Electronically Delivered July 14, 2020 Administrator Guardian Angels

P r o t e c t i n g , M a i n t a i n i n g a n d I m p r o v i n g t h e H e a l t h o f A l l M i n n e s o t a n s

Electronically delivered

July 14, 2020

Administrator Guardian Angels Care Center 400 Evans Avenue Elk River, MN 55330

RE: CCN: 245012 Survey Start Date: April 21, 2020

Dear Administrator:

On July 1, 2020 the Minnesota Department of Health completed a revisit to verify that your facility had achieved and maintained compliance. We have determined that your facility has achieved substantial compliance as of May 20, 2020. Per the CMS Memo QSO‐20‐20‐All, enforcement remedies were suspended from March 23, 2020 to May 31, 2020 and will be evaluated at a later date.

The CMS Region V Office may notify you of their determination regarding any remedies.

Feel free to contact me if you have questions.

Alison Helm, Enforcement Specialist Licensing and Certification Minnesota Department of Health P.O. Box 64970 Saint Paul, Minnesota 55164‐0970 Phone: 651‐201‐4206 Email: [email protected]

An equal opportunity employer.

P r o t e c t i n g , M a i n t a i n i n g a n d I m p r o v i n g t h e H e a l t h o f A l l M i n n e s o t a n s

Electronically delivered May 10, 2020

Administrator Guardian Angels Care Center 400 Evans Avenue Elk River, MN 55330

SUBJECT: SURVEY RESULTS CCN: 245012 Cycle Start Date: April 21, 2020

Dear Administrator:

SUSPENSION OF SURVEY AND ENFORCEMENT ACTIVITIES The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America’s health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID‐19). In accordance with Memorandum QSO‐20‐20‐All, CMS is suspending certain Federal and State Survey Agency surveys, and delaying revisit surveys, for all certified provider and supplier types.

During this time, CMS is prioritizing and conducting only the following surveys: focused infection control surveys, investigations of complaints and facility‐reported incidents that are triaged at the Immediate Jeopardy (IJ) level, and revisit surveys for unremoved IJ level deficiencies. With the exception of unremoved IJs, CMS will also be exercising enforcement discretion during the suspension period. For additional information on the prioritization of survey activities please visit https://www.cms.gov/files/document/qso‐20‐20‐allpdf.pdf‐0.

SURVEY RESULTS On April 21, 2020, the Minnesota Department of Health completed a COVID‐19 Focused Survey at Guardian Angels Care Center to determine if your facility was in compliance with Federal requirements related to implementing proper infection prevention and control practices to prevent the development and transmission of COVID‐19. The survey revealed that your facility was not in substantial compliance. The findings from this survey are documented on the electronically delivered CMS 2567.

PLAN OF CORRECTION You must submit an acceptable electronic plan of correction (ePOC) for the enclosed deficiencies that were cited during the April 21, 2020 survey. Guardian Angels Care Center may choose to delay submission of an ePOC until after the survey and enforcement suspensions have been lifted. The provider will have ten days from the date the suspensions are lifted to submit an ePOC. An acceptable

An equal opportunity employer. Guardian Angels Care Center May 10, 2020 Page 2 ePOC will serve as your allegation of compliance. Upon receipt of an acceptable ePOC, we will authorize a revisit to your facility to determine if substantial compliance has been achieved. Please note that if an onsite revisit is required, the revisit will be delayed until after survey and enforcement suspensions are lifted. The failure to submit an acceptable ePOC can lead to termination of your Medicare and Medicaid participation.

To be acceptable, a provider's ePOC must include the following:

• How corrective action will be accomplished for those residents found to have been affected by the deficient practice; • How the facility will identify other residents having the potential to be affected by the same deficient practice; • What measures will be put into place, or systemic changes made, to ensure that the deficient practice will not recur; • How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur; and • The date that each deficiency will be corrected.

Questions regarding this letter and all documents submitted as a response to the resident care deficiencies (those preceded by a "F" tag), i.e., the plan of correction should be directed to:

Susie Haben, Unit Supervisor Email: [email protected] Phone: (651) 201‐3794 Fax: 320‐223‐7348

INFORMAL DISPUTE RESOLUTION You have one opportunity to dispute the deficiencies cited on the April 21, 2020 survey through Informal Dispute Resolution (IDR) in accordance with 42 CFR § 488.331. To receive an IDR, send (1) your written request, (2) the specific deficiencies being disputed, (3) an explanation of why you are disputing those deficiencies, and (4) supporting documentation by fax or email to:

Susie Haben, Unit Supervisor Email: [email protected] Phone: (651) 201‐3794 Fax: 320‐223‐7348

An IDR may not be used to challenge any aspect of the survey process, including the following:

• Scope and Severity assessments of deficiencies, except for the deficiencies constituting immediate jeopardy and substandard quality of care; • Remedies imposed; • Alleged failure of the surveyor to comply with a requirement of the survey process; • Alleged inconsistency of the surveyor in citing deficiencies among facilities; and • Alleged inadequacy or inaccuracy of the IDR process.

