59. On April 5, 2020, at approximately 01:30 PM, during the Facility tour, Certified Nursing Assistant (CNA) L was observed behind the nurse's station pulling her facemask down and leaving it below her nose and mouth while she looked through a record. 60. | CNA L did not perform hand hygiene before or after touching the facemask. 61. The CHA also observed this and provided education immediately. 62. On April 5, 2020, at approximately 01:30 PM, RN K was observed standing at the medication cart next to the nurses' station on the back (North and South Unit) hall. 63. Her facemask was observed to be ill-fitting and positioned improperly on her face. The top of the facemask was positioned halfway down the bridge of her nose and exposed a wide gap between the facemask and the nose. 64. The surveyor provided education regarding proper fit and placement. 14 65. | RNK informed the surveyor that some staff had come to her and expressed interest in training and demonstrations relevant to COVID-19. She asked if the Agency provided any Facility staff training. The surveyor replied "no" and informed the nurse that staff training and education was the Facility's responsibility. 66. On April 5, 2020, at approximately 01:45 PM, the CHA observed LPN J during medication administration on the East Unit. 67. | LPN J was observed to have physical contact with a resident while administering their medication, write in the Medication Administration Record, and then proceed to pass medications to the next resident without performing hand hygiene in-between residents. 68. On April 5, 2020, at approximately 01:50 PM, the CHA observed a housekeeper collecting soiled laundry and trash from a resident's room without gloves. 69. On April 5, 2020, at approximately 02:00 PM, the CHA and the Epidemiologist observed two of two staff in the kitchen with no facemasks or gloves on. 70. One of the kitchen staff, Staff O, was observed with her N95 facemask around her neck and was preparing a modified texture meal in a blender. 71. When the staff observed the CHA and the Epidemiologist, Staff O pulled her N95 facemask up from around her neck while the other dietary aide retrieved her N95 facemask. 72. Both staff also applied gloves. 73. On April 5, 2020, at approximately 02:30 PM, the surveyor asked Staff O, a dietary aide, when she received her N95 facemask. She replied, “yesterday” (04/04/2020). 74. The surveyor further asked if she had been fit tested for the facemask, or shown how to wear it, and she shook her head no. 75. The surveyor asked her name, and she was very reluctant to give it. She stated she 15 was afraid of losing her job. 76. On April 5, 2020, at approximately 03:00 PM, the surveyor observed a housekeeper exit one of the freshly setup isolation rooms on the East Unit. 77. The housekeeper exited the isolation room without first removing and disposing of potentially contaminated PPE. 78. The housekeeper removed the disposable gown without rolling it inside out to contain any potential contaminants. 79. The housekeeper discarded the gown in a regular trash can located on the housekeeping cart in the hall instead of a red biohazard bag. 80. | The housekeeper did not perform hand hygiene afterwards. 81. The surveyor educated the housekeeper regarding how to properly doff (take off) PPE, 82. Several CNAs on the hall approached and expressed concern regarding having to re-use the same facemask each day as well as uncertainty regarding how to properly don (put on) and doff PPE. 83. The Regional NHA and Housekeeping Supervisor arrived afterwards, and the surveyor informed them that staff could use additional training. 84. The surveyor suggested that the CDC's videos on donning and doffing PPE be shared with staff or provided as an in-service. 85. On April 5, 2020, at approximately 03:15 PM, the surveyor asked the Regional NHA about the Facility facemask policy. 86. | The Regional NHA stated that each staff member was issued one N95 facemask and they were responsible for maintaining it. 16 87. She further stated that instructions to disinfect the facemask were given to staff at the time of issue. 88. On April 5, 2020, at approximately 04:30 PM, before exiting for the day, the surveyor shared concerns observed during the visit with the NHA and Regional NHA. 89. | These concerns included: failing to follow DOH instructions to immediately isolate PUIs, inadequate hand hygiene, widespread lack of knowledge among staff with no heightened sense of urgency, N95 facemasks not worn or worn improperly, and PPE removed and disposed of improperly. The surveyor asked the facility administration to develop a Performance Improvement Plan (PIP) to address how the facility planned to mitigate the further spread of COVID-19 throughout the building. 90. On April 5, 2020, at approximately 07:00 PM, the Epidemiologist notified the surveyor by telephone that two additional residents (Resident #2 and #3) and one staff tested positive for COVID-19. 91. A record review was conducted of the CHD "Nursing Home Infection Prevention Assessment Tool for COVID-19," which was completed by the CHD RN as part of the DOH's Level 1 response enacted as a result of the April 5, 2020, visit. 92. This assessment was conducted on the next day, April 6, 2020. 93. Areview of the assessment revealed that the Facility's confirmed case count to date was three residents (Resident #1, #2 and #3) and one health care staff. 94. Two more residents (Resident #6 and #7) were tested during the visit, as they were former roommates of COVID-19 positive residents. 95. The Facility owner as well as two of his regional nurses were noted to be at the Facility for all, or at least a portion of the assessment. 17 96. A further review revealed the Facility's screening process was "inadequate," "haphazard," and "not tracked" by a designated individual. 97. Part time staff were observed to “just come in, disorganized” with “no distancing instructions given.” Therefore, ways to improve the process were discussed at length. 98. The assessment noted that “staff doesn't have a clue!” about COVID-19 symptoms or how it is transmitted. 99. The assessment also noted that hand hygiene is “not being practiced.” 100. The CHD RN also wrote that she “had to remind several staff members” to perform hand hygiene after having contact with a resident and “asked staff to H/H (hand hygiene) after opening/closing door.” 101. Hand hygiene supplies were “inadequate” in resident rooms or care areas. 102. A recommendation was made to have more dispensers made available outside of isolation rooms. 103. The Facility did not place suspected residents on appropriate transmission-based precautions as no signage was posted outside the room of a hospital readmission PUI. 104. Positive residents and PUIs were all in proximity, but the Facility did not have designated staff assigned to reduce traffic to those rooms. 105. The assessment revealed that the CHD RN “got deflected or inconsistent answers” when attempting to determine if the Facility was performing appropriate monitoring of ill residents to quickly identify residents who require transfer to a higher level of care, so recommendations of best practices were provided. 