**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to have a system in place to prevent and control the transmission of COVID-19 infections in the facility by: 1.) failing to ensure staff used personal protective equipment (PPE) with COVID-19 positive residents (Resident #44, Resident#47, Resident #55 and Resident #66); 2.) failing to ensure staff quarantined and immediately tested residents (Resident #22 and Resident #46) who displayed symptoms of COVID-19; and 3.) failing to ensure COVID-19 screenings for signs and symptoms were completed by visitors and staff. This deficient practice resulted in an Immediate Jeopardy situation on 02/13/2023, when the facility identified Resident #6, Resident #14, Resident #44, Resident #47, Resident #55, and Resident #66 tested positive for COVID-19. The facility failed to utilize proper PPE (KN95 or N95 masks) and to quarantine Resident #22 and Resident #46 displayed signs and symptoms of COVID-19 on 02/15/2023. The facility failed to immediately test Resident #22 and Resident #46 who had symptoms of COVID-19. The facility failed to ensure staff and visitors were screened for signs and symptoms of COVID-19 prior to entering the facility. The facility's failure to implement infection control measures, resulted in Resident #43 and Resident #53 testing positive for COVID-19 on 02/15/2023. As of 02/15/2023, there were 8 active resident COVID-19 cases. S1Adminisistrator was notified of the Immediate Jeopardy situation on 02/15/2023 at 2:42 p.m. This deficient practice continued at more than minimal harm and had the potential to cause serious injury, harm or death for the remaining 63 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19. The facility presented the following Plan of Removal on 02/16/2023 at 4:30 p.m.: There were eight active COVID-19 resident cases and two active COVID-19 staff cases in the facility. This had the potential to affect any of the 63 non-COVID-19 positive residents who resided in the facility. Resident #43 and Resident #53 were affected by the deficient practice and tested positive for COVID-19 on 02/15/2023. All remaining 63 non-COVID-19 residents were at potential risk for COVID-19. The residents and staff (who were at the facility for his or her scheduled shift) were tested on [DATE] at 5:30 p.m. for COVID-19. From the testing conducted on 02/15/2023, two new resident (Resident #43 and Resident #53) cases were identified. The confirmed cases were placed on isolation precautions immediately after positive results on 02/15/2023. On 02/15/2023 at 8:15 p.m., the staff who were not tested on [DATE] were notified by phone that he or she will need to be tested at the facility on 02/16/2023 or prior to his or her next scheduled shift. The facility implemented a policy and procedure on the proper usage and application of PPE with a COVID-19 positive resident. On 02/15/2023 at 6:30 p.m. an in-service with return demonstration was conducted with staff (direct hire, contract, hospice, other) on the proper procedure for applying and removing PPE with a COVID-19 positive and removing PPE with a COVID-19 positive resident. Staff in-service were completed on 02/16/2023 at 12:30 p.m. The Director of Nursing (DON), Assistant Director of Nursing (ADON), or designee would conduct evaluations on random staff (one from each department) from each shift with return demonstration on proper application and removal of personal protective equipment twice per week for two weeks beginning 02/15/2023 and ending 03/15/2023, then once per week for two weeks beginning 03/06/2023 and ending 03/19/2023. Staff (one from each department) from each shift would perform return demonstration on proper application and removal of personal protective equipment twice a month for one month beginning on 03/20/2023 and ending 04/16/2023, then once a month for four months beginning 04/17/2023 and ending 08/06/2023 (one from each department). A form had been created that would be completed with each evaluation. All staff (direct hire, contract, hospice, other) would be educated/re-educated on the facility's policy and procedure on the proper usage and application of personal protective equipment with a COVID-19 positive resident on hire, annually, and as needed. On 02/15/2023 at 6:30 p.m. the facility implemented a policy and procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing. All staff (direct hire, contract, hospice, other) were in-serviced on the proper procedures on who to notify when signs and symptoms were identified and completed on 02/16/2023 at 12:30 p.m. Resident #22 and Resident #46 exhibited signs and symptoms of having COVID-19 and were not tested or isolated. Resident #46 was tested on [DATE] at 12:30 p.m. and tested negative. Resident #22 was tested on [DATE] at 12:35 p.m. and tested positive. Resident #22 was placed on isolation. The DON, ADON, or designee would re-educate and evaluate three random staff