**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R207's Face Sheet, undated, documents R207 was admitted to the facility on [DATE], with diagnoses of fracture of unspecified part of neck of right femur, COVID-19 acute respiratory disease, depression, hypertension (HTN), chronic kidney disease-stage 3, and cerebral infarction. R207's Nursing Note, dated [DATE] at 8:56 AM, documented, Patient has excess nasal drainage with cough noted in dining room. Brought out of dining room and tested for COVID, patient was positive at this time. POA (Power of Attorney) was notified. NP (Nurse Practitioner) was notified and responded with orders for anti-viral Lagevrio 200mg give 4 caps BID (twice daily) x 5 days, ASA 81mg daily x 30 days from positive test, vital signs every shift x 10 days, and Mucinex 600mg BID x 10 days. Lungs are clear at this time. 97.8 89 18 133/76. 93%. R207's Nursing Note, dated [DATE] at 6:29 PM, documented, Resident looks really bad. Fingertips blue, not eating and drinking. Notified son of situation. Resident refused to take medication. R207's Nursing Note, dated [DATE] at 9:21 PM, documented, Resident was found by CNA approx. 6:30pm stated that resident looked really bad and his fingertips were blue, and resident was not eating and drinking for dinner. CNA states that the previous nurse was notified prior. the nurse prior then notified POA son of resident change in condition. Resident is currently COVID +, upon assessing resident, resident appears to be uncomfortable and anxious, cyanotic at the lips and nailbeds, this nurse immediately obtained VS (vital signs) as a result, resident VS were unstable Spo2 84% RA (room air) resident immediately placed on 2L O2 with HOB (head of bed) elevated for comfort, HR (heart rate) ranging 36-56, Temp. 98.3, unable to access B/P (blood pressure) at this hour. Son is at bedside and is made aware of resident being on comfort care, notified the on call MD (medical doctor) for reinstatement of PRN (as needed) Lorazepam 2mg/mL 0.25mL Q 4hr d/t (due to) anxiousness and Morphine Sulfate 5 mg/0.25ml PRN Q 4hrs for pain. MD returned call with okay to reinstate PRNs. Son made aware. R207's Nursing Note, dated [DATE] at 9:58 PM, documented, Called to room per CNA. Resident observed with no vital signs of life. No pulse or respirations noted. No heart or lung sounds on ausc. (auscultated) MD notified. Coroner, notified. POA notified. Administrator and nurse manager on call notified. New order received to release remains to (funeral home) in (nearby town). Postmortem care provided. R207's Death Certificate, dated [DATE], documents R207's cause of death was Palliative Care, CVA (cerebral vascular accident), and COVID-19. 4. R208's Face Sheet, undated, documented R208 was admitted to the facility on [DATE],3 with diagnoses of Chronic obstructive pulmonary disease (COPD), Pneumonia, COVID-19 acute respiratory disease, Dysphagia, Emphysema, Congested Heart Failure (CHF), Atherosclerotic heart disease (ASHD), and HTN. R208's Nursing Note, dated [DATE] at 8:41 AM, documented, Patient had coughing episode in dining room, patient was taken out of dining room, where nasal congested was noted in excess patient expressed, he did not feel well. Patient was tested for COVID at this time, positive results. Lungs are congested. POA updated at this time. NP was notified and responded with orders to monitor vitals every shift, ASA 81mg x 30 days from positive date, anti-viral Lagevrio 200mg give 4 caps BID x 5 days and contact isolation x 10 days. 97.8 89 18 133/76 94%. R208's Nursing Note, dated [DATE] at 10:59 AM, documented, 0820 called to residents room, res was moaning, HOB elevated, respirations labored at 26 resp (respirations) per min. SPO2 78%, res had removed O2 from nose, placed back into place, at 4L/NC due to SOB (shortness of breath), spo2 83%. Lungs diminished in bilateral lower lobes, unable to assess upper lobes accurately due to res moaning. Wet cough present. Lips dry, res did continue to ask for a drink, he drank 120ml of water. 0845 911 notified of need of transfer and DON notified. 0850 Daughter notified. 