Summit View Of Rocky Top

F-F658

The facility Administration failed to ensure there was sufficient staff to ensure 5 residents received their scheduled showers. Resident #33 missed 3 scheduled showers, Resident #39 missed 5 scheduled showers, Resident #49 missed 5 scheduled showers, Resident #77 missed 4 scheduled showers, and Resident #84 missed 1 scheduled shower during the time frame of 8/1/2024-8/16/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 During an interview on 8/13/2024 at 6:30 PM, Licensed Practical Nurse (LPN) E stated she worked form 6:00 PM-6:00 AM and was typically assigned care for 50 residents on the hallway with 1 CNA and 2 nurses. LPN Level of Harm - Immediate E stated showers were scheduled to be completed on both shifts and there were times when scheduled jeopardy to resident health or showers were not completed (unable to give exact dates) due to not enough staff. On Thursday 8/8/2024 safety there was 1 nurse and 1 CNA from 6:00 PM-6:00 AM on the hallway. LPN E further stated the Administrator had not asked if needs of the residents were being met or if the staff were able to complete the work Residents Affected - Many assignments.

During an interview on 8/13/2024 at 6:38 PM, LPN F stated she worked 6:00 PM-6:00 AM, worked the east hallway, there were typically 50 residents on the wing, and 2 nurses with 1 CNA to work the hallway. LPN F stated showers were scheduled to be completed on both shifts. There had been times when the scheduled showers were unable to be completed due to not enough staff (unable to give exact dates). The Administrator had not asked if needs of the residents were being met or if the staff were able to complete the work assignments.

During an interview on 8/14/2024 at 1:13 PM, the DNS stated she received voiced concerns from CNAs and nurses regarding low staffing and scheduled showers not being completed.

During an interview on 8/14/2024 at 3:00 PM, the Administrator stated he was aware the facility had some staffing concerns and stated, .I do know it [staffing concerns] exists . The Administrator confirmed he was aware some of the residents had not received scheduled showers at times.

During an interview on 8/20/2024 at 6:31 PM, the DNS and the Administrator confirmed the facility failed to ensure the expected and sufficient level of staffing was available in the facility to meet all the resident care needs including the scheduled showers and transportation for scheduled outpatient physician appointments.

Refer to

F-F725

During an interview on 8/20/2024 at 7:35 PM, the Administrator stated the facility had some areas of improvement to address regarding infection prevention and control practices and sufficient staffing provisions.

Validation of the Allegation of Compliance (AOC) Removal Plan to remove the immediacy of the Jeopardy (IJ) was conducted on 8/22/2024 through review of facility documentation, medical record reviews, and interviews.

On 8/20/2024, the Administrator and DNS were educated on Infection Control Policies, COVID-19 Guidelines from the Infection Control Manual and CDC Recommendations, Transmission Based Precautions, Enhanced Barrier Precautions, QAPI, and Handling Soiled Linen by Regional [NAME] President, Regional Director of Clinical Operations, and Senior Director of Clinical Quality and Education.

On 8/20/2024-8/21/2024, staff education was started by the DNS, or designee, with all staff on duty regarding isolation precautions for infection control including transmission- based precautions, hand hygiene, and enhanced barrier precautions, in-service on COVID-19 testing and guidelines related to safe care and prevention of COVID-19. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 On 08/20/24, (named commercial laundry service) agreed to a contract revision with the Administrator to provide personal laundry services twice per week (refer to exhibit 5). The personal laundry will be removed Level of Harm - Immediate from the resident ' s area in bags and placed in labeled bin for (named commercial laundry service) pickup jeopardy to resident health or which is located in the laundry storage building. All personal laundry will be returned from (named safety commercial laundry service) in lined clean bin folded or layered flat and covered with protective sheeting on

the south station administrative hall. Housekeeping services will sort, hang, and deliver to residents upon Residents Affected - Many return.

Administrator and DNS began educating staff on duty on 8/21/2024 regarding removal of personal laundry, placement in bin for transport to (named commercial laundry service) and return to residents upon return from (named commercial laundry service) on 8/21/24. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed.

Facility adopted a policy titled, Handling Soiled Linen, on 8/21/2024. The policy was reviewed and approved

in an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting held on 8/21/24. Review of

the sign in sheet revealed the Administrator, Director of Nursing Services, Medical Director, and Regional Director of Clinical Operations Q were in attendance.

Education was started on 8/21/2024, by DNS, or designee, with all staff on duty regarding policy on Handling Soiled Linen. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed.

On 8/21/24, the Administrator and DNS conducted environmental rounds audit utilizing the environmental rounds tool and handling of soiled linens with no issues identified.

