**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure food was stored, distributed, and served to residents in a manner to prevent food contamination. The facility failed to have a system in place for sanitizing dishware and food service equipment during the renovations of the kitchen. This failure resulted in the local health department revoking the facility's permit to prepare food on site and resulted in an Immediate Jeopardy. This has the potential to affect all 161 residents that consume food from the facility. Finding include: The Immediate Jeopardy began on August 26, 2024, when the facility's kitchen was closed for floor repair and food preparation continued in the facility without the ability to maintain safe food temperatures and sanitize food service equipment and dishware. As a result, the local health department revoked the facility's permit to prepare food on August 27, 2024. On August 28, 2024, the facility was still attempting to prepare puree and mechanically altered food onsite from catered food items and use plastic food trays and other dietary service equipment without a means of sanitation. V1(Administrator), V3(Dietitian Consultant), V4 (Corporate Consultant) and V5 (Nursing Consultant) were notified of the Immediate Jeopardy on August 28, 2024, at 4:30PM. The facility submitted a removal plan on August 29, 2024, at 10:00AM, that was returned for modification and the plan was accepted at 2:20PM. The immediacy was confirmed as removed by observations, interviews, and record reviews. Although the immediacy was removed on August 29, 2024, the facility remains out of compliance at a Level II because additional time is needed to evaluate the implementation and effectiveness of the plan. The facility's census sheet dated August 28, 2024, documents a facility census of 165 residents. V8 (Assistant Director of Nursing) stated on August 28, 2024, that 4 residents were NPO (nothing by mouth). The facility diet list that the facility has 11 residents on puree diets and 30 residents on mechanical soft diets. R3 to R13 are listed as residents receiving puree textured diets. The local County Health Department documented on August 27, 2024, a suspension to operate (food service operations) related to, inadequate refrigeration and ongoing construction project. V6 (Director of Environmental Services from the local County Health Department) stated during phone interview on August 27, 2024, that food service operation needed to close due to inability to maintain food temperatures and lack of hand washing sinks for dietary employees. V6 stated that the rented refrigeration unit was not holding temperatures. The facility's incident report submitted to the department August 27, 2024, that charted, The facility was inspected by the local food health department that food temperatures were not holding in the temporary refrigerated container. The facility enacted our emergency crisis management plan. The facility's kitchen was observed on August 28, 2024, at 10:30AM to be closed and nonfunctional. Construction workers were noted in the kitchen removing floor tiles. Dietary equipment food service carts, food trays, wash bins and dishware were noted being stored in the hallway near the kitchen and door leading to the parking lot. This area did not have a hand sink or means for staff to perform hand washing. V2 (Dietary Manager) and V1 (Administrator) stated during interviews of August 28, 2024, that the facility needed to close the kitchen for removal and repair of the floor. Both V1 and V2 confirmed that the kitchen was closed, and work began on August 26, 2024, at 8:30AM. The facility rented three 20-foot storage containers, one of which was a refrigerated unit. These storage containers were located outside the building near the kitchen in the parking lot. This area did not contain any handwashing stations for staff. The area surrounding the refrigerator unit outside was observed with puddles of free-standing water from the previous night rainfall. V2 then added that prior to the local health department shutting down the kitchen, staff was attempting to prepare food in other areas of the facility and 20-foot storage containers. V2 confirmed that temperatures in the refrigerated storage container were high secondary to the warm weather conditions and need to open the door. V2 stated that he had only a few days' notice prior to the work starting in the kitchen and did not have a plan for this project. V2 continued to add that the facility had numerous issues with the refrigerated container and needed to obtain a generator to provide power. V1 also stated a brief notice about the kitchen closure and that corporate had discussed this project but specific plans were not developed. On August 28, 2024, the residents were still being served breakfast at 10:00AM until 10:30AM. R1 was observed without the super cereal (high protein/calorie hot cereal) on his tray. R1's diet is listed in the medical record as no added salt with super cereal supplement for breakfast. R8 was observed with puree eggs, bread, and hash browns on his tray. R8's diet order is listed in the medical record as regular puree diet with nectar thick liquids and house supplement 2.0 three times a day. Residents were being served the meal in take out