Based on observations, interviews and record reviews, the facility failed to ensure it was administered in a manner that enabled it to use its resources by failing to ensure an effective system was implemented for preventing and controlling COVID-19 infections. The facility failed to ensure: 1. Visitors were notified of active COVID-19 infections, screened, educated and provided appropriate PPE prior to entering the facility; 2. All employees performed COVID-19 screening prior to working; and 3. Agency staff were COVID-19 tested prior to working during a COVID-19 outbreak. This deficient practice resulted in an Immediate Jeopardy situation on 12/09/2022 with the likelihood of severe injury and/or death for 12 (F1, F2, F3, F6, RF1, RF2, RF3, RF4, RF5, RF6, RF7, and RF8) non COVID-19 positive residents residing in the facility during a COVID-19 outbreak. On 12/09/2022 at 9:22 a.m., S2DON confirmed agency staff should have been tested prior to working each shift and were not. On 12/09/2022 at 10:50 a.m. an employee was observed entering the facility without being screened. On 12/09/2022 at 3:01 p.m., a visitor was observed exiting the COVID-19 unit without a face mask and walked down the main hallway into the general population area before exiting the facility at the side entrance. As of 12/09/2022 there were 17 residents residing in the facility with 5 active COVID-19 cases. S1ADM was notified of the immediate jeopardy on 12/09/2022 at 3:15 p.m. Plan of Removal: Identification of Residents Affected or Likely to be Affected: Review of facility census data on 12/09/2022 determined there were 17 patients in the facility. DON and Infection Interventionist immediately identified that 12 patients were determined to have potential risk related to the deficient practice (F1, F2, F3, F6, RF1, RF2, RF3, RF4, RF5, RF6, RF7, and RF8). Corrective Action: -On 12/09/2022 the corporate Director of Compliance and Board Certified Infection Preventionist reviewed all applicable facility policies and procedures with the Administrator, Director of Nursing, and Infection Preventionist to ensure the systems established for infection prevention and control program including COVID-19 related policies to prevent the spread of COVID-19 infections in the facility are followed as outlined in the facility's policies and CDC guidelines. -Effective 12/09/2022, the DON re-educated all staff , including agency and contract workers, on the following COVID-19 related infection control and COVID screening policies regarding the following facility's policies. Any remaining staff will be provided education prior to their next work shift. The remaining staff will be educated by the charge nurse as they report for COVID screening and testing until all remaining staff have been educated on the following: a. COVID-19 and COVID-19 Vaccine Reporting b. Coronavirus Surveillance c. Coronavirus Testing d. Interim COVID-19 Visitation e. Coronavirus Prevention and Response Staff education will be completed by 12/16/2022. Compliance will be monitored by post education testing that will be kept on file with the screening and testing logs. Testing will be administered by the DON and Infection Preventionist. -Beginning 12/09/2022 and continuing for a duration of 4 weeks, the corporate infection control consultant will review all employee and visitor screening logs for compliance, as well as reviewing all employee post education testing. Any non-compliant findings during this period will result in immediate corrective action. After 4 weeks, on future site visits, corporate infection control consultant will randomly review audits conducted by DON and Infection Preventionist related to COVID screening, testing, and education. DON, Infection Preventionist, and Administrator completed post education testing on 12/12/2022. -Training and education will be provided to staff during orientation, annually, and as needed with any updated changes and recommendations for infection prevention and control and COVID-19 related policies as outlined in the CDC's Interim Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. -The DON and/or Infection Preventionist designee will conduct a review of daily timesheets/schedule to cross-match the COVID testing and screening logs of all employed and contracted staff working to identify all direct care staff in the facility has completed COVID-19 testing anytime the facility's COVID-19 Outbreak Testing protocol is activated. The Immediate Jeopardy was removed on 12/13/2022 at 12:05 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. This deficient practice continued at more than minimal harm for the remaining 12 negative COVID-19 residents residing in the facility that were at risk for contracting COVID-19. Findings: Cross Reference F880 Cross Reference F882 Cross Reference F886 Review of the Policy titled, Infection Prevention and Control Program -LTC revealed the following, in part: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. Review of the Policy titled, Coronavirus Surveillance revealed the following, in part: Policy: This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. 1. The facility's Infection Preventionist will monitor the status of COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. 2. Heightened surveillance will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening visitors, staff, and residents. 3. Screening for visitors and staff: a. Symptoms of COVID-19; b. A positive viral test for SARS-CoV-2 c. Close contact with someone with SARS-CoV-2 infection (for visitors) or a higher-risk exposure (for healthcare personnel) 5. Symptomatic healthcare personnel, regardless of vaccination status, should be restricted from work pending evaluation for SARS-CoV-2 infection and should follow facility policy regarding testing and return to work. 8. The facility's Infection Preventionist, or designee, will track the following information: c. The number of residents and staff who have been tested for COVID-19 (testing in accordance with current CDC guidelines and priorities). Review of the Policy titled, Coronavirus Prevention and Response revealed the following, in part: Policy: The facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus. 4. Ensuring that everyone is aware of the recommended IPC practices in the facility by posting visual alerts (e.g., signs, posters) at the entrance and in strategic places to include instructions about current IPC recommendations. Review of the Policy titled, COVID-19 and COVID-19 Vaccine Reporting-LTC/SNF revealed the following, in part: Policy: It is the policy of this facility to share appropriate information regarding COVID-19 with staff, residents and their representatives and to report COVID-19 information to the local/state health department and the Centers for Disease Control and Prevention (CDC). Policy Explanation and Compliance Guidelines: 1. The facility has implemented a system of surveillance designed to identify possible communicable diseases or infections, including COVID-19, before they can spread to other persons in the facility. 2. Positive COVID-19 test results are reported to the Infection Preventionist, or designee, within one hour of receipt so that reporting activities may begin. 