Based on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, and review of the job description for the Executive Director (ED), facility Administration failed to ensure the health and safety of the residents by not maintaining an effective Infection Prevention Control Program (IPCP) that would identify and investigate an infection outbreak to prevent or reduce the spread of Covid-19 by not following current guidelines for resident and staff testing (contact tracing or broad based testing). This failure resulted in a total of 28 residents and eight staff members tested positive for COVID-19, three COVID related hospitalizations, and one COVID related death. The census was 99. On August 15, 2023, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Executive Director, Regional Director of Clinical Services, Regional [NAME] President, and the Division Director of Clinical Services were notified on August 15, 2023, at 2:30 p.m. of the Immediate Jeopardy. The IJ situation was ongoing at the time of exit on August 17, 2023. Findings include: Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated May 8, 2023, revealed when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected units, if using a broad-based approach, regardless of vaccination status. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue for the affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. Review of the document title Executive Director Job Description - Corporate Primary revised January 8, 2021, revealed the position summary is 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 clinical operations. Implements policies pertaining to patient care, caregiving, and support staff. Reports to Regional [NAME] President. Specific Requirements include knowledge of administration practices and procedures as well as the laws, regulations, and guidelines governing administrative functions in the post-acute care facility, must have the ability to implement and interpret program goals, objectives, policies, and procedures of the administration department, and must perform proficiently in all competency areas including but not limited to: daily leadership responsibilities, supervisory responsibilities, financial responsibilities, regulatory compliance, patient rights, and safety sanitation. The job description was signed by the current Administrator and dated April 25, 2022. Interview on 8/16/2023 at 12: 40 p.m. with the Admissions Department Head, stated it is concerning that the COVID positive numbers are rising. She revealed the facility has a morning meeting with the Administrator with the Infection Control Preventionist (ICP) present and concerns with each department are discussed in the meeting. She revealed the ICP discusses newly identified Covid-19 positive residents, but stated testing is not necessarily covered as it relates to contact tracing or broad-based testing. Interview on 8/16/2023 at 12:45 p.m. with the Physical Therapy Director, revealed the Administrator and ICP are present during all morning meetings. She revealed the rising number of COVID positive residents is increasing in the building, but stated there has been no discussion regarding contact tracing or broad-based testing. During continued interview, she stated facility was only testing residents and staff if they had signs and symptoms. She stated all the therapists are going in and out of resident rooms; and residents are coming to the Therapy Department if they are not COVID positive. She revealed the number of positives is continuing to rise and indicated is a concern. Interview on 8/16/2023 at 1:00 p.m. with the Minimum Data Set (MDS) Director revealed the facility has a morning meeting and confirmed that the Administrator and the ICP are part of the morning meeting. She stated they discuss isolation and the number of COVID cases, but added she cannot recall if they have discussed the testing process in the morning meetings. She stated despite the MDS staff going in and out of resident rooms to perform assessments, while maintaining six feet apart, the number of positive residents is rising. Interview on 8/16/2023 at 2:16 p.m. with the backup IC RN FF, revealed that they have conversations and meetings with the Administrator related to the current outbreak and the increase in COVID cases. They revealed there has not been discussions related to when to do contact trace testing and/or broad-based testing. The ICP revealed they speak with the local Health Department keeping them informed of the cases of COVID in the building and receive guidance that they pass along to the staff. Interview on 8/16/2023 at 2:43 p.m. with the Regional [NAME] President of Operations revealed the Administrator made him aware of number of positive Covid-19 cases in the facility, but it was never discussed what type of testing was being done, if it was contact tracing testing or broad-based testing. He revealed the Administrator is responsible for keeping up to date with both State and Federal Regulatory Guidance and that she is responsible for every department in the facility. Interview on 8/16/2023 at 2:51 p.m. with the Administrator revealed she meets daily with the Department Head staff. She revealed during the morning meeting, she and the ICP discuss