**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure 5 of 5 employees, (licensed practical nurse (LPN)-A, dietary aide (DA)-D, activity aide (AA)-C, nursing assistant (NA)-D and LPN-B) were appropriately cleared to return to work following reports of potential symptoms of COVID-19; failed to initate contact tracing or facility wide testing for COVID-19 following potential exposure from a staff who tested positive for COVID-19; failed to ensure 3 of 53 residents (R108, R29, R41) were isolated while presenting with symptoms of COVID-19; and failed to utilize appropriate protective equipment for 2 of 3 residents (R41, R50) when they were placed in isolation. In addition, the facility failed to ensure twelve employees (cook (CK)-A, activity director (AD)-A, DA-B, the director of nursing (DON), DA-C, assistant dietary manager (ADM)-A, DA-B, registered nurse (RN)-D, DA-D, NA-C, NA-A,NA-B) who were out ill with potentially communicable illness' were cleared to return to work: failed to to track resident symptoms of infection and implement an ongoing analysis of collected data to ensure patterns and trends were identified and acted upon to reduce the risk of disease spread within the facility as recommended by the Centers for Disease Control (CDC) guidance to prevent/or minimize the transmission of COVID-19. This resulted in a system wide failure in infection control procedures to prevent the spread of illness within the facility to vulnerable residents and the staff of the facility and resulted in an immediate jeopardy (IJ) which placed all 54 residents at a high likelihood to for serious illness and/or death by contracting a communicable disease, including but not limited to COVID-19. The IJ began on 12/20/22, when NA-D returned to work following COVID-19 symptoms on 12/19/22 and subsequently became positive on 12/21/22. Following the positive COVID-19 test result, the facility failed to conduct contact tracing or initate facility wide testing for COVID-19. The facility failed to isolate and implement transmission based precautions for R108, R29 and R41 when they displayed signs and symptoms of COVID-19. In addition, after the facility placed residents in isolation, staff were observed to not use the appropriate PPE. The administrator and DON were notified of the IJ on 1/11/23, at 2:00 p.m. The IJ was removed on 1/12/23, at 3:00 p.m. when the facility implemented actions to reduce/prevent the spread of illness, including COVID-19. However, noncompliance remained at the lower scope and severity, F, widespread, which indicated no actual harm with potential for more than minimal harm that was not IJ. Findings include: The Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 23, 2022, identified anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for COVID-19 as soon as possible. Mild illness is defined as any various signs and symptoms of COVID-19 such as fever, cough, sore throat, malaise, headache, muscle pain, without shortness of breath, dyspnea or abnormal chest imaging. Moderate illness is defined as evidence of lower respiratory disease, by clinical assessment or imaging, and a saturation of oxygen of <94% on room air. CDC further indicated HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. Further, patients with symptoms of COVID-19 (even before results or diagnostic testing) should be placed in Transmission-Based Precautions. The decision to discontinue empiric transmission based precautions by excluding the diagnosis of a current COVID-19 infection for a patient with symptoms can be made based upon having negative results from at least one viral test. If using an antigen test, a negative result should be confirmed by either a negative molecular test or a second negative antigen test taken 48 hours after the first negative test. Patients with suspected or confirmed COVID-19 should be placed in a single person room and the door should be kept closed, if safe to do so. Healthcare workers who enter the patients rooms should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The CDC Symptoms of COVID-19, updated October 26, 2022, identified people with COVID-19 have had a wide range of symptoms reported-ranging from mild symptoms to severe illness. Symptoms may appear 2 to 14 days after exposure to the virus. Possible symptoms include: fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea. Employee Illness Tracking The facility employee infection control logs for the month of December 2022, identified the following: Respiratory Illness - On 11/24/22, dietary aide (DA)-A tested positive for RSV. DA-A was not tested for COVID-19 illness. DA-A returned to work on 11/28/22. -On 12/4/22, licensed practical nurse (LPN)-A reported aching, sore throat, and headache. LPN-A was not tested for COVID-19 illness. LPN-A returned to work on 12/5/22. LPN-A was not tested for COVID-19 illness. LPN-A worked 12/5/22, 12/6/22 and 12/7/22. On 12/8/22, LPN-A tested positive for influenza B and was still not tested to rule out COVID-19. An analysis of potential contacts who may have been exposed or resolution of symptoms was not documented. -On 12/6/22, DA-D reported increase respiratory symptoms. DA-D was not tested for COVID-19 illness. DA-D returned to work on 12/21/22. -On 12/7/22, AA-C reported symptoms of aching and cough. AA-C was not tested for COVID-19 illness. AA-C returned to work on 12/12/22. -On 12/19/22, NA-D reported respiratory symptoms. NA-D was not tested for COVID-19 illness. NA-D returned to work on 12/20/22. On 12/21/22, NA-D reported illness and tested positive for COVID-19. Contact tracing and testing for COVID-19 to evaluate staff and residents potential exposure and limit the spread of the illness within the facility was not initiated, despite NA-D having worked providing direct care to residents the day prior to her positive test result. -On 12/24/22, LPN-B reported illness of headache and aching while working her shift. LPN-B tested positive for COVID-19 on 12/27/22. LPN-B returned to work on 12/29/22. Contact tracing and testing for COVID-19 to evaluate staff and residents potential exposure and limit