members per shift (direct hire, contract, hospice, other) on the identification of signs and symptoms of COVID-19, reporting, and testing twice per week for two weeks beginning 02/15/2023 and ending on 03/05/2023, then once per week for two weeks beginning 03/06/2023 and ending 03/19/2023. Staff (one from each department) from each shift would be evaluated on proper identification, reporting, and testing procedures twice a month for one month beginning on 03/20/2023 and ending 04/16/2023, then once a month for four months 04/17/2023 and ending 08/06/2023 (one from each department). A competency form has been created and will be completed with each evaluation of staff. All staff (direct hire, contract, hospice, other) would be educated/re-educated on the facility's policy and procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing on hire, annually, and (as needed) such as an outbreak. On 02/14/2023 a designated administrative staff will be present at all times to instruct visitors on proper screening procedures. Upon entering the facility all visitors must take their temperature and answer the signs and symptoms questionnaire. On 02/15/2023 at 7:00 p.m., an email/phone calls were sent out to the responsible parties as a reminder of the procedure. All email/phone calls were completed on 02/15/2023 at 7:30 p.m. by the administrative staff. On 02/16/2023 at 3:30 p.m., all staff were re-educated on the process of taking his or her temperature and answering the signs and symptoms questionnaire prior to entering the facility. The staff were also re-educated on the signs and symptoms of COVID-19 per Centers for Disease Control and Prevention (CDC) guidelines. If any staff's temperature is below 100 degrees and none of the signs and symptoms are present on the questionnaire, the staff may report to work. Beginning on 02/16/2023, the DON, ADON, or designee would monitor the questionnaire for completion daily for two weeks, then twice a week for two weeks. On 02/15/2023, A COVID-19 Action Plan was implemented to designate administrative staff of specific job duties in the event of a COVID-19 outbreak. The administrator would be notified immediately of a resident or staff positive COVID-19 result. The administrator, DON, or designee will be responsible for notifying the Medical Director, Facility Board of Directors, and Region 3 Office of Public Health (OPH). On 02/16/2023 at 2:30 p.m., S1Administrator, S2Director of Nursing, S3Assistant Director of Nursing held a telephone conference with the Facility's President of the Board. The deficient practices cited on the plan removal was discussed detailing the submitted corrective actions submitted for approval. The topics discussed was the current status of COVID-19 in the building, surveillance policy, isolation policy, identification of COVID-19 signs and symptoms, future plans to update and implement the Infection Prevention Program. The teleconference was completed on 02/16/2023 at 3:30 p.m. The Board President would monitor the plan of removal implemented by the facility for compliance starting on 02/16/2023. The Board President, Administrator, DON, and ADON will meet once a week for two months ending 04/16/2023, then once every other week for a month beginning 04/17/2023 ending 05/14/2023. Afterwards monthly, they would meet for three months, beginning 05/15/2023 ending 08/06/2023. The Immediate Jeopardy was removed on 02/16/2023 at 6:47 p.m., when the provider presented an acceptable plan of removal. Through observations, interviews, and record reviews, it was determined the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings: Cross reference F880 and F882. In an interview on 02/15/2023 at 11:25 a.m., S1Administrator confirmed signs and symptoms of COVID-19 and temperatures had not been checked when all visitors entered the facility. S1Administrtor further stated visitor sign in log should be completed for all visitors who enter the facility. In an interview on 02/15/2023 at 11:35 a.m., S2Director of Nursing (DON) stated and confirmed that staff should have used PPE to include gowns, KN95 masks or N95 masks, surgical mask to cover the KN95 masks or N95 masks, face shields or goggles, and shoe covers when in the room of a COVID-19 positive resident and they were not. S2DON further stated and confirmed this also applied to housekeeping staff who cleaned the rooms of a COVID-19 positive residents. In an interview on 02/16/2023 at 5:15 p.m., S1Administrator confirmed she did not ensure the facility used its resources to effectively prevent the spread of COVID-19 in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to have a system in place to prevent and control the transmission of COVID-19 infections in the facility by: 1.) failing to ensure staff used personal protective equipment (PPE) with COVID-19 positive residents (Resident #44, Resident#47, Resident #55 and Resident #66); 2.) failing to ensure