3. Notify the state/local health department promptly about any of the following: a. > 1 residents or healthcare personnel (HCP) with suspected or confirmed SARS-CoV-2 infection. On 12/09/2022 at 9:22 a.m., S2DON provided a list of nine agency staff who worked at the facility since the COVID-19 outbreak started on 11/11/2022 and their COVID-19 testing requisition forms. She confirmed all nine of the agency staff should have been tested prior to working each shift and were not. On 12/09/2022 at 2:03 p.m., an interview was conducted with S2DON. She said the current COVID-19 outbreak started on 11/11/2022, after a family member who visited a resident called the facility and notified staff she tested COVID-19 positive. She said the resident who was exposed and his roommate tested COVID-19 positive. She said the COVID-19 positive visitor was not tracked or checked to see if she was screened. She confirmed there was no signage posted at either entrance or in the facility indicating a COVID-19 outbreak or visitor screening and should be. She said the visitor screening process included performing hand hygiene, don a face mask, temperature checks and signs and symptoms filled out on the visitor screening form. She said all staff were responsible for making sure visitors were screened. She said S14R was responsible for screening visitors at the front entrance. She said S12US and any staff that was in that area were responsible for screening visitors at the side entrance. She said staff and visitors should wear face masks in the facility. She said she would have expected staff to stop any visitor in the hall that did not screen or were not wearing a face mask and direct them to do both. She reviewed the employee screening log dated 12/07/2022 and 12/08/2022 and confirmed two visitors had signed the employee log but did not document their temperature or signs or symptoms and should have. She said by not screening all visitors, it could contribute to the spread of COVID-19. She said all staff were expected to screen every time they came in for a shift, which would include checking their temperature and documenting any signs or symptoms on the employee log. She was unable to provide documentation of employee and visitor screening logs since the COVID-19 outbreak from 11/11/2022 to 12/06/2022. She said all staff including agency staff should be COVID-19 tested prior to working their shift or every 48 hours if they worked back to back shifts. She said the charge nurses were responsible for ensuring all staff including agency staff COVID-19 tested accordingly. She confirmed S27LPN, S16CNA, and S11LPN were agency staff and were not COVID-19 tested prior to working their shifts and should have been. She said she and S3IP shared the infection control responsibilities. She said S3IP was responsible for ensuring staff and visitors were screened and staff were COVID-19 tested prior to working. S2DON said she had not reviewed any screening logs or staff's COVID-19 test results. S2DON confirmed she was S3IP's supervisor and did not review or audit her work and should have been. On 12/09/2022 at 2:14 p.m., an interview was conducted with S3IP who stated she was the facility's infection control nurse and responsible for the facility's infection control program, including tracking facility infections; staff and visitor screening; and staff and resident COVID-19 testing. She said the first positive COVID-19 case during the outbreak was a resident on 11/11/2022. She said staff were to inform visitors upon entry of COVID-19 in the building, assist with screening and encourage them to wear a face mask. She said S14R was responsible for screening visitors at the front entrance and S12US was responsible for screening visitors on the side entrance. She confirmed there was no signage posted indicating a COVID-19 outbreak or signage directing visitors at either entrance to screen for signs and symptoms, take their temperature, perform hand hygiene and wear a face mask. She said all employees were expected to screen themselves for COVID-19 including a temperature check prior to every shift worked. She reviewed the employee screening log dated 12/07/2022 and 12/08/2022 and confirmed two visitors had signed the employee log but did not document their temperature or signs or symptoms and should have. She said she would have expected employees to stop and redirect any visitor who had not been screened or were not wearing a mask to do so right away. She was unable to provide documentation of employee and visitor screening logs since the COVID-19 outbreak from 11/11/2022 to 12/06/2022. She confirmed visitors not being screened could have contributed to the spread of the COVID-19 infection. She said agency staff should be rapid COVID-19 tested prior to every shift or if they worked several days in a row then every 48 hours. She said the charge nurses were responsible for making sure all staff including agency staff were COVID-19 tested accordingly. S3IP said she did not review the visitor and staff COVID-19 screening logs along with resident and staff testing on a consistent basis, and she should have. She said she did not consistently check the schedules and COVID-19 test results to ensure agency staff were tested and should have. She said S1ADM and S2DON were her supervisors and no one checked her work behind her. On 12/09/2022 at 3:00 p.m., an interview was conducted with S1ADM. He said S3IP was the facility's Infection Preventionist. He said S29DQ was the facility's corporate Quality Infection Control Nurse who assisted from a corporate level and was not responsible for auditing S3IP's work. He said S2DON was S3IP's direct supervisor and was responsible for checking S3IP's work. He said he was S2DON's supervisor and had not been supervising her in that capacity and should have been. He confirmed there was no signage posted at either entrance or in the facility indicating a COVID-19 outbreak or visitor screening process and there should be. He said there was no designated staff member assigned to screen visitors at the side entrance. He said it was a collaborative effort between staff and S12US to make sure visitors were screened when they entered through the side entrance. He said S14R was responsible for screening visitors at the front entrance. He said the visitor screening process included performing hand hygiene, don a face mask, temperature checks and signs and symptoms filled out on the visitor screening form. He said he would expect staff to stop and redirect visitors that were not wearing a face mask, had not screened and signed in. He reviewed the employee screening log dated 12/07/2022 and 12/08/2022 and confirmed two visitors had signed the employee log but did not document their temperature or signs or symptoms and should have. He said he expected all employees to screen themselves with a temperature check prior to starting their shift. He confirmed visitor and staff screening had not been monitored as close as they should. He said visitors and staff not being screened could contribute to the spread of COVID-19. He said the charge nurses on each shift were responsible for making sure all staff, including agency staff, COVID-19 tested prior to working their shift. He was notified the charge nurse reported it was the responsibility of the agency staff and S3IP to COVID-19 test agency staff; and S2DON and S3IP reported it was the charge nurses responsibility. He confirmed there was a definite breakdown with communication in general and staff were not on the same page. He confirmed the agency staff that worked since the COVID-19 outbreak on 11/11/2022 were not COVID-19 tested prior to working every shift and should have been. He said staff, including agency staff, not being COVID-19 tested prior to working could contribute to the spread of COVID-19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure an effective infection control and prevention program was implemented for preventing and controlling COVID-19 infections for 12 (F1, F2, F3, F6, RF1, RF2, RF3, RF4, RF5, RF6, RF7, and RF8) non positive residents who resided in the facility during a COVID-19 outbreak. The facility failed to ensure: 1. Visitors were notified of active COVID-19 infections, screened, and educated on precautions prior to entering the facility; 2. All employees performed COVID-19 screening prior to working; and 3. Soiled linens were properly stored on the COVID-19 unit. This deficient practice resulted in an Immediate Jeopardy situation on 12/09/2022 with the likelihood of severe injury and/or death for 12 (F1, F2, F3, F6, RF1, RF2, RF3, RF4, RF5, RF6, RF7, and RF8) non COVID-19 positive residents residing in the facility during a COVID-19 outbreak. On 12/09/2022 at 9:22 a.m., S2DON confirmed agency staff should have been tested prior to working each shift and were not. On 12/09/2022 at 10:50 a.m. an employee was observed entering the facility without being screened. On 12/09/2022 at 3:01 p.m., a visitor was observed exiting the COVID-19 unit without a face mask and walked down the main hallway into the general population area before