**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections. Record review revealed the facility has been in outbreak status since late December 2021. Specifically, the facility was in outbreak status as of 12/23/21 when a staff member tested positive for COVID-19. On 12/27/21, another staff member tested positive for COVID-19. Thereafter, the following staff tested positive for COVID: one positive staff member (1/3/22), two positive staff members (1/11/22), one positive staff member (1/14/22), one positive staff member (1/20/22), two positive staff members (1/21/22), one positive staff member (2/15/22), one positive staff member (2/16/22), one positive staff member (3/8/22), one positive staff member (3/21/22), two positive staff members (3/22/22), two positive staff members (3/25/22), one positive member (3/29/22), one positive staff member (4/3/22), and one positive staff member (4/5/22). The current line listing on 4/6/22, showed 13 residents had tested positive for COVID-19. Results from the 4/8/22 tests showed two residents were positive. Results from the 4/12/22 test results included an additional five residents were positive. Results from the 4/18/22 revealed another three residents testing positive. Observations, record review and staff interviews, from 4/6/22 through 4/19/22, revealed multiple and repeated failures in the facility's infection control program. This created an immediate jeopardy situation with the likelihood of serious harm due to the potential for further transmission of the highly infectious COVID-19 virus to residents throughout the facility, staff, and others, if not corrected immediately. Specifically: -The facility failed to follow the Center for Medicare and Medicaid Services (CMS) outbreak testing guidance, beginning on 12/23/21, to routinely test staff bi-weekly while in outbreak status, creating a situation for the transmission of highly infectious COVID-19. Cross-reference F886L. -The facility failed to ensure staff properly wore personal protective equipment (PPE) throughout the facility and when caring for residents in isolation rooms. -The facility failed to ensure staff followed proper hand hygiene procedures for themselves and for the residents. -The facility failed to ensure equipment was sanitized between residents and dining room tables were cleaned properly prior to the next meal. -The facility failed to ensure resident rooms were properly cleaned. Cross-reference F886 and F888. Findings include: I. The facility's COVID-19 status On 4/6/22, upon entry into the facility, the facility had the following confirmed positive cases of COVID-19: 13 residents in isolation; four residents in isolation who were roommates of residents who had tested positive; and nine positive staff members since 3/8/22. II. Immediate Jeopardy A. Findings of Immediate Jeopardy Record review revealed the facility has been in outbreak status since late December 2021. Specifically, the facility was in outbreak status as of 12/23/21 when a staff member tested positive for COVID-19. On 12/27/21, another staff member tested positive for COVID-19. Thereafter, the following staff tested positive for COVID: one positive staff member (1/3/22), two positive staff members (1/11/22), one positive staff member (1/14/22), one positive staff member (1/20/22), two positive staff members (1/21/22), one positive staff member (2/15/22), one positive staff member (2/16/22), one positive staff member (3/8/22), one positive staff member (3/21/22), two positive staff members (3/22/22), two positive staff members (3/25/22), one positive member (3/29/22), one positive staff member (4/3/22), and one positive staff member (4/5/22). The facility has had the following number of COVID positive residents since January 2022. Specifically, COVID positive residents were identified as follows: three residents (1/11/22), one resident (1/11/22), one resident (3/11/22), two residents (3/15/22), two residents (3/18/22), four residents (3/22/22), one resident (3/23/22), four residents (3/25/22), one resident (3/29/22), one resident (3/31/22), one resident (4/1/22), one resident (4/2/22), three residents (4/5/22), and two residents (4/8/22). Thereafter, during the survey, there were five residents positive on 4/12/22 and another three residents on 4/18/22. Observations, record review and staff interviews, from 4/6/22 through 4/19/22, revealed multiple and repeated failures in the facility's infection control program, including the facility's failure to follow outbreak testing guidance, failure to properly and appropriately use PPE and perform staff and resident hand hygiene, failure to clean equipment and sanitize the dining room tables using proper technique, and failure to properly clean resident rooms. The above failures in the facility's infection control program created an immediate jeopardy situation with the likelihood of serious harm and the potential for further transmission of the highly infectious COVID-19 virus to residents throughout the facility, staff, and others, if not corrected immediately. B. Facility notice of immediate jeopardy On 4/12/22 at 7:43 p.m. the nursing home administrator (NHA) was notified that the failures identified above in infection control created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm (COVID-19). C. Facility plan to remove immediate jeopardy On 4/14/22 p.m. the NHA provided a plan to remove the immediate jeopardy. The plan read: Observations and monitoring of PPE usage (which included N95 respirator masks, eye protection, gowns and gloves) and handwashing was conducted by members of the interdisciplinary team (department managers) during the overnight shift on 4/12/22. On 4/12/22, the door code was changed by the maintenance director on the service hall door and a sign posted for all staff to enter the facility through the front door of the facility only to ensure screening is being conducted for every staff member prior to starting their shift and entering resident areas. The screening will be conducted by the supervisor on duty or receptionist and will ensure each staff member has donned an N95 respirator mask and eye protection prior to entering a resident area. All resident equipment was disinfected with Eco Lab's Peroxide Multi-Surface Cleaner disinfectant on 4/12/22 by the interdisciplinary team (department managers). All dining tables were disinfected with Eco Lab's Peroxide Multi-Surface Cleaner disinfectant on 4/12/22 by the interdisciplinary team. Housekeeping Supervisor or designee will observe for proper cleaning of the dining room tables after each meal, every shift. Housekeeping Supervisor or designee will monitor through audits the observation completed for proper cleaning of the dining room tables after each meal, every shift. Education with return demonstration was completed on 4/12/22 to 52 out of 71 total facility staff members regarding the facility policies and procedures for PPE use, including the requirement for N95 respirator masks and eye protection to be worn in all resident areas, the procedures for the donning and doffing of PPE, discarding single-use gowns after each use, sanitization of eye protection, proper handwashing procedures, equipment sanitization in between resident use, and providing residents with hand hygiene prior to meals. All staff will complete the education with return demonstration prior to the start of their next scheduled shift. The director of nursing and/or designee will track and monitor each staff member who has received or not yet received the training to ensure compliance. Education was started on 4/12/22 with the housekeeping staff regarding the disinfecting of dining room tables after each meal, performing hand hygiene in between resident rooms when delivering linen and personal laundry and performing hand hygiene prior to donning and after doffing gloves. Education will be provided to new staff during orientation. The education for all the housekeeping staff will be completed by 4/13/22. The director of nursing and/or designee