**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F658 remains a deficiency at a scope and severity of a D based on the following: Part D Based on observation, interview, and record review, it was determined that the facility failed to a.) assure accurate documentation of administration, and documentation of blood pressure (BP) parameters as ordered by the physician in accordance with professional standards, b.) administer Extended Release (ER) medication per manufacturer's guidelines, and c.) assure accurate documentation of administration and placement of a medication patch. This deficient practice was identified for 2 of 4 residents reviewed (Resident #15, #37), during medication pass and reconciliation (ensures accuracy of information) after a medication pass and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. a.) and b.): On [DATE] at 8:30 AM, during the medication pass observation, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare six (6) medications for Resident #15. Review of the physician order (PO) dated [DATE] revealed an order to administer: Diltiazem 30 milligram tablet (Cardizem; mg), one tablet by mouth every 8 hours for AFIB (atrial fibrillation; uncontrolled heart rhythm) hold for SBP (systolic blood pressure) less than 100 hold for heart rate less than 55 (parameters), originally ordered on [DATE]. Another PO order dated [DATE] revealed to administer Acetaminophen ER (extended-release) 650 mg caplet (Tylenol), one tablet by mouth every 12 hours for pain, originally ordered on [DATE]. At that time, LPN #1 placed the medications in front of Resident #15. Resident #15 stated they received their larger medications (tablets/pills) cut in half. LPN #1 identified one of the medications as Acetaminophen ER, which she removed, cut in half, and administered to the resident. On [DATE] at 08:46 AM, the surveyor and LPN #1 reviewed the resident's bingo card (a multidose card containing individually packaged medications) for Acetaminophen ER. The bingo card had an affixed cautionary label that indicated, Swallow Whole. Do not crush or chew. LPN #1 stated that the cautionary did not specify that the Acetaminophen caplet could not be cut in half. She added that she did not know if she could cut the ER medication. She informed the surveyor that she would need to call the pharmacy. She also stated that she had not called the pharmacy in the past because the resident was not chewing and that she [the nurse] was not crushing the medication for the resident. A review of the 8/22 Medication Administration Record (MAR) in use reflected an administration charting omission for Diltiazem HCl 30mg on [DATE] at 06:00 AM. Further review of the MAR revealed parameter charting omission for Diltiazem HCl 30mg with scheduled administration at 06:00 AM on [DATE], 06:00 AM on [DATE], 06:00 AM on [DATE], and 06:00 AM on [DATE]. On [DATE] at 12:17 PM, the surveyor and the Registered Nurse/Supervisor (RN/S) reviewed Resident #15's MAR. RN/S acknowledged the missing documentation for Resident #15's Diltiazem administration and parameters. RN/S stated that he was unable to ascertain if the medication was given on [DATE]. He added that there was nothing documented behind the MAR to explain the missing documentation. At that time, RN/S informed the surveyor that the facility's policy required nurses to document the parameters when ordered on the MAR. He stated that the documentation of parameters was a vital reference for the resident's evaluation and that the parameters also dictated the administration or withholding of the Diltiazem dose. He further stated that improper administration could lead to the resident's uncontrolled heart rhythm. On [DATE] at 10:26 AM, during an interview with surveyors, the Director of Nursing (DON) stated that Acetaminophen Extended Release should not have been cut and the prescriber should have been called. The DON further stated, if it (Diltiazem) was not documented on the MAR, it was not given. The DON informed the surveyors that the nurse should have obtained the BP and heart rate, documented the parameters and administration of the medication or not, and signed the MAR. She added that the nurse should have documented on the back of the MAR the reason that a medication was not given and confirmed again that the parameters should have been documented. c.) On [DATE] at 09:08 AM, during the medication pass observation, the surveyor observed LPN #2 prepare nine (9) medications for Resident #37. The medications prepared included Rivastigmine (Exelon) 9.5mg/24- hour patch for Alzheimer's Dementia. LPN #2 informed the surveyor that she would place the patch on location #12. LPN #2 also informed the surveyor that the top right of the medication administration record (MAR) contained the corresponding locations to the numbers for the patch administration. She identified location #12 to be the right chest. At 09:28 AM, the surveyor and LPN #2 reviewed the resident's MAR and the Exelon Patch Tracker, which revealed instructions, use in general area but not the exact spot for 14 days. LPN #2 acknowledged that location #12 was used 13 days ago. She informed the surveyor that she decided to apply the patch at location 3 (left deltoid) because it has not been documented as used on the MAR. LPN #2 could not recall if she was given education on Rivastigmine (Exelon) patch. A review of the PO dated [DATE] reflected an order that included Rivastigmine 9.5mg/24-hour patch (Exelon), apply one patch externally to skin once daily for Alzheimer's Disease, originally ordered on [DATE]. A review of Resident #37's MAR for [DATE] to [DATE] during medication reconciliation revealed the following locations were used within 14 days: location 8 (abdomen lower left quadrant) was used on [DATE], [DATE] and [DATE] location 7 (abdomen left upper quadrant) was used on [DATE], [DATE], [DATE] and [DATE] location 14 (back right) was used on [DATE] and [DATE] location 13 (back left) was used on [DATE] and [DATE] location 11 (chest left) was used on [DATE] and [DATE] On [DATE] at 10:26 AM, the DON stated the Exelon patches should have been rotated, and the nurses should have followed the instructions that corresponded with the tracking regimen. A review of the manufacturer specifications for Acetaminophen ER reflected that the tablets were film-coated and must be swallowed whole, do not crush, chew, split or dissolve. A review of the manufacturer specifications for Exelon patch section 2.4 Important Administration Instructions subsection (e) reflected Change the site of patch application daily to minimize potential irritation, although a new patch can be applied to the same general anatomic site (e.g., another spot on the upper back) on consecutive days. Do not apply a new patch to the same location for at least 14 days. A review of the facility's Medication Administration policy titled Medication Charting, revised 4/15 revealed Section 2. CHARTING THE ADMINISTRATION OF A MEDICATION Subsection (a) When a drug is administered to a resident, the nurse administering the medication shall initial the MAR according to the date and time the dose has been administered. Subsection (b) If a medication is not administered, the corresponding date/time space on the MAR should be circled. The nurse must initial and document the reason why the medication was not administered on the back of the MAR. Subsection (c) All medications shall be immediately charted on the resident's MAR after administration of the drug. A review of the facility's Medication Administration policy titled ADMINISTRATION OF TREATMENTS/ TOPICAL MEDICATIONS revised 04/15, under procedure subsection (f), revealed, When possible, rotate sites of application to prevent skin irritation. Sites of administration should be noted on the appropriate Administration record. NJAC 8:39-11.2(b), 27.1(a), 29.2(d) Complaint #NJ00156516 Part A Based on interviews, record review, and review of other facility documentation, it was determined that the facility failed to ensure nursing staff appropriately removed an indwelling urinary catheter (soft plastic or rubber tube that is inserted into the bladder to drain urine) in accordance with professional standards of nursing practice which necessitated a transfer to the hospital for treatment, and a urinary tract infection. This deficient practice was identified for 1 of 3 Residents reviewed for indwelling urinary catheter care (Resident #179) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The facility's failure to have a system in place to ensure that nursing staff appropriately removed an indwelling catheter posed a serious and immediate threat to the health, and welfare of all residents who required catheter care. An adverse outcome had occurred and was likely to occur as the identified non-compliance resulted in an immediate Jeopardy (IJ) situation that began on [DATE] at 2:50 PM when the Registered Nurse (RN) improperly removed the indwelling catheter. The RN used scissors to cut through Resident #179's indwelling catheter, which then caused the remaining catheter to retract into the bladder. The Immediate Jeopardy (IJ) situation was identified during an onsite survey conducted on [DATE], and the facility was notified of the IJ, on the same day, at 3:20 PM. The facility submitted an acceptable removal plan on [DATE] at 2:55 PM. The team verified the removal plan during an onsite visit conducted on [DATE]. Findings included: On [DATE] at 10:30 AM, the surveyor toured the 200 Unit of the facility and observed that Resident #179's door was closed. On the door, the surveyor observed signage posted which identified the required PPE (Personal Protective Equipment) to enter the room. The surveyor observed staff donning (putting on) and doffing (removing) with the required PPE before entering and exiting the room. An interview with the Registered Nurse/Unit Manager (RN/UM) revealed that Resident #179 was on isolation for Extended Spectrum Beta Lactamase (ESBL, antibiotic-resistant bacteria) and Methicillin Resistant Staphylococcus Aureus (MRSA, antibiotic-resistant bacteria) in the urine. On [DATE] at 11:29 AM, the surveyor donned the appropriate PPE, knocked at the door, waited for Resident #179 to answer, and entered the room. The surveyor observed Resident #179 in bed, awake with eyes open, and the surveyor observed a splint to the left arm. The surveyor explained the purpose of the visit, and Resident #179 agreed to be interviewed. Resident #179 was alert and stated that he could not move their left arm. Resident #179 answered all questions appropriately. The surveyor observed an indwelling urinary catheter covered with a catheter drainage bag hung on the bed frame. On [DATE] at 09:30 AM, the surveyor returned to the 200 Unit, the door was open, and Resident #179 was not inside the room. Upon