residents who have tested positive, their room numbers, and what/if anything was done. The Administrator revealed the facility is following the guidance from the local Health Department related to testing, and monitoring for signs and symptoms. She stated she had discussions with the ICP regarding the COVID positive resident and staff numbers increasing, and revealed local Health Department had not recommended they do broad-based testing during the current outbreak until August 15th. During further interview, the Administrator confirmed she is responsible for all that goes on within the facility. Telephone interview on 8/15/2023 at 12:15 p.m. with the Epidemiology Assistant with the local Health Department confirmed the correspondence with the facility regarding the current outbreak that began on 8/2/2023. She revealed the facility has been doing contact tracing, but when there is more than one positive case in a facility, she recommends doing the broad-based testing. The Epidemiology Assistant revealed during the facility's previous outbreak several months ago, she informed them with more than one positive case, they need to do broad-based testing. She stated she does not know why they did not do the broad-based testing with this current outbreak. During further interview, she revealed she has spoken with the ICP a couple of times, but most of her communications have been with a Licensed Practical Nurse (LPN) who works in Human Resources. She confirmed at this time that she has not spoken with the Administrator related to the current outbreak in the facility. Cross Refer F880, F882

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, and review of the facility policies, the facility failed to implement initial and ongoing testing of residents and staff as recommended by Center for Disease Control and Prevention (CDC) and the Georgia Department of Public Health (GDPH) to lessen the exposure of Covid-19 during an outbreak and failed to obtain Physician's Orders for Covid-19 testing for 21 of 28 residents (R#'s 59, 2, 114, 80, 322, 113, 46, 112, 74, 13, 27, 324, 222, 51, 469, 323, 119, 10, 58, 120, and 21) reviewed that were positive for Covid-19. In addition, the facility failed to maintain documentation of negative test results of residents and staff. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Executive Director, Regional Director of Clinical Services, Regional [NAME] President, and the Division Director of Clinical Services were notified on [DATE] at 2:30 p.m. of the Immediate Jeopardy. The IJ situation was ongoing at the time of exit on [DATE]. Findings include: Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated [DATE], revealed when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any Healthcare Provider (HCP) or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected units) if using a broad-based approach, regardless of vaccination status. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every three to seven days until there are no new cases for 14 days. Review of the facility policy titled Covid-19 Outbreak Investigation revised [DATE] revealed the policy statement is the facility will perform COVID-19 outbreak investigations in accordance with local, state, and federal regulations to mitigate the spread of COVID-19 within the facility. Procedure number 1. An outbreak investigation is initiated when a single new case of Covid-19 occurs among residents or staff to determine if others have been exposed. Number 2. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. Number 3. Upon identification of a single new case of Covid-19 infection in any associate or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Number 4. The facility has the option to perform outbreak testing through two approaches, contact tracing or broad-based (facility wide) testing. Number 5. If the facility can identify close contacts of the individual with Covid-19, they could choose to conduct focused testing (contact tracing) based on known close contacts. Number 6. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide level broad-based) or group level (unit, floor, or other specific area(s) of the facility). Number 7. The use of broad-based testing might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt the transmission. Number 8. Perform testing for all residents and associates identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Number 9. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of broad-based approach, testing should continue on affected unit(s) or facility-wide every three to seven days until there are no new cases for 14 days. Review of the facility policy titled Covid-19 (SARS-CoV-2) Resident Testing revised [DATE] revealed the facility should plan to test in accordance with accepted national standards such as the CDC, unless ordered more stringently by the local and state officials. Procedure: Conducting Testing number 1. Obtain an order from a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with the State law, including scope of practice laws to provide or obtain laboratory services for a resident, which includes Covid-19 testing. 