106. The CHD RN wrote that she “never saw any lists” to demonstrate that symptomatic residents and staff were being tracked and monitored by the Facility. 18 107. The cleaning and disinfecting of high touch surfaces were not observed during the visit. 108. The Facility was observed using string mop heads. 109. It was recommended to change these to microfiber mop heads, as they are easier to effectively clean and disinfect. 110, The Facility's disinfectant bottles were observed without full labels and missing contact time. 111. The outcome of the assessment was that Facility staff were determined to have “educational deficits” in the following areas and would benefit from additional training, for signs/symptoms of COVID-19, 6' minimum distancing, reporting illness to supervisor, hand hygiene, wearing mask properly, PPE donning and doffing, cleaning and disinfection of environment, employee symptom assessment and home isolation (positive symptoms/test). 112. On April 6, 2020, at approximately 03:30 PM, the Agency received a copy of the PIP from the Facility's owner. 113, A review of the facility's PIP dated 04/02/2020 revealed the following: - "Re-educate staff on COVID-19 virus/disease signs/symptoms" - "Educate and demonstrate use of proper hand washing to all staff" - "Educate & demonstrate correct application and removal of PPE" - "Educate about correct use of face mask including leaving it on and not to touch their face with hands" - "Educated on how to preserve PPE due to limited amount" - "Staff will be screened multiple times daily on their shift. Everytime [Every time] a staff goes outside and returned [returns] they will be screen [screened] and temps [temperature taken], staff tempted [body temperatures taken] at the beginning & end of shift" - "Screening visitors/staffs more thorough at front door, by asking the questions, listen and reading the answers while maintaining 6 foot distancing" - "Screening staff for community exposure" 114. On April 7, 2020, in a written correspondence to the Agency, the Epidemiologist stated that requests for staff contact information had been made to the following individuals: the NHA, the Regional NHA, the DON, and two Regional Nurses at the Facility, but not yet received. 115. In a written correspondence dated April 7, 2020, from the Jefferson and Madison County Health Administrator (CHA) to the Agency, assistance in obtaining information from the Facility was requested stating that DOH had to get their legal team involved and "the facility is impeding our ability to do our job." 116. That correspondence further revealed that the Facility's lawyer called the CHA earlier that day requesting to be on all of the telephone calls that the CHD makes to any of the Facility's staff. 117. A review of a written correspondence between the CHA and the Facility's owner revealed the request for staff contact information was made directly to the Facility's owner on April 7, 2020, citing Florida Administrative Code, 64D-3.041, that gives the DOH the right to obtain this information. In a written response dated April 7, 2020, the FOM informed the CHA that the Agency’s Chief of Field Operations also had a conversation with the Facility's owner requesting that the staff contact information urgently be provided to the CHD. 118. On April 8, 2020, at approximately 09:30 AM, a team consisting of a FHA IP and DOH Epidemiologist (who did not enter the facility) conducted a joint visit with the surveyor as part of the CHD's Level II response protocol and to determine if the Facility's PIP had been implemented. 119. At the time of entrance, the Facility's positive COVID-19 case count was four residents (Resident #1, #2, #3 and #7), one of which was still at the hospital (Resident #1), and three health care staff. 120. Results were pending for one resident (Resident #6) and four health care staff and 20 one resident returned from the hospital (Resident #23). 121. On April 8, 2020, at approximately 10:00 AM, StaffP from Activities was wearing an N95 facemask improperly positioned on her face and head. 122. The FHA IP asked Staff P for permission to touch her so that the facemask could be re-positioned. Staff P shook her head yes and the FHA IP proceeded to move the facemask higher up on her face and reposition the straps. 123. The FHA IP then spent time educating Staff P on how to check for a tight fit and secure seal. The FHA IP had Staff P hover both hands in a cup shape around all edges of the facemask to ensure no escaped air could be felt on her palms. Staff P confirmed to the FHA IP that she now had a secure seal. 124. On April 8, 2020, at approximately 10:05 AM, Regional RN D, a regional Facility nurse introduced herself to the joint team members. 125. The Regional RN D was also wearing an improperly positioned N95 facemask. 126. Her hair was down and covering her ears which prevented the top strap from being able to rest atop the ears in a fixed position. 127. As a result of both straps being worn too low in the back of the head, a wide gap was created between the facemask and the face (specifically around the bridge of the nose). 128. The FHA IP educated the Regional RN D on how to properly wear a facemask. 129. On April 8, 2020, at approximately 10:10 AM, the surveyor, the FHA IP, along with the Regional RN D who joined the tour, observed Staff S, a housekeeper, wetting a string mop head in a bucket on the housekeeping cart on the East Unit. 130. The FHA IP asked Staff S how frequently she changes the mop head and floor cleaning solution. Staff S replied that she changes both out every three rooms. 21 131. The FHA IP asked Staff S what chemical cleaning solution she used for mopping and Staff replied that she did not know. 132, The team observed three other housekeeping carts during the tour, all of which had string mop heads, rather than microfiber mop heads. 133. The CHD recommended the microfiber mops previously April 6, 2020, for their ability to be laundered appropriately for re-use, especially as it relates to infection control in isolation rooms. 134. On April 8, 2020, the team observed two unlabeled bottles, one of which also had no lid, on top of one of four housekeeping carts. 135. The closed bottle contained a dark blue liquid while the open bottle contained a light blue liquid. 136. At approximately 10:30 AM, the team brought this to the attention of the Regional NHA, the NHA and the Housekeeping Supervisor. 137. The team educated the staff on the importance of labels as they provide essential information to housekeeping staff. 138. Some of the information these labels provide include whether or not the chemical should be prevented from coming into direct contact with skin, requiring gloves to be worn; the surfaces and the materials it's intended to be used on; and the length of contact time required. 139. The Regional NHA placed both bottles in a plastic bag and removed them from the cart. 140. On April 8, 2020, at approximately 10:45 AM, four CNAs (CNA M, CNA N, CNA Q and CNA R) on the East Hall and were asked if they had received any COVID-19 or infection control related training since the surveyor's last visit on April 5, 2020. 22 141. The surveyor reminded the CNAs that the CHD was on-site on April 6, 2020 and provided some training material. 