Based on interviews, medical record review, and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility was in compliance with the following regulatory requirements, which affected the safety of all residents in the facility. The LNHA failed to a.) oversee the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) to ensure that the facility followed their Outbreak Response Plan, b.) maintain compliance with Regulation F880, and c.) ensure the implementation of Transmission Based Precautions (TBP) in accordance with CDC guidance. This affected 11 unvaccinated residents with a known exposure to COVID-19, which are considered, according to CDC, as PUI (persons under investigation), for 2 of 3 units (A-B and C-D Units). Refer to F880K as it pertains to the facility's failure to ensure the implementation of Infection Control Practices and Precautions during an identified COVID-19 outbreak. During the Standard Survey conducted on 12/30/21, the surveyors identified deficient practices concerning Infection Control related to the identification of residents who had been exposed to staff members with known COVID-19 positive test results; and timely implementation of TBP for these residents. These deficient practices were identified on 2 of 3 nursing units (A-B and C-D Units). This deficient practice was evidenced by the following: A review of the Administrator.s job description provided by the facility revealed the following: Position Summary: This position is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet residents' needs in accordance with federal, state and local regulations. Also, develop and maintain systems that are effective and efficient to operate the facility in a financially sound manner. Responsibilities/Accountabilities included: Develop, maintain and implement operational policies and procedure to meet residents' need in compliance with federal, state and local requirements; Develop and enforce a monitoring program to assure compliance with federal, state and local requirements; Prepare reports for, and attend meetings with the governing body regarding the total activities of the nursing home, as well as governmental developments, which effects health care;Establish systems to enforce the facility policies and procedures; Interpret all federal, state and local regulations for the facility staff; Establish systems to ensure compliance with all federal, state and local regulation. On 12/10/21 at 12:27 PM, the facility's LNHA was notified that an Immediate Jeopardy (IJ) situation was identified related to his failure to oversee the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) to ensure that the facility followed their Outbreak Response Plan, maintain compliance with Regulation F880, and ensure the implementation of Transmission Based Precautions (TBP) in accordance with CDC guidance for a period of 12/03/21-12/09/21. On 12/10/21, the facility's removal plan was accepted. The non-compliance remained on 12/10/2021 for actual harm that is not immediate jeopardy based on the following: The gfacility's removal plan included the follwoing: - Review all state and federal guidelines pertaining to Covid-19 - Review facility policies to ensure we are aligned with all mandated regulations - Review the infection preventionist audit tool from the New Jersey Department of Health (NJDOH) that will allow us to provide an environment that protects residents, staff, and visitors from acquiring or transmitting Covid-19 and any other associated infections or communicable diseases. - Review the requirements for Covid-19 testing of staff and residents that are fully vaccinated and non-vaccinated during an outbreak, weekly or bi-weekly testing depending on the county levels, and exposure - Quarantine timeframes and who needs to be quarantined and who does not - Review the Co-horting process - Ensure all contact tracing and risk assessments are being completed - Address environmental controls that includes isolation rooms, plastic barriers, sanitation stations, specialized EPA disinfectants, appropriate infectious disease, and special areas for contaminated waste - Review our emergency operations plan, we will maintain a supply of personal protective equipment (PPE), including moisture-barrier gowns, face masks/goggles, assorted sizes of disposable N95 respirators or higher, surgical masks, approved disinfectants, and gloves to meet to requirements of a 30-day supply. The admissions department will provide the administration with a log on each resident's start and end date on TBP. The administrator will round the unit daily and ensure all necessary PPE supplies are in place. The administrator will conduct competency on each employee on the unit to ensure they are in compliance. Effectively immediately, on 12-10-2021 at 3:45 PM, the Regional Director will be re-educating the LNHA on all areas listed above, meet with the LNHA weekly, and expect him to demonstrate return competency in all areas. All findings will be reviewed during our QAPI meeting. A review of the facility's Outbreak Plan, revised on 09/10/21, indicated that testing would begin immediately upon identifying a single new case of COVID-19 infection in any staff or residents. The policy further instructed to refer to the CDC guidance Interim Infection Prevention and Control