type containers with milk in disposable Styrofoam cups. V2(Dietary Manager) was asked about the meal and stated that the meal was catered due to the kitchen closure. V2 was asked about the food temperatures and stated, I have them in my head, I have not had time to write them down. V2 was interviewed about preparation of puree food items and stated that the staff was using the blender in the sub kitchen and then cleaning it. This sink was a single hand washing type of sink with one compartment. Space for air drying cleaned items was not noted in place. Later during the tour of the rented food storage containers, V2 stated that the facility was going to use plastic food trays for lunch meal service. V2 then added that the dietary staff would use the sinks in the activity room to clean used food trays and other dietary service equipment and dishware. The two sinks in the activity room were observed to be household type sinks measuring 12 inches by 12 inches that would not allow the food trays or larger pots/pans to be totally submerged for sanitation. Again, space for air drying items was not noted in this area. The only available hand wash sink for food service employees was noted in the service kitchen. This service kitchen is in another area of building and not near the back door entry and outdoor rented food storage containers. This consisted of a large steam table and small hand wash sink. The other hand wash sink located in the main dining area was disconnected and nonfunctional since it was connected to the main kitchen. V7 (Cook) was observed on August 28, 2024, attempting to prepare the puree dinner rolls for the evening meal. V7 was using the food processor in the sub kitchenette with only the single hand sink to provide for cleaning and sanitizing. V7 stated he would clean the food processor in this sink. This same sink would be used for hand hygiene. V6 (Director of Environmental Services from the local County Health Department) was interviewed by phone on August 28, 2024, at 12:52PM and stated that the facility was told, no food preparation on site and that the facility could, plate the catered food. V6 confirmed that additional processing of food for puree diets should not happen on site secondary to lack of hand washing stations and ability to safely clean and sanitize dishware. V6 stated the facility was advised to use all disposable items. The facility's policy for Monitoring Food Temperatures for Meal Services, dated 2020 documents: Prior to serving a meal food temperature will be taken and documented for all hot and cold foods to ensure proper serving temperature. The temperature for each food item will be recorded on the Food Temperature Log. Foods that require a corrective action (such as reheating) will have the new temperature recorded with a notation of the corrective action interventions. The FDA documents in the Food Code of 2022 that, Food employees shall keep their hand hands and exposed portions of their arms clean. Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. Food employees shall clean their hands and exposed portions of their arms as specified. Immediately before engaging in food preparation including working with exposed food, clean equipment, and utensils. Food service employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation. The FDA Code of 2022 also documents that Equipment food-contact surfaces and utensils shall be clean to sight and touch. The code continues to add that when cleaning food contact surfaces and equipment the item must be submersed in the solution between 7 to 30 seconds depending upon the solution for sanitation and then air-dried. The facility submitted the following plan to remove the immediacy: 1. Facility will utilize a local organization's kitchen in [NAME] to prepare mechanical and puree diets for residents that are on puree or mechanically altered diets to have their food safely prepared. This will be managed by the Dietary Director/Designee. Facility spoke with V6 (Director of Environmental Services from the local County Health Department) and V6 approved the facilities use of the local organization's kitchen to be used in the interim. 2. The facility anticipates a completion date of 9/4/24 to have the Local County Health Department come in and inspect the facilities project and approve food service operations. 3. Facility has 1 handwashing sink in each serving room; a total of 1 of operational handwashing sinks since there are two serving rooms in the facility. In addition, the facility will obtain 2 portable hand washing stations to ensure that dietary staff is able to perform appropriate hand washing process. The portables were on site on 8/29/2024. 4. The facility will obtain disposable foil pans. For Utensils, 3 containers will be provided to rinse, wash and sanitize to ensure a method for sanitizing food service equipment and service items between meals to prevent food borne illnesses. This will be on site at local organization's kitchen in [NAME]. Once sanitized the equipment will be transported back to the facility. A delivery was made this morning for additional disposable supplies and the facility can obtain more as needed during this project. Facility will utilize test strips to ensure proper Ph for sanitation. This will be managed by the Dietary Director/Designee and monitored by the facility Administrator. 