Starting 8/21/2024 the following guidelines, recommended by cdc.gov titled Infection Control Guidelines: SARS-CoV-2 dated 6/24/2024, were initiated. The following steps will be:

HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met:

At least 7 days have passed since the date of their first positive viral test if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7).

HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met:

At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and,

At least 24 hours have passed since last fever without the use of fever-reducing medications, and

Symptoms (e.g., cough, shortness of breath) have improved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Current employees are required to test twice a week during COVID-19 outbreak and as needed with development of any signs or symptoms (e.g., those with runny nose, cough, sneezing, shortness of breath). Level of Harm - Immediate jeopardy to resident health or If current employee tests positive while at work, employee will notify Administrator, DNS, and/or ADNS safety (Assistant Director of Nursing Services), and the employee will be sent home immediately and will remain off work according to current CDC guidelines. Residents Affected - Many

In the possibility of a staffing crisis, facility will initiate the following:

Call all off duty staff including cross-trained staff

Offer incentives

Offer shift swaps or bonus day off

Offer split shifts

Call all licensed administrative staff that can come in and work under any capacity.

If above points unsuccessful involve Corporate Regional Support Team for further guidance.

An Ad Hoc QAPI meeting was conducted on 8/21/2024 with the Administrator, Director of Nursing Services, Director of Clinical Operations, Infection Preventionist, Minimum Data Set Coordinator, Director of Care Coordination and Medical Director to discuss, address, and review the deficient practice identified during the survey related to infection control practices and guidance to mitigate the spread of COVID-19 to staff and residents and infection control concerns identified with the handling of residents ' personal laundry.

All corrective actions will continue until a Plan of Correction is developed.

Refer to

F-F867

Review of the QAPI meeting minutes dated 6/25/2024 and 7/23/2024, revealed no documentation the facility's QAPI program identified or reported quality deficiencies, performed a root cause analysis which identified serious outcomes, developed or implemented processes or corrective action plans related to the facility's infection control program and practices with the recent COVID-19 outbreak (6/18/2024-8/7/2024), and laundry services. Continued review of the meeting minutes revealed no documentation or root cause analysis which identified, addressed, or discussed, the repeated deficiencies related to abuse.

The facility Administration and Governing Body failed to address in QAPI the facility's widespread problem of unsafe and unsanitary handling, storing, and processing of the residents' contaminated and potentially hazardous personal laundry and ensuring COVID-19 positive employees were excluded from work for the required isolation time frame recommended by the Centers of Disease Control (CDC) to control the exposure and spread of COVID-19.

During an interview on 8/20/2024 at 7:35 PM, the Administrator stated the facility had some areas of improvement to address regarding infection prevention and control practices.

Refer to F-835

Validation of the Allegation of Compliance (AOC) Removal Plan to remove the immediacy of the Jeopardy (IJ) was conducted on 8/22/2024 through review of facility documentation, medical record reviews, and interviews.

On 8/20/2024, the Administrator and DNS were educated on Infection Control Policies, COVID-19 Guidelines from the Infection Control Manual and CDC Recommendations, Transmission Based Precautions, Enhanced Barrier Precautions, QAPI, and Handling Soiled Linen by RVP, Regional Director of Clinical Operations, and Senior Director of Clinical Quality and Education.

On 8/20/2024-8/21/2024, staff education was started by the DNS, or designee, with all staff on duty regarding isolation precautions for infection control including transmission- based precautions, hand hygiene, and enhanced barrier precautions, in-service on COVID-19 testing and guidelines related to safe care and prevention of COVID-19. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0837 On 08/20/24, (named commercial laundry service) agreed to a contract revision with Administrator to provide personal laundry services twice per week (refer to exhibit 5). The personal laundry will be removed from the Level of Harm - Immediate resident ' s area in bags and placed in labeled bin for (named commercial laundry service) pickup which is jeopardy to resident health or located in the laundry storage building. All personal laundry will be returned from (named commercial laundry safety service) in lined clean bin folded or layered flat and covered with protective sheeting on the south station administrative hall. Housekeeping services will sort, hang, and deliver to residents upon return. Residents Affected - Many Administrator and DNS began educating staff on duty on 8/21/2024 regarding removal of personal laundry, placement in bin for transport to (named commercial laundry service) and return to residents upon return from (named commercial laundry service) on 8/21/24. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed.

Facility adopted a new policy titled, Handling Soiled Linen, on 8/21/2024. The policy was reviewed and approved in an Ad Hoc QAPI meeting held on 8/21/24. Review of the sign in sheet revealed the Administrator, Director of Nursing Services, Medical Director, and Regional Director of Clinical Operations Q were in attendance.