142. CNA R responded that she watched a video at the Facility on April 6, 2020, about donning and doffing PPE. 143. CNA M, CNA N and CNA Q stated that they did not work on April 6, 2020. 144. The surveyor asked if they watched the video or received other training before beginning their next shift on April 7, 2020, and they collectively replied "no." 145. On April 8, 2020, at approximately 11:00 AM, the surveyor asked the NHA if staff who were not scheduled to work on April 6, 2020, received the infection control training before beginning their next scheduled shift. 146. The NHA replied that he had experienced technical difficulties with showing the video to staff on April 6, 2020, so even those present that day were not able to view the entire video. 147. He further stated that he provided staff absent on April 6, 2020, with printed material related to the video content. Next, he provided an in-service sheet that contained all four CNAs signatures. 148. A few days later, on April 13, 2020, at approximately 4:20 PM, the surveyor conducted a follow-up telephone interview with CNA N regarding the video training. 149. The interview was conducted offsite via telephone because private interviews could not be conducted on-site due to the NHA or other administrative personnel followed the surveyor around while on-site. 150. On April 10, 2020, the NHA confirmed this practice as he informed the surveyor that the owner had instructed him to not let the surveyor out of his sight. 23 151. CNAN replied that this was not the first time the Facility staff have been made to sign in-service sheets for training that the Facility never provided. 152. CNA N continued that the NHA follows staff around the Facility until he gets the signature. 153. CNA N stated that with families to support, there is really no choice but to comply in order to keep their jobs. 154. On April 8, 2020, at approximately 11:15 AM, the surveyor asked the NHA and Regional RN C, a regional nurse and certified infection preventionist, if goggles and facemasks were available in the Facility's PPE supply. 155. They stated that they had seven pairs of goggles and 34 face shields. 156. Neither the surveyor nor the FHA IP observed staff use goggles or face shields at any time during the visit. 157. Both the surveyor and the FHA IP made multiple observations of staff touching their facemasks and face during the visit. 158. The surveyor and FHA IP conducted a random audit of staff to determine if any symptomatic staff were working. 159. The surveyor asked CNA M if any respiratory symptoms were being experienced. 160. CNA M reported currently having a cough and sore throat to the surveyor. 161. The surveyor asked if CNA M informed the Facility, and she replied, “Yes, they know, but they told me I still had to come to work.” 162. CNA M expressed concern regarding the contact she had with Resident #1 (who was infected with COVID-19) before she was issued the N95 facemask that she now had in place. 163. The surveyor asked CNA M if any Facility-wide facial coverings were in place 24 prior to the distribution of the N95 facemasks. 164. CNA M stated that Staff P from Activities had brought in some homemade cloth facemasks a while ago that she received from someone in the community, possibly from church. 165. The surveyor asked CNA M if the facemasks were distributed by administration or requested to be worn by administration and she replied, “no.” 166. The surveyor asked CNA M if the facemasks were worn by most staff and she replied, “no.” 167. The FHA IP asked CNA N if she was experiencing any respiratory symptoms. 168. CNAN reported she currently had a cough and sore throat. 169. The FHA IP asked CNA N if she made the facility aware and she responded “yes,” but staying home was not permitted by the facility due to inadequate staffing. 170. The surveyor and the FHA IP brought this matter to the NHA and Regional NHA's attention. 171. The surveyor and FHA IP instructed the administrators that both staff must go home and that even with facemasks they should not be working while symptoms were present. 172. The FHA IP further instructed the administrators that these staff must be reported as PUIs to the CHD. 173. On April 8, 2020, at approximately 11:45 AM, the surveyor and the FHA IP exited the Facility. 174, Both the surveyor and the FHA IP observed CNA M exit the building and get into vehicle. 175. The team did not observe CNA N exit the building prior to the team's departure. 176. The CHD deployed a response team grounded in infection control principles to 25 support the Facility over a four-day period. 177. A DOH contracted strike team, a specialized infection control team consisting of four registered nurses, Strike RN A, Strike RN B, Strike RN C and Strike RN D, made visits to the Facility on April 9, 10, 11, and 13, 2020. 178. The Agency provided additional on-site monitoring on April 10, 11, and 13, 2020. 179. According to an interview with the strike team on April 10, 2020, the team arrived on-site at approximately 09:00 AM on April 9, 2020. 180. The team departed at approximately 10:00 AM due to the Facility's administration denying them entry to the building. 181. The administration informed the team that they were not needed and the NHA stated that the Facility would not provide them with PPE for use during their visit. 182. The team went to the Jefferson County Health Department to obtain full PPE before returning to the Facility at approximately 03:00 PM. 183. The team remained at the Facility until approximately 07:00 PM. 184. The team's mission on the first day was to make general observations and develop an educational plan based on where there was room for improvement. 185. Arecord review of the strike team's Day 1 assessment revealed the team observed the following on 04/09/2020: -Several staffmembers did not wear their PPE properly as evidenced by wearing a surgical facemask underneath the N95 facemask. -Several staff removed facemasks without performing hand hygiene afterwards. -Hand sanitizer was sparse throughout the facility, especially when entering and exiting isolation areas. -Several staff were not sanitizing hands when going into or out of the facility, before or after providing resident care and during meal pass. -Several staff who did use alcohol-based hand rub failed to utilize a technique that disinfected all parts of the hands such as the backs of the hands and the thumbs. -All staff had to walk through the isolation unit due to its location at the front of the 26 building. A food cart with uncovered dinner trays sitting on top also had to pass through the isolation unit. -A community ice cooler located in the hallway in-between the nurse's station and the activity room at the back of the building had no gloves or sanitizer present at the station. 186. The strike team developed a plan offsite to educate at least 75%-80% of the staff and have the staff successfully complete a return demonstration to ensure that they will continue to use the proper methods and decrease the likelihood of COVID-19 spreading throughout this facility and their community. 