5. The facility is only storing milk products in the cooler located in the dining room. The cooler temperature is being monitored to maintain at safe temperatures during holding. A log for temperatures will be maintained by the Dietary Director/Designee and is being checked every shift. The facility will continue to cater food for the residents until the project has been completed. Administrator will maintain documentation of temperatures. 6. The facility is having food delivered from vendor in insulated bags via private vehicle to the facility. Food is then transferred back and forth to local organization's kitchen in [NAME] via private vehicle in insulated bags. The facility has developed a temperature tool to monitor and document temperatures of food - pick up time and temps, after transfer time and temps. 7. Prior to start of shift, the Dietary Director/Designee will monitor food temperatures and document temperature on the newly developed log. The Administrator will monitor and maintain these logs daily during the kitchen closure and make immediate corrective action if not complete. 8. An emergency QA meeting has been conducted with facility medical director and IDT team to review the incident and action plan. The facility has reviewed the policies and procedures and has developed and amendment on how the facility will monitor temperatures during this interim. The QA team will also refer this incident for review of emergency action plan for any changes.

Based on observation, interview and record review, the facility failed to identify an infectious outbreak, implement measures to prevent the spread of this infectious outbreak, and failed to have an infection control program in place to monitor and track infectious diseases at the facility. This failure has the potential to affect all 166 residents residing at the facility. The Facility Data Sheet dated 8/29/2023 documents 166 residents reside at the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/11/2023 at 12:37 PM after R1 tested positive for scabies and the facility failed to implement measures to prevent the spread. The Immediate Jeopardy was identified on 9/7/23. V1 (Administrator) was notified of the Immediate Jeopardy on 9/7/23 at 9am. The surveyor confirmed by observation, record review and interview that the immediacy was removed on 9/12/2023, non-compliance remains at a Severity Level Two due to the need to evaluate the implementation of policies and procedures, audits, and quality assurance monitoring. Findings include: The Scabies Outbreak Report documents on 8/24/2023 R7-R41 were identified with rashes that were treated with Permethrin (medicated cream used to treat scabies) beginning 8/25/2023. On 9/1/2023 at 9:21 AM V5 (County Infectious Disease Investigator) stated the facility has been in continuous outbreak status for scabies since 5/11/2023 and the facility just reported a large number of new cases in the past week for which she provided the facility with recommendations in an email on 8/25/2023 to treat the outbreak. On 8/29/2023 at 9:30 AM V1 (Administrator) stated the corporate office reported to her there was an outbreak of rashes at the facility. V2 stated a whole house sweep was completed on 8/23/2023 and the facility identified several residents with rashes. V1 stated V6 (Medical Director) was at the facility to assess the rash outbreak on 8/24/2023 and provided orders to treat the rashes as suspected scabies. V1 confirmed staff were also identified with suspicious rashes. 1. On 9/1/2023 at 11:29 AM, V2 (Director of Nursing) stated R1 tested positive for scabies on 5/11/2023 and the facility policy is for roommates to be treated and isolated in the effected room and if there is an adjoining bathroom, the residents in that room are also treated and isolated. V2 confirmed R1's room had an adjoining bathroom so the residents in the adjoining room were also to be treated. R1's scabies scraping lab report, resulted 5/11/2023, shows R1 positive for scabies. R1's Physician Progress Note, dated 5/5/2023, documents R1 with a scattered red itchy red rash noted from head to toe of his body. R1's Order Recap Report dated 5/1-6/30/2023 does not document R1 being placed in contact isolation. R1- R3's Census List Report dated 9/5/2023 shows R1 residing in the same room as R2 and R3. Census List Report dated 9/5/2023 shows R4 and R5 residing in the adjoining room with a shared bathroom. R2-R5's Order Recap Report dated 5/1-6/30/2023 does not show R2-R5 receiving prophylactic treatment or being placed in isolation. 