2. Rapid Point of Care (POC) testing devices are prescription use tests under the Emergency Use Authorization and must be ordered by a healthcare professional licensed under the applicable state law or a pharmacist under U.S. Department of Health and Human Services (HHS) guidance. Accordingly, the facility must have an order from a healthcare professional or pharmacist, as previously described, to perform a rapid POC Covid-19 test on an individual. Facilities must document compliance with the testing requirements. To do so, facilities should do the following: 1. For symptomatic residents, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. 2. Upon identification of a new Covid-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents are tested, the dates that residents who tested negative are retested, and the results of all tests. 5. For residents, the facility must document testing results in the medical record. The following 21 residents were positive for COVID-19 and reviewed related to the ongoing outbreak in the facility: 1. Review of the admission Minimum Data Set (MDS) Assessment for R#59 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A Nurse's Note dated [DATE] documented resident had symptoms of runny nose and nausea. A Covid test was performed, and the result was positive. A Nurse's Note dated [DATE] revealed the resident began complaining of severe abdominal pain and was transferred to the hospital. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was no physician order for Covid-19 testing. 2. Review of the Quarterly MDS Assessment for R#2 dated [DATE] revealed a BIMS of 15 indicating intact cognition. A Nurse's Note dated [DATE] documented symptoms of malaise and cough. A Covid test was performed, and result was positive. Contact and droplet isolation initiated. Review of the [DATE] Physician Orders revealed there was not an order for Covid-19 testing or isolation. 3. Review of the admission MDS Assessment for R#114 dated [DATE] revealed a BIMS of 15 indicating intact cognition. A Nurse's Note dated [DATE] documented that resident complained of a sore throat and cough. A Covid test was administered, and the result was positive. Review of the [DATE] Physician Orders revealed Covid-19 testing ordered on [DATE], [DATE] and [DATE]. Droplet and Contact Precautions ordered on [DATE]. 4. Review of the admission MDS Assessment for R#80 dated [DATE] revealed a BIMS score of six, indicating severely impaired cognition. A Nurse's Note dated [DATE] documented resident tested positive for Covid on [DATE]. Resident was placed on isolation per facility protocol. Review of the [DATE] Physician Orders revealed there was not an order for Covid-19 testing. 5. Review of the admission MDS Assessment for R#322 dated [DATE] revealed a BIMS score of 13, indicating intact cognition. A Nurse's Note dated [DATE] documented resident with symptoms of upper respiratory infection (cough, congestion, and scratchy throat). A Covid test was performed, and the result was positive. Review of the [DATE] Physician Orders revealed an order on [DATE] for isolation. There were no orders for Covid-19 testing. 6. Review of the admission MDS Assessment for R#113 dated [DATE] revealed a BIMS score of 12, indicating moderately impaired cognition. A Nurse's Note dated [DATE] documented staff spoke with resident's son regarding residents Covid positive diagnosis and the initiation of contact and droplet isolation. Review of the [DATE] Physician Orders revealed an order for isolation dated [DATE]. There was an order for a Covid test dated [DATE] (11 days after the resident was diagnosed with Covid-19). 7. Review of the Quarterly MDS Assessment for R#46 dated [DATE] revealed a BIMS score of 13, indicating intact cognition. A Nurse's Note dated [DATE] documented resident was tested for Covid, and test result was positive. Resident was placed on isolation per facility policy. Review of the [DATE] Physician Orders revealed an order for Covid-19 testing per state and federal guidelines dated [DATE], and an order for isolation on [DATE]. 8. Review of the admission MDS Assessment for R#112 dated [DATE] revealed a BIMS score of nine, indicating moderate cognitive impairment. A Nurse's Note dated [DATE] documented resident had symptoms of cough. Resident was tested for COVID-19 and confirmed positive. Resident placed on isolation. Review of the [DATE] Physician Orders did not reveal an order for Covid-19 testing. 9. Review of the Quarterly MDS Assessment for R#74 dated [DATE] revealed a BIMS score of 13, indicating intact cognition. A Nurse's Note dated [DATE] documented resident tested positive for Covid-19 and isolation precautions were in place. Review of the [DATE] Physician Orders revealed there was not an order for Covid-19 testing. 10. Review of the Quarterly MDS Assessment for R#13 dated [DATE] revealed a BIMs of 15, indicating intact cognition. A Nurse's Note dated [DATE] documented the nurse spoke with resident regarding her Covid positive diagnosis and the initiation of contact and droplet isolation. Review of the Nurse's Note dated [DATE] documented resident observed with no vital signs. Respiration ceased and skin was still warm and cooling fast. The DON, Medical Doctor (MD)/Nurse Practitioner (NP), and family were notified. On [DATE] R#13 tested positive for Covid-19 but there was no documented evidence indicating why she was tested, no mention of signs or symptoms or if she had a roommate that was positive that indicated the need for her to be tested. An [DATE] Nurse's Note documented she had no acute changes and there were no other notes related to her health status until she was found deceased on [DATE]. Review of the [DATE] Physician Orders revealed there was not a physician order for Covid-19 testing. 