Education was started on 8/21/2024, by DNS, or designee, with all staff on duty regarding policy on Handling Soiled Linen. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed.

On 8/21/24, Administrator and DNS conducted environmental rounds audit utilizing the environmental rounds tool and handling of soiled linens with no issues identified.

Starting 8/21/2024 the following guidelines, recommended by cdc.gov titled Infection Control Guidelines: SARS-CoV-2 dated 6/24/2024, were initiated. The following steps will be:

Healthcare Providers (HCP) who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met:

At least 7 days have passed since the date of their first positive viral test if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7).

HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met:

At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and,

At least 24 hours have passed since last fever without the use of fever-reducing medications, and

Symptoms (e.g., cough, shortness of breath) have improved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0837 Current employees are required to test twice a week during COVID-19 outbreak and as needed with development of any signs or symptoms (e.g., those with runny nose, cough, sneezing, shortness of breath). Level of Harm - Immediate jeopardy to resident health or If current employee tests positive while at work, employee will notify Administrator, DNS, and/or ADNS safety (Assistant Director of Nursing Services), and the employee will be sent home immediately and will remain off work according to current CDC guidelines. Residents Affected - Many

In the possibility of a staffing crisis, facility will initiate the following:

Call all off duty staff including cross-trained staff

Offer incentives

Offer shift swaps or bonus day off

Offer split shifts

Call all licensed administrative staff that can come in and work under any capacity.

If above points unsuccessful involve Corporate Regional Support Team for further guidance.

An Ad Hoc QAPI meeting was conducted on 8/21/2024 with the Administrator, Director of Nursing Services, Director of Clinical Operations, Infection Preventionist, Minimum Data Set Coordinator, Director of Care Coordination and Medical Director to discuss, address, and review the deficient practice identified during the survey related to infection control practices and guidance to mitigate the spread of COVID-19 to staff and residents and infection control concerns identified with the handling of residents ' personal laundry.

All corrective actions will continue until a Plan of Correction is developed

Refer to

F-F880

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41291 jeopardy to resident health or safety Based on facility policy review, facility assessment review, Centers for Disease (CDC) recommendations and guidance review, facility documentation review, medical record review, observations, and interviews, the Residents Affected - Many facility failed to ensure residents' personal laundry was stored in a sanitary condition, and failed to ensure practices to prevent or mitigate the potential spread of infection and communicable disease were maintained through the process of handling, storing, processing, and transporting residents' personal laundry. The facility's non-compliance had the potential to affect 85 of 90 residents who resided in and whose laundry service was provided by the facility. The facility failed to ensure COVID-19 positive employees were excluded from work for the required isolation time frame recommended by the CDC to control the exposure and spread of the COVID-19 virus during the facility's COVID-19 outbreak from 6/18/2024-8/7/2024 placing 22 residents (Resident #1, #2, #20, #33, #36, #42, #46, #53, #57, #71, #72, #78, #82, #340, #341, #3, #11, #27, #43, #12, #30, and #79) in an Immediate Jeopardy (IJ) 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. The facility's failure to exclude COVID-19 positive employees from work had the potential to cause a serious adverse outcome for all 90 residents in the facility. The facility failed to ensure 3 resident rooms (Resident #8, #39, and #60) had Enhanced Barrier Precautions (EBP) signage posted on the doors. The facility census was 90.

The Administrator, Director of Nursing Services, Regional [NAME] President, and Regional Director of Clinical Operations Q were informed of the Immediate Jeopardy for F-880 on 8/20/2024 at 9:27 PM, in the Administrator's office.

The facility was cited IJ at F-880 at a scope and severity of L.

An Extended survey was conducted onsite from 8/20/2024 through 8/21/2024.

The IJ began on 5/1/2024 and continued through 8/21/2024. The IJ ended on 8/21/2024 and was removed

on site.

An acceptable removal plan, which removed the immediacy of the jeopardy, was provided by the facility on 8/21/2024 at 9:48 PM for F-880.

The corrective actions were validated onsite by the surveyors on 8/22/2024 for F-880.

Noncompliance continues at F-880 at a scope and severity of F.

The facility is required to submit a Plan of Correction (POC).

The findings include:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 1. Review of the facility policy titled, Linen Handling Guidelines, effective date 11/1/2017, revealed .the purpose of this procedure is to provide a process for the safe and aseptic handling, processing, transporting, Level of Harm - Immediate and storage of linen .consider all soiled linen to be potentially infectious .anyone who handles soiled laundry jeopardy to resident health or must wear protective gloves .and other .protective equipment .staff will bag contaminated laundry .to be safety picked up and processed by commercial means .