2. On 8/29/2023 12:39 PM, R7 stated he was hospitalized Father's Day weekend for pain in his foot and during this hospitalization he was diagnosed and treated for scabies. R7 stated he had a rash for approximately 2 months before being hospitalized in June. R7 further stated he was treated again a few days ago and his rash is now gone. R7's scabies scraping lab reports, dated 5/10/2023 and 6/1/2023, shows R7 negative for scabies. R7's Order Recap Report dated 5/1-6/30/2023 documents R7 with orders on 5/26/2023 for Mupirocin twice per day and Doxycycline for 5 days for a rash and Impetigo. R7's Physician Progress Notes dated 5/5/2023 documents R7 with an itchy rash to right upper and bilateral lower extremities. R7's Progress Note dated 6/1/2023 documents R7 with a rash to his arms, abdomen, and legs. R7's Physician Progress Note dated 6/7/2023 documents R7 with a rash to his body and a diagnosis of impetigo was made. R7's Progress Notes dated 6/18/2023 shows R7 sent to the hospital and admitted with a diagnosis of cellulitis. R7's Physician Note dated 6/23/2023 shows R7 diagnosed for scabies during his hospital admission. The Scabies Outbreak Report documents R7 with a rash to his arms, legs, and abdomen, identified on 8/24/2023, and treated for scabies on 8/25/2023. R7's Brief Interview of Mental Status (BIMS) report dated 7/21/2023 documents R7 as cognitively intact. 3. On 8/29/2023 at 12:25 PM R6 stated approximately a month ago he was treated for a rash and itching. R6's Order Recap Report dated 6/1-9/5/2023 shows R6 with orders dated 6/30/2023 for Diphenhydramine for 3 days to treat a rash, and Hydrocortisone 6/30-8/10/2023. R6's Practitioner Visit Note dated 6/30/2023 documents R6 with a rash and itching. R6's Order Recap Report dated 6/1-9/5/2023 shows R6 treated for scabies on 7/28/2023 and 8/5/2023. The Scabies Outbreak Report documents R6 with a rash to his arms, legs, and abdomen, identified and diagnosed as scabies on 7/27/2023 per a positive skin scraping. R6's BIMS report dated 8/22/2023 documents R6 as cognitively intact. 4. On 8/31/2023 at 11:10 AM R11 had scratches and scabs to both her upper arms. On 9/5/2023 at 9:50 AM a skin assessment completed with V7 showed R11's rash improving. R11's Order Recap Report dated 6/1-9/5/2023 documents R10 with orders on 6/12/2023 for Clotrimazole External Cream to her left-hand rash for 10 days, 6/14 and 21/2023 for Promethean Cream, 6/17/2023 with Doxycycline Monohydrate for a skin infection, and Clotrimazole External Cream for a rash 6/22-7/6/2023. R11's Initial Wound Evaluation and Summary Report dated 6/14/2023 documents R11's rash diagnosed as scabies and a reassessment on 6/21/2023 shows R11's rash as resolving. R11's scabies scraping lab report, dated 6/14/2023, shows R11 negative for scabies. On 8/31/2023 at 11 AM V7 stated she noted R11 would screaming out frequently during the day when she had the rash on her hands which is not her usual behavior. On 9/5/2023 at 3:05 PM V23 (Wound Physician) stated she does not usually see residents for skin rashes but did assess R11 as a favor. V23 stated she was suspicious the rash could be scabies and her protocol are if is suspicious, she treats. 5. On 8/31/2023 at 10:50 AM R8 stated, It (rash) is starting to go away. They are finally treating me right. Not sure what they treated me with before. R8 stated the rash is all over and lifted his shirt showing a visible rash to his arms and chest-multiple areas of this rash showed healing scratches and scabbed lesions. R8 stated, I had it a long time .I have been suffering for a long time. I scratch and bleed, I am up all night, and I was not getting any relief. On 9/5/2023 at 9:25 AM a skin assessment completed with V7 showed R8's rash resolving. R8 stated, he is feeling a lot better. R8's Physician Progress Notes dated 4/28, 5/8, 5/16, 6/6, and 8/3/2023 document R8 with itching and rashes to his body. R8's Order Recap Report dated 6/1-9/5/2023 documents R8 with orders 6/2/2023 for Triamcinolone Acetonide External Cream twice a day through 8/3/2023 for itching and Hydroxyzine at bedtime for itching (order continues). R8's scabies scraping lab report, dated 4/10/2023, shows R8 negative for scabies. 9/6/2023 6:59 AM V24 (Night Nurse) stated he was not sleeping well because of the itching from his rash but after the Hydroxyzine was ordered that did help. Since he was treated with Promethean he is improving. R8's BIMS dated 7/4/2023 documents R8 as cognitively intact. 6. On 8/31/2023 at 10:56 AM R9 stated, I have been scratching the (heck) out of them. R9 stated he has been scratching at his itchy rash for a couple of months, and since a cream was applied a few days ago it is now going away. R9 exposed his arms which had a resolving red rash and scratches to both his arms. On 9/5/2023 at 9:30 AM a skin assessment completed with V7 showed R9's rash resolving. R9 stated, his rash is much better. R9's Order Recap Report dated 6/1-9/5/2023 documents R9 with an ongoing order dated 6/23/2023 for Triamcinolone Acetonide External Cream for itching twice daily. R9's Weekly Skin Observation Notes dated 7/5/2023 documents R9 with healing scabs to shoulder from scratching, 8/9/2023 with a rash to back and chest and scabs to lower extremities. R9's Physician Progress Notes dated 8/1, 18 and 21/2023 document R9 with a rash to his body. R9's scabies scraping lab report, dated 7/31/2023, shows R9 negative for scabies. R9's BIMS dated 8/5/2023 documents R9 with moderate cognitive impairments. 