Based on observation, interview and document review, the facility failed to maintain sanitary conditions for mechanical lifts for four (R2, R25, R7, R15) out of five residents observed who used a mechanical lift. Finding include: During an observation on 1/6/25 at 6:59 p.m., nursing assistant (NA)-A assisted R7 into bed with a mechanical lift. NA-A placed the mechanical lift away in the nook without sanitizing the mechanical lift. No sanitizing wipes were in the nook where the lifts were stored. During an observation on 1/7/25 at 8:48 a.m., NA-B took the mechanical lift out of R2's room and placed the mechanical lift in the nook without sanitizing the machine. During an observation on 1/7/25 at 9:15 a.m., NA-C took the mechanical lift out of R25's room, placed it in the corner of the living room, and did not sanitize the mechanical lift. During an observation on 1/7/25 at 9:31 a.m., NA-D took the mechanical lift without sanitizing it before bringing it into R7's room. NA-D and NA-C hooked R7's lift pad to the lift and lifted R7 out of the wheelchair. R7's arms came into contact with the mechanical lift during the transfer. NA-D took the mechanical lift out of the room along with a bag of garbage. The garbage bag touched the mechanical lift as NA-D pushed the mechanical lift to the corner of the living room. NA-D did not sanitize the mechanical lift. During an observation on 1/7/25 at 10:00 a.m., NA-D took the mechanical lift to R25's room. NA-D hooked R25 up to the mechanical lift and lifted R25 out of the wheelchair. R25 grabbed onto the mechanical lift. NA-D laid R25 into bed. NA-D placed the mechanical lift in the living room corner, without sanitizing the mechanical lift. During an observation on 1/7/25 at 3:55 p.m., licensed practical nurse (LPN)-A took the mechanical lift into R15's room. At 4:02 p.m., LPN-A took the mechanical lift out of R15's room and placed it in the nook without sanitizing the lift. After continuous observations at 4:20 p.m., NA-A brought the lift into room R2's room without being sanitized. During an observation on 1/8/25 at 8:10 a.m., LPN-B brought a mechanical lift into R25's room without sanitizing the lift first. At 8:14 a.m., LPN-B brought the mechanical lift to the living room corner and walked away without sanitizing the mechanical lift. During an observation on 1/8/25 at 8:36 a.m., NA-E took the mechanical lift into R7's room without sanitizing the lift. At 8:45 a.m., NA-E brought the mechanical lift out of R7's room and placed the lift in the corner of the living room without sanitizing the lift. During an interview on 1/6/25 at 7:39 p.m., NA-A verified the mechanical lift was not sanitized after use. NA-A's normal practice was not to sanitize mechanical lifts. NA-A believed night shift sanitized and cleaned the mechanical lifts. During an interview on 1/7/25 at 10:16 a.m., NA-B verified the mechanical lift was not sanitized after use in R2's room. NA-B did not sanitize the lift after using it as there were not any sanitizing wipes nearby. During an interview on 1/7/25 at 10:35 a.m., NA-D verified the mechanical lift was not sanitized after being in R25's and R7's rooms. NA-D was not certain when a mechanical lift should have been sanitized. During an interview on 1/7/25 at 4:26 p.m., LPN-A verified the mechanical lift had not been sanitized after being used in R15's room. LPN-A verified mechanical lifts were to be sanitized between each resident. During an interview on 1/8/25 at 11:33 a.m., LPN-B verified she did not sanitize the mechanical lift before or after use in R25's room. LPN-B verified lifts were to be sanitized between residents. During an interview on 1/8/25 at 11:37 a.m., NA-E indicated her normal process was to sanitize the mechanical lifts before use and not after use to ensure the lifts were clean. During an interview on 1/7/25 at 12:20 p.m., infection preventionist (IP) indicated his expectation would be for staff to sanitize mechanical lifts between residents to prevent cross-contamination between residents. During an interview on 1/8/25 at 12:11 p.m., director of nursing (DON) verified mechanical lifts were to be sanitized between residents. The DON's expectation was that sanitizing wipes were to be kept in the cubby next to the lifts. DON verified sanitizing lifts was important to prevent cross contamination. Review of policy titled Cleaning and disinfecting mechanical lifts policy dated 10/27/23, revealed it was the policy of the facility to clean and disinfect mechanical lifts that were shared between residents. Indirect contact transmission- Mechanical lifts may transmit pathogens if devices contaminated with blood or body fluids were shared between residents without cleaning and disinfecting between residents. If a mechanical lift had been used for one resident and must be reused for another resident, the device must be cleaned and disinfected before it can be used for another resident.

