**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. In September of 20, the facility was cited for failure to implement and monitor an effective screening process for staff to prevent a novel Coronavirus Disease (COVID-19) outbreak. The facility implemented a screening policy that indicated nurses, or any department head, could screen employees upon entrance to the facility. In March of 21, the facility revised the policy and established that any staff could witness another employee screening prior to working. The facility lacked evidence of monitoring the new policy and, on [DATE], a facility staff member failed to screen themselves for symptoms of COVID-19 prior to working her shift and knowingly worked while having symptoms of COVID-19. As a result, ten facility residents and six additional staff members tested positive for COVID-19. The lack of screening by facility staff placed all residents and staff at risk of contracting COVID-19. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.75(g) - Quality Assurance and Performance Improvement (QAPI) at a scope and severity of K. The IJ began on [DATE] at 2:00 PM, when Staff A, Registered Nurse, started her shift without self-screening and worked while having COVID-19 symptoms. The Administrator was notified of the IJ on [DATE] at 12:08 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 7:00 PM. The IJ was removed on [DATE] at 1:10 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F867 remained at the lower scope and severity of a pattern of an E, with no actual harm and potential for more than minimal harm that was not immediate jeopardy. Findings Included: A review of the facility's, QAPI Written Plan, with no revision date, revealed, .The purpose of QAPI for [the facility] is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to provide home like levels of care where residents feel loved, valued, safe and content . The outcome of QAPI in our organization is the quality of care and quality of life of our residents . 3. How the QAPI Plan will address key issues: .We will track, investigate, and try to prevent recurrent of adverse events . A review of the Statement of Deficiencies and Plan of Correction, Centers for Medicare and Medicaid Services (CMS) Form 2567, dated [DATE], revealed, .The facility failed to implement and monitor an effective screening process for staff to prevent a Coronavirus Disease (COVID-19) outbreak for 20 of 33 residents . Twenty of the facility residents tested positive for COVID-19 including one resident who passed away by the end of survey [DATE] . Further review of the Plan of Correction revealed a Staff Screening for the Pandemic procedure that stated, any department head or nurse can screen employees. A review of the facility's Risk Assessment on Change in Policy for Staff Screening, dated [DATE], revealed the Infection Control/QAPI Committee met to analyze the facility screening process. The risk assessment revealed the committee reviewed the current process that indicated, since September of 20, when a staff member arrives at work, a nurse or manager would screen the incoming staff member, asking the standard Covid-19 screening questions, witnessing the temperature reading from the wall mounted machine, or using the handheld temperature thermometer. The staff member or supervisor would record the findings on the daily log sheet . Anything outside of normal parameters would be immediately reported to the Charge Nurse or the Director of Nursing Services for further screening. Further review revealed a modification that stated staff may now screen in at the beginning of their shift using any staff member as witness. The witness is no longer required to put down their initial. It is of utmost importance that the witness must report any signs or symptoms, including temperature over 100 degrees, to the Charge Nurse immediately. The justification for the change in policy revealed the infection control/QAPI committee has studied the overall screening process . The committee feels that any coworker should be competent to witness another employee screen in. The assessment did not include how the facility would monitor or track the progress of this change. During an interview on [DATE] at 3:47 PM, Staff A, Registered Nurse (RN), stated she tested positive for COVID-19 on [DATE]. Staff A stated that she had worked the previous day, [DATE], from 2:00 PM to 8:00 PM. Staff A stated that she woke up on [DATE] feeling like she had allergies due to mowing the grass the day before. Staff A stated that throughout her shift, the symptoms got worse and included severe gastrointestinal (GI) symptoms, vomiting, dry heaving, fever, weakness, fatigue, sinus pressure, very stuffy, sore ears, and headache. Staff A stated she usually filled out the COVID screening form but did not remember what she