Recommendations to prevent SARS-CoV-2 Spread in Nursing Homes. for further information on contact tracing and broad-based testing. Under the Cohort Policy section, the policy indicated that Cohort 2 consisted of both symptomatic and asymptomatic residents who test negative for COVID-19 with an identified exposure to someone who is positive, regardless of vaccination status. The policy further indicated that exposed individuals would be quarantined for 14 days from the last exposure date, regardless of negative test results. During an interview with the surveyors on 12/09/21 at 11:01 AM, the ADON stated that the facility was currently in a COVID-19 outbreak which started 11/30/21. There were no positive residents in the facility, and six staff members tested positive for COVID-19. One positive staff member was a nurse who worked on Thursday, 12/02/21, went on vacation, and then tested positive during vacation. One CNA tested positive before her shift and was sent home, but the ADON did not provide the date at that time. A second CNA worked on the 11 PM-7 AM shift on 11/29/21 and felt sick during the shift with flu-like symptoms. The CNA went home, tested on Wednesday, and called out of work with a positive COVID-19 result on Friday, 12/03/21. The ADON stated that the facility completed two rounds of rapid testing, and no residents exhibited signs/symptoms of COVID-19. As a result, they did not initiate TBP for any exposed residents. At that time, the ADON provided the team with a Resident & Staff Outbreak Line List (Line List) dated 12/09/21. The surveyors reviewed the Line list, which revealed the following: 1. The facility became aware on 12/03/21 that CNA #1, who last worked on 11/29/21, tested positive for COVID-19 on 12/01/21. Once the facility became aware on 12/03/21 that CNA#1 tested positive and was experiencing symptoms following her shift on 11/29/21, the facility did not identify possible exposed residents and did not implement TBP. 2. The facility became aware on 12/04/21 that LPN #1 tested positive for COVID-19. Once the facility became aware on 12/04/21 that LPN #1 tested positive, the facility did not identify possible exposed residents and did not implement TBP. 3. The facility became aware on 12/07/21 that CNA #2 tested positive for COVID-19. Once the facility became aware on 12/07/21 that CNA#2 tested positive, the facility did not identify possible exposed residents and did not implement TBP. 4. The facility became aware on 12/08/21 that CNA #3 tested positive for COVID-19. Once the facility became aware on 12/08/21 that CNA #3 tested positive, the facility did not identify possible exposed residents and did not implement TBP. During an interview with the survey team on 12/09/2021 at 12:35 PM, the Infection Preventionist (IP) confirmed that the identified residents on CNA #1's assignment were not vaccinated for COVID-19. The IP further stated that the process for contact tracing of a positive employee included looking back 48 hours prior to the positive test to identify residents and staff who had contact with the positive employee for greater than 15 minutes. The IP then stated that all residents and staff, regardless of vaccination status, undergo two rounds of testing for COVID-19. During the same interview with the survey team, the ADON stated that on Friday, 12/03/21, CNA #1 notified the facility that she became symptomatic after her 11 PM - 7 AM shift on Monday, 11/29/21, took a COVID-19 test on Wednesday, 12/01/21, and received a positive COVID-19 test result on Friday, 12/03/21. The ADON further stated that residents who are unvaccinated and identified as exposed to someone with COVID-19 were monitored for signs and symptoms of COVID-19 and that staff performed hand hygiene and wore surgical masks when caring for those residents. The ADON also stated that TBP were not implemented for the unvaccinated, exposed residents. During the same interview with the survey team, the IP explained that new admission and re-admission residents are placed on PUI isolation for 14 days due to their unknown exposure status to COVID-19. The IP further stated the importance of placing residents on Persons Under Investigation (PUI) isolation is because you can still test positive and shed the virus within 14 days of exposure. During an interview with the survey team on 12/09/2021 at 2:29 PM, the IP confirmed that the identified residents on CNA #2 and CNA #3's assignments were not fully vaccinated for COVID-19 During an interview with the surveyor on 12/10/21 at 12:27 PM, the LNHA stated that he thought this tag would be included in the F880. The LNHA did not comment on his job responsibilities related to this deficient practice. During an interview with the survey team on 12/16/2021 at 11:45 AM, the IP stated that residents who have been exposed to COVID-19, regardless of vaccination status, are placed on PUI isolation for 14 days and that the required Personal Protective Equipment (PPE) for those rooms included an N95 mask, eye protection, a gown, and gloves. The IP further stated that when an employee tests positive for COVID-19, contact tracing is performed to identify residents who had contact with the employee up to 48 hours prior to the positive test result so that non-vaccinated, exposed residents can be placed on