Based on observation, interview, and document review, the facility failed to maintain the ice machines located in the kitchen and on the 300 wing in a sanitary manner to prevent potential illness. This deficient practice had the potential to affect all 32 residents who received water from the ice machines. Findings include: During an observation on 1/6/25 at 10:13 a.m., the ice machine in the dining room had a thick white hard powder substance approximately one-fourth of an inch in height around the entire inside and outside of the ice spout. During an observation on 1/6/25 at 11:33 a.m., the ice machine on the 300 wing had a thick white hard powder substance approximately one-fourth of an inch in height around the entire inside and outside of the ice spout. The drip pan drain below the ice and water spouts had a thick white hard powder substance. During an observation on 1/7/25 at 4:15 p.m., the ice machine on 300 wing continued to have the white hard powder substance around the ice spout and drain. The ice machine in the dining room appears to have been cleaned and no longer had a thick white hard powder build-up. During an observation on 1/8/25 at 7:20 a.m., the ice machine on the 300 wing continued to have the white hard powder substance around the ice spout and drain. During an interview on 1/6/25 at 11:47 a.m., the dining director confirmed the build-up on the ice machine in the dining room had a thick hard white powered substance buildup. The dining director indicated the kitchen staff were not responsible for the cleaning of the ice machines. During an interview on 1/6/25 at 4:41 p.m., the environmental services director (ESD) verified a thick, white, hard, powder substance was present on the outside and inside of the ice machine in the dining room. The ESD verified there was a thick, white, hard, powder substance present on the outside and inside of the ice machine on the 300 wing. The ESD indicated the ice machine on the 300 wing had a continuous water drip. The ESD stated the water spouts were removed and cleaned monthly. The ESD indicated the water spouts would still have build-up even after being cleaned. The ESD printed out an ice machine cleaning log identifying the spouts that were cleaned monthly and the entire ice machines that were cleaned inside and out every three months. ESD verified keeping the waterspouts clean was important since residents drank the water that came out of the machines. During an interview on 1/8/25 at 12:11 p.m., the infection preventionist (IP) indicated he expected staff to clean the ice machines more frequently when needed. IP verified maintenance was responsible for the cleaning of the ice machines. Keeping the ice machines clean was important as it is was the source of drinking water for the residents. IP indicated a resident could become ill if there was a build-up as it could cause food-borne illness. During an interview on 1/8/25 at 12:11 p.m., the director of nursing (DON) indicated housekeeping was responsible for cleaning the ice machines. DON indicated her expectation was the ice machines would have been kept clean and sanitary, as that was where the residents obtained their drinking water from. DON indicated a resident could become ill if there was a build-up present as it could be a source for food-borne illness. Review of the ice machines cleaning and service spreadsheet titled 2024 ice machine cleaning and service, recorded the ice machines had been fully cleaned every three months. The exterior of the ice machines had been cleaned monthly along with the shower head and faucets. Review of the ice machine manual titled Scotsman ice systems installation and user's manual for meridian ice maker dispenser's models HID312, HID625, and HID 540 dated 2015, revealed steps to clean the ice machine, along with time to clean was when the clean light was on when unit had not been cleaned for at least six months. Water drips from spout may be normal, a few drops per minute is normal. Maintenance and cleaning wash out the drip tray and dispense chutes. Use ice machine scale remover if needed to dissolve scale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 1 of 2 residents( R22) reviewed for activities of daily living (ADL)'s. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had intact cognition and had diagnosis which included leukemia, hypertension (elevated blood pressure), (HTN) and coronary artery disease (plaque buildup in the arteries). Identified R22 required extensive assistance with activities of daily living (ADL's) which included bed mobility, toileting, transfers, and personal hygiene. R22's current care plan last revised 10/10/23, indicated R22 had deficits with ADL's related to Chronic Lymphocytic Leukemia. R22 required staff participation with set up for personal hygiene. R22's comprehensive Care Area assessment dated [DATE], identified R22 required extensive assistance with ADL's. Indicated R22 had weakness and HTN. During an observation on 11/6/23 at 2:20 p.m., R22 was seated in the hallway in her wheelchair and had 1/4 inch long gray facial hairs on her chin. During an interview on 11/6/23 at 2:30 p.m., R22 stated she required staff assistance to shave her chin hairs and that she had wished they would assist her to shave more often. During an observation on 11/7/23 at 8:30 a.m., R 22 was seated in her wheelchair in the dining room and continued to have 1/4 inch long gray facial hairs present on her chin. During an interview on 11/7/23 at 8:45 a.m., nursing assistant (NA)-A stated R22 required staff assistance to shave facial hair. NA-A stated she had not assisted R22 with shaving recently and was unsure of the last time R22 had been shaved. During an interview on 11/7/23 at 8:50 a.m., registered nurse (RN)-A stated R22 required staff