Residents Affected - Many Review of the CDC Guidelines titled, Environmental Infection Control in Health-Care Facilities, Section G Laundry and Bedding, revised 1/8/2024, revealed .OSHA [Occupational Safety and Health Administration] defines contaminated laundry as .laundry which has been soiled with blood or other potentially infectious materials .The laundry facility in a health-care setting should be designed for efficiency in providing hygienically clean textiles [a type of cloth or woven fabric], fabrics, and apparel for patients .Guidelines for laundry .for health-care facilities, including nursing facilities .Laundry workers should wear appropriate personal protective equipment ([example] gloves and protective garments) while sorting soiled fabrics and textiles .Fabrics .textiles, and clothing used in health-care settings are disinfected during laundering and generally rendered free of .pathogens .Laundering cycles consist of .main wash, bleaching, rinsing .The antimicrobial action of the laundering process results from a combination of mechanical, thermal, and chemical factors .Hot water provides an effective means of destroying microorganisms. A temperature of at least 160 .F [Fahrenheit] .for a minimum of 25 minutes .for hot water washing. The use of chlorine bleach assures an extra margin of safety. Chlorine alternatives .[example] activated oxygen-based laundry detergents .provide added benefits for fabric and color safety in addition to antimicrobial activity . Health-care workers should note the cleaning instructions of textiles, fabrics .Low-temperature laundry cycles rely heavily

on the presence of chlorine- or oxygen-activated bleach to reduce the levels of microbial contamination .

Review of a facility document titled, [Named] Management Services Position Descriptions, dated 5/1/2024, revealed Position Title .Laundry Aide .Facility .[name of facility] .Accountability Objective .Loads and unloads washers/dryers, sorts clothing .distributes throughout the facility .Key Responsibilities .Washes linens/personal clothing using proper chemicals .follows proper infection control techniques .Handles chemicals .and follows instructions for type and amount .

Review of the facility assessment, titled Center Assessment Tool, updated 7/28/2024, revealed .Infection prevention and control .Identification and containment of infections, prevention of infections .PPE [Personal Protective Equipment] utilization .services .Laundry .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation and interview with Housekeeper R and the Regional Director of Clinical Operations P

in a building behind the facility on 8/16/2024 at 9:03 AM, a large green bin was observed filled with a large Level of Harm - Immediate stack of residents' uncontained soiled clothing items. Multiple clothing items had a dried brown substance on jeopardy to resident health or the clothing, smelled of urine, was stiff/rigid, and difficult to unfold. Other clothing items had a white and safety greenish/black unidentified substance on them and had a musty smell. Housekeeper R stated she had not observed residents' personal clothes in the large green bin prior to 8/16/2024. She stated the clothes might Residents Affected - Many have gotten mixed with the facility linen and sent back to the facility from the linen company who provided

the facility's linen laundry service. Housekeeper R stated the linen company did not provide cleaning of the residents' personal clothing. She also stated the former Housekeeping Supervisor was responsible to ensure

the residents' personal laundry was taken off-site to be laundered, and she no longer worked at the facility (Housekeeping Supervisor's last date of employment was 8/8/2024). Housekeeper R stated the former Housekeeping Supervisor (or designee) loaded the laundry in the facility van, took it to a local laundromat and washed it but was unsure how often the laundry had been taken to be washed. After the Housekeeping Supervisor quit, Housekeeper V was responsible for taking the residents' personal laundry to the laundromat.

The Regional Director of Clinical Operations P stated the residents' personal clothing in the large green bin was in .horrible condition .

During an observation on 8/16/2024 at 9:22 AM, in a building behind the facility where dirty clothes were stored, revealed Certified Nursing Assistant (CNA) T drove the facility van and parked the van near the storage area. CNA T stated she was asked by the Administrator to bring the van around so it could be loaded with the residents' personal laundry. CNA T stated she had not been asked by the Administrator to bring the van to the back of the facility prior to 8/16/2024 for the soiled laundry.

During an interview and observation on 8/16/2024 at 9:30 AM, CNA U stated the process of the residents' personal laundry was as follows:

1a) After a resident's clothing was changed, the dirty clothes were placed in a white plastic top community rolling hamper, and a disposable plastic bag could be attached and detached as need. The rolling hamper was labeled Personal Laundry.

1b) At the end of the shift, the bag with residents' personal clothes was removed, taken to a building at the back of the facility, and placed in a blue plastic container. There was a sign over the blue containers which identified the residents' personal laundry.