187. A written correspondence from the DOH Epidemiologist revealed that staff contact information was not provided by the Facility until April 9, 2020, despite daily requests being made. 188. The staff information provided on April 9, 2020, did not include the names of other facilities that also employ the Facility's staff. 189. The additional requested information of infection prevention and control policies and staff education related to infection control and COVID-19 were also not provided. 190. On April 10, 2020, the strike team was in the building from approximately 08:30 AM to approximately 11:00 AM and returned after lunch from approximately 02:00 PM to 07:00 PM. 191. On April 10, 2020, the Agency surveyor was also in the building from approximately 09:15 AM to approximately 11:15 AM. 192. At the time of entrance, the Facility's positive COVID-19 resident case count was four residents (Resident #1, #2, #3 and #7), one of which was still at the hospital (Resident #1), and three PUIs (Resident #8, #9 and #10) with results pending. 193. On April 10, 2020, at approximately 09:20 AM, the surveyor asked the Regional RN C for an update regarding the isolated residents or residents with a new onset of respiratory 27 symptoms, 194, The Regional RN C reported that Resident #8, #9 and #10 were going to be tested and moved to the isolation unit today due to having fevers. 195. The surveyor asked who was designated to provide care to the residents that were confirmed or under suspicion. 196. The Regional RN C replied that she, the Regional RN D and RN T were designated and were on eight-hour rotations. 197. A review of the strike team's Day Two Assessment revealed: -While the team was being screened, the staff member did not sanitize the temporal thermometer in-between uses. -The team observed a staff member walk through the isolation unit with no facemask or PPE on. -The team observed Staff U, a housekeeper, wearing a misshaped facemask. The team questioned Staff U about the facemask and she stated that the facility would not give her another one due to lack of supplies. -The team observed a resident in the hallway with no facemask and not socially isolating from other residents and staff were not directing the resident to do so. - Staff were unable to provide resident vital sign sheets upon the team's request. -The team observed a meal cart with a missing door was left in the isolation area for 20 minutes at lunchtime. Some meals were exposed by unsecured lids. 198. The strike team observed a housekeeper take her housekeeping cart in and out of several rooms, including isolation rooms, while cleaning. 199. The housekeeper did not sanitize or disinfect equipment in-between rooms and some chemical bottles were missing labels. 200. On April 10, 2020, at approximately 09:40 AM, the surveyor also observed bottles with missing labels. 201. 202. 203. The surveyor observed a housekeeping cart in the hall outside of room 22. There was an unlabeled bottle with a clear yellowish liquid on the cart. The surveyor asked Staff X, a housekeeper, if she knew what cleaning product was 28 in the bottle. 204. Staff X stated that she believed it was a floor cleaner but was not sure. 205. The surveyor informed the NHA of this finding and reminded him that this concern was previously discussed on April 8, 2020, when two unlabeled bottles were identified on a cart. 206. On April 10, 2020, at approximately 09:50 AM, both the strike team and the surveyor observed Resident #19 self-propel in her wheelchair from the main section of the East Unit hall and pushed her way through a set of double doors and into the isolation unit. 207. The surveyor observed the resident's surgical facemask to be below her nose. 208. The surveyor observed the Strike RN B intervene as she was in closer proximity to the resident. 209. The surveyor observed the Strike RN B redirect Resident #19 back towards her room and instruct her to reposition her surgical facemask. 210. The surveyor then observed the Strike RN B promptly inform facility RN T who was at the nurses’ station charting. 211. The surveyor heard the Strike RN B educate RN T that residents must be escorted by staff and have proper face protection before entering the isolation unit. 212. According to the assessment, the team observed staff hang up used disposable gowns in the isolation rooms for re-use after being educated not to do so yesterday. 213. The team brought this to the Regional RN C's attention. 214. On April 10, 2020, at approximately 10:30 AM, the surveyor observed the Strike RN A provide one-on-one education to CNA M and the Strike RN D provide one-on-one education to CNA Y. 215. CNAM observed CNA Y donning a disposable gown and asked the Strike RN A 29 if they could be re-used. 216. The Strike RN A replied “no” and that disposable gowns are intended for single use only. 217. CNA M reported that she and other staff had been using those gowns and then hanging them up in the isolation rooms for re-use. 218. The Strike RN A stated that he had observed this practice yesterday and that was part of the reason education was being provided regarding proper donning and doffing of PPE. 219. A further review of the DOH Strike Team's Day Two Assessment dated April 10, 2020, was conducted. 220. A CNA asked Strike RN B to assist with changing Resident #21 while the floor nurse was outside receiving one-on-one training from other team nurses. 221. A soiled brief was on the floor with the soiled surface on the floor, next to soiled perineal wipes. 222. There were no gloves, hand sanitizer, trash bags or hand soap in the resident's room or adjacent bathroom. 223. Resident #21 was lying on a bare mattress with no sheet. 224. Strike RN B asked the CNA why the resident did not have any linens on her bed, and she replied, “I don't know.” 225. Resident #21 had reddened bilateral boggy heels that were not off-loaded from the mattress, an open area to her sacrum and a reddened raised area on her right lateral side. 226. Strike RN B assisted with making the bed and providing care to the resident. 227. Resident #21 and her roommate, Resident #24, were both coughing while Strike RN B was in the room assisting with care. 30 228. Strike RN B notified Licensed Practical Nurse H (LPN H) of Resident #21's observed skin integrity problems, and that both residents were coughing. 229. LPN H informed Strike RN B that Resident #21 had just completed an antibiotic on April 2, 2020 and referred her to the treatment book at the nurses’ station. 230. Strike RN B reviewed the treatment book, and revealed there was no documentation related to the resident. 231. The last body audit/skin assessment for resident #21 was dated January 29, 2020. 232. The Regional RN C questioned why Strike RN B about why she was reviewing the resident's treatment record. 233. Regional RN C informed Strike RN B. “You are not here to review charts; you are here for training. If you guys are not here to help, the owner requests for you to leave.” 234. Due to the inability to complete the record review, the team was unable to determine if the Facility had identified all observed concerns for further monitoring or treatment. 235. The team was discussing the day's findings in the conference room when the Regional RN C came in and stated that from then on, all conversations would be recorded, and the owner was involving his attorney. 