exiting the facility at the side entrance. As of 12/09/2022 there were 17 residents residing in the facility with 5 active COVID-19 cases. S1ADM was notified of the immediate jeopardy on 12/09/2022 at 3:15 p.m. Plan of Removal: Identification of Residents Affected or Likely to be Affected: On 12/09/2022, through review of the facility census data, Infection Preventionist, DON, and Administrator reviewed and identified the COVID-19 cases in the building. After notification of deficient practices, it was determined that there were 3 active COVID-19 cases in the building, and 2 cases that were previously COVID positive during the outbreak. The following 12 patients were at risk (F1, F2, F3, F6, RF1, RF2, RF3, RF4, RF5, RF6, RF7, and RF8). Corrective Action: -As of 12/09/2022, the facility had 3 active COVID-19 cases. The facility had 2 COVID-19 cases that had met the criteria to discontinue isolation precautions post positive COVID Day 10 accordance to CDC guidelines on 12/09/2022. -Immediately on 12/09/2022 the DON assigned a staff member designated to the screening station at each visitor entrance to ensure visitors are screened appropriately. The assigned staff member was educated by the DON on COVID screening practice. The screening staff will provide education both verbally as well as through signage posted in building regarding COVID screening. -Screening stations will be staffed daily beginning 12/09/2022 continuing for a duration of the next 4 weeks. Staffed screening stations will be implemented at the beginning of any potential future COVID outbreak. -Signage was posted at each visitor entrance declaring COVID outbreak/COVID cases in the facility on 12/09/2022. -Educational resources related to COVID were posted at each visitor entrance and each screening station. -Facemasks are provided for source control, at each screening station. -On 12/09/2022 the corporate Director of Compliance and Board Certified Infection Preventionist reviewed all applicable facility policies and procedures with the Administrator, Director of Nursing, and Infection Preventionist to ensure the systems established for infection prevention and control program including COVID-19 related policies to prevent the spread of COVID-19 infections in the facility are followed as outlined in the facility's policies and CDC guidelines. Re-education on COVID-19 prevention and control was provided by the corporate Director of Compliance and Board Certified Infection Preventionist to DON, Infection Preventionist, and Administrator. COVID education testing was completed on DON, Infection Preventionist, and Administrator on 12/12/2022. -Effective 12/09/2022, the DON re-educated all staff , including agency and contract workers, on the following COVID-19 related infection control and COVID screening policies regarding the following facility's policies. Any remaining staff will be provided education prior to their next work shift. The remaining staff will be educated by the charge nurse as they report for COVID screening and testing until all remaining staff have been educated on the following: a. COVID-19 and COVID-19 Vaccine Reporting b. Coronavirus Surveillance c. Coronavirus Testing d. Interim COVID-19 Visitation e. Coronavirus Prevention and Response Staff education will be completed by 12/16/2022. Compliance will be monitored by post education testing that will be kept on file with the screening and testing logs. Testing will be administered by the DON and Infection Preventionist. -Staff will be tested daily prior to starting their work day, effective 12/09/2022 and continuing for a duration of 14 days without any additional COVID cases. At the conclusion of the designated testing period, staff will revert to established COVID testing guidelines. In the event of future COVID cases, staff will implement outbreak protocol and test daily through the duration of the outbreak. -Beginning 12/09/2022, staff will be screened for COVID daily prior to their working day. This screening will take place at the nurses' station, and compliance will be ensured by pre-filled employee logs listing each employee scheduled that day. The employee will sign by their name, and the charge nurse will document compliance on the employee log. Screening procedures will be ongoing. -Employee logs for testing and screening will be reviewed by Administrator, DON, Infection Preventionist, or designee twice daily, once for AM shift and once for PM shift to ensure compliance beginning 12/09/2022 and continuing for a minimum duration of 4 weeks. -In addition to daily review of the employee logs for a minimum of 4 weeks beginning 12/09/2022, the Director of Nursing (DON), or designee, will conduct a weekly review of the visitor screening sign in log and employee screening log. The DON, or designee, will conduct weekly review for 3 consecutive months until 100% compliance is achieved and sustained. Once 100% compliance is achieved and sustained the DON will continue to conduct an audit review of the screening logs monthly ongoing. -The Director of Nursing (DON), or designee, will conduct 5 weekly random observational rounds to ensure COVID screening is conducted at the stations for 3 consecutive months until 100% compliance is achieved and sustained. Once 100% compliance is achieved and sustained the administrative staff will continue to conduct observational rounds of the facility's screening stations to ensure compliance with education to visitors of alerting them of active COVID-19 cases, infection control education related to hand hygiene, social distancing, and adhering to face masks to be used anytime the facility has identified any active COVID cases. The Immediate Jeopardy was removed on 12/13/2022 at 12:05 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. This deficient practice continued at more than minimal harm for the remaining 12 negative COVID-19 residents residing in the facility that were at risk for contracting COVID-19. Findings: Review of the Policy titled, Infection Prevention and Control Program -LTC revealed the following, in part: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 10. Linens: a. Direct care staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linens shall be separated from soiled linen at all times. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is completed, the bag shall be closed securely and placed in the soiled utility room. 11. Resident/Family/Visitor Education: c. Isolation signs are used to alert staff, family members, and visitors of isolation precaution. d. Reminders are posted in the facility to alert family members and visitors to adhere to handwashing, respiratory etiquette, and other infection control principles to limit spread of infection from family members and visitors. Review of the Policy titled, Coronavirus Prevention and Response revealed the following, in part: Policy: The facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus. 4. Ensuring that everyone is aware of the recommended IPC practices in the facility by posting visual alerts (e.g., signs, posters) at the entrance and in strategic places to include instructions about current IPC recommendations. Environmental Infection Control: 3. Management of laundry should be performed in accordance with routine procedures. Review of the Policy titled, Coronavirus Surveillance revealed the following, in part: Policy: This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. 1. The facility's Infection Preventionist will monitor the status of COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. 2. Heightened surveillance will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening visitors, staff, and residents. 