PUI isolation. The IP added that it is important to wear the correct PPE to protect the residents and staff from COVID-19. Review of the CDC's Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 09/10/2021, included unvaccinated residents who have had close contact with someone with SARS-CoV-2 infection, should be placed in quarantine for 14 days after their exposure, even if viral testing is negative. Healthcare Professionals (HCP) caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). If testing of close contacts reveals additional HCP or residents with SARS-CoV-2 infection, contact tracing should be continued to identify residents with close contact to the newly identified individual(s) with SARS-CoV-2 infection. The guidelines further included that unvaccinated residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. The resident should not participate in group activities. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F880 continues at a lower s/s based on the following: Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) implement personal protective equipment according to the New Jersey Department of Health (NJ DOH) and Centers for Disease Control and Prevention (CDC) guidelines to minimize the potential spread of infection to residents on 3 of 3 units (A-B Unit, C-D Unit, and G-H Unit) and b.) minimize the potential spread of infection to residents for 1 of 3 nurses observed during medication pass on 1 of 3 units (C-D Unit). This deficient practice was evidenced by the following: 1. Upon entrance into the facility on [DATE], the ADON stated that the required PPE for the PUI rooms were full PPE, which consisted of an N95 mask (respirator), eye protection, gown, and gloves, and the required PPE for non-PUI rooms was a surgical mask. The ADON further stated that eye protection was not required in non-PUI rooms. On 12/13/21, from 8:33 AM to 9:10 AM, Surveyor #2 observed the LPN #2, on the C-D Unit, prepare and administer medications to two residents (Resident #76 and Resident #13) without donning eye protection. On 12/13/21, from 8:50 AM to 9:22 AM, Surveyor #1 observed LPN #7 on the A-B Unit, prepare and administer medications to three residents (Resident #5, Resident #30, and Resident #56) without donning eye protection. On 12/13/21 at 9:55 AM, Surveyor #3 observed a staff member talking with a resident while on the G-H unit. The staff member's PPE consisted of an N95 mask without eye protection. On 12/13/21 at 9:55 AM, Surveyor #4 observed a CNA in the hallway of the A-B unit, within 6 feet of a resident, wearing only a surgical mask with no eye protection. Surveyor #4 also observed a housekeeper sweeping the floor around the nurses' station and hallway near room numbers 15-23, wearing only a surgical mask without eye protection. On 12/13/21 at 9:57 AM, Surveyor #4 observed a CNA enter a resident's room wearing only a surgical face mask, without eye protection. On 12/13/21 at 10:00 AM, Surveyor #4 observed two therapists, one wearing only a surgical mask and the other wearing an N-95 mask, both without eye protection, performing direct care with the resident. One therapist applied a surgical mask on the resident while the other therapist assisted the resident by putting their shoes on their feet. At 10:06 AM, the surveyor then observed the same two therapists using handheld assistance, ambulating the resident with a walker in the hallway. On 12/13/2021 at 12:40 PM, Surveyor #5 observed the Social Worker (SW) enter a PUI room on the G-H unit wearing a surgical mask under her N95 mask, a gown, and gloves. The SW did not don eye protection prior to entering the PUI room. During an interview with Surveyor #5 on 12/13/2021 at 12:43 PM, the Social Worker (SW) stated that the resident in the PUI room was in isolation for being exposed to a COVID-19 positive person. The SW further stated that the required PPE for the PUI room consisted of an N95 mask, a gown, and gloves. When asked if eye protection was required in the PUI room, the SW responded, I don't believe so. The SW further stated that she was unsure of the correct order of donning the surgical mask and N95 mask and that she wore the surgical mask underneath the N95 for comfort. The SW then stated that the importance of wearing the correct PPE in the PUI room was to protect herself and the resident from spreading or contracting COVID-19. On 12/14/21, from 8:55 AM to 9:02 AM, Surveyor #1 observed LPN #3 on the C-D Unit prepare and administer medications to one resident (Resident #88) without donning eye protection. On 12/14/21 from 9:13 AM and 9:35 AM, Surveyor #1 observed LPN #3 and LPN#4 complete the sacral wound treatment for Resident #52 without donning eye protection. On 12/14/21 at 09:19 AM, Surveyor #4 observed all staff members on the A-B unit wearing only surgical face masks without eye protection. On 12/14/21 at 9:25 AM, Surveyor #3 observed LPN #6 pushing a medication cart down the hall on the G-H unit. LPN #6's PPE consisted of an N95 mask with no eye protection. During an interview with Surveyor #3 on 12/14/2021 at 9:28 AM, LPN #6 stated the required PPE on the G-H unit was an N95 mask. LPN #6 further stated that she would don the required PPE when entering a PUI room. LPN #6 added the required PPE for the PUI room consisted of an N95 mask, a gown, and