236. By exit, the team had provided one-on-one education to eight staff, which included two nurses, two housekeepers, one supervisor, and three CNAs. 237. On April 11, 2020, the strike team was in the building from approximately 09:00 AM to approximately 01:00 PM, and the Agency surveyor was in the building from approximately 12:20 PM to approximately 02:30 PM. 238. A review of the strike team's Day Three Assessment from 04/11/2020 revealed: -Staff U was still pushing a housekeeping cart inside of resident rooms on the East Unit hall while cleaning. 31 -the facility failed to follow isolation protocol for a PUI (Resident #8) as evidenced by the team's observation of the resident sitting in the hall without a facemask and not socially distanced from non-suspected residents. The team also observed his bedroom door open with no signage or PPE located outside the door. The assessment also noted that Resident #8 did not appear to be doing well as evidenced by being slumped over in his wheelchair, although a nurse reported that he was improving. The assessment further noted that the team observed Resident #25 wander into a PUI's (Resident #8) room with no facemask. The team notified LPN J. -the team observed a nurse in the building not wearing a facemask. -the team observed staff enter and exit through an emergency exit in the back of the building when the main entrance at the front was supposed to be the only point of entry. Staff exited the building with their facemasks during smoke breaks. There were no hand sanitizing stations located at the emergency exit. The team notified the Regional RN D who they would observed exit out of the emergency exit for a smoke break earlier. The Regional RN D stated that the door was broken and that she would have maintenance fix it. The door was fixed as a result. -the team observed two of three CNAs pass out lunch trays without gloves and without performing hand hygiene in-between resident rooms. The team notified the Regional RN C. -the team observed that PPE including N95 facemasks and gloves were located in the NHA's office but were not readily available to staff as evidenced by empty glove boxes in multiple resident rooms. -the team observed the Regional NHA entering the facility without being screened, including not having her temperature taken. When the team attempted to review the staff-screening logbook, the NHA came, closed the book, and took it to his office stating that it was confidential information. 239. Both the strike team and the surveyor observed Staff W, a housekeeper, experiencing an allergic reaction to her facemask. Her top lip was swollen. 240. The Regional NHA attempted to give her another facemask that was the same type that was causing the adverse reaction; however, Staff W declined the facemask and went home. 241. Upon arrival on April 11, 2020, at approximately 12:20 PM, the surveyor also observed Staff W sitting on a bench outside with a swollen upper lip. 242. Staff W stated that she had been experiencing itchiness and irritation since she started wearing the facemask last week. 243. She stated that the Facility would not give her a different type of facemask to use 32 or any medicine to manage her lip, so she was going home. 244. On April 11, 2020, at 12:27 PM, the surveyor observed Staff W get picked up and leave. 245. Both the strike team and the surveyor interviewed CNA V. 246. The strike team assessment revealed CNA V informed the team that it was her first day and that she had not received any orientation or training related to COVID-19. 247. The Facility gave CNA V a facemask that was too large for her face. 248. When CNA V asked the Regional NHA for a smaller size, the Regional NHA told her that there were not any available. 249. The Regional NHA then attempted to give CNA V an N95 facemask that appeared used. 250. The Regional NHA retrieved it from the trunk of her car and it was in a Ziplock bag. 251. The Facility's PPE was stored in the NHA or DON's office. 252. CNA V declined the N95 facemask. 253. The Regional RN C instructed CNA V to return to work and to not listen to the team because they are “trouble.” 254. On April 11, 2020, at 12:27 PM, upon arrival to the Facility, the surveyor also conducted an interview with CNA V before she left. 255. CNA V stated that today was her first day and that she had come to the Facility yesterday to complete some paperwork. 256. The surveyor asked CNA V if she was screened yesterday and today when she entered the building. 33 257. CAN V stated that she was screened yesterday, but today she only had her temperature taken and was not asked to answer any screening questions. 258. CNA V stated that the Facility was not able to provide her with a facemask that fit properly. 259. CNA V stated that the N95 facemask given to her was too big for her face. 260. CNA V stated that the Regional NHA tried to give her a facemask in a resealable bag that she retrieved from her trunk, but she was not comfortable taking it because it appeared used. 261. The surveyor asked if she had received any pre-service, orientation, or training related to COVID-19 and she replied, “no.” 262. The surveyor asked how long she had worked today, and she replied that she worked from 07:00 AM to approximately 11:30 AM when the strike team invited her outside for one-on-one training. CNA V stated that she was not going to return to work if the Facility could not provide her with the equipment necessary to keep her safe. CNA V got in her car and left. 263. On April 11, 2020, at 12:50 PM, the strike team left for the day. 264. By exit, the team had provided one-on-one education to seven more staff, which included three nurses, two housekeepers, and two CNAs. 265. On April 11, 2020, at approximately 01:00 PM, immediately after having her own screening completed by Staff P from Activities, the surveyor observed the NHA return from lunch and enter the building holding a fast food cup. 266. StaffP took his temperature and he headed straight to his office to notify the owner of the surveyor's presence. 267. No screening questions were asked or answered. 34 268. The surveyor educated Staff P on how to properly wear an N95 facemask as the surveyor observed the facemask straps to be crossed creating a wide gap around her nose. 269. Staff P offered no response and made no attempt to re-position her facemask. 270. The surveyor further explained that it was for her own safety, but Staff P did not correct her facemask. 271. On April 11, 2020, at approximately 01:10 PM, the surveyor asked the NHA and the Regional RN D to provide paperwork for any newly hired CNAs. 272, The surveyor reviewed some printouts that were in the new hire packet such as “Mask Conservation Process,” “How to Properly Put On and Take Off Disposable Respirators,” and a “CNA Competency Checklist.” 273. The surveyor asked the Regional RN D to provide a copy of CNA V's CNA Competency Checklist, but she was unable to do so. 274. The surveyor asked if CNA V had completed orientation and the Regional RN D confirmed that she had not. 275. On April 13, 2020, the strike team was in the building from approximately 10:30 AM to approximately 01:00 PM and returned from approximately 06:00 PM to approximately 07:00 PM, at which time the administration asked the team to leave. 