documented on [DATE]. Staff A stated she was scheduled to work a 16-hour shift on [DATE] but called out sick. The facility asked her to come in to take a COVID-19 test, which she did, and it was positive. A review of the Daily Temps and Screening for COVID-19 on [DATE] revealed Staff A, did not self-screen before starting her shift. A review of the Evening Shift Assignment indicated Staff A was scheduled to work from 2:00 PM to 10:00 PM on [DATE] and worked the 100 Hall, providing direct care to 18 residents. A review of a list titled, Covid Suspected or Confirmed, revealed the resident list included five COVID-19 positive residents on 100 Hall (Resident #21, Resident #17, Resident #31, Resident #19, and Resident #13) and five COVID-19 positive residents on 200 Hall (Resident #2, Resident #6, Resident #12, Resident #10, and Resident #3). The document indicated that within the last four weeks, the ten residents who tested positive started on [DATE] and ended on [DATE]. During an interview on [DATE] at 11:51 AM, the Administrator (ADM) reviewed the facility's Quality Assurance Program with the surveyor. He explained the team met quarterly unless an issue were to arise. The ADM stated that issues were monitored as long as they need to be and further stated that once improvement was seen they would downgrade the monitoring. The ADM couldn't provide any information regarding the previous F880 IJ cited in [DATE], only stating that the committee addressed the IJ and stated it was related to the previous administrator. Removal Plan As of the afternoon of [DATE], the following procedures were put into place to correct the F865 [F867] deficiency: 1. [Facility] QAPI Committee will be called to order on the afternoon of [DATE] to review the F880 IJ tag, examine where the process failed and study the corrective actions currently put into place to immediately correct the deficiencies stated and make any further recommendations to improve the process. 2. Added to the QAPI committee is the newly hired Infection Preventionist that will bring a a higher level of professionalism to our process and help ensure compliance. Going forward, the QAPI committee will review past compliance issues at each meeting (agenda item) and document the discussion in the minutes. 3. A nurse consultant will be brought in on [DATE] to review our overall QAPI process and make recommendations for any needed changes in order to prevent further issues. 4. Staff will be educated on the facility's screening process for signs and symptoms of Covid-19 and the importance of reporting said signs and symptoms of Covid-19 to their supervisor. They will sign off acknowledging their understanding/competence of the issue. 5. This will be implemented today ([DATE]) by the Administrator. The IJ will be removed on [DATE]. Onsite Verification: The IJ was removed on [DATE] at 1:10 PM after the survey team performed onsite verification that the Removal Plan had been implemented. A review of the Special Session of QAPI Committee Re [regarding]: F865 [F867] IJ Tag revealed the facility conducted a QAPI meeting on [DATE]. A total of 17 staff interviews were conducted on [DATE] with staff from all three shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants (CNAs), Registered Nurses (RNs), Housekeeping, Environmental Services, Kitchen Staff, and the Activity Director. The staff interviewed verified that they received training on reporting signs and symptoms of COVID-19, the screening process before entry into the facility, the proper fit, and use of N95 respirators. A review of the in-service sheets provided indicated that all 67 staff members had been provided training on reporting signs and symptoms of COVID-19, the screening process before entry into the facility, the proper fit, and use of N95 respirators. Those staff who were not physically present to provide the in-services were messaged via telephone with the in-service information provided and the employee acknowledging receipt and voicing understanding. During verification of the Removal Plan, the Administrator introduced the nurse consultant to the surveyor and provided a document indicating that the nurse consultant arrived at 9:45 AM on [DATE], to assist the Administration staff with auditing their Infection Control compliance as well as assisting them in their plan of correction, education, audit tools, and ongoing QAPI PIP's [performance improvement plans].

Based on observations, record review, staff interviews, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program to prevent the transmission of novel Coronavirus Disease 2019 (COVID-19). Specifically, 1. The facility failed to implement and monitor an effective screening process for staff to prevent a COVID-19 outbreak for 10 (Residents #21, #17, #31, #19, #13; #2, #6, #12, #10, and #3) of 34 residents. The lack of effective screening resulted in a staff member being able to work while exhibiting symptoms of COVID-19. Ten of the facility residents tested positive for COVID-19, as well as six other staff members. 