inquiry, the RN/UM informed the surveyor that Resident #179 had tested + for COVID-19 in the evening during routine testing and was transferred to the 700 Unit. On [DATE] at 08:30 AM, the surveyor observed Resident #179 on the 700 Unit. The door was closed. Signage with the required PPE was posted on the door. The surveyor reviewed the medical record for Resident #179 on [DATE]. According to the admission Face Sheet (an admission summary), Resident #179 was readmitted to the facility on [DATE] following a hospitalization for urinary retention. Resident #179 had diagnoses which included, but were not limited to, hypertension, diabetes mellitus, depression, hyperlipidemia, and End Stage Renal Disease. A review of Resident #179's Plan of Care, updated on [DATE] and [DATE], revealed that Resident #179 had decreased range of motion (ROM) and muscle strength related to co-existing chronic medical conditions. Resident #179 also was at risk for infection due to urinary retention. The care plan goal was for Resident #179 to not have a urinary tract infection and to receive the care needed to maintain their current functional status. The Annual Minimum Data Set Assessment (MDS), an assessment tool used by the facility to prioritize care, dated [DATE], revealed that Resident #179 scored 13/15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. The section H of the MDS, which addressed Bladder and Bowel, Resident #179 received a score of 9 for H 0300. The score was indicative of the presence of an indwelling catheter in the bladder. The Interdisciplinary Progress Notes (IDPN) revealed that on [DATE] at 3:00 PM, a Registered Nurse documented in the IDPN, Per assigned desk nurse statement, in the process of removing resident catheter. She cut it and put a towel under it to prevent the urine from draining into the resident's pants. Before she could pull the catheter out part of the catheter retracted. It was reported to the writer. Director of Nursing (DON) and Assistant Director of Nursing (ADON) made aware. NP (Nurse Practitioner) made aware and gave order to transfer Resident #179 to the Emergency Department (ED) for retracted [indwelling urinary] catheter . Resident #179 was picked up at 2:55 PM by 911 crew. A late IDPN entry dated [DATE], timed 3:30 PM, read, Dc' d [indwelling urinary] catheter retracted in the process of removing it. Resident transferred to ED. On [DATE] at 11:52 AM, the surveyor interviewed the RN/UM regarding the IDPN dated [DATE]. The RN/UM stated that the Registered Nurse (RN #1), who oversaw the unit on [DATE], cut the indwelling urinary catheter in the process of removing the indwelling urinary catheter. She stated that there was an order to remove the indwelling urinary catheter on [DATE]. RN #1 proceeded to execute the order to remove the urinary catheter. The RN/UM stated that RN #1 reportedly had never removed a urinary catheter before. She cut the urinary catheter with a pair of scissors instead of using a syringe to remove the water to deflate the balloon. The remaining urinary catheter then retracted into the bladder. Resident #179 was transferred to the ED for evaluation and treatment the same day. The hospital discharge summary was requested and was not available for review by the surveyor. The RN/UM stated she would inform the DON of the request for the hospital discharge summary. On [DATE] at 12:30 PM, the surveyor interviewed the Director of Nursing (DON). The DON confirmed that she was aware of the above incident and informed the surveyor that RN #1 was currently suspended pending disciplinary action. The surveyor requested the investigation and the employee file for review. The surveyor also requested RN #1's telephone contact to conduct an interview. On [DATE] at 9:23 AM, the surveyor interviewed a random Registered Nurse (RN) assigned to the 200 unit regarding nursing resource materials available to the staff. The RN directed the surveyor to the binder outside the nursing station that contained all the policies and procedures. The surveyor located in the binder policy # 4:035 B titled, Indwelling Catheter Replacement, dated [DATE], which outlined the following: Indwelling Catheter replacement must have a physician order indicating size and schedule. Indwelling catheter replacement must be done by a registered nurse whose clinical skill has been checked by the instructor of nursing. If the physician and/or registered nurse, who has demonstrated clinical competence for this procedure is not available, send Resident to the emergency room for indwelling Catheter. The policy did not include a procedure to remove an indwelling urinary catheter. On [DATE] at 11:00 AM, the surveyor conducted a telephone interview with RN#1, who confirmed she was the nurse who received the order to remove the indwelling urinary catheter on [DATE]. RN #1 stated that she was overwhelmed that day and did not want to leave the procedure for the next shift. RN #1 stated she went to Resident #179's room with the Certified Nurse Aide (CNA), and she then used a pair of scissors from the treatment cart, cut the indwelling urinary catheter, and urine was splashing all over. She stated she then looked for the indwelling urinary catheter but could not locate it on the bed. RN #1 stated she realized that the indwelling urinary catheter retracted into the bladder. She stated she applied a towel to protect the resident's clothing, informed the RN/UM what had happened, and went to the desk and called and reported the incident to the Nurse Practitioner (NP). The NP then gave an order to transfer Resident #179 to Emergency Department for evaluation and treatment, and she reported the incident to the DON and initiated the 911 call for transfer. She stated that the DON informed her to leave the floor once she completed her statement. RN #1 stated that she had not received any in-service education on how to remove an indwelling urinary catheter at the facility. She stated she was aware that besides deflating the balloon, another simple way was to cut the indwelling urinary catheter. She stated, I made a mistake. RN #1 stated that she met with the DON in the office and explained what had happened. The DON informed her that she was suspended. The surveyor then asked RN #1 to elaborate on her work history prior to being employed by the facility. RN #1 stated that she worked as a floor nurse for a long-term care facility and a psychiatric hospital before working at the current facility. She stated she had been a Registered Nurse for 13 years. RN #1 stated after being hired by the facility, during orientation, she was able to demonstrate and was evaluated on the skill sets of inserting an indwelling urinary catheter. However, she was not evaluated on indwelling urinary catheter removal. A review of RN #1's orientation file provided by the Nurse Educator (NE) confirmed that she received in-service education on inserting a urinary drainage catheter on [DATE] during orientation. The surveyor requested RN #1's employee file from the DON. RN #1's employee file contained three written warnings, one for a medication error, the second for not donning the proper PPE during an outbreak, and the most recent was for an allegation of verbal abuse toward a family member. RN #1 also stated that she was informed during her hearing with the Employee Relation Officer ([NAME]) that she did not document all the required information on the hospital transfer form prior to sending Resident #179 to the ED. The surveyor then asked RN #1 if there were any resource materials on the floor that she could have used prior to removing the indwelling urinary catheter. She stated that she did not review any indwelling urinary catheter removal procedure before cutting the urinary catheter with scissors. She stated that she was provided with a form titled Wisconsin Technical College (Nursing Skills 21.13 Checklist for [indwelling urinary catheter Removal] during her hearing with [NAME] on [DATE]. On [DATE] at 10:15 AM, the surveyor reviewed the Facility assessment dated [DATE]. According to the documentation provided, the Facility Assessment had to identify and analyze the facility's resident population, which must be considered when determining staffing and resources needed to care for the residents. Understaffing training, it is revealed, Licensed nursing staff receive training and demonstrate competencies in areas of responsibility related to providing skilled nursing care to residents of the facility. Nurses receive updated and additional training as necessary to meet the changing needs of our residents. Training and competencies include, but not limited to: Licensed nurse training and/ or competencies. Oxygen set up Oxygen masks . Nasal cannula / Non-Rebreather /Simple face mask Wound care / Dressing Change Suctioning skill/ Trach care Glucometer Medication Pass Indwelling catheter replacement CPR The facility's Indwelling Catheter Replacement policy did not cover Foley Catheter Removal. On [DATE] at 10:37 AM, the surveyor conducted an interview with the NP responsible for Resident #179's care. The NP stated that she wrote an order to remove the indwelling urinary catheter and initiate a voiding trial. She received a call from the nurse, who stated that something had happened. The nurse stated she cut the indwelling urinary catheter to remove it, and the catheter retracted. The NP stated, I came on the unit, examined the Resident, the resident was not in pain. I gave an order to transfer Resident #179 to the ED for evaluation and treatment. The NP stated, I had never heard of such a procedure. The NP further stated that she was not informed of any follow-up or recommendations from the ED. The NP stated that she reviewed the After Visit Summary the next day and could not identify what treatment was provided. She said she called the hospital and spoke to the staff, but the hospital staff could not comment on what treatment was provided. The NP stated she asked for the Urology report and was informed that the Urologist was not called in to see Resident #179. The NP then explained to the ED, what had happened, and that the issue needed to be addressed immediately. The NP stated the Urologist was then made aware that Resident #179 had the retracted catheter in the bladder. On [DATE] at 12:03 PM, the surveyor interviewed the NE in charge of orientation and staff competencies. The surveyor inquired about specific competencies and skill sets necessary to care for resident needs. The NE provided the surveyor with the orientation package. A review of the orientation package confirmed that indwelling urinary catheter removal was not included in the competencies. RN #1 did not receive in-service training for indwelling urinary catheter removal. The NE stated that Licensed Staff had to go to general orientation classes for two days and