will monitor facility staff for infection control practices 3 times every shift and on the spot education with return demonstration will be provided upon a negative observation. The interdisciplinary team to include the medical director will conduct a root cause analysis to determine the progress of the corrective action and will provide a report to the quality performance improvement committee to discuss recommendations and additional C. Removal of immediate jeopardy On 4/14/22 at 1:00 p.m. the NHA was notified that the immediate jeopardy was lifted based on the facility's plan to address the immediate jeopardy (see above). However, deficient practice remained at F level, widespread with the potential for more than minimal harm. II. Failure to maintain an effective infection prevention and control program A. The facility failed to follow CMS and CDC outbreak testing guidance, as well as the Residential Care Facility (RCF) Comprehensive Mitigation Guidance, revised on 4/8/22, to routinely test all staff bi-weekly, creating a situation for the transmission of highly infectious COVID-19. Cross-reference F886. Professional reference: Consistent with CMS and CDC testing guidance, the Residential Care Facility (RCF) Comprehensive Mitigation Guidance, revised on 4/8/22, read: When one or more positive tests are identified in a resident or health care professional (HCP) (regardless of vaccination status), the facility moves to outbreak testing and following additional response measures outlined below. -Asymptomatic HCP (including ancillary non-medical services providers) and residents who are up to date with all recommended COVID-19 vaccine doses should test twice weekly for SARS-CoV-2 using a lab-based PCR test. If HCP work infrequently at the facility, the lab-based PCR test should be performed within three days before their shift. -A HCP who tests positive, regardless of vaccination status, should be excluded from work and instructed to isolate at home. HCP should self-report positive results to any additional employer so that disease control measures can be implemented if necessary. Contrary to the above testing guidance, the facility failed to test all staff following notification of an outbreak as of 12/23/21. Specifically: -A line list, dated 4/12/22, was provided by the consultant director of nursing (DON) on 4/12/22 at 3:15 p.m. It documented that only 18 staff members had been tested for COVID-19 that day (4/12/22), out of 72 total staff members who worked at the facility. -A line list for Friday, 4/8/22, documented 32 staff members had a COVID-19 PCR test out of 72 total staff members. The facility was unable to provide documentation that the staff who were not PCR tested had been POC (point of care) tested (alternative testing that does not require sending the test to the lab) until the next testing date on 4/12/22. -A line list for Tuesday, 4/5/22, documented 22 staff members had a COVID-19 PCR test out of 72 total staff members. The facility was unable to provide documentation that the staff who were not PCR tested had been POC tested until the next testing date on 4/8/22. The facility was unable to provide documentation that the staff members who were not tested had been contacted, provided education, been removed from the schedule, or had disciplinary action to ensure compliance with the testing requirements. Moreover, the facility failed to ensure staff were conducting self-testing in accordance with testing guidelines and in a manner to prevent the spread of infection. Observations showed staff members failed to swab their nose with five circular motions in each nostril to ensure the testing was effective and would produce an accurate result. Staff failed to complete appropriate hand hygiene during and after the testing process and staff interviews showed that not all staff were aware of the testing day and admitted to not completing a PCR test. The last PCR test results were on 4/8/22, and 22 out of 70 staff were tested. Ten staff were within the 90 days of testing positive for COVID-19 and the facility had two staff members with religious exemptions. As a result of testing, three residents tested positive for COVID-19 and upon observation, a fourth resident had been placed in isolation after testing positive for COVID-19. B. The facility failed to ensure staff properly wore personal protective equipment (PPE) throughout the facility and when caring for residents in isolation rooms. And, the facility failed to ensure staff followed proper hand hygiene procedures for themselves and for the residents. On 4/12/22 at 10:40 a.m., CNA #3 was interviewed. He said he had been working at the facility for a month and the facility had been in outbreak status the entire time. He said he had not been told by nursing management at the facility to wear a N95 respirator mask or eye protection until the survey process started. He said he had worn a surgical mask since his first day at the facility. CNA #3 said he said he had observed housekeeping staff entering COVID-19 positive rooms and not donning any PPE. He said when he arrived in the morning, the night shift never wore any masks or eye protection. 1. Professional References and facility infection control manual PPE: CDC and CMS Guidance on PPE when COVID-19 has been identified in the building: The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 2/2/22), retrieved on 4/22/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, read in pertinent part, HCP (health care provider) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. According to the CDC guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 2/2/22, retrieved on 4/22/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html: -PPE must be donned correctly before entering the patient area. - PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted. - Face masks should be extended under the chin. - Both your mouth and nose should be protected . The facility infection control manual received on 4/6/22 from the NHA at a sister facility (NHA#1), read in pertinent part, If a center has the capability to accept a patient/resident who requires droplet/airborne transmission-based precautions and the patient/resident can be placed in a non-negative pressure room with the door kept closed with employees wearing at least an N95 fit tested respirator, as in the case of a suspected or confirmed case of COVID-19, the employees caring for the patient/resident are required to be fit tested for an N95 or equivalent respirator before entering the patient's/resident's room. The Strategies for Optimizing the Supply of Isolation Gowns (updated 1/21/21, retrieved on 4/27/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html, Regarding Conventional Capacity Strategies, reads in pertinent part: In general, CDC does not recommend the use of more than one isolation gown at a time by HCP when providing care to patients with suspected or confirmed SARS-CoV-2 infection. Use isolation gown alternatives that offer equivalent or higher protection. Nonsterile, disposable patient isolation gowns, which are used for routine patient care in healthcare settings, are appropriate for use by HCP when caring for patients with suspected or confirmed COVID-19. In times of gown shortages, surgical gowns should be prioritized for surgical and other sterile procedures . Once gown availability returns to normal, healthcare facilities should promptly resume conventional practices . The director of nursing from a sister facility (mobile DON) was interviewed on 4/12/22 at 4:47 p.m. The mobile DON said the facility was in conventional practice, which indicated they had no shortages of N 95 masks, surgical masks and gowns. Hand hygiene: The Centers for Disease Control (CDC) Hand Hygiene updated 1/30/2020, retrieved on 4/22/22 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate SARS-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. The facility infection control manual received on 4/6/22 from the NHA at a sister facility (NHA#1), read in pertinent part, Standard precaution principles are designed to reduce the risk of transmitting microorganisms from both recognized unrecognized sources of infection in healthcare settings. Standard precautions are designed to protect both healthcare personnel and patients from contact with infectious agents. Standard precautions include: -Hand hygiene (handwashing with soap and water or use of an alcohol-based sanitizer) before and after patient contact and after contact with the immediate patient care environment. -Perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites, if necessary. -Wash hands or use alcohol-based hand sanitizer upon completion of patient contact and before caring for another patient -Perform hand hygiene before touching a patient, performing an invasive procedure or manipulating an invasive device. -Perform hand hygiene after contact with patient's intact or non-intact skin, after touching items or surfaces in the immediate care environment, even if you did not touch the patient. 