Based on observation, interview and record review it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include but not limited to:

During an unannounced site visit on 7/7/2022, Compliance Specialist (CS) observed multiple staff members not wearing masks. Many more employees were not wearing masks appropriately, with the masks worn below their nose.

A review of the facility's screening records for 7/7/2022 indicated that two employees did not have their temperature taken and at least two employees, Staff #1 (S1) and Staff #2 (S2), were not screened at all.

These findings were reviewed with and acknowledged by S1 on 7/7/2022.

Facility Plan of Correction: Receptionist to review all screening sheets immediately and verify temperatures. Staffing coordinator to be second set of eyes to verify. Executive Director to provide inservice and education on masking and screening policies to all staff.