the spread of the illness within the facility was not initiated, despite LPN-B having worked providing direct care to residents the day she began exhibiting symptoms of illness. Gastrointestinal Illness (GI) -On 12/8/22, cook (CK)-A reported diarrhea illness and went home. CK-A was not tested for COVID-19 illness. CK-A returned to work on 12/9/22. -On 12/8/22, activity director (AD)-A reported nausea and went home. AD-A was not tested for COVID-19 illness. AD-A returned to work on 12/9/22. -On 12/8/22, dietary aide (DA)-B reported nausea, vomiting and diarrhea and went home. DA-B was not tested for COVID-19 illness. DA-B returned to work on 12/9/22 -On 12/9/22, the director of nursing (DON) reported diarrhea and headache. The DON was not tested for COVID-19 illness. The DON returned to work on 12/12/22. -On 12/9/22, DA-C reported GI symptoms. DA-C was not tested for COVID-19 illness. DA-C returned to work on 12/19/22. -On 12/9/22, assistant dietary manager (ADM)-A reported GI symptoms. ADM-A was not tested for COVID-19 illness. -On 12/12/22, DA-B reported GI symptoms. DA-B was not tested for COVID-19 illness. DA-B returned to work on 12/13/22. -On 12/14/22, registered nurse (RN)-D reported body aches, nausea and vomiting. RN-D did not test for COVID-19 illness. RN-D returned to work on 12/16/22 -On 12/21/22, DA-D reported GI symptoms. DA-D was not tested for COVID-19 illness. DA-D returned to work on 12/30/22 -On 12/27/22, nursing assistant (NA)-C reported vomiting and diarrhea. NA-C was not tested for COVID-19 illness. NA-C returned to work on 12/29/22 -On 12/28/22, NA-A reported nausea and dizziness. NA-A was not tested for COVID-19 illness. NA-A returned to work on 1/9/23. -On 12/29/22, NA-B reported nausea, vomiting and diarrhea. NA-B was not tested for COVID-19 illness. NA-B returned to work on 12/31/22. There was no evidence assessments were conducted to determine if employee illness could potentially be COVID-19 symptoms and require testing prior to return to work or if there were potential resident and staff exposures and a need to conduct contact or outbreak testing. The infection control logs lacked evidence the facility conducted a comprehensive analysis of the collected outcome surveillance data to determine if any of the infections identified were potentially related or corresponded with resident illness for the same month period. There was no evidence the facility had investigated the infections identified for potential causes and/or subsequent actions to reduce the risk of recurrence. When interviewed on 1/10/23, at 2:15 p.m. LPN-A stated if an employee came to her with complaints of feeling sick she would ask them about their symptoms. If it was just sniffles or a little under the weather, she would not send them home. If they were really sick and they had coverage, she would send them home. During interview on 1/10/23 at 2:35 p.m. NA-C stated she would not come to work if she felt sick. If NA-C was already working and started to feel sick, she would try to get someone to come in and replace her but if could not find anyone, she couldn't just go home. It depended on what her symptoms were and which of the nurses was working. If she was throwing up she would probably go home, but if was just feeling run down she would have to work out her shift. When interviewed on 1/10/23, at 3:40 p.m. NA-D stated she was ill with COVID in December of 2022, and tested positive for COVID-19 on 12/21/22. The symptoms NA-D experienced during that illness were GI upset of nausea, vomiting and diarrhea. During interview on 1/11/23, at 10:30 a.m. LPN-B stated she was sick the day she worked on 12/24/22. LPN-B called the administrator that evening to let her know and did not work on 12/25/22 or 12/26/22. LPN-B tested positive on 12/27/22, as she knew she would as a family member in her home was ill with COVID-19 the week before. LPN-B returned to work on 12/29/22, when she was no longer feeling ill and it was five days since her symptoms first appeared. During interview on 1/10/23, at 10:20 a.m. RN-D, who was the infection preventionist, stated she saw the employees when they returned to work after having called in and none appeared ill. RN-D did not test the employees on their return to work. RN-D had known LPN-B had a family member who was ill with COVID-19 living in her home and reported not feeling well on 12/24/23; however, continued to work her entire shift. LPN-B did test positive on 12/27/22. The facility had not initiated any testing of potentially exposed residents or staff, as RN-D felt the doctors in the area believed people tested for COVID too often. RN-D was aware of the facility's policies for staff who had signs and symptoms of COVID-19 like illness (based on screening) and/or a temperature (100 degrees or higher) should not report to work until testing could be completed as well as contact tracing for potential exposures; however, the policies were written by the corporate office and did not necessarily reflect current practice. RN-D stated she visualized all the staff members LPN-B worked with when LPN-B was presenting with symptoms at work. The unidentified staff did not display any symptoms of illness, so RN-D did not feel any COVID-19 testing was necessary, despite COVID-19 having asymptomatic transmission. RN-D saw DA-A on her return to work on 11/28/22, after testing positive for RSV on 11/24/22, and DA-A had no obvious symptoms of illness, and there were no other cases of RSV in the facility. The employees who reported symptoms of GI illness during the month of December were not tested for COVID-19 as their symptoms did not act like a COVID-19 illness. It depended on staff symptoms if they would need to test before returning to work after an illness. An interview was conducted with the DON and administrator on 11/10/22, at 3:30 p.m. The administrator stated if staff or residents displayed illness that could indicate a COVID-19 infection, the ill resident or staff were to isolate and COVID-19 testing would be done on day one, day three and day five of symptom onset. If the results were negative and the resident