0915 (local hospital) Ambulance service arrived, res transferred from bed onto stretcher using sheet. Res continued to pull O2 off and mask. 0920 Report called to RN at (local hospital) ER (emergency room), ED (emergency department) form, med list, face sheet, and POLST (Physician Orders for Life-Sustaining Treatment) form sent with EMTS (emergency medical technicians) R208's Nursing Note, dated [DATE] at 2:15 PM, documented, 1245 Res returned from (local hospital) ER via ambulance, res was on RA (room air) upon arriving, respirations are even and unlabored, res was moaning, but would answer when asked questions. VS 97.8 80 20 134/88, unable to obtain a pulse ox with finger monitor. New orders: Decadron 6mg 1 tab PO (orally) daily x 5 days; to start on 12/16 and Augmentin 875mg 1 tab PO Q12h x 7 days for chronic bronchitis. Staff assisting res with lunch. R208's Nursing Note, dated [DATE] at 10:29 PM, documented, Standing comfort orders noted in MAR (medication administration record). R208's Nursing Note, dated [DATE] at 6:01 AM, documented, Upon entering residents room, resident appeared to be in an uncomfortable state with chest rise and fall equal bilaterally, POA at bedside for support. resident was due for schedule Morphine Sulfate. and Lorazepam at this hour, resident appearing to show s/sx (signs/symptoms) of distress with respiration of 26-28 that plummet to 6-2 while attempting to obtain vitals, Resident took last breath before administering schedule medication, while this nurse was at bedside, POA present in facility at the time of resident expiring. after assessing resident for 5 minutes resident is showing no signs of life or respiratory effort, has no palpable carotid pulse, has no heart sounds on auscultation, no respiratory sounds on auscultation, absence of pupillary reflexes and corneal reflex, and absence of motor response to supra-orbital pressure. This nurse provided privacy and notified [NAME] funeral home per family, corner notified, and MD notified. [SIC] R208's Death Certificate, dated [DATE], documented that R208's Cause of Death was Pneumonia, COPD, and COVID-19. 5.R209's Face Sheet, undated, documented that R209 was admitted to the facility on [DATE], with diagnoses of Chronic ischemic heart disease, atrial fibrillation, Sick sinus syndrome, Peripheral vascular disease, and stage 1 through stage 4 chronic kidney disease. R209's Nursing Note, dated [DATE] at 11:30 AM, documented, Patient continues with poor appetite. Congested cough noted. Patient roommate positive for COVID. Patient tested and came positive as well. Patient currently on (local hospice). POA and (local hospice) notified of positive test and symptoms. No new orders at this time from (local hospice). Nurse will be in today to see patient. COVID orders per facility will be placed at this time. Vital signs every shift, droplet precautions. R209's Nursing Note, dated [DATE] at 10:36 AM, documented, 10:19 Called to residents room, res expired, no HR, BP, or respirations noted. 10:25 This nurse called POA and notified of res expired, she voiced no one would be coming to facility due to her herself having COVID. She confirmed (funeral home in nearby town) is whom they would be using. 10:36 Called placed to (local hospice), care notified of res expired at 10:19. Nurse is to be returning phone call. R209's Death Certificate, dated [DATE], documents R209's Cause of Death Ischemic Heart Disease. Based on observation, interview, and record review, the facility failed to implement a system to track and trend infections, failed to implement a system for testing for the spread of COVID-19, and failed to implement infection control procedures including isolation precautions and personal protective equipment (PPE) to prevent the spread of COVID-19. These failures resulted in 23 residents developing COVID-19, including 5 residents (R37, R51, R207, R208, and R209) who expired after becoming positive with COVID-19. Two residents (R19, and R40), and one staff member (V27, Certified Nursing Assistant/CNA) are currently positive with COVID-19. These failures have the potential to affect all 52 residents in the facility. The Immediate Jeopardy began on [DATE], when R35 developed COVID-19 and the facility failed to conduct testing and surveillance to prevent the spread of COVID-19. Subsequently, 22 other residents have developed COVID-19. Although the facility tested those with COVID-19 symptoms, the facility did not conduct testing for all residents and health care personnel identified as close contacts twice a week as per CDC guidance after these residents were diagnosed. Subsequently, R51 was diagnosed with COVID and expired on [DATE] with COVID and Congestive Heart Failure (CHF), R207 was diagnosed with COVID and expired on [DATE] with COVID, R209 was diagnosed with COVID and expired on [DATE] with Heart Disease, R208 