7. On 8/31/2023 at 11:13 AM R12 was noted with scratches and a rash to his abdomen, entire right arm and from his left elbow up toward his shoulder. R12 was scratching at these areas stating he itches. On 9/5/2023 at 9:40 AM a skin assessment completed with V7 showed R12's rash was resolving but he was continuing to itch. R12's Order Recap Report dated 6/1-9/5/2023 documents R12 with orders dated 6/30/2023 for Hydrocortisone Cream to abdomen, chest, and left trunk for 10 days and Diphenhydramine for 3 days for itching, 7/18/2023 for Hydrocortisone Cream to abdomen, chest, and left truck for 10 days for itching. Another order on 8/2/2023 documents Hydrocortisone to abdomen, chest, arms for severe itching and rashes related to restlessness and agitation. An order 8/18/2023 documents R11 to receive Diphenhydramine at bedtime and Loratadine every morning for a rash. R12's Progress Notes dated 6/30-8/23/2023 do not document any assessments of R12's rash. 9/6/2023 6:59 AM V24 (Night Nurse) stated R12 had the worst time sleeping because of itching, .I felt sorry for him. He would be up at night unable to sleep because of the scratching . V24 stated he is much better and sleeping again. R12's BIMS dated 8/8/2023 documents R9 as severely cognitive impaired. 8. On 8/29/2023 at 12:21 PM R10 laid in bed scratching at her arms which had scabbed scratches in various stages of healing and open bleeding wounds up and down both of her upper arms and chest. On 9/5/2023 at 9:45 AM a skin assessment completed with V7 showed R10's rash to her arms almost gone and the rash to the chest improving. R10's Order Recap Report dated 7/1-9/5/2023 documents R10 with orders dated 7/22/2023 for Alclometasone Dipropionate External Cream for 7 days and Claritin daily (current order) for a rash, 8/18/2023 for Diphenhydramine and Loratadine for 5 days for a rash and 8/23/2023 for Alclometasone Dipropionate Cream for 7 days for a rash. R10's Progress Notes dated 7/22-8/23/2023 do not document assessments of R10's rash. 9. R29's Order Recap Report dated 6/1-9/5/2023 documents R29 with a current order dated 6/20/2023 for DermaCerin External Cream twice a day for itching to left abdominal area. R29's Progress Notes dated 6/20/2023 documents R29 with complaints of itching and a rash to her trunk. A note dated 7/10/2023 documents R29 with a rash and complaints of itching with no new orders. 10. R36's Order Recap Report dated 7/1-9/5/2023 documents R36 with orders dated 7/22/203 for Triamcinolone Acetonide External Cream for 7 days to a rash to his right underarm and face, and 8/8/2023 for Cephalexin Oral Capsule and Mupirocin (antibiotics) for 7 days for a rash. R36's Physician Progress Notes dated 7/12/2023 document R36 with a rash and on 8/7/2023 with itching and rash to his bilateral arms. 11. R35's Order Recap Report dated 7/1-9/5/2023 documents R35 with an order dated 7/22/2023 for Hydrocortisone to bilateral leg rash twice a day for 7 days. R35's Progress Notes dated 7/22-8/23/2023 do not document any assessments of R35's rash. 12. On 8/31/2023 at 10:05 AM R15 stated she had a rash to her arms and legs with itching for about a month. On 8/31/2023 at 10:10 AM R14 stated he had a rash to his legs with itching for about over a month. Both these residents reside in the behavior health area at the facility. On 8/31/2023 at 10:05 AM R20 stated he had a rash to his entire body with itching for about a month. R20 residents on the main resident living area. On 9/1/2023 at 12:54 PM, V7 (Nurse) stated rashes were consistently present after being identified for R9, R10, R12, and R35 and intermittent for R21 and R36. V7 stated if the resident ran out of their ordered treatment cream, she would place the resident on the physician list for renewal. V7 further stated, if she still had some treatment cream left, she would apply it as needed when the nursing assistants reported the rash or itching and confirmed she was applying these treatments, even if the order was not currently in place. On 8/29/2023 11:03 AM V2 (Director of Nursing) stated the facility noted rashes in the building the 2nd week of July and did a sweep through the building between 7/11-13/2023, with the main focus on the dementia area. V2 confirmed direct care staff also reported rashes but continued working. On 8/29/2023 at 10:20 AM V3 (Acting Infection Control Preventionist) stated she started employment at the facility on 8/22/2023, on 8/23/2023 an in-service was completed with staff to ensure rashes were identified and reported; we in-service staff because the rashes were prevalent and noticeable. On 8/24/2023 she was notified by employees that they had rashes that they reported have been present anywhere from 10 days to 3 months. 8/29/202 11:19 AM V7 (Nurse) confirmed she is the nurse on the dementia area and is working on this date providing direct care to residents. V7 was wearing short sleeve shirt and had a rash visible to her arms, stating she also has the same rash behind her knees, abdomen, and feet for approximately 1- 2 months. V7 stated she reported this rash to V8 (Wound Care Nurse) at the time she noticed it. V7 stated after V6 (Medical Director) came and assessed the residents on 8/24/2023, V4 (Quality Assurance Nurse) instructed staff to apply Promethean cream, but she has not because the cream was not available on 8/24/2023, on 8/25/2023 she was off, there was nobody present at the facility on 8/26-27/2023 to issue her the Promethean cream and still has not yet received it as of the time of this interview. V7 stated the facility did not tell her she could not work with her rash and has worked 8/26, 27, and 29/2023 without being treated. V7 stated she primarily works on the dementia area and first noted R11 with