**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the residents' rights to be free from neglect by failing to follow/implement facility policy and procedures and Centers for Disease Control and Prevention (CDC) guidelines related to transmission-based precautions for the prevention of the possible spread of infection to staff, visitors, and residents. The facility neglected to ensure appropriate visual alerts were posted outside of the memory care unit and on the 200 Hall related to identified COVID-19 (Coronavirus Disease 2019) outbreak. The facility neglected to maintain contact/droplet precautions by not having the staff donning appropriate Personal Protective Equipment (PPE) to include N95 respirators, gowns, gloves, and eye protection when in close and prolonged contact with COVID-19 positive residents on the memory care unit. On 5/11/2023, the facility had a total of 28 COVID-19 positive residents out of a census of 109 residents. This failure has the likelihood for serious harm, serious impairment or death for people [AGE] years of age or older, people who have a severe underlying medical condition, and people who live in nursing homes are at higher risk for developing serious complications from COVID-19 illness. Individuals who are infected might develop serious diseases with difficulty breathing. Some individuals might require intensive care for the treatment of multi organ failure, respiratory failure, and septic shock. COVID-19 infection can lead to death. Findings include: During an observation on 5/8/2023 at 8:45 AM, the facility's main entrance did not have visual alerts posted to inform visitors and staff of an infection outbreak. There were surgical masks in a box on the receptionist desks. There was no other PPE observed in the lobby for visitors and staff to don (putting on) prior to entering the facility. During an observation on 5/8/2023 beginning at 9:45 AM of the Memory Care Unit entrance double doors, there were no visuals alerts posted to inform visitors and staff of an identified infection outbreak. There was no signage of the need to don PPE before entering the unit and there was no personal protective equipment at the entry to indicate the need for donning PPE prior to entering. After entering the unit, there were two rooms observed to have bins containing PPE consisting of gowns, gloves, N95 respirators, and face shields for Residents #45, #60, #42, and #72's rooms. There were no visual postings on the doors for Residents #45, #60, #42, and #72 to inform visitors or staff of the need to see the nurse prior to entering the room or the need to don PPE prior to entering the rooms. Staff A, Licensed Practical Nurse (LPN), was observed wearing an N95 respirator, and another staff member was observed wearing a surgical mask. Neither staff member was wearing a gown, gloves, or eye protection. Three residents were observed in the dining room and five residents were observed in the common living area of the Memory Care Unit. During an observation on 5/8/2023 at 9:45 AM, Staff A, LPN, exited the nursing station and administered medications to a resident sitting in the dining room of the Memory Care Unit. Staff A, LPN was wearing an N95 respirator, and was not wearing a gown, gloves or eye protection. During an observation on 5/8/2023 at 9:46 AM, Staff E, Certified Nursing Assistant (CNA), was observed exiting a resident's room toward the end of the hallway and entered the living area where the five residents were sitting. Staff E was observed to be wearing a surgical mask, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 9:46 AM, Staff C, CNA, was wearing an N95 respirator in the dining room area. A resident stood up and Staff C assisted the resident back to a sitting position in a chair. Observations were made of the remaining rooms on the unit that did not have a storage bin in front of the rooms. During an observation on 5/8/2023 at 10:10 AM, Staff B, Director of Central Supply, and Staff C, CNA, were wearing N95 respirators, and Staff E, CNA, was wearing a surgical mask. Staff B, Staff C, and Staff E were not wearing gowns, gloves, or eye protection. Staff B, Staff C, and Staff E were placing Contact Precautions signs on multiple room doors of the Memory Care Unit. During an interview on 5/8/2023 at 10:10 AM on the Memory Care Unit, Staff A, LPN, stated, [Resident #94's name] is COVID positive. That is why the room door has a contact precaution sign posted. This is the sign we use for COVID positive. During an observation on 5/8/2023 at 10:11 AM, Residents #26, #70, #58, #157, #71, #69, #45, #60, #42, #72, #53, #99, #76, #61, #52, #85, #13, #88, #94, and #37's room doors had signage which read, Contact Precautions. Review of the COVID-19 Line List documented as of 5/4/2023 revealed the facility had a total of 7 COVID-19 positive residents. Four (4) of the 7 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/7/2023 revealed the facility had a total of 16 COVID-19 positive residents. Twelve (12) of the 16 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/8/2023 revealed the facility had a total of 21 COVID-19 positive residents. Fourteen (14) of the 21 positive residents resided on the Memory Care Unit. During an observation on 5/8/2023 at 9:53 AM of Residents #92 and #50's rooms, which were located on the 200 Hall, there was a visual posting that read, Contact Precaution. During an interview on 5/8/2023 at 9:55 AM, Staff D, Registered Nurse (RN), stated, Both of the residents in the room had tested positive last Thursday [Resident #92 tested positive on 5/5/2023 and Resident #50 tested positive on 5/8/2023]. We use masks, gowns, gloves, and face shields. Both residents are in isolation and cannot come out until they are negative. During an interview on 5/8/2023 at 10:27 AM, the Infection Preventionist stated, [Resident #50's name] is negative as of right now. [Resident #92's name] tested COVID positive on Saturday [5/6/2023]. [Resident 92's name] son came into the building to visit, and he tested COVID positive. Both [Resident #50's name and Resident #92's name] are sharing a room since they are both isolated due to the exposure. I recommended that they share a room due to the level of their exposure. We will test [Resident #50's name] today and again tomorrow. The Memory Care Unit census is 20 residents, and 12 residents are positive as of 5/8/2023. These residents are severely cognitively impaired, and the approach was to isolate the entire wing. We have residents who wander into other residents' rooms. They are exit seekers and at risk for elopement and we cannot move them anywhere else safely. Memory care should have Personal Protective Equipment (PPE) outside of the double doors to Serenity [Memory Care Unit name]. I cannot say that is in place now. I tested positive on 5/2/2023 and I am not sure where it came from. My symptoms started late Monday afternoon. I did the 5-day quarantine and returned today [5/8/23]. The Serenity Unit has only contact precaution signs and not droplet precautions [signs]. I came back to work using the CDC criteria and came back due to 'crisis staffing criteria' as I was needed to come back in to work. The Memory Care Unit staff started testing positive on 5/4/2023. We had a staff member who tested positive on 5/1/2023 [The Activity Director]. Her last day working in the facility was 4/28/2023. She worked on all three units. Our community rate was low enough that we were not wearing masks. We started wearing masks on 5/1/2023. We have three staff members out due to COVID. We are testing staff twice a week on Tuesday and Thursday. We last tested residents on 5/4/2023. We will be testing residents again tomorrow. During an observation on 5/8/2023 at 10:45 AM, the Memory Care Unit entrance double doors had no visual posting to alert visitors and staff before entering the unit with instructions about current infection prevention and control recommendations for the unit. No personal protective equipment was observed outside of the doors. During an observation on 5/8/2023 at 10:45 AM, in the Memory Care Unit, Staff A, LPN, was assisting residents and was wearing an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff C, CNA, was supervising a resident in the dining area. Staff C was wearing an N95 respirator and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff E, CNA, was supervising a resident in the dining area. Staff C was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an interview on 5/8/2023 at 10:46 AM in the Memory Care Unit, the Infection Preventionist stated, All rooms in the locked memory care unit were incorrectly labeled with contact precaution signs and the signs should say droplet and contact precautions. Signs should be posted on residents' doors as soon as the test results come in. During an observation on 5/8/2023 at 12:03 PM, Staff E, CNA, was passing out lunch trays to the residents in the Memory Care Unit. Staff E was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. Coming in close contact, she placed each food tray on the table in front of each resident. During an interview on 5/8/2023 at 12:15 PM, Staff A, LPN, stated, I was not here over the weekend. What I did when I came back to work was to do my own report and test all the residents again to make sure what their COVID status was at this time. I had the staff take all the signs down. That is why when you entered the unit, some rooms did not have signs posted on the doors. The Infection Preventionist was out due to COVID and [Staff F, LPN's name] took over. The girls [Certified Nursing Assistants assigned to the Memory Care Unit] were helping me put the signs back on the doors after the COVID test results came back. Normally if a resident tested positive for COVID, we will move the resident out of the room to a single room or if two residents are positive, we will double them up in the same room. This is the memory care unit, and we need to be careful that the residents do not get out of the unit making it harder to arrange room changes. We were all off this weekend and I had the signs being copied to place on the doors. We had bins outside some rooms. This was sporadic. I stopped everything after I received the shift report and started testing all the residents from scratch since we have agency staff working in the unit. We were not aware we needed to wear gowns and gloves on the unit. The Infection Preventionist informed us we needed to wear proper PPE after you had been on the unit. [Staff E, CNA's name] was the staff who didn't have the N95 mask on while on the unit. We all found out we needed to wear gowns in the halls and only N95 mask afterwards. The Infection Preventionist came into the unit and provided the correct signs for all the rooms. We were using the contact signs because that was what we had at that time. I had sent a text message to [Staff F, LPN's name] at 9:22 AM stating some rooms had signs and some did not. She replied that we needed to have signage on resident doors for contact/droplet precautions and since I was off during the weekend that is why I decided to do my own report since I did not know when those signs went on the doors. I am the primary nurse on the unit and do my own thing due to the agency staff that work the unit. During an interview on 5/8/2023 at 1:01 PM, Staff C, CNA, stated, I was off during the weekend and just came back to work today. We get report on the unit at 6:45 AM. Residents were starting to come up positive for COVID. [Staff A, LPN's name] decided to recheck to make sure [to determine if additional residents were positive]. We were not aware we needed to wear a gown and gloves while working on the unit. I know as you go into the room you wear a face shield, N95 mask, gloves, and gown. This unit is different. COVID positive residents are outside of the rooms. We had contact precaution signs on the doors. Contact precautions is pretty much used for everything. [Staff A, LPN's name] never mentioned that the signs provided were not the correct ones. During an interview on 5/8/2023 at 1:21 PM, Staff E, CNA, stated, I was wearing a surgical mask because that was what we were supposed to do until they told us to wear N95 masks later on 5/8/2023. [Staff A, LPN's name] told us to put up the contact precaution signs on the COVID positive resident doors. Nobody told us that we needed to include droplet precautions. I worked Friday and rooms for [Residents #70, #42, #37 and #94's names] all had contact precaution signs on the door. I was wearing only a surgical mask while in contact with two COVID positive residents that were sitting in the living room area. The residents were not wearing masks. It is hard for them to keep the masks on. I did not know we had to wear gowns while in the common area. During an interview on 5/8/2023 at 1:31 PM, Staff B, Director of Central Supply, stated, On Friday night, three residents tested positive for COVID and I posted the signs I had available. Monday, [Staff A, LPN's name] said to make copies. It was the same two signs. One said, 'stop see the nurse' and the other one 'contact precautions.' I went and got the copies. That is when you saw us posting the signs on the doors. Later that day, I saw the Infection Preventionist hanging the other signs which basically say the same things as the other ones. When [Staff A, LPN's name] asked me to make copies and hang the signs, she never mentioned they were not appropriate [signs]. I placed the signs on Friday before I left, so at least the people entering would at least stop at the door [resident's door]. I think we use the same protocol for all, the same precautions. I did not have a gown when entering the Memory Care Unit. I was not going in the rooms. I was just hanging signs on the resident rooms. I did hear some more residents tested positive but I'm not familiar with their faces. I was not aware the residents that were COVID positive were in the common areas in the Memory Care Unit. For contact precautions, I would say we use a blue mask [surgical mask], gown, and gloves. If it is droplet, we are expected to wear a face shield, N95, and gown. When I exited the Memory Care Unit, I went around the facility and made sure all PPE bins were fully stocked. During an interview on 5/8/2023 at 1:45 PM, the Director of Nursing (DON) stated, As far as monitoring infection control, I do it with the Infection Preventionist. We collaborate on how we are going to move forward. Residents who test negative for COVID should be removed from COVID positive rooms. Signage should be on the door as well as personal protective equipment. I do not know what happened with [Resident #92's name]. I reached out to the nurse that worked that weekend and she has not reached out back. I round daily regarding education on PPE. I am in the middle of my infection control training. Staff should wear appropriate PPE when in contact with positive residents. I went to the memory care unit on 5/4/2023 and again on 5/5/2023 and I was wearing an N95 and face shield. I was not wearing a gown since I was only at the nursing station and hallway. The staff were informing me of a COVID positive resident, and I then informed my boss and the Infection Control Preventionist. Staff was instructed