staff quarantined and immediately tested residents (Resident #22 and Resident #46) who displayed symptoms of COVID-19; and 3.) failing to ensure COVID-19 screenings for signs and symptoms were completed by visitors and staff. This deficient practice resulted in an Immediate Jeopardy situation on 02/13/2023, when the facility identified Resident #6, Resident #14, Resident #44, Resident #47, Resident #55, and Resident #66 tested positive for COVID-19. The facility failed to utilize proper PPE (KN95 or N95 masks) and to quarantine Resident #22 and Resident #46 who displayed symptoms of COVID-19 on 02/15/2023. The facility failed to immediately test Resident #22 and Resident #46 who had symptoms of COVID-19. The facility failed to ensure staff and visitors were screened for signs and symptoms of COVID-19 prior to entering the facility. The facility's failure to implement infection control measures, resulted in Resident #43 and Resident #53 testing positive for COVID-19 on 02/15/2023. As of 02/15/2023, there were 8 active resident COVID-19 cases. S1Adminisistrator was notified of the Immediate Jeopardy situation on 02/15/2023 at 2:42 p.m. This deficient practice continued at more than minimal harm and had the potential to cause serious injury, harm or death for the remaining 63 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19. The facility presented the following Plan of Removal on 02/16/2023 at 4:30 p.m.: 1. Resident #43 and Resident #53 were affected by the deficient practice by testing positive for COVID-19. 2. Resident #43 and Resident #53 were then put on isolation precautions. 3. All the remaining 63 COVID-19 negative residents were at risk for the potential to become positive with COVID-19. All staff were required to wear KN95 masks at all times, except when eating or drinking. Staff that were directly caring for COVID-19 positive residents were required to wear a N95 mask. Residents were encouraged to wear surgical masks when in common areas. All visitors were required to wear a mask. A sign was posted at the entrance of the facility on how to properly wear a mask. Visitation and Staff Log On 02/15/2023 a designated administrative staff will be present at all times to direct the visitors on the proper procedure. Upon entering the facility all visitors must take their temperature and answer the signs and symptoms questionnaire. On 02/15/2023 at 7:00 p.m., an email/phone call was sent out to the responsible parties as a reminder of the procedure. All email/phone calls were completed on 02/15/2023 at 7:30 p.m. by the Administrative staff. On 02/16/2023 at 3:30 p.m., all staff were re-educated on the process of taking his or her temperature and answering the signs and symptoms questionnaire, prior to entering the facility. The staff were also re-educated on the signs and symptoms of COVID-19 per Center for Disease Control guidelines. If any staff's temperature was below 100 degrees and none of the signs and symptoms were present, the staff will be able to report to work. Effective on 02/16/2023, S2Director of Nursing (DON), S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) or designee will monitor the signs and symptoms questionnaire for completion daily for two weeks, then twice a week for two weeks. The residents and staff (ones who were at the facility for his or her scheduled shift) were tested on [DATE] at 5:30 p.m. for COVID-19 due to the identification of a potential risk of spreading COVID-19. From the testing conducted on 02/15/2023, two new resident cases (Resident #43 and Resident #53) were identified. The confirmed cases were placed on isolation precautions immediately after positive results on 02/15/2023. On 02/15/2023 at 8:15 p.m., the staff who were not tested on [DATE] were notified by phone that he or she would need to be tested at the facility on 02/16/2023 prior to his or her next scheduled shift. The facility implemented a policy and procedure on the proper procedure for usage and application of PPE with a COVID-19 positive resident. On 02/15/2023 at 6:30 p.m., an in-service with return demonstration was conducted with staff (direct hire, contract, hospice, other) on the proper procedure for applying and removing personal protective equipment with a COVID-19 positive resident. In-servicing with all staff was completed on 02/16/2023 at 12:30 p.m. S2DON, S3ADON/IP, or designee will conduct evaluations on random staff (one from each department) from each shift with return demonstration on proper application and removal of personal protective equipment twice per week for two weeks beginning 02/15/2023 and ending 03/05/2023, then once per week for two weeks beginning 03/06/2023 and ending 03/19/2023. Staff (one from each department) from each shift will perform return demonstration on proper application and removal of personal protective equipment twice a month for one month beginning on 03/20/2023 and ending 04/16/2023, then