276. The DOH Epidemiologist requested that the team return to the Facility to determine precisely who was and was not on isolation as well as review records to ensure symptomatic residents were being closely monitored. 277. On April 13, 2020, the Agency surveyor was also in the building from approximately 10:30 AM to approximately 01:00 PM. At the time of entrance, the Facility's positive COVID-19 resident case count was seven residents (Resident #1, #2, #3, #7, #8, #9 and 35 #10), however, Resident #2 expired in the Facility on April 11, 2020, and two residents were in the hospital (Resident #1 and #10). 278. Review of the strike team's Day Four Assessment revealed: -the team observed CNA N, a PUI, who was still working rather than self-isolating at home, was observed touching the facemask and passing out meal trays without performing hand hygiene. The Regional RN C was made aware and educated the CNA as a result. -the team observed housekeeping staff not performing glove changes after exiting the building to discard trash. Instead, they were returning to the building and continuing to use the same gloves. -the team observed the Regional RN D exited the main entrance with her facemask and smoked a cigarette. She put her facemask back on without performing hand hygiene and was not screened at the door upon re-entry. -Staff were still entering and exiting through the emergency door at the back of the building. The door was not locked. The Regional RN D was notified of the issue yesterday. 279. The assessment also noted that the team observed several staff members wearing their PPE improperly as evidenced by wearing a surgical facemask underneath the N95 facemask. 280. Regional RN C was observed by both the surveyor and the strike team. 281. The surveyor observed the Strike RN D advise against the practice of double masking to the Regional RN C as she was setting an example for other staff to follow, but she refused to remove the surgical facemask. 282. The Strike RN D explained that the bulkiness of the surgical facemask underneath the N95 facemask prevents the N95 facemask from fitting snuggly on the face and thereby compromises the integrity of the N95 facemask. 283. The surveyor observed the Regional RN C to continue the practice of double masking. 284. The surveyor also observed the Strike RN D communicate the concern to the Regional NHA. 36 285. A further review of the assessment revealed the team observed staff not being properly screened as evidenced by the staff were screening themselves at times and not completing all required fields on the screening form. 286. On April 13, 2020, at approximately 10:30 AM, this concern was also identified by the surveyor. 287. Immediately after being screened by Staff Z, activities staff, the surveyor observed CNA N, a PUI, enter the building and have a brief temperature reading obtained by Staff Z. 288. Staff Z did not ask CNA N any screening questions. 289. CNAN then proceeded to the wall-mounted shoe organizer that housed the staffs’ facemasks, removed the facemask from a resealable bag and put it on. 290. CNAN failed to perform hand hygiene prior to or after donning the facemask. 291. CNA N bypassed the wall-mounted hand sanitizer dispenser next to the shoe organizer. 292. The surveyor asked the NHA if CNA N was just arriving to begin a shift or was re-entering in the middle of a shift. 293. The NHA confirmed that CNA N was re-entering as the CNA's shift began at 07:00 AM. 294. The surveyor reviewed the staff-screening logbook and was unable to find an entry dated 04/13/2020 for CNA N. 295. The surveyor asked CNA N who conducted the staff screening at 07:00 AM at the start of the shift. CNA N replied that there was no one at the screening desk, so the CNA obtained a temperature reading independently. 296. The surveyor asked Staff Z what time she arrived to work. Staff Z replied, “07:30 37 AM.” 297. CNAN was unable to show the surveyor where the screening had been documented in the staff-screening logbook earlier that morning. 298. A further review of the staff-screening logbook revealed that some entries were not dated, many entries were missing the screener's signature, or staff screened themselves and signed in the screener field also. 299. On April 13, 2020, at approximately 10:45 AM, the surveyor asked the Regional RN D what the protocol is for ensuring that screening is completed when designated staff are not posted at the station. 300. She stated that the staff on the previous shift are supposed to screen the staff on the oncoming shift (i.e. the 11-7 shift should be screening the 7-3 shift), but this was not done. 301. On April 13, 2020, at approximately 10:50 AM, the surveyor provided education to the NHA, Regional NHA, the Regional RN C, the Regional RN D, and Staff Z regarding the importance of a thorough screening process as it is intended to serve as the Facility's first line of defense against COVID-19 transmission to residents. 302. Screener Competency Checklists with staff signatures were revicwed by the surveyor on a previous visit. 303. This was noted to be insufficient and the surveyor requested that the leadership team come up with a new plan and re-educate staff on the process immediately. 304. On April 13, 2020, at approximately 11:00 AM, the surveyor asked the Regional RN C for a status update on confirmed or suspected COVID-19 residents. 305. The Regional RN C responded that Resident #3, #5 and #7 were re-swabbed (tested) today. 38 306. On April 13, 2020, at approximately 11:00 AM, the Strike RN B informed the surveyor that she identified a resident (Resident #26) with a fever of 99.9 degrees Fahrenhcit while reviewing the temperature log. 307. The Regional RN D who was also present inquired about which resident had the fever and headed down the hall towards the nurses' station. 308. On April 13, 2020, at approximately 11:10 AM, the surveyor stopped the Regional RN C in the hall to obtain a status update on Resident #26. 309. Regional RN C stated that the Regional RN D had re-checked the resident's temperature, which no longer indicated a fever. 310. The surveyor asked the Regional RN C ifa fever reducing aid had been given prior to the resident's temperature being re-checked. 311. The Regional RN C said, “no,” and that she had re-educated the nurse on the floor to notify her immediately if a high temperature reading is obtained. 312. On April 13, 2020, at approximately 11:15 AM, after speaking with the Regional RN C, the surveyor conducted a brief record review, which revealed that the nurse-administered Tylenol to Resident #26 immediately after the 99.9 degrees Fahrenheit temperature reading was obtained. 313. On April 13, 2020, at approximately 11:15 AM, both the surveyor and the strike team observed Resident #20 sitting in her wheelchair on the East Unit hall wearing her surgical facemask below her nose and not covering part of her mouth. 314. The surveyor observed the team attempt to intervene and assist with proper placement. 315. Thestrike team assessment noted that the facemask was heavily soiled on the inside 39 with food debris and secretions. 316. There was also skin breakdown behind her ears. 317. The breakdown was not documented in the resident's chart. 