to notify the physician, family, and follow orders. They were also instructed to isolate residents as much as they can. I would say I oversee infection prevention when the Infection Preventionist is not available. During a telephonic interview on 5/9/2023 at 2:33 PM, Staff F, LPN/Infection Prevention Trainee, stated, I would keep communication via phone with Infection Preventionist, Administrator and DON for guidance as to my role I wasn't sure. I tested positive on the 3rd [May] showing symptoms. When I spoke to [Staff A, LPN's name], I told them to follow normal protocol which include signs, carts with PPE, and wearing proper PPE. There was a lot of texting back and forth, a lot of the guidance came from the Infection Control Preventionist. Staff needed to make sure that signs stated droplet and contact if I am not mistaken. Via text, I was notified that Sunday [5/7/2023], 10 residents tested positive for COVID. I did not give any guidance. It was pretty much the DON and Administrator who were going back and forth providing guidance. Last time I was in the building was Wednesday [5/3/2023] until 4 PM. When the Infection Preventionist is not available, the DON and the Regional Clinical Consultant were responsible. During a telephonic interview on 5/9/2023 at 2:55 PM, the Medical Director stated, I was not aware of the COVID-19 outbreak status in the facility. I have been the Medical Director since January. No one contacted me in the last two weeks concerning the COVID-19 outbreak status at the facility. My expectation was for residents who have a roommate and test positive for COVID, the positive resident should be put in a room with others who are positive. The roommate would generally be placed or transferred with patients with a negative test result. I would have expected the resident who tested negative to be removed from the room of the one who tested positive. During an interview on 5/11/2023 at 12:15 PM, Staff E, CNA, stated, I do not take lunch in the breakroom. I go outside using the back door. We are allowed to use the employee breakroom for lunch if we want. When my shift is over, I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:16 PM, Staff G, CNA, stated, I work all over the facility. Last time I worked in the Memory Care Unit was last Thursday or Friday [5/4/2023 or 5/5/2023]. I worked with [Staff E, CNA's name] and we were only wearing surgical face masks while taking care of the residents in the Memory Care Unit. Residents were already coming up positive and I didn't know I was supposed to wear an N95. During an interview on 5/11/2023 at 12:20 PM, Staff H, LPN, stated, I only work in the Memory Care Unit and worked last Sunday [5/7/2023]. I wore an N95 mask. I did not leave the unit on Sunday for lunch or break. I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:50 PM, Staff I, CNA, stated, I do not remember what rooms I was assigned to. I think I worked in the back hall of the 200 Hall. On Monday, I was wearing a surgical mask when I came in, then we were told to wear an N95 mask when you guys showed up. Review of the COVID-19 Line List documented as of 5/11/2023 revealed the facility had a total of 28 COVID-19 positive residents. During an interview conducted on 5/12/2023 at 8:49 AM, the Administrator stated, Biggest thing was on 5/1/2023 when residents started testing positive for COVID. I sat down with my Director of Nursing (DON) and Infection Preventionist (IP) and referred back to our policies and procedures. I had the DON and IP come up with a clinical procedure and isolation and personal protective equipment to go into place. We had an Ad Hoc meeting on 5/1/2023, got the isolation signs and continued to test. We reviewed residents and patient care and began putting a plan in place. I took the clinical piece and had my DON and IP work together. The Medical Director was aware of the policies we have in place, but he was not involved in the meeting held on 5/1/2023. The DON provided coverage while the Infection Preventionist was out. My Infection Preventionist tested positive on 5/2/2023. The DON was responsible for overseeing infection control in the facility. With COVID positive [residents], we need to have droplet and contact precautions. The signs [visual alerts] should have been posted. I became aware the COVID Unit [Memory Care Unit] was not on isolation on 5/8/2023. COVID positives are not allowed to cohort with non-positive residents. They are not allowed to remain in the same room. When this was brought to my attention, we separated them on 5/8/2023 [Residents #92 and #50]. It was my understanding that staff were wearing the appropriate personal protective equipment and appropriate signage was posted. The DON was here on Friday [5/5/2023] and she was here on [5/6/2023] on Saturday. The signage was provided to her and put in place. The DON notified me on 5/7/2023 of the COVID positives and it was my understanding that we had made the Memory Care Unit a red unit [COVID Unit]. During an interview on 5/12/2023 at 8:50 AM, the Regional [NAME] President stated, As long as the staff is properly donning and doffing [taking off] their PPE and handwashing before they exit the unit, they are able to go through the facility to clock out. During an interview on 5/12/2023 at 8:57 AM, the Regional Director of Clinical Services stated, I personally provided the correct signs on 5/4/2023. I know the two signs on Serenity [Memory Care Unit] signs were not on the doors on Monday morning [5/8/2023]. The CDC wants correct singular signs of contact and droplet precaution signs versus a combined sign. I knew the individual rooms in the Serenity Unit did not have signs posted. I was not aware of the incident in the C-wing [200 Hall where Residents #92 and #50 reside]. I was not aware of the room in the C-wing [200 Hall, having the wrong sign]. On 5/4/2023, signage was identified as a concern and I personally placed a color sign on the A-wing [100 Hall] and provided two signs to the DON to place on the Serenity doors. The plan we had in place was not working. I provided correct signs, and the facility was not using them. On Monday morning [5/8/2023] when I showed up, I realized that signs had not been posted. On 5/4/2023, a cover message was sent out to all staff stating to wear eye protection and N95 mask for the A-wing and Serenity Unit [100 Hall and Memory Care Unit]. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. During an interview on 5/12/2023 at 10:30 AM, the Regional Director of Clinical Services stated, The incorrect signage [in the Memory Care Unit] on 5/4/2023 was corrected immediately and didn't warrant follow up. It was a singular incident. No performance plan was needed. We would not evaluate at a later date. The signage was incorrect on the entrance of Serenity on that day [5/4/2023]. I did not enter the Serenity Unit; less people is better. The signage on the outside was what was observed. I was not notified that the facility had positives in the building over the weekend. If I had that information as a Clinical Leader, I would have come into the facility. Especially with a cluster as big as seven. I would have come in, the Director of Nursing and/or the Infection Preventionist facilitated the room changes, notifications, and process. I would not say it was a systemic break, it was the action of employees regardless of the education provided. The system was in place but not followed. The process broke. There was a hole, definitely a gap. I did not put in a root cause analysis. I had included it in my notes and dealt with it appropriately. The expectation is that PPE and handwashing are followed. They are allowed to come into facility to exit [to clock out]. I was not aware that staff was not using the appropriate PPE, but I can prove that 128 staff members received the message sent regarding the PPE to wear. I am not able to say if the Director of Nursing went into the Memory Care Unit to verify staff were following instructions on PPE. The audits [5/1/2023 and 5/3/2023] do not have to do with the current issue. Currently, we suspended the Director of Nursing for failure to follow clinical direction and follow the clinical policy in relation to infection control. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. Review of Resident #26's admission record documented the resident was [AGE] years old with diagnoses to include congestive heart failure, chronic kidney disease, stage III and age-related cognitive decline. Review of Resident #26's progress note dated 5/4/2023 documented, Resident COVID tested with positive result. Resident placed on transmission-based precautions. Review of Resident #94's admission record documented the resident was [AGE] years old with diagnoses to include urinary tract infection, hypertensive, chronic kidney disease, neoplasm of uncertain behavior of prostate, chronic kidney disease, and cognitive communication deficit. Review of Resident #94's progress note dated 5/4/2023 documented, Resident noted with head congestion. States he does not feel well. Temp. [temperature] 99.6. Covid test positive. Residents are [Sic.] placed in transmission-based precautions. Review of Resident #42's admission record documented the resident was [AGE] years old with diagnosis to include chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, and dementia. Review of Resident #42's progress note dated 5/4/2023 documented, Resident with positive covid test. Noted with temp 99.5. No cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of Resident #72's admission record documented the resident was [AGE] years old with diagnosis to include chronic obstructive pulmonary disease, type II diabetes mellitus, viral hepatitis C, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #72's progress note dated 5/4/2023 documented, Resident with positive covid test. Afebrile, no cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of Resident #92's admission record documented the resident was [AGE] years old with diagnoses to include hypertension, depression, osteoarthritis, repeated falls, dementia, and dysphagia. Review of the progress note dated 5/5/2023 for Resident #92, who resided on the 200 Hall in a semi-private room with Resident #50, documented, Pt [patient] experiencing SOB [shortness of breath], shallow respirations, tachypnea. 114/60 [blood pressure] 92P [pulse] 98.4T [temperature] 24R [respirations] 95% RA [oxygen saturation on room air]. Lungs have crackles in bilateral lower lobes. Blood glucose 156. Covid + [positive] rapid test. PCP [Primary Care Physician] contacted, new orders for Paxlovid BID x 5 days [twice a day times 5 days, an antiviral pill that reduces the amount of the virus that cause COVID-19 in the body and prevents symptoms from getting worse], Son notified of covid+ status and informed that he recently has gotten over covid and would like to know if a mask needs to be worn while visiting his mother. Son educated on proper PPE. Review of the admission record for Resident #50 documented the resident was [AGE] years old, with diagnosis to include chronic kidney disease, stage 3, type II diabetes mellitus, and cognitive communication deficit and resided on the 200 Hall in a semi-private room with Resident #92. Review of Resident #61's admission record documented the resident was [AGE] years old with diagnosis to include atrial fibrillation, altered mental status, chronic obstructive pulmonary disease, and dementia. Review of Resident #61's progress notes dated 5/7/2023 documented, Resident tested for covid due to other residents' positive status. Resident tested positive. Review of the medical record for Resident #61 did not provide on order to place the resident on transmission-based precautions dated 5/7/2023. Review of Resident #45's admission record documented the resident was [AGE] years old with diagnosis to include hypertensive chronic kidney disease, Alzheimer's Disease with early onset, squamous cell carcinoma of skin of left upper limb, type 2 diabetes, and unspecified dementia. Review of Resident #45's progress note dated 5/8/2023 documented, Resident tested this morning for COVID positive. [Doctor's name] PA [Physician Assistant's name] was notified, waiting for response. Asked to advise for any orders. Waiting for response from [Physician Assistant's name] PA. Review of Resident #58's admission record documented the resident was [AGE] years old with diagnosis to include dementia, hypertensive chronic kidney disease stage IV, and personal history of tuberculosis. Review of the Line Listing dated 5/7/2023 documented Resident #58 tested positive. Review of the medical record for Resident #58 did not provide documentation of the resident having tested positive for COVID-19. Review of Resident #99's admission record documented the resident was [AGE] years old with diagnosis to include dementia and mood affective disorder. Review of Resident #99's progress note dated 5/7/2023 documented, Resident tested for covid d/t [due to] other residents' positive status. Residents tested positive. Review of Resident #13's admission record documented the resident was [AGE] years old with diagnosis to include chronic kidney disease, heart failure, dementia, and type II diabetes mellitus. Review of Resident #13's progress note dated 5/7/2023 documented, Resident noted with mild symptoms, runny nose. Tested for covid, positive result. Review of Resident #85's admission record documented the resident was [AGE] years old with diagnosis to include hypertensive heart disease, dementia, and cognitive communication deficit. Review of Resident #85's progress note dated 5/8/2023 documented, Resident was tested this morning with results of COVID positive. Called [Physician Assistant's name] PA with [Doctor's name] asking to advise for any new orders. Waiting for response. Review of Resident #69's admission record revealed the resident was [AGE] years old with diagnosis to include paranoid schizophrenia, dementia, bipolar disorder, and anxiety. Review of Resident #69's progress note dated 5/7/2023 documented, Resident tested for covid due to positive status of other residents. Resident with positive result. Review of Resident #60's admission record documented the resident was [AGE] years old with diagnosis to include dementia, pseudo bulbar, and cognitive communication. Review of Resident #60's progress note dated 5/7/2023 documented, Resident with mild cold symptoms. Tested for covid, results positive. Review of Resident #53's admission record documented the resident was [AGE] years old with diagnosis to include dementia, COPD (chronic obstructive pulmonary disease), Alzheimer's Disease, and palliative care. Review of Resident #53's progress note dated 5/9/2023 documented, Spoke with son, [Resident #53 son's name] of mother testing positive for COVID. Review of Resident #88's admission record documented the resident was [AGE] years old with diagnosis to include Alzheimer's Disease and schizoaffective. Review of Resident #88's progress note dated 5/8/2023 documented, Attempted to contact family message left with family of mother positive results when tested this afternoon for COVID. Review of Resident #59's admission record documented the resident was [AGE] years old with