11. Review of the Quarterly MDS Assessment for R#27 dated [DATE] revealed a BIMS of 14 indicating intact cognition. A Nurse's Note dated [DATE] documented resident complained of feeling sick in the stomach and nauseous, resident tested for Covid and was placed on isolation per protocol. Review of the [DATE] Physician Orders revealed an order for Covid-19 test as needed per State and Federal Guidelines on [DATE] with no end date, but it was not listed on the current Medication Administration Record (MAR). 12. Review of the admission MDS Assessment for R#324 dated [DATE] revealed a BIMS score of 10, indicating moderately impaired cognition. A Nurse's Note dated [DATE] documented due to resident roommate with symptoms, resident and roommate were both tested for Covid. Resident result was positive. MD (medical doctor) made aware. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE] and there was not an order for Covid-19 testing. 13. Review of the Entry MDS Assessment for R#222 dated [DATE] revealed it was in progress and no information was documented. A Nurse's Note dated [DATE] documented resident with symptoms of Covid, was tested and result came back positive for Covid. NP (Nurse Practitioner) made aware. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was a physician order for Covid testing on [DATE] (five days after testing positive). 14. Review of the Quarterly MDS Assessment for R#51 dated [DATE] revealed a BIMS score of 13 indicating intact cognition. A Nurse's Note dated [DATE] documented resident complained of feeling cold and general malaise. Resident swab for Covid test and was positive. MD notified. Isolation precautions in place. Review of [DATE] Physician Orders revealed an order for Covid-19 testing per state and federal regulations dated [DATE] and an order for isolation dated [DATE]. 15. Review of the admission MDS Assessment for R#469 dated [DATE] revealed a BIMS score of three, indicating severe cognitive impairment. A Nurse's Note dated [DATE] documented resident tested positive for Covid via rapid test. Patient had one episode of vomiting before lunch. Patient stated that he just didn't feel well and had a runny nose. NP has been notified. Orders to monitor and treat symptoms if they occur. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was no order for Covid-19 testing. 16. Review of the admission MDS Assessment for R#323 dated [DATE] revealed a BIMS score of 12, indicating intact cognition. A Nurse's Note dated [DATE] documented resident with complaint of weakness, chills, and body aches. Covid test noted positive. Isolation precaution started. The physician was made aware. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was no evidence of an order for Covid-19 testing. 17. Review of the admission MDS Assessment for R#119 dated [DATE] revealed a BIMS score of 15 indicating intact cognition. A Nurse's Note dated [DATE] documented all patient care done in room per contact and droplet precautions due to Covid-19. There was no documentation in the nurse's notes of a Covid-19 test result. Review of the [DATE] Physician Orders revealed there was not an order for Covid-19 testing. 18. Review of the MDS admission Assessment for R#10 dated [DATE] revealed a BIMS score of 12, indicating intact cognition. A Nurse's Note dated [DATE] revealed resident tested positive for Covid. NP notified. Orders received to encourage fluids. Isolation Precautions initiated. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. Review of the Nurse's Note dated [DATE] documented the resident was found unresponsive by nurse around 8:00 a.m., with respiratory distress and shortness of breath. Resident regained consciousness, 911 was called and resident was then transferred to the hospital for further evaluation and treatment. NP was made aware. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There were no orders for Covid-19 testing. 19. Review of the MDS admission Assessment for R#58 dated [DATE] revealed a BIMS score of seven, indicating severely impaired cognition. A Nurse's Note dated [DATE] documented received orders from the physician for a one-time COVID test. Resident tested positive with symptoms of increased coughing. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was no documented physician order for Covid-19 testing. 20. Review of the MDS admission Assessment for R#120 dated [DATE] revealed a BIMS score of 13, indicating resident was cognitively intact. A Nurse's Note dated [DATE] documented the nurse spoke with the physician and received a one-time order for a COVID test due to resident having an increased runny nose. Resident tested positive for Covid and was put on isolation. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was no documented physician order for Covid-19 testing. 