2. The facility failed to implement a respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protections standards, which included medical evaluations, training, and fit testing for the use of N95 respirators. Two COVID-19 positive staff, one of whom wore an N95 respirator incorrectly, were allowed to work with COVID-19 negative residents. The facility reported a census of 34 residents. Ten residents had tested positive for COVID-19. The facility identified the first COVID-19 positive resident in the facility on 5/15/22. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 (Infection Control) at a scope and severity of K. The IJ began on 5/11/22 at 2:00 PM, when Staff A, Registered Nurse (RN), started her shift without self-screening and worked while having COVID-19 symptoms. The Administrator received notification of the IJ on 5/19/22 at 12:08 PM. At that time a Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 5/19/22 at 7:00 PM. The IJ was removed on 5/20/22 at 1:10 PM after the survey team performed onsite verification of implementation the Removal Plan. Noncompliance for F880 remained at the lower scope and severity of a pattern of an E, with no actual harm, and a potential for more than minimal harm that was not immediate jeopardy. Findings Included: A review of the facility policy titled, Staff Screening & [and] Return to Work Protocols, revised on 1/10/22, indicated, 1. All employees will enter and exit through a specific entrance door, as designated to them by their supervisor, that is setup with equipment and a log book to allow for screening of an employee prior to having access to any other areas in the facility. 2. Screening is to be done by a nurse, a department head, or an employee trained to properly screen by a nurse or department head. If an employee has been trained to screen for Covid-19 [sic], a note shall be placed in that employee's education file indicating the date of training and what was covered in the training. At the discretion of a community's Administrator based on vaccination rates of staff, tenants, and residents as well as a review of positivity rates and community transmission, self-screening by asymptomatic employees may be allowed. Employees with signs or symptoms will still get a nurse, department head, or other trained employee to conduct the screening . 6. If an employee has any symptoms consistent with Covid-19 and/or a fever of one hundred (100.0) degrees or greater, the employee will not be allowed to enter the facility and will be tested for COVID-19 . A review of a list of staff that were confirmed positive for COVID-19 and titled, Staff COVID 19 Positive or Suspected, indicated the first positive staff member was Staff A, Registered Nurse (RN), who tested positive on 5/12/22. The form further noted that Staff A had signs and symptoms of COVID-19 and got sent home prior to working her shift. A review of a list titled, Covid Suspected or Confirmed, revealed the resident list included five COVID-19 positive residents on 100 Hall (Resident #21, Resident #17, Resident #31, Resident #19, and Resident #13) and five COVID-19 positive residents on the 200 Hall (Resident #2, Resident #6, Resident #12, Resident #10, and Resident #3). The document indicated that within the last four weeks, the dates of the ten residents who tested positive started on 5/12/22 and ended on 5/15/22. A review of the Evening Shift Assignment indicated Staff A's schedule indicated she worked from 2:00 PM to 10:00 PM on 5/11/22 and worked the 100 Hall, providing direct care to 18 residents. A review of the Attendance Application indicated Staff A worked for 6.25 hours on 5/11/22. A review of the Daily Temps and Screening for COVID-19 on 5/11/22 revealed Staff A, did not self-screen before starting her shift. A review of POC Tracking List, the facility's COVID-19 test tracking form, for May 2022, indicated that Staff A tested positive for COVID-19 on 5/12/22. The list lacked documentation of Staff A having a test on 5/11/22. A review of an untitled time clock report indicated that on 5/17/22, Staff J worked from 2:00 PM to 10:00 PM, and Staff K worked from 6:00 AM to 2:00 PM. A review of the Daily Temps and Screening for COVID-19 on 5/17/22 revealed Staff J, Certified Nursing Assistant (CNA), and Staff K, CNA, did not fill out the screening form. During an interview on 5/17/22 at 3:47 PM, Staff A stated she tested positive for COVID-19 on 5/12/22. Staff A stated that she worked the previous day, 5/11/22, from 2:00 PM to 8:00 PM. Staff A said that she woke up on 5/11/22 feeling like she had allergies due to mowing the grass the day before. However, Staff