diagnosis to include cognitive communication deficit, allergic rhinitis, and other idiopathic peripheral autonomic neuropathy. Review of Resident #59's progress noted dated 5/8/2023 documented, Resident COVID positive. Review of Resident #76's admission record documented the resident was [AGE] years old with dia[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when failing to follow/implement facility policy and procedures and Centers for Disease Control and Prevention (CDC) guidelines related to transmission-based precautions for the prevention of the possible spread of infection to staff, visitors, and residents. The facility failed to ensure appropriate visual alerts were posted outside of the memory care unit and on the 200 Hall related to identified COVID-19 (Coronavirus Disease 2019) outbreak. The facility failed to maintain contact/droplet precautions by not having the staff donning appropriate Personal Protective Equipment (PPE) to include N95 respirators, gowns, gloves, and eye protection when in close and prolonged contact with COVID-19 positive residents on the memory care unit. On 5/11/2023, the facility had a total of 28 COVID-19 positive residents out of a census of 109 residents. This failure has the likelihood for serious harm, serious impairment or death for people [AGE] years of age or older, people who have a severe underlying medical condition, and people who live in nursing homes are at higher risk for developing serious complications from COVID-19 illness. Individuals who are infected might develop serious diseases with difficulty breathing. Some individuals might require intensive care for the treatment of multi organ failure, respiratory failure, and septic shock. COVID-19 infection can lead to death. Findings include: Review of the job description titled Executive Director (ED) Job Description- Corporate Primary dated 3/13/2023 read, Position Summary: The Executive Director provides leadership and direction for overall facility operations to provide quality patient care in accordance with all laws, regulations, and Life Care standards. Provides oversight of key areas including financial operations, human resources, customer service, business development, and clinical operations. Implements policies pertaining to patient care, caregiving, and support staff, financial control, public relations, and maintenance of physical plant through consultation with the facility management team. Essential Functions: Must ensure patients receive high quality care, Must ensure facility is compliant with all Federal, State, Local, and JCAHO requirements as well as serve as the facility's Compliance and Ethics Liaison. Must ensure facility is clean and safe for the comfort, convenience and safety of patients, families, and staff. Must effectively supervise team. Review of the job description titled Director of Nursing (DON) Job Description Primary dated 4/4/21 read, Position Summary: The Director of Nursing plans, organizes, develops, and directs the overall operation of the Nursing department to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient in accordance with all applicable laws, regulations, and Life Care Standards. Reports to Executive Director. Must be knowledgeable of nursing administration practices and procedures as well as the laws, regulations, and guidelines governing nursing administration functions in the post-acute facility. Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the nursing administration department. Review of the job description titled LPN [Licensed Practical Nurse] Infection Preventionist (IP) Job Description Primary dated 9/29/2022 read, The LPN Infection Preventionist evaluates the quality of resident care and outcomes as they relate to Healthcare Acquired Infections (HAI) and Community Acquired Infections (CAI) in accordance with all applicable laws, regulations, and Life Care standards. Collects, prepare, and analyzes HAI data. Presents infection data and makes recommendations for actions. Monitors associate compliance with infection control standards through the use of barriers and infection prevention measures. Prepares and presents education for the staff, residents, and families. Serves as a resource to all departments and personnel. Reports to the Director of Nursing (DON). Specific requirements: Serves as the on-site IPC for Covid-19 prevention and response activities, in accordance with current CDC recommendations. Essential functions: Must be able to plan, develop, organize, implement, and evaluate facility-wide systems for the prevention, identification, investigation, and control of infections of residents, staff, and visitors. Must be able to plan, develop, organize, implement, and evaluate a high-quality infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible. Must be able to serve as the educational resource for ensuring the facility is able to properly educate; residents, families, associates, consultants, contractors, and volunteers on information regarding: COVID-19, infectious disease, outbreaks, and infection control practices the facility uses to mitigate the spread of infection. Review of the Medical Director Agreement dated 4/27/2023 read, 3. Duties of Medical Director. A. Director shall perform such Services and functions as are customary for a Medical Director in a skilled nursing facility comparable in size and scope of services to that of Facility, and to perform such services in accordance will all applicable requirements of Facility policies and federal, state and local laws, rules, and regulations, which shall include but not be limited to full compliance with Title 42, Section 483.75 (h) of the Code of Federal Regulations, the Interpretive Guidelines implementing that regulatory requirement at State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities, F-841, and any applicable state regulations. Director shall on an ongoing basis advise the Executive Director of facility (Executive Director) of the adequacy of Facility's scope of Services, resident care programs, medical equipment, and its professional and support staff. D. In addition, Director shall: 1.1 Assist in coordinating medical care in Facility to ensure that adequate and appropriate medical services are provided to the residents in Facility and making periodic rounds to evaluate the adequacy of nursing care furnished to Facility residents. The Medical Director will collaborate with Facility Leadership, staff, and other practitioners and consultants to help develop, implement and evaluate resident care policies and procedures that reflect current standards of practice. During an observation on 5/8/2023 at 8:45 AM, the facility's main entrance did not have visual alerts posted to inform visitors and staff of an infection outbreak. There were surgical masks in a box on the receptionist desks. There was no other PPE observed in the lobby for visitors and staff to don prior to entering the facility. During an observation on 5/8/2023 beginning at 9:45 AM of the Memory Care Unit entrance double doors, there were no visuals alerts posted to inform visitors and staff of an identified infection outbreak. There was no signage of the need to don PPE before entering the unit and there was no personal protective equipment at the entry to indicate the need for donning PPE prior to entering. After entering the unit, there were two rooms observed to have bins containing PPE consisting of gowns, gloves, N95 respirators, and face shields for Residents #45, #60, #42, and #72's rooms. There were no visual postings on the doors for Residents #45, #60, #42, and #72 to inform visitors or staff of the need to see the nurse prior to entering the room or the need to don PPE prior to entering the rooms. Staff A, Licensed Practical Nurse (LPN), was observed wearing an N95 respirator, and another staff member was observed wearing a surgical mask. Neither staff member was wearing a gown, gloves, or eye protection. Three residents were observed in the dining room and five residents were observed in the common living area of the Memory Care Unit. During an observation on 5/8/2023 at 9:46 AM, Staff E, Certified Nursing Assistant (CNA), was observed exiting a resident's room toward the end of the hallway and entered the living area where the five COVID-19 exposed residents were sitting. Staff E was observed to be wearing a surgical mask, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 9:46 AM, Staff C, CNA, was wearing an N95 respirator in the dining room area. A resident stood up and Staff C assisted the resident back to a sitting position in a chair. Observations were made of the remaining rooms on the unit that did not have a storage PPE bin in front of the rooms. During an observation on 5/8/2023 at 10:10 AM, Staff B, Director of Central Supply, and Staff C, CNA, were wearing N95 respirators, and Staff E, CNA, was wearing a surgical mask. Staff B, Staff C, and Staff E were not wearing gowns, gloves, or eye protection. Staff B, Staff C, and Staff E were placing Contact Precautions signs on multiple room doors of the Memory Care Unit. During an interview on 5/8/2023 at 10:10 AM on the Memory Care Unit, Staff A, LPN, stated, [Resident #94's name] is COVID positive. That is why the room door has a contact precaution sign posted. This is the sign we use for COVID positive. During an observation on 5/8/2023 at 10:11 AM, Residents #26, #70, #58, #157, #71, #69, #45, #60, #42, #72, #53, #99, #76, #61, #52, #85, #13, #88, #94, and #37's room doors had signage which read, Contact Precautions. Review of the COVID-19 Line List documented: 5/4/2023 - 7 COVID-19 positive residents, 4 resided on the Memory Care Unit (MCU); 5/7/2023 - 16 COVID-19 positive residents, 12 resided on the MCU; 5/8/23 - 21 COVID-19 positive residents, 14 residents resided on the MCU. During an observation on 5/8/2023 at 9:53 AM of Residents #92 and #50's rooms, which were located on the 200 Hall, there was a visual posting that read, Contact Precaution. During an interview on 5/8/2023 at 10:27 AM, the Infection Preventionist stated, [Resident #50's name] is negative as of right now. [Resident #92's name] tested COVID positive on Saturday [5/6/2023]. [Resident 92's name] son came into the building to visit, and he tested COVID positive. Both [Resident #50's name and Resident #92's name] are sharing a room since they are both isolated due to the exposure. The Serenity Unit has only contact precaution signs and not droplet precautions [signs]. I came back to work using the CDC criteria and came back due to 'crisis staffing criteria' as I was needed to come back in to work. The Memory Care Unit staff started testing positive on 5/4/2023. We had a staff member who tested positive on 5/1/2023 [The Activity Director]. She worked on all three units. Our community rate was low enough that we were not wearing masks. We started wearing masks on 5/1/2023. We have three staff members out due to COVID. During an observation on 5/8/2023 at 10:45 AM, the Memory Care Unit entrance double doors had no visual posting to alert visitors and staff before entering the unit with instructions about current infection prevention and control recommendations for the unit. No personal protective equipment was observed outside of the doors. During an observation on 5/8/2023 at 10:45 AM, in the Memory Care Unit, Staff A, LPN, was assisting residents and was wearing an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff C, CNA, was supervising a resident in the dining area. Staff C was wearing an N95 respirator and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff E, CNA, was supervising a resident in the dining area. Staff C was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an interview on 5/8/2023 at 10:46 AM in the Memory Care Unit, the Infection Preventionist stated, All rooms in the locked memory care unit were incorrectly labeled with contact precaution signs and the signs should say droplet and contact precautions. Signs should be posted on residents' doors as soon as the test results come in. During an observation on 5/8/2023 at 12:03 PM, Staff E, CNA, was passing out lunch trays to the residents in the Memory Care Unit. Staff E was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. Coming in close contact, she placed each food tray on the table in front of each resident. During an interview on 5/8/2023 at 12:15 PM, Staff A, LPN, stated, I was not here over the weekend. What I did when I came back to work was to do my own report and test all the residents again to make sure what their COVID status was at this time. I had the staff take all the signs down. That is why when you entered the unit, some rooms did not have signs posted on the doors. The Infection Preventionist was out due to COVID and [Staff F, LPN's name] took over. The girls [Certified Nursing Assistants assigned to the Memory Care Unit] were helping me put the signs back on the doors after the COVID test results came back. Normally if a resident tested positive for COVID, we will move the resident out of the room to a single room or if two residents are positive, we will double them up in the same room. This is the memory care unit, and we need to be careful that the residents do not get out of the unit making it harder to arrange room changes. We were all off this weekend and I had the signs being copied to place on the doors. We had bins outside some rooms. This was sporadic. I stopped everything after I received the shift report and started testing all the residents from scratch since we have agency staff working in the unit. We were not aware we needed to wear gowns and gloves on the unit. The Infection Preventionist informed us we needed to wear proper PPE after you had been on the unit. [Staff E, CNA's name] was the staff who didn't have the N95 mask on while on the unit. We all found out we needed to wear gowns in the halls and only N95 mask afterwards. The Infection Preventionist came into the unit and provided the correct signs for all the rooms. We were using the contact signs because that was what we had at that time. I had sent a text message to [Staff F, LPN's name] at 9:22 AM stating some rooms had signs and some did not. She replied that we needed to have signage on resident doors for contact/droplet precautions and since I was off during the weekend that is why I decided to do my own report since I did not know when those signs went on the doors. I am the primary nurse on the unit and do my own thing due to the agency staff that work the unit. During an interview on 5/8/2023 at 1:01 PM, Staff C, CNA, stated, We get report on the unit at 6:45 AM. Residents were starting to come up positive for COVID. [Staff A, LPN's name] decided to recheck to make sure [to determine if additional residents were positive]. We were not aware we needed to wear a gown and gloves while working on the unit. I know as you go into the room you wear a face shield, N95 mask, gloves, and gown. This unit is different. COVID positive residents are outside of the rooms. We had contact precaution signs on the doors. Contact precautions is pretty much used for everything. [Staff A, LPN's name] never mentioned that the signs provided were not the correct ones. During an interview on 5/8/2023 at 1:21 