21. Review of the MDS admission Assessment for R#21 dated [DATE] revealed a BIMS score of 13, indicating resident was cognitively intact. A Nurse's Note dated [DATE] documented resident had tested positive for Covid, and the physician was notified. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There were no orders for Covid-19 testing. Even with the Covid increasing in the facility as described above, the facility was unable to demonstrate contact tracing or broad-based testing of staff for Covid-19. Review of facility documents and infection control surveillance documentation revealed from [DATE] through [DATE], there was no documented evidence of staff testing for close contacts or facility wide. Staff members QQ, RR, SS, TT, UU, VV, WW, YY were tested due to having symptoms. No other staff were tested. In addition, there was no documented evidence of resident or staff testing negative for Covid-19. Interview on [DATE] at 10:35 a.m. with Registered Nurse (RN) Infection Preventionist (IP) FF stated she was the back-up RN IP. She stated that RN GG was the full time IP. She stated on [DATE] there were 14 residents and two staff members that were positive for Covid-19. She stated the outbreak began on [DATE] when two residents (R) (R#59 and R#2) and one staff member (QQ) tested positive for Covid-19. She stated the Covid positive residents were currently in Transmission Based Precaution (TBP) rooms without roommates. She stated when a resident tested positive for Covid, the roommate was moved to an empty room on the same unit, monitored for symptoms of Covid and tested on days 1, 3, and 5. She stated if the roommate tested positive, the residents remained in the same room on TBP. Interview on [DATE] at 11:55 a.m. with the Administrator and RN IP FF confirmed the Covid-19 outbreak began on [DATE] with R#59 testing positive after exhibiting symptoms of cough, body aches and nausea. It was reported a staff member tested positive on [DATE] after exhibiting symptoms of headache, body aches, and cough, but the staff member was not at work on the day of the positive test. The Administrator stated staff identified as a close contact of a Covid positive resident or staff with symptoms of Covid were tested. The Administrator stated the facility had been in communication with the local Georgia Department of Public Health (GDPH) to report Covid positive residents and staff. Review of the e-mail documentation provided by the Administrator revealed guidance was provided on [DATE] from GDPH that included the document Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated [DATE]. Interview on [DATE] at 3:40 p.m. with the Assistant Director of Therapy stated she could not recall the last time she had had a Covid test performed. She stated she was aware that staff should report signs or symptoms of Covid to the RN IP and have a Covid test if symptomatic. Interview on [DATE] at 3:49 p.m. with Physical Therapy (PT) Assistant HH stated she had provided PT services to R#59 on [DATE] and [DATE] in the resident's room for a total of 40 minutes each day. She stated she wore full Personal Protective Equipment (PPE) consisting of gloves, gown, and face shield after learning resident tested positive Covid test on [DATE]. She stated she would provide therapy services to the residents on TBP as her last residents of each day. Interview on [DATE] at 5:55 p.m. with RN IP FF stated she did not know where to find the documentation of staff testing. She stated she was the back-up RN IP, and the full time RN IP would be in the facility on [DATE]. RN IP FF stated both positive and negative results for residents were documented on the MAR in the electronic medical record (EMR). Interview on [DATE] at 9:55 a.m. with Certified Nursing Assistant (CNA) II stated she had a Covid-19 test on [DATE] due to the facility outbreak. She confirmed she provided resident care to residents on TBP who tested positive for Covid. Interview on [DATE] at 10:07 a.m. with Housekeeping Staff JJ stated she had worked at the facility for two to three weeks. She stated her last Covid test was about one year ago, and she had not had a Covid test while employed at this facility. She stated during orientation she was educated to have a Covid test if she had symptoms of covid. She stated she did clean rooms of residents on TBP due to a positive Covid test. Interview on [DATE] at 10:11 a.m. with RN KK stated he had received recent education to have a Covid test if he had symptoms. He stated if a resident exhibited symptoms, he would notify the physician and obtain a physician's order for testing prior to testing and document the physician's order in the EMR. He further stated he would document the physician's order and document the test results in the progress notes. Interview on [DATE] at 10:21 a.m. with Licensed Practical Nurse (LPN) LL stated she had not received Covid testing education since [DATE] and the only guidance provided by the facility was to test if she was symptomatic. She stated she was aware to monitor residents for symptoms of Covid and if symptoms were present, she would notify the physician and obtain a verbal order to perform a Covid test. She stated the physicians order would be documented in the physician order section of the EMR and the Covid test results should be documented in the nurses' progress