2. Observations revealed staff failed to properly wear and dispose of PPE and perform hand hygiene to prevent the transmission of infectious COVID-19. a. Observations 4/6/22 - Hand hygiene failures (i) During a continuous observation on the 200 unit on 4/6/22 starting at 12:04 p.m. and ending at 12:44 p.m., the following was observed: -At 12:04 p.m. the lunch meal cart was delivered to the 200 unit nursing station. -At 12:16 p.m. CNA #3 opened the cart and started passing trays. He donned gloves and entered room [ROOM NUMBER]. He did not perform hand hygiene prior to donning the gloves. The CNA set up the resident's meal, asked her if she needed anything else and left the room. With the same gloved hands, he returned to the meal cart and picked up another tray for the same room. He entered the room and delivered the meal to the resident in bed B. He grabbed the bed controls and raised the head of the bed, then took the lids off the beverages and poured the beverages into a sippy cup. He set up her meal and left the room. He had not offered either resident in room [ROOM NUMBER] hand hygiene prior to the start of their meal. The CNA doffed his gloves, threw them into the trash, reached into his pocket, pulled out a new pair of gloves and donned the gloves. He did not perform hand hygiene prior to donning the gloves. The CNA returned to the meal cart, picked up another tray and entered room [ROOM NUMBER]. He delivered the meal tray to bed A. He placed the tray on the over bed table and left the room. He did not offer hand hygiene to the resident before leaving the room. He doffed his gloves, reached into his pocket and donned new gloves. He did not perform hand hygiene prior to donning the gloves. The CNA then entered room [ROOM NUMBER] and walked to bed B. He delivered the meal tray, took off the plate cover and the covers for the beverages. He did not offer the resident hand hygiene. He left the room and returned to the meal cart and picked up the meal tray for the resident in bed A. He placed the meal tray in front of the resident. He left the room, doffed his gloves, went to the nursing cart and took a handful of gloves and put them in his pocket. He donned a new pair of gloves. He did not perform hand hygiene prior to donning the gloves. -An unidentified CNA took a meal tray from the meal cart and entered room [ROOM NUMBER]. She did not offer the resident hand hygiene prior to the resident's meal. (ii) During a continuous observation on the 200 unit on 4/6/22 beginning at 12:15 p.m. and ending at 12:29 p.m., the following was observed: -CNA #2 delivered a meal tray to room [ROOM NUMBER], removed personal items from the bedside table, provided set-up meal assistance for the resident and upon exiting the room, she did not perform hand hygiene, but rather, went back to the food cart for another tray; -CNA #2 delivered two meal trays to bed A and B in room [ROOM NUMBER]. She did not perform hand hygiene upon exiting the room; and -CNA #2 put on a gown and gloves and entered room [ROOM NUMBER] to deliver the last meal tray. She did not sanitize her hands before donning her gloves. b. Observations 4/7/22 - Hand hygiene failures On 4/7/22 at 9:55 a.m. certified nurse aide (CNA) #4 failed to perform hand hygiene after doffing personal protective equipment (PPE) and upon leaving room [ROOM NUMBER], a Covid 19 isolation room. On 4/7/22 beginning at 9:45 a.m. and ending at 10:43 a.m., an unidentified CNA entered numerous resident rooms without performing hand hygiene before entering or after exiting. Observations were as follows: -The CNA entered room [ROOM NUMBER] and removed the resident's breakfast tray. No hand hygiene was performed before entering the room or after exiting. -The CNA entered room [ROOM NUMBER] with a pen and paper to obtain the resident's lunch order. No hand hygiene was performed before entering the room or after exiting. -The CNA then entered and exited room [ROOM NUMBER] quickly, without performing hand hygiene, and immediately entered room [ROOM NUMBER]. The CNA exited room [ROOM NUMBER] with the resident's meal tray and returned to the room to obtain the resident's lunch order. No hand hygiene was performed before entering the room or after exiting. -The CNA entered and exited room [ROOM NUMBER]. No hand hygiene was performed. -The CNA entered room [ROOM NUMBER] with vital sign equipment. No hand hygiene or cleaning of vital sign equipment was performed. -The CNA entered and exited room [ROOM NUMBER] without performing hand hygiene. -The same CNA entered room [ROOM NUMBER] with vital sign equipment. No hand hygiene was performed after exiting room [ROOM NUMBER]. -The CNA then entered room [ROOM NUMBER]. No hand hygiene was performed before entering or after exiting room [ROOM NUMBER]. c. Observations 4/10/22, 4/11/22 and 4/12/22 - PPE and hand hygiene failures (100, 200 and 400 units) On 4/10/22 at 11:34 p.m. CNA #9 was observed in a resident area on the 400 unit, in the hallway near resident rooms, without wearing eye protection. On 4/10/22 at 11:34 p.m., upon entering the 200 nursing station, registered nurse (RN) #4 was observed putting a surgical mask on her face. She was not wearing a N95 respirator mask or eye protection. She said she was aware the facility was in outbreak status. She then doffed the surgical mask and donned a N95 respirator mask and goggles. On 4/10/22 at 11:35 p.m., RN #4 was observed at the nurses' station on the 200 unit. Her surgical mask was below her nose and mouth. An unidentified CNA also was observed in the area, wearing a surgical mask below her nose which was changed to a N95 at 11:53 p.m. On 4/10/22 at 11:38 p.m. an unidentified nurse and an unidentified CNA were observed at the 100 unit nursing station without a mask and face shield. Upon prompting, they began to don a N95 respirator mask and a face shield. On 4/11/22 at 10:30 a.m., CNA #11 was observed sitting at the 400 unit nurses' desk. She was not wearing a face mask. She said she had just sat down and she had to get a drink of water. She said a break room was available to use when she needed to remove her mask, although she had not gone there to remove her mask. On 4/11/22 at 11:12 a.m., the maintenance director (MTD) was in his office across from the 400 unit nurses' station. He did not have his mask on and his door was wide open. Residents walked by his office. At 11:30 a.m., he continued to sit at his desk with his mask off. On 4/11/22 beginning at 11:25 a.m., licensed practical nurse ( LPN) #4 was observed passing medications and providing care to residents wearing a N95 mask with the straps cut off and covered with a cloth mask. On 4/11/22 at 1:15 p.m., an unidentified laundry worker was observed to enter resident rooms on the 400 unit without sanitizing prior to entering rooms and upon exit. She was touching the doors, and removing hangers and other laundry from the rooms. On 4/12/22 at 9:05 a.m. an unidentified housekeeper was observed in the hallway of the 100 hall. Her mask was below her