We will advise you in writing of the outcome of the IDR. Should the IDR result in a change to the Guardian Angels Care Center May 10, 2020 Page 3 Statement of Deficiencies, we will send you a revised CMS‐2567 reflecting the changes.

An IDR, including any face‐to‐face meetings, constitutes an informal administrative process that in no way is to be construed as a formal evidentiary hearing. If you wish to be accompanied by counsel for your IDR, then you must indicate that in your written request for informal dispute resolution.

Guardian Angels Care Center may choose to delay a request for an IDR until after the survey and enforcement suspensions have been lifted. The provider will have ten days from the date the suspensions are lifted to submit a request for an IDR in accordance with the instructions above.

QUALITY IMPROVEMENT ORGANIZATION (QIO) RESOURCES The Quality Improvement Organization (QIO) Program is committed to supporting healthcare facilities in the fight to prevent and treat COVID‐19 as it spreads throughout the United States. QIO resources regarding COVID‐19 and infection control strategies can be found at https://qioprogram.org/. This page will continue to be updated as more information is made available. QIOs will be reaching out to Nursing Homes to provide virtual technical assistance related to infection control. QIOs per state can be found at https://qioprogram.org/locate‐your‐qio.

Sincerely,

Kamala Fiske‐Downing Licensing and Certification Program Minnesota Department of Health P.O. Box 64900 St. Paul, MN 55164‐0900 Telephone: (651) 201‐4112 Fax: (651) 215‐9697 Email: Kamala.Fiske‐[email protected] PRINTED: 06/05/2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING ______

245012 B. WING ______04/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 EVANS AVENUE GUARDIAN ANGELS CARE CENTER ELK RIVER, MN 55330

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY)

E 000 Initial Comments E 000

On 4/21/20, a COVID-19 Focused Infection Control survey was conducted at your facility by the Minnesota Department of Health (MDH) to determine compliance with Emergency Preparedness regulations §483.73(b)(6). Guardian Angels Care Center was found to be in compliance with the requirement. Because you are enrolled in ePOC, your signature is not required at the bottom of the first page of the CMS-2567 form. Although no plan of correction is required, it is required that the facilty acknowledge receipt of the electronic documents. F 000 INITIAL COMMENTS F 000

On 4/21/20, a COVID-19 Focused Infection Control survey was conducted at your facility by the Minnesota Department of Health (MDH) to determine compliance with §483.80 Infection Control. Guardian Angels Care Center was found not in compliance with the requirements.

The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance. Because you are enrolled in ePOC, your signature is not required at the bottom of the first page of the CMS-2567 form.

Upon receipt of an acceptable electronic POC, an revisit of your facility will be conducted to validate substantial compliance with the regulations has been attained in accordance with your verification. F 880 Infection Prevention & Control F 880 5/20/20 SS=F CFR(s): 483.80(a)(1)(2)(4)(e)(f)

§483.80 Infection Control

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 05/20/2020 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 ObsoleteEvent ID: JCKQ11 Facility ID: 00611 If continuation sheet Page 1 of 9 PRINTED: 06/05/2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING ______

245012 B. WING ______04/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 EVANS AVENUE GUARDIAN ANGELS CARE CENTER ELK RIVER, MN 55330

F 880 Continued From page 1 F 880 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: (A) The type and duration of the isolation, depending upon the infectious agent or organism

FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: JCKQ11 Facility ID: 00611 If continuation sheet Page 2 of 9 PRINTED: 06/05/2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING ______

245012 B. WING ______04/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 EVANS AVENUE GUARDIAN ANGELS CARE CENTER ELK RIVER, MN 55330

F 880 Continued From page 2 F 880 involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and document F880 review, the facility failed to implement a comprehensive infection control program to Guardian Angels Care Center strives to include routine, documented analysis of collected adhere to all infection control standards in data to reduce the risk of infection spread within accordance with state and federal the facility. In addition, the facility failed to ensure regulations and current standard of staff were being actively screened on a daily practice. basis to reduce the risk of COVID-19 Guardian Angels Care Center did conduct transmission to residents and other staff all of the components of a comprehensive members. These findings had potential to affect infection control program including all residents residing in the facility at the time of surveillance monitoring, antibiotic the COVID-19 Focused Infection Control Survey. stewardship checks, observations for cross-contamination, utilization of FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: JCKQ11 Facility ID: 00611 If continuation sheet Page 3 of 9 PRINTED: 06/05/2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING ______