assistance to shave facial hair. RN-A verified R22 had several long facial hairs and was unsure the last time R22 had been shaved. RN-A stated her expectation was R22 would have been shaved when facial hair was present. During an interview on 11/7/23 at 11:03 a.m., director of nursing (DON) indicated R22 required staff assistance with shaving. DON stated her expectation was R22 would have been shaved weekly or when facial hair was present. Facility policy titled Activities of Daily Living (ADLs) Policy amended 4/8/22, indicated residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Further indicated residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 3 of 5 residents (R5, R10, R134) reviewed for immunizations. Findings include: R5 R5's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of diabetes, heart and kidney disease. R5's undated immunization record, identified R5 received the pneumococcal conjugate vaccine 13 variant (PCV13) on 2/6/19. R5's medical record lacked documentation the PCV20 (pneumonia immunization) was offered and/or education was provided in conjunction with the provider to R5/R5's representative. R10 R10's quarterly MDS dated [DATE], identified diagnoses of chronic obstructive pulmonary disease (COPD), diabetes, obesity and heart failure. R10's undated immunization record, identified R10 received PPSV23 on 5/30/02, and the PCV13 on 10/29/18. R10's medical record lacked documentation the PCV20 was offered and/or education was provided in conjunction with the provider to R10/R10's representative. R134 R134's admission MDS dated [DATE], identified a diagnosis of encephalopathy. R134's undated immunization record, identified R134 received the PCV13 on 4/7/15. R134's medical record lacked documentation the PCV20 was offered and/or education was provided in conjunction with the provider to R134/R134's representative. During an interview on 11/6/23 at 3:20 p.m., with the director of nursing (DON) the DON confirmed the facility had not been currently offering the PCV20 to their residents. They had just completed resident's yearly influenza vaccination review and planned to review PCV20 requirements for the residents in the future. A vaccination policy was requested, however none was provided.

Based on interview and document review, the facility failed to develop and implement a comprehensive infection control program to include ongoing process and outcome surveillance, and routine analysis of the collected data to ensure infections were not spreading within the facility to other residents and/or employees. This deficient practice had potential to affect all 29 residents in the facility. Findings include: During review of the facility's infection prevention program on 11/6/23 at 3:00 p.m., with the Infection Preventionist (IP), IP stated he received information on resident illnesses when the nurses on the floor completed a resident infection form. The nurses completed the form when a resident was displaying symptoms of illness such as cough or fever, the form was provided to the IP and he then filed the form in his office. Since IP did not have access to the facility's computer tracking system, the director of nursing (DON) entered resident illnesses into the system. IP stated when staff called in ill, whoever took the call completed an absence report and provided it to the staff scheduler. The scheduler tracked staff illnesses and notified IP or the DON if there were more than one similar staff illness at a time. During an interview on 11/6/23 at 3:20 p.m., the staff scheduler (SS) stated she received staff absence reports and reviewed them to assist her in replacing the shifts. After SS worked on replacing the ill staff member's shift, the reports were then filed. SS did not track or trend staff illness, as she was not a nurse and only referred to them for scheduling purposes. SS filed the reports until the first of every month and then returned the reports back to the floor nurses. SS could not recall any staff member asking to review the absence reports and was not sure what was done with the reports after she returned them every month. During an interview on 11/6/23 at 7:30 p.m., the DON stated when a resident displayed symptoms of illness or infection, the floor nurse opened a symptom tracker on their computer system. The system directed the nurses to chart on the resident for three days. At the end of the three days, the nurses would determine if further follow up was needed. DON stated the facility did have an infection control tracking system in their computer program, however the last entry made had been in May 2023, by the previous IP and had not currently been in use. DON confirmed the facility had not been tracking or trending resident or staff illnesses at the time and there was no overall facility wide monitoring in place. DON stated IP was having difficulty accessing the infection control computer programs and was unsure why. DON stated it was important to track and trend all illnesses in the facility to be able to look at the bigger picture for any potential spread of infections. Review of the facility policy Infection Prevention and Control amended 6/7/22, identified the infection prevention and control program would attempt to meet federal and state regulations for infection control where applicable. A system of identifying, reporting, investigating, and controlling infections and communicable diseases for ill residents, all employees, volunteers, visitors, and other individuals providing services under a contractual arrangement would be tracked where possible on a infection control tracking record and reviewed by the infection preventionist and Quality Assurance and Performance Improvement (QAPI) committee who would keep record of corrective action taken.