gloves. When asked if eye protection was required on the G-H unit, LPN #6 stated that staff donned eye protection prior to entering the PUI room. LPN #6 further stated that eye protection was not required while on the G-H unit. During an interview with Surveyor #1 on 12/16/21 at 9:33 AM, LPN #5 stated that she currently worked as an agency nurse at the facility and previously worked full time at the facility, on and off for nine years. LPN #5 stated that no residents on the A-B Unit had symptoms, were exposed to, or had an active case of COVID-19. The required PPE for the A-B Unit was a surgical mask, and the staff do not have to wear eye protection. The agency provided PPE education. During an interview with Surveyor #2 on 12/16/21 at 9:42 AM, CNA #4 on the C-D Unit responded to the surveyor's question about the type of PPE that should be worn while care is rendered to residents. CNA #4 stated it is necessary to wear a gown, gloves, face mask, and goggles when there is a sign on the door and a storage container next to the room. The sign usually indicates to see the nurse because there are transmission-based precautions. In such cases, CNA #4 indicated all the previously mentioned articles of PPE should be worn, in addition to an N-95 face mask. If there is no sign and no transmission-based precautions in place, CNA #4 stated it was necessary to always wear a face mask, knock on the door to enter the room and wear the face mask and a pair of gloves while rendering care to residents. CNA #4 further stated PPE training was most recently conducted with staff last month by an individual who was no longer employed at the facility. During an interview with Surveyor #2 on 12/16/21 at 9:50 AM, LPN #4 on the same Unit addressed the surveyor's question regarding the type of PPE that should be worn while care is rendered to residents. LPN #4 advised the surveyor that it was always necessary to wear gloves, a mask and perform hand hygiene to render care. LPN #4 stated that staff did not don or doff PPE on this Unit, specifically mentioning that no gowns or booties (shoe coverings) were used on the C-D Unit. In cases where staff is irrigating a wound, they would be expected to wear a face shield or goggles. LPN #4 further clarified that the type of mask to be worn on the Unit should be a surgical mask. PPE training was most recently conducted with staff during the past week or so by the Regional Nurse/Infection Preventionist. During an interview with Surveyor #5 on 12/16/21 at 9:52 AM, CNA #5 for the G-H Unit stated that residents on the Unit were under quarantine isolation and that the required PPE consisted of an N95 mask with a surgical mask over it, eye protection, a gown, and gloves. CNA #5 further stated that PPE is donned prior to entering the isolation room and removed prior to exiting the room. During a follow-up interview with Surveyor #5 on 12/16/2021 at 9:56 AM, LPN #6 stated the residents on the Unit were on PUI isolation and that the required PPE consisted of an N95 mask, surgical mask, eye protection, a gown, and gloves. LPN #6 further stated that PPE is donned prior to entering the PUI room and removed prior to exiting the room. LPN #6 added that the importance of wearing the correct PPE was for infection control. During an interview with Surveyor #4 on 12/16/21 at 10:26 AM, CNA #6 stated she was the CNA for the A-B Unit and only needed to wear a surgical face mask without eye protection on this Unit. CNA #6 further stated that the Unit did not have any COVID-19 positive residents on the Unit. If a resident has a sign on the door indicating isolation, staff was educated to wear a gown, gloves, mask, and face shield prior to entering the isolation room. During an interview with Surveyor #4 on 12/16/21 at 10:29 AM, the housekeeper stated she was responsible for cleaning rooms on the A-B unit. The housekeeper further stated that the PPE required on this Unit was only a surgical face mask, without eye protection. If a resident was positive for COVID-19 or PUI, she would need to wear full PPE, which included a mask, gloves, gown, and face shield prior to entering the resident's rooms. During an interview with Surveyor #1 on 12/16/21 at 10:39 AM, CNA #7 stated that she worked at the facility for four years and was a permanent CNA on the A-B Unit. CNA #7 further stated that the required PPE on this Unit was a surgical mask and gloves when giving care and reviewed daily PPE education. During an interview with Surveyor #5, in the presence of the survey team, on 12/16/2021 at 11:45 AM, the IP stated that the required PPE for the PUI rooms consisted of an N95 mask, eye protection, a gown, and gloves. The IP further stated that staff should don their N95 masks and then a surgical mask over them, so that staff can discard the surgical mask between rooms. When asked about the current NJ DOH COVID-19 Activity Level Index ([NAME]) Score and the CDC COVID Data Tracker County Transmission Rate, the IP was unsure of the [NAME] Score but stated the County Transmission Rate was high or substantial. The IP then noted that the facility utilized PPE according to the regulations to determine what PPE was required throughout the facility. The IP added that it is important to wear the correct PPE to protect the residents and staff from COVID-19. On 12/16/2021 at 12:45 PM, the IP followed up with Surveyor #5 and the survey team to provide the [NAME] Score for the Southeast region of NJ (where the facility is located), which indicated the current activity level was high. The IP also provided the CDC COVID Data Tracker for [NAME] county (where the facility is located), which indicated the transmission rate was high. Review of the NJDOH Executive Directive 20-026 included, Facilities shall implement universal eye protection, in addition to source control and other infection prevention and control measures, for all staff and for compassionate care or essential caregiver visitors unable to maintain social distancing when the NJDOH [NAME] Level is Very High/High or Moderate. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic guidelines, dated 09/10/2021, included, If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP [healthcare professionals] working in facilities located in counties with substantial or high transmission should also use PPE as described below: . Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Review of the CDC's How to Properly Put on and Take off a Disposable Respirator guideline included, Do not allow facial hair, hair, jewelry, glasses, clothing, or anything else to prevent proper placement or come between your face and the respirator. 2. On 12/13/21 at 8:58 AM, Surveyor #2 observed LPN #2, upon completion of administering medications to a resident, enter the bathroom of a second resident. There were no paper towels present in the wall dispenser, so the LPN asked a staff member to replace a large roll of paper towels within the dispenser. The LPN then wet her hands, briefly lathered them with soap, and placed both hands under the stream of water while applying friction to her hands. The entire process lasted 12 seconds. Afterward, the LPN prepared medications and administered them to the second resident. During an interview with Surveyor #2 on 12/13/21 at 10:00 AM, LPN #2 described the handwashing process. The LPN explained it was necessary to turn the water on for warmth, use soap, and rub hands, including between the fingers. When asked about the length of time-related to handwashing, LPN #2 stated she sings the Happy Birthday song to herself to know how long to wash and added that the process should take longer than two seconds. She further stated that she probably washes her hands for 60 seconds and that the facility policy indicates that handwashing is longer than 30 seconds. During an interview with Surveyor #2 on 12/16/21 at 12:06 PM, the IP described the facility's handwashing procedure to the survey team. She stated that handwashing occurs with soap and water, followed by lathering the hands and scrubbing them for 20 seconds. The hands are held in a downward manner, and scrubbing should include the area under the nails, so the dirt goes down the drain. The lathering process occurs outside the stream of water because otherwise, there is no point. At this time, the surveyor questioned the wording on the facility's policy, which indicated that hands should be lathered under the stream of water. The IP then stated lathering could occur under the stream of water and referenced CDC guidelines, which indicated to lather for 20 seconds. The IP then stated she could not remember whether lathering of the hands should occur outside or under the stream of water but acknowledged that if the entire handwashing process occurred for a total of 12 seconds, such a practice would be considered problematic because the process was not long enough. The IP then stated she would like to investigate matters further and follow up with the survey team. During an interview with Surveyor #2 and the survey team on 12/16/21 at 12:34 PM, the IP stated it is necessary to scrub hands outside the stream of water per CDC guidelines and referenced a poster to that effect. She further stated that the posters are displayed everywhere and that she understood there was a need to look at the facility's policy regarding handwashing further. A review of the facility's Handwashing/Hand Hygiene policy reviewed 8/17/21 revealed handwashing included vigorously lathering the hands with soap and rubbing them together, creating friction to all surfaces, for a minimum of 20 seconds under a moderate stream of water, with water at a comfortable temperature. Review of the facility's Hand Hygiene How-To poster provided by the IP, who stated that the poster was obtained online from the CDC website, revealed it is necessary to rub the hands for at least 20 seconds to get rid of bacteria. It included the following steps, both in words and depicted in pictures: 1. Wet (picture of two hands under a faucet of running water) 2. Soap (picture of two hands under a soap dispenser) 3. Wash 20 Seconds (picture of hands being rubbed together) 4. Rinse (picture of hands under a stream of running water) 5. Dry (picture of one hand drying the other with a paper towel, with a roll of paper towels in the background) 6. Turn off water with paper towel (picture of a faucet and hand turning a nob, using a paper towel). Review of LPN #2's Hand Washing Skills Evaluation, undated, indicated to, Rub hands together vigorously to create lather, wash all areas of hands including fingernails by rubbing against palm of the