then work with a mentor on the floor for 14 days (for full time) employees. Mandatory training was scheduled yearly, and skill sets for competencies were completed every two years. Based on the orientation package provided, the facility staff did not receive competency training for indwelling urinary catheter removal. The NE stated that he was aware of the adverse outcome with the Foley catheter on the [DATE] incident. He was informed that Resident #179 was transferred to ED for treatment because the indwelling urinary catheter was improperly removed. The surveyor requested in-service education training provided after the incident, but none had been provided. When asked how nursing staff competency education was being tracked, the NE added the DON would inform him of any needed in-service education training. The Orientation package provided by the facility was reviewed with the NE on [DATE] and did not include Foley Catheter Removal. The current policy revealed how to insert an indwelling urinary catheter only. The facility was unable to provide the rationale for nursing staff not being trained or assessed for competency on how to remove an indwelling urinary catheter. On [DATE] at 4:40 PM, the surveyor conducted a second interview with RN #1. She stated that she had performed the skill to remove an indwelling urinary catheter before deflating the balloon. She stated that cutting the indwelling urinary catheter was a simple procedure that she had not used prior. She stated that she overheard nurses saying that you could cut the indwelling urinary catheter to remove it, and that was why she cut the indwelling urinary catheter. She stated that after the incident, she went to the internet, watched a video, and realized that she did not follow the proper technique. RN #1 stated that she cut the catheter 4 to 5 inches below the insertion site, not by the port, to evacuate the water. The surveyor then asked RN #1 to elaborate on the procedure for indwelling urinary catheter removal. She stated: 1. Verify the order, identify the patient, explain the procedure, provide privacy, use a syringe to deflate the balloon by aspirating the water, and gently pull the indwelling urinary catheter. She stated she was very concerned regarding the resident's well-being. She kept calling every day to inquire regarding Resident #179's status. RN #1 was able to elaborate on the process of properly removing an indwelling urinary catheter. She could not provide the rationale for cutting the indwelling urinary catheter, which caused Resident #179 to be transferred to the ED for treatment. On [DATE] at 09:30 AM, The DON provided the Investigation Report for review. The surveyor reviewed the final report, which revealed the following: Physical Evidence On [DATE], the charge nurse reported that in the process of removing Resident #179's indwelling urinary catheter, she cut the catheter and part of it retracted into the bladder. Resident #179 was immediately discharged to the hospital for intervention. CT urogram (used to examine the kidneys and bladder) without contrast was performed in the hospital with the impression there is significant bladder wall thickening with peri cystic inflammation suggesting cystitis (inflammation of the urinary bladder), no hydronephrosis or renal calculi identified, a note is made of small bilateral pleural effusion (abnormal fluid collection between thin layers of tissue lining the lung and the wall of the chest cavity), and urinary bladder is partially collapsed around Foley catheter. No further intervention was taken at the hospital. Recommendations: [DATE] Urology consult by ___, with recommendation for bladder ultrasound. [DATE] Bladder ultrasound taken on with conclusion of bladder not visualized, to consider ST scan not ordered. On [DATE] resident was seen by the Cardiology group and cleared for cystoscopy. On [DATE], cystoscopy was performed for removal, and a new Foley catheter was placed. The resident was referred for follow-up with Urologist. Resident's care plan revision: Bladders scan every shift Monitor for signs and symptoms of infection Observe Resident for any abdominal pain Encourage fluids Refer to MD if no urinary output Staff Education All nurses were given competency for Foley catheters. Conclusion A Cystoscopy was performed on Resident #179; the retracted piece of the indwelling urinary catheter was removed, and a new indwelling urinary catheter was re-inserted. The resident is being monitored for any signs and symptoms of infection. A bladder scan is being performed every shift to monitor for bladder retention. Resident #179 will be seen by a urologist on [DATE] at the facility. The RN who cut the Foley catheter remains on suspension pending investigation. On [DATE] at 9:51 AM, an interview was conducted with the DON, who stated that she made her last rounds at 2:50 PM and was informed that Resident #179 had to be sent out because the nurse cut the indwelling urinary catheter. When asked if the nurse provided the rationale for cutting the indwelling urinary catheter, the DON added that the indwelling urinary catheter removal was a skill set that was taught in school, and all licensed staff should know how to remove an indwelling urinary catheter. The DON did not interview RN #1 to identify the causal factor, implement corrective action, or prevent recurrence. The DON stated that during her career, she had never heard of cutting the indwelling urinary catheter as a skill set to remove the indwelling urinary catheter. The DON stated that RN #1 was suspended pending disciplinary action, and the incident had been reported to the Department of Health. On [DATE] at 11:17 AM, a second surveyor interviewed the Physician Assistant (PA) covering for the Urologist. He stated they had been assigned to the facility for about 1 1/2 to 2 years. Their responsibilities consisted of reviewing all urology consults and changing all indwelling urinary catheters monthly. Resident #179 was seen at the hospital for urinary retention ([DATE]- [DATE]), and an indwelling urinary catheter was inserted prior to discharge to the facility. He was made aware of the adverse outcome of the indwelling urinary catheter removal by the NP. Resident #179 had to have a scheduled cystoscopy to remove the remaining catheter in the bladder. He stated if the resident had a cardiac history, medical clearance had to be obtained to ensure that the resident was stable to sustain the procedure under anesthesia. The PA stated that based on the report obtained from the facility, Resident #179 was able to void and did not develop signs/ symptoms of infection. The PA was unaware that Resident #179's urine culture and sensitivity tested positive for E Coli, ESBL, and MRSA on [DATE] and that Resident #179 had to be placed on Macrobid (antibiotic) to treat the urinary tract infection. On [DATE] at 12:06 PM, the surveyor interviewed the CNA who assisted the RN #1 on [DATE]. The CNA stated that Resident #179 got out of bed three times weekly. It was almost 3:00 PM, and Resident #179 had been dressed and was up and sitting in a wheelchair. The nurse asked her to assist with removal of the indwelling urinary catheter. She stated, she went to the room, pulled Resident #179's pants down just enough to see the indwelling urinary catheter. The CNA stated the catheter was long, the nurse retrieved a pair of scissors from her packet and cut the yellow part that goes into the penis. The nurse then told me to pull out the long part from the pants. The CNA stated that the nurse asked her, What happened to the other part? The CNA stated, &q[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Reference F 600, F 658, F 880 and F 886 Based on observations, interviews, review of medical records and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure: a) that an alert and oriented resident (Resident #24) who was being verbally abused by an Agency Nurse was not prevented from leaving the unit to seek help by a Certified Nurses Aide (CNA) on [DATE], who was permitted to work for seven shifts without any additional abuse training or investigation to rule out possible abuse until surveyor inquiry b) that a resident's (Resident #179) Foley urinary catheter was removed in accordance with professional standards of practice which resulted in transfer to an acute care hospital on [DATE] and the resident returned to the facility on [DATE] with a portion of the severed catheter which remained in the bladder and the resident was consequently ordered a prophylactic antibiotic to prevent infection to be administered at the facility that the resident did not receive, prior to a required urological surgical procedure after awaiting cardiac clearance to extract the foreign body that remained in the bladder and later resulted in the resident receiving additional antibiotic treatment for ESBL (Extended-spectrum beta lactamases, a bacterium with antibiotic resistance) and MRSA (methicillin-resistant Staphylococcus aureus, a bacterium with antibiotic resistance) in the urine c) that immediate contact tracing was completed in response to to newly identified COVID-19 staff and residents in accordance with local health department guidance provided on [DATE] d) that immediate action was taken to prevent the spread of COVID-19 during an outbreak which began on [DATE] by failing to complete contact tracing and complete immediate follow-up resident and staff testing upon identification of COVID-19 positive staff and residents to prevent the continued spread of infection. This posed a serious and immediate threat to the safety and well-being of all residents who resided at the facility, were made subject and vulnerable to abuse, had foley urinary catheters, and were placed at risk for contracting COVID-19, which is a harmful and deadly virus. The failure of the LNHA to ensure the facility operated in a manner that ensured residents were cared for in a manner and an environment that enabled residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being posed a serious and immediate threat to the health, safety, and welfare of all residents who resided at the facility in compliance with federal, state and local requirements as outlined in the Administrator Job Description, resulted in an immediate jeopardy (IJ) that was identified on [DATE] at 4:16 PM, and was sent to the facility via e-mail at 4:18 PM. A Removal Plan was received on [DATE] at 9:37 AM, and the survey team verified the implementation of the Removal Plan on [DATE] at 9:26 AM. This deficient practice was evidenced by the following: A review of the facility's Job Specification 60293, Chief Executive Officer, Care Facility ([DATE]), revealed that the duties of the CEO/LNHA included but were not limited to: Oversees the development, implementation, and monitoring of clinical programs