or staff was asymptomatic isolation was lifted. For contact tracing, the facility did outbreak testing with COVID-19 antigen tests. The facility had not completed an assessment to see if outbreak testing would be needed when LPN-B had tested positive as her positive test was more than 48 hours since she had last worked, despite having displayed symptoms of COVID-19 while at work on 12/24/22. The facility allowed staff to return to work in five to ten days of a positive COVID test, five days if emergency staffing, if they had improved symptoms and were fever free. They allowed LPN-B to return to work on 12/29/22, because they had used onset of symptoms 12/24/22, for the start of her illness. RESIDENT OBSERVATIONS: During observation of R41 on 1/11/23, at 8:40 a.m. there was a sign on R41's door which directed staff/visitors to stop at nurses station prior to going into the room. An isolation cart was outside of the room. During observation of R41 on 1/11/23, at 8:51 a.m. R41's door was wide open and R41 was not in the room. During observation of R41 on 1/11/23, at 8:56 a.m. R41 was in the dining room and seated at a table in the far corner of the room approximately 10-12 feet (ft) from other residents. Nursing assistant (NA)-C was wearing a face mask and was seated next to R41 to assist R41 with eating. During observation of R41 on 1/11/23, at 8:58 a.m. activity aide (AA)-C wheeled R41 out of the dining room and into the hallway near the waterfall. R41 was not wearing a face mask. During observation on 1/11/23, at 9:06 a.m. R41 was seated in her wheelchair, was not wearing a face mask and was seated next to two unidentified residents in the hallway near the waterfall. During observation of R41 on 1/11/23, at 9:06 a.m. R41 was observed unmasked and seated in her wheelchair in the activity area. R41 stated she didn't feel well. R41 coughed several times. Licensed practical nurse (LPN)-C stated R41 could eat in the dining room as long as the resident wore a face mask and sat at the table in the far corner. LPN-C needed to give R41 a breathing treatment and started to wheel R41 out of the activity area. While LPN-C was wheeling R41 down the hallway, LPN-C was interrupted and left R41 in the hallway. R41 was still unmasked. During observation of R41 on 1/11/23, at 9:17 a.m. LPN-C returned to R41 and started wheeling R41 towards her room. LPN-C stated R41 should be wearing a face mask since she was in the hallway. During observation on 1/11/23, at 9:21 a.m. LPN-C was standing next to R41, nurse prepped nebulizer equipment near R41 and then exited residents room. LPN-C did not put on personal protective equipment (PPE) prior to entering R41's room, and did not perform hand hygiene prior to entering or upon exiting the room. LPN-C re-entered R41's room wearing a face mask and carried gloves balled up in her left hand. LPN-C did not put on PPE or use hand sanitizer prior to entered R41's room. With bare hands, LPN-C prepped R41's nebulizer medication (inhaled medication used to reduce inflammation in the lungs or to open airways to improve breathing ability), and placed the face mask over R41's face, secured the elastic straps around R41's head and turned the machine on. LPN-C proceeded to clean and walk around the area near R41 while the nebulizer machine was bubbling and running. LPN-C maintained a distance between 2 feet and 8 feet from R41 during the entire time. During observation at 9:28 a.m. NA-F entered R41's room, talked with LPN-C and then exited the room. Upon entering R41's room NA-F did not use hand sanitizer or put PPE on prior to entering room, use hand sanitizer upon exiting the room or to change face mask after exiting the room. During observation at 9:30 a.m. LPN-C continued to walk around R41's room. LPN-C leaned over R41 and stand face-to-face with R41 while R41's nebulizer was still running. LPN-C was wearing a face mask . LPN-C then removed R41's nebulizer mask, walked behind resident and turned nebulizer machine off. With bare hands, LPN-C carried the nebulizer mask into the bathroom. LPN-C exited the bathroom and walked to R41's side. LPN-C arranged R41's oxygen tubing, placed the nasal cannula on the resident's face and listened to her chest with a stethoscope. LPN-C was within one to two feet of R41 the entire time. Then LPN-C walked into the bathroom, washed hands, removed the face mask, exited R41's room and put on a clean face mask. LPN-C was in R41's room for a total of 8 minutes while in close proximity of R41 and only wearing a face mask. During interview on 1/11/23, at 9:28 a.m. NA-F stated despite there being a sign on the door and a cart outside R41's room she completely forgot to put on PPE prior to entering R41's room. During interview on 1/11/23, at 9:35 a.m. LPN-C stated R41 had a cough and tested negative for COVID-19 on 1/10/23. LPN-C stated R41 was on contact and droplet precautions due to R41's cough and R41 should wear a face mask when out of the room. Staff were supposed to wear on a gown, gloves and face mask when entering R41's room and the sign on the door identified that information. LPN-C did not wear a gown and gloves upon entering R41's room but should have. COVID-19 testing recommendations were to test on day 1, day 3 and day 5 before residents were considered negative. Yesterday was R41's first test. LPN-C stated she did not think R41 would be considered free from COVID-19 after one negative test. When interviewed on 1/11/23, at 9:57 a.m. NA-G stated when she came to work that morning R41 had transmission based precautions (TBP) cart with PPE and a sign on the door directing staff to wear a gown, gloves, eye goggles and face mask when entering the room. Wearing PPE was used to help reduce the risk of spreading infections to other staff and residents. NA-G was initially told R41 had to stay in her room but then later was told the resident could go to the dining room for breakfast as long as she sat at the table furthest in the corner and away from other people. When NA-G wheeled R41 through the dining room R41 did not wear a face mask. During interview on 1/12/23, at 3:48 p.m. the