A reported that she didn't have allergies but thought allergies may have been the issue. Staff A stated her symptoms were that she felt really stuffy and full and she had ear pain. She stated she sneezed and, my throat was scratchy. No upset stomach or headache. Staff A stated she was feeling ill, so tested herself for COVID-19 at work, and got a negative result. Staff A stated that throughout her shift, the symptoms got worse and included severe gastrointestinal (GI) symptoms, vomiting, dry heaving, fever, weakness, fatigue, sinus pressure, very stuffy, sore ears, and headache. She stated she told the other nurse on shift, name not provided, that she was not feeling well. Staff A added that she called Staff B, Licensed Practical Nurse (LPN)/MDS Coordinator, to tell her that she was not feeling good, but got no further instructions. Staff A reported that she did not think it was going to be COVID. Staff A stated that the they self-screened by taking their temperature and documenting if they had any signs and symptoms of COVID-19 for the screening process when they came to work. Staff A stated she usually filled out the screening form but did not remember what she documented on 5/11/22. She stated, I do believe that I filled it out and put 'sinus,' but I don't remember. Staff A stated she was scheduled to work a 16-hour shift on 5/12/22 but called out sick. The facility asked her to come in to take a COVID-19 test, which she did, and it was positive. Staff A stated she came back to work on 5/16/22 at 4:30 PM. The facility advised her that she could return to work due to being in a crisis mode for staffing and that positive staff were allowed to come back to work after five days from testing positive, as long as the staff member was fever-free. Staff A stated her fever ended on Friday night, 5/13/22. Staff A stated she tested positive still on Sunday night, 5/15/22, when she tested herself. Staff A reported that she still had symptoms of nasal congestion and pressure. Staff A acknowledged that she completed the self-screening form that day and put down the symptoms she experienced. Staff A stated that she was the first direct care staff that tested positive for COVID-19. During an interview on 5/17/22 at 4:39 PM, Staff C, Infection Preventionist (IP)/Registered Nurse (RN), stated that the screening process for staff included them taking their temperature and documenting if they were having any symptoms of COVID-19. Staff C stated that staff self-screened upon entry to the facility and staff had to notify her, the Director of Nursing (DON), or the nurse on duty if they were having any symptoms or a temperature. Staff C stated that both the DON and she reviewed the daily screening forms for any discrepancies. Staff C stated that currently, the facility was in crisis mode and was allowing COVID-19 positive staff members to work. Staff A stated that three out of seven nurses tested positive for COVID-19, as well as numerous Certified Nursing Assistants (CNAs). Staff C stated that they used contract staff but had trouble with staff picking up shifts due to the current COVID-19 outbreak in the facility. Regarding Staff A, Staff C confirmed that Staff A worked on 5/11/22 but Staff C didn't get notified that of the symptoms Staff A experienced. Staff C stated Staff A was scheduled to work on 5/12/22 but became symptomatic and come in to be tested. Staff C was shown the self-screen form for 5/11/22, which indicated Staff A did not self-screen, and Staff C stated she did not know why Staff A did not self-screen and that all staff were to self-screen. On 5/17/22 at 6:00 PM, observed no signage at the Director of Nursing's office, medication room, or staff screening room notifying staff of any changes related to the screening process. On 5/18/22 at 7:30 AM, the surveyor noted that the facility front door was locked, which previously had been open in the morning. Upon entry, the facility had numerous colored signs posted, which indicated, 5/17/22, Effective Immediately. Two procedures are now in place: 1. General screening at the start of your shift will require ALL staff to ring the outside doorbell to be let into the facility. Once in you will be screened for the following: a. Do you have fever or chills? b. Do you have a sore throat? c. Do you have a cough? d. Do you have congestion or runny nose? e. Do you have shortness of breath or difficulty breathing? f. Do you have fatigue? g. Do you have muscle or body aches? h. Do you have a headache? i. Do you have a new loss of taste or smell? j. Do you have nausea or vomiting? k. Do you have diarrhea? l. Do you have a temperature of 100.4 or more? m. Have you had an exposure or higher risk exposure to someone who has Covid-19? Charge nurse or designated/trained staff member will temp employee and fill out check in sheet and initial next