nose and mouth. d. Observation 4/11 and 4/12/22 on the 200 unit - isolation rooms - PPE and hand hygiene failures. On 4/11/22 at 10:32 a.m., LPN #2 was observed entering room [ROOM NUMBER], an isolation room for COVID-19. She put on a gown, gloves, and booties. She then took off the gloves and put new gloves on without performing hand hygiene. She disposed of the gown, booties, and gloves in the room prior to exiting. However, she did not sanitize her face shield upon exiting the isolation room and returning to the nurses' station. On 4/11/22 at 10:43 a.m., LPN #2 was observed entering room [ROOM NUMBER], an isolation room for potential norovirus. She put on a gown, booties, and gloves. She disposed of the gown, booties, and gloves in the room prior to exiting. However, she again did not sanitize her face shield. She also did not perform hand hygiene upon exiting the room. She returned to the nurses' station to chart. On 4/11/22 at 10:45 a.m., CNA #8 was observed in room [ROOM NUMBER], an isolation room for presumptive COVID-19. She had a gown, gloves, N95 mask, and a face shield on. She was observed pulling down her mask to speak to the resident. On 4/11/22 at 10:57 a.m., an unidentified CNA was observed entering room [ROOM NUMBER], an isolation room for COVID-19. She put on gloves, a gown, then booties. She did not change gloves or perform hand hygiene after touching her shoes to put the booties on. On 4/11/22 at 11:11 a.m., CNA #8 was observed leaving room [ROOM NUMBER], an isolation room. She disposed of the gown and gloves in the room. She replaced her mask in the hallway. She did not perform hand hygiene after leaving the isolation room. On 4/11/22 at 11:49 a.m., the director of rehabilitation (DOR) was observed entering room [ROOM NUMBER], an isolation room for presumptive COVID-19. He put on a gown and gloves. He disposed of his gown and gloves inside the room. However, upon leaving the room, he did not sanitize his face shield or perform hand hygiene. On 4/11/22 at 12:18 p.m. CNA #8 was observed in room [ROOM NUMBER], an isolation room for COVID-19. Her PPE gown was not tied and was falling off her shoulders. Upon exiting the room, she hung her gown in the room and stated she would use it again. She left the room, without sanitizing her face shield or performing hand hygiene. -CNA #8 then picked up a tray for room [ROOM NUMBER], an isolation room for presumptive COVID-19. She entered the room and put on a used gown which she did not tie. The gown kept falling off while she was in the room. She did not put gloves on. She helped the resident set up the lunch tray, but did not encourage hand hygiene for the resident prior to eating. CNA #8 left her used gown in the room. She did not sanitize her face shield or perform hand hygiene upon leaving the room. On 4/11/22 at 12:25 p.m. LPN #2 put on a gown, booties, and gloves prior to entering room [ROOM NUMBER] which was an isolation room. Upon exiting the room, she disposed of the gown, booties, and gloves inside the room. She did not perform hand hygiene or sanitize her face shield upon exiting the room. On 4/11/22 at 2:18 p.m. CNA #8 entered COVID-19 isolation room [ROOM NUMBER] again, this time with a clipboard and pen. She put on the gown she had left hanging in the room earlier. She did not put on gloves. She held the clipboard and used the pen to take the resident's meal order. Thereafter, she exited the room, leaving the used gown hanging in the room. On 4/11/22 at 2:55 p.m. the resident in room [ROOM NUMBER], an isolation room for COVID-19, activated her call light. CNA #8 knocked and opened the door. She stood in the doorway and asked the resident what she needed. A used gown was hanging on the wall. The CNA then entered the room and put on the used gown which was on the wall. She took the resident's meal order. Upon exiting the room, she hung her gown back up in the room. She then realized she had not turned off the call light. She re-entered the room and put the used gown back on but did not don gloves. Upon exiting the room, she hung up the gown. She did not sanitize her face shield. On 4/12/22 at 9:24 a.m. a small trash can was observed outside room [ROOM NUMBER], an isolation room for COVID-19; it was overflowing with used PPE. On 4/12/22 at 9:34 a.m. LPN #4 was observed on the 200 unit in the hallways and entering resident rooms. While she was in the resident area, she was wearing a N95 mask with the straps cut off and covered with a cloth mask to hold the N95 in place. On 4/12/22 at 2:30 p.m. CNA #5 was observed wearing a N95 mask below her nose while sitting at the nurses' station near the 100 and 200 unit with residents in close proximity. On 4/12/22 at 7:54 p.m. LPN #5 was observed in the 200 hallway with her medication cart with a N95 mask on her chin, below her nose and mouth. On 4/12/22 at 7:59 p.m. CNA #7 was observed in room [ROOM NUMBER], an isolation for presumptive COVID-19. CNA #7 did not have a gown or gloves on. Her N95 mask was below her nose and mouth. On 4/12/22 at 8:01 p.m. an unidentified nurse was observed standing at the medication cart on the 300 unit. She was pulling medications out of the cart and checking the computer. She was not wearing a facial covering or eye protection. Upon prompting, she donned a N95 respirator mask and eye protection. Upon entering the 200 unit nursing station, LPN #3 and an unidentified CNA were observed sitting at the nursing station. The CNA was scrolling through her phone with [T

Based on observations, record review and interviews, the facility failed to test staff, including individuals providing services under arrangement for Coronavirus (COVID-19). Specifically, the facility had been in a COVID-19 outbreak status since 12/23/21 that included positive cases for both residents and staff. The facility failed to conduct bi weekly PCR testing for all staff per the CDC and CMS guidance due to outbreak status since 12/23/21, to ensure the virus did not spread to residents within the facility. The facility failed to protect individuals, equipment and supplies, allowing individual and testing items within six feet of the testing area and each other. Observations showed staff performing testing in front of the testing supplies, therefore not protecting the testing equipment from being contaminated. The testing area was shared by two individuals with the testing occurring within six feet of the individuals and their desk area. In addition, the facility failed to ensure staff were conducting self-testing in accordance with testing guidelines. Observations showed staff members failed to swab their nose with five circular motions in each nostril to ensure the testing was effective and would produce an accurate result. Nursing management, in the room during the testing process, failed to instruct and provide education to facility staff members who were testing themselves incorrectly. The facility staff failed to complete appropriate hand hygiene during and after the testing process and staff interviews showed that not all staff were aware of the testing day and admitted to not completing a PCR test. The last PCR test results were on 4/8/22 and 22 out of 70 staff were tested. Ten staff were within the 90 days of testing positive for COVID-19 and the facility had two staff members with religious exemptions. As a result of testing, three residents tested positive for COVID-19 and upon observation, a fourth resident had been placed in isolation after testing positive for COVID-19. In addition, observations revealed numerous infection control breaches which led to the facility's failure to prevent the spread of COVID-19. Cross reference F880 (Infection control), F888 (COVID-19 vaccination), F835 (administration), F837 (governing body) and F867 (QAPI). Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy The facility had been in a COVID-19 outbreak status since 12/23/21 that included positive cases for both residents and staff. The facility failed to conduct bi weekly PCR testing for all staff per the CDC and CMS guidance due to outbreak status since 12/23/21, to ensure the virus did not spread to residents within the facility. The facility failed to protect individuals, equipment and supplies, allowing individuals and testing items within six feet of the testing area and each other. Observations showed staff performing testing in front of the testing supplies, therefore not protecting the testing equipment from being contaminated. The testing area was shared by two individuals with the testing occurring within six feet of the individuals and their desk area. The facility staff failed to complete appropriate hand hygiene during and after the testing process and staff interviews showed that not all staff were aware of the testing day and admitted to not completing a PCR test. The last PCR test results were on 4/8/22 and 22 out of 70 staff were tested. Ten staff were within the 90 days of testing positive for COVID-19 and the facility had two staff members with religious exemptions. As a result of testing, three residents tested positive for COVID-19 and upon observation at the facility, a fourth resident had been placed in isolation after testing positive for COVID-19. In addition, observations revealed numerous infection control breaches which led to the facility's failure to prevent the spread of COVID-19. Cross-reference F880 and F888. B. Imposition of immediate jeopardy On 4/12/22 at 7:43 p.m., the nursing home administrator (NHA) and the regional nursing consultant (RNC) were notified of the immediate jeopardy situation created by the facility's failure to conduct COVID-19 testing as directed by the state health department, CMS and CDC guidelines while in outbreak since 12/23/21. C. Facility plan to remove immediate jeopardy On 4/14/22 at 11:15 a.m. the facility submitted a plan to remove the immediate jeopardy. The plan to remove the immediacy read: 1. Corrective action COVID-19 POC rapid testing (point of care) was completed on 4/12/22 for 22 of 72 employees. All staff members who did not complete the mandatory testing were contacted and educated that they were not able to work their shift without completing the mandatory COVID-19 POC test. All staff will complete the COVID-19 testing prior to the start of their scheduled shift. The supervisor on duty or designee will check each staff member before the start of their shift to ensure they have been tested. The supervisor on duty will contact the director of nursing and administrator for permission to remove a staff member from the facility if they refuse to comply with the mandatory COVID-19 POC test. Employee COVID-19 PCR testing will occur on Tuesdays and Fridays in the front entrance conference room. Notices will be posted at the time clock, on the director of nursing's office door and the employee bulletin board. On Monday and Thursday, the day prior to the testing day, reminders will be sent to all staff by utilizing a text messaging system. The testing room was moved to the front entrance conference room on 4/14/22: the emergency door will be kept open during testing to provide ventilation, distancing of six feet or more will occur during the testing process, surfaces will be disinfected before, in between and after testing with Eco Lab's Peroxide Multi-Surface Cleaner disinfectant. Monitoring of testing will be completed on each testing day by the director of nursing or designee, dressed in full PPE. Education was provided to all staff on the proper testing procedures such as hand hygiene prior to and following the swab test and accepted swab techniques of five circular motions in each nostril. Education was completed on 4/12/22 and 4/13/22. Testing requirements and frequency will be based on CMS/CDC and local public health authority guidance. 2. Systemic changes Education will be provided to all new staff, including agency, on the testing day's procedures and requirements, to include the proper testing procedures such as, hand hygiene prior to and following the swab test and accepted swab techniques of five circular motions in each nostril. Education will be provided to the director of nursing and/or designee on ensuring unused testing supplies and other PPE/equipment is removed from the testing room, ensuring social distancing of six feet or more during employee testing, disinfecting testing surfaces before, in-between, and after employee testing, ensuring the emergency door in the office will remain open during testing for ventilation, and proper testing procedures are completed such as hand hygiene prior to and following the swab test and swab techniques of five circular motions in each nostril. Education will be completed on 4/12/22. The nursing home administrator or designee will monitor CDC testing requirements and public health recommendations and implement any new changes to ensure testing compliance. 3. Monitoring The director of nursing and/or designee will monitor employee testing twice per week to ensure all staff have been tested. If a staff member fails to be tested, the director of nursing will remove the employee from the schedule and discipline action will follow. The interdisciplinary team, which includes department managers, will have access to the lab results for COVID-19 testing to review both resident and staff COVID-19 test results. The team member assigned will be responsible to notify the nursing home administrator and the director of nursing to create a plan of action. Each team member will have lab result access on 4/18/22. The interdisciplinary team, to include the medical director, will conduct a root cause analysis to determine the progress of the corrective plan and will provide a report to the quality assurance performance improvement committee to discuss recommendations and additional corrective actions. D. Removal of the immediate jeopardy The NHA and DON were notified on 4/14/22 that the above plan was accepted on 4/14/22 at 12:54 p.m. and the immediate jeopardy was removed based on the facility's plan set forth above. However, deficient practice remained at F level, widespread with the potential for more than minimal harm. II. Facility policy and procedure The Obtaining Anterior Nasal Specimen, dated 2/21/22, was provided by the assistant nursing home administrator (ANHA) on 4/21/22 at 4:44 p.m. It revealed, in pertinent part, Procedure steps to conduct an anterior nasal specimen collection for COVID-19: -Perform hand hygiene. -DON required PPE in the following order: gown, N-95 mask, face shield or goggles and gloves. -To collect an anterior nasal specimen: remove the swab from the package, carefully insert the swab into the nostril, using gentle rotation, push the swab until resistance is met at the level of turbinates (approximately one centimeter or half an inch into the nostril), rotate the swab five time or more against the nasal wall, slowly remove the swab from the nostril, and using the same swab, repeat the process in the other nostril. -Process the swab in accordance with manufacturer recommendations. -Discard used testing materials in a biohazard container. -Remove and discard gloves. Perform hand hygiene. [NAME] clean gloves for the next test. III. Professional reference Consistent with CMS and CDC testing guidance, the Residential Care Facility (RCF) Comprehensive Mitigation Guidance, revised on 4/8/22, documented: When one or more positive tests are identified in a resident or health care professional (HCP) (regardless of vaccination status), the facility moves to outbreak testing and following additional response measures outlined below. -Asymptomatic HCP (including ancillary non-medical services providers) and residents who are up to date with all recommended COVID-19 vaccine doses should test twice weekly for SARS-CoV-2 using a lab-based PCR test. If HCP work infrequently at the facility, the lab-based PCR test should be performed within three days before their shift. -A HCP who tests positive, regardless of vaccination status, should be excluded from work and instructed to isolate at home. HCP should