director of nursing (DON) stated when a resident was on TBP the staff were expected to wear a gown, gloves, mask, and depending on the precaution would also expect staff to wear eye goggles, face shield or N95 mask. The staff would also be expected to use hand sanitizer prior to and upon exiting the residents room. That was the policy and staff knew and were expected to follow the policy. When interviewed on 1/11/23, at 10:34 a.m. LPN-B stated R50 started to complain of a sore throat and headache that morning. R50's first COVID-19 test that morning was negative; however, R50 was placed on isolation until confirmatory COVID-19 testing could be completed and her symptoms evaluated. During observation of R50 on 1/11/23, at 10:50 a.m. housekeeper (HK)-A was cleaning R50's room while wearing a surgical face mask and gloves. R50's room had an isolation cart outside of her door and the door way to her room was clearly marked with a sign that indicated anyone who entered needed to observe transmission based precautions and put on a disposable gown, gloves, eye protection and face mask before entering the room. R50 was lying on her bed reading a magazine. The DON approached the room and asked HK-A to leave the room to talk with her. HK-A was instructed on contact precautions. HK-A removed and discarded her gloves in the garbage; however, continued to wear the same surgical mask. HK-A stated they were not told residents were placed in transmission based precautions. HK-A did not see the signs indicating the TBP on R50's door, as R50's door was open when she approached it. During observation odf R50 on 1/11/23, at 10:53 a.m. HK-B entered R50's room to deliver laundry. R50 was lying on her bed reading a magazine. HK-B wore a surgical face mask under her chin, that did not cover her mouth or nose. HK-B did not put on a gown, gloves or eye protection, and entered the room with clean laundry. HK-B delivered the resident's laundry, putting the clean clothes in the residents closet and exited the room; however, did not perform hand hygiene. HK-B stated the transmission based precaution sign hanging on R50's door and the isolation cart outside her door was set up just for visitors, if they were staying in the room for a long time. If the resident was being quarantined for COVID infection there would have been a large COVID sign on her door and in that case, she would not have entered the resident's room and just hung the clean laundry outside her door for nursing staff to put away. HK-B knew her mask was to cover her nose and mouth. It kept sliding down and so she adjusted it back in place. Resident Illness Tracking Resident illness tracking logs for the month of November 2022, identified the following: Respiratory illness -On 11/4/22, R15 developed symptoms of lethargy, decrease oxygen saturation, cough and increase confusion. R15 received two antibiotics for treatment of pneumonia; however, sensitivities were not identified and COVID-19 testing was not conducted. -On 11/19/22, R34 developed symptoms of nasal drainage, cough, loss of taste and smell. R34 tested positive for COVID-19 on 11/22/22 and placed in isolation. -On 11/28/22, R38 was identified as positive for COVID-19 and placed in isolation. Urinary Tract Infections (UTI) -On 11/21/22, R3 developed a UTI. R3 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified. -On 11/28/22, R38 developed a UTI. R38 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified. Resident illness tracking logs for the month of December 2022, identified the following: Urinary Tract Infections (UTI) The December 2022 Infection Surveillance Log (ISL) identified : -On 11/30/22, R23 developed a UTI -On 11/24/22, R3 developed a UTI. R3 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified. -On 12/2/22, R35 developed a UTI. -On 12/6/22, R23 developed a UTI. R23 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified. -On 12/8/22, R33 developed a UTI. R38 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified. -On 12/8/22, R41 developed a UTI. R41 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified -On 12/27/22, R23 developed a UTI. R23 received two different antibiotics for treatment; however, sensitivities to see if the organism was sensitive to the antibiotics ordered, were not identified The summary of December 2022 infection control log identified eight resident UTI's, 7 consisted of bacterial infections and 1 was contaminated but treated anyway. The infection control logs lacked evidence the facility conducted a comprehensive analysis of the collected outcome surveillance data to determine if any of the infections identified were potentially related or corresponded with staff illness for the same month period to initiate appropriate corrective action. There was no evidence the facility investigated the infections identified for potential causes and/or subsequent actions to reduce the risk of reoccurrence. The following resident medical records in conjunction with the facility infection control logs identified the following: - Progress note (PN) dated 12/16/22, identified R108 developed decrease lung sounds and oxygen saturations of 70 to 80% with oxygen in place. R108 required hospitalization and returned with diagnosis of pneumonia with unknown origin. R108 was not identified on resident illness logs for surveillance when he presented with initial illness, or throughout his illness. R108 was not evaluated or tested for COVID-19 during the initial course of illness and was not isolated from other residents until COVID-19 testing could be completed to rule out the infectious illness. -PN dated 1/9/23, identified R29 developed symptoms of nausea and vomiting. A rapid COVID-19 test was performed and was negative. R29 was not listed on the resident illness tracking log for surveillance, nor placed on isolation pending a confirmatory test. -PN dated 1/4/23, identified R41 developed low grade temperature of 99. 