Health inspection·December 27, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19) for one of 3 residents reviewed (Resident 1). Residents Affected - Some Findings Include: Review of the facility policy titled, COVID-19 Infection Control Protocols to Minimize Exposure, with an annual review in 2023, For residents going to medical appointments, regular communication between the medical facility and the nursing home (in both directions) is essential to help identify residents with potential exposures or symptoms of COVID-19 before they enter the facility so that proper precautions can be implemented. Review of the closed clinical record on December 26, 2023, revealed Resident 1 with diagnoses that included end stage renal disease (kidneys lose the ability to remove waste and balance fluids) and hypertension (elevated blood pressure). Further review of the closed clinical record on December revealed that Resident 1 attended dialysis on December 1, 2023, and on return from dialysis the facility did their routine COVID-19 test on Resident 1. The facility had active cases of COVID-19 during this time, so they were testing every Tuesday and Friday. Resident 1 tested positive for COVID-19 on Friday December 1, 2023, at 4:15 PM. During an interview with Employee 1 (Licensed Practical Nurse) on December 26, 2023, at 10:30 AM, she stated that the dialysis center was closed at the time Resident 1 tested positive, so she informed the next shift to notify dialysis on Saturday during the dialysis center's open hours. The facility was unable to provide any documentation or staff confirmation that the dialysis facility was made aware that Resident 1 was COVID-19 Positive. Documentation received from the dialysis center revealed they were never notified regarding Resident 1 testing positive for COVID-19, and were only made aware on December 13, 2023, when Resident 1 was sent to the hospital. Resident 1 attended dialysis on December 4, 6, and 8, 2023, and was placed in the waiting area with other residents at the dialysis center. Resident 1 refused dialysis on December 11, 2023, and when the facility notified the dialysis center of the cancellation there was no mention of COVID-19 positive status at that time per them dialysis center. During a telephone correspondence with the Registered Nurse at the Dialysis Center on December 28, 2023, at approximately 11:15 AM, the Registered Nurse said the dialysis center was made aware that the resident was COVID-19 positive through the hospital system when the resident was being transferred to the hospital. The dialysis center made a call to the ICP at the facility on December 13, 2023, Page 1 of 2 395613 395613 12/27/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some informing the ICP the dialysis center was never notified about the COVID-19 positive status. The Registered Nurse added that the facility is aware that dialysis days are changed to Tuesday, Thursday, and Saturday for COVID-19 positive residents so they are isolated from COVID-19 negative residents. During an interview on December 26, 2023, 10:00 AM, with Resident 3, who also attends dialysis but a different dialysis center, Resident 3 stated that she wears a mask when attending dialysis. Resident 3's chart revealed she was COVID-19 positive on November 23, 2023. This dialysis center doesn't change days but separates residents in the waiting room and treatment area when they are COVID-19 positive. Resident 3's dialysis center confirmed that they were made aware of Resident 3's positive COVID-19 status timely to prevent any exposure. During an interview with the Director of Nursing (DON) on December 27, 2023, the DON was unable to confirm that the dialysis center was notified regarding Resident 1's COVID-19 positive status on December 1, 2023, through December 13, 2023. The DON was able to confirm that Resident 1's days were never switched to Tuesday, Thursday, and Friday which would have been done by the dialysis center if they were notified of Resident 1's COVID-19 positive status. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. 395613 Page 2 of 2