318. The Regional RN C and the Regional RN D were notified. 319. By approximately 01:00 PM when the surveyor and strike team left, the team had provided one-on-one education to eight more staff, which included one nurse, two activities staff, four CNAs and the Regional NHA. 320. A review of the strike team's Day Four Addendum revealed the team observed the following during their second visit on the evening of April 13, 2020: 321. Staff entered through the rear exit door from breaks without being screened. 322. The team entered Resident #9's room on the isolation unit. 323. Resident #9 occupied the A bed, the bed closest to the door, while the B bed, the bed closest to the window, was empty. 324. Resident #9 was wearing only a brief and lying on a stained bare mattress. 325. Resident #9 was inside of a red biohazard bag as if it were a sleeping bag and was attempting to pull it up over his head. 326. Resident #9's room was in disorder as the nightstand drawers were open and there was a puddle of liquid on the floor in-between the bed and the bedside table. 327. The liquid was mostly yellow in color, but approximately half was tinged with red. 328. The following items were also present in or around the liquid puddle: a pair of dirty gloves, several shreds of cardboard, an individual sleeve of disposable utensils, a crumpled-up hospital gown, and a sneaker. 329. On the window side of the room, the cover of the air conditioning unit was on the 40 floor along with a crumpled-up mattress pad and sneaker. 330. The air conditioning unit was unplugged, and the power chord stretched out into the room. 331. Another chord was also lying on the floor. 332. The team attempted to locate a nurse on the isolation unit, but could not find one. 333. The team notified the NHA and then a nurse at the nurses! station at the opposite end of the hall. 334. The two nurses who have reported to be the designated caretakers of the isolation unit, Regional RN C and Regional RN D, were later found in the conference room and informed of the situation. 335. Resident #5, a PUI, was in a room on the North Unit (isolation unit is located on the East Unit) with no isolation precautions in place. 336. Resident #5 was one of several residents observed in the hall without wearing a facemask when the team was on-site on April 11, 2020. 337. The team was concerned that the resident was experiencing an altered mental status as she was acting agitated and aggressive after being pleasant and conversational with the team on April 11, 2020. 338. The team notified the Regional RN C of their concerns. 339. The team attempted to review the charts of all five of the confirmed or suspected residents. 340. They were able to review four of the five as the Regional RN D denied access to Resident #5's chart. 341. She took the record from the team and stated that the owner said the team had no 41 right to the records and she takes her orders from him. 342. The team explained that they had received orders to review those charts from the Epidemiologist, but she still refused to provide access. 343. The Regional RN C and the Regional RN D asked the team to leave. 344. As the team was leaving, the Regional RN D went outside to smoke. 345. She left the Facility with her N95 facemask and did not clean her hands when exiting and entering the building. 346. On April 14, 2020, at approximately 4:45 PM, the CHA served the NHA, the Regional RN C, the Regional RN D and the Regional NHA with a Quarantine/Isolation Order which called for the immediate transfer to another nursing home of five residents (Resident #3, #5, #7, #8 and #9) who were either confirmed or suspected of having COVID-19. 347. On April 16, 2020, at approximately 10:15 AM, the CHA served the Facility with Quarantine/Isolation Orders for eight additional residents who tested positive for COVID-19 on April 15, 2020. 348. The orders called for the immediate transfer of the following residents to another to another nursing home: Resident #11, #12, #13, #14, #15, #16, #17 and #18. 349, A written correspondence dated April 15, 2020, from the DOH Epidemiologist to the Agency’s Field Office Manager confirmed that the line list of ill residents including name, date of birth, and symptoms with onset dates, still not been received from the Facility to date. 350. The DOH Epidemiologist verbally confirmed to the Agency’ Field Office Manager on April 18, 2020, at 3:33 PM, that she had also not received the requested infection prevention and control policies and procedure, and staff education related to infection control and COVID-19. 351. The Facility’s noncompliance has caused, or is likely to cause, serious injury, harm, 42 impairment, or death to a resident receiving care in the Facility and thus constituted a class I widespread deficiency. 352. The Facility’s noncompliance constituted an intentional or negligent act materially affecting the health or safety of residents of the Facility. 353. The Facility’s noncompliance constituted a violation of the authorizing statutes and applicable rules, to wit: a violation of resident rights through (a) the denial of immediate access to the residents to representatives of the state government Department of Health, (b) the denial of adequate and appropriate health care and protective and support services consistent with the resident care plan and established and recognized practice standards within the community, and with rules as adopted by the agency, and (c) the failure to treat residents courteously, fairly, and with the fullest measure of dignity. 354. The Facility’s noncompliance constituted a demonstrated pattern of deficient performance. Relief License Revocation 355. Under Florida law, any of the following conditions shall be grounds for action by the Agency against a licensee: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility. § 400.102(1), Fla. Stat. (2019). 356. Under Florida law, the Agency may deny an application, revoke or suspend a license, and impose an administrative fine, not to exceed $500 per violation per day for the violation of any provision of this part, part II of chapter 408, or applicable rules, against any applicant or licensee for the following violations by the applicant, licensee, or other controlling interest: (a) A violation of any provision of this part, part I of chapter 408, or applicable rules. § 43 400.121(1), (3), Fla. Stat. (2019). 357. Under Florida law, grounds that may be used by the Agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: . . . (b) An intentional or negligent act materially affecting the health or safety of a client of the provider, (c) Violation of this part, authorizing statutes, or applicable rules. (d) A demonstrated pattern of deficient performance. § 408.815(1), (b)-(d), Fla. Stat. (2019), Administrative Fines 358. Under Florida law, a class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine must be levied notwithstanding the correction of the deficiency. § 400.23(8)(a), Fla. Stat. (2019). 