designed to meet the level of functioning and/or care needs of clients. Ensures the implementation of department policies and statutes applicable to the operation of the care facility. Oversees the development and management of a quality assurance system to comply with standards promulgated by accrediting and certifying agencies; .Federal Department of Health and Human Services and NJ Department of Health and Senior Services. Provides protection of clients' civil and legal rights . Findings included: Refer F600 On [DATE], the LNHA failed to ensure residents were free from abuse after a resident (Resident #24) was prevented from leaving an abusive situation by Certified Nursing Aide (CNA #1), who continued to work with other residents following no investigation. This deficient practice was identified for 1 of 5 residents reviewed for abuse (Resident #24). On [DATE] at 10:38 AM, the surveyor interviewed Resident #24, who stated on [DATE], they received Percocet and Xanax every six hours and asked an aide to find the nurse to administer the medications. An Agency Nurse (LPN #1) entered my room and informed me that they would administer my medications and take my vital signs and proceeded to leave the room and closed the door. The resident stated that they proceeded to use the call bell, and LPN #1 came back into the room to tell me to stop pushing the call bell; she pulled down her mask and attempted to bite my finger as I pointed at her. The resident continued that they got out of bed to get away from LPN #1. LPN #1 lunged her nurse's cart at me three times and hit their left foot, causing a wound to re-open. The resident stated that they were trying to get away from LPN #1 and get to the Registered Nurse Supervisor (RN Supervisor). The resident stated as they were attempting to leave the unit in the hallway, the nurse assaulted them by pulling the wheelchair (w/c) 2-3 times, which positioned the resident on only two back wheels, and the two front wheels were lifted off of the floor. The resident stated that there was a (CNA #1) there, but they could not recall the name of who tried to calm the crazy nurse down. A review of the Resident Facesheet (an admission summary) reflected that the resident was admitted to the facility in September of 2021 but did not include admitting diagnoses. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], reflected a brief interview of mental status (BIMS) score of 15 out of 15, which indicated the resident was fully cognitively intact. It further reflected the resident had verbal and behavioral symptoms directed toward others that occurred four to six days in the last seven days of assessment. Section I Active Diagnoses included the resident having hypertension (high blood pressure), anxiety, depression, psychotic disorder, and PTSD. It further included a seven-day look back period. The resident received daily antianxiety, antidepressant, and opioid medications. A review of the individualized comprehensive Care Plan (CP) included a problem area initiated on [DATE], for at risk for altercation in mood/behavior; history of major depressive disorder, anxiety, use of Seroquel (antipsychotic medication) for agitation, use of Xanax for anxiety, and Remeron for anxiety/depression/mood with interventions that included to observe for efficiency of medications; monitor for target behaviors or behaviors not easily redirected; refer to nurse if noted behaviors worsening, unable to redirect; keep the room well lit, open blinds for sunlight; and give medications Remeron, Xanax, Seroquel as ordered. A further review of the CP included a diagnosis of PTSD, however, did not include a problem area or interventions pertaining to the resident's diagnosis of PTSD. On [DATE] at 10:00 AM, the surveyor reviewed the facility provided investigation report for Resident #24's incident which occurred on [DATE]. A review of the staff statements included a statement provided by CNA #2, which detailed that they were taking care of a resident when they heard a noise in the hallway and came out into the hallway and saw Resident #24 trying to leave the floor. She stated that, I stopped them from leaving the floor. CNA #2 stated that both she and another CNA called the charge nurse, but I did not know what was going on. CNA #2's statement appeared to be what the surveyor witnessed CNA #1 do in the surveillance video. No statement from CNA #1 in the investigation report was provided. On [DATE] at 10:31 AM, the surveyor reviewed the surveillance video with the Assistant Licensed Nursing Home Administrator (ALNHA) #1, Employee Relations/Legal Specialist, another surveyor, and the Employee Relations/Legal Specialist confirmed CNA #1 was the aide who was blocking the door. CNA #2 was the aide observed later walking up the hallway towards LPN #1, CNA #1, and the resident during the altercation. At this time, the surveyor reviewed the investigation packet with ALNHA #1, who confirmed there should have been a statement from CNA #1 included in the investigation report. On [DATE] at 10:59 AM, the DON provided the surveyor with CNA #1's statement dated [DATE], which was the exact same statement provided by CNA #2. At this time, the surveyor asked the DON to read both CNA #1 and CNA #2's statements, and she confirmed that both statements were the same but was signed by the corresponding CNA. At this time, the surveyor requested to watch the video footage again with the DON. On [DATE] at 11:10 AM, the surveyor with the DON, Employee Relations/Legal Specialist, and another surveyor viewed the video footage. When comparing the surveillance footage with the statements, the surveyor asked the DON if the statements clearly reflected what had happened. The DON reported that she completed a three-page reportable to the New Jersey Department of Health (NJDOH) and told RN #1 to watch the video to see if anything should be added to her statement. Then the DON reported she had left for vacation. The DON stated that the ADON had watched the video with RN #1, who did not want to change her statement. The DON stated the purpose of an investigation was to determine a root cause analysis and confirmed these statements were not clear. The DON stated when she returned from vacation, the investigation was completed by the ADON, and she did not review it even though she was responsible for oversight of all aspects of nursing. The DON confirmed the resident had the right to leave the unit, and no staff, including the two CNAs, should have stopped the resident from leaving the unit. The surveyor reviewed the video with the DON. The DON acknowledged CNA #1 was standing in front of the exit door blocking Resident #24 from exiting the unit, which was an issue because this was considered a restraint. The DON stated that even if the resident was confused, which Resident #24 was not, staff could not stop the resident from leaving. The DON stated staff had to ensure the resident's safety and could follow the resident from a distance, but staff could not prevent the resident from leaving the unit. The DON stated the ADON was on vacation but confirmed the investigation was incomplete. She had to re-open the investigation to clarify the statements and determine why CNA #1 stood in front of the door. On [DATE] at 01:14 PM, the surveyor re-interviewed Resident #24, who stated CNA #1 was stopping LPN #1 from verbally abusing them, but confirmed CNA #1 was preventing them from leaving the unit and told them they were not allowed to leave the unit. The resident stated CNA #1 could have done more since she was not letting them leave, and they did not know why. On [DATE] at 10:30 AM, the surveyor reviewed the nursing schedules since [DATE], which revealed CNA #1 worked seven shifts at the facility after the incident. On [DATE] at 09:51 AM, the surveyor interviewed Resident #24, who stated they were imprisoned for twenty months and preferred the door to their room remain open because the closed door triggered their PTSD, causing anxiety. The resident stated on [DATE]; they were waiting for LPN #1 to administer their routine Percocet and Xanax medication so they could go back to sleep. LPN #1 closed their room door and started yelling at them, and the resident reported they just wanted to escape LPN #1, who grabbed their wheelchair and almost tipped the chair over. Resident #24 stated that they remembered the aide (CNA #1) saying their name and that they knew her and they could not leave, but Resident #24 stated they could not determine who the aide was at the time. Resident #24 stated they just wanted the RN Supervisor, which made them feel angry because they were being prevented from escaping from LPN #1, and CNA #1 was not helping the situation. CNA #1 could have opened the door to let me leave, but she would not let me leave, which made me mad. The resident stated they had never been prevented from leaving the unit before, so they could not understand why that was happening. The facility's failure to ensure all residents were free from abuse, including verbal, physical, restraints, and involuntary seclusion by not investigating the actions of CNA #1 after a written statement acknowledged she stopped the resident from leaving the unit as well as video footage confirming she blocked the exit door preventing the resident from leaving the unit posed a serious and immediate threat for abuse which can cause serious physical and emotional harm or impairment. This resulted in an Immediate Jeopardy situation. The IJ was identified on [DATE], and the LNHA, ALNHA #1, ALNHA #2, DON, and Director of Veterans Health Care Services were notified of the IJ at 02:55 PM. A written Removal Plan was accepted and verified onsite on [DATE], which included staff members will be immediately relieved from their duties; to ensure the safety of the residents, a comprehensive investigation will commence at the time of the event to ensure a thorough and complete review of all contributing factors have been conducted; all staff in-serviced on the Abuse and Neglect Policy. Refer to F658 Based on interviews, record review, and review of other facility documentation, it was determined that the facility failed to ensure nursing staff appropriately removed an indwelling urinary catheter (soft plastic or rubber tube that is inserted into the bladder to drain urine) in accordance with professional standards of nursing practice which necessitated a transfer to the hospital for treatment, and a urinary tract infection. This deficient practice was identified for 1 of 3 Residents reviewed for indwelling urinary catheter care (Resident #179) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The facility's failure to have a system in place to ensure that nursing staff appropriately removed an indwelling catheter posed a serious and immediate threat to the health