3. Screening for visitors and staff: a. Symptoms of COVID-19; b. A positive viral test for SARS-CoV-2 c. Close contact with someone with SARS-CoV-2 infection (for visitors) or a higher-risk exposure (for healthcare personnel) 5. Symptomatic healthcare personnel, regardless of vaccination status, should be restricted from work pending evaluation for SARS-CoV-2 infection and should follow facility policy regarding testing and return to work. 1. On 12/07/2022 at 8:35 a.m., an observation was made of two of the three facility entrances. No signage was posted on the front entrance or side entrance to inform visitors there was a COVID-19 outbreak in the facility. No signage was posted directing visitors to screen and wear a face mask in the facility. No thermometer or visitor screening forms were available at the side entrance screening station. No staff direction or education was provided on the visitor screening process. On 12/07/2022 at 8:50 a.m., an interview was conducted with S1ADM. He said there were 17 residents residing in the facility with 5 active COVID-19 cases. He said the facility's current COVID-19 outbreak began on 11/11/2022 when a resident tested COVID-19 positive. He said only one staff member, S6DA, tested COVID-19 positive on 11/28/2022. On 12/08/2022 at 8:20 a.m., an observation was made of the front entrance of the facility. There was no signage posted indicating the facility was in a COVID-19 outbreak or staff present to assist and direct visitors to screen at the front receptionist window by taking their temperature, performing hand hygiene or to wearing a face mask. On 12/08/2022 at 8:25 a.m., an observation was made of the side entrance of the facility. There was no signage posted indicating the facility was in a COVID-19 outbreak or staff present to assist and direct visitors to screen at the entrance by taking their temperature, performing hand hygiene or to wearing a face mask. On 12/08/2022 at 9:11 a.m., an interview was conducted with Resident #F1's visitors. Both visitors said they did not know there was a COVID-19 outbreak in the facility. Neither visitor was aware they needed to wear a face mask. Both visitors verbalized they did not take their temperature because there were no directions or staff at the entrance to instruct them. The visitors confirmed they did not know there was a screening process or additional precautions that needed to be taken to visit Resident #F1. Both visitors confirmed that no staff stopped them, directed them to screen or to wear a face mask. Neither of the visitors were observed wearing a face mask or performing hand hygiene. On 12/08/2022 at 10:00 a.m., an observation was made of a visitor for Resident #RF1 entering the side entrance of the facility. No staff were observed at the entrance assisting the visitor. The visitor was not wearing a face mask and was not screened upon entering the facility. S9LPN was observed to walk the visitor to Resident #RF1's room. On 12/08/2022 at 10:09 a.m., an interview was conducted with Resident #RF1's wife and RP. The visitor was observed seated at the resident's bedside. The visitor was observed not wearing a face mask. She said she had not been informed of any COVID-19 positive residents in the facility. She confirmed she had not been screened for COVID-19 upon entry to the facility and was not asked to wear a face mask or to check her temperature. She verified she was escorted to Resident #RF1's room by S9LPN and was not told to put on a facemask or perform hand hygiene before entering Resident #RF1's room. On 12/08/2022 at 10:15 a.m., an interview was conducted with S9LPN. She verified she had walked Resident #RF1's visitor from the side entrance, down the hall, and into Resident #RF1's room. She verified the visitor did not have on a face mask and confirmed she had not instructed her to place a face mask on or verify she had been screened prior to entering the facility. She said all visitors should be screened, including a temperature check, and should wear a face mask upon entry. S9LPN verified she did not follow the facility's COVID-19 infection control policy. On 12/08/2022 at 10:30 a.m., an interview was conducted with Resident #RF1's daughter. She said she visited Resident #RF1 daily at the facility. She verified she visited Resident #RF1 yesterday (12/07/2022) and did not wear a face mask at any time inside of the building and had not been instructed of the need to wear a face mask by any staff member. She said today was the first day she had ever been asked to put a face mask on and to sign in upon entry into the facility. She further stated she had never been made aware there were COVID-19 cases in the facility. On 12/08/2022 at 11:00 a.m., an interview was conducted with S10RN. She said staff and visitors were to screen themselves upon entry to the facility. She said staff and visitors screened by performing hand hygiene, donning a face mask, taking their temperature, writing their names, temperature reading on a log and answering COVID-19 screening questions. She reviewed the log book at the side entrance and verified there were no visitor sign in sheets or employee log sheets in the binder since the COVID-19 outbreak which started on 11/11/2022. On 12/08/2022 at 11:10 a.m., an interview was conducted with Resident #RF2's RP and a visitor. Both said they were not notified of the facility having any COVID-19 positive residents. Both said they did not see a sign posted on the doors indicating there was COVID-19 in the facility. On 12/08/2022 at 11:35 a.m., a telephone interview was conducted with Resident #F2's RP. She said she visited Resident #F2 every other day. She said staff had never instructed or asked her to do a temperature check or wear a face mask upon entry to the facility since Resident #F2 was admitted on [DATE]. On 12/09/2022 at 8:24 a.m., an observation was made of the side entrance of the facility. There were no staff at the check-in area. There was no signage posted at the check-in table directing visitors to take their temperature, perform hand hygiene or to wear a face mask. On 12/09/2022 at 3:01 p.m., an observation was made of a visitor exiting the COVID-19 unit. He was not wearing a face mask and did not perform hand hygiene after exiting the enclosed barrier of the COVID-19 unit. He proceeded to walk down the main hallway into the general population area and exited the facility at the side entrance. On 12/12/2022 at 8:03 a.m., an observation was made of a visitor entering the facility at the front entrance. The visitor asked the surveyor how to screen in. No facility staff member was observed at the front entry and no thermometer was observed at the sign-in station. 2. On 12/07/2022 at 12:45 p.m., an interview was conducted with S15CNA. She said the facility staff members were supposed to check their temperatures when they arrived for their shift, however, she did not do temperature checks every day. On 12/08/2022 at 12:00 p.m., an interview was conducted with S6DA. She said she tested positive for COVID-19 on 11/28/2022 after reporting to work. She stated she began having signs and symptoms of COVID-19 while working in the kitchen. She said she never screened herself prior to working and entered through the back door of the facility. She said no one told her she was supposed to screen herself prior to working. She said since she did not work directly with the residents, she did not think she needed to be screened. On 12/08/2022 at 12:05 p.m., an interview was conducted with S7DA. She said she began working in the facility's kitchen on 11/28/2022. She said prior to each shift, she entered the facility through the back door and did not screen herself for COVID-19. She said she was not told she needed to screen herself for COVID-19 with a temperature check prior to each shift and sign in on the employee log. On 12/09/2022 at 10:50 a.m., an observation was made of an employee entering the front entrance of facility. The employee was noted to bypass the screening window and proceeded to walk into the facility. On 12/10/2022 at 8:35 a.m., an interview was conducted with S17HS. She said since 12/09/2022, she had not been re-educated by the facility's staff on COVID-19 related infection control, COVID screening or testing policies prior to working her shift. She said she entered the facility this morning, screened herself at the front entrance desk, but there was no thermometer. She was not aware she had to screen herself at the nurses' station, sign the employee log, and have the charge nurse review her completed forms. On 12/10/2022 at 8:42 a.m., an interview with S18HK. She said since 12/09/2022, she had not been re-educated by the facility's staff on COVID-19 related infection control, COVID screening or testing policies prior to working her shift. She said she entered the facility this morning, screened herself at the front entrance desk, but there was no thermometer. She was not aware she had to screen herself at the nurses' station, sign the employee log, and have the charge nurse review her completed forms. On 12/10/2022 at 9:06 a.m., an interview was conducted with S19RN. She said she was responsible for making sure all staff were educated, screened, and COVID-19 tested at the nurses' station prior to starting their shift. She confirmed she was supposed to review the staff's completed education, screening, and COVID-19 testing forms and place them in the binder labeled Staff and agency screening and testing book for COVID. She confirmed she had not ensured S17HS and S18HK were educated, screened or COVID-19 tested prior to working their shift today. 