245012 B. WING ______04/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 EVANS AVENUE GUARDIAN ANGELS CARE CENTER ELK RIVER, MN 55330

F 880 Continued From page 3 F 880 Findings include: transmission based precautions, etc. however documentation to validate these INFECTION CONTROL PROGRAM: checks was not available for survey review for the months of March and April On 4/21/20, the facility' Infection Control Program (survey conducted 4/21/20). Actions surveillance and corresponding analysis were taken to achieve compliance will include requested. The following was provided: contemporaneous documentation of reviews of all active infections as well as An electronic MN DOH (Department of Health) surveillance monitoring. ABX (antibiotic) tracking sheet, dated 3/1/20 to The Infection Preventionist will continue to 4/21/20, identified a line listing format used to provide surveillance, review all infections, record infections within the facility. The data track, review for antibiotic collected included various items tracked appropriateness, transmission based including, but not limited to, resident names, precautions, and analysis of potential room numbers, infection types, symptoms, onset cross contamination. A system has been dates, antibiotic usage and if transmission-based established to document all of this precautions were needed/used. concurrently with submission to the Director of Nursing for second check and MARCH 2020: review of completeness. Training has been conducted for all staff The listing (outlined above) identified a total of 30 who provide employee, vendor and visitor resident infections between all four listed units screening upon entry to the facility. Daily (100 unit, 300 unit, 400 unit, and 500 unit). The screening of employee, vendor, and visitor 100 unit had an identified two urinary tract must include all necessary elements infections (UTI) with a single infection listed as, including: "Other." The 300 unit had an identified three • Recent travel to areas of sustained respiratory infections, two UTI, one skin infection COVID-19 transmission. and one eye infection. The two identified UTI • Exposure to individuals with both had symptoms listed of dysuria (difficult confirmed or presumed COVID-19 urination) with onset dates listed of 3/4/20, and • Respiratory symptoms or other 3/16/20, respectively. A culture was obtained on symptoms associated with COVID-19 the infection which began on 3/4/20 which include sore throat, GI upset/diarrhea, identified klebsiella pneumoniae (a bacteria). The fatigue/malaise, myalgias (and more as other UTI had a culture obtained, however, added to the list) resulted with, "No growth." The 400 unit had an • Febrile status. identified five UTI, four skin infections, one Documentation of screening will be respiratory infection and four recorded as, performed each day. "Other." Further, the 500 unit had an identified Weekly audits will be conducted to ensure three respiratory infections, one skin infection and adherence to all components. Audits of FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: JCKQ11 Facility ID: 00611 If continuation sheet Page 4 of 9 PRINTED: 06/05/2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING ______

245012 B. WING ______04/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 EVANS AVENUE GUARDIAN ANGELS CARE CENTER ELK RIVER, MN 55330

F 880 Continued From page 4 F 880 four infections listed as, "Other." the Infection Control Program will be conducted by the Director of Nursing. No further information was provided. Elements of the screening program will be audited by the Administrator. APRIL 2020: Audits will be reviewed by QAA/QAPI Committee to determine further action. The listing (outlined above) identified a total of 18 Date of correction 5/20/2020 resident infections had been recorded so far throughout the facility between all the units. The 100 unit had four UTI and two respiratory-related infections identified. The 300 unit had one respiratory infection and one UTI identified. The 400 unit had three UTI, two skin infections and one recorded as, "Other." Further, the 500 unit had two UTI, and two infections recorded as, "Other."

No further information was provided.

There was no provided evidence demonstrating the facility had conducted a comprehensive analysis of the collected outcome surveillance data to determine if any of the infections identified were potentially related or corresponded with staff illness for the same month period. Further, there was no evidence the facility had investigated the infections identified as developing in-house for potential causes and/or subsequent actions to reduce the risk of recurrence.

On 4/21/20, at 12:44 p.m. registered nurse (RN) -D was interviewed and verified they were in charge of the facility' infection control program. RN-D stated she spent "two to three days" a week on the infection control program and explained the program process which included reviewing progress notes, physician orders and various reports in the electronic medical record system to determine if residents are having FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: JCKQ11 Facility ID: 00611 If continuation sheet Page 5 of 9 PRINTED: 06/05/2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING ______

245012 B. WING ______04/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 EVANS AVENUE GUARDIAN ANGELS CARE CENTER ELK RIVER, MN 55330

F 880 Continued From page 5 F 880 symptoms of infections. If so, the resident is recorded on the provided electronic line listing which RN-D stated she reviews "everyday" for trends and patterns. However, RN-D expressed there had been no documented, comprehensive analysis completed of the provided data to demonstrate this process was being completed and to ensure infections were not spreading or correlating with staff illnesses. RN-D stated she had been busy doing "other things" and added she would complete the analysis of the data "as soon as possible."