and welfare of all residents who required catheter care. An adverse outcome was likely to occur as the identified non-compliance resulted in an immediate Jeopardy (IJ) situation that began on [DATE] at 2:50 PM when the Registered Nurse (RN) improperly removed the indwelling catheter. The RN used scissors to cut through Resident #179's indwelling catheter, which then caused the remaining catheter to retract into the bladder. The Immediate Jeopardy (IJ) situation was identified during an onsite survey conducted on [DATE], and the facility was notified of the IJ, on the same day, at 3:20 PM. The facility submitted an acceptable removal plan on [DATE] at 2:55 PM. The team verified the removal plan during an onsite visit conducted on [DATE]. Findings included: On [DATE] at 10:30 AM, the surveyor toured the 200 Unit of the facility and observed that Resident #179's door was closed. On the door, the surveyor observed signage posted which identified the required PPE (Personal Protective Equipment) to enter the room. The surveyor observed staff donning (putting on) and doffing (removing) with the required PPE before entering and exiting the room. An interview with the Registered Nurse/Unit Manager (RN/UM) revealed that Resident #179 was in isolation for Extended Spectrum Beta Lactamase (ESBL, antibiotic-resistant bacteria) and Methicillin Resistant Staphylococcus Aureus (MRSA, antibiotic-resistant bacteria) in the urine. On [DATE] at 11:29 AM, the surveyor donned the appropriate PPE, knocked at the door, waited for Resident #179 to answer, and entered the room. The surveyor observed Resident #179 in bed, awake with eyes open, and the surveyor observed a splint to the left arm. The surveyor explained the purpose of the visit, and Resident #179 agreed to be interviewed. Resident #179 was alert and stated that he could not move their left arm. Resident #179 answered all questions appropriately. The surveyor observed an indwelling urinary catheter covered with a catheter drainage bag hung on the bed frame. On [DATE] at 09:30 AM, the surveyor returned to the 200 Unit, the door was open, and Resident #179 was not inside the room. Upon inquiry, the RN/UM informed the surveyor that Resident #179 had tested + for COVID-19 in the evening during routine testing and was transferred to the 700 Unit. On [DATE] at 08:30 AM, the surveyor observed Resident #179 in the 700 Unit. The door was closed. Signage with the required PPE was posted on the door. The surveyor reviewed the medical record for Resident #179 on [DATE]. According to the admission Face Sheet (an admission summary), Resident #179 was readmitted to the facility on [DATE] following hospitalization for urinary retention. Resident #179 had diagnoses that included but were not limited to, hypertension, diabetes mellitus, depression, hyperlipidemia, and End Stage Renal Disease. A review of Resident #179's Plan of Care, updated on [DATE] and [DATE], revealed that Resident #179 had decreased range of motion (ROM) and muscle strength related to co-existing chronic medical conditions. Resident #179 also was at risk for infection due to urinary retention. The care plan goal was for Resident #179 to not have a urinary tract infection and to receive the care needed to maintain their current functional status. The Annual Minimum Data Set Assessment (MDS), an assessment tool used by the facility to prioritize care, dated [DATE], revealed that Resident #179 scored 13/15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. Section H of the MDS, which addressed Bladder and Bowel, Resident #179 received a score of 9 for H 0300. The score was indicative of the presence of an indwelling catheter in the bladder. The Interdisciplinary Progress Notes (IDPN) revealed that on [DATE] at 3:00 PM, a Registered Nurse documented in the IDPN, Per assigned desk nurse statement, in the process of removing the resident catheter. She cut it and put a towel under it to prevent the urine from draining into the resident's pants. Before she could pull the catheter out, part of the catheter retracted. It was reported to the writer. Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware. NP (Nurse Practitioner) made aware and gave the order to transfer Resident #179 to the Emergency Department (ED) for retracted [indwelling urinary] catheter . Resident #179 was picked up at 2:55 PM by 911 crew. A late IDPN entry dated [DATE], timed 3:30 PM, read, Dc' d [indwelling urinary] catheter retracted in the process of removing it. Resident transferred to ED. On [DATE] at 11:52 AM, the surveyor interviewed the RN/UM regarding the IDPN dated [DATE]. The RN/UM stated that the Registered Nurse (RN #1), who oversaw the unit on [DATE], cut the indwelling urinary catheter in the process of removing the indwelling urinary catheter. She stated that there was an order to remove the indwelling urinary catheter on [DATE]. RN #1 proceeded to execute the order to remove the urinary catheter. The RN/UM stated that RN #1 reportedly had never removed a urinary catheter before. She cut the urinary catheter with a pair of scissors instead of using a syringe to remove the water to deflate the balloon. The remaining urinary catheter then retracted into the bladder. Resident #179 was transferred to the ED for evaluation and treatment on the same day. The hospital discharge summary was requested and was not available for review by the surveyor. The RN/UM stated she would inform the DON of the request for the hospital discharge summary. On [DATE] at 12:30 PM, the surveyor interviewed the Director of Nursing (DON). The DON confirmed that she was aware of the above incident and informed the surveyor that RN #1 was suspended pending disciplinary action. The surveyor requested the investigation and the employee file for review. The surveyor also requested RN #1's telephone contact to conduct an interview. On [DATE] at 9:23 AM, the surveyor interviewed a random Registered Nurse (RN) assigned to the 200 unit regarding nursing resource materials available to the staff. The RN directed the surveyor to the binder outside the nursing station that contained all the policies and procedures. The surveyor located in the binder policy # 4:035 B titled, Indwelling Catheter Replacement, dated [DATE], which outlined the following: Indwelling Catheter replacement must have a physician order indicating size and schedule. Indwelling catheter replacement must be done by a registered nurse whose clinical skill has been checked by the instructor of nursing. If the physician and/or registered nurse, who has demonstrated clinical competence for this procedure, is not available, send the resident to the emergency room for an indwelling Catheter. The policy did not include a procedure to remove an indwelling urinary catheter. On [DATE] at 11:00 AM, the surveyor conducted a telephone interview with RN#1, who confirmed she was the nurse who received the order to remove the indwelling urinary catheter on [DATE]. RN #1 stated that she was overwhelmed that day and did not want to leave the procedure for the next shift. RN #1 stated she went to Resident #179's room with the Certified Nurse Aide (CNA), and she then used a pair of scissors from the treatment cart, cut the indwelling urinary catheter, and urine was splashing all over. She stated she then looked for the indwelling urinary catheter but could not locate it on the bed. RN #1 stated she realized that the indwelling urinary catheter retracted into the bladder. She stated she applied a towel to protect the resident's clothing, informed the RN/UM what had happened, and went to the desk and called and reported the incident to the Nurse Practitioner (NP). The NP then gave an order to transfer Resident #179 to Emergency Department for evaluation and treatment, and she reported the incident to the DON and initiated the 911 call for transfer. She stated that the DON informed her to leave the floor once she completed her statement. RN #1 stated that she had not received any in-service education on how to remove an indwelling urinary catheter at the facility. She stated she was aware that besides deflating the balloon, another simple way was to cut the indwelling urinary catheter. She stated, I made a mistake. RN #1 stated that she met with the DON in the office and explained what had happened. The DON informed her that she was suspended. The surveyor then asked RN #1 to elaborate on her work history before being employed by the facility. RN #1 stated that she worked as a floor nurse for a long-term care facility and a psychiatric hospital before working at the current facility. She stated she had been a Registered Nurse for 13 years. RN #1 stated after being hired by the facility, during orientation, she was able to demonstrate and was evaluated on the skill sets of inserting an indwelling urinary catheter. However, she was not evaluated for indwelling urinary catheter removal. A review of RN #1's orientation file provided by the Nurse Educator (NE) confirmed that she received in-service education on inserting a urinary drainage catheter on [DATE] during orientation. The surveyor requested RN #1's employee file from the DON. RN #1's employee file contained three written warnings, one for a medication error, the second for not donning the proper PPE during an outbreak, and the most recent was for an allegation of verbal abuse toward a family member. RN #1 also stated that she was informed during her hearing with the Employee Relation Officer ([NAME]) that she did not document all the required information on the hospital transfer form prior to sending Resident #179 to the ED. On [DATE] at 10:15 AM, the surveyor reviewed the Facility assessment dated [DATE]. According to the documentation provided, the Facility Assessment had to identify and analyze the facility's resident population, which must be considered when determining staffing and resources needed to care for the residents. Understaffing training, it is revealed, Licensed nursing staff receive training and demonstrate competencies in areas of responsibility related to providing skilled nursing care to residents of the facility. Nurses receive updated and additional training as necessary to meet the changing needs of our residents. Training and competencies include, but are not limited to: Licensed nurse training and/ or competencies. Oxygen set up Oxygen masks . Nasal cannula / Non-Rebreather /Simple face mask Wound care / Dressing Change Suctioning skill/ Trach care Glucometer Medication Pass Indwelling catheter replacement CPR The facility's Indwelling Catheter Replacement policy did not cover Foley Catheter Removal. On [DATE] at 10:37 AM, the surveyor interviewed with the NP responsible for Resident #179's care. The NP stated that she wrote an order to remove the indwelling urinary catheter and initiate a voiding trial. She