PM, Staff E, CNA, stated, I was wearing a surgical mask because that was what we were supposed to do until they told us to wear N95 masks later on 5/8/2023. [Staff A, LPN's name] told us to put up the contact precaution signs on the COVID positive resident doors. Nobody told us that we needed to include droplet precautions. I worked Friday and rooms for [Residents #70, #42, #37 and #94's names] all had contact precaution signs on the door. I was wearing only a surgical mask while in contact with two COVID positive residents that were sitting in the living room area. The residents were not wearing masks. It is hard for them to keep the masks on. I did not know we had to wear gowns while in the common area. During an interview on 5/8/2023 at 1:31 PM, Staff B, Director of Central Supply, stated, On Friday night, three residents tested positive for COVID and I posted the signs I had available. Monday, [Staff A, LPN's name] said to make copies. It was the same two signs. One said, 'stop see the nurse' and the other one 'contact precautions.' I went and got the copies. That is when you saw us posting the signs on the doors. Later that day, I saw the Infection Preventionist hanging the other signs which basically say the same things as the other ones. When [Staff A, LPN's name] asked me to make copies and hang the signs, she never mentioned they were not appropriate [signs]. I placed the signs on Friday before I left, so at least the people entering would at least stop at the door [resident's door]. I think we use the same protocol for all, the same precautions. I did not have a gown when entering the Memory Care Unit. I was not going in the rooms. I was just hanging signs on the resident rooms. I did hear some more residents tested positive but I'm not familiar with their faces. I was not aware the residents that were COVID positive were in the common areas in the Memory Care Unit. For contact precautions, I would say we use a blue mask [surgical mask], gown, and gloves. If it is droplet, we are expected to wear a face shield, N95, and gown. When I exited the Memory Care Unit, I went around the facility and made sure all PPE bins were fully stocked. During an interview on 5/8/2023 at 1:45 PM, the Director of Nursing (DON) stated, As far as monitoring infection control, I do it with the Infection Preventionist. We collaborate on how we are going to move forward. Residents who test negative for COVID should be removed from COVID positive rooms. Signage should be on the door as well as personal protective equipment. I do not know what happened with [Resident #92's name]. I reached out to the nurse that worked that weekend and she has not reached out back. I round daily regarding education on PPE. I am in the middle of my infection control training. Staff should wear appropriate PPE when in contact with positive residents. I went to the memory care unit on 5/4/2023 and again on 5/5/2023 and I was wearing an N95 and face shield. I was not wearing a gown since I was only at the nursing station and hallway. The staff were informing me of a COVID positive resident, and I then informed my boss and the Infection Control Preventionist. Staff was instructed to notify the physician, family, and follow orders. They were also instructed to isolate residents as much as they can. I would say I oversee infection prevention when the Infection Preventionist is not available. During a telephonic interview on 5/9/2023 at 2:33 PM, Staff F, LPN/Infection Prevention Trainee, stated, I would keep communication via phone with Infection Preventionist, Administrator and DON for guidance as to my role I wasn't sure. When I spoke to [Staff A, LPN's name], I told them to follow normal protocol which include signs, carts with PPE, and wearing proper PPE. There was a lot of texting back and forth, a lot of the guidance came from the Infection Control Preventionist. Staff needed to make sure that signs stated droplet and contact if I am not mistaken. Via text, I was notified that Sunday [5/7/2023], 10 residents tested positive for COVID. I did not give any guidance. It was pretty much the DON and Administrator who were going back and forth providing guidance. When the Infection Preventionist is not available, the DON and the Regional Clinical Consultant were responsible. During a telephonic interview on 5/9/2023 at 2:55 PM, the Medical Director stated, I was not aware of the COVID-19 outbreak status in the facility. I have been the Medical Director since January. No one contacted me in the last two weeks concerning the COVID-19 outbreak status at the facility. My expectation was for residents who have a roommate and test positive for COVID, the positive resident should be put in a room with others who are positive. The roommate would generally be placed or transferred with patients with a negative test result. I would have expected the resident who tested negative to be removed from the room of the one who tested positive. During an interview on 5/11/2023 at 12:15 PM, Staff E, CNA, stated, I do not take lunch in the breakroom. I go outside using the back door. We are allowed to use the employee breakroom for lunch if we want. When my shift is over, I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:16 PM, Staff G, CNA, stated, I work all over the facility. Last time I worked in the Memory Care Unit was last Thursday or Friday [5/4/2023 or 5/5/2023]. I worked with [Staff E, CNA's name] and we were only wearing surgical face masks while taking care of the residents in the Memory Care Unit. Residents were already coming up positive and I didn't know I was supposed to wear an N95. During an interview on 5/11/2023 at 12:20 PM, Staff H, LPN, stated, I only work in the Memory Care Unit and worked last Sunday [5/7/2023]. I wore an N95 mask. I did not leave the unit on Sunday for lunch or break. I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:50 PM, Staff I, CNA, stated, I do not remember what rooms I was assigned to. I think I worked in the back hall of the 200 Hall. On Monday, I was wearing a surgical mask when I came in, then we were told to wear an N95 mask when you guys showed up. Review of the COVID-19 Line List documented as of 5/11/2023 revealed the facility had a total of 28 COVID-19 positive residents. During an interview conducted on 5/12/2023 at 8:49 AM, the Administrator stated, Biggest thing was on 5/1/2023 when residents started testing positive for COVID. I sat down with my Director of Nursing (DON) and Infection Preventionist (IP) and referred back to our policies and procedures. I had the DON and IP come up with a clinical procedure and isolation and personal protective equipment to go into place. We had an Ad Hoc meeting on 5/1/2023, got the isolation signs and continued to test. We reviewed residents and patient care and began putting a plan in place. I took the clinical piece and had my DON and IP work together. The Medical Director was aware of the policies we have in place, but he was not involved in the meeting held on 5/1/2023. The DON provided coverage while the Infection Preventionist was out. My Infection Preventionist tested positive on 5/2/2023. The DON was responsible for overseeing infection control in the facility. With COVID positive [residents], we need to have droplet and contact precautions. The signs [visual alerts] should have been posted. I became aware the COVID Unit [Memory Care Unit] was not on isolation on 5/8/2023. COVID positives are not allowed to cohort with non-positive residents. They are not allowed to remain in the same room. When this was brought to my attention, we separated them on 5/8/2023 [Residents #92 and #50]. It was my understanding that staff were wearing the appropriate personal protective equipment and appropriate signage was posted. The DON was here on Friday [5/5/2023] and she was here on [5/6/2023] on Saturday. The signage was provided to her and put in place. The DON notified me on 5/7/2023 of the COVID positives and it was my understanding that we had made the Memory Care Unit a red unit [COVID Unit]. During an interview on 5/12/2023 at 8:50 AM, the Regional [NAME] President stated, As long as the staff is properly donning and doffing their PPE and handwashing before they exit the unit, they are able to go through the facility to clock out. During an interview on 5/12/2023 at 8:57 AM, the Regional Director of Clinical Services stated, I personally provided the correct signs on 5/4/2023. I know the two signs on Serenity [Memory Care Unit] signs were not on the doors on Monday morning [5/8/2023]. The CDC wants correct singular signs of contact and droplet precaution signs versus a combined sign. I knew the individual rooms in the Serenity Unit did not have signs posted. I was not aware of the incident in the C-wing [200 Hall where Residents #92 and #50 reside]. I was not aware of the room in the C-wing [200 Hall, having the wrong sign]. On 5/4/2023, signage was identified as a concern and I personally placed a color sign on the A-wing [100 Hall] and provided two signs to the DON to place on the Serenity doors. The plan we had in place was not working. I provided correct signs, and the facility was not using them. On Monday morning [5/8/2023] when I showed up, I realized that signs had not been posted. On 5/4/2023, a cover message was sent out to all staff stating to wear eye protection and N95 mask for the A-wing and Serenity Unit [100 Hall and Memory Care Unit]. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. During an interview on 5/12/2023 at 10:30 AM, the Regional Director of Clinical Services stated, The incorrect signage [in the Memory Care Unit] on 5/4/2023 was corrected immediately and didn't warrant follow up. It was a singular incident. No performance plan was needed. We would not evaluate at a later date. The signage was incorrect on the entrance of Serenity on that day [5/4/2023]. I did not enter the Serenity Unit; less people is better. The signage on the outside was what was observed. I was not notified that the facility had positives in the building over the weekend. If I had that information as a Clinical Leader, I would have come into the facility. Especially with a cluster as big as seven. I would have come in, the Director of Nursing and/or the Infection Preventionist facilitated the room changes, notifications, and process. I would not say it was a systemic break, it was the action of employees regardless of the education provided. The system was in place but not followed. The process broke. There was a hole, definitely a gap. I did not put in a root cause analysis. I had included it in my notes and dealt with it appropriately. The expectation is that PPE and handwashing are followed. They are allowed to come into facility to exit [to clock out]. I was not aware that staff was not using the appropriate PPE, but I can prove that 128 staff members received the message sent regarding the PPE to wear. I am not able to say if the Director of Nursing went into the Memory Care Unit to verify staff were following instructions on PPE. The audits [5/1/2023 and 5/3/2023] do not have to do with the current issue. Currently, we suspended the Director of Nursing for failure to follow clinical direction and follow the clinical policy in relation to infection control. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. Review of Resident #26's progress note dated 5/4/2023 documented, Resident COVID tested with positive result. Resident placed on transmission-based precautions. Review of Resident #94's progress note dated 5/4/2023 documented, Resident noted with head congestion. States he does not feel well. Temp. [temperature] 99.6. Covid test positive. Residents are [Sic.] placed in transmission-based precautions. Review of Resident #42's admission record documented diagnosis to include chronic respiratory failure with hypercapnia, and chronic obstructive pulmonary disease. Review of Resident #42's progress note dated 5/4/2023 documented, Resident with positive covid test. Noted with temp 99.5. No cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of Resident #72's admission record documented diagnosis to include chronic obstructive pulmonary disease. Review of Resident #72's progress note dated 5/4/2023 documented, Resident with positive covid test. Afebrile, no cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of the progress note dated 5/5/2023 for Resident #92, who resided on the 200 Hall in a semi-private room with Resident #50, documented, Pt [patient] experiencing SOB [shortness of breath], shallow respirations, tachypnea. 114/60 [blood pressure] 92P [pulse] 98.4T [temperature] 24R [respirations] 95% RA [oxygen saturation on room air]. Lungs have crackles in bilateral lower lobes. Blood glucose 156. Covid + [positive] rapid test. PCP [Primary Care Physician] contacted, new orders for Paxlovid BID x 5 days [twice a day times 5 days, an antiviral pill that reduces the amount of the virus that cause COVID-19 in the body and prevents symptoms from getting worse], Son notified of covid+ status and informed that he recently has gotten over covid and would like to know if a mask needs to be worn while visiting his mother. Son educated on proper PPE. Review of the clinical record for Resident #50 documented the resident tested positive for COVID-19 on 5/8/2023. Review of Resident #61's progress notes dated 5/7/2023 documented, Resident tested for covid due to other residents' positive status. Resident tested positive. Review of the medical record for Resident #61 did not provide on order to place the resident on transmission-based precautions dated 5/7/2023. Review of Resident #45's progress note dated 5/8/2023 documented, Resident tested this morning for COVID positive. [Doctor's name] PA [Physician Assistant's name] was notified, waiting for response. Asked to advise for any orders. Waiting for response from [Physician Assistant's name] PA. Review of the Line Listing dated 5/7/2023 documented Resident #58 tested positive. Review of the medical record for Resident #58 did not provide documentation of the resident having tested positive for COVID-19. Review of Resident #99's progress note dated 5/7/2023 documented, Resident tested for covid d/t [due to] other residents' positive status. Residents tested positive. Review of Resident #13's progress note dated 5/7/2023 documented, Resident noted with mild symptoms, runny nose. Tested for covid, positive result. Review of Resident #85's progress note dated 5/8/2023 documented, Resident was tested this morning with results of COVID positive. Called [Physician Assistant's name] PA with [Doctor's name] asking to advise for any new orders. Waiting for response. Review of Resident #69's progress note dated 5/7/2023 documented, Resident tested for covid due to positive status of other residents. Resident with positive result. Review of Resident #60's progress note dated 5/7/2023 documented, Resident with mild cold symptoms. Tested for covid, results positive. Review of Resident #53's admission record documented diagnosis to include COPD (chronic obstructive pulmonary disease). Review of Resident #53's progress note dated 5/9/2023 documented, Spoke with son, [Resident #53 son's name] of mother testing positive for COVID. Review of Resident #88's progress note dated 5/8/2023 documented, Attempted to contact family message left with family of mother positive results when tested this afternoon for COVID. Review of Resident #59's progress noted dated 5/8/2023 documented, Resident COVID positive. Review of Resident #76's progress note dated 5/10/2023 documented, Resident status updated to COVID positive, resident is currently on airborne isolation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure their quality assessment and assurance committee developed and implemented appropriate plans of action to investigate, develop and implement an effective performance improvement plan (PIP) for the prevention of the possible spread of infection, when a COVID-19 outbreak was identified in the facility. The facility failed to ensure appropriate visual alerts were posted outside of the memory care unit and on the 200 Hall related to identified COVID-19 (Coronavirus Disease 2019) outbreak. The facility failed to implement monitoring to maintain contact/droplet precautions to ensure the donning appropriate Personal Protective Equipment (PPE) to include N95 respirators, gowns, gloves, and eye protection when in close and prolonged contact with COVID-19 positive residents on the memory care unit. On 5/11/2023, the facility had a total of 28 COVID-19 positive residents out of a census of 109 residents. This failure has the likelihood for serious harm, serious impairment or death for people [AGE] years of age or older, people who have a severe underlying medical condition, and people who live in nursing homes are at higher risk for developing serious complications from COVID-19 illness. Individuals who are infected might develop serious diseases with difficulty breathing. Some individuals might require intensive care for the treatment of multi organ failure, respiratory failure, and septic shock. COVID-19 infection can lead to death. Findings include: During an interview on 5/8/2023 at 1:45 PM, the Director of Nursing (DON) stated, As far as monitoring infection control, I do it with the Infection Preventionist. We collaborate on how we are going to move forward. Residents who test negative for COVID should be removed from COVID positive rooms. Signage should be on the door as well as personal protective equipment. I do not know what happened with [Resident #92's name]. I reached out to the nurse that worked that weekend and she has not reached out back. I round daily regarding education on PPE. I am in the middle of my infection control training. Staff should wear appropriate PPE when in contact with positive residents. I went to the memory care unit on 5/4/2023 and again on 5/5/2023 and I was wearing an N95 and face shield. I was not wearing a gown since I was only at the nursing station and hallway. The staff were informing me of a COVID positive resident, and I then informed my boss and the Infection Control Preventionist. Staff was instructed to notify the physician, family, and follow orders. They were also instructed to isolate residents as much as they can. I would say I oversee infection prevention when the Infection Preventionist is not available. During an interview conducted on 5/12/2023 at 8:49 AM, the Administrator stated, Biggest thing was on 5/1/2023 when residents started testing positive for COVID. I sat down with my Director of Nursing (DON) and Infection Preventionist (IP) and referred back to our policies and procedures. I had the DON and IP come up with a clinical procedure and isolation and personal protective equipment to go into place. We had an Ad Hoc meeting on 5/1/2023, got the isolation signs and continued to test. We reviewed residents and patient care and began putting a plan in place. I took the clinical piece and had my DON and IP work together. The Medical Director was aware of the policies we have in place, but he was not involved in the meeting held on 5/1/2023. The DON provided coverage while the Infection Preventionist was out. My Infection Preventionist tested positive on 5/2/2023. The DON was responsible for overseeing infection control in the facility. With COVID positive [residents], we need to have droplet and contact precautions. The signs [visual alerts] should have been posted. I became aware the COVID Unit [Memory Care Unit] was not on isolation on 5/8/2023. COVID positives are not allowed to cohort with non-positive residents. They are not allowed to remain in the same room. When this was brought to my attention, we separated them on 5/8/2023 [Residents #92 and #50]. It was my understanding that staff were wearing the appropriate personal protective equipment and appropriate signage was posted. The DON was here on Friday [5/5/2023] and she was here on [5/6/2023] on Saturday. The signage was provided to her and put in place. The DON notified me on 5/7/2023 of the COVID positives and it was my understanding that we had made the Memory Care Unit a red unit [COVID Unit]. During an interview on 5/12/2023 at 10:30 AM, the Regional Director of Clinical Services stated, The incorrect signage [in the Memory Care Unit] on 5/4/2023 was corrected immediately and didn't warrant follow up. It was a singular incident. No performance plan was needed. We would not evaluate at a later date. The signage was incorrect on the entrance of Serenity on that day [5/4/2023]. I did not enter the Serenity Unit; less people is better. The signage on the outside was what was observed. I was not notified that the facility had positives in the building over the weekend. If I had that information as a Clinical Leader, I would have come into the facility. Especially with a cluster as big as seven. I would have come in, the Director of Nursing and/or the Infection Preventionist facilitated the room changes, notifications, and process. I would not say it was a systemic break, it was the action of employees regardless of the education provided. The system was in place but not followed. The process broke. There was a hole, definitely a gap. I did not put in a root cause analysis. I had included it in my notes and dealt with it appropriately. The expectation is that PPE and handwashing are followed. They are allowed to come into facility to exit [to clock out]. I was not aware that staff was not using the appropriate PPE, but I can prove that 128 staff members received the message sent regarding the PPE to wear. I am not able to say if the Director of Nursing went into the Memory Care Unit to verify staff were following instructions on PPE. The audits [5/1/2023 and 5/3/2023] do not have to do with the current issue. Currently, we suspended the Director of Nursing for failure to follow clinical direction and follow the clinical policy in relation to infection control. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. During an observation on 5/8/2023 at 8:45 AM, the facility's main entrance did not have visual alerts posted to inform visitors and staff of an infection outbreak. There were surgical masks in a box on the receptionist desks. There was no other PPE observed in the lobby for visitors and staff to don prior to entering the facility. During an observation on 5/8/2023 beginning at 9:45 AM of the Memory Care Unit entrance double doors, there were no visuals alerts posted to inform visitors and staff of an identified infection outbreak. There was no signage of the need to don PPE before entering the unit and there was no personal protective equipment at the entry to indicate the need for donning PPE prior to entering. After entering the unit, there were two rooms observed to have bins containing PPE consisting of gowns, gloves, N95 respirators, and face shields for Residents #45, #60, #42, and #72's rooms. There were no visual postings on the doors for Residents #45, #60, #42, and #72 to inform visitors or staff of the need to see the nurse prior to entering the room or the need to don PPE prior to entering the rooms. Staff A, Licensed Practical Nurse (LPN), was observed wearing an N95 respirator, and another staff member was observed wearing a surgical mask. Neither staff member was wearing a gown, gloves, or eye protection. Three residents were observed in the dining room and five residents were observed in the common living area of the Memory Care Unit. During an observation on 5/8/2023 at 9:45 AM, Staff A, LPN, exited the nursing station and administered medications to a resident sitting in the dining room of the Memory Care Unit. During an observation on 5/8/2023 at 9:46 AM, Staff E, Certified Nursing Assistant (CNA), was observed exiting a resident's room toward the end of the hallway and entered the living area where the five residents were sitting. Staff E was observed to be wearing a surgical mask, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 9:46 AM, Staff C, CNA, was wearing an N95 respirator in the dining room area. A resident stood up and Staff C assisted the resident back to a sitting position in a chair. Observations were made of the remaining rooms on the unit that did not have a storage bin in front of the rooms. During an observation on 5/8/2023 at 10:10 AM, Staff B, Director of Central Supply, and Staff C, CNA, were wearing N95 respirators, and Staff E, CNA, was wearing a surgical mask. Staff B, Staff C, and Staff E were not wearing gowns, gloves, or eye protection. Staff B, Staff C, and Staff E were placing Contact Precautions signs on multiple room doors of the Memory Care Unit. During an interview on 5/8/2023 at 10:10 AM on the Memory Care Unit, Staff A, LPN, stated, [Resident #94's name] is COVID positive. That is why the room door has a contact precaution sign posted. This is the sign we use for COVID positive. During an observation on 5/8/2023 at 10:11 AM, Residents #26, #70, #58, #157, #71, #69, #45, #60, #42, #72, #53, #99, #76, #61, #52, #85, #13, #88, #94, and #37's room doors had signage which read, Contact Precautions. Review of the COVID-19 Line List documented as of 5/4/2023 revealed the facility had a total of 7 COVID-19 positive residents. 4 of the 7 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/7/2023 revealed the facility had a total of 16 COVID-19 positive residents. 12 of the 16 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/8/2023 revealed the facility had a total of 21 COVID-19 positive residents. 14 of the 21 positive residents resided on the Memory Care Unit. During an observation on 5/8/2023 at 9:53 AM of Residents #92 and #50's rooms, which were located on the 200 Hall, there was a visual posting that read, Contact Precaution. During an interview on 5/8/2023 at 9:55 AM, Staff D, Registered Nurse (RN), stated, Both of the residents in the room had tested positive last Thursday [Resident #92 tested positive on 5/5/2023 and Resident #50 tested positive on 5/8/2023]. We use masks, gowns, gloves, and face shields. Both residents are in isolation and cannot come out until they are negative. During an interview on 5/8/2023 at 10:27 AM, the Infection Preventionist stated, [Resident #50's name] is negative as of right now. [Resident #92's name] tested COVID positive on Saturday [5/6/2023]. [Resident 92's name] son came into the building to visit, and he tested COVID positive. Both [Resident #50's name and Resident #92's name] are sharing a room since they are both isolated due to the exposure. I recommended that they share a room due to the level of their exposure. We will test [Resident #50's name] today and again tomorrow. The Memory Care Unit census is 20 residents, and 12 residents are positive as of 5/8/2023. These residents are severely cognitively impaired, and the approach was to isolate the entire wing. We have residents who wander into other residents' rooms. They are exit seekers and at risk for elopement and we cannot move them anywhere else safely. Memory care should have Personal Protective Equipment (PPE) outside of the double doors to Serenity [Memory Care Unit name]. I cannot say that is in place now. I tested positive on 5/2/2023 and I am not sure where it came from. My symptoms started late Monday afternoon. I did the 5-day quarantine and returned today [5/8/23]. The Serenity Unit has only contact precaution signs and not droplet precautions [signs]. I came back to work using the CDC criteria and came back due to 'crisis staffing criteria' as I was needed to come back in to work. The Memory Care Unit staff started testing positive on 5/4/2023. We had a staff member who tested positive on 5/1/2023 [The Activity Director]. Her last day working in the facility was 4/28/2023. She worked on all three units. Our community rate was low enough that we were not wearing masks. We started wearing masks on 5/1/2023. We have three staff members out due to COVID. We are testing staff twice a week on Tuesday and Thursday. We last tested residents on 5/4/2023. We will be testing residents again tomorrow. During an observation on 5/8/2023 at 10:45 AM, the Memory Care Unit entrance double doors had no visual posting to alert visitors and staff before entering the unit with instructions about current infection prevention and control recommendations for the unit. No personal protective equipment was observed outside of the doors. During an observation on 5/8/2023 at 10:45 AM, in the Memory Care Unit, Staff A, LPN, was assisting residents and was wearing an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff C, CNA, was supervising a resident in the dining area. Staff C was wearing an N95 respirator and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff E, CNA, was supervising a resident in the dining area. Staff C was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an interview on 5/8/2023 at 10:46 AM in the Memory Care Unit, the Infection Preventionist stated, All rooms in the locked memory care unit were incorrectly labeled with contact precaution signs and the signs should say droplet and contact precautions. Signs should be posted on residents' doors as soon as the test results come in. During an observation on 5/8/2023 at 12:03 PM, Staff E, CNA, was passing out lunch trays to the residents in the Memory Care Unit. Staff E was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. Coming in close contact, she placed each food tray on the table in front of each resident. During an interview on 5/8/2023 at 12:15 PM, Staff A, LPN, stated, I was not here over the weekend. What I did when I came back to work was to do my own report and test all the residents again to make sure what their COVID status was at this time. I had the staff take all the signs down. That is why when you entered the unit, some rooms did not have signs posted on the doors. The Infection Preventionist was out due to COVID and [Staff F, LPN's name] took over. The girls [Certified Nursing Assistants assigned to the Memory Care Unit] were helping me put the signs back on the doors after the COVID test results came back. Normally if a resident tested positive for COVID, we will move the resident out of the room to a single room or if two residents are positive, we will double them up in the same room. This is the memory care unit, and we need to be careful that the residents do not get out of the unit making it harder to arrange room changes. We were all off this weekend and I had the signs being copied to place on the