once a month for four months beginning 04/17/2023 and ending 08/06/2023 (one from each department). A form has been created that will be completed with each evaluation. All staff (direct hire, contract, hospice, other) will be educated/re-educated on facility's policy and procedure on the proper procedure for usage and application of personal protective equipment with a COVID-19 positive resident on hire, annually, and as needed if there is an outbreak. On 02/15/2023 at 6:30 p.m., the facility implemented a Policy and Procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing, All staff (direct hire, contract, hospice, other) were in-serviced on the proper procedures on who to notify when these signs are identified and completed on 02/16/2023 at 12:30 p.m. The DON, ADON/IP, or designee will re-educate and evaluate three random staff members per shift (direct hire, contract, hospice, other) on the identification of signs and symptoms, reporting, and testing twice per week for two weeks beginning 02/15/2023 and ending 03/05/2023, then once per week for two weeks beginning 03/06/2023 and ending 03/19/2023. Staff (one from each department) from each shift will be evaluated on proper identification, reporting, and testing procedures twice a month for one month beginning on 03/20/2023 and ending 04/16/2023, then once a month for four months 04/17/2023 and ending 08/06/2023 (one from each department). A competency form has been created that will be completed with each evaluation of staff. All staff (direct hire, contract, hospice, other) will be educated/re-educated on the facility's policy and procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing on hire, annually, and (as needed) if there is an outbreak. On 02/15/2023, the facility failed to quarantine and test Resident #22 and Resident #46 who exhibited signs and symptoms of COVID-19. The residents who exhibited signs and symptoms were tested for COVID-19. Once it was confirmed that Resident #22 tested positive, she was placed on isolation precautions per facility protocol. On 02/15/2023, education was conducted with the nurses on the importance of immediate action, following identification of a resident with signs and symptoms of COVID-19 to prevent the transmission of the virus. The nurses were instructed to immediately place the resident in his or her room if signs and symptoms were exhibited, perform COVID-19 testing immediately, and place on surveillance list if negative or isolation precautions if positive. On 02/15/2023, education on proper use and applying/removing personal protective equipment when in contact with a COVID-19 resident was conducted with staff. In-services and education were completed with all staff on 02/16/2023 at 12:30 p.m. If a resident exhibits signs and symptoms of COVID-19, it should be reported to the nurse immediately. If the resident is in a general area of the facility, he or she will be placed in his or her room for testing. If the results are negative, the resident will be placed on a surveillance list for five days for continued monitoring. Nurses will monitor for worsening signs and symptoms. Nurses will assess and document on these residents every shift while on the surveillance list. The residents on the surveillance list will be retested on day three. If a resident's symptoms worsen prior to next the next scheduled test date, he or she will be tested immediately. Residents who test positive will be placed on isolation precautions per facility protocol. Testing will be performed on residents and staff who exhibit signs and symptoms of COVID-19. If any resident or staff test results are positive for COVID-19, the facility will test all residents and staff as soon as possible on the same day to prevent transmission of COVID-19. The facility will test in accordance with CDC guidelines. In the event that there are new cases identified prior to the next scheduled testing day, all resident and staff will be tested as soon as possible on that same day due to the identification of potential risks of spreading COVID-19. Signs are placed on the entrance doors to inform visitors and staff that the facility has a current outbreak of COVID-19. These signs include education on identifying signs and symptoms of COVID-19, hand hygiene, and how to properly wear face masks. The Immediate Jeopardy was removed on 02/16/2023 at 6:47 p.m., when the provider presented an acceptable plan of removal. Through observations, interviews, and record reviews, it was determined the facility implemented an acceptable Plan of Removal, prior to exit. Findings: 1. Review of the facility's Personal Protective Equipment Policy, revealed, in part, 3. Protective clothing provide to our employees includes but is not necessarily limited to: a. Gowns (disposable); b. Gloves (sterile, non-sterile); c. Masks; d. Eyewear (disposable glasses, goggles and/or face shields); and e. Shoe covers (disposable). Review of the facility's Isolation Transmission Base Precautions Policy, revealed, in part 4.a. Ensure that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need. Review of Resident #47's Nurse's Notes dated 02/13/2023 at 2:29 p.m., revealed Resident #47 tested positive for COVID-19 and was moved to an isolation room. Review of Resident #44's Nurse's Notes dated 02/13/2023 at 6:17 p.m., revealed Resident #44 tested positive for COVID-19 was placed in quarantine. Review of Resident #55's Nurse's Notes dated 02/13/2023 at 6:14 p.m., revealed Resident #55 tested positive for COVID-19 and placed in quarantine and droplet/contact precautions initiated. Review of Resident #6's Nurse's Notes dated 02/13/2023 at 6:16 p.m., revealed Resident #6 tested positive for COVID-19 and place in quarantine and droplet/contact precautions initiated. Review of Resident #14's Nurse's Notes dated 02/13/2023 at 6:19 p.m., revealed Resident #14 tested positive for COVID-19 and placed in quarantine and droplet/contact precautions initiated. Review of Resident #66's Nurse's Notes dated 02/13/2023 at 6:18 p.m., revealed Resident #66 tested positive for COVID-19 and placed in quarantine and droplet/quarantine precautions initiated. Observation on 02/14/2023 at 10:37 a.m., revealed S12Certified Nursing Assistant (CNA) put on PPE and entered Resident #47's room COVID-19 isolation Room c without a face shield or googles. In an interview on 02/14/2023 at 10:38 a.m., S12Certified Nursing Assistant stated that she did not wear a face shield or goggles in COVID-19 isolation Room b, COVID-19 isolation Room d, or COVID-19 isolation Room c. Observation on 02/14/2023 at 10:55 a.m., revealed S22Housekeeper did not have a KN95 mask on and entered isolation room c. Observation on 02/14/2023 at 10:59 a.m. revealed, S22Housekeeper exited room 'g which contained a COVID-19 positive resident with contaminated shoe covers, gown, face shield, gloves, surgical masks, and hair cover. In an interview on 02/14/2023 at 11:06 am. S22Housekeeper confirmed she exited room g with shoe covers, gown face shield, gloves, surgical masks and hair cover on. S22 Housekeeper further state she was only going to her cart and not down the hall. Observation on 02/14/2023 at 11:11 a.m., revealed S22Housekeeper entered COVID-19 isolation room b without and N95 Mask on or shoe covers on. Observation further revealed S22Houskeeper to have on two surgical masks. Observation on 02/14/2023 at 11:19 a.m., revealed S22Housekeeper exited COVID-19 Isolation room b with no mask and entered COVID-19 isolation room d with a surgical mask in place. In an interview on 02/14/2023 at 2:36 p.m., S3ADON/IP stated staff should put on shoe covers, face shields, hair nets, gowns, and surgical mask to cover KN95 masks prior to entering COVID-19 isolation rooms. S3ADON/IP further stated visitors should wear surgical masks and complete screening questions regarding sign and symptoms of COVID-19, along with taking temperatures prior to entering the facility. In an interview on 02/14/2023 at 5:05 p.m., S13Dietary Manager stated that she did not need to wear PPE because she was not going into Resident #44's room and was only in her doorway. In an interview on 02/15/2023 at 11:35 a.m., S2Director of Nursing stated that staff should be in full personal protective equipment, including eye protection when going into COVID-19 positive rooms or when cleaning a room after a COVID-19 positive resident has been moved. 2. Review of the facility's COVID-19 Test Frequency for Residents and Staff Policy, revealed, in part, residents with signs or symptoms of COVID-19 should be tested immediately and be placed on transmission-based precautions until test results are obtained. In an interview on 02/14/2023 at 2:36 p.m., S3Assistant Director of Nursing (ADON) stated COVID-19 testing was completed on 02/13/2023 and would not be completed again until 02/17/2023. In an interview on 02/15/2022 at 8:15 a.m., Resident #22 stated that she vomited yesterday and she had not been tested for COVID-19 since 02/13/2023. Observation on 02/15/2022 at 8:15 a.m. revealed Resident #22 was not on isolation precautions at this time. In an interview on 02/15/2023 at 9:37 a.m., Resident #46 stated she was very nauseous this morning and she had not been tested for COVID-19 since 02/13/2023. Observation on 02/15/2023 at 9:45 a.m. revealed Resident #22 in the facility chapel with her mask underneath her chin with other residents present. In an interview on 02/15/2023 at 10:50 a.m., S7LPN confirmed that both Resident #22 and Resident #46 were having GI issues such as nausea this morning. Observation on 02/15/2023 at 11:26 a.m., revealed Resident #43 sitting in the Minimum Data Set (MDS) Coordinator's office, with her mask sitting underneath her nose, while awaiting to be tested due to symptoms of COVID-19. Observation further revealed S11MDS Coordinator, S17MDS Coordinator, and