to the temperature . During an interview on 5/18/22 at 8:28 AM, Staff L, Licensed Practical Nurse (LPN), stated the screening process for staff was that staff entered through the back door of the facility and self-screened by taking their own temperature, filling out a paper, and noting if they had any signs or symptoms. Staff L stated there was a list of symptoms located on the wall for staff to read. During an interview on 5/18/22 at 8:43 AM, Staff E, RN, stated that as of that day, 5/18/22, staff had to ring the bell at the back door of the facility to be let in by a nurse, who would screen the staff member. Prior to that day, staff were self-screening at the back door. During an interview on 5/18/22 at 9:00 AM, Staff B stated that starting that day, 5/18/22, the facility locked the back door, and they had to have a staff nurse open the door to screen the employee entering the building. Prior to 5/18/22, staff were self-screening. However, a nurse was supposed to be screening the staff. Staff B stated that Staff A called her on 5/11/22 after Staff A had already left their shift early, at 8:00 PM, but was scheduled to work until 10:00 PM. Staff B stated that Staff A complained of a sore throat and left work early. Staff B stated that Staff A was scheduled to work the following day and told Staff A to complete a COVID-19 test before starting her shift. However, Staff A did not show up for her shift. Staff B stated that Staff A called Staff E, RN, the morning of Staff A's shift and stated she would be late but never showed. Staff B stated that they finally were able to reach Staff A and stated she needed to come in to test for COVID-19, which she did and was positive. Staff B stated that she did not notify anyone that Staff A called her on 5/11/22 notifying Staff B that Staff A left work early and had symptoms of COVID-19. During an interview on 5/18/22 at 10:57 AM, the Director of Nursing (DON) stated that prior to the evening of 5/17/2021, staff were self-screening at the back door of the facility. As of the evening of 5/17/22, the DON sent out a mass text message to nursing staff notifying them of the change in the screening process, that staff had to be let in the back door and screened by another staff member. The DON stated that this process changed after the surveyor requested copies of the daily screening forms and the DON noticed missing employee screening information. The DON stated they felt it best to get started immediately on the new screening process. The DON stated that Staff A should have screened in before her shift on 5/11/22. During an interview on 5/18/22 at 12:46 PM, the Administrator (ADM) stated that prior to the evening of 5/17/22, staff were self-screening at the back door of the facility. The ADM stated that this process changed after the surveyor requested copies of the daily screening forms and he noticed the form had missing screening information. The ADM stated it was pointed out that there were missing entries for staff who had worked and did not screen and, it wasn't working the way it was supposed to. The ADM stated he didn't know that Staff A had any symptoms of COVID-19 on 5/11/22. During an interview on 5/18/22 at 2:55 PM, Staff J, Certified Nursing Assistant (CNA), stated that currently, the facility had the back door locked, staff had to ring the doorbell, a nurse would take their temperature, and screen them for signs and symptoms. Staff J stated prior to 5/17/22, the staff would self-screen. During an interview on 5/19/22 at 9:16 AM, Staff O, Laundry Aide, stated that the staff self-screened before starting their shift until 5/18/22, and a nurse now had to screen the staff. 2. A review of the CDC's, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/22, indicated, Source control options for HCP [healthcare personnel] include: A NIOSH [National Institute for Occupational Safety and Health] approved N95 or equivalent or higher-level respirator OR A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering face piece respirators. (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated). A review of OSHA's Occupational Safety and Health Standard 1910.134, titled, Respiratory Protection, indicated the following: - 1910.134(c)(1) - In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite-specific procedures. The program shall be updated as necessary to reflect those changes in workplace conditions that affect respirator use. The employer shall include in the program the following provisions of this section, as applicable: Procedures for selecting respirators in the workplace; Medical evaluations of employees required to use respirators; Fit testing procedures for tight-fitting respirators; Training of employees in the proper use of respirators, including putting on and removing them, any limitations on their use, and their