3. On 12/07/2022 at 10:05 a.m., an interview was conducted with S16CNA. She said she was agency staff and assigned to the COVID-19 unit. She said a COVID-19 resident's laundry was placed into soiled linen bags. She said there was no laundry receptacle in the COVID-19 positive resident's rooms or on the COVID-19 unit. An observation was made of an open soiled linen bag containing soiled linen on the floor in the staff's break room on the COVID-19 unit. S16CNA confirmed there was soiled linen from the COVID-19 positive residents' rooms in the open soiled linen bag. She said after resident care was completed for the COVID-19 positive residents, she placed the soiled linen bag outside the resident's room on the floor, then transferred the soiled linens into the soiled linen bag. She then brought the soiled linen bag containing COVID-19 positive resident's linens into the break room until it was full, and last exited out the side door to bring it to the laundry receptacle. She confirmed bringing an open bag of COVID-19 soiled linens into the staff's break room was an infection control issue and could mitigate the spread of the COVID-19 infection. On 12/08/2022 at 10:30 a.m., an observation was made on the COVID-19 unit of an open soiled linen bag containing soiled linens that was tied to the clean linen cart containing clean linens. On 12/08/2022 at 11:48 a.m., the COVID-19 unit was observed with S3IP. She verified the observation of an open blue soiled linen bag that contained soiled linens tied to the clean linen cart on the COVID-19 unit hallway. She confirmed the bag of soiled linens should not be open and tied to the clean linen cart. She confirmed this posed a risk for the spread of COVID-19. On 12/08/2022 at 11:50 a.m., an interview was conducted with S11LPN. She said she was agency staff assigned to the COVID-19 unit. She verified the observation of the open soiled linen bag tied to the clean linen cart. She confirmed the soiled linen bag contained the soiled gowns staff used as PPE when caring for the COVID-19 residents. She confirmed the soiled linen bag should not be open and tied to the clean linen cart on the hallway. On 12/09/2022 at 2:03 p.m., an interview was conducted with S2DON. She said the current COVID-19 outbreak started on 11/11/2022 after a COVID-19 positive family member notified facility staff that she tested positive. She said the visitor had exposed the resident and his roommate tested COVID-19 positive afterwards. She confirmed there was no signage posted at either entrance or within the facility indicating a current COVID-19 outbreak or directions for visitor screening and should be. She said the visitor screening process included performing hand hygiene, donning a face mask, temperature checks and signs and symptoms filled out on the visitor screening form. She said all staff were responsible for making sure visitors were screened. She said S14R was responsible for screening visitors at the front entrance. She said S12US and any staff that was in that area were responsible for screening visitors at the side entrance. She said staff and visitors should wear face masks in the facility. She said she would have expected staff to stop any visitor in the hall that did not screen or were not wearing a face mask and direct them to do both. She said not screening all visitors could contribute to the spread of COVID-19. She said all staff were expected to screen every time they came in for a shift, which would include checking their temperature and documenting any signs or symptoms on the employee log. She said all staff including dietary staff should screen themselves prior to working their shift no matter what door they entered into the facility. She was unable to provide documentation of employee and visitor screening logs since the COVID-19 outbreak from 11/11/2022 to 12/06/2022. She confirmed linen bags containing COVID-19 resident's soiled linen should not be kept in the staff's break room or tied to the clean linen cart. She said her expectations were to not leave soiled linens in the clean area, and if staff did not have a dirty linen cart, to tie up the soiled linen bag, leave it in the COVID-19 resident's bathroom, pick it up and place in the dirty linen cart at the end of their shift and exit out the side door that led to the dirty linen receptacle. On 12/09/2022 at 2:14 p.m., an interview was conducted with S3IP. She said the first positive COVID-19 case during the outbreak was on 11/11/2022. She explained a resident's visitor called the nurses station and reported she had tested positive for COVID-19. She said that resident and his roommate both tested COVID-19 positive afterwards. She said the facility staff were responsible to inform visitors upon entry of COVID-19 in the building, assist with screening and encourage them to wear a face mask. She said S14R was responsible for screening visitors at the front entrance and S12US was responsible for screening visitors on the side entrance. She confirmed there was no signage posted indicating a COVID-19 outbreak or signage directing visitors at either entrance to screen for signs and symptoms, take their temperature, perform hand hygiene and wear a face mask. She said she did not think it through and thought only the residents RP's should be notified. She said a COVID-19 positive resident's soiled linen should stay in the resident's room, be double bagged and left in the room until staff were ready to take it directly out of the facility to the laundry receptacle. She confirmed a linen bag containing soiled linens should not be left open, tied to the clean linen cart or be placed on the floor in the staff's break room. She said all employees were expected to screen themselves for COVID-19 including a temperature check prior to every shift worked. She said she would have expected employees to stop and redirect any visitor who had not been screened or were not wearing a mask to do so right away. She was unable to provide documentation of employee and visitor screening logs since the COVID-19 outbreak from 11/11/2022 to 12/06/2022. She confirmed visitors and staff not being screened could have contributed to the spread of the COVID-19 infection. On 12/09/2022 at 3:00 p.m., an interview was conducted with S1ADM. He confirmed there was no signage posted at either entrance or within the facility indicating a current COVID-19 outbreak or directions for the visitor screening process and there should be. He said there was no designated staff member assigned to screen visitors at the side entrance. He said it was a collaborative effort between staff and S12US to make sure visitors were screened when they entered through the side entrance. He said S14R was responsible for screening visitors at the front entrance. He said the visitor screening process included performing hand hygiene, donning a face mask, temperature checks and signs and symptoms filled out on the visitor screening form. He said he would expect staff to stop and redirect visitors that were not wearing a face mask, had not screened or signed in. He said he expected all employees, including dietary staff, to screen themselves with a temperature check prior to starting their shift. He confirmed visitor and staff screening was not monitored since the outbreak began. He said there was a definite breakdown with communication in general and staff were not on the same page. He said visitors and staff not being screened could contribute to the spread of COVID-19. He said placing COVID-19 positive resident's soiled linens in a clean area could contaminate the clean area and spread the COVID -19 infection. He said it was common sense not to put dirty linen in a clean area because then that area was contaminated. On 12/10/2022 at 9:11 a.m., an interview was conducted with S1ADM. He confirmed S19RN was responsible for ensuring all staff were educated, screened, and COVID-19 tested prior to working their shift. He confirmed there was a continued breakdown in communication with the staff on the facility's COVID-19 policies and procedures.