received a call from the nurse, who stated that something had happened. The nurse stated she cut the indwelling urinary catheter to remove it, and the catheter retracted. The NP stated, I came on the unit, examined the resident, and the resident was not in pain. I gave an order to transfer Resident #179 to the ED for evaluation and treatment. The NP stated, I had never heard of such a procedure. The NP further stated that she was not informed of any follow-up or recommendations from the ED. The NP stated that she reviewed the After Visit Summary the next day and could not identify what treatment was provided. She said she called the hospital and spoke to the staff, but the hospital staff could not comment on what treatment was provided. The NP stated she asked for the Urology report and was informed that the Urologist was not called in to see Resident #179. The NP then explained to the ED, what had happened, and that the issue needed to be addressed immediately. The NP stated the Urologist was then made aware that Resident #179 had the retracted catheter in the bladder. On [DATE] at 12:03 PM, the surveyor interviewed the NE in charge of orientation and staff competencies. The surveyor inquired about specific competencies and skill sets necessary to care for resident needs. The NE provided the surveyor with the orientation package. A review of the orientation package confirmed that indwelling urinary catheter removal was not included in the competencies. RN #1 did not receive in-service training for indwelling urinary catheter removal. The NE stated that Licensed Staff had to go to general orientation classes for two days and then work with a mentor on the floor for 14 days (for full-time) employees. Mandatory training was scheduled yearly, and skill sets for competencies were completed every two years. Based on the orientation package provided, the facility staff did not receive competency training for indwelling urinary catheter removal. The NE stated that he was aware of the adverse outcome with the Foley catheter on the [DATE] incident. He was informed that Resident #179 was transferred to ED for treatment because the indwelling urinary catheter was improperly removed. The surveyor requested in-service education training provided after the incident, but none had been provided. When asked how nursing staff competency education was being tracked, the NE added that the DON would inform him of any needed in-service training. The Orientation package provided by the facility was reviewed with the NE on [DATE] and did not include Foley Catheter Removal. The current policy revealed how to insert an indwelling urinary catheter only. The facility was unable to provide the rationale for nursing staff not being trained or assessed for competency on how to remove an indwelling urinary catheter. On [DATE] at 4:40 PM, the surveyor conducted a second interview with RN #1. She stated that she had performed the skill to remove an indwelling urinary catheter before deflating the balloon. She stated that cutting the indwelling urinary catheter was a simple procedure that she had not used prior. She stated that she overheard nurses saying that you could cut the indwelling urinary catheter to remove it, and that was why she cut the indwelling urinary catheter. She stated that after the incident, she went to the internet, watched a video, and realized that she did not follow the proper technique. RN #1 stated that she cut the catheter 4 to 5 inches below the insertion site, not by the port, to evacuate the water. The surveyor then asked RN #1 to elaborate on the indwelling urinary catheter removal procedure. She stated: 1. Verify the order, identify the patient, explain the procedure, provide privacy, use a syringe to deflate the balloon by aspirating the water, and gently pull the indwelling urinary catheter. She stated she was very concerned regarding the resident's well-being. She kept calling every day to inquire regarding Resident #179's status. RN #1 elaborated on the process of properly removing an indwelling urinary catheter. She could not provide the rationale for cutting the indwelling urinary catheter, which caused Resident #179 to be transferred to the ED for treatment. On [DATE] at 09:30 AM, The DON provided the Investigation Report for review. The surveyor reviewed the final report, which revealed the following: Physical Evidence On [DATE], the charge nurse reported that in the process of removing Resident #179's indwelling urinary catheter, she cut the catheter and part of it retracted into the bladder. Resident #179 was immediately discharged to the hospital for intervention. CT urogram (used to examine the kidneys and bladder) without contrast was performed in the hospital with the impression there is significant bladder wall thickening with peri cystic inflammation suggesting cystitis (inflammation of the urinary bladder), no hydronephrosis or renal calculi identified, a note is made of small bilateral pleural effusion (abnormal fluid collection between thin layers of tissue lining the lung and the wall of the chest cavity), and urinary bladder is partially collapsed around Foley catheter. No further intervention was taken at the hospital. Recommendations: [DATE] Urology consult by ___, with recommendation for bladder ultrasound. [DATE] Bladder ultrasound taken on with conclusion of bladder not visualized, to consider ST scan not ordered. On [DATE] resident was seen by the Cardiology group and cleared for cystoscopy. On [DATE], a cystoscopy was performed for remov[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part A Based on interview and review of pertinent documents, it was determined that the facility, who has been in an active COVID-19 outbreak status since 11/23/21, failed to conduct immediate and thorough contact tracing to further prevent the spread of COVID-19 (a deadly virus) by failing to ensure: a.) a process was in place to conduct comprehensive contact tracing upon the identification of a single new case of COVID-19 in a staff or resident. b.) a facility contact tracing policy was completed and implemented, c.) appropriate staff were trained on the contact tracing policy, d.) the facility followed all Centers for Disease Control (CDC), local health department, state health department, and all current guidance related to infection control. The deficient practice was identified during a review of eight sampled COVID-19 positive residents (Residents #444, #446, #3, #445, #447, #46, #76, and #179), dates ranging from 12/28/21 through 08/16/22 and a review of six sampled COVID-19 positive staff members dates ranging from 08/1/22 through 08/16/22 and was identified by the following: The facility's system wide failure to conduct and retain complete COVID-19 close contact tracing upon the identification of a single new case of COVID-19 posed a serious and immediate risk to the health and well-being of all staff and residents who resided at the facility and who were placed at risk for contracting a contagious infectious and potentially deadly virus. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 09/06/22 at 4:16 PM. The survey team verified the removal plan during an on-site visit conducted on 09/08/22 at 12:47 PM. Reference: Contact Tracing for COVID-19 CDC https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/contact-tracing.html Reference F 886L On 08/16/22 at 10:24 AM, during the entrance conference, the Administrative team informed the survey team that the facility was currently experiencing an outbreak of COVID-19, which began on 11/23/21. The survey team was provided with the facility's ongoing line listing (a document that is transmitted to the department of health and lists all COVID-19 cases during an outbreak) and a blank copy of the Contact Tracing Form undated that the team was told was currently being used for tracking close exposures. The surveyor asked to review the facility Contact Tracing. The facility provided and the surveyor reviewed the Resident & Staff COVID-19 Incident Reports updated 4/21, which included but were not limited to please be as detailed as possible and type all responses 9. Explain contact tracing that has been completed in detail. The surveyor reviewed the facility and provided Incident Reports for the following COVID-19 positive residents: #444 who was fully vaccinated and resided in the Old [NAME] unit, presented symptomatic with a cough and sneezing and tested positive on 12/28/21. The contact tracing section failed to list any staff or residents who may have been a close contact (persons who may have been exposed to an infectious contagious disease and may require quarantine measures to help prevent further spread of the disease). #446, who was fully vaccinated and resided in the Eagle unit, presented symptomatic with a cough and tested positive on 01/4/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #445, who was fully vaccinated and resided in the Freedom unit, presented symptomatic with fever and shortness of breath and tested positive on 01/30/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #447, who was fully vaccinated and resided in the Freedom unit, presented symptomatic with a fever and shortness of breath and tested COVID-19 positive on 02/03/22. The form identified Resident #447 as leaving the facility three times per week to attend hemodialysis treatment (treatment to remove impurities from the blood). The contact tracing section failed to list any facility staff, hemodialysis staff, transport staff, visitors, or residents who may have been identified as a close contact. #3, who was fully vaccinated and resided in the Freedom unit, presented asymptomatic (having no symptoms) and tested COVID-19 positive on 08/03/22. The contact tracing section failed to list any staff or residents who may have been identified as a close contact. #46, who was fully vaccinated and resided in the Freedom unit, presented symptomatic with a cough and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #76, fully vaccinated and resided in the Freedom unit, was asymptomatic and tested positive on 08/11/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #179, who was fully vaccinated and resided in the Freedom unit, was asymptomatic and tested positive on 08/16/22. The contact tracing section failed to list any staff or residents who may have been a close contact. A review of the facility provided COVID-19 Resident & Staff Incident Reports for the positive staff members revealed the following: Licensed Practical Nurse (LPN) #2 was asymptomatic and tested positive on 08/1/22. The contact tracing section failed to list any staff or residents who may have been a close contact. Noted LTC facility 07/30/22, 7 (am) - 3 (pm). passed medication, did not have close contact with any staff residents. An Administrative staff