Based on interview and document review, the facility failed to develop an antibiotic stewardship program which included the development of protocols and a system to monitor antibiotic use for 3 of 3 residents (R2, R135, R28) reviewed for antibiotic stewardship. This deficient practice had the potential to affect all 29 residents who resided in the facility. Findings include: On 11/6/23 at 7:30 p.m., the facility's infection control program was reviewed with the director of nursing (DON). The infection control program lacked protocols for a facility-wide system to monitor the use of antibiotics which included appropriate prescribing of antibiotics, and periodic review of antibiotic use by physicians. In addition, the program lacked protocols for review of labs, determination of appropriate antibiotic use and reporting of any patterns identified. Review of R2's progress notes dated 9/19/23, identified an order to start antibiotic treatment for cellulitis. and progress note 10/12/23, identified an order to start antibiotic treatment for a urinary tract infection. Review of R135's undated physician order sheet identified an order had been received to start antibiotic treatment for ten days on 11/2/23. Review of R28's undated physician order sheet identified an ongoing antibiotic treatment had been initiated on 8/16/23, for blood infection. The facility's monthly Infection Surveillance Report indicated the last resident illness entered for antibiotic use was on 5/11/23, for an ear infection in which R13 had received antibiotic treatment. The report lacked any documentation of antibiotic use for R2, R135, R28 or any other residents since 5/11/23. During an interveiw on 11/7/23 at 1:45 p.m., the DON confirmed the facility had not established an antibiotic stewardship program that tracked and trended antibiotic use. The facility's computer system automatically entered in a resident's name and antibiotic when staff entered the information into the resident's medication list. The data just included the resident's name and the name of the antibiotic ordered. DON stated the data was not individualized and confirmed the last time anyone had reviewed the antibiotic program was in May 2023, when R13's ear infection had been entered. The facility's infection preventionist had left the facility shortly after that. DON indicated the facility had recently hired a new infection preventionist nurse however he had not been fully trained yet on how to access the system. The facility policy Antibiotic Stewardship Program with revision date 12/1/22, identified the purpose was to maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. The facility would incorporate seven core elements outlined by the Centers of Disease Control (CDC) of leadership commitment, accountability, drug expertise, action, tracking, reporting and education. A key objective for 2023 was to establish an antibiotic stewardship program and a system to track antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect an accurate cognitive pattern and mood status for 1 of 1 residents (R25) reviewed for Pre-admission Screening and Resident Review (PASARR). Findings Include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2019, Section C: Cognitive Patterns, identified the intent of this section was to determine the resident's attention, orientation and ability to register and recall new information and these items were crucial factors in many care-planning decisions. The RAI manual indicated Section D: Mood, the intent of this section was to address mood distress, a serious condition that was under diagnosed and under treated in the nursing home and was associated with significant morbidity. The RAI manual continued to identify section D as particularly important to identify signs and symptoms of mood distress among nursing home residents as these signs and symptoms were treatable. R25's quarterly MDS dated [DATE], identified section C-Cognitive pattern, included CO100: Should Brief Interview for Mental Status be conducted?, identified yes with a check mark. The rest of section C-cognitive pattern of the MDS had not been completed. R25's MDS section D-Mood, included D0100: Should Resident Mood Interview Be Conducted?, identified yes with a check mark. The rest of section D had not been completed. R25's quarterly MDS dated [DATE], identified section C-Cognitive pattern, included CO100: Should Brief Interview for Mental Status be conducted?, identified yes with a check mark. The rest of section C-cognitive pattern of the MDS had not been completed. R25's MDS section D-Mood, included D0100: Should Resident Mood Interview Be Conducted?, identified yes with a check mark. The rest of section D-mood, of the MDS had not been completed. R25's care plan revised 11/11/22, identified R25 had impaired cognitive function and/or impaired thought processes related to cognitive communication deficit and had a need for social service intervention related to borderline intellectual functioning. R25's care plan indicated R25 had an activities of daily living (ADL) self care performance deficit related