A provided Infection Control - Care Center policy, dated 4/12/16, identified a section labeled, "H. Reporting," which directed several steps to be completed including, "ICC will submit monthly compilation report to DON [director of nursing], along with any identified trends," and, "Employee health infections/trends are tracked. Any transmission to residents will be noted in reports."

LACK OF SCREENING:

A Centers for Medicare and Medicaid (CMS) COVID-19 Long-Term Care Facility Guidance, dated 4/2/20, identified procedures to be implemented to reduce the risk of COVID-19 transmission in a long-term care setting. This included, " ... every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked."

On 4/21/20, at approximately 10:00 a.m. the survey team entered the facility through the main entrance. A table was set up inside the door FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: JCKQ11 Facility ID: 00611 If continuation sheet Page 6 of 9 PRINTED: 06/05/2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING ______

245012 B. WING ______04/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 EVANS AVENUE GUARDIAN ANGELS CARE CENTER ELK RIVER, MN 55330

F 880 Continued From page 6 F 880 which had nursing assistant (NA)-A seated. NA-A directed the surveyors to complete a questionaire and then proceeded to take the temperatures of each surveyor before being allowed into the building.

When interviewed on 4/21/20, at 10:59 a.m. NA-A stated she was responsible to screen everyone who entered the facility. NA-A explained the staff members complete a questionaire, which screens them for symptoms of the virus and any known exposures to persons with the virus, on a weekly basis and have their temperature checked everyday. NA-A voiced the administrator was tracking the completed weekly questionnaires using an Excel spreadsheet; and NA-A verified she did not ask every person the individual screening questions on the questionaire aloud each time they work.

When interviewed on 4/21/20, at 11:19 a.m. NA-G explained the process when staff enter the building for their shift. The staff were using just the main entrance and they were completing a questionaire, including questions about if they have been exposed to anyone with COVID-19 or developed symptoms of the virus; however, they were only doing it on a weekly basis and not everytime they report for a shift. NA-G stated they used to complete the questionaire daily; however, stopped doing so. NA-G voiced they were unsure who or how the completed forms were being tracked and stated she just completed her's every Monday as she just decided to pick that day and do it.

During interview on 4/21/20, at 11:50 a.m. therapeutic recreation (TR)-A stated when they come to work, they use the main entrance only FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: JCKQ11 Facility ID: 00611 If continuation sheet Page 7 of 9 PRINTED: 06/05/2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING ______

245012 B. WING ______04/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 EVANS AVENUE GUARDIAN ANGELS CARE CENTER ELK RIVER, MN 55330

F 880 Continued From page 7 F 880 and have their temperature taken. TR-A explained a questionaire is completed on a weekly basis which screens for symptoms, other than temperature, of COVID and if they have been exposed to the virus.

When interviewed on 4/21/20, at 11:44 a.m. nursing assistant (NA)-F stated the staff "fill out a form" when they come to work "once a week." NA-F stated they do not complete the questionaire, nor does the person at the table when they arrive, each time they come to work and sometimes could have several days off work between shifts and completing the form.

On 4/21/20, at 1:12 p.m. registered nurse (RN)-D and RN-C were interviewed. RN-D explained she was in charge of the infection control program and RN-C voiced she had been the director of nursing (DON) until recently. They verified the questionaire used to screen for symptoms and exposure to COVID-19 was not completed each time the staff worked, but rather every "five to seven days." The questionaire had been completed on a daily basis, however, they stopped doing so as their corporate offices had directed it could be done less frequently. Further, they added the questionnaires were being tracked electronically and the person manning the desk to check temperatures was responsible to check if it was needed again when the person reported.

A provided Coronavirus/COVID-19 Preparedness/Employee Illness policy, dated 4/21/20, identified the facility was seeking to ensure the safety of residents and staff during the COVID-19 pandemic. COVID-19 was identified as being spread by person-to-person contact and the incubation period was considered to be 2-14 FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: JCKQ11 Facility ID: 00611 If continuation sheet Page 8 of 9 PRINTED: 06/05/2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING ______

245012 B. WING ______04/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 EVANS AVENUE GUARDIAN ANGELS CARE CENTER ELK RIVER, MN 55330

F 880 Continued From page 8 F 880 days after exposure. A procedure was listed to help reduce the risk of virus transmission which included, "Employees are being screened on arrival to work using screening questionnaire regarding travel, recently being near anyone with COVID-19 or other respiratory illness or if they themselves have respiratory illness ... Staff will not be allowed to work who do not pass the screening."

FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: JCKQ11 Facility ID: 00611 If continuation sheet Page 9 of 9