member presented symptomatic with nasal congestion and an itchy throat and tested positive on 08/6/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN #1 presented symptomatic with a runny nose and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN was noted to have worked on 08/06/22. On 08/29/22 at 8:39 AM, during an interview with the surveyor, in the presence of the survey team, the facility Infection Preventionist Registered Nurse (IP RN) was asked to provide contact tracing for the residents and staff members who had tested COVID-19 positive. The IP/RN stated that when someone was exposed to COVID-19, she was responsible for completing the contact tracing to identify any close contacts. However, she stated she would not list or include any staff or residents in her contact tracing. She then stated she could not provide any additional documentation related to any staff or residents who may have been exposed to COVID-19 because she kept that information in a personal notebook. The IP/RN stated that she was alone, no secretary, no help, and that she did not document any potential exposers to COVID-19 that may have occurred to others. The surveyor then requested a list of the exposed close contacts. The IP/RN stated she would not be able to provide a list. The IP/RN also stated that there was no facility policy or procedure on contact tracing, and she was unaware that she was responsible for completing and retaining any contact tracing documents. On 08/29/22 at 9:32 AM, during an interview with the surveyor, a Licensed Practical Nurse Unit Manager (LPN/UM) in the Liberty Unit stated that if a resident tested COVID-19 positive, the IP/RN would isolate the resident and do the investigation. She further stated that if a staff member tested COVID-19 positive, they would be sent home, and the IP/RN would do all the paperwork. On 08/29/22 at 9:40 AM, during an interview with the surveyor, the RN Employee Health Nurse stated that she was responsible for the routine COVID-19 testing for the staff and residents and when a resident would return to the facility. She stated that the IP/RN would complete all contact tracing and that she would not be provided any of the contact tracing information. The RN Employee Health Nurse further stated that contact tracing was important to warn others who were exposed to COVID-19 so that they would be tested. On 08/29/22 at 11:27 AM, the IP/RN provided six incomplete facility Contact Tracing Forms for the requested COVID-19 positive staff. The IP/RN again stated to the surveyor that there was no policy for contact tracing, so she would use the Center for Disease Control and Prevention (CDC) guidance. On 08/30/22 at 10:58 AM, during an interview with the surveyor, the IP/RN stated that the facility had enough testing supplies to perform facility-wide COVID-19 testing. When asked again about documented COVID-19 positive close contacts and the actions taken, the IP/RN stated she would talk to the staff but not write things down. She again stated that she would keep the information in a personal notebook and would throw out that information when the case was resolved. The IP/RN stated she was unaware of any formal documentation or form to use, so she would not be able to inform the surveyor of the exposed staff or residents or their COVID-19 testing in response. The IP/RN stated that contact tracing would be used to prevent the spread of infection in the facility. On 08/31/22 at 9:37 AM, the IP/RN provided incomplete contact tracing for the requested COVID-19 positive residents. The contact tracing forms revealed the following missing or incomplete information for the residents: # 444: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection, no breaks/meals rooms & areas, no actions taken listed for follow up testing, and there was nothing documented under reviewed by facility infection control nurse. The only potential contacts listed were one Certified Nursing Assistant (CNA) on each shift for the day of the COVID-19 positive test and previous 48 hour lookback. # 446: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection. The only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and the previous 48 hour look back. No actions were taken for follow-up testing, and the facility infection control nurse noted nothing under review. # 3: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection, no known exposures to residents, the only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no actions taken listed for follow up testing, and nothing noted under reviewed by facility infection control nurse. # 445: no name of interviewer, contact tracing does not include the date 01/30/22 which the resident tested positive or 01/29/22, which was 24 hours prior, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection, the only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no breaks/meals rooms & areas, no action taken by the facility for follow up testing, and nothing noted under reviewed by facility infection control nurse. # 447: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no breaks/meals rooms & areas, the only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no actions taken by the facility for follow up testing, and nothing noted under reviewed by facility infection control nurse. # 46: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection. The only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no action taken by the facility for follow up testing, and nothing noted under review by facility infection control nurse. # 76: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection. The only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no known exposures to residents, no breaks/meals rooms & areas, and no action taken by the facility for follow up testing, and nothing noted under reviewed by facility infection control nurse. # 179: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection. The only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no breaks/meals rooms & areas, no action taken by the facility for follow up testing, and nothing noted under reviewed by facility infection control nurse. A review of the contact tracing forms for the COVID-19 positive staff revealed the following missing or incomplete information: LPN #2: No known exposures to residents were listed, and it was noted on the form that the LPN worked normally during the 3:00 PM - 11:00 PM shift, and no actions had been taken by the facility. The contact tracing form noted, LTC facility 7/30/22, 7 (am) to 3 (pm) passed medication and did not have close contact with any staff or residents. LPN #3: the form was not completed until 08/31/22 after the surveyor inquiry. The surveyor inquired where the IP RN retrieved the information since she had indicated she had discarded all of her documents related to contact tracing. The IP/ RN stated to the surveyor that she had completed from memory. Administrative staff: The form was not completed until 08/31/22 after the surveyor inquiry. The IP RN stated she had completed the document from memory. LPN #1: There was a known exposure and had listed the initials of one resident, the area was left blank, and there was no documentation of the identified resident who was exposed to COVID-19 as having a follow up COVID-19 test. A section under review by the facility infection control nurse was blank. Food Service Worker #2: form not completed until 08/31/22 after surveyor request. IP RN stated she had completed it from memory. Food Service Worker #1: form not completed until 08/31/22 after surveyor request. IP RN stated she had completed from memory. Nothing was noted under reviewed by the facility infection control nurse. On 08/31/22 at 11:21 AM, during an interview with the surveyor, in the presence of the survey team, the IP/RN stated the contact tracing forms she had provided were all filled out yesterday (08/30/22) based on memory. When asked about additional staff who may have had close contact, such as the nurses caring for the residents who tested COVID-19 positive, the IP/RN stated the nurses were not with the residents long enough. The IP/RN stated that exposure would be traced back 48 hours prior for someone who had been within six feet for 15 minutes or more. She further stated, I know from memory that none of the nurses were. Although, she was unable to provide any documented evidence of interviews, reviews of assignment sheets, or any process related to contact tracing to determine a possible COVID-19 exposure. The IP/RN stated that the facility implemented routine broad based COVID-19 testing. She stated the facility tested the staff thrice a week in December 2021 and the residents once or twice a week. The IP/RN stated she was not sure why that stopped. The IP/RN stated that the close contacts were not all tested when exposed. On 08/31/22 at 1:12 PM, during an interview with the surveyor, in the presence of the survey team, the facility Licensed Nursing Home Administrator (LNHA) stated the facility was familiar with the process for contact tracing. At 1:14 PM, the IP/RN joined the interview and told the surveyor that it was the facility process for her to keep her notes. The IP/RN further stated that she remembered from December 2021 onward that none of the nurses who cared for the COVID-19 positive residents spent over 15 minutes with the residents and that no treatments were done either. The LNHA stated that what the IP/RN stated was incorrect, and the facility required formal tracking (contact tracing). The LNHA further stated that the IP/RN should have conducted the contact tracing at the time of the exposure and not from her memory. The LNHA stated that the IP/RN's statement that the nurses did not spend more than 15 minutes was not fully accurate. On 09/01/22 at 9:22 AM, during an interview with surveyors in the conference room, the IP RN stated that she consulted with the local health department (LHD) mostly about deaths, not contact tracing. The IP RN stated, the nurses (facility) I spoke to were in and out (of the resident rooms); I should have kept my contact tracing and personal notes, and the IP/RN stated, we didn't have a policy for contact tracing. The IP/RN confirmed to the surveyor that there was no facility contact tracing policy and stated, unfortunately, no. The surveyor inquired to the IP/RN if she was able to confirm if the nurses who tested COVID-19 positive did not spend 15 minutes or more with residents, and the IP/RN stated she cannot say 100% if the nurses did not stay 15 minutes or more. The IP/RN again stated that contact tracing was important to not spread the virus in the facility. The surveyor requested communication information from the LHD. A review of the communication with the LHD provided by the IP/RN on 09/02/22 at 9:30 AM, revealed emails