was diagnosed with COVID and expired on [DATE] with Pneumonia and COVID, R37 was sent to the hospital and diagnosed with COVID on [DATE] and expired on [DATE]. On [DATE] at 2:15 PM, V2, Director of Nurses (DON), stated at the time R35 tested positive for COVID-19, there was no contact tracing done with residents or employees. On [DATE] at 8:53 AM, V1, Administrator, V2, Director of Nursing, and V3, MDS Nurse/Infection Control Nurse, V4, Business Office Manager/Admissions, and V37, Regional Director of Operations and Clinical Services (via phone), were notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time was needed to evaluate the implementation and effectiveness of the in-service training. Findings include: 1.Upon entrance into the building on [DATE] through [DATE], there was no signage on the doors indicating any of the residents had COVID-19 or were on contact isolation. On [DATE], the facility provided a list of 18 residents in the facility including R13, R34, R18, R25, R17, R6, R207, R208, R42, R47, R32, R31, R3, R209, R7, R22, R2, and R210 who were positive with COVID-19 from [DATE] through [DATE], and no contact tracing or further testing was completed. During the investigation, there were three more residents (R35, R37, and R51) who were noted to have COVID-19 in the facility during that same time frame. 2. R35's Face Sheet, undated, documents, R35 was admitted on [DATE], with diagnoses of Atrial Fibrillation and right sided heart failure. R35's Nurses Note, dated [DATE] 11:59 PM, documents, Res c/o (complaint of) new onset generalized weakness. Writer tested res (resident) for COVID and res is positive. Droplet isolation precautions initiated. Res assisted to bathroom and to bed. Educated res (resident) to use call light for assistance during NOC (night). V/S (vital sign) @ 98.3, 47, 18, 116/70, Sp02 (oxygen saturation) 96% ORA (on room air). NP (Nurse Practitioner) notified via fax. Left message for POA (Power of Attorney) to call facility. DON (Director of Nurses) notified. 6. R37's face sheet, undated, documents a diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute respiratory failure, personal history of COVID-19. R37's progress notes, dated [DATE] at 3:43, documented, Resident observed with shortness of breath (SOB), congestion and wet lungs sounds, SP02 81-84% on 2liters of 02 per nasal cannula, Notes document nebulization treatment administered and SPO2 dropped to 50's. Head of bed elevated. Medical Doctor notified and POA notified. New order notes to send resident to emergency room for evaluation and treatment 911 called. R37's notes, dated [DATE] at 10:20, documented, Call placed to hospital for updates, notes document resident is COVID positive. Progress notes, dated [DATE] at 11:15, documented, Hospital called and gave report resident passed away. R37's hospital emergency room report, dated [DATE], documented, Date of service at 08:43 with reason for admission hypoxic respiratory failure/copd exacerbation. Chief complaint history and physical, dated date of service [DATE], documented, (R37) with a past medical history of COPD, congestive heart failure was brought to the ER by Emergency Medical Services (EMS) for complaints of shortness of breath and increased somnolence. (R37's) Emergency Report (ER) documents in the ED (R37) was found to be tachypneic sating low on room air. It continues, Treated with BIPAP, albuterol nebulizing treatment. Documents given one dose of diuretic. Despite Bipap treatment the patient continued to desat down into the 80%. Documents DNR/DNI. It continues, (R37) was then transferred to ICU on airborne isolation for further management. R37's notes documented throughout the morning, the patient became increasingly somnolent and when she would fall asleep, she would desaturate to 50-70%. R37's report also documented when she was roused and coached by the nurse, her 02 sats would improve to the low 90% and this was needed with increased frequency. R37's death certificate documented R37 expired on [DATE] with the following diagnosis, Respiratory Arrest, Chronic Obstructive Pulmonary Disease (COPD) and COVID. 