maintenance. - 1910.134(f) - Fit testing. This paragraph requires that, before an employee may be required to use any respirator with negative or positive pressure tight-fitting face piece, the employee must be fit tested with the same make, model, style, and size of respirator that will be used. - 1910.134(f)(2) - The employer shall ensure that an employee using a tight-fitting face piece respirator is fit tested prior to initial use of the respirator, whenever a different respirator face piece (size, style, model or make) is used, and at least annually thereafter. A review of the Makrite 9500-N95 instruction sheet provided with the masks utilized by facility staff indicated, the respirator should be fit checked for each wearing. Place both hands completely over the respirator and exhale. If air leaks around the nose or the edges, adjust the nosepiece and/or headbands until a good fit is achieved. During an interview on 5/17/22 at 3:47 PM, Staff A, Registered Nurse (RN), was wearing a 3M brand N95 respirator mask. Staff A stated she had not been fit tested for the N95 mask and didn't know what fit testing meant. Staff A tested positive for COVID-19 on 5/12/22, but worked due to the facility being in crisis mode for staffing. During an interview on 5/17/22 at 4:39 PM, Staff C, Infection Preventionist (IP)/Registered Nurse (RN) stated the facility did not have a respiratory protection program, nor had the facility completed fit testing for the use of N95 respirators, which were currently in use at the facility. During an interview on 5/18/22 at 8:28 AM, Staff L, Licensed Practical Nurse (LPN), was wearing a surgical mask underneath an N95 mask. Staff E stated they had not been fit tested for the N95 mask they were wearing and did not know what fit testing was. Staff L stated they were wearing the surgical mask underneath the N95 mask because, I want to be extra safe. During an interview on 5/18/22 at 8:43 AM, Staff E, RN, was wearing a surgical mask underneath an N95 mask. Staff E tested positive for COVID-19 on 5/15/22. Staff E stated they didn't get fit tested for the N95 mask they wore and did not know what fit testing was. Staff E stated that they were wearing the surgical mask underneath the N95 mask as an extra precaution, since I'm positive. Prior to the interview, Staff E was witnessed wearing the N95 respirator incorrectly and donning personal protective equipment (PPE), and then entered a resident's room to provide medication to the resident. During an interview on 5/18/22 at 9:00 AM, Staff B was wearing a KN95 mask and stated staff were to wear KN95 masks during the current outbreak and didn't know if the facility had any N95 masks. Staff B stated they didn't get fit tested for an N95 mask, nor received any training regarding how to properly wear a KN95 or an N95 mask. During an interview on 5/18/22 at 10:57 AM, the Director of Nursing (DON) stated she didn't know if the facility had a respiratory protection program, but it was going to be reviewed. The DON stated that staff were to wear N95 masks during the outbreak. The DON was wearing a KN95 with a face shield, she reported that she had asthma and could not wear an N95. The DON stated that depending on the size of the N95, fit testing should be completed, but she would have to look at the manufacturer's guidelines and go off their recommendations. The DON stated that staff should not wear regular masks underneath an N95 mask because it, defeats the purpose of the N95. During an interview on 5/18/22 at 12:46 PM, the Administrator (ADM) stated the facility did not have a respiratory protection program and didn't know what the program would consist of. The ADM stated the facility did utilize N95 masks but did not fit test the masks because they couldn't find a service provider to provide the facility with the training. The ADM stated that regular masks should not be worn underneath an N95 mask because it would defeat the purpose of the N95 fitting more snug. During an interview on 5/18/22 at 2:55 PM, Staff J, Certified Nursing Assistant (CNA), wore a 3M N95 mask. Staff J stated they didn't get fit tested for the mask and had not received any formal training on how to properly wear the mask, except for signs posted on the wall. During an interview on 5/18/22 at 4:30 PM, the DON stated the facility did not have a policy regarding the use and/or training of N95 masks. Removal Plan: As of the afternoon of 5/19/22, the following procedures were put into place to correct the F880 deficiency: On the evening of 5/17/22 item #1 [below] was posted at the employee entrance, time clock, Director of Nursing's office, Medication Room, Breakroom, Nurses' charting room, and the staff screening station. This was put into place for all employees to review and comply with. 1. General screening at the start of your shift will require