Based on interviews and record review, the facility failed to ensure the individual designated as the Infection Preventionist established and maintained an infection prevention and control program to prevent the spread of COVID-19. This deficient practice resulted in an Immediate Jeopardy situation on 12/09/2022 with the likelihood of severe injury and/or death for 12 (F1, F2, F3, F6, RF1, RF2, RF3, RF4, RF5, RF6, RF7, and RF8) non COVID-19 positive residents residing in the facility during a COVID-19 outbreak. On 12/09/2022 at 9:22 a.m., S2DON confirmed agency staff should have been tested prior to working each shift and were not. On 12/09/2022 at 10:50 a.m. an employee was observed entering the facility without being screened. On 12/09/2022 at 3:01 p.m., a visitor was observed exiting the COVID-19 unit without a face mask and walked down the main hallway into the general population area before exiting the facility at the side entrance. As of 12/09/2022 there were 17 residents residing in the facility with 5 active COVID-19 cases. S1ADM was notified of the immediate jeopardy on 12/09/2022 at 3:15 p.m. Plan of Removal: Identification of Residents Affected or Likely to be Affected: After notification of deficiency, a review of facility census data on 12/09/2022 determined there were 17 patients in facility. DON and Infection Interventionist immediately identified that 17 patients were determined to have potential risk related to the deficient practice (F1, F2, F3, F4, F5, F6, RF1, RF2, RF3, RF4, RF5, RF6, RF7, RF8, RF9, RF10, and RF11). Corrective Action: -As of 12/09/2022, the facility had 3 active COVID-19 cases. The facility had 2 COVID-19 cases that had met the criteria to discontinue isolation precautions post positive COVID Day 10 in accordance to the CDC guidelines on 12/09/2022. -On 12/09/2022 the corporate Director of Compliance and Board Certified Infection Preventionist reviewed all applicable facility policies and procedures with the facility's Infection Preventionist to ensure the systems established for infection prevention and control program including COVID-19 related policies to prevent the spread of COVID-19 infections in the facility are followed as outlined in the facility's policies and CDC guidelines. -Beginning 12/09/2022 and continuing for a duration of 4 weeks, the corporate infection control consultant will review all employee and visitor screening logs for compliance, as well as reviewing all employee post education testing. Any non-compliant findings during this period will result in immediate corrective action. After 4 weeks, on future site visits, corporate infection control consultant will randomly review audits conducted by DON and Infection Preventionist related to COVID screening, testing, and education. -On 12/09/2022, the facility's infection preventionist received re-education and infection control competencies on the facility's infection prevention and control program. The corporate infection control consultant will provide oversight to the facility's infection preventionist by conducting review of infection control audits, environmental rounds, and COVID-19 protocol for compliance. The corporate infection control consultant will perform site visits with the facility's infection preventionist for 4 consecutive weeks. Any non-compliant findings will result in immediate corrective action. DON, Infection Preventionist, and Administrator completed post education testing on 12/12/2022. -Effective 12/09/2022 and continuing on as an ongoing process, the corporate Board Certified Infection Control consultant will be notified of any COVID positive cases and activation of COVID outbreak testing any time it is activated. Notification will be provided via email by either the DON or the Infection Preventionist in the facility. -On 12/09/2022, the corporate consultant provided the facility's infection preventionist with resources, tools, and checklist to ensure all components of COVID guidelines are being completed. The corporate consultant will continue to provide the facility's infection preventionist with additional resources, tools, and checklists related to any changes in existing documentation by the CDC. The Immediate Jeopardy was removed on 12/13/2022 at 12:05 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. This deficient practice continued at more than minimal harm for the remaining 12 negative COVID-19 residents residing in the facility that were at risk for contracting COVID-19. Findings: Cross Reference F880 Review of the Policy titled, Infection Prevention and Control Program -LTC revealed the following, in part: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. Review of the Policy titled, Coronavirus Surveillance revealed the following, in part: Policy: This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. 1. The facility's Infection Preventionist will monitor the status of COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. 2. Heightened surveillance will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening visitors, staff, and residents. 3. Screening for visitors and staff: a. Symptoms of COVID-19; b. A positive viral test for SARS-CoV-2 c. Close contact with someone with SARS-CoV-2 infection (for visitors) or a higher-risk exposure (for healthcare personnel) 5. Symptomatic healthcare personnel, regardless of vaccination status, should be restricted from work pending evaluation for SARS-CoV-2 infection and should follow facility policy regarding testing and return to work. 8. The facility's Infection Preventionist, or designee, will track the following information: c. The number of residents and staff who have been tested for COVID-19 (testing in accordance with current CDC guidelines and priorities). Review of the Policy titled, Coronavirus Prevention and Response revealed the following, in part: Policy: The facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus. 4. Ensuring that everyone is aware of the recommended IPC practices in the facility by posting visual alerts (e.g., signs, posters) at the entrance and in strategic places to include instructions about current IPC recommendations. Review of the Policy titled, COVID-19 and COVID-19 Vaccine Reporting-LTC/SNF revealed the following, in part: Policy: It is the policy of this facility to share appropriate information regarding COVID-19 with staff, residents and their representatives and to report COVID-19 information to the local/state health department and the Centers for Disease Control and Prevention (CDC). Policy Explanation and Compliance Guidelines: 1. The facility has implemented a system of surveillance designed to identify possible communicable diseases or infections, including COVID-19, before they can spread to other persons in the facility. 2. Positive COVID-19 test results are reported to the Infection Preventionist, or designee, within one hour of receipt so that reporting activities may begin. 