5, oxygen saturation of 93% with supplemental oxygen at 2L/min, and complaints of not feeling well. A rapid COVID-19 test was performed and was negative. However, R41 was not listed on the resident illness tracking log. R41 remained symptomatic with cough and general malaise, no further COVID-19 test were performed and R41 was not placed into transmission based precautions as recommended by the Centers for Disease Control (CDC) until facility was notified of surveyor concerns on 1/11/23. During interview on 1/10/23, at 10:20 a.m. RN-D stated the nursing staff were supposed to fill out a sick log form when residents had symptoms of illness and she would update her surveillance logs from those forms weekly. RN-D was notified R41 was tested for COVID-19 on 1/4/23, and was negative. R41 had nasal drainage and a cough when she had assisted her in the dining room on 1/6/23. RN-D then notified the charge nurse after wheeling R41 out of the dining room. Testing was usually done on day one, day three and day five for symptomatic staff and residents because of the potential incubation period of the illness. RN-D usually did the COVID-19 testing for residents but did not fill out the sheets for R41's follow up tests, so the required follow up testing was not completed. RN-D was not sure why R108 was not on the resident infection December 2022 logs, as R108 should have been, especially because of his emergency room visit and diagnosis of pneumonia. RN-D indicated it was important to be sure to include all ill resident and employees on the surveillance logs so you could track where they were, how the illness was going and if it was spreading. During interview on 1/10/23, at 4:00 p.m. registered nurse (RN)-A stated if a resident showed signs of COVID-19, they would isolate the resident and test with a rapid antigen test. If still showing symptoms they would retest the resident. They always notified RN-D when they tested a resident for COVID-19. R41 displayed a cough and low grade fever. R41 was tested on [DATE] and was negative for COVID-19. R41 still exhibited symptoms of cough and her oxygen saturation was 95% at rest with supplemental oxygen. R41's cough was loose and in her chest, not in her lungs. RN-A had not personally done a repeat COVID test and would have to check with the nurses working on the floor if another test was needed. No second confirmatory testing was completed after the initial test was done on 1/4/23, despite her continued symptoms. R41 had not been isolated, although continued to exhibit symptoms of cough and shortness of breath. When interviewed on 1/11/23, at 8:30 a.m. RN-D stated some of the resident UTI infections should not have had an antibiotic ordered because no specific bacteria was cultured. RN-D looked for patterns and trends with the resident infections but could only find incontinence of urine and resisting staff assist with peri care after an incontinent episode as a common factor. There did not seem to be a common bacteria with the infections or in the same areas of the facility or she would have suspected staff as the source. RN-D did not document sensitivities to cultures or follow up to make sure the antibiotic ordered was effective against the identified organism. Some times the facility would get sensitivity results on cultures and sometimes they would not. In some instances the lab would not even do a sensitivity on a culture. RN-D stated she watched some staff complete peri care to ensure proper technique; however, had not documented audits formally. She had tried to start audit forms but staff had become angry with the audits and so they were not completed. RN-D did not identify if any concerns or training with peri care had been completed while performing audits. The facility's Coronavirus Prevention, Screening and Identification policy dated 10/9/22, indicated If a resident exhibited any symptoms of respiratory infection, or other COVID-19 related symptoms the resident's provider would be notified immediately. Quarantine interventions and testing would be initiated. If initial test was negative, the resident would be encouraged to use mask and social distance. For residents with suspected or confirmed COVID; monitoring of vital signs and respiratory symptoms would be at least twice a day. and any vital sign changes would be identified and further licensed nurse assessment would occur. During an outbreak, any breach of Personal Protective Equipment (PPE) would be reported immediately to the supervisor or designee. Staff who had signs and symptoms of COVID-19 like illness (based on screening) and/or a temperature (100 degrees or higher) would not report to work until testing could be completed. Staff who had mild to moderate illness, who were not moderately to severely Immunocompromised, could return to work if at least 7 days if a negative antigen or PCR was obtained within 48 hours prior to returning to work or 10 days have passed since symptoms had first appeared, and at least 24 hours had passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) had improved. Staff who were asymptomatic throughout their infection and were not moderately to severely Immunocompromised could return to work if at least 7 days if a negative antigen or PCR was obtained within 48 hours prior to returning to work or after 10 days if testing was not performed. Staff who had a high risk exposure would have three viral tests for SARS-CoV-2 infection. testing would occur (as able) on day one (where day of exposure is day 0), day three, and day five. Care center would keep a list of any staff unprotected exposure to COVID-19. The list would include all staff that interacted with the positive person from two days before symptoms started. For potential staff exposure, the facility would complete Assessment for Health Care Workers (HCW) Assessment for Health Care Workers Potentially Exposed to COVID-19 in Minnesota. Identify the risk level using assessment. Contact tracing may indicate low risk when there was no direct exposure to a COVID-19 infected person. Contact risk was identified as close (within 6 feet for 15 minutes or more, or within same living space) contact of person(s) with COVID-19 within 48 hours. Communicate the risk level to the staff with work-related