opposite hand for at least 20-30 seconds. Keep fingertips pointed down. NJAC 8:39 - 19.4(a)(1) Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to appropriately identify residents exposed to COVID-19 as Persons Under Investigation (PUI) for the COVID-19 virus; and as a result, failed to implement Transmission Based Precautions (TBP) in a timely manner to prevent the transmission of COVID-19. This deficient practice was identified for 11 of 11 residents (Residents #10, #11, #25, #48, #51, #60, #63, #65, #73, #84, and #94) who were exposed to four known COVID-19 positive staff members on 2 of 3 nursing units (A-B Unit and C-D Unit) during a Standard Survey on 12/09/21. The facility's failure to identify residents exposed to COVID-19 positive staff and implement strategies to prevent the spread of COVID-19 posed a serious and immediate threat to the safety and wellbeing of all non-ill residents (residents who were negative for COVID-19). This resulted in an Immediate Jeopardy (IJ) situation that began on 12/03/21 when the facility was notified of the confirmed COVID-19 positive CNA #1. The facility Administration was notified of the IJ on 12/09/21 at 6:22 PM. The immediacy was removed on 12/10/2021, based on an acceptable Removal Plan that was implemented by the facility and verified by the surveyors during the Standard Survey conducted on 12/10/2021. The non-compliance remained on 12/10/2021 for actual harm that is not immediate jeopardy based on the following: The evidence was as follows: During an interview with the surveyor on 12/09/21 at 8:30 AM, the Assistant Director of Nursing (ADON) stated there were no COVID-19 positive cases in the facility. The ADON further stated there were three units, A-B, C-D, and G-H, and the required Personal Protective Equipment (PPE) for the A-B and C-D Units was a surgical mask. The G-H Unit included long-term care residents, new admissions, and readmissions. The ADON stated that two residents on the G-H Unit were recently admitted and considered PUI. The required PPE in the hallways of the G-H Unit were surgical masks, and staff dons an N95 mask, gown, gloves, and eye protection prior to entering a PUI room. During a follow-up interview with the ADON on 12/09/21 at 11:01 AM, the ADON stated that the facility was currently in a COVID-19 outbreak which started 11/30/21. There were no positive residents in the facility, and six staff members tested positive for COVID-19. One positive staff member was a nurse who worked on Thursday, 12/02/21, went on vacation, and then tested positive during vacation. One CNA tested positive before her shift and was sent home, but the ADON did not provide the date at that time. A second CNA worked on the 11 PM-7 AM shift on 11/29/21 and felt sick during the shift with flu-like symptoms. The CNA went home, tested on Wednesday, and called out of work with a positive COVID-19 result on Friday, 12/03/21. The ADON stated that the facility completed two rounds of rapid testing, and no residents exhibited signs/symptoms of COVID-19. As a result, the facility did not initiate TBP for any exposed residents. At that time, the ADON provided the team with a Resident & Staff Outbreak Line List (Line List) dated 12/09/21. The surveyors reviewed the Line list, which revealed the following: 1. The facility became aware on 12/03/21 that a Certified Nursing Assistant #1 (CNA), who last worked on 11/29/21, tested positive for COVID-19 on 12/01/21. Once the facility became aware on 12/03/21 that CNA #1 tested positive and was experiencing symptoms following her shift on 11/29/21, the facility did not identify possible exposed residents and did not implement TBP. 2. The facility became aware on 12/04/21 that a Licensed Practical Nurse #1 (LPN) tested positive for COVID-19. Once the facility became aware on 12/04/21 that LPN #1 tested positive, the facility did not identify possible exposed residents and did not implement TBP. 3. The facility became aware on 12/07/21 that CNA #2 tested positive for COVID-19. Once the facility became aware on 12/07/21 that CNA #2 tested positive, the facility did not identify possible exposed residents and did not implement TBP. 4. The facility became aware on 12/08/21 that CNA #3 tested positive for COVID-19. Once the facility became aware on 12/08/21 that CNA #3 tested positive, the facility did not identify possible exposed residents and did not implement TBP. The surveyors reviewed the Line List, COVID-19 Contact Tracing Forms (Contact Tracing Form), staff assignments, and vaccination status of the staff and residents provided by the facility. 