7. R51's face sheet, undated, documents a diagnosis of acute or chronic diastolic (congestive) heart failure (primary admission) and pneumonia. R51's progress notes, dated [DATE] at 6:28, documented, Resident had sudden onset of Shortness of breath (SOB) RN raised head of bed 45 degrees, resident still could not catch breath. It continues, RN put resident on 2L (liters) of 02 per nasal cannula for comfort., resident subside right away and requested to keep o2 on. R51's progress notes, dated [DATE] at 12:22. Documented, (R51) will have a room move today, resident will be moving 230-b-308a due to positive covid isolation. Documents will continue to monitor. Any changes will be made next care plan meeting. [DATE] at 12:42 PM, R51's progress notes, documented, Nurse Practitioner (NP) here, new order to obtain covid test due to decline and SOB. Progress notes documents COVID test completed, positive results noted. Progress notes documents droplet isolation, Lagevrio 200 milligram(mg), give 4 caps by mouth (po) twice a day (bid) x 5 days Mucinex Extended Release (ER) 60mg 1 tab po x 10 days. R51's Progress notes document lungs have rubs to bilateral upper lobes 02 in place at 2l per nasal canula (nc). R51's notes, dated [DATE] at 3:00PM, documented, (R51) complained of SOB, requested a breathing treatment, this RN administered prn treatment per electronic medical record (emar). It continued, Resident stated treatment was effective and she is breathing much better. Resident is currently on 2 liters of 02, hob elevated, 02 sat is 94%, and lungs have rubs to bilateral upper lobes 02 in place at 2l nc. R51's notes, dated [DATE] at 15:00, documented, Resident on covid isolation, respirations even and unlabored. lying quietly in bed at present time. no acute distress noted this shift, daughter will be taking mom home tomorrow. R51's progress notes, dated [DATE] at 16:39, documented, Lungs diminished bilaterally; resident has congested sounding cough that's occasionally productive of cream colored phlegm. Progress notes, dated [DATE] at 10:05 AM, documented, CNA states upon entering room to get resident dressed, resident not to have any respiration. Resident expired at this time. R51's death certificate, dated [DATE], documented the cause of death as Congestive Heart Failure (CHF) Fractured Humerus, and COVID. 8.R40's Face Sheet, undated, documented that R40 was admitted on [DATE], and has diagnoses of Chronic Obstructive Pulmonary Disease, Hypertension, Cardiac Arrhythmia and Type 2 Diabetes. R40's Physician Orders documented, Start date of [DATE] Droplet Isolation. Start date of [DATE] Ipratropium - Albuterol solution for nebulization; 0.5 mg (milligram) - 3 mg; amount 1 vial; inhalation. every 6 hours. dx (diagnosis) 2019- nCov (covid). Start date of [DATE] End date of [DATE] Lagevrio capsule 200 mg; amount 4 caps (capsules) Twice a Day. Dx 2019 nCov. Mucinex tablet extended release 12 hour; 600 mg; amount 1 tab; oral Twice a day. R40's Nurses Note, dated [DATE] 1:31 PM, documented, Patient has complaints of congestion and cough. Patient lungs have bilateral crackles. SP02 (oxygenation saturation)-95% on RA (room air). NP (Nurse Practitioner) gave orders to obtain covid swab. COVID swab done x 3 swabs, all positive. Patient is being moved and droplet isolation precautions will be in place. New orders received for lagevrio 200mg, give 4 caps BID x 5 days, mucinex 600mg BID x 7 days, and duonebs q (every) 6hrs while awake. POA (Power of Attorney) made aware of diagnosis and room move. R40's Nurses Note, dated [DATE] 2:06 PM, documents, Resident had a temp. room move, due to positive covid isolation, family was made aware, resident moved from 234b-302a, resident will continue to be monitored, any changes will be in next care plan meeting. 9. R19's most current undated face sheet documents diagnoses of acute respiratory disease, Chronic obstructive pulmonary disease, and mild intermittent asthma. R19's care plan, dated [DATE], documented R19 has a tested positive for COVID-19. R19's care plan documents this places R19 at higher risk for severe illness. R19's progress notes, dated [DATE] at 20:09, documents R19 positive for COVID-19. R19's progress notes, dated [DATE], documents R19 is on antibiotics for pneumonia. On [DATE] at 10:05 AM, V31, Housekeeper, entered R19's room, which has isolation cart outside room and sign on door for transmission-based precautions. V31 did not sanitize hands prior to entering R19's room or don any Personal Protective equipment (PPE). V31 then exited room and did not sanitize hands, V31 then walked down hall and got floor sign from cart and sit out in hallway. On [DATE], V31 stated he is expected to don PPE prior to entering and isolation room. 10.On [DATE] at 8:45 AM, V16, Regional Nurse stated V27, Certified Nursing Assistant (CNA) tested positive for Covid 