doors. We had bins outside some rooms. This was sporadic. I stopped everything after I received the shift report and started testing all the residents from scratch since we have agency staff working in the unit. We were not aware we needed to wear gowns and gloves on the unit. The Infection Preventionist informed us we needed to wear proper PPE after you had been on the unit. [Staff E, CNA's name] was the staff who didn't have the N95 mask on while on the unit. We all found out we needed to wear gowns in the halls and only N95 mask afterwards. The Infection Preventionist came into the unit and provided the correct signs for all the rooms. We were using the contact signs because that was what we had at that time. I had sent a text message to [Staff F, LPN's name] at 9:22 AM stating some rooms had signs and some did not. She replied that we needed to have signage on resident doors for contact/droplet precautions and since I was off during the weekend that is why I decided to do my own report since I did not know when those signs went on the doors. I am the primary nurse on the unit and do my own thing due to the agency staff that work the unit. During an interview on 5/8/2023 at 1:01 PM, Staff C, CNA, stated, I was off during the weekend and just came back to work today. We get report on the unit at 6:45 AM. Residents were starting to come up positive for COVID. [Staff A, LPN's name] decided to recheck to make sure [to determine if additional residents were positive]. We were not aware we needed to wear a gown and gloves while working on the unit. I know as you go into the room you wear a face shield, N95 mask, gloves, and gown. This unit is different. COVID positive residents are outside of the rooms. We had contact precaution signs on the doors. Contact precautions is pretty much used for everything. [Staff A, LPN's name] never mentioned that the signs provided were not the correct ones. During an interview on 5/8/2023 at 1:21 PM, Staff E, CNA, stated, I was wearing a surgical mask because that was what we were supposed to do until they told us to wear N95 masks later on 5/8/2023. [Staff A, LPN's name] told us to put up the contact precaution signs on the COVID positive resident doors. Nobody told us that we needed to include droplet precautions. I worked Friday and rooms for [Residents #70, #42, #37 and #94's names] all had contact precaution signs on the door. I was wearing only a surgical mask while in contact with two COVID positive residents that were sitting in the living room area. The residents were not wearing masks. It is hard for them to keep the masks on. I did not know we had to wear gowns while in the common area. During an interview on 5/8/2023 at 1:31 PM, Staff B, Director of Central Supply, stated, On Friday night, three residents tested positive for COVID and I posted the signs I had available. Monday, [Staff A, LPN's name] said to make copies. It was the same two signs. One said, 'stop see the nurse' and the other one 'contact precautions.' I went and got the copies. That is when you saw us posting the signs on the doors. Later that day, I saw the Infection Preventionist hanging the other signs which basically say the same things as the other ones. When [Staff A, LPN's name] asked me to make copies and hang the signs, she never mentioned they were not appropriate [signs]. I placed the signs on Friday before I left, so at least the people entering would at least stop at the door [resident's door]. I think we use the same protocol for all, the same precautions. I did not have a gown when entering the Memory Care Unit. I was not going in the rooms. I was just hanging signs on the resident rooms. I did hear some more residents tested positive but I'm not familiar with their faces. I was not aware the residents that were COVID positive were in the common areas in the Memory Care Unit. For contact precautions, I would say we use a blue mask [surgical mask], gown, and gloves. If it is droplet, we are expected to wear a face shield, N95, and gown. When I exited the Memory Care Unit, I went around the facility and made sure all PPE bins were fully stocked. During a telephonic interview on 5/9/2023 at 2:33 PM, Staff F, LPN/Infection Prevention Trainee, stated, I would keep communication via phone with Infection Preventionist, Administrator and DON for guidance as to my role I wasn't sure. I tested positive on the 3rd [May] showing symptoms. When I spoke to [Staff A, LPN's name], I told them to follow normal protocol which include signs, carts with PPE, and wearing proper PPE. There was a lot of texting back and forth, a lot of the guidance came from the Infection Control Preventionist. Staff needed to make sure that signs stated droplet and contact if I am not mistaken. Via text, I was notified that Sunday [5/7/2023], 10 residents tested positive for COVID. I did not give any guidance. It was pretty much the DON and Administrator who were going back and forth providing guidance. Last time I was in the building was Wednesday [5/3/2023] until 4 PM. When the Infection Preventionist is not available, the DON and the Regional Clinical Consultant were responsible. During a telephonic interview on 5/9/2023 at 2:55 PM, the Medical Director stated, I was not aware of the COVID-19 outbreak status in the facility. I have been the Medical Director since January. No one contacted me in the last two weeks concerning the COVID-19 outbreak status at the facility. My expectation was for residents who have a roommate and test positive for COVID, the positive resident should be put in a room with others who are positive. The roommate would generally be placed or transferred with patients with a negative test result. I would have expected the resident who tested negative to be removed from the room of the one who tested positive. During an interview on 5/11/2023 at 12:15 PM, Staff E, CNA, stated, I do not take lunch in the breakroom. I go outside using the back door. We are allowed to use the employee breakroom for lunch if we want. When my shift is over, I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:16 PM, Staff G, CNA, stated, I work all over the facility. Last time I worked in the Memory Care Unit was last Thursday or Friday [5/4/2023 or 5/5/2023]. I worked with [Staff E, CNA's name] and we were only wearing surgical face masks while taking care of the residents in the Memory Care Unit. Residents were already coming up positive and I didn't know I was supposed to wear an N95. During an interview on 5/11/2023 at 12:20 PM, Staff H, LPN, stated, I only work in the Memory Care Unit and worked last Sunday [5/7/2023]. I wore an N95 mask. I did not leave the unit on Sunday for lunch or break. I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:50 PM, Staff I, CNA, stated, I do not remember what rooms I was assigned to. I think I worked in the back hall of the 200 Hall. On Monday, I was wearing a surgical mask when I came in, then we were told to wear an N95 mask when you guys showed up. Review of the COVID-19 Line List documented as of 5/11/2023 revealed the facility had a total of 28 COVID-19 positive residents. During an interview on 5/12/2023 at 8:50 AM, the Regional [NAME] President stated, As long as the staff is properly donning and doffing their PPE and handwashing before they exit the unit, they are able to go through the facility to clock out. During an interview on 5/12/2023 at 8:57 AM, the Regional Director of Clinical Services stated, I personally provided the correct signs on 5/4/2023. I know the two signs on Serenity [Memory Care Unit] signs were not on the doors on Monday morning [5/8/2023]. The CDC wants correct singular signs of contact and droplet precaution signs versus a combined sign. I knew the individual rooms in the Serenity Unit did not have signs posted. I was not aware of the incident in the C-wing [200 Hall where Residents #92 and #50 reside]. I was not aware of the room in the C-wing [200 Hall, having the wrong sign]. On 5/4/2023, signage was identified as a concern and I personally placed a color sign on the A-wing [100 Hall] and provided two signs to the DON to place on the Serenity doors. The plan we had in place was not working. I provided correct signs, and the facility was not using them. On Monday morning [5/8/2023] when I showed up, I realized that signs had not been posted. On 5/4/2023, a cover message was sent out to all staff stating to wear eye protection and N95 mask for the A-wing and Serenity Unit [100 Hall and Memory Care Unit]. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. Review of the facility assessment tool, last reviewed on 3/29/2023, read, Part 2. Resident Support/Care Needs. Specific Care or Practices. Monitoring and maintaining infection control practices. Identification and containment of infections, prevention of infections. Prevent abuse and neglect. Review of the policy and procedure titled Quality Assurance and Performance Improvement Plan lasted reviewed on 4/27/2023 read, Policy: The facility will develop and maintain a written Quality Assurance and Performance Improvement (QAPI) written plan in accordance with state and federal regulation. Definitions: Performance Improvement (PI): PI (also called Quality Improvement-QI) is the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying opportunities for improvement, and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. PI aims to improve facility processes involved in care delivery and enhance resident quality of life. Procedure: 5. The QAPI plan should describe the process for identifying and correcting quality deficiencies. Key components of the process include: a. Tracking and measuring performance; b. Establishing goals and threshold for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; f. Monitoring or evaluating the effectiveness of the corrective action /performance improvement activities, and revising as needed. Review of the policy and procedure titled Area of Focus: QAA and QAPI Program lasted reviewed on 4/27/2023 read, What: The QAA committee determines what performance date will be monitored and the frequency for monitoring. The QAA committee responsibilities include identifying and responding to quality deficiencies throughout the facility, and oversight of the QAPI program. Additionally, the committee must develop and implement corrective action, and monitor to ensure performance goals or targets are achieved and revising corrective action when necessary. Regulation: 483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program. The committee must: (i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues a with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary. (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; When: The facility may utilize one of the following actions to ensure planned changes are implemented and effective: a. Choose key performance indicators that tie directly to the new changes, b. Conduct on going periodic measurements review to ensure the new changes have been implemented and are effective. C. Based on review, make changes as indicated. Review of the policy and procedure titled Coronavirus (COVID 19) (SARS-CoV-2) [Severe acute respiratory syndrome coronavirus 2] last reviewed on 4/27/2023 read, Policy. The facility will follow the Core Principles of COVID-19 Infection Prevention as outlined below and defined by CMS [Centers for Medicare and Medicaid] and CDC to mitigate COVID-19 entry into the facility. 3. Face covering or well fitted mask (covering mouth or nose) in accordance with CDC guidance. 4. Instructional signage throughout the facility and proper visitor education on COVID19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene). 6. Appropriate staff use of Personal Protective Equipment (PPE). 7. Effective cohorting or residents (e.g., separate areas dedicated COVID-19 care). Infection Prevention and Control Recommendations. Infection control recommendations include the following: 1. Ensure everyone is aware of recommended IPC [Infection Prevention and Control] practices in the facility. a. Post signs, or posters at the entrance and in strategic places (e.g. waiting areas, elevators) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations. 6. The facility should provide visitors with education on hand hygiene, limiting surfaces touched, and use of PPE according to current CDC guidelines. Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices. 4. Personal Protective Equipment (PPE): c. Make necessary PPE available in areas where resident care is provided. Associate Education and Assignment: 2. Ensured that associates are educated, trained, and have practiced the appropriate use of PPE prior to caring for a resident/residents. Bed Management Strategies and Cohorting: COVID-19 Positive Residents. 1. HCP [Health Care Professional] caring for residents with confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved [The National Institute for Occupational Safety and Health] N95 or equivalent or higher-level respirator) 2. Place a patient with suspected or confirmed SARS-CoV-2 infection in a single person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. 3. The facility could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Recommendations for Newly Identified Active Cases in the Facility. 1. Because of the high risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any HCP or SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak. 4. HCP should care for residents using N95 or higher-level respirator, eye protection (i.e. goggles or a face shield that covers the front and sides of the face), gloves and gown. 5. The facility will ensure that appropriate PPE is available outside the resident room for any resident who is on isolation unless the resident resides on a dedicated COVID-19 unit. If the facility has COVID-19 positive residents on a dedicated unit, the PPE will be available in designated areas on the unit. Suspected or Confirmed COVID-19 cases on a Memory Care Unit. As it may be challenging to restrict residents to their rooms, the facility should implement the use of eye protection and N95 or other respirators (or facemask if respirators are not available) for all associates when on the unit to address potential for encountering a wandering resident who might have COVID-19. d. Facilities may determine that it is safer to maintain care of residents with COVID-19 on the memory unit with dedicated personnel. Review of the policy and procedure titled Personal Protective Equipment (PPE) for SARS-CoV-2 last reviewed on 4/27/2023 read, Policy. The facility will provide and utilize the appropriate PPE for the care of residents during the COVID-19 Pandemic in accordance with CMS and CDC guidance. The facility will provide and ensure associates use respirators and other PPE for exposure to residents with suspected or confirmed COVID-19. PPE Recommended for Symptomatic, Suspected, or Confirmed COVID-19. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow/implement the facility's policy and procedures and Centers for Disease Control (CDC) guidelines for Transmission Based Precautions to prevent the possible spread of infection to staff, visitors, and residents. The facility failed to ensure appropriate visual alerts were posted outside of the memory care unit and on the 200 Hall when residents were identified to be COVID-19 (Coronavirus 2019) positive. The facility failed to maintain contact/droplet precautions by not donning appropriate Personal Protective Equipment (PPE) to include N95 respirators, gowns, gloves, and eye protection when in close and prolonged contact with COVID-19 positive residents on the memory care unit, and would exit the unit, walk through the facility to clock out at the end of the shift. On 5/11/2023, the facility had a total of 28 COVID-19 positive residents out of a census of 109 residents. This failure has the likelihood for serious harm, serious impairment or death for people [AGE] years of age or older, people who have a severe underlying medical condition, and people who live in nursing homes are at higher risk for developing serious complications from COVID-19 illness. Individuals who are infected might develop serious diseases with difficulty breathing. Some individuals might require intensive care for the treatment of multi organ failure, respiratory failure, and septic shock. COVID-19 infection can lead to death. Findings include: During an observation on 5/8/2023 at 8:45 AM, the facility's main entrance did not have visual alerts posted to inform visitors and staff of an infection outbreak. There were surgical masks in a box on the receptionist desks. There was no other PPE observed in the lobby for visitors and staff to don prior to entering the facility. During an observation on 5/8/2023 beginning at 9:45 AM of the Memory Care Unit entrance double doors, there were no visuals alerts posted to inform visitors and staff of an identified infection outbreak. There was no signage of the need to don PPE before entering the unit and there was no personal protective equipment at the entry to indicate the need for donning PPE prior to entering. After entering the unit, there were two rooms observed to have bins containing PPE consisting of gowns, gloves, N95 respirators, and face shields for Residents #45, #60, #42, and #72's rooms. There were no visual postings on the doors for Residents #45, #60, #42, and #72 to inform visitors or staff of the need to see the nurse prior to entering the room or the need to don PPE prior to entering the rooms. Staff A, Licensed Practical Nurse (LPN), was observed wearing an N95 respirator, and another staff member was observed wearing a surgical mask. Neither staff member was wearing a gown, gloves, or eye protection. Three residents were observed in the dining room and five residents were observed in the common living area of the Memory Care Unit. During an observation on 5/8/2023 at 9:45 AM, Staff A, LPN, exited the nursing station and administered medications to a resident sitting in the dining room of the Memory Care Unit. During an observation on 5/8/2023 at 9:46 AM, Staff E, Certified Nursing Assistant (CNA), was observed exiting a resident's room toward the end of the hallway and entered the living area where the five residents were sitting. Staff E was observed to be wearing a surgical mask, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 9:46 AM, Staff C, CNA, was wearing an N95 respirator in the dining room area. A resident stood up and Staff C assisted the resident back to a sitting position in a chair. Observations were made of the remaining rooms on the unit that did not have a storage bin in front of the rooms. During an observation on 5/8/2023 at 10:10 AM, Staff B, Director of Central Supply, and Staff C, CNA, were wearing N95 respirators, and Staff E, CNA, was wearing a surgical mask. Staff B, Staff C, and Staff E were not wearing gowns, gloves, or eye protection. Staff B, Staff C, and Staff E were placing Contact Precautions signs on multiple room doors of the Memory Care Unit. During an interview on 5/8/2023 at 10:10 AM on the Memory Care Unit, Staff A, LPN, stated, [Resident #94's name] is COVID positive. That is why the room door has a contact precaution sign posted. This is the sign we use for COVID positive. During an observation on 5/8/2023 at 10:11 AM, Residents #26, #70, #58, #157, #71, #69, #45, #60, #42, #72, #53, #99, #76, #61, #52, #85, #13, #88, #94, and #37's room doors had signage which read, Contact Precautions. Review of the COVID-19 Line List documented as of 5/4/2023 revealed the facility had a total of 7 COVID-19 positive residents. Four (4) of the 7 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/7/2023 revealed the facility had a total of 16 COVID-19 positive residents. Twelve (12) of the 16 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/8/2023 revealed the facility had a total of 21 COVID-19 positive residents. Fourteen (14) of the 21 positive residents resided on the Memory Care Unit. During an observation on 5/8/2023 at 9:53 AM of Residents #92 and #50's rooms, which were located on the 200 Hall, there was a visual posting that read, Contact Precaution. During an interview on 5/8/2023 at 9:55 AM, Staff D, Registered Nurse (RN), stated, Both of the residents in the room had tested positive last Thursday [Resident #92 tested positive on 5/5/2023 and Resident #50 tested positive on 5/8/2023]. We use masks, gowns, gloves, and face shields. Both residents are in isolation and cannot come out until they are negative. During an interview on 5/8/2023 at 10:27 AM, the Infection Preventionist stated, [Resident #50's name] is negative as of right now. [Resident #92's name] tested COVID positive on Saturday [5/6/2023]. [Resident 92's name] son came into the building to visit, and he tested COVID positive. Both [Resident #50's name and Resident #92's name] are sharing a room since they are both isolated due to the exposure. I recommended that they share a room due to the level of their exposure. We will test [Resident #50's name] today and again tomorrow. The Memory Care Unit census is 20 residents, and 12 residents are positive as of 5/8/2023. These residents are severely cognitively impaired, and the approach was to isolate the entire wing. We have residents who wander into other residents' rooms. They are exit seekers and at risk for elopement and we cannot move them anywhere else safely. Memory care should have Personal Protective Equipment (PPE) outside of the double doors to Serenity [Memory Care Unit name]. I cannot say that is in place now. I tested positive on 5/2/2023 and I am not sure where it came from. My symptoms started late Monday afternoon. I did the 5-day quarantine and returned today [5/8/23]. The Serenity Unit has only contact precaution signs and not droplet precautions [signs]. I came back to work using the CDC criteria and came back due to 'crisis staffing criteria' as I was needed to come back in to work. The Memory Care Unit staff started testing positive on 5/4/2023. We had a staff member who tested positive on 5/1/2023 [The Activity Director]. Her last day working in the facility was 4/28/2023. She worked on all three units. Our community rate was low enough that we were not wearing masks. We started wearing masks on 5/1/2023. We have three staff members out due to COVID. We are testing staff twice a week on Tuesday and Thursday. We last tested residents on 5/4/2023. We will be testing residents again tomorrow. During an observation on 5/8/2023 at 10:45 AM, the Memory Care Unit entrance double doors had no visual posting to alert visitors and staff before entering the unit with instructions about current infection prevention and control recommendations for the unit. No personal protective equipment was observed outside of the doors. During an observation on 5/8/2023 at 10:45 AM, in the Memory Care Unit, Staff A, LPN, was assisting residents and was wearing an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff C, CNA, was supervising a resident in the dining area. Staff C was wearing an N95 respirator and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff E, CNA, was supervising a resident in the dining area. Staff C was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an interview on 5/8/2023 at 10:46 AM in the Memory Care Unit, the Infection Preventionist stated, All rooms in the locked memory care unit were incorrectly labeled with contact precaution signs and the signs should say droplet and contact precautions. Signs should be posted on residents' doors as soon as the test results come in. During an observation on 5/8/2023 at 12:03 PM, Staff E, CNA, was passing out lunch trays to the residents in the Memory Care Unit. Staff E was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. Coming in close contact, she placed each food tray on the table in front of each resident. During an interview on 5/8/2023 at 12:15 PM, Staff A, LPN, stated, I was not here over the weekend. What I did when I came back to work was to do my own report and test all the residents again to make sure what their COVID status was at this time. I had the staff take all the signs down. That is why when you entered the unit, some rooms did not have signs posted on the doors. The Infection Preventionist was out due to COVID and [Staff F, LPN's name] took over. The girls [Certified Nursing Assistants assigned to the Memory Care Unit] were helping me put the signs back on the doors after the COVID test results came back. Normally if a resident tested positive for COVID, we will move the resident out of the room to a single room or if two residents are positive, we will double them up in the same room. This is the memory care unit, and we need to be careful that the residents do not get out of the unit making it harder to arrange room changes. We were all off this weekend and I had the signs being copied to place on the doors. We had bins outside some rooms. This was sporadic. I stopped everything after I received the shift report and started testing all the residents from scratch since we have agency staff working in the unit. We were not aware we needed to wear gowns and gloves on the unit. The Infection Preventionist informed us we needed to wear proper PPE after you had been on the unit. [Staff E, CNA's name] was the staff who didn't have the N95 mask on while on the unit. We all found out we needed to wear gowns in the halls and only N95 mask afterwards. The Infection Preventionist came into the unit and provided the correct signs for all the rooms. We were using the contact signs because that was what we had at that time. I had sent a text message to [Staff F, LPN's name] at 9:22 AM stating some rooms had signs and some did not. She replied that we needed to have signage on resident doors for contact/droplet precautions and since I was off during the weekend that is why I decided to do my own report since I did not know when those signs went on the doors. I am the primary nurse on the unit and do my own thing due to the agency staff that work the unit. During an interview on 5/8/2023 at 1:01 PM, Staff C, CNA, stated, I was off during the weekend and just came back to work today. We get report on the unit at 6:45 AM. Residents were starting to come up positive for COVID. [Staff A, LPN's name] decided to recheck to make sure [to determine if additional residents were positive]. We were not aware we needed to wear a gown and gloves while working on the unit. I know as you go into the room you wear a face shield, N95 mask, gloves, and gown. This unit is different. COVID positive residents are outside of the rooms. We had contact precaution signs on the doors. Contact precautions is pretty much used for everything. [Staff A, LPN's name] never mentioned that the signs provided were not the correct ones. During an interview on 5/8/2023 at 1:21 PM, Staff E, CNA, stated, I was wearing a surgical mask because that was what we were supposed to do until they told us to wear N95 masks later on 5/8/2023. [Staff A, LPN's name] told us to put up the contact precaution signs on the COVID positive resident doors. Nobody told us that we needed to include droplet precautions. I worked Friday and rooms for [Residents #70, #42, #37 and #94's names] all had contact precaution signs on the door. I was wearing only a surgical mask while in contact with two COVID positive residents that were sitting in the living room area. The residents were not wearing masks. It is hard for them to keep the masks on. I did not know we had to wear gowns while in the common area. During an interview on 5/8/2023 at 1:31 PM, Staff B, Director of Central Supply, stated, On Friday night, three residents tested positive for COVID and I posted the signs I had available. Monday, [Staff A, LPN's name] said to make copies. It was the same two signs. One said, 'stop see the nurse' and the other one 'contact precautions.' I went and got the copies. That is when you saw us posting the signs on the doors. Later that day, I saw the Infection Preventionist hanging the other signs which basically say the same things as the other ones. When [Staff A, LPN's name] asked me to make copies and hang the signs, she never mentioned they were not appropriate [signs]. I placed the signs on Friday before I left, so at least the people entering would at least stop at the door [resident's door]. I think we use the same protocol for all, the same precautions. I did not have a gown when entering the Memory Care Unit. I was not going in the rooms. I was just hanging signs on the resident rooms. I did hear some more residents tested positive but I'm not familiar with their faces. I was not aware the residents that were COVID positive were in the common areas in the Memory Care Unit. For contact precautions, I would say we use a blue mask [surgical mask], gown, and gloves. If it is droplet, we are expected to wear a face shield, N95, and gown. When I exited the Memory Care Unit, I went around the facility and made sure all PPE bins were fully stocked. During an interview on 5/8/2023 at 1:45 PM, the Director of Nursing (DON) stated, As far as monitoring infection control, I do it with the Infection Preventionist. We collaborate on how we are going to move forward. Residents who test negative for COVID should be removed from COVID positive rooms. Signage should be on the door as well as personal protective equipment. I do not know what happened with [Resident #92's name]. I reached out to the nurse that worked that weekend and she has not reached out back. I round daily regarding education on PPE. I am in the middle of my infection control training. Staff should wear appropriate PPE when in contact with positive residents. I went to the memory care unit on 5/4/2023 and again on 5/5/2023 and I was wearing an N95 and face shield. I was not wearing a gown since I was only at the nursing station and hallway. The staff were informing me of a COVID positive resident, and I then informed my boss and the Infection Control Preventionist. Staff was instructed to notify the physician, family, and follow orders. They were also instructed to isolate residents as much as they can. I would say I oversee infection prevention when the Infection Preventionist is not available. During an observation on 5/9/2023 at 12:32 PM of the Memory Care Unit double door entrance, there was a sign, which read, STOP! You are entering a COVID-19 Positive Unit. Associates must wear the following at all times in this unit: Eye