CNA U stated the residents did not have personal laundry containers in their individual rooms and all the residents' personal clothing was placed in the same white community linen container together. Observation with CNA U of the outside building laundry storage area revealed 2 large blue plastic containers with several plastic bags stored in them. The observation revealed a sign over the blue containers which identified the containers as the residents' personal laundry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation of the laundry storage area (located behind the facility) and interview on 8/16/2024 at 9:41 AM, the Administrator and CNA T removed the soiled clothes from the large green bin and placed them Level of Harm - Immediate in plastic bags. The Administrator stated he had called Housekeeper V to see if she could work today jeopardy to resident health or (8/16/2024) and take the clothes to be washed at the local laundromat. The Administrator further stated, if safety Housekeeper V was unable to come to work, he would contact the sales manager of the contracted commercial linen service (the linen service who laundered the facility's linens) to inquire if the linen company Residents Affected - Many could wash the residents' personal laundry today. The Administrator and CNA T was asked to remove the plastic bags from the 2 blue plastic containers which had the residents' personal laundry stored for surveyor

observation. The observation revealed 12 closed plastic bags which contained the residents' soiled laundry.

The Administrator confirmed the residents' personal laundry had not been contained or maintained in a sanitary condition.

During a telephone interview on 8/16/2024 at 11:19 AM, the former Housekeeping Supervisor stated she worked at the facility for 3 years and had resigned from her position on 8/8/2024. The former Housekeeping Supervisor stated Housekeeper V and herself were responsible for taking the residents' personal laundry to

a local laundromat. The former Housekeeping Supervisor stated the facility initiated a new laundry process approximately 1 week prior to 5/1/2024 [date unknown], after the new management company had taken over. She stated the new process for residents' personal laundry was as follows:

1c) After the CNAs bathed the residents, the residents' soiled clothes were changed, placed in a white plastic top community rolling hamper, and the container was marked personal laundry.

1d) At the end of the shift, the soiled clothes were bagged, taken to an outside storage building, and placed

in a blue plastic container. There was a sign posted on the wall hanging over the containers which identified

the containers as the residents' personal laundry.

1e) Housekeeper V took the soiled laundry to the local laundromat .Coin Laundry . 3 times a week. The laundry was not separated, and the residents' laundry was washed together. Sometimes the laundry would be brought back to the facility .smelling like urine and stained with poop [feces] . after it had been washed.

The former Housekeeping Supervisor also stated if Housekeeper V was unable to get the laundry clean, the laundry was placed separately from the clean clothes, brought back to the facility in plastic bags, placed back

in the blue plastic containers to rewash. If a resident was on isolation precautions, the personal clothing items were placed in a yellow biohazard bag identified as .infectious . and washed at the local laundromat.

The former Housekeeping Supervisor stated washing the residents' clothes at the laundromat was not .a good idea . because the water was not hot enough to get the clothes clean and certain chemicals had to be used. The facility purchased [named household laundry detergent] and no bleach, bleach alternatives, or chemicals were used (to ensure proper sanitization). Former Housekeeping Supervisor had expressed her concern to the Administrator with no solution to the concern. The former Housekeeping Supervisor stated

she had educated Housekeeper V on the proper handling of the residents' contaminated personal laundry to include the process of handling, storing, processing, and transporting residents' personal laundry, which included wearing gloves and a gown to cover her clothing when handling the soiled laundry to mitigate the spread of infection and communicable diseases.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 8/16/2024 at 11:51 AM, the Administrator stated the contracted commercial linen services was contacted by the facility on 8/16/2024 and had agreed to wash the residents' personal laundry Level of Harm - Immediate effective Monday, 8/19/2024. The Administrator also stated, .we did not know there was molded clothes jeopardy to resident health or [residents'] in the storage shed .this has never happened before . safety

During an interview on 8/16/2024 at 3:05 PM, the Regional [NAME] President (RVP) stated the new Residents Affected - Many management company started managing the facility on 5/1/2024.

During a telephone interview on 8/16/2024 at 8:22 PM, Housekeeper V stated she was responsible for washing the residents' personal laundry at the local laundromat and she had taken the first load on 5/1/2024.