to weakness and impaired cognition. Required limited assistance of one staff with bathing and instructed staff to report any changes in ADL abilities to the charge nurse. During an interview on 2/22/23, at 1:49 p.m. director of nursing (DON) reviewed R25's MDS's and confirmed the above findings. DON indicated she would expect all sections of the MDS be completed as required. DON stated Section D was important to determine a resident's potential depression symptoms and indicated she was unaware section C or D had not been completed for R25. DON stated MDS coordinator (MDSC)-A typically informed the staff if areas of the MDS were not completed. In addition, MDSC-A sent out a MDS schedule to assure MDS assessments were completed timely. During a telephone interview on 2/22/23, at 3:03 p.m. MDSC-A indicated she was responsible for completing the MDS assessments in the facility. MDSC-A stated she monitored the resident's MDS schedules and sent reminders to facility staff via e-mail. MDSC-A confirmed the above findings and indicated she had been aware section C and D had not been completed for R25's MDS assessments. MDSC-A stated she had informed the facility staff and the social service designee (SSD)-A of the incomplete MDS. In addition, MDSC-A indicated she had repeatedly reported the R25's MDS's had not been completed at the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings since November, 2022. During an interview on 2/22/23, at 3:08 p.m. SSD-A confirmed the above findings. SSD-A stated she remembered she did not have time to document her assessment findings in R25's MDS's. SSD-A indicated section D of the MDS assessment was important to assist in identifying depressive feelings, anxiety or thoughts of harm to self. Additionally, SSD-A stated section C was important to assess since it identified if there was a decline in cognition which could be an indicator of an underlying medical condition. During an interview on 2/22/23, at 5:10 p.m. the administrator confirmed the above findings. The administrator stated the problem of incomplete MDS's had been identified and discussed at their monthly QAPI meetings. Administrator indicated the facility audited residents' MDS completion rates in the past and initially noted improvement however it had regressed. The facility policy titled MDS 3.0 (Minimum Data Set) Policy amended 6/17/22, identified the resident assessment process was completed by the interdisciplinary team (IDT) within the federally mandated timeline to provide a baseline of the resident's functional status on admission with scheduled assessments to determine ongoing functional status and changes. The policy indicated the MDS coordinator determined the MDS schedule and routed it to all IDT members. The policy identified the MDS coordinator oversaw the MDS completion process and all department managers were expected to be knowledgeable for ensuring accurate documentation of the MDS for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) level one assessment had been completed for 1 of 4 residents (R25) reviewed for PASARR. Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], identified R25 had diagnoses which included: anxiety, depression, and post traumatic stress disorder (PTSD). R25's MDS indicated R25 required supervision with dressing, walking in corridor, locomotion, and was independent with other areas of activities of daily living (ADL). R25's care plan revised 11/11/22, identified R25 had impaired cognitive function and/or impaired thought processes related to cognitive communication deficit. The care plan indicated R25 had a need for social service intervention related to borderline intellectual functioning. R25's care plan identified R25 had an ADL self care performance deficit related to weakness and impaired cognition and required limited assistance of one staff with bathing. Review of R25's medical record (MR) lacked a level one PASARR screening had been completed to consider a referral for further evaluation and determination of need for specialized services. During an interview on 2/21/23, at 3:34 p.m. administrator confirmed the above findings. During an interview on 2/22/23, at 9:17 a.m. social service designee (SSD)-A indicated she was responsible for the completion of PASARR screenings and confirmed R25 did not have a PASARR screening in her medical record. SSD-A stated the facility did did not have a process to assure the PASARR screenings were received prior to resident admissions. SSD-A indicated the PASARR was important to assure the residents received specialized services and referrals when needed. The facility policy titled Preadmission Screening Level II (PASARR) dated 8/5/2017, identified prior to admission all residents would have a PASARR completed and if the level I screening identified the need for a PASARR level II then it would be completed prior to the resident being admitted to the facility. The policy identified the level I and level II screening would be kept on file in the resident's chart and the recommendations from the level II screening would be followed by the facility.