self-report positive results to any additional employer so that disease control measures can be implemented if necessary. IV. Failure to ensure all staff were tested for COVID-19 during an outbreak and failure to ensure staff were testing themselves in accordance with testing guidelines to achieve an accurate result. A. Record review A sign, undated, was posted on the director of nursing's (DON's) office door indicating COVID-19 testing was on Tuesdays and Fridays in the DON's office. It documented all staff were required to be tested by 2:00 p.m. A line list, dated 4/12/22, was provided by the consultant DON on 4/12/22 at 3:15 p.m. It documented that only 18 staff members had been tested for COVID-19, that day (4/12/22), out of 72 total staff members who worked at the facility. A line list for Friday, 4/8/22, documented 32 staff members had a COVID-19 PCR test out of 72 total staff members. The facility was unable to provide documentation that the staff who were not PCR tested had been POC (point of care) tested (alternative testing that does not require sending the test to the lab) until the next testing date on 4/12/22. A line list for Tuesday, 4/5/22, documented 22 staff members had a COVID-19 PCR test out of 72 total staff members. The facility was unable to provide documentation that the staff who were not PCR tested had been POC tested until the next testing date on 4/8/22. The facility was unable to provide documentation that the staff members who were not tested had been contacted, provided education, been removed from the schedule, or had disciplinary action to ensure compliance with the testing requirements. B. Observations On 4/12/22 at 1:43 p.m., facility staff COVID-19 testing was observed. The social services assistant (SSA) getting ready to self-test in the DON office. The DON told the SSA to write his name and birth date onto the testing tube and also the bag. The DON did not provide the SSA with any other instructions. -He used the swab in a circular motion three times in each nostril. He then proceeded to place the swab in the tube and then placed the tube in the bag. He pumped the container to obtain hand sanitizer, however it made a sputtering sound, which indicated the hand sanitizer container was almost empty. -The door in the office, which led to the outside of the facility, was not open for ventilation. -The SSA left the room. The DON was informed that the SSA did not perform the COVID-19 self PCR test correctly. The DON said the swab should be twirled in a round fashion, five times in each nostril. She said he would have to return to conduct the test correctly to ensure an accurate result. At approximately 1:55 p.m. certified nurse aide (CNA) #12 came into the DON's office to conduct her COVID-19 test. The DON told her to make sure she twirled the swab in five full circles. The DON and the regional nurse manager (RNM) were in the room; they did not watch CNA #12 perform the self-test. CNA #12 swabbed each nostril four times. V. Failure to ensure the testing location followed CDC guidance for source control and failure to protect individuals, equipment and supplies, by keeping individuals and items six feet from the testing area and from each other. In addition, the failure to ensure infection control practices were observed during the testing process. A. Observations On 4/12/22 at 11:15 a.m. an unidentified housekeeping staff member was observed entering the DON's office for the COVID-19 PCR self-test. She approached the table, labeled the testing tube with her name as directed by the DON. -The DON was observed sitting at her desk, closer than six feet from the housekeeping staff member, with her face shield on the top of her head and the N95 respirator mask pulled beneath her chin. She was not wearing any other form of PPE. -The RNM was sitting at another desk in the room. She was wearing a N95 respiratory mask and a face shield. She was not wearing any other form of PPE. -The housekeeper, while performing the swab self-test, was informed by the DON she needed to turn around. The housekeeper turned to the area directly behind her. The area had boxes and packages of unopened PPE and testing supplies. She performed the swab self-test, placed the tube into a bag and then left the room. She did not perform hand hygiene after performing the test. At approximately 1:50 p.m., the SSA returned to complete the PCR test. He removed his mask and faced the DON while he did the swab test. He removed his gloves and then wiped down the table. He did not perform hand hygiene after testing. At 1:55 p.m., CNA #12 entered the DON's office to perform the COVID-19 self-test. After she was finished, she placed the swab in the tube and the tube in the bag. She did not perform hand hygiene following the self-test. VI. Staff interviews CNA #2 was interviewed on 4/12/22 at 3:43 p.m. She said staff were required to be tested twice a week on Tuesdays and Fridays. She said management informed staff they needed to be tested these days via the intercom system in the facility. She said testing was done in the DON's office. She said the testing supplies were set up and she tested herself each time. She said she used the swab in each nostril for three spins. She said she then placed the swab in a vial and handed it to the manager in the office. She said she then placed her mask back on and returned to work. She said she was required to get a rapid test prior to her shift when she had COVID-19 symptoms. The staffing coordinator (SC) was interviewed on 4/12/22 at 4:00 p.m. She said both direct hire and agency staff were notified in orientation that COVID-19 testing days were conducted on Tuesdays and Fridays. She aid then it was the staff' s responsibility to remember to get tested. She said agency staff signed a waiver prior to starting that stated they will be tested twice a week for COVID-19. She said if management noticed agency staff was not tested, that staff member would be reviewed in a compliance call on Thursdays with the agency. If agency staff continued to not get tested, the contract was terminated by the facility. Licensed practical nurse (LPN) #2 was interviewed on 4/12/22 at 3:36 p.m. She said COVID-19 testing days were on Tuesdays and Fridays. She said she got a notification via the phone as a reminder to get tested. She said she tested herself in the DON's office. She said hand hygiene should be performed prior to the test. She said the swab should be put into each nostril and twirled in a circular motion for a few seconds. She said she had only been rapid tested, not PCR tested, since starting at the facility three weeks ago. LPN #1 was interviewed on 4/12/22 at 3:30 p.m. She said all staff were tested twice a week for COVID-19, on Tuesdays and Fridays. She said she recently had COVID-19, so she was not required to take the test for 90 days. She said staff were notified to be tested via posted signs, in-person meetings, on the facility intercom, or a phone call. She said testing occurred in the DON's office. She said during testing, first she took off her mask, put a sticker with her name and birth date on the vial, swabbed each nostril for five seconds, put the swab in in the vial, put the vial in a biohazard bag, and then performed hand hygiene. CNA #5 was interviewed on 4/12/22 at 3:26 p.m. She said testing days were on Thursday and Friday afternoons before 2 p.m. She said if she had not completed her testing, she received a call from management to get tested. She said testing was conducted in the DON's office. She said a manager was in the office and conducted the test. The DON was interviewed on 4/12/22 at 2:14 p.m. She said the facility had completed 18 PCR COVID-19 tests for facility staff members. She said every staff member should be tested by 2:00 p.m. that day. She said the facility was in outbreak and staff were required to be tested twice a week. She confirmed the facility had a lot more employees than 18. She said she had been working at the facility for four days. She said based on the