MARYVILLE, TN- ASBURY PLACE AT MARYVILLE

Based on review of Center for Disease Control and Prevention (CDC) guidelines, facility policy review,
review of facility documentation, interview, and observation, the facility Administration failed to implement
and monitor effective interventions once aware of employees not reporting symptoms of COVID-19 during
the facility screening process and failed to ensure staff compliance with Personal Protective Equipment
(PPE) usage to provide a safe and sanitary environment to prevent the development and transmission of
infections. The facility had 38 residents and 48 staff test positive for COVID-19. These failures placed 38
residents, including Residents #2, #5, #8, #13 and #26, in Immediate Jeopardy (a situation in which the
provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause,
serious injury, harm, impairment, or death to a resident) when Certified Nursing Assistant (CNA) #1 and CNA
#2 provided direct care to residents while having symptoms related to COVID-19 and when staff were
observed entering droplet precaution rooms without wearing appropriate PPE. The facility’s failure had the
potential to affect all 97 residents residing in the facility.

During an observation and interview on 2/14/2022 at 2:12 PM, CNA # 4 entered a droplet precautions room
without a gown or gloves and turned off the call light, performed hand hygiene, and left the room. Interview
with CNA #4 confirmed the CNA did not don a gown or gloves prior to entering a droplet precautions room
(gown and gloves are required PPE for droplet precautions) .I know basics .if not doing direct care I do not
need a gown .gloves .I sanitized .that is just my understanding as a CNA.

During a telephone interview on 2/25/2022 at 12:04 PM, the Administrator confirmed she was responsible for
oversight of the facility and staff and confirmed .contact tracing .that was primarily [the ICP’s] arsenal .the
screening process was in place .understood associates fill out that .I trusted [ICP] to do the contact tracing .
The Administrator confirmed she was made aware of the ICP’s conclusions after contact tracing connected
the current outbreak back to CNA #1 and CNA #2 .an employee lied .an associate .a person lied .I can tell
you that .I can just tell you the system is the system .can’t stop people from lying .we can temp .screen .ask
them questions .temp when they leave . Continued interview confirmed the Administrator was not aware of
staff non-compliance with PPE .made aware yesterday .QAPI meeting .2/21/22 .I know infections were
discussed .can’t recall if the outbreak was specifically discussed at this point . When asked about the
facility’s effort to correct staff non-compliance, the Administrator confirmed the facility was .tracking trending
and making sure anybody that identifies with symptoms and/or if a questionnaire is not done .they are turned
away .if it is an employee .yes they are asked to leave .if they don’t follow infection control protocol they are
asked to leave .there is a process that [the ICP] managed .I defer to [ICP] on all of those questions .if an
employee fails to do that or lies on a form. Its terrible.