1. CNA #1: Review of the staff vaccination status revealed that CNA #1 was fully vaccinated. Review of the Line List indicated that the facility became aware on 12/03/21 that a CNA #1 tested positive for COVID-19 on 12/01/21. The Line List reflected, Saff [Staff] called in facility on 12/3/21 stated that started to feel sick on 11/29 after her shift. Went to get tested at RidAid [Rite Aid] on 12/1/21 PCR [Polymerase Chain Reaction] test result resived [received] positive on 12/3/21. Called the facility to notify of results. Last day of work 11/29/21. Quratined [quarantined] for 14 days at home. Fully vaccinated. Once the facility became aware on 12/03/21 that CNA #1 tested positive and was experiencing symptoms following her shift on 11/29/21, the facility completed a Contact Tracing Form dated 12/03/21, which reflected that CNA #1 Came into contact with the following for longer than a combined total of 15 minutes throughout the shift at closer than 6 feet in the last 24 hours: Assignment #3. [indecipherable]. The Contact Tracing Form further revealed Testing Dates and Results: 12/1/21 PCR test at Rite Aid results received on 12/3/21 + [positive] with an Outcome: Quarantine at home. At that time, the facility did not identify possible exposed residents on CNA #1's assignment and implement TBP. The surveyors reviewed CNA #1's 11 PM - 7 AM assignments on the C-D Unit and identified that on 11/27/21-11/28/21, CNA #1 was assigned to provide care for 15 residents, two of which were unvaccinated (Residents #51 and #84). The 11/28/21-11/29/21 assignment reflected that CNA #1 was assigned to provide care for nine residents, two of which were unvaccinated (Residents #10 and #51). On 12/10/21 at 8:30 AM, the ADON provided a revised Contact Tracing Form dated 12/03/21, which revealed that on 11/28/21, CNA #1 was in contact with two unvaccinated residents [Residents #10 and #51], and 2 half vaccinated residents [#47 and #102]. The Contact Tracing form further reflected an Outcome: quarantine at home x 14 days. Residents in contact placed on TBP x 14 days. The surveyors reviewed CNA #1's 11 PM - 7 AM assignment on the C-D Unit dated 11/27/21-11/28/21 and confirmed that CNA #1 was assigned to provide care for Residents #47, #51, #84, and #102. The surveyors further reviewed CNA #1's 11 PM - 7 AM assignment on the C-D Unit dated 11/28/21-11/29/21 and confirmed that CNA #1 was assigned to provide care for Residents #10 and #51. 2. LPN #1's staff vaccination status review revealed that LPN #1 was unvaccinated. Review of the Line List indicated that the facility became aware on 12/04/21 that LPN #1 tested positive for COVID-19. The Line List reflected, Employee last day worked on 12/2 and went on vacation. Anticipated to return to work on 12/7. Called facility stated that she started to feel sick, sore throat rapid tested Positive on 12/4 while been on vacation. Employee staying home quarantine. Once the facility became aware that LPN #1 tested positive, the facility completed a Contact Tracing Form dated 12/07/21, which reflected that LPN #1 Came into contact with the following for longer than a combined total of 15 minutes throughout the shift at closer than 6 feet in the last 24 hours: No contact with residents. The Contact Tracing Form further revealed Testing Dates and Results: employee rapid test on 12/4/21 on vacation. Vacation days 12/3/21 - 12/6/21 with an Outcome: quarantine at home x 14 days. Notified job of possible rapid test. Did not return to work. At that time, the facility did not identify possible exposed residents on LPN #1's assignment and implement TBP. The surveyors reviewed LPN #1's 7 AM - 3 PM and 3 PM - 11 PM assignments on the A-B Unit. They identified that on 12/02/21, LPN #1 was assigned to provide care for 22 residents, three of which were unvaccinated (Residents #11, #60, and #94) and one partially vaccinated resident receiving one (1) dose of a two-dose series (Resident #63). On 12/10/21 at 8:30 AM, the ADON provided further information that Resident #11 was fully vaccinated. On 12/10/21 at 8:30 AM, the ADON provided a revised Contact Tracing Form dated 12/07/21, which revealed that on 12/02/21, LPN #1 also had contact on 12/2/21 with two unvaccinated residents [Residents #60 and #94]. One half vaccinated resident [Resident #63]. The revised Contact Tracing Form further reflected that Resident half vaccinated and unvaccinated placed on PUI + [and] TBP x14 days. The surveyors reviewed LPN #1's 7 AM - 3 PM and 3 PM - 11 PM assignments on the A-B Unit dated 12/02/21 and confirmed that LPN#1 was assigned to provide care for Residents #60, #63, and #94. 3. Review of CNA #2's staff vaccination status revealed that CNA #2 was unvaccinated. Review of the Line List indicated that the facility became aware on 12/07/21 that a CNA #2 tested positive for COVID-19. The Line List reflected, Employee was rapid test before her shift on 12/7 positive COVID-19. Send home imidiatly [immediately], no s/s [signs/symptoms] reported by employee, no direct contact was made with residents. Last day at work 12/5. Once the facility became aware on 12/07/21 that CNA #2 tested positive, the facility completed a Contact Tracing Form dated 12/07/21, which reflected that CNA #2 Came into contact with the following for longer than a combined total of 15 minutes throughout the shift at closer than 6 feet in the last 24 hours: Non [none] sent home before providing care to Residents. The Contact Tracing Form further revealed Testing Dates and Results: Rapid test 12/7/21 with an Outcome: sent home to quarantine x 14 days. At that time, the facility did not identify possible exposed residents on CNA #2's assignment and implement TBP. The surveyors reviewed CNA #2's 3 PM - 11 PM assignment on the C-D Unit. They noted that on 12/05/21, CNA #2 was assigned to provide care for 14 residents, two of which were unvaccinated (Residents #25 and #73) and one partially vaccinated resident receiving one (1) dose of a two-dose series (Resident #65). On 12/10/21 at 8:30 AM, the ADON provided a revised Contact Tracing Form dated 12/07/21 for CNA #2, which revealed that on 12/5/21, Employee was in contact with the following Residents on 12/5/21: [Residents #25 and #73] unvaccinated and 1 [one] half vaccinate [vaccinated] [Resident #65]. The contact Tracing Form further reflected that Residents in contact with employee placed on TBP x14 days. The surveyors reviewed CNA #2's 3 PM - 11 PM assignment on the C-D Unit dated 12/05/21 and confirmed that CNA #2 was assigned to provide care for Residents #25, #65, and #73. 