S18Transportation Driver in the office without a gown, gloves, eye protection nor shoe covers. In an interview on 02/15/2023 at 11:51 a.m., S1Administrator stated that Resident #43 tested positive for COVID-19. S1Administrator confirmed that Resident #43 should have been wearing her mask over her nose and mouth and that staff should have used PPE while in the room with Resident #43. In an interview on 02/15/2023 at 12:25 p.m., S23Medical Director stated residents who are positive for COVID-19 should be contained in their rooms. S23 Medical Director further stated a COVID-19 test should be performed immediately after symptom onset and that residents with symptoms should be quarantined as soon as possible until a test is performed to confirm if they are COVID-19 positive or COVID-19 negative. S23Medical Director further stated the facility did not consult with him in regards to when COVID-19 testing should be performed. S23Medical Director further recommended COVID-19 testing be performed on 02/16/2023. In an interview on 02/15/2023 at 1:00 p.m., S7LPN stated that both Resident #22 and Resident #46 were having symptoms of COVID-19 since the beginning of the shift and should have been tested for COVID-19. 3. Review of the facility's visitor screening log for 02/13/2023 revealed, in part, signs and symptoms of COVID-19 were not monitored for 68 of 134 visitors. Further review of the facility's visitor sign in log revealed temperatures were not taken for 16 of 134 visitors. Review of the facility's visitor screening log for 02/14/2023 revealed, signs and symptoms of COVID-19 were not monitored for 68 of 73 visitors. Further review of the facility's visitor sign in log revealed temperatures were not taken for 15 of 73 visitors. Review of the facility's staff screening log for 02/14/2023 revealed, signs and symptoms of COVID-19 were not monitored for 20 of 47 staff members that worked that day. Further review of the facility's staff screening log for 02/14/2023 revealed, temperatures were not taken for 6 of 47 staff members that worked that day. Review of the facility's visitor screening log for 02/15/2023 revealed, signs and symptoms of COVID-19 were not monitored for 8 of 21 visitors. Further review of the facility's visitor sign in log revealed temperatures were not taken for 4 of 21 visitors. Review of the facility's staff sign in log for 02/15/2023 revealed, signs and symptoms of COVID-19 were not monitored for 20 out of 45 staff members that worked that day. Further review of the facility's staff sign in log for 02/15/2023 revealed, temperatures were not taken for 9 out of 45 staff members that worked that day. Observation on 02/15/2023 at 11:01 a.m., revealed a visitor did not use hand sanitizer after signing in and continuing into facility. Observation further revealed facility staff did not stop the visitor to inquire about symptoms or encourage the visitor to use alcohol sanitizer. In an interview on 02/15/2023 at 11:23 a.m., S21Accounts Payable stated she is responsible for monitoring the family/visitor sign in log and ensuring temperatures are taken. S21 Accounts Payable confirmed she did not always ensure the visitor sign in log was filled out in completion. In an interview on 02/15/2023 at 11:25 a.m., S1Administrator confirmed signs/symptoms of COVID-19 and temperatures had not been checked when all visitors entered the facility and they should have. In an interview on 02/15/2023 at 11:30 a.m., S2ADON/IP confirmed staff had not answered the screening questions for signs and symptoms of COVID-19 nor had their temperatures taken and they should have prior to entering the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Infection Preventionist established and maintained an effective infection prevention and control program to prevent the transmission of COVID-19 infections in the facility by: 1.) failing to ensure staff used personal protective equipment (PPE) with COVID-19 positive residents (Resident #44, Resident#47, Resident #55 and Resident #66); 2.) failing to ensure staff quarantined and immediately tested residents (Resident #22 and Resident #46) who displayed symptoms of COVID-19; and 3.) failing to ensure COVID-19 screenings for signs and symptoms were completed by visitors and staff. This deficient practice resulted in an Immediate Jeopardy situation on 02/13/2023, when the facility identified Resident #6, Resident #14, Resident #44, Resident #47, Resident #55, and Resident #66 tested positive for COVID-19. The facility failed to utilize proper PPE (KN95 or N95 masks) and to quarantine Resident #22 and Resident #46 who displayed symptoms of COVID-19 on 02/15/2023. The facility failed to immediately test Resident #22 and Resident #46 who had symptoms of COVID-19. The facility failed to ensure staff and visitors were screened for signs and symptoms of COVID-19 prior to entering the facility. The facility's failure to implement infection control measures, resulted in Resident #43 and Resident #53 testing positive for COVID-19 on 02/15/2023. As of 02/15/2023, there were 8 active resident COVID-19 cases. This deficient practice had the likelihood to cause serious harm, injury, or death to the remaining 63 residents identified by the facility to be negative for COVID-19. S1Adminisistrator was notified of the Immediate Jeopardy situation on 02/15/2023 at 2:42 p.m. This deficient practice continued at more than minimal harm and had the potential to cause serious injury, harm or death for the remaining 63 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19. The facility presented the following Plan of Removal on 02/16/2023 at 4:30 p.m.: The Infection Preventionist failed to do the following: perform resident and staff testing, complete a surveillance list, complete identification, reporting, testing, education, implement proper usage of person protective equipment, monitor visitation and staff log, and ensure rooms were cleaned properly. On 02/15/2023, there were eight active resident cases and two active staff cases of COVID-19 in the facility. This deficient practice had the potential to affect any of the 63 COVID-19 negative residents residing in the facility. 1. Resident and Staff Testing Resident #43 and Resident #53 were affected by the deficient practices. The residents and staff were tested on [DATE] at 5:30 p.m. for COVID-19 due to the identification of potential risk of spreading COVID-19. From this testing on 02/15/2023, two (2) new resident cases were identified. The confirmed cases were placed on isolation precautions on 02/15/2023. On 02/15/2023 at 8:15 p.m., the staff who had not been tested on [DATE] were notified by phone that he or she will need to be tested at the facility on 02/16/2023 or prior to working their next scheduled shift. The facility implemented a Policy and Procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing. The staff (direct hire, contract, hospice, other) were in-serviced on the proper procedures on who to notify when these signs and symptoms are identified. CDC possible symptoms include fever, cough, fatigue, shortness of breath, vomiting and loss of taste or smell. 2. Surveillance List Resident #22 and Resident #46 were observed to have signs and symptoms of COVID-19. Resident #46 was tested on [DATE] and the test result was negative. Resident #22 was tested on [DATE] and the result was positive and was immediately placed on isolation. The residents who were identified with signs and symptoms of COVID-19 were placed on a surveillance list for continued monitoring of signs and symptoms of COVID-19. This list was updated every shift by the nurses. The nurses monitored for worsening of signs and symptoms. If the signs and symptoms worsened, the resident was retested on Day 3 (or prior if needed). The nurses assessed and documented the resident's condition every shift. The surveillance was monitored daily by the Infection Preventionist or designee. On 02/15/2023 at 5:30 p.m. the residents that were identified with signs and symptoms of COVID-19 remained on the surveillance for 5 days from the start date of 02/15/2023. 3. Identification, Reporting, Testing Education On 02/15/2023 at 6:30 p.m., the facility implemented a Policy and Procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing per CDC guidelines. In the event of multiple positives before the next scheduled round of testing, the residents and staff will be tested immediately. On 02/15/2023 at 6:30 p.m., the staff (direct hire, contract, hospice, other) who were present during the assigned shift were in-serviced on the proper procedure on who to notify when these signs were identified. The in-service on the proper procedure on how to identify residents with signs and symptoms of COVID-19 was completed on 02/16/2023 at 12:30 p.m. Attached are the CDC possible symptoms. 4. Personal Protective Equipment On 02/15/2023, the facility implemented a Policy and Procedure on the proper usage of personal protective equipment with a COVID-19 positive resident. On 02/15/2023 at 6:30 p.m., the staff (direct hire, contract, hospice, other) were educated on when to use a KN95 or a N95 while in the facility. The staff who were assigned to work with the COVID-19 positive residents were to wear a N95 with a surgical mask while providing direct care. On 02/15/2023, one CNA and one nurse was assigned to the identified COVID-19 positive residents. The staff were educated on how to properly wear masks and to keep masks on unless eating or drinking. Beginning on 02/15/2023, the Director of Nursing (DON), Assistant Director of Nursing (ADON), or designee re-educated and re-evaluated the staff on all shifts (direct hire, contract, hospice, other) on the identification of signs and symptoms, reporting, and testing twice a week for two weeks on all shifts, then once a week for two weeks. After four weeks of conducting education and evaluation with random staff (one from each department) for each shift will be evaluated on proper identification, reporting and testing procedure, twice a month for one month and once a month for four months (one from each department). 