The housekeeper stated the clothes were not being cleaned sufficiently because the water was not hot enough to clean the laundry. The residents' soiled personal laundry was bagged together and placed in blue plastic containers in a storage building at the back of the facility. When she transported the residents' personal laundry to the laundromat, the 2 blue plastic containers were placed in the back of the facility van and transported to the laundromat. Housekeeper V stated she donned gloves prior to placing the residents' clothing in the washer but did not wear an apron or gown to protect her clothing. The laundry detergent used was [named household laundry detergent] and there were no other chemical products, bleach, or bleach alternatives used. Housekeeper V stated the laundry was not separated by individual residents, was washed all together, and she was unsure of what temperature the water was or needed to be [to ensure proper sanitization]. Housekeeper V further stated after she emptied the blue plastic containers, she sanitized the containers with sanitizing wipes before she placed the clean clothes back in the plastic containers. When the laundry was dried, some of the clothing still smelled of urine and had .poop stains . She stated isolation laundry was to be placed in red or yellow bags but did not remember washing any personal clothing that was

in red or yellow bags. Housekeeper V stated .not sure where the isolation laundry went . (The facility had a COVID-19 outbreak from 6/2024-8/2024). Housekeeper V denied receiving formal education by the former Housekeeping Supervisor on how to process and handle residents' personal or soiled laundry to mitigate the spread of communicable or infectious diseases.

Review of an email dated 8/16/2024, authored by the Infection Prevention Specialist 2 with the Tennessee Department of Health revealed .If heavily soiled/contaminated laundry was taken to a laundromat, there is a concern that temperatures and chemicals would not be sufficient to kill bacteria, viruses, fungi, or even parasites and could lead to exposure .to organisms .One of the concerns that come to mind is C [clostridium] difficile [a highly contagious bacteria that causes diarrhea] and could be spread through this avenue .If offsite laundry services are used, the laundry should be safely transported and taken to a commercial laundry facility that is knowledgeable on proper healthcare laundry processes to include temperatures and chemicals to ensure the laundry is rendered safe and sanitary .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a telephone interview on 8/19/2024 at 10:33 AM, the owner of a local Coin Laundry (another area laundromat, not the one used by the facility) stated he previously worked for a (Named) commercial Level of Harm - Immediate company with expertise in infection prevention services prior to purchasing his own laundromat. He also jeopardy to resident health or stated laundromat water did not get hot enough for nursing home residents' personal clothing (temperature safety should be at least 160 degrees Fahrenheit), and there were certain chemicals needed to ensure the clothes were clean and to reduce contamination. The hot water for washing machines at the laundromats were Residents Affected - Many typically set between 140-142 degrees Fahrenheit. Nursing home residents' personal clothing would need to be washed at a higher temperature with pre-oxygenated bleach. The laundromat owner also stated if a long-term care facility reached out to him to provide laundry services, he would decline because the laundromat washers were not equipped to process this type of clothing to mitigate the spread of infection.

During an interview on 8/19/2024 at 4:17 PM, the Administrator stated he was in charge of laundry and housekeeping services in the absence of the housekeeping supervisor.

During an interview on 8/19/2024 at 7:13 PM, CNA G stated residents did not have personal laundry containers in their rooms. The residents' personal laundry was placed in a white community linen container and the container was marked personal laundry. At the end of the shift, the soiled clothes were bagged together, taken to a building at the back of the facility, and placed in a blue plastic container.

During a telephone interview on 8/20/2024 at 9:04 AM, the Production Manager (PM) at the facility's contracted commercial linen service stated the company laundered the facility's linens and if resident's personal clothing was found mixed in with the linen, the clothes were tossed in a bin and sent back to facility

on the next delivery date (deliveries were made twice a week to the facility). The PM stated the company would not have waited until the large bin was filled with the residents' clothing before sending it back to the facility. The PM stated the linen company was TRSA certified (the certification verifies that processes used in

the facility meet appropriate hygienically clean standards). The linen service had been contacted by the facility's Administrator to provide laundry services for the facility residents' personal laundry, the first .batch . would be completed today [8/20/2024]. The PM stated, .I was shocked to learn the facility was taking items to a laundromat to wash .certain chemicals have to be used .

During an interview on 8/20/2024 at 11:00 AM, the Administrator stated he was aware certain chemicals and water temperatures were to be used when washing resident's personal laundry .I don't know what the temperatures were at the laundromat .

During an interview on 8/20/2024 at 4:46 PM, the Business Office Manager (BOM) stated the facility purchased laundry detergent to wash the residents' personal laundry. The laundry detergent purchased was (named household laundry detergent) and there were no bleach products purchased.