Based on interview and document review, the facility failed to test staff for COVID-19 according to Centers for Medicare and Medicaid (CMS) guidance for outbreak testing requirements for 4 of 5 staff reviewed for COVID-19 testing. This deficient practice had the potential to affect all 26 residents residing in the facility, all staff, and any visitors to the facility. Findings include: The CMS QSO-20-38-NH memo revised 9/23/22, directed, upon identification of a single new case of COVID-19 infection in any staff or residents, outbreak testing should begin immediately. Furthermore, the memo directed testing should follow the Centers for Disease Control (CDC) guidelines and be repeated every 3-7 days until no new cases were identified for 14 days. A facility form titled Positive Resident's past three months undated, indicated R5 had tested positive for COVID-19 on 1/26/23, with no further outbreaks noted since this date. Review of Facility hand written form titled R5 positive contact tracing form dated 1/26/23, indicated R26 tested positive and R5 had not been out of her room in the last 24 hours. Contact tracing of staff included nursing assistant (NA)-A, NA-B, NA-C, registered nurse (RN)-A and RN-B for the 1/24/23, 1/25/23 and 1/26/23. Review of the COVID-19 Testing Staff Consent Forms (TSCF) for staff in the facility's plastic COVID-19 testing binder from 1/1/23, to 2/22/23, revealed the following: NA-C's TSCF identified the last time COVID-19 testing had been completed was 9/27/22 and lacked evidence of any further testing. RN-B's TSCF identified the last time COVID-19 testing had been completed was on 1/25/23, 1/30/23, 2/8/23, 2/12/23, and 2/20/23, with negative results of COVID-19 and lacked evidence of any further testing. The binder lacked evidence of testing for NA-A, NA-B and RN-A. NA-A, NA-B and RN-A TSCF forms in the binder indicating no testing had been completed for COVID-19. During an interview on 2/22/23, at 2:43 p.m. NA-C indicated she was up to date on her COVID-19 vaccinations and was not required to test on a regular basis. NA-C indicated she would test if she had any symptoms of COVID-19 and stated she had tested last week due to allergy symptoms, then tested again three days later and was negative for COVID-19. NA-C confirmed she had not completed any testing after being exposed to a resident who had a positive case of COVID-19 and was not directed to test. During an interview on 2/22/23, at 11:57 a.m. RN-B indicated she was currently not vaccinated for COVID-19 and was required to test on a weekly basis. RN-B confirmed the weekly testings were the only times she had been tested. RN-B stated there was a testing station in the director of nursing (DON)'s office along with a book staff were expected to sign and enter the results of their COVID-19 tests into. During an interview on 2/22/23, at 2:21 p.m. DON confirmed the above findings and indicated she was responsible for overseeing the COVID-19 testing and contact tracing for staff. DON indicated staff were responsible to record their own results and had not been consistently recording them. The DON stated her expectations were for staff to be tested on day one, day three and day five after being exposed or when an outbreak had occurred. DON indicated staff were expected to record their test results so she could verify the testing had occurred as required. Review of the facility policy titled, Health Care Worker COVID-19 Testing and Returning to Work updated on 10/13/22, indicated when a health care worker or resident has tested positive, outbreak testing will begin, either by method of contact tracing/targeted testing or broad-based testing. Contact tracing must be completed within 24 hours, if this was not feasible, broad-based testing will be conducted.