4. Review of CNA #3's staff vaccination status revealed that CNA #3 was unvaccinated. Review of the Line List indicated that the facility became aware on 12/08/21 that a CNA #3 tested positive for COVID-19. The Line List reflected, Emplyee [Employee] rapid tested Positive before the sift [shift] on 12/8. Rapid test is positive. Sent home imiditaly [immediately] to quarantine. Last day off work before testing on 12/6. Once the facility became aware on 12/08/21 that CNA #3 tested positive, the facility completed a Contact Tracing Form dated 12/08/21, which reflected that CNA #3 Came into contact with the following for longer than a combined total of 15 minutes throughout the shift at closer than 6 feet in the last 24 hours: N/A [not applicable]. The Contact Tracing form further revealed Testing Dates and Results: 12/8/21 rapid test + [positive] with an Outcome: employee sent home immediately, quarantine x 14 days. At that time, the facility did not identify possible exposed residents on CNA #3's assignment and implement TBP. The surveyors reviewed CNA #3's 7 AM - 3 PM assignment on the C-D Unit and noted that on 12/06/21, CNA #3 was assigned to provide care for nine residents, one of which was unvaccinated (Resident #48). On 12/10/21 at 8:30 AM, the ADON provided a revised Contact Tracing Form dated 12/08/21, which revealed that on 12/6/21, CNA #3 Employee was in contact with unvaccinated Resident on 12/6/21 [Resident #48]. The Contact Tracing Form further reflected that Resident in contact with + [positive] employee placed on TBP x14 days. During an interview with the survey team on 12/09/2021 at 12:35 PM, the Infection Preventionist (IP) confirmed that the identified residents on CNA #1's assignment were not vaccinated for COVID-19. The IP further stated that the process for contact tracing of a positive employee included looking back 48 hours prior to the positive test to identify residents and staff who had contact with the positive employee for greater than 15 minutes. The IP then stated that all residents and staff, regardless of vaccination status, undergo two rounds of testing for COVID-19. During the same interview with the survey team, the ADON stated that on Friday, 12/03/21, CNA #1 notified the facility that she became symptomatic after her 11 PM - 7 AM shift on Monday, 11/29/21, took a COVID-19 test on Wednesday, 12/01/21, and received a positive COVID-19 test result on Friday, 12/03/21. The ADON further stated that residents who are unvaccinated and identified as exposed to someone with COVID-19 are monitored for signs and symptoms of COVID-19 and that staff perform hand hygiene and wear surgical masks when caring for those residents. The ADON also stated that TBP were not implemented for the unvaccinated, exposed residents. During the same interview with the survey team, the IP explained that new admission and readmission residents are placed on PUI isolation for 14 days due to their unknown exposure status to COVID-19. The IP further stated the importance of placing residents on PUI isolation is because you can still test positive and shed the virus within 14 days of exposure. During an interview with the survey team on 12/09/2021 at 2:29 PM, the IP confirmed that the identified residents on CNA #2's and CNA #3's assignments were not fully vaccinated for COVID-19 During an interview with the survey team on 12/16/2021 at 11:45 AM, the IP stated that residents who have been exposed to COVID-19, regardless of vaccination status, are placed on PUI isolation for 14 days and that the required Personal Protective Equipment (PPE) for those rooms included an N95 mask, eye protection, a gown, and gloves. The IP further stated that when an employee tests positive for COVID-19, contact tracing is performed to identify residents who had contact with the employee up to 48 hours prior to the positive test result so that non-vaccinated, exposed residents can be placed on PUI isolation. The IP added that it is important to wear the correct PPE to protect the residents and staff from COVID-19. A review of the facility's Outbreak Plan, revised 09/10/21, included the following: Testing of staff and Residents during an Outbreak investigation: A. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have an option to perform outbreak testing through two approaches, contact tracing or broad based (e.g., facility wide) testing. For further information on contact tracing and broad-based testing, see CDC guidance Interim Infection Prevention and Control Recommendations to prevent SARS-CoV-2 Spread in Nursing Homes. Cohort Policy: 1. Cohort 1- COVID-19 Positive. This cohort consists of both symptomatic and asymptomatic patients/residents who tested positive for COVID-19, regardless of c\vaccination s[TRUNCATED]