documentation she had seen and observations of staff being tested, she did not feel the facility was meeting the requirement of testing the facility staff as directed by the state health department. She said the testing location was not adequate because it was located in the DON's office. She said the office contained many boxes of PPE, testing supplies and other various items and paperwork. She confirmed the testing table was located in front of her desk and did not allow for her to be distanced by six feet. She confirmed boxes of PPE, testing supplies and documents on her desk were within fewer than six feet from the testing table. She confirmed the door, which led to the outside of the facility, was not open for ventilation. She confirmed she had not worn full PPE when facility staff members were performing the COVID-19 self-test. (See above) She said she wore an N95 respirator mask and a face shield but said she and the RNM should have donned full PPE while staff were in the office, testing. The RNM was interviewed on 4/12/22 at 3:45 p.m. She said they had been able to get 22 staff members tested today. She said the facility had over 70 employees. She said she was just made aware that not all the staff in the facility had been tested. She said the facility was only conducting rapid POC testing if the staff members were showing signs and symptoms of COVID-19, not if they missed the PCR testing on Tuesdays and Fridays. She said any residents or staff members who tested positive for COVID-19 went into a tracking system. She said after the testing occurred on Tuesdays and Fridays, the facility designated person could log into the laboratory system and get the results usually within 24 to 48 hours. She said the designated person at the facility had been the DON and the NHA. She said the DON resigned and the current DON did not have access to the laboratory system to obtain the test results. She said the facility would ensure the DON would have access to the laboratory system that day, 4/12/22. She said she looked at past test results and it appeared as though the facility had not been testing all 72 staff members, which was directed by the state health department because of the facility's outbreak status. The NHA was interviewed on 4/12/22 at 4:44 p.m. She said she had been out for a few weeks because her COVID-19 test had come back positive. She said the facility had been in outbreak status since 12/23/21. She said the facility conducted COVID-19 testing twice a week, on Tuesdays and Fridays. She said the facility utilized signs posted on the DON's office and time clock, text messaging system and word of mouth to remind staff of testing days. She said the facility had been having a difficult time keeping the agency staff accountable for coming and testing. She said the facility kept track of who had not been tested and had started compliance calls with the agencies approximately four weeks ago. She said there were 72 staff members who worked at the facility and were required to be tested. She said she was aware the facility had not been in compliance with testing all of the staff. She said she did not have any documentation to indicate staff members had completed rapid POC testing if they missed the required PCR test. She said staff should not be working if they did not get tested. She said she did not know what happened, but said the previous DON was allowing the staff to continue working without being tested. She said going forward, a new plan was being put into place for education, verbal and written warnings and termination for staff who missed testing.

Based on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including unvaccinated staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to monitor each contracted staff member's vaccination status to ensure proper advanced PPE (personal protective equipment) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. The facility was non-compliant with the requirement of 100% vaccination rate, except those exempted, because of its failure to adequately track all employees (vendors and contractors) vaccination status to prevent the spread of COVID-19. A review of the facility vaccination policy and procedure revealed the facility did not require proof of vaccination for all contracted providers, but instead, required a generalized provider company attestation agreement which indicated the provider agreed to comply with the facility's vaccination policy. Cross-reference F880 (Infection control), F886 (COVID-19 testing), F835 (Administration), F837 (Governing body) and F867 (QAPI). The facility was non-compliant with infection control practices to protect residents from contracting COVID-19. Observations on 4/6/22 to 4/12/22 showed: -Facility staff did not consistently wear N95 or equivalent respirators while engaged in resident care and in resident areas and did not follow required use of eye protection in an outbreak. -Facility staff did not perform hand hygiene appropriately in between caring for residents and tasks; - Equipment (medical and non-medical) was not sanitized in between use; -Re-use of gowns in COVID-19 positive rooms and improper donning of gowns in COVID-19 positive rooms and lack of sanitization of face shields; -Facility staff not performing hand hygiene in between rooms/residents; -Facility staff were not providing residents with hand hygiene prior to meals; and, -Facility staff were not properly cleaning tables in the dining rooms after resident use. -Facility staff were not properly cleaning resident rooms. Since 3/22/22, 18 residents have tested positive for COVID-19. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy The facility failed to monitor each contracted staff member's vaccination status to ensure proper advanced PPE strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. During the survey, 4/6 through 4/19/22, the facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. The facility was non-compliant with the requirement of 100% vaccination rate except for those exempted, because of its failure to adequately track all employees (vendors and contractors) vaccination status to prevent the spread of COVID-19. A review of the facility vaccination policy and procedure revealed the facility did not require proof of vaccination for all contracted providers, but instead, required a generalized provider company attestation agreement, which indicated the provider agreed to comply with the facility's vaccination policy. Observations revealed the facility was non-compliant with infection control practices to protect residents from contracting COVID-19.(Cross-reference F880) Observations on 4/6/22 to 4/12/22 showed: -Facility staff did not consistently wear N95 or equivalent respirators while engaged in resident care and in resident areas and did not follow required use of eye protection in an outbreak. -Facility staff did not perform hand hygiene appropriately in between caring for residents and tasks; - Equipment (medical and non-medical) was not sanitized in between use from a COVID-19 positive resident to a negative and unvaccinated resident; -Facility staff re-using gowns in COVID-19 positive rooms and improper donning of gowns in COVID-19 positive rooms and sanitization of face shields; -Facility staff not providing residents with hand hygiene prior to meals; and, -Facility staff not properly cleaning tables in the dining rooms after resident use or properly cleaning resident rooms. Since 3/22/22, 18 residents have tested positive for COVID-19. B. Imposition of immediate jeopardy On 4/13/22 at 1:00 p.m., the nursing home administrator (NHA) and the regional nursing consultant (RNC) were notified of the immediate jeopardy situation created by the facility's failure to monitor each contracted staff member's vaccination status to ensure proper advanced PPE strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. C. Facility plan to remove immediate jeopardy On 4/14/22 at 2:32 p.m. the facility submitted a plan to remove the immediate