3. Notify the state/local health department promptly about any of the following: a. > 1 residents or healthcare personnel (HCP) with suspected or confirmed SARS-CoV-2 infection. On 12/07/2022 at 8:38 a.m., an interview was conducted with S1ADM. He said the facility's current COVID-19 outbreak began on 11/11/2022 when a resident tested COVID-19 positive. He said only one staff member, S6DA, tested COVID-19 positive on 11/28/2022. On 12/09/2022 at 2:03 p.m., an interview was conducted with S2DON. She said she and S3IP shared the infection control responsibilities. She said S3IP was responsible for ensuring staff and visitors were screened and staff were COVID-19 tested prior to working. S2DON said she received her instructions from S3IP and worked closely with S29DQ. S2DON said S3IP educated her on any new infection control information during their staff meetings. S2DON said she was responsible for providing staff with any new or changed infection control information. She said S3IP was responsible for everything else related to infection control. She said S3IP kept track of all staff and residents' COVID-19 testing documentation and provided her with the logs. She said since the COVID-19 outbreak, she nor S3IP had done anything new related to infection control. S2DON said she had not reviewed any screening logs or staff's COVID-19 test results. S2DON confirmed she was S3IP's supervisor and did not review or audit her work and should have been. On 12/09/2022 at 2:14 p.m., an interview was conducted with S3IP who stated she was the facility's infection control nurse and responsible for the facility's infection control program, including tracking facility infections; staff and visitor screening; and staff and resident COVID-19 testing. She said her title was the Inpatient Quality Improvement and Compliance Assistant not the Infection Preventionist, but she was treated as though she was. She said she shared the infection control roles and duties with S1ADM, S2DON, the charge nurses and staff nurses. She said she could not perform all of the infection control duties by herself along with her other job responsibilities, including Quality. She said S29DQ was the director of the Infection Control program and only came to the facility one to two times a month and did not audit her work. S3IP said she did not review the visitor and staff COVID-19 screening logs along with resident and staff testing on a consistent basis, and she should have. She said the first positive COVID-19 case during the outbreak was a resident on 11/11/2022. She said a resident's visitor called the nurses station and reported she was COVID-19 positive. She said she was unaware if that visitor had been screened upon entrance to the facility. She said she was not aware staff had tested COVID-19 positive during the outbreak. She contacted S1ADM on the telephone during the interview and he confirmed S6DA had tested COVID-19 positive at the facility on 11/28/2022. She reported to S1ADM, she was unaware a staff member had tested COVID-19 positive and this should have been communicated to her right away. She said had she known, she would have had the dietary staff COVID-19 test daily for several days to make sure no additional staff tested positive. She said agency staff needed to be rapid COVID-19 tested prior to every shift, or if working several days in a row then every 48 hours. She said the charge nurses were responsible for making sure staff including agency staff were COVID-19 tested accordingly. She said she did not consistently check the schedules and COVID-19 test results to make sure agency staff were tested and should have. She confirmed she had not posted signage indicating there was a COVID-19 outbreak or signage directing visitors at either entrance to screen themselves upon entering the facility. S3IP said she was part of the QA committee that met monthly but had not met since the outbreak. She said S1ADM and S2DON were her supervisors and no one checked her work behind her. On 12/09/2022 at 3:00 p.m., an interview was conducted with S1ADM. He said S3IP was the facility's Infection Preventionist who also had other job duties. He said S3IP worked full time. He said S29DQ was the facility's corporate Quality Infection Control Nurse who assisted from a corporate level and was not responsible for auditing S3IP's work. He said S2DON was S3IP's direct supervisor and was responsible for checking S3IP's work. He said he was S2DON's supervisor and had not been supervising her in that capacity and should have been.

Based on interviews and record reviews, the facility failed to ensure COVID-19 testing of staff prior to providing direct care to residents during a COVID-19 outbreak. This deficient practice resulted in an Immediate Jeopardy situation on 12/09/2022 with the likelihood of severe injury and/or death for 12 (F1, F2, F3, F6, RF1, RF2, RF3, RF4, RF5, RF6, RF7, and RF8) non COVID-19 positive residents residing in the facility during a COVID-19 outbreak. On 12/09/2022 at 9:22 a.m., S2DON confirmed agency staff should have been tested prior to working each shift and were not. On 12/09/2022 at 10:50 a.m. an employee was observed entering the facility without being screened. On 12/09/2022 at 3:01 p.m., a visitor was observed exiting the COVID-19 unit without a face mask and walked down the main hallway into the general population area before exiting the facility at the side entrance. As of 12/09/2022 there were 17 residents residing in the facility with 5 active COVID-19 cases. S1ADM was notified of the immediate jeopardy on 12/09/2022 at 3:15 p.m. Plan of Removal: Identification of Residents Affected or Likely to be Affected: After notification of deficiency, a review of facility census data on 12/09/2022 determined there were 17 patients in facility. DON and Infection Interventionist immediately identified that 12 patients were determined to have potential risk related to the deficient practice (F1, F2, F3, F6, RF1, RF2, RF3, RF4, RF5, RF6, RF7, and RF8). Corrective Action: -Upon notice of deficient practice on 12/09/2022, immediate re-education on COVID-19 prevention and control was provided by the corporate Director of Compliance and Board Certified Infection Preventionist to DON, Infection Preventionist, and Administrator. -The DON immediately reviewed current testing log on 12/09/2022 and all staff and agency staff. All direct care staff scheduled have been tested within the past 48 hours. -Any oncoming staff for 6 p.m. shift will complete COVID testing in accordance to the CDC COVID-19 outbreak testing guidelines prior to providing direct care at the beginning of their shift. On 12/09/2022, DON oversaw COVID testing and screening for all staff working including incoming PM shift staff. -Effective 12/09/2022, the DON re-educated all staff , including agency and contract workers, on the following COVID-19 related infection control and COVID screening policies on facility policies regarding the following facility's policies. Any remaining staff will be provided education prior to their next work shift. The remaining staff will be educated by the charge nurse as they report for COVID screening and testing until all remaining staff have been educated on the following: a. COVID-19 and COVID-19 Vaccine Reporting b. Coronavirus Surveillance c. Coronavirus Testing d. Interim COVID-19 Visitation e. Coronavirus Prevention and Response Staff education will be completed by 12/16/2022. Compliance will be monitored by post education testing that will be kept on file with the screening and testing logs. Testing will be administered by the DON and Infection Preventionist. -Beginning 12/09/2022 and continuing for a duration of 4 weeks, the corporate infection control consultant will review all employee and visitor screening logs for compliance, as well as reviewing all employee post education testing. Any non-compliant findings during this period will result in immediate corrective action. After 4 weeks, on future site visits, corporate infection control consultant will randomly review audits conducted by DON and Infection Preventionist related to COVID screening, testing, and education. DON, Infection Preventionist, and Administrator completed post education testing on 12/12/2022. -Effective 12/09/2022, and continuing for the following 14 days without COVID cases, employee logs have been distributed to each department head for them to fill in all employees scheduled including any agency employee. The employee will sign by their name and list their testing status. Employee