359. Under Florida law, the Agency shall every 15 months conduct at least one unannounced inspection to determine compliance by the licensee with statutes, and with rules promulgated under the provisions of those statutes, governing minimum standards of construction, quality and adequacy of care, and rights of residents. The survey shall be conducted every 6 months for the next 2-year period if the facility has been cited for a class I deficiency, has been 44 cited for two or more class II deficiencies arising from separate surveys or investigations within a 60-day period, or has had three or more substantiated complaints within a 6-month period, each resulting in at least one class I or class II deficiency. In addition to any other fees or fines in this part, the agency shall assess a fine for each facility that is subject to the 6-month survey cycle. The fine for the 2-year period shall be $6,000, one-half to be paid at the completion of each survey. The Agency may adjust this fine by the change in the Consumer Price Index, based on the 12 months immediately preceding the increase, to cover the cost of the additional surveys, The Agency shall verify through subsequent inspection that any deficiency identified during inspection is corrected. However, the Agency may verify the correction of a class III or class IV deficiency unrelated to resident rights or resident care without re-inspecting the facility if adequate written documentation has been received from the facility, which provides assurance that the deficiency has been corrected. The giving or causing to be given of advance notice of such unannounced inspections by an employee of the agency to any unauthorized person shall constitute cause for suspension of not fewer than 5 working days according to the provisions of chapter 110. § 400.19(3), Fla. Stat. (2019). Due to the presence of one or more class I deficiencies at the time of the survey, the Facility is subject to a six-month survey cycle and its corresponding fine. Conditional Licensure 360. Under Florida law, the Agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations, and inspections. In addition to license categories authorized under part II of chapter 408, the Agency shall assign a 45 licensure status of standard or conditional to each nursing home. § 400.23(7), Fla. Stat. (2019). A conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the Agency. § 400.23(7)(b), Fla. Stat. (2019). Due to the presence of a class I deficiency at the time of the survey, the Agency assigned the Respondent conditional licensure status for the period alleged above in the nature of the action. Costs 361. Under Florida law, in addition to any other sanction imposed under this part or part II of chapter 408, in any final order that imposes sanctions, the agency may assess costs related to the investigation and prosecution of the case. § 400.121(8), Fla. Stat. (2019). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks licensure revocation, an administrative fine of $15,000.00, a six-month survey cycle fine of $6,000.00, the assignment of conditional licensure status and costs of investigation and prosecution against the Respondent CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks a final order that: 1. Renders findings of fact and conclusions of law as set forth above. 2. Grants the relief set forth above. 46 Respectfully Submitted, PUAN Doyle Carlton Enfinger II, Florida Bar No. 793450 Thomas M. Hoeler, Chief Facttities Counsel Florida Bar No. 709311 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, MS #7 Tallahassee, Florida 32303 Telephone: 850-412-3681 Facsimile: 850-922-9634 Carlton.Enfinger(@ahca.myflorida.com 47 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to the below named persons/entities by the method LL Ef Doyle Carlton Enfinger II, Senior Attorney Florida Bar No. 793450 4 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, MS #7 Tallahassee, Florida 32303 Telephone: 850-412-3681 Facsimile: 850-922-9634 Carlton.Enfinger@ahca.myflorida.com St designated on this A day of May, 2020. Current Administrator Owner/Licensee Cross Landings Health and Cross Landings Health and Rehabilitation Center Rehabilitation Center 1780 North Jefferson Highway 4700 Sheridan Street, Suite B Monticello, FL 32344-5563 Hollywood, FL 33021 (U.S. Certified Mail) | (U.S. Certified Mail) 9469 0050 O08? 6049 Lael 64 9469 0090 O02? 6049 1921 Fl 49 NOTICE OF RIGHTS Pursuant to Section 120.569, F.S., any party has the right to request an administrative hearing by filing a request with the Agency Clerk. In order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), F.S., however, a party must file a request for an administrative hearing that complies with the requirements of Rule 28- 106.2015, Florida Administrative Code. Specific options for administrative action are set out in the attached Election of Rights form. The Election of Rights form or request for hearing must be filed with the Agency Clerk for the Agency for Health Care Administration within 21 days of the day the Administrative Complaint was received. If the Election of Rights form or request for hearing is not timely received by the Agency Clerk by 5:00 p.m. Eastern Time on the 21st day, the right to a hearing will be waived. A copy of the Election of Rights form or request for hearing must also be sent to the attorney who issued the Administrative Complaint at his or her address. The Election of Rights form shall be addressed to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630, Facsimile (850) 921-0158. Any party who appears in any agency proceeding has the right, at his or her own expense, to be accompanied, represented, and advised by counsel or other qualified representative. Mediation under Section 120.573, F.S., is available if the Agency agrees, and if available, the pursuit of mediation will not adversely affect the right to administrative proceedings in the event mediation does not result in a settlement. 48 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: CL Golden, LLC, d/b/a ACHA No. 2020007964 Cross Landings Health and Rehabilitation Center ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but must be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time. of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter] 20, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights form to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: 850-412-3630 — Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. I understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed agency action is too severe or that the sanction should be reduced. OPTION THREE (3) TI dispute the allegations of fact alleged in the Administrative Complaint and request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before 50 the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed agency action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) Thereby certify that I am duly authorized to submit this Election of Rights form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: 51 USPS Tracking® Tracking FAQs Track Another Package + Track Packages Anytime, Anywhere Get the free Informed Delivery® feature to receive automated notifications on your packages Learn More Remove Tracking Number: 9489009000276049192184 Your item was delivered to the front desk, reception area, or mail room at 10:29 am on May 7, 2020 in MONTICELLO, FL 32344. Status: Delivered

Docket for Case No: 20-003006