ALL staff to ring the outside doorbell to be let into the facility. Once in your [sic] will be screened for the following: a. Do you have fever or chills? b. Do you have a sore throat? c. Do you have a cough? d. Do you have congestion or runny nose? e. Do you have shortness of breath or difficulty breathing? f. Do you have fatigue? g. Do you have muscle or body aches? h. Do you have a headache? i. Do you have a new loss of taste or smell? j. Do you have nausea or vomiting? k. Do you have diarrhea? l. Do you have a temperature of 100.4 or more? m. Have you had an exposure or higher risk exposure to someone who has Covid-19? The Charge Nurse or designated staff member will temp the employee and go over the above questions and fill out check in sheet and initial next to the temperature or symptom column. Further testing may be necessary depending on results of the questions above including but not limited to high temperature. The Administrator, Director of Nursing, or Infection Control/Preventionist will need to be contacted immediately for any question marked yes or temperature above 100.4. The document used for training on screening is our Staff Screening & Return to Work Protocols. The infection Preventionist or designee will administer the training and each team member trained will sign a copy that will be retained in the personnel file. Furthermore, the charge nurse or designee will compare the daily assignment sheet/schedules to the screening sheets no later than 30 minutes after the shift has started to verify all employees on duty were properly screened during their shift. Any discrepancies will be rectified with proper screening and the Administrator, Director of Nursing, or Infection Preventionist notified. 2. Signage was posted on the evening of 5/17/22 at eh [sic] employee entrance, time clock, Director of Nursing office, Medication Room, Breakroom, Nurses [sic] charting room, and the staff screening station to alert all staff members to the Protocols and the importance of reporting symptoms. In addition, starting on the afternoon of 5/19/22, all staff will be required to review the Covid-19 Signs and Symptoms sheet (included) and verify their competency and understanding by signing the education sheet. This will be done to all staff currently working (on duty) and as they come on duty prior to working the floor. This will be verified by the Administrator or designee. 3. Staff that are Covid positive and working the floor during crisis staffing, and staff that are taking care of Covid positive residents will be educated on how to properly wear an N95 based on the manufacturer's instructions. They will need to demonstrate the procedure based on those instructions and sign that they understand and completed the process. This will be done to affected staff currently working (on duty) and as they come on shift prior to working the floor. This sheet will be kept in the employee file or a file designated for contract staff. Training began the afternoon of 5/18/22 by the Administrator, Director of Nursing, MDS Coordinator, Human Resources Director, Social Services Designee. 4. Corrective action for staff currently on duty will be completed by 10pm [10:00 PM] today 5/19/22. Shifts that follow will be completed as they come on duty having all scheduled staff completed by 2pm [2:00 PM] the following day 5/20/22. Unscheduled staff will be contacted via telephone and conversation documented. The IJ will be removed by 5/20/22. Onsite Verification: The IJ was removed on 5/20/22 at 1:10 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began at 8:10 AM on 5/20/22, when signage was verified at the employee entrance, time clock, Director of Nursing's office, medication room, breakroom, nurses' charting room, and the staff screening station. Verification completed at 8:40 AM of the employee screening sheet and audit. All staff got screened appropriately. A total of 17 staff interviews were conducted with staff from all three shifts to verify training got completed. The staff interviewed included Certified Nursing Assistants (CNAs), Registered Nurses (RNs), Housekeeping, Environmental Services, Kitchen Staff, and the Activity Director. The staff interviewed verified they got trained on reporting signs and symptoms of COVID-19, the screening process before entry into the facility, and the proper fit and use of N95 respirators. A review of the in-service sheets provided indicated that all 67 staff members had been provided training on reporting signs and symptoms of COVID-19, the screening process before entry into the facility, and the proper fit and use of N95 respirators. Those staff that were not physically present to receive the in-services were messaged via telephone, with the in-service information provided, the employee acknowledged the receipt, and voiced understanding.