During an interview on 8/21/2024 at 12:00 PM, the Administrator stated he was informed on 4/28/2024 the facility would no longer have a linen service to wash the residents' personal laundry effective 4/30/2024. The facility had to .put something in place . It was decided the residents' personal laundry would be washed at

the local laundromat and the process started 5/1/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. Review of the facility policy titled, COVID [COVID-19] Comprehensive Guide, dated 5/2023, revealed . Team Members Return to Work Criteria .with COVID Infection .should be restricted from work and follow Level of Harm - Immediate recommended practices .Team members with mild to moderate symptoms .not .immunocompromised jeopardy to resident health or [weakened immune system] .At least 7 days have passed since symptoms first appeared .or 10 days if safety testing is not performed .At least 24 hours have passed since last fever without the use of .medications and symptoms .have improved .HCP [Healthcare Personnel] should have a negative test obtained on day 5 and Residents Affected - Many again 48 hours later .Team members .asymptomatic .not .immunocompromised .At least 7 days have passed since the date of their first positive viral test .negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7) .HCP should follow all recommended infection prevention and control practices including wearing well-fitting source control .not reporting to work when ill or if testing positive for SARS-CoV-2 [COVID-19] infection .Contingency and crisis strategies .Work Restrictions for Team Members with COVID Infection .Crisis .No work restrictions . asymptomatic . (outdated guidance (5/2023) the facility was following during the COVID-19 outbreak).

Review of the CDC's guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 [COVID-19] Pandemic, updated 3/18/2024, revealed .Return to Work Criteria for HCP [healthcare personnel] with SARS-CoV-2 Infection [COVID-19] . HCP with mild to moderate illness [fever, cough, sore throat, malaise, headache, muscle pain without shortness of breath, dyspnea, or abnormal chest imaging] could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g.,[example] cough, shortness of breath) have improved .HCP who were asymptomatic throughout their infection .could return to work after the following criteria have been met: At least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7) .HCP with severe to critical illness [respiratory failure, septic shock, and/or multiple organ dysfunction] .could return to work after

the following criteria have been met: At least 10 days and up to 20 days have passed since symptoms first appeared, and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved .HCP who are moderately to severely immunocompromised may produce replication-competent virus beyond 20 days after symptom onset or, for those who were asymptomatic throughout their infection, the date of their first positive viral test . HCP who are not symptomatic could return to work after the following criteria are met: Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT [Nucleic Acid Amplification Test] . (This CDC guidance was published 3/18/2024 and this was the guidance the facility should have followed for the 6/18/2024-6/23/2024 outbreak).

Review of the CDC ' s guidance titled, Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 3/28/2024, revealed .When an acute respiratory infection is identified in a resident or HCP, it is important to take rapid action to prevent the spread to others in the facility .Implement universal masking for source control on affected units or facility-wide, including for residents around others (e.g., out of their room) and for HCP when in the facility . Consult with the local or state public health department about additional interventions .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the CDC's guidance titled, Infection Control Guidance: SARS-CoV-2, dated 6/24/2024, revealed, .

The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Level of Harm - Immediate Health Emergency [5/11/2023] .To provide the greatest assurance that someone does not have jeopardy to resident health or SARS-CoV-2 infection, if using an antigen test .facilities should use 3 tests, spaced 48 hours apart .testing safety should be repeated every 3-7 days until no new cases are identified for at least 14 days .Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection .Ensure everyone is Residents Affected - Many aware of recommended IPC [infection prevention and control] practices in the facility .Source control is recommended for individuals in healthcare settings who: Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days

after their exposure .Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible .Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 . (The CDC published this recommendation on 6/24/2024 and this was the guidance the facility should have followed from 6/24/2024 to present).

The following residents who resided on the 300 and 500 Hallways tested positive for COVID-19 during the COVID-19 outbreak in the facility from 6/18/2024-8/7/2024. (The last resident to test positive was on 7/24/2024, the outbreak ended on 8/7/2024).

2a) Review of the medical record revealed Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses including Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, and Schizoaffective Disorder.

Review of the medical record revealed Resident #1 resided in room [ROOM NUMBER]B on the 500 Hallway at the time of the COVID-19 outbreak.

Review of an annual [NAME] Data Set (MDS) assessment dated [DATE REDACTED], revealed Resident #1 scored a 9

on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment.

Review of the Nurse's Notes for Resident #1 dated 6/26/2024, revealed .Covid [COVID-19] test positive. Resident congested with cough .Notified .resident daughter .

Review of the Physician's Orders for Resident #1 dated 6/26/2024, revealed .Molnupiravir [an antiviral medication used to treat mild to moderate COVID-19 in adults who are at high risk of developing severe COVID-19 symptoms] .200 mg [milligrams] .Give 4 capsule [capsules] by mouth two times a day for COVID until 7/02/2024 .

2b) Review of the medical record revealed Resident #2 was admitted to the facility on [DATE REDACTED] with diagnoses including Dementia, Muscle Weakness, and Seizures.