recommendations. Recommendation[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all staff were tested for COVID-19 during outbreak testing; and failed to test and/or implement confirmatory testing for symptomatic residents and staff, licensed practical nurse (LPN)-A, LPN-B, dietary aide (DA)-D, activity aide (AA)-C, nursing assistant (NA)-D, R108, R29 and R41, who were not tested or had an initial negative rapid antigen testing for COVID-19, per the Centers for Disease Control (CDC) guidance on testing protocols. This system wide breakdown resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death to all 54 residents residing in the facility, along with staff and visitors. The IJ began on 11/23/22, when the facility identified an outbreak of COVID-19 in November and failed to ensure all staff were tested according to CDC outbreak testing requirements. The facility failed to provide evidence 34 staff who worked during outbreak were tested. In addition, the facility failed to initially test or provide a confirmatory test for residents and/or staff who exhibited or reported symptoms of COVID-19 and were tested with antigen tests. The administrator and the director of nursing (DON) were notified of the IJ on 1/10/23, at 2:00 p.m. The immediate jeopardy was removed on 1/11/23, at 3:00 p.m. when the facility implemented interventions to ensure all staff would be tested according to CDC guidelines; however, noncompliance remained at the lower scope and severity level of F, widespread, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: The CDC guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Diseases 2019 (COVID-19) Pandemic updated 9/23/22, indicated for nursing homes, a single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts could not be identified or managed with contact tracing or if contact tracing failed to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. 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. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. The CDC guidance Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 (COVID-19) Infection or Exposure to SARS-CoV-2 updated 9/23/22 indicated when testing a person with symptoms of COVID-19, negative results from at least one viral test indicate that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. HCP who are not symptomatic could return to work after results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT. STAFF OUTBREAK TESTING: The facility's undated staff line testing forms identified outbreak testing began on 11/23/22, and the facility was testing three times weekly through 12/5/22. The staff line testing form and corresponding working schedules for November 23, 2022 through 12/9/22, identified the following: - On 11/23/22, the facility began their first week of outbreak testing for all staff and residents in the facility following two residents who tested positive for COVID-19. The facility scheduled the first week of testing for staff on 11/23/22, 11/25/22, and 11/28/22. Of the 76 staff listed on the testing logs, 21 staff tested negative on 11/23/22, two staff were not eligible to be tested and the remaining 53 staff did not have test results recorded. On 11/25/22, 10 staff tested negative for COVID-19, two staff were ineligible for testing and 64 staff did not have test results recorded. On 11/28/22, 18 staff tested negative for COVID-19, two staff were ineligible to test and 56 staff did not have test results recorded. - On 11/29/22, the facility began their second week of outbreak testing for COVID-19. The facility scheduled the second week of testing staff on 11/29/22, 12/1/22, and 12/5/22. On 11/29/22, of the 82 staff listed on the testing logs, 14 staff tested negative on 11/29/22, two were ineligible to test, and 64 staff did not have test results recorded. On 12/1/22, 22 staff tested negative, two were ineligible to test and 58 staff did not have test results recorded. On 12/5/22, 25 staff tested negative for COVID-19, two staff were ineligible to test and 55 staff did not have test results recorded. The facility time sheets during the entire outbreak period identified 34 of the facility staff worked in the facility during the outbreak period 11/23/22, through 12/5/22, without having completed any of the required outbreak testing. During interview on 1/10/22, at 10:15 a.m. registered nurse (RN)-D, who was also the infection prevention (IP) nurse, stated the facility conducted outbreak testing 11/23/22 through 12/5/22, after two residents tested positive for COVID-19 in the facility. Staff were notified of the facility test dates and were expected to test prior to working. RN-D went on the nursing floor and reminded staff who had not tested to do so, but they refused to test. The facility policy to send the staff home if they refused to test was not enforced because the facility would not have enough staff to care for their residents. Some staff who did not test during the outbreak testing were still permitted to work. RN-D stated she notified the administrator of staff non-compliance with testing; however, felt she would not have the back up to enforce staff to not work if do not test. - LPN-B had a family member who was ill with COVID-19 living in her home and reported not feeling well on 12/24/22; however, continued to work her entire shift and tested positive on 12/27/22. The facility did not initiate any testing of potentially exposed residents or staff, as RN-D thought the doctors in the area felt people tested for COVID to often. RN-D was aware of the facility's policy's regarding COVID-19 testing; however, the policies were written by the corporate office and did not necessarily reflect current practice. RN-D had observed the staff LPN-B worked with and they did not display any symptoms of illness, and didn't feel testing them was necessary. When interviewed on 1/10/22, at 3:30 p.m. the administrator stated when outbreak testing, the facility would conduct antigen testing three times a week for two weeks. If any COVID positive tests were obtained the start cycle of testing would start over, until no new positive tests