logs and testing will be verified by charge nurse administering testing. Employee logs for testing and screening will be reviewed by Administrator, DON, Infection Preventionist, or designee twice daily, once for AM shift, and once for PM shift to ensure compliance beginning 12/09/2022 and continuing for a minimum duration of 4 weeks. -After testing, each department head or designee will scan and email the completed log and test verification results to DON, Infection Preventionist, and Administrator every shift. This is to be done through the duration of outbreak testing and will resume again in the event of a future outbreak requiring outbreak testing. -All department heads including contracted companies have been notified that all staff must test prior to the start of their shift. -Staff and agency staff will complete COVID testing in accordance to the CDC COVID-19 outbreak testing guidelines prior to providing direct care at the beginning of their shift anytime the facility has activated their COVID outbreak protocol. -The facility will maintain documentation of COVID-19 Testing Log and ensure testing documentation is completed for staff and agency staff as required. -In addition to daily review of the employee logs for a minimum of 4 weeks beginning 12/09/2022, the Director of Nursing (DON), or designee, will conduct a weekly review of the visitor screening sign in log and employee screening log. The DON, or designee, will conduct weekly review for 3 consecutive months unitl 100% compliance is achieved and sustained. Once 100% is achieved and sustained the DON will continuue to conduct an audit review of the screening logs monthly ongoing. -The DON and/or Infection Preventionist designee will conduct a review of daily timesheets/schedule to cross-match the COVID testing and screening logs of all employees and contracted staff working to identify all direct care staff in the facility has completed COVID-19 testing anytime the facility's COVID-19 Outbreak Testing protocol is activated. The Immediate Jeopardy was removed on 12/13/2022 at 12:05 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. This deficient practice continued at more than minimal harm for the remaining 12 negative COVID-19 residents residing in the facility that were at risk for contracting COVID-19. Findings: Cross Reference F880 Review of the Policy titled, COVID Testing revealed the following, in part: Policy: The facility will implement testing of facility staff including individuals providing services under agreement (contracted staff, agency staff) for COVID-19. Policy Explanation and Compliance Guidelines: 1. The facility will conduct testing through the use of rapid point-of-care (POC) diagnostic testing devices or through an arrangement with an offsite laboratory. Table 1: Testing Summary (regardless of vaccination status) Newly identified COVID-19 positive staff or resident in a facility that can identify close contacts: Staff: Test all staff, regardless of vaccination status, that had a higher-risk exposure with a COVID-19 positive individual. Testing of Staff and Residents in Response to an Outbreak Investigation: 1. An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. 2. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing will begin immediately. 5. Contact tracing or broad-based testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. 7. If possible, testing should be repeated every 3-7 days until no new cases are identified for at least 14 days. Documentation of Testing a. Upon identification of a new Covid-19 case in the facility (i.e., outbreak), document: i. Date the case was identified ii. Date other staff and residents are tested iii. Dates that staff and residents who tested negative are retested iv. Results of all tests Review of the Agency staff scheduled during the COVID-19 outbreak dated 11/11/2022 - 12/08/2022 revealed the following Agency staff did not have COVID-19 testing performed for the following shifts worked: S11LPN: 11/16/2022, 12/01/2022, 12/02/2022, 12/06/2022, 12/08/2022; S16CNA: 11/27/2022, 11/28/2022, 11/29/2022, 11/30/2022, 12/01/2022, 12/05/2022, 12/07/2022; S20LPN: 11/17/2022, 11/18/2022, 11/26/2022, 12/06/2022; S21LPN: 11/17/2022, 11/18/2022, 11/19/2022, 12/01/2022, 12/08/2022; S22LPN: 11/15/2022, 11/18/2022, 11/19/2022, 11/20/2022, 11/23/2022, 11/27/2022; S23LPN: 11/25/2022, 11/26/2022, 11/27/2022, 12/02/2022; S24LPN: 11/19/2022, 11/20/2022, 11/21/2022, 11/24/2022, 11/25/2022, 11/27/2022, 11/28/2022, 12/02/2022, 12/04/2022, 12/07/2022, 12/08/2022; S25CNA: 11/16/2022, 11/17/2022, 11/18/2022, 11/19/2022, 11/20/2022, 11/21/2022, 11/22/2022, 11/23/2022, 11/26/2022, 11/27/2022, 12/01/2022, 12/02/2022, 12/03/2022; and S26CNA: 11/29/2022, 11/30/2022, 12/01/2022, 12/02/2022. On 12/07/2022 at 9:45 a.m., an interview was conducted with S27LPN. She said she was agency staff and worked on the COVID-19 unit. She said no one at the facility told her she needed to test for COVID-19 prior to working her shift. She confirmed she had not COVID-19 tested at the facility today or in the last 48 hours. On 12/07/2022 at 10:05 a.m., an interview was conducted with S16CNA. She said she was agency staff and worked on the COVID-19 unit. She confirmed she was not COVID-19 tested prior to working her shift today or in the last 48 hours. On 12/08/2022 at 11:05 a.m., an interview was conducted with S3IP. She said agency staff should be rapid COVID-19 tested prior to every shift or if they worked several days in a row then every 48 hours. She said the charge nurses were responsible for making sure all staff including agency staff were COVID-19 tested accordingly. She said she did not consistently check the schedules and COVID-19 test results to ensure agency staff were tested and should have. On 12/08/2022 at 11:50 a.m., an interview was conducted with S11LPN in the presence of S3IP. S11LPN said she was agency staff and worked on the COVID-19 unit. S11LPN confirmed she was not COVID-19 tested prior to working her shift today or in the last 48 hours. S3IP told S11LPN she should have COVID-19 tested prior to working her shift. On 12/08/2022 at 1:25 p.m., an interview was conducted with S30RN. She said it was the agency staff's responsibility to self COVID-19 test every 48 hrs. She said S3IP was responsible for monitoring agency staff for COVID-19 testing. On 12/08/2022 at 1:53 p.m., an interview was conducted with S2DON. She said all staff including agency staff should be COVID-19 tested prior to working their shift or every 48 hours if they worked back to back shifts. She said the charge nurses were responsible for ensuring all staff including agency staff COVID-19 tested accordingly. She confirmed S27LPN, S16CNA, and S11LPN were not COVID-19 tested prior to working their shifts and should have been. On 12/09/2022 at 9:22 a.m., S2DON provided a list of agency staff who worked at the facility since the COVID-19 outbreak started on 11/11/2022 and their COVID-19 testing requisition forms. She confirmed agency staff should have been tested prior to working each shift and were not. On 12/09/2022 at 9:28 a.m., an interview was conducted with S1ADM. He said the charge nurses on each shift were responsible for making sure all staff, including agency staff, COVID-19 tested prior to working their shift. He was notified the charge nurse reported it was the responsibility of the agency staff and S3IP to COVID-19 test agency staff; and S2DON and S3IP reported it was the charge nurses responsibility. He confirmed there was a definite breakdown with communication in general and staff were not on the same page. He confirmed the agency staff that worked since the COVID-19 outbreak on 11/11/2022 were not tested prior to working every shift and should have been. He said staff, including agency staff, not being COVID-19 tested prior to working could contribute to the spread of COVID-19. On 12/09/2022 at 2:44 p.m., an interview was conducted with S28CNA. She said this was her first day back to work after being out for the last two months. She said she had not been COVID-19 tested upon returning to work today. She said she was supposed to have been COVID-19 tested but she had not been.