19 on [DATE] at home and positive at clinic on [DATE]. V16 stated V27 worked at the facility on [DATE] and returned to work at the facility on [DATE]. V27's employee timecard, dated [DATE]- [DATE], documents V27 worked 7:55AM -9:56PM on [DATE]. V27's timecard documents V27's next day of work as [DATE] at 5:29AM. V16, Regional Nurse stated she would have expected V27, CNA, to remain off work for 10 days. The facility was unable to provide any documentation the facility had implemented any type of contact tracing. On [DATE] at 9:57 AM, V3, MDS/ Infection Control Nurse, stated he started employment at the facility on [DATE]. V3 continued to state he has taken the infection control modules for certification, but he has not taken the test as he had not had time. V3 stated on [DATE], all residents and staff at the facility were tested and there were no positive cases of COVID-19. V3 stated all employees on duty were tested, and all employees who were not on duty will be tested prior to their shift. V3 stated he has not been in contact with the local health department regarding COVID 19 infection. V3 stated he has a roster of all employees, and is tracking testing on that roster. V3 stated he also has a list of all residents. V3 stated when R40 tested positive, he had a roommate, R47, and he did not test R47. V3 stated V4, Business Office Manager, put the current signage on the front door, which still does not document there is COVID-19 in the building. On [DATE] at 9:18 AM, per telephone interview, V34, Jersey County Health Department Infection Control Nurse, stated she has not been contacted by anyone at the facility, or made aware of any COVID-19 infection. V34 stated if the health department would have been contacted, she would have provided them a copy of the current IDPH guidance. V34 stated she would have discussed with the facility to provide additional staff education regarding handwashing. V34 stated signage on the door at entry should document the facility has COVID-19 in the building so visitors could be made aware of infection in the building. V34 stated she would expect the facility to be testing twice a week until no positives for 2 incubation periods. V34 stated the facility should be maintaining a line list of COVID-19 positive residents and submitting to the list to the health department on a weekly basis. V34 stated staff should be wearing gown, gloves, N95 masks, and face shield/or goggles when entering a COVID 19 positive room. On [DATE] at 10:58 AM, V2, Director of Nursing, stated she had not reached out to the local health department regarding COVID-19 infection. The QA meeting summary documented there was an Interdisciplinary Team (IDT) meeting held on [DATE], at 2:51PM, and a discussion was held with V36, Medical Director, regarding staffing, integrating new referral/admission processes, new lab process, but there was no documentation in regard to the COVID-19 outbreak at the facility recently. The facility policy, Screening: Residents, Health Care Personnel and Residents, dated [DATE], documented, The facility will put into place measures and processes to inform residents, visitors, and health care peroneal of recommended actions to prevent the transmission of COVID-19. It continues, The facility will post visual alerts at entrances and other strategic areas that include instructions about current infection prevention and control recommendations. This includes when to use source control and when to perform hand hygiene. It continues, Visitors- visual prompts will be posted to ensure visitors are aware of when their visitations should be limited or deferred including when they are infectious or potentially infectious or until they have met the health care criteria to end isolation to preserve the safety of the residents. It continues, Visitors should defer visits for the following: they have a positive viral test for SARS-COV-2, they have symptoms of COVID-19, they have close contact with someone with SARS-COV-2 infection, they have been in a situation that put them at high risk for transmission until 10 days after close contact. The facility policy, Healthcare Personnel Work Restrictions, dated [DATE], documented, The facility will implement appropriate work restrictions for Healthcare Personnel according to current regulatory guidance. It continues, Healthcare personnel with confirmed Covid-19 return to work criteria Covid 19 documents confirmed infection are excluded from work and may return to work