Review of the medical record revealed Resident #2 resided in room [ROOM NUMBER]B on the 300 Hallway at the time of the COVID-19 outbreak.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of an annual MDS assessment dated [DATE REDACTED], revealed Resident #2 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Level of Harm - Immediate jeopardy to resident health or Review of the Nurse's Notes for Resident #2 dated 6/24/2024, revealed .Resident tested for Covid due to safety high fever .headache .tested positive .

Residents Affected - Many Review of the Physician's Orders for Resident #2 dated 6/24/2024, revealed .Molnupiravir .200 mg .Give 4 capsule by mouth two times a day for COVID until 6/29/2024 .

2c) Review of the medical record revealed Resident #20 was admitted to the facility on [DATE REDACTED] with diagnoses including Chronic Atrial Fibrillation, Depression, and Weakness.

Review of the medical record revealed Resident #20 resided in room [ROOM NUMBER]B on the 300 Hallway at the time of the COVID-19 outbreak.

Review of a quarterly MDS assessment dated [DATE REDACTED], revealed Resident #20 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment.

Review of the Nurse's Notes for Resident #20 dated 6/26/2024, revealed .Resident tested positive COVID . notified resident and left message for son .denies .distress .

Review of the Physician's Orders for Resident #20 dated 6/26/2024, revealed .Molnupiravir .200 mg .Give 4 capsule by mouth two times a day for COVID for 5 days .

2d) Review of the medical record revealed Resident #33 was admitted to the facility on [DATE REDACTED] with diagnoses including Autistic Disorder, Adult Failure to Thrive, Dementia, Transient Ischemic Attack, and Cerebral Infarction.

Review of the medical record revealed Resident #33 resided in room [ROOM NUMBER]B on the 300 Hallway at the time of the COVID-19 outbreak.

Review of a quarterly MDS assessment dated [DATE REDACTED], revealed Resident #33 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment.

Review of the Nurse's Notes for Resident #33 dated 6/19/2024, revealed .resident notified of testing positive for COVID .denies symptoms at this time except for slightly 'not feeling well' .residents [resident's] brother/POA [Power of Attorney] notified .

Review of the Physician's Orders for Resident #33 dated 6/19/2024, revealed .Molnupiravir .800 mg .two times a day for COVID for 5 days .

2e) Review of the medical record revealed Resident #36 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including Chronic Obstructive Pulmonary Disease, History of Falling and Dementia.

Review of the medical record revealed Resident #36 resided in room [ROOM NUMBER]A on the 300 Hallway at the time of the COVID-19 outbreak.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 64 445259 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 445259 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit View of Rocky Top 204 Industrial Park Rd Rocky Top, TN 37769

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of an annual MDS assessment dated [DATE REDACTED], revealed Resident #36 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Level of Harm - Immediate jeopardy to resident health or Review of the Nurse's Notes for Resident #36 dated 6/26/2024, revealed .Resident tested positive for Covid safety [COVID-19] .Resident notified as well as son .Resident denies .distress .

Residents Affected - Many Review of the Physician's Orders for Resident #36 dated 6/26/2024, revealed .Molnupiravir .200 mg .Give 4 capsule by mouth two times a day for COVID for 5 days .

2f) Review of the medical record revealed Resident #42 was admitted to the facility on [DATE REDACTED] with diagnoses including Dementia, Muscle Weakness, Need for Assistance with Personal Care, and Difficulty Walking.

Review of the medical record revealed Resident #42 resided in room [ROOM NUMBER]A on the 300 Hallway at the time of the COVID-19 outbreak.

Review of an admission MDS assessment dated [DATE REDACTED], revealed Resident #42 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment.

Review of the Nurse's Notes for Resident #42 dated 6/22/2024, revealed .Spoke with family .notified of positive C0vid 19 [COVID-19] test today .Resident Complains [complains] of feeling tired .

Review of the Physician's Orders for Resident #42 dated 6/24/2024, revealed .Molnupiravir .Give 4 capsule by mouth two times a day for COVID 19 for 5 Days .

2g) Review of the medical record revealed Resident #46 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including Chronic Obstructive Pulmonary Disease, Dependence on Supplemental Oxygen, and Chronic Respiratory Failure.

Review of the medical record revealed Resident #46 resided in room [ROOM NUMBER]B on the 300 Hallway at the time of the COVID-19 outbreak.

Review of a quarterly MDS assessment dated [DATE REDACTED], revealed Resident #46 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact.

Review of the Nurse's Notes for Resident #46 dated 6/26/2024, revealed .Resident tested positive for COVID

this shift .Resident is self responsible and notified of results .resident denies any distress .has some sinus drainage .

Review of the Physician's Orders for Resident #46 dated 6/26/ [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 64 445259