a rash approximately 2 months prior and reported R10 currently has the worst rash. V7 further stated R11, R29 and R35 have been placed on the physician list for a few weeks related to their rashes which are not resolving. On 8/29/2023 at 11:51 V10 (Nursing Assistant) confirmed she is primarily assigned to the dementia area and is working on this date providing direct care to residents. V10 was wearing short sleeve shirt and had a rash visible to her arms stating she also had the same rash to her legs and abdomen. V10 stated her primary assignment is the dementia area and she has not been treated because they told her they were out of Promethean and needed to order more; V10 was off 8/25-28/2023. V10 stated she reported her rash to a nurse a while back but does not remember who. V10 stated there was a facility meeting approximately 8 weeks ago with V2 and V4 and during this meeting the staff were asked to put up hand if they had a rash which multiple staff did. V10 stated some residents have had a rash for 2-3 months and some have creams ordered which are being applied by nurses. V10 stated she has reported and observed rashes to R8, R9 and R41. On 8/29/2023 at 12:10 PM V9 (Nursing Assistant) confirmed she is a nursing assistant assigned to work on the dementia area and is providing direct care to residents on this date. V9 had on a short sleeved and had a visible rash to her hands but stated she also has a rash to her stomach, feet, and back for approximately 2 months. V9 stated she treated herself 3 weeks ago with a bottle of Promethean provided by V8 (Former Wound Nurse) in the past but has not received treatment since. V9 stated she has reported these rashes multiple times to multiple people, including V2, V4 and the regular floor nurses. V9 stated she has never been taken off work. V9 stated the first resident she noted with a rash was R8 about 3 months ago, then after that she saw R11. On 8/31/2023 at 11:20 AM V9 stated she worked 8/30/2023 until approximately 8:30 AM when they sent her home instructing her to treat her rash and report back to work 8/31/2023. V9 said she on occasion will work on other units in the facility. On 8/29/2023 11:30 AM V11 (Nursing Assistant) confirmed she is a nursing assistant assigned to work on the dementia area and is providing direct care to residents on this date. V11 was wearing short sleeves and had a visible rash to her arms, and reported she also has the rash to her wrists, stomach, and underarms. V11 stated R9 and R41, who reside in the same bedroom, had rashes approximately 1 month after her return from medical leave. V11 stated she reported the resident rashes which was reported to V7 who would apply treatments, but the rashes were not resolving. V11 stated on 8/22/2023 she noted rashes to R9, R36, R40 and R12 while providing care. V11 stated she told V4 on 8/24/2023 that she had a rash, and he did not remove her from directly providing care to the residents but offered her to see the company workers compensation nurse. V11 stated she treated herself with Promethean cream she purchased herself on 8/25/2023 after working her shift. On 9/5/2023 12:37 PM V1 confirmed V11 returned from medical leave on 9/5/2023. On 8/30/2023 at 1:10 PM V14 (Nursing Assistant) stated she primarily works in the dementia area and routinely takes care of R8, R11, R29, and R10 who all have had rashes for the past 2 months. V14 stated she will occasionally work on other units in the facility. V14 had a rash visible to her arms and stated she is providing direct care to residents on the dementia area on this date. V14 stated she has reported her ongoing rash to V1, V2, V4, V7, V8, and V15 (Wound Care Nurse). V14 stated, V15 scraped her for scabies in June and it came back negative and gave her Promethean cream. V14 stated she also worked 8/28/2023 and has not treated or been removed from resident contact. On 8/29/2023 at 12:23 PM V12 (Nursing Assistant) stated she has been employed at the facility for 3 weeks. V12 stated she worked 8/24, 8/25, and 8/28/2023 and was first treated after work on 8/28/2023 after she went to the emergency room. V12 stated she reported her rash to her stomach, arms, and chest to the nurses and V4 last week when first noted it and was not told to remain off work. On 8/31/2023 at 11:00 AM V28 (Agency Nursing Assistant) stated he is agency and works at other facilities, only working at this facility a several days per month. V28 stated when he works, he is scheduled in all the different areas within the facility. V28 showed a visible rash to both his forearms stating it stared on 8/28/2023. He stated when he arrived to work on 8/29/2023 he was sent home and has since been treated. On 8/29/2023 at 1:07 PM V13 (Nursing Assistant) stated she started at the facility on August 1, 2023, and trained and worked throughout the facility. V13 stated she has a rash for a week and a half and received treatment outside of the facility on 8/24/2023. V13 stated when she started there were multiple residents in the facility with rashes, but she can only remember, R9 and R12 had rashes while she cared for them. The Daily Staffing Schedules show on 8/22/2023 V13 worked the main residential unit, 8/25 and 28/2023 working the dementia unit and 8/29/2023 working the regular unit but escorted a R36 to an appointment in the community. On 9/1/2023 at 1:55 PM V25 (Restorative Nursing Assistant) stated she had a rash which she did not report to the facility and treated herself on 8/21/2023 with Promethean cream the facility provided her last year. V25 stated her rash resolved after she treated herself. V25 confirmed she provides care to residents throughout the facility. On 8/31/2023 at 11:35 AM V20 (Human Resources) stated a couple of months ago there was a staff meeting and some staff, including V10 and V14, reported they had rashes. An in-service sheet dated 7/14/2023 document V10 and V14 attended this meeting. On 8/31/2023 at 11:48 AM V2 (Director of Nurses) stated she has been employed at the facility since October 2022. V2 stated she did not notify or involve V6 (Medical Director) of the outbreak of employee and resident rashes until their corporate office contacted the facility. V2 stated she was unaware a negative skin scraping did not necessarily indicate a resident did not have a scabies infestation. V2 stated she has an ongoing argument with wound care nurses as to who should track and monitor rashes, stating the wound care nurses state they do not track or monitor rashes. V2 stated currently there is no specific facility protocol to track and monitor rashes but the nurses and herself are responsible for tracking, monitoring, and reporting these rashes. V2 confirmed there was no facility infection control surveillance being completed at the facility prior to June 2023 to monitor resident infections and outbreaks, except for Covid, and no employee tracking at all. V2 stated the employees did report itching and rashes in July and the staff affected were instructed to go through their dermatologist or they were informed they could see the facility workers compensation nurse. No employees were removed from direct resident care. V2 stated she had no direction, and she was doing the best she could. V2 stated she has since become aware V8 had provided some employees with cream to treat scabies while he was employed at the facility. The Employee Rash Survey provided 9/6/2023 at 9:04 AM additionally documents V26-34 (Nursing Assistants) and V35 (Nurse) with rashes. The Monthly Infection Log was provided on 8/31/2023 for the months June-August 2023 for residents. No rashes which were identified between June-August were present on these logs and no logs were provided for employees. The facilities Daily Staffing Schedules showed on 8/25/2023 V11, V12 and V14 worked at the facility, on 8/26 and 27/2023 V7 worked on 8/28/2023 V7, V12, and V14 worked, and on 8/29/2023 V7, V9, V10 and V14 worked. The Daily Staffing Schedules show V34 (Nursing Assistant) worked the main residential unit on 8/23/2023, the dementia area on 8/25 and 8/28/2023; V33 (Nursing Assistant) worked the behavior health unit on 8/22 and 8/24/2023 and the dementia area on 8/26-27/2023. On 9/1/2023 1:29 PM V6 (Medical Director) stated he was at the facility to assess the residents last week. V6 stated the rashes he saw appeared to be an infectious rash and he is treating those rashes as suspicious for scabies. V6 stated the big picture is to prevent this from happening again and he has discussed protocol going forward so an outbreak at this level can be prevented in the future. V6 stated he was not aware of the number of resident and employee rashes further stating he does expect the facility to let him know, follow the protocol, and monitor and report to the physicians as they should. V6 stated employees with rashes need to be assessed to determine if it is infectious and removed from work if infectious to prevent spreading. V6 confirmed scabies is worse at night and if the scraping is negative, it does not rule out scabies as the cause of the rash. V6 confirmed delay in treatment can cause spread of the rash and residents experiencing symptoms, but each resident needs to be assessed and evaluated individually. On 9/5/2023 at 11:56 AM V21 (Local Health Department Epidemiologist) stated any new onset rash that appears to be spreading or affecting more than one resident should be suspected as possibly contagious and investigated to determine the diagnosis and medically investigated to determine if it is infectious. Until the rash can be ruled out as not infectious, residents should be isolated, and employees should not provide direct care. V21 stated the County Health Department expects the facility to follow Center for Disease Control (CDC) guidelines, monitor their infectious diseases at the facilities, report their outbreaks, and follow protocols to prevent outbreaks. V21 stated failure to contain the spread is up to the facility to monitor and work with their Medical Director to determine the cause of the rash, establish a treatment plan, and implement of measures to prevent the spread. V21 confirmed if a scraping resulted as negative that does not mean the resident does not have scabies, stating it is up to the facility and the Medical Director to diagnose and treat accordingly. V21 confirmed if treated for scabies and symptoms resolve, the rash is likely from scabies, particularly if there have been recent exposures. V21 confirmed, if an affected person is treated and the rash resolves, and then re-occurs, there is likelihood they were re-exposed again and re-infected. V21 stated untreated scabies can lead to further spread within the facility, in the community and to the family of employees. V21 stated if a person with scabies goes untreated, they will continue with symptoms, including an itching rash, often more prevalent at night, and potential infection of the wounds from scratching. V21 stated, it is negligent for the facilities not to take the proper care to prevent the spread and to follow CDC guidelines and lack of surveillance and delay of treatment causes ongoing transmittal and spread. Email correspondence dated 8/24/2023 at 4 PM between V1 and V5 includes direction from V5 that all residents and employees (symptomatic and asymptomatic) should be treated on the same day. This email includes an attached document titled, Management of Scabies in Illinois Healthcare and Residential Facilities. This document includes guidance including, healthcare workers should immediately report any signs of infestation to themselves or residents to the infection control practitioner and should have process in place to identify and controlling a scabies outbreak. Signs and symptoms include rash to the skin which may vary greatly in appearance according to pre-existing skin conditions and the site, and secondary bacterial infections may develop because of intense scratching caused by the mites. The Scabies Control policy dated 2/15/2018 documents scabies is a highly communicable disease of the skin caused by the itch mite. The purpose is to eliminate and treated irritated skin areas and prevent the spread of infection. Signs include intense itching and eruptions of burrows which is transmitted by physical contact. The physician is to be notified promptly upon identification and the physician will provide an examination. Treatment for residents infected or being considered for prophylactic treatment will be provided and all affected individuals will be completed at the same time. Contact isolation will be initiated until after initial treatment. The Infection Surveillance, Tracking and Reporting policy dated 2/14/2018 documents the purpose is to identify, monitor, track and report infections and monitor adherence to infection control practices. Infection tracking includes but is not limited to completing infection tracking logs for all residents with an infection, monitor for trends by unit/location, clusters of the same infection, outbreaks and employee illnesses, track resident and staff outbreaks and complete outbreak line-listing report/investigation. The Immediate Jeopardy that began on 5/11/2023 was removed on 9/12/2023 when the facility took the following actions to remove the immediacy: 1. House wide skin checks of residents was completed by nursing staff on 8/23/23. Residents identified with skin rashes were given treatment of Permethrin cream 5% and placed on contact precautions until treatment was completed by nurses. All residents identified with skin rashes received second treatments by nursing staff. Exposed residents (asymptomatic) were educated and treated prophylactically with Permethrin cream 5% and placed on contact precautions until treatment was completed by nursing staff. 2. All staff were checked and or interviewed for any signs and symptoms of any skin rashes by Nursing staff. All staff were provided with Permethrin cream 5% and completed treatment overseen by Infection Preventionist. 3. All staff were in-serviced regarding guidance on Infection Control: Identification of outbreaks and implementation of measures to prevent the spread once outbreak occurs, education of general communicable diseases, contact precautions, and prevention of transmission of any communicable disease and prevent further spread. Any new employees, agency staff and any staff on vacation shall receive in-service prior to working on the unit. 4. Skin checks to be completed for all new resident admissions upon arrival at the facility and will be performed by nursing staff to be monitored by Infection Preventionist (IP). 5. New hire staff will complete a self-skin assessment questionnaire during first day of orientation. 6. Facility has implemented an infection surveillance procedure to monitor and track outbreaks for both residents and employee infection and identify outbreaks. 7. Call off log will be monitored by IP and Administrator daily to identify staff with potential infectious illness. Any staff identified with a rash will not be able to return to work without proper medical clearance to be monitored by Human Resources and IP. 8. Resident and employee skin checks will continue weekly until outbreak ends. 9. Audits will be conducted weekly to ensure that skin checks are completed to be overseen by IP and Administrator. 10. Any new occurrences of rash will be assessed by nurse, findings will be reported to Director of Nursing, or IP, proper notification to family and proper physician notification, in house skin assessment by MD/NP for appropriate treatments and interventions. 11. Currently new hired IP to complete CDC infection control training. 12. Emergency Quality Assurance Performance Improvement (QAPI) with Medical Director was done and action plan will be reviewed monthly during QAPI meeting thereafter overseen by Administrator and IP nurse.