based on the severity of their illness. The facility policy, Covid-19 testing plan, dated [DATE], documented, The facility will implement a testing plan to assist in preventing the transmission of COVID-19. The policy documents testing is required in the following instances: residents who are symptomatic regardless of vaccination status even if symptoms are mild as soon as possible, asymptomatic residents and health care personnel with close contract or higher risk exposure with someone with SARS_COV-2 infection (serial testing: series of 3 viral tests). It continues, If the facility is in outbreak status (immediately and twice weekly or very 3-7 days until no more positive cases for 14 days. The facility's Infection Prevention and Control Program Policies and Procedures: General Statement, dated 8/2018, documented, The organization has made a commitment to prudent infection prevention and control measures by promoting the concept of compassionate, common-sense resident and patient care, with an emphasis on cleanliness and infection prevention strategies. This organization has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. We strive to implement evidenced based approaches to infection prevention. The infection prevention and control program: Investigates, controls, and prevents infections in the organization. Decides what procedures, such as isolation, should be applied to the individual resident/patient. Maintains a record of incidents and corrective actions related to infections. Has written procedures as a basis of determination for isolation (transmission based precautions) to help prevent the spread of infection. Has an employee health directive to prevent the spread of communicable diseases through work restriction and hand hygiene. The Immediate Jeopardy that began on [DATE], and was removed on [DATE], when the facility took the following actions: 1. V40, Medical Records, notified the facility's Medical Director, V36, of the Immediate Jeopardy. 2. Facility infection control policies were reviewed by Regional Nurse, V37, and V1, Administrator, to ensure it is acceptable with Standards of Practice and CDC Guidelines. 3. On [DATE], V2, DON, and V3, MDS Nurse, immediately assessed and tested all residents for COVID-19, and then tested all staff members immediately or prior to their next working shift for COVID-19. 4. On [DATE], V38, Corporate Infection Preventionist Nurse, trained V1, Administrator, V2, DON, V3, MDS Nurse, V4, Business Office Manager, and V22, ADON, on Vaccine and Reporting Policy, Screening of Resident and Healthcare Personal Policy, COVID-19 Plan Policy, Management of Residents with confirmed and suspected COVID-19 infection and transmittal-based precautions policy, and Healthcare personal work restriction policy. 5. On [DATE], all staff members were educated, via in-service, email, or phone call, by V1, V2, V4, and V38, regarding the facility's policy on COVID-19 required testing and monitoring including biweekly testing during outbreak status for staff and residents initiated on [DATE] and/or prior to the next working shift. No staff will be allowed to begin their scheduled shift prior to being educated in accordance with these policies and procedures. 1. Vaccine and Reporting Policy. 2. Screening of resident and healthcare personal policy. 3. COVID-19 testing plan policy. 4. Management of residents with confirmed and suspected COVID-19 infection and transmittal-based precautions policy. 5. Healthcare personal work restriction policy. 6. V3, MDS Nurse/Infection Preventionist, will review COVID testing log bi-weekly to ensure completion according to CDC guidelines and facility policy for four weeks and again when outbreak status occurs in the facility. 7. V38, Corporate Infection Preventionist, will be reviewing V3's audits upon completion. On [DATE], the survey team validated the removal of the immediacy by interviewing V14, LPN, V37, CNA, V39, CNA, V15, RN, V40 Medical Records Director, V41, Housekeeping Supervisor, V13, Activities Director, and V18, Cook, about the in-services they received related to the following policies and procedures: 1. Vaccine and Reporting Policy. 2. Screening of resident and healthcare personal policy. 3. COVID-19 testing plan policy. 4. Management of residents with confirmed and suspected COVID-19 infection and transmittal-based precautions policy. 5. Healthcare personal work restriction policy. The completed facility audits, in-services and policies were reviewed.