were obtained. The facility would stop testing and consider the outbreak resolved when no new positive tests were documented for two weeks. The administrator was not sure how the facility determined the outbreak had resolved when all the employees had not tested as required. All staff were notified by mass text to comply with outbreak testing and assumed they were compliant. If staff did not work on the scheduled test dates, they could test prior to their next scheduled shift. The administrator was not aware any staff were refusing to test. The facility expected all staff to test prior to working with residents when in outbreak status. The administrator did not think this was enforced but it was the expectation. If staff displayed illness that could indicate a COVID-19 infection, the ill staff was to isolate and COVID-19 testing would be done on day one, day three and day five of symptom onset. If results of the testing was negative and the staff was asymptomatic, isolation was lifted. The facility had not initiated outbreak testing when LPN-B had tested positive as her positive test was more than 48 hours since she had last worked, despite having displayed symptoms of COVID-19 while at work on 12/24/22. During interview on 1/11/23, at 8:51 a.m. LPN-C stated outbreak testing was done two times per week. LPN-C may have forgotten to get tested during the outbreak as required. No one ever stated a test was needed to be done before the start of the shift. Sometimes RN-D would remind staff to come and test but LPN-C was already working on the floor by then. If LPN-C remembered to test she did so. LPN-C was not aware of any consequences if staff did not test as required. When interviewed on 1/11/23, at 9:15 a.m. NA-G stated facility outbreak testing was done sometimes two times per week and sometimes three times per week. NA-G tested when she was told to test. NA-G did not think the last round of facility testing was for everyone to test, just some of the staff, as not all of the staff were exposed to the COVID positive resident. On 1/11/23, at 10:30 a.m. LPN-B stated the staff did have to test for COVID-19 during the outbreak starting 11/23/22. The testing was done one or two times per week or if you lived a distance from the facility, staff just had to test prior to start of their shift. When interviewed on 1/11/23, at 10:50 a.m. NA-H stated facility outbreak testing was conducted two times per week. NA-H did not come in for the testing but did a rapid antigen test prior to starting her shift. The nurse on the duty did the test and gave the results to RN-D. RN-D did not always document all the staff COVID antigen tests, but NA-H knew she tested when required. During interview on 1/11/23, at 9:55 a.m. the administrator stated she was not aware so many of the facility staff had not tested during the outbreak testing that was conducted 11/23/22 through 12/5/22, and thought the facility compliance had improved. The administrator did not know why the untested staff were allowed to work and felt the facility needed to do a better job with their COVID-19 testing. The expectation was a list would be made of all the staff who had not tested and a plan to see who had not been tested and how it would get done prior to their next scheduled shifts. TESTING WITH SYMPTOMS: Staff: The facility staff infection control logs for the month of December 2022, identified the following: -On 12/4/22, licensed practical nurse (LPN)-A reported aching, sore throat, and headache. LPN-A was not tested for COVID-19 illness. LPN-A returned to work on 12/5/22. LPN-A worked 12/5/22, 12/6/22 and 12/7/22. On 12/8/22, LPN-A tested positive for influenza B. LPN-A was not tested for COVID-19. LPN-A returned to work on 12/10/22. -On 12/6/22, DA-D reported increase respiratory symptoms. DA-D returned to work on 12/21/22. A COVID-19 test was not documented prior to return to work. -On 12/7/22, AA-C reported symptoms of aching and cough. AA-C was not tested for COVID-19. AA-C returned to work on 12/12/22. -On 12/19/22, NA-D reported respiratory symptoms. NA-D was not tested for COVID-19. NA-D returned to work on 12/20/22. On 12/21/22, NA-D reported illness and tested positive for COVID-19. -On 12/24/22, LPN-B reported illness of headache and aching while working her shift. LPN-B tested positive for COVID-19 on 12/27/22. LPN-B returned to work on 12/29/22. There was no evidence an assessment was conducted to determine potential resident and staff exposures or if there were a need to conduct contact or outbreak testing based on the positive staff results. Residents: -Progress note (PN) on 12/16/22, identified R108 developed decrease lung sounds and oxygen saturations of 70 to 80% with oxygen in place. R108 required hospitalization and returned with a diagnosis of pneumonia with unknown origin. R108 was not evaluated or tested for COVID-19 during the initial course of illness to rule out COVID-19. -PN on 1/9/23, identified R29 developed symptoms of nausea and vomiting. A rapid antigen COVID-19 test was performed and was negative. The medical record lacked documentation of a secondary test performed to confirm the negative finding. -PN on 1/4/23, identified R41 developed a low grade temperature of 99. 