notes. Interview on [DATE] at 12:35 p.m. with LPN MM stated she was tested for Covid on [DATE] due to an exposure at the facility. She stated the facility began testing staff every three days on [DATE] due to the outbreak and she was unaware if all staff were tested. She stated prior to [DATE], the facility recommended testing only if staff had symptoms of Covid. She stated if a resident had symptoms of Covid, she would notify the physician to obtain a verbal order for a Covid test, document the order in the physicians' order tab of the EMR, and document the test results in the nurses' progress notes. Interview on [DATE] at 12:56 p.m. with CNA NN stated prior to [DATE], the facility only required Covid testing if staff was symptomatic. Interview on [DATE] at 1:00 p.m. with CNA OO stated the facility required Covid testing for symptomatic staff. Interview on [DATE] at 1:25 p.m. with RN IP GG and RN IP FF revealed the covid outbreak began on [DATE] with two residents and one staff testing positive. They stated the residents were placed on contact and droplet isolation, the physician and family were notified. They were unable to provide names of staff identified as close contacts or documentation of the testing results for staff tested. They stated if staff were in close proximity to a resident with a positive Covid test, the staff member would be tested the following day and results would be documented on a log; if the results were negative, the staff member would be tested again on days three and five and results documented on a log, but they were unable to provide any documentation of staff testing. During further interview it was revealed if a resident exhibited symptoms of covid, the nurse would notify the physician and obtain an order for a covid test and document the results in the nurse's notes, notify the IP and resident representative. They stated the nurses should monitor for symptoms of covid each shift and should document the monitoring each shift. During continued interview, it was reported there were confirmed 17 residents and six staff members to test positive for covid from [DATE] to [DATE], one resident death (R#13) and two resident hospitalizations (R#10 and R#59). They were unable to provide the number of residents or staff with a negative Covid test, and stated the staff Covid test log that contained both positive and negative test results was in the Administrator's office. Interview on [DATE] at 2:10 p.m. with the Administrator stated the only logs she could provide were resident and staff logs of Covid positive results. She verified she could not provide a Covid testing log for staff or residents with negative test results and further verified she was unsure how many staff or residents had been tested or had a negative test. Telephone interview on [DATE] at 12:15 p.m. with the Epidemiology Assistant with the local Health Department revealed on [DATE] she provided guidance to the facility that once there was one Covid positive resident, and the spread of Covid continued with contact tracing, she recommended broad-based testing. During further interview, she stated the facility had an outbreak in [DATE], and she recommended then to conduct broad-based testing when it was identified that contact trace testing did not contain the spread of Covid. Interview on [DATE] at 4:23 p.m. with the Administrator revealed her expectations were for the RN IPs to follow the facility Covid-19 Policies, CDC Guidelines, and GDPH Guidelines. She stated the RN IP attended the morning meetings to report any newly identified infectious disease. She stated her expectations was for the RN IP to keep her informed of any concerns of Covid-19. Review of the line listing dated [DATE], that included dates of [DATE], through [DATE], documented there were 28 residents and eight staff members with Covid-19 positive test results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the Registered Nurse (RN) Infection Preventionist (IP) job description, the facility failed to ensure that the person in the role of (IP) adequately assessed, developed, implemented, monitored, and managed the Infection Control and Prevention (IPCP) program, to prevent and control the spread of infections. Specifically, a Covid-19 outbreak began on August 2, 2023, and the facility's failure to implement the Centers for Disease Control (CDC) and the Georgia Department of Public Health's (GDPH) recommended practices for contact tracing or broad-based testing, resulted in 28 residents and eight staff members testing positive, three Covid-19 related hospitalizations, and one Covid related death during this outbreak of Covid-19. The census was 99. On August 15, 2023, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Executive Director, Regional Director of Clinical Services, Regional [NAME] President, and the Division Director of Clinical Services were notified on August 15, 2023, at 2:30 p.m. of the Immediate Jeopardy. The IJ situation was ongoing at the time of exit on August 17, 2023. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated May 8, 2023, revealed when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected units) if using a broad-based approach, regardless of vaccination status. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue for affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. 2. Review of the document titled RN Infection Preventionist (IP), revised September 2, 2022, revealed the position summary for the Registered Nurse (RN) IP is to 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 {provider}standards. Collects, prepares, 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. Specific Requirements: include: Serves as designated associate responsible for monitoring Public Health Advisories from local, state, and federal agencies including the CDC. Serves as the on-site IPC for Covid-19 prevention and response activities, in accordance with current CDC recommendations. Maintains a current knowledge of infection control trends, methodologies, and employee health practices. Must be knowledgeable of Infection Prevention and Control practices and procedures as well as the laws, regulations and guidelines governing nursing functions in the post-acute care facility. Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the Infection Prevention and Control Program. Essential Functions include: 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 (ICPC) to prevent, recognize, and control the onset and spread of infection to the extent possible. Must be able to regularly review CDC and State Health websites for Infection Control Guidance for Healthcare Professionals for current information and ensure associates and residents are updated when guidance changes. Must be able to complete on-going monitoring of HAIs and CAIs including antibiotic use, micro report, line listings, and trending of infections. Must be able to conduct outbreak tracking, symptom monitoring, investigation, and reporting in accordance with local health and state agency as required by law. Must be able to initiate follow-up on associate/resident exposure to communicable diseases. Interview on 8/12/2023 at 10:35 a.m. with RN IC FF stated she was the back-up ICP. She confirmed the Covid outbreak began when two residents tested positive for Covid on 8/2/2023. She stated contact tracing was performed and the two residents' roommates were either placed on Transmissions Based Precautions (TBP) in the same room if tested positive or moved to a single resident room on TBP if tested negative. She stated if the roommate tested negative, they would remain on TBP and be retested on days three and five. Interview on 8/14/2023 at 5:55 p.m. with RN IC FF stated she was unsure if staff or other residents were tested on [DATE] when the two residents tested positive for Covid. She stated she did not know where to find documentation of staff testing, but stated if residents were tested, it would be documented in the electronic medical record (EMR). She revealed the full-time RN IC would be in the facility on 8/15/2023. Interview on 8/15/2023 at 1:25 p.m. with RN IC GG confirmed she worked full-time as the RN IC and RN IC FF was the back-up RN IC. They confirmed the Covid outbreak began on 8/2/2023 with two residents and two staff tested positive. She stated the two residents were placed on contact and droplet isolation, and contact tracing was performed. She explained the contact tracing was done by identifying staff who worked on the units where the two residents resided and tested anyone identified as a close contact. The staff identified to have been near the two Covid residents would be tested the following day and results would be documented on a log; if the results were negative, then the staff member would be tested again on days three and five. RN IC GG was unable to provide documentation of staff names identified as close contacts or provide documentation of the testing and/or test results. Interview on 8/15/2023 at 2:10 p.m. with the Administrator stated the only documentation she could provide were resident and staff logs that contained covid positive results. She verified she could not provide a covid testing log of staff or residents that contained documentation of negative test results. Telephone interview on 8/16/2023 at 12:15 p.m. with the Epidemiology Assistant with local Health Department revealed she had been in communication with the facility to provide guidance for Covid-19 testing. She stated she was aware the facility was in Covid outbreak status because the facility made her aware of all new positive Covid cases daily. During further interview, she revealed she informed the facility that once a facility was in Covid outbreak, she recommended broad-based testing. She further stated the facility was in Covid-19 outbreak in May 2023 and she had provided guidance to the facility at that time to implement broad-based testing if contact tracing did not prevent the spread of Covid-19. Interview on 8/16/2023 at 4:23 p.m. the Administrator stated the RN IC attended the morning meetings to report any newly identified infectious disease cases. She stated her expectation was for the RN IC to follow all Covid-19 Infection Control Policies, CDC Guidelines, and the GDPH Guidelines for broad-based testing. She revealed her expectations were for the RN IC to keep her informed of all concerns related to the Infection Control program. The Director of Nursing (DON) was unavailable for interview. Cross reference F880