jeopardy. The plan to remove the immediacy read: 1. Corrective action -On 4/14/22, the nursing home administrator and/or designee contacted all contracted providers to obtain verification of vaccination for all providers who enter the facility on a regular basis. This will be completed by 4/14/22 as any incoming vendor will be asked for proof of vaccination. The human resources director will continue to review and ensure outside contractors are fully vaccinated or have an approved exemption with a copy of their vaccination card and exemption on file. -On 4/14/22 a healthcare vaccine mandate vendor communication contract was developed and distributed to contracted vendors with the stipulations of the facility's requirements for verifying each provider's vaccination status, and the PPE strategies for those with accepted exemptions. Each contract will be signed and the facility will keep a copy by 4/14/22 or prior to allowing vendors into the facility. -All new contracted staff members' vaccination status and/or exemptions will be reviewed by the human resources director and documented on the vaccination log. -A list of contracted staff members' vaccination dates will be documented on the contracted staff member's vaccination log by the HRD or designee. -The receptionist or scheduler will validate the contracted staff member's vaccination status prior to having contact with the residents. -If a contracted staff member's vaccination status is unknown, the human resources director will request a copy from the contracted vendor prior to entering the facility. 2. Systemic changes -Education was provided to the nursing home administrator, director of nursing, and human resources director on the vaccination requirements and the Healthcare Vaccine Mandate Vendor Communication on 4/13/22. 3. Monitoring -Interdisciplinary team, to include the medical director, will conduct a root cause analysis to determine the progress of the corrective plan and will provide a report to the quality assurance performance improvement committee to discuss recommendations and additional corrective actions. D. Removal of the immediate jeopardy The NHA and DON were notified on 4/14/22 that the above plan was accepted on 4/14/22 at 3:13 p.m. based on the facility's plan above, and the immediate jeopardy was removed. However, deficient practice remained at F level, deficient practice that is widespread. II. Facility policy and procedure The Mandatory COVID-19 vaccination policy and procedure, revised January 2022, was provided by the NHA on 4/6/22 at 2:00 p.m. It read, in pertinent part, This COVID-19 vaccination policy applies to all employees, resident providers, independent providers, volunteers, students, contractors, and vendors who work in a healthcare facility or provide healthcare services in a client's home. Senior care (includes skilled nursing): be fully vaccinated or have an approved medical or religious exemption. Employees are considered fully vaccinated two weeks after completing primary vaccination with a COVID-19 vaccine, with if applicable, at least the minimum recommended interval between doses. For example, this includes two weeks after a second dose in a two-dose series, such as the Pfizer or Moderna Vaccines, two weeks after a single-dose vaccine, such as the Johnson & Johnson vaccine, or two weeks after the second dose of any combination of two doses of different COVID-19 vaccines as part of one primary vaccination series. Employees and volunteers are required to provide proof of COVID-19 vaccination. Employees and volunteers vaccinated by [the facility] already have proof of vaccination status. All other employees are required to provide proof of COVID-19 vaccination to their local human resources designee. Acceptable proof of vaccination status is one of the following: the record of immunization from a healthcare provider or pharmacy; a copy of the COVID-19 vaccination record card; a copy of medical records documenting the vaccination; a copy of immunization records from a public health, state, or tribal immunization information system; and a copy of any other official documentation that contains the type of vaccine administered, dates of administration, and the name of the healthcare professionals or clinic site administering the vaccine. All contractors and business partners who have a recurring interaction with staff, patients, or residents, by contract or other arrangement, are required to comply with the vaccination requirements outlined in this policy prior to performing work in a facility. This includes but is not limited to licensed practitioners/independent medical staff, students, and trainees. III. Failure to monitor each contracted staff member's vaccination status to ensure proper advanced PPE strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. A. Record review The vaccination matrix, provided by the NHA on 4/6/22 at 4:00 p.m., documented a list of facility staff members, including agency staff. It indicated each staff member's vaccination status, including if any exemptions had been approved. It included 66 staff members in the nursing, housekeeping, dietary and administration departments. The vaccination matrix did not include any providers, such as physicians, nurse practitioners, or hospice staff. The Mandatory COVID-19 vaccination policy and procedure, revised January 2022, documented the following: Agencies, universities, and other contracted services who have employees or students present in our facilities that provide care, treatment, or other services for the healthcare location or patients must provide a signed attestation statement that all their employees or students are vaccinated or have a qualifying exemption. The Vendor Vaccination Attestation documented The [vendor organization's name] agrees to comply with [the facility's] vaccine requirements based on the interim final rule issued by the Centers for Medicare and Medicaid Services (CMS) in the Department of Health and Human Services. Vendors who have employees or students present in our facilities who provide care, treatment, or other services must provide a signed attestation statement that all of those employees or students are vaccinated or have a qualifying exemption and will do the following: Upon request, and only upon request, provide additional data of vaccination status. The facility provided a binder of documented attestations during the survey process from different vendor agencies; however, the facility was unable to provide documentation of each specific provider's vaccination status who entered the facility and provided direct care to residents. The facility failed to have a monitoring system in place to ensure each provider who entered the facility and provided care to residents was fully vaccinated or had an exemption and was exercising the facility's PPE (personal protective equipment) requirements while in the facility. IV. Staff interviews The NHA was interviewed on 4/12/22 at 4:44 p.m. She said the facility kept track of the vaccination status of all of their staff, including agency staff. She said she had 66 staff members documented on the staff vaccination matrix, which included their vaccination status and any with approved exemptions. However, she confirmed the facility had 72 employees and acknowledged that not all facility staff members were included on the staff vaccination matrix. She also confirmed providers, such as physicians, nurse practitioners, or hospice staff, were not included on the staff vaccination matrix. She said the facility policy was to get an attestation from the provider's agency to ensure vaccination status. She said each physician's medical group or hospice agency should have an attestation on file indicating their staff was vaccinated. She said the facility did not have copies of each individual provider's vaccination card or exemption. She said the facility had not been tracking each individual provider's vaccination status. She said she thought the group or agency's attestation was enough.