Failure to Notify Families During COVID-19 Outbreak
Summary
The facility failed to notify residents' representatives and families of the COVID-19 status during an outbreak, as required by CMS guidelines. This deficiency was identified through a review of medical records, staff interviews, and CMS guidance. The facility had a census of 93 residents at the time of the survey. The review of the medical record for one resident revealed that the resident was admitted with multiple diagnoses, including COVID-19, and was placed in droplet isolation. Another resident, also with multiple diagnoses, was similarly placed in droplet isolation due to COVID-19. Despite these measures, the facility did not inform the residents' representatives and families about the outbreak. An interview with the Administrator revealed a lack of awareness regarding the requirement to notify residents' representatives and families during a COVID-19 outbreak, other than posting a sign on the front door. The facility did not comply with the CMS Quality Safety and Oversight Memorandum, which mandates informing residents, their representatives, and families by 5:00 P.M. the next calendar day following a confirmed COVID-19 infection or the onset of respiratory symptoms in multiple residents or staff. The facility's failure to provide timely notifications had the potential to affect all residents, as it did not adhere to the required communication protocols during the outbreak.
Penalty
A resident tested positive for COVID-19, but the facility failed to notify the resident or their representative in a timely manner, as required by their policy. The resident was informed of the positive result three days later by a doctor. Staff acknowledged the oversight and stated that the notification should have occurred within 24 hours.
The facility failed to notify the families of two residents who tested positive for COVID-19, as required by their policy. Despite the residents exhibiting symptoms and testing positive, there was no documentation that their families were informed. This deficiency was confirmed by the DON.
The facility failed to notify family representatives of two residents about positive COVID-19 test results and the presence of COVID-19 in the building. One resident, moderately cognitively impaired, was not documented as having their responsible party informed of their positive status. Another resident, severely cognitively impaired, was not documented as having their POA informed about exposure to a COVID-positive resident or the outbreak. This was contrary to the facility's policy requiring notification of changes in condition.
Failure to Notify Resident of Positive COVID-19 Test
Penalty
Summary
The facility failed to notify a resident's family and/or representative of a positive COVID-19 test result, which was a requirement according to their policy. The policy, dated May 15, 2020, stated that the facility must inform residents, their representatives, and families by 5:00 p.m. the next calendar day following a confirmed COVID-19 infection. Resident 75, who was alert and oriented, tested positive for COVID-19 on September 27, 2024, as documented in their Treatment Administration Record. However, there was no documentation in the resident's Electronic Health Record indicating that the resident or their representative was informed of the positive result. Interviews with the resident and staff revealed that the resident was not notified of the positive COVID-19 test until about three days later, when a doctor mentioned it in passing. Staff D, the Infection Preventionist and RN, stated that the facility's practice was to notify residents and their representatives as soon as possible, ideally within 24 hours of the test. Staff B, the Director of Nursing Services and RN, acknowledged that the facility failed to notify Resident 75 as per the policy, admitting that they missed this notification.
Failure to Notify Families of COVID-19 Positive Residents
Penalty
Summary
The facility failed to notify the families of two residents who tested positive for COVID-19 in a timely manner, as required by their policy. The policy, titled 'Guidance in Managing Respiratory Illnesses and Outbreaks' dated January 2, 2024, mandates that upon identifying residents with COVID-19, the facility should notify both the residents and their families. However, the clinical records for two residents, identified as R3 and R37, did not include documentation that their representatives were informed of their COVID-19 status. Resident R3, who had diagnoses including high blood pressure, dysphagia, and iron deficiency anemia, tested positive for COVID-19 on August 7, 2024, after complaining of not feeling well. Similarly, Resident R37, with diagnoses of high blood pressure, dysphagia, and chronic pain syndrome, tested positive for COVID-19 on August 26, 2024, after exhibiting flu-like symptoms. Despite these positive test results, there was no documentation in the progress notes indicating that the families of these residents were notified. This deficiency was confirmed during an interview with the Director of Nursing on September 13, 2024.
Failure to Notify Family Representatives of COVID-19 Cases
Penalty
Summary
The facility failed to notify the family representatives or Power of Attorney (POA) of two residents, R3 and R4, about positive COVID-19 test results and the presence of COVID-19 in the building. R3, who is moderately cognitively impaired, was placed under strict contact/droplet isolation due to COVID-19. However, the facility did not document notifying R3's responsible party about the positive COVID-19 status on the date of the test. Although R3's daughter stated she was informed of the positive test result, she was not notified when the facility first identified COVID-19 in the building. R4, who is severely cognitively impaired, tested negative for COVID-19 but was in proximity to a COVID-positive resident, R3. The facility's records did not document any notification to R4's POA about the exposure to a COVID-positive resident or the outbreak in the facility. The facility's policy requires notifying the resident, their physician, and responsible party of any change in condition, which was not adhered to in these cases.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