5 F, oxygen saturation of 93% with supplemental oxygen at 2L/min, and had complaints of not feeling well. A rapid antigen COVID-19 test was performed and was negative. On 1/10/23, R41 was observed symptomatic with cough and general malaise and out with other residents; however, no further COVID-19 tests had been conducted. During interview on 1/10/22, at 10:15 a.m. registered nurse RN-D, the IP nurse, was notified R41 was tested for COVID-19 on 1/4/23, and was negative. RN-D was not sure why further follow up testing for COVID-19 was not done for R41. RN-D assisted R41 in the dining room on 1/6/23, and observed R41 with nasal drainage and was coughing, so she wheeled her out of the dining room and notified the charge nurse. Testing was usually done on day one, day three and day five for symptomatic staff and residents because of the potential incubation period of the illness. RN-D usually did the COVID testing for residents but had not filled out the sheets for R41's follow up tests .The sheets were completed so the required follow up testing can be completed. When interviewed on 1/10/22, at 3:30 p.m. the administrator stated if residents displayed illness that could indicate a COVID-19 infection, the ill resident was to isolate and COVID-19 testing would be done on day one, day three and day five of symptom onset. If results of the testing was negative and the resident was asymptomatic isolation was lifted. During interview on 1/10/23, at 4:00 p.m. registered nurse (RN)-A stated if a resident showed signs of COVID-19, they would isolate the resident and test with a rapid antigen test. If still showing symptoms they would retest the resident. They always notified RN-D when they tested a resident for COVID-19. R41 displayed a cough and low grade fever. R41 was tested on [DATE], and was negative for COVID-19. R41 still exhibited symptoms of cough and her oxygen saturation was 95% at rest with supplemental oxygen, but the cough was loose and in the chest, not in the lungs. RN-A had not personally done a repeat COVID test and would have to check with the nurses working on the floor if another test was needed. No second confirmatory testing was completed after the initial test was done on 1/4/23, despite R41's continued symptoms. The facility's Coronavirus Prevention, Screening and Identification policy dated 10/9/22, indicated If a resident exhibited any symptoms of respiratory infection, or other COVID-19 related symptoms the resident's provider would be notified immediately. Quarantine interventions and testing would be initiated. If initial test was negative, the resident would be encouraged to use mask and social distance. Staff who had signs and symptoms of COVID-19 like illness (based on screening) and/or a temperature (100 degrees or higher) would not report to work until testing can be completed. Staff who had mild to moderate illness who were not moderately to severely Immunocompromised, could return to work if at least 7 days if a negative antigen or reverse transcription polymerase chain reaction (PCR) was obtained within 48 hours prior to returning to work or 10 days have passed since symptoms had first appeared, and at least 24 hours had passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) had improved. Staff who were asymptomatic throughout their infection and were not moderately to severely Immunocompromised could return to work if at least 7 days if a negative antigen or PCR was obtained within 48 hours prior to returning to work or after 10 days if testing was not performed. Staff who had a high risk exposure would have three viral tests for SARS-CoV-2 infection. testing would occur (as able) on day one (where day of exposure is day 0), day three, and day five. Care center would keep a list of any staff unprotected exposure to COVID-19. The list would include all staff that interacted with the positive person from two days before symptoms started. For potential staff exposure, the facility would complete Assessment for Health Care Workers (HCW) Assessment for Health Care Workers Potentially Exposed to COVID-19 in Minnesota. Identify the risk level using assessment. Contact tracing may indicate low risk when there was no direct exposure to a COVID-19 infected person. Contact risk was identified as close (within 6 feet for 15 minutes or more, or within same living space) contact of person(s) with COVID-19 within 48 hours. Communicate the risk level to the staff with work-related recommendations. Recommendations would be followed for staff who had high-risk workplace exposure to COVID-19 and staff with household or intimate contacts who had confirmed or suspected COVID-19. The facility's policy COVID-19 Testing, dated 9/29/22, indicated COVID-19 testing strategies would be implemented to assist with identification and mitigation of spread of COVID-19 illness. The care center would test residents and staff based on parameters defined by the Center for Medicare and Medicaid Services (CMS), the Minnesota Department of Health (MDH) and the CDC. Symptomatic residents or staff would be tested. If newly identified COVID-19 positive staff or resident were identified all staff and residents would be tested, regardless of vaccination status. Any care center staff who refused to test would not be allowed to work within the care center. An employee must be tested prior to returning to work. Positive results from antigen tests are highly accurate, but there would be a chance of false negatives. A negative rapid antigen test may need to be confirmed using a RT-PCR test, especially if the result of the antigen test was inconsistent with the clinical symptoms. Individuals who have signs and symptoms must be tested on days one, three and five for COVID-19. If positive results the employee must be removed from the care center and may remain out for up to ten days from the beginning of symptoms. Residents with signs and symptoms must be tested and if positive test, quarantine for ten days. All residents and staff with exposure should be tested immediately and all staff and residents that tested negative should be retested every five to seven days until testing identified no new cases of COVID-19 infection among staff or residents. Care centers will complete testing according to MDH, CDC and CMS guidelines. For symptomatic residents and staff, the date and time of identification of symptoms, when testing was conducted and the results and the actions the care center took based on the results would be documented. The facility would document the actions taken for residents and staff who refuse testing. The IJ which began on 11/23/22, was removed on 1/11/23, at 3:00 p.m. when it could be verified through interview and document review the facility implemented housewide COVID-19 testing in accordance with CDC guidance, including performing confirmatory testing on symptomatic antigen negative residents and staff. Education was provided to all employees on current and updated COVID-19 protocols for testing.