sent to the LHD as follows: 01/04/22, the IP/RN asked for a meeting, and the LHD asked for her concerns; 01/25/22 the IP RN asking for clarification if she needed to test the roommate of a COVID-19 positive resident and would she need to test again in 48 hours; 04/22/22 the IP/RN asking about quarantining residents not up to date with COVID-19 vaccinations in response to COVID-19 positive residents on the same unit; and 07/18/22 regarding staff going on vacation and coming back COVID-19 positive if they would need to be reported. The IP/RN could not provide any communication to her from the LHD regarding guidance on contact tracing. On 09/02/22 at 9:47 AM, the IP/RN stated that if someone tested COVID-19 positive on a Saturday, she was told she could wait until Monday but could not state who gave her that directive. She stated, the nurses on the weekend would verbally tell her, but there was no documentation regarding the conversation. The IP/ RN acknowledged that close contacts should have included visitors, and physicians, therapy staff but that she did not have documentation that they were ever included on the contact tracing forms. On 09/02/22 at 11:34 AM, during a telephone interview with the survey team, the Medical Director (MD) stated he started at the facility in July 2022. He stated that he had not had any discussions about contact tracing yet, but he was aware of the facility statistics. The MD further stated that he had finished reviewing the Infection Control manual, which was not complete regarding close contacts, and that it would be on the agenda to discuss with the IP RN during their next meeting. On 09/02/22 at 12:04 PM, during an interview with two surveyors, the Assistant Nursing Home Administrator (ANHA) stated she was responsible for the oversight of the IP/RN. She stated her responsibilities were to ensure that the IP/RN completed her job functions and was supported. The ANHA stated a form should be used regarding contact tracing and that the IP/RN had no choice but to follow the facility directives and complete the form. The ANHA stated that the contact tracing form should be done that day (the day of the exposure). The ANHA further stated that if it was not documented, how do we know. She stated that the contact tracing forms were completed to prevent the spread of infection and that exposed close contact should not have been working until they have been tested for COVID-19. On 09/06/22 at 11:31 AM, the surveyor attempted to reach either of the two representatives from the LHD that the IP/RN stated she was in contact with. Two phone messages and email communication was sent. There was no response from either LHD Representative assigned to the facility. On 09/06/22 at 12:03 PM, during a follow-up interview with the survey team, the IP/ RN was asked again if she had received any guidance from the LHD, given the facility had been active COVID-19 outbreak since 11/23/21. The IP/RN stated that she would have to check her emails but believed the LHD may have sent her links to reference. At 12:13 PM, the IP/RN presented the surveyor with additional guidance from the LHD dated 01/19/22, which had not been provided previously. The IP/RN and the surveyor reviewed a guidance in part which included but was not limited to: if the facility can perform contact tracing and can identify close contacts, testing should be done as follows: staff .with exposure with COVID-19 positive individual, residents .who had close contact with a COVID-19 positive individual. If the facility is unable to perform contact tracing and is unable to identify close contacts, testing should be done as follows: staff .test all staff facility wide or at a group level if staff are assigned to a specific location where the new case occurred. Residents .test all residents facility wide or at a group level if staff are assigned to a specific location where the new case occurred. The IP/RN again stated she had stopped doing things this way because the facility was short staffed, so if someone tested positive over the weekend, they (facility staff) were short staffed, so nobody was immediately tested. The IP/RN stated we were told to just do routine testing by the administration. The IP/RN stated when she found out that was incorrect, she followed what the administration had told her to do but could not provide a name or a directive. On 09/06/22 at 12:28 PM, during an interview with two surveyors, the LHNA stated they were never made aware that the IP/RN had stopped following the LHD guidance. The LHNA further stated that the guidance should have always been followed. At 1:04 PM, the LHNA further stated that upon questioning other administrative staff, there was no administrative staff who instructed the IP/RN to stop following the LHD guidance. On 09/07/22 at 10:54 AM, during an interview with the survey team, the MD stated that contact tracing should include all who were exposed, such as food service workers, nurses, residents, visitors, and everyone. A review of the facility provided, Outbreak Response Plan revised 2/22, included but was not limited to the following: Purpose - to protect our residents, families, and staff from harm resulting from an outbreak of an infectious disease organism; the IP would be responsible for conducting routine audits of Infection Control in the facility, establish and implement policies and procedures for screening for exposure, will collaborate with facility medical director, public health authorities, regarding interventions to implement responses; Contact Tracing Form - to include name of interview/contact tracer, date of interview, name of resident, history prior positive COVID, date of a + (positive) COVID, date of symptoms/asymptomatic subtract 2 days prior to test result date or symptoms listed (this is the contact tracing date), known exposures, staff in close contact, activities/locations/shift times visited, breaks/meals contacts, outside employment, actions taken by the facility, and reviewed by the Infection Control nurse. The facility's Outbreak Response Plan had not been followed. A review of the facility provided, Facility Assessment, dated 02/17/22, included but was not limited to Interventions for Controlling Infectious/Communicable Diseases for all Individuals with Residents and Facility Contact - daily surveillance by Infection Control to monitor for any new infections or spread of infections; during the COVID-19 pandemic, the home (facility) identified the need to improve upon the Infectious Disease Outbreak Response Plan. A review of the facility provided CDC guidance the IP RN stated she was referencing, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 (COVID-19) Spread in Nursing Homes updated 02/02/22, included but was not limited to: older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens such as SARS-CoV-2; a strong infection prevention and control program (IPC) is critical to protect residents and healthcare personnel (HCP); even as nursing homes resume normal practices, they must remain vigilant for SARS-CoV-2 infection in order to prevent spread and protect residents and HCP; New Infection in HCP or Residents - because of the risk of unrecognized infection among residents, a single new case of SARS-CoV-2 in any HCP or resident should be evaluated as a potential outbreak; perform contact tracing to identify any HCP who have had a higher-risk exposure or resident who may have had close contact with individual SARS-CoV-2 infection regardless of vaccination status. The CDC guidance had not been followed by the facility for contact tracing. A review of the facility provided, [redacted] Testing of Residents and Healthcare Personnel for COVID-19 dated August 2021, included but was not limited to: Purpose - will comply with all local and/or state health departments for guidance; all residents shall be tested if there is a new confirmed case (resident or staff) in the facility. A review of the facility provided IP responsibilities, undated, included but was not limited to: The IP is accountable for decreasing the incidence and transmission of infectious diseases between patients, staff, visitors, and the community; establishing a routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections, infection risks, communicable disease outbreaks and to maintain or improve resident health status. A review of the facility provided, Job Specification Infection Control Nurse dated 06/05/21, included but was not limited to: Conducting surveillance rounds to eliminate risks of infection to residents, patients, and personnel; evaluating and maintains records of infections among residents, patients, and staff; acts as the infection control liaison between all hospital departments and medical services, the infection control committee, and hospital administration; prepares clear, technically sound, accurate, and informative reports on epidemiologic and infection matters containing findings, conclusions, and recommendations; and establishes and maintains records, reports, and files. Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, Revised 03/10/22, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements. A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 03/10/22, included but was not limited to the definition of Close contact, which refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over 24 hour period. Guidance - To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary. The testing summary included that for newly identified COVID-19 positive staff or residents in a facility that can identify close contacts, the facility should, regardless of vaccination status, test all staff that had a higher-risk exposure with a COVID-19 positive individual and test all residents who had close contact with a COVID-19 positive individual. Testing during an outbreak revealed -that upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g., facility-wide) testing. Documentation of testing - upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests. NJAC 8:39-19.2(a); 19.4(a); 19.4(d)(f)(g) Refer to F 886 Part B. F 880 remains a deficiency at a scope and severity of a D based on the following: Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain proper infection control practices identified during 1 of 2 wound treatment observations (Resident #81). This deficient practice was evidenced by the following: On 08/17/22 at 01:20 PM, during the initial tour of the facility, the surveyor observed Resident #81 seated in a motorized wheelchair in the main recreation area, participating in activities. A review of the Face Sheet (an admission summary) reflected that Resident #81 was admitted to the facility in November of 2014 with diagnoses that included cardiac dysrhythmia (irregular heartbeat), hypertension (high blood pressure), and chronic ischