**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observations of Staff F, Housekeeper, with her mask down below her nose a. On 7/25/22 at 11:31 AM: Staff F entered and exited rooms in the 200 hall with her mask worn below her nose. b. On 7/25/22 at 1:55 PM: Staff F seen in the intersection of the 200 and 300 hall with a mask worn below her nose. c. On 7/26/22 at 8:01 AM: Staff F worked in the 200 hall with her mask worn below her nose as residents passed by. d. On 7/26/22 at 9:50 AM: Staff F observed at the intersection of 200 and 300 hall with a mask worn below her nose as residents passed by. e. On 7/27/22 at 8:01 AM watched Staff F in the 200 hall wearing a mask below her nose as a resident passed by. When asked if she had trouble with the mask staying on her face, Staff F stated that she pulls her mask down sometimes because it gets hard for her to breathe. On 7/26/22 at 3:55 PM, the Administer and DON reported that they expected staff to wear their PPE appropriately. The DON acknowledged that she previously addressed mask expectations with Staff F. The Personal Protective Equipment Guidelines policy updated 6/7/22 directed that all facility personnel should wear source control (a well-fitting mask or a N95) when in resident care areas and/or when it is likely that they could encounter another person. The mask or respirator should cover the individual's nose and mouth at all times. 6. Resident #1's MDS assessment dated [DATE] identified a BIMS score of 9, indicating moderately impaired cognition. Resident #1's diagnoses included non-Alzheimer's dementia, obstructive sleep apnea (adult), and obesity. On 7/25/22 at 1:33 PM, observed Resident #1 with a loose hacky, productive cough. Resident #1 reported that he tested negative for COVID the day before and the day of the interview. Resident #1's cough appeared to be frequent as it occurred approximately every 30-90 seconds. At the time of interview Resident #1 was not in transmission based precautions (TBP) for symptoms of COVID. On 7/25/22 at 4:16 PM noted that Resident #1 could be heard coughing in the hall. TBP not initiated. In an interview on 7/26/22 at 9:05 AM, the Administrator reported that Resident #1 tested positive for COVID. The facility failed to initiate TBP until 9:29 AM by the DON. On 7/26/22 at 2:06 PM, the DON reported that the facility did not initiate TBP unless the resident had a positive test result for COVID. The Personal Protective Equipment Guidelines policy updated 6/7/22 instructed staff about providing care for a COVID positive person or a person in quarantine. Personnel who enter the room of a resident with suspected or confirmed COVID infection should adhere to Standard Precautions and use an N95, equivalent, or a higher-level respirator, gown, gloves and eye protection. The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes. Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection, last updated on Feb. 2, 2022 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) indicated that when healthcare professionals cared for residents with suspected or confirmed SARS-CoV-2 infection they should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). The facility abated the IJ on 7/27/22 after initiating the following corrective actions: 1. The facility established a COVID wing behind a set of double doors that would remain closed until the facility is out of outbreak status. 2. The facility replaced the cloth gowns with disposable gowns in the isolation areas. 3. All staff received education on the proper use of PPE. 4. The facility would assign designated staff to the COVID hallway whenever possible. Based on observations, interviews and record review the facility failed to implement adequate infection control strategies and practices to mitigate the transfer of viruses for 7 of 29 residents reviewed. In a series of observations on 7/25/22 and 7/26/22 it was discovered that residents that tested positive and negative for novel Coronavirus 2019 (COVID) remained in the same hallway, and many times had their bedroom doors left open. An observation showed staff not wearing full Personal Protective Equipment (PPE) when administering a nasal COVID test to a symptomatic resident, staff wore surgical masks improperly, and a symptomatic resident did not have isolation precautions and later tested positive for COVID. The facility reported a census of 28 residents. Due to these findings, the care of the residents, their health, and safety resulted in an immediate jeopardy (IJ) situation on 7/26/22. The facility removed the IJ situation on 7/27/22 decreasing the scope to an F. The facility reported a census of 29 residents. Findings include: On 7/25/22 at 9:35 AM, the Administrator reported that they had five residents that tested positive for COVID at that time. The Director of Nursing (DON) stated that the COVID positive residents stayed in their rooms on isolation precautions and added that the facility did not have the proper set up to provide a designated unit to separate those who tested positive from the healthy residents. 1. On 7/26/22 at 6:05 AM observed a cloth gown hanging on the outside of the open door to room [ROOM NUMBER]. On 7/26/22 observed the door to room [ROOM NUMBER] wide open at 10:00 AM and 12:06 PM. The Health Status Note dated 7/24/22 at 7:00 AM documented that Resident #23 got tested with a rapid COVID test twice. Each test result indicated Resident #23 as positive with COVID. Resident #23's skin, warm, and dry. The auscultation (listening) of Resident #23's lungs determined them to be clear with an occasional nonproductive cough reported by Resident #23. Resident #23 denied shortness of breath (dyspnea) and not feeling well. Isolation precautions initiated and explained to Resident #23. 2. On 7/26/22 at 8:47 AM, noted room [ROOM NUMBER] with their door wide open. On 7/26/22 at 9:24 AM observed the door to room [ROOM NUMBER] remained wide open and with the resident coughing. On 7/26/22 witnessed the door to room [ROOM NUMBER] open at 7:45 AM and 8:47 AM. The review on 7/28/22 at 1:43 PM of Resident #2's electronic health record determined the diagnosis tab listed Resident #2 in room [ROOM NUMBER]. The diagnosis of COVID got added to Resident #2's chart on 7/25/22. 3. On 7/26/22 at 11:15 AM witnessed the door to room [ROOM NUMBER] wide open with a container of PPE outside the door. On 7/26/22 at 12:06 PM saw the door to room [ROOM NUMBER] open. On 7/26/22 at 12:23 PM Staff D, Dietary, put on a cloth gown and went into room [ROOM NUMBER]. She soon came back out of the room wearing the same gown, gathered more items from the food cart in the hallway, and went back into room [ROOM NUMBER]. Staff D then exited out of room [ROOM NUMBER] and stood in the middle of the hallway. Staff D asked several staff members what she should do with her PPE. She explained that she just started and didn't get trained on PPE use. The Health Status Note documented that Resident #24 had no signs or symptoms per the list of CDC guidelines of apparent illness indicating COVID noted that shift for the following notes: 7/24/22 at 10:09 AM, 7/24/22 at 3:10 PM, and 7/25/22 at 4:23 AM. The Condition Note dated 7/25/22 at 1:53 PM documented that Resident #24 tested positive for COVID that morning. Resident #24 continued to cough and have congestion. Resident #24's electronic health record reviewed 8/1/22 at 1:19 PM diagnoses tab got updated with the diagnosis of COVID on 7/29/22 for a diagnosis date of 7/25/22. 4. On 7/26/22 at 8:40 AM, observed Staff C, Social Services, enter Resident #16's room, number 116, without wearing a gown. After she entered the room she administered a COVID nasal test. From there Staff C went into Resident #14's room. The Communication Note dated 7/26/22 at 3:37 PM documented by Staff C indicated that they visited with Resident #16's responsible party about moving him temporarily out of his room to remove him from the COVID area of the building as he did not have signs or symptoms. On 7/26/22 at 2:06 PM, the Director of Nursing (DON) said that they used cloth gowns due to the shortage of PPE back in 2020 and Public Health told them it was acceptable to use the cloth gown. She said that she had taught staff to use them only once and that they were not to hang them on the outside of the door. The DON said that the facility wasn't set up to have a separate COVID unit and they didn't feel that it was in the best interest of the residents to move them if/when they tested positive for COVID. She said that they did not talk about plans for a possible outbreak but that they all had the knowledge base to handle an outbreak. The DON acknowledged with the resident isolating in their rooms, the doors should have been closed and that the staff knew to close the doors. The DON explained that she felt they should be closed. The DON began typing up a list of processes to follow for isolation precautions to put at each room and said that she would add it to the list to remind staff to close the doors. She reported that she was making up a list of reminders to put outside of the residents rooms. On 7/26/22 at 2:13 PM the DON said that she instructed the dietary staff to stay out of COVID positive rooms. She also told staff to keep the doors closed to positive rooms and instructed staff not to hang used cloth gowns on the outside of the bedroom doors.