5. Visitation and Staff Log On 02/14/2023 a designated administrative staff was present at all times to direct the visitors on the proper procedure. Upon entering the facility, visitors must take their temperature and complete the signs and symptoms questionnaire. On 02/15/2023 at 7:00 p.m., an email/phone calls were sent out to the responsible parties as a reminder of the procedure. All email/phone calls were completed 02/15/2023 at 7:30 p.m. by the Administrative staff. On 02/16/2023 at 3:30 p.m., all staff were re-educated on the process of taking his or her temperature and completing the signs and symptoms questionnaire prior to entering the facility. The staff were also re-educated on the signs and symptoms of COVID-19 per CDC guidelines. If any staff's temperature was below 100 degrees and none of the sign and symptoms were present on the questionnaire, the staff reported to work. Beginning on 02/16/2023, the DON, ADON or designee will monitor the questionnaire for completion daily for two weeks, then twice a week for 2 weeks. 6. Proper Cleaning of Rooms On 02/16/2023 at 7:30 a.m., the housekeepers were trained on the proper procedure for cleaning rooms of residents who tested positive for COVID-19 (See attached). The housekeepers were also trained on the proper usage of PPE. The Service Administrator/Designee will monitor daily for 10 days (beginning on 02/16/2023), which may be extended based on COVID-19 status in facility. In the event of a new COVID outbreak, the housekeepers will be re-educated on the proper procedure with monitoring. The staff (direct hire, contact, hospice, other) will be re-educated on this upon hire, annually, and as needed (such as an outbreak). 7. Infection Preventionist On 02/16/2023 at 3:37 p.m., the Infection Preventionist was re-educated on the key components of an effective Infection Prevention and Control Program. On 02/16/2023, the DON will monitor the Infection Preventionist starting on 02/16/2023, the Infection Preventionist and DON will meet once a week for two months with an end date of 04/15/2023, then once every other week for a month beginning 04/17/2023, then once every other week for a month beginning 04/17/2023 with an end date of 05/14/2023. Afterwards monthly, they will meet for three months, beginning 05/15/2023 with an end date of 08/06/2023. Infection prevention and control program revealed the Infection Preventionist responsibilities included the following: quality assessment and performance improvement integration, infection surveillance, outbreaks, principles of standard precautions, principles of transmission-based precautions, hand hygiene, injection safety, respiratory hygiene and cough etiquette, device (i.e. indwelling urinary and central venous catheters) and wound management, Point of care blood testing, reprocessing reusable resident care equipment, environmental cleaning, water management program, linen management, preventing respiratory infections, tuberculosis prevention, occupational health considerations, antibiotic stewardship, and care transitions. The staff (direct hire, contract, hospice, other) will be re-educated on this upon hire, annually, and as needed (such as an outbreak). The Immediate Jeopardy was removed on 02/16/2023 at 6:47 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews, and record reviews, it was determined the facility implemented an acceptable Plan of Removal. Findings: Cross reference F880. In an interview on 02/14/2023 at 2:36 p.m., S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated staff should use shoe covers, face shields, hair nets, gowns, and surgical mask to cover KN95 masks prior to entering COVID-19 isolation rooms. S3ADON/IP confirmed staff were not wearing all components of PPE. In an interview on 02/15/2023 at 9:50 a.m., S3ADON/IP stated residents should be tested for COVID-19 if they have symptoms such as cough, fever, shortness of breath, or any gastrointestinal issues. S3ADON/IP confirmed residents with gastrointestinal symptoms were not tested for COVID-19 and should have been. In an interview on 02/14/2023 S3ADON/IP stated visitors should wear surgical masks and complete the screening questionnaire regarding signs and symptoms of COVID-19, as well as have their temperatures taken upon entrance to the facility. S3ADON/IP confirmed screenings were not being done consistently. In an interview on 2/15/2023 at 11:25 a.m., S1Administrator confirmed S3ADON/IP should have ensured staff were monitoring visitors for signs/symptoms of COVID-19 and temperatures were obtained when visitors entered the facility and staff wore all components of PPE. S1Administrator confirmed she did not.