Protection, Respirator or surgical face mask. Associates must wear the following when entering resident rooms: Gown, Gloves. During a telephonic interview on 5/9/2023 at 2:33 PM, Staff F, LPN/Infection Prevention Trainee, stated, I would keep communication via phone with Infection Preventionist, Administrator and DON for guidance as to my role I wasn't sure. I tested positive on the 3rd [May] showing symptoms. When I spoke to [Staff A, LPN's name], I told them to follow normal protocol which include signs, carts with PPE, and wearing proper PPE. There was a lot of texting back and forth, a lot of the guidance came from the Infection Control Preventionist. Staff needed to make sure that signs stated droplet and contact if I am not mistaken. Via text, I was notified that Sunday [5/7/2023], 10 residents tested positive for COVID. I did not give any guidance. It was pretty much the DON and Administrator who were going back and forth providing guidance. Last time I was in the building was Wednesday [5/3/2023] until 4 PM. When the Infection Preventionist is not available, the DON and the Regional Clinical Consultant were responsible. During a telephonic interview on 5/9/2023 at 2:55 PM, the Medical Director stated, I was not aware of the COVID-19 outbreak status in the facility. I have been the Medical Director since January. No one contacted me in the last two weeks concerning the COVID-19 outbreak status at the facility. My expectation was for residents who have a roommate and test positive for COVID, the positive resident should be put in a room with others who are positive. The roommate would generally be placed or transferred with patients with a negative test result. I would have expected the resident who tested negative to be removed from the room of the one who tested positive. During an interview on 5/11/2023 at 12:15 PM, Staff E, CNA, stated, I do not take lunch in the breakroom. I go outside using the back door. We are allowed to use the employee breakroom for lunch if we want. When my shift is over, I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:16 PM, Staff G, CNA, stated, I work all over the facility. Last time I worked in the Memory Care Unit was last Thursday or Friday [5/4/2023 or 5/5/2023]. I worked with [Staff E, CNA's name] and we were only wearing surgical face masks while taking care of the residents in the Memory Care Unit. Residents were already coming up positive and I didn't know I was supposed to wear an N95. During an interview on 5/11/2023 at 12:20 PM, Staff H, LPN, stated, I only work in the Memory Care Unit and worked last Sunday [5/7/2023]. I wore an N95 mask. I did not leave the unit on Sunday for lunch or break. I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:50 PM, Staff I, CNA, stated, I do not remember what rooms I was assigned to. I think I worked in the back hall of the 200 Hall. On Monday, I was wearing a surgical mask when I came in, then we were told to wear an N95 mask when you guys showed up. Review of the COVID-19 Line List documented as of 5/11/2023 revealed the facility had a total of 28 COVID-19 positive residents. During an interview conducted on 5/12/2023 at 8:49 AM, the Administrator stated, Biggest thing was on 5/1/2023 when residents started testing positive for COVID. I sat down with my Director of Nursing (DON) and Infection Preventionist (IP) and referred back to our policies and procedures. I had the DON and IP come up with a clinical procedure and isolation and personal protective equipment to go into place. We had an Ad Hoc meeting on 5/1/2023, got the isolation signs and continued to test. We reviewed residents and patient care and began putting a plan in place. I took the clinical piece and had my DON and IP work together. The Medical Director was aware of the policies we have in place, but he was not involved in the meeting held on 5/1/2023. The DON provided coverage while the Infection Preventionist was out. My Infection Preventionist tested positive on 5/2/2023. The DON was responsible for overseeing infection control in the facility. With COVID positive [residents], we need to have droplet and contact precautions. The signs [visual alerts] should have been posted. I became aware the COVID Unit [Memory Care Unit] was not on isolation on 5/8/2023. COVID positives are not allowed to cohort with non-positive residents. They are not allowed to remain in the same room. When this was brought to my attention, we separated them on 5/8/2023 [Residents #92 and #50]. It was my understanding that staff were wearing the appropriate personal protective equipment and appropriate signage was posted. The DON was here on Friday [5/5/2023] and she was here on [5/6/2023] on Saturday. The signage was provided to her and put in place. The DON notified me on 5/7/2023 of the COVID positives and it was my understanding that we had made the Memory Care Unit a red unit [COVID Unit]. During an interview on 5/12/2023 at 8:50 AM, the Regional [NAME] President stated, As long as the staff is properly donning and doffing their PPE and handwashing before they exit the unit, they are able to go through the facility to clock out. During an interview on 5/12/2023 at 8:57 AM, the Regional Director of Clinical Services stated, I personally provided the correct signs on 5/4/2023. I know the two signs on Serenity [Memory Care Unit] signs were not on the doors on Monday morning [5/8/2023]. The CDC wants correct singular signs of contact and droplet precaution signs versus a combined sign. I knew the individual rooms in the Serenity Unit did not have signs posted. I was not aware of the incident in the C-wing [200 Hall where Residents #92 and #50 reside]. I was not aware of the room in the C-wing [200 Hall, having the wrong sign]. On 5/4/2023, signage was identified as a concern and I personally placed a color sign on the A-wing [100 Hall] and provided two signs to the DON to place on the Serenity doors. The plan we had in place was not working. I provided correct signs, and the facility was not using them. On Monday morning [5/8/2023] when I showed up, I realized that signs had not been posted. On 5/4/2023, a cover message was sent out to all staff stating to wear eye protection and N95 mask for the A-wing and Serenity Unit [100 Hall and Memory Care Unit]. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. During an interview on 5/12/2023 at 10:30 AM, the Regional Director of Clinical Services stated, The incorrect signage [in the Memory Care Unit] on 5/4/2023 was corrected immediately and didn't warrant follow up. It was a singular incident. No performance plan was needed. We would not evaluate at a later date. The signage was incorrect on the entrance of Serenity on that day [5/4/2023]. I did not enter the Serenity Unit; less people is better. The signage on the outside was what was observed. I was not notified that the facility had positives in the building over the weekend. If I had that information as a Clinical Leader, I would have come into the facility. Especially with a cluster as big as seven. I would have come in, the Director of Nursing and/or the Infection Preventionist facilitated the room changes, notifications, and process. I would not say it was a systemic break, it was the action of employees regardless of the education provided. The system was in place but not followed. The process broke. There was a hole, definitely a gap. I did not put in a root cause analysis. I had included it in my notes and dealt with it appropriately. The expectation is that PPE and handwashing are followed. They are allowed to come into facility to exit [to clock out]. I was not aware that staff was not using the appropriate PPE, but I can prove that 128 staff members received the message sent regarding the PPE to wear. I am not able to say if the Director of Nursing went into the Memory Care Unit to verify staff were following instructions on PPE. The audits [5/1/2023 and 5/3/2023] do not have to do with the current issue. Currently, we suspended the Director of Nursing for failure to follow clinical direction and follow the clinical policy in relation to infection control. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. Review of Resident #26's admission record documented the resident was [AGE] years old with diagnoses to include congestive heart failure, chronic kidney disease, stage III and age-related cognitive decline. Review of Resident #26's progress note dated 5/4/2023 documented, Resident COVID tested with positive result. Resident placed on transmission-based precautions. Review of Resident #94's admission record documented the resident was [AGE] years old with diagnoses to include urinary tract infection, hypertensive, chronic kidney disease, neoplasm of uncertain behavior of prostate, chronic kidney disease, and cognitive communication deficit. Review of Resident #94's progress note dated 5/4/2023 documented, Resident noted with head congestion. States he does not feel well. Temp. [temperature] 99.6. Covid test positive. Residents are [Sic.] placed in transmission-based precautions. Review of Resident #42's admission record documented the resident was [AGE] years old with diagnosis to include chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, and dementia. Review of Resident #42's progress note dated 5/4/2023 documented, Resident with positive covid test. Noted with temp 99.5. No cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of Resident #72's admission record documented the resident was [AGE] years old with diagnosis to include chronic obstructive pulmonary disease, type II diabetes mellitus, viral hepatitis C, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #72's progress note dated 5/4/2023 documented, Resident with positive covid test. Afebrile, no cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of Resident #92's admission record documented the resident was [AGE] years old with diagnoses to include hypertension, depression, osteoarthritis, repeated falls, dementia, and dysphagia. Review of the progress note dated 5/5/2023 for Resident #92, who resided on the 200 Hall in a semi-private room with Resident #50, documented, Pt [patient] experiencing SOB [shortness of breath], shallow respirations, tachypnea. 114/60 [blood pressure] 92P [pulse] 98.4T [temperature] 24R [respirations] 95% RA [oxygen saturation on room air]. Lungs have crackles in bilateral lower lobes. Blood glucose 156. Covid + [positive] rapid test. PCP [Primary Care Physician] contacted, new orders for Paxlovid BID x 5 days [twice a day times 5 days, an antiviral pill that reduces the amount of the virus that cause COVID-19 in the body and prevents symptoms from getting worse], Son notified of covid+ status and informed that he recently has gotten over covid and would like to know if a mask needs to be worn while visiting his mother. Son educated on proper PPE. Review of the admission record for Resident #50 documented the resident was [AGE] years old with diagnosis to include chronic kidney disease, stage 3, type II diabetes mellitus, and cognitive communication deficit and resided on the 200 Hall in a semi-private room with Resident #92. Review of Resident #61's admission record documented the resident was [AGE] years old with diagnosis to include atrial fibrillation, altered mental status, chronic obstructive pulmonary disease, and dementia. Review of Resident #61's progress notes dated 5/7/2023 documented, Resident tested for covid due to other residents' positive status. Resident tested positive. Review of the medical record for Resident #61 did not provide on order to place the resident on transmission-based precautions dated 5/7/2023. Review of Resident #45's admission record documented the resident was [AGE] years old with diagnosis to include hypertensive chronic kidney disease, Alzheimer's Disease with early onset, squamous cell carcinoma of skin of left upper limb, type 2 diabetes, and unspecified dementia. Review of Resident #45's progress note dated 5/8/2023 documented, Resident tested this morning for COVID positive. [Doctor's name] PA [Physician Assistant's name] was notified, waiting for response. Asked to advise for any orders. Waiting for response from [Physician Assistant's name] PA. Review of Resident #58's admission record documented the resident was [AGE] years old with diagnosis to include dementia, hypertensive chronic kidney disease stage IV, and personal history of tuberculosis. Review of the Line Listing dated 5/7/2023 documented Resident #58 tested positive. Review of the medical record for Resident #58 did not provide documentation of the resident having tested positive for COVID-19. Review of Resident #99's admission record documented the resident was [AGE] years old with diagnosis to include dementia and mood affective disorder. Review of Resident #99's progress note dated 5/7/2023 documented, Resident tested for covid d/t [due to] other residents' positive status. Residents tested positive. Review of Resident #13's admission record documented the resident was [AGE] years old with diagnosis to include chronic kidney disease, heart failure, dementia, and type II diabetes mellitus. Review of Resident #13's progress note dated 5/7/2023 documented, Resident noted with mild symptoms, runny nose. Tested for covid, positive result. Review of Resident #85's admission record documented the resident was [AGE] years old with diagnosis to include hypertensive heart disease, dementia, and cognitive communication deficit. Review of Resident #85's progress note dated 5/8/2023 documented, Resident was tested this morning with results of COVID positive. Called [Physician Assistant's name] PA with [Doctor's name] asking to advise for any new orders. Waiting for response. Review of Resident #69's admission record revealed the resident was [AGE] years old with diagnosis to include paranoid schizophrenia, dementia, bipolar disorder, and anxiety. Review of Resident #69's progress note dated 5/7/2023 documented, Resident tested for covid due to positive status of other residents. Resident with positive result. Review of Resident #60's admission record documented the resident was [AGE] years old with diagnosis to include dementia, pseudo bulbar, and cognitive communication. Review of Resident #60's progress note dated 5/7/2023 documented, Resident with mild cold symptoms. Tested for covid, results positive. Review of Resident #53's admission record documented the resident was [AGE] years old with diagnosis to include dementia, COPD (chronic obstructive pulmonary disease), Alzheimer's Disease, and palliative care. Review of Resident #53's progress note dated 5/9/2023 documented, Spoke with son, [Resident #53 son's name] of mother testing positive for COVID. Review of Resident #88's admission record documented the resident was [AGE] years old with diagnosis to include Alzheimer's Disease and schizoaffective. Review of Resident #88's progress note dated 5/8/2023 documented, Attempted to contact family message left with family of mother positive results when tested this afternoon for COVID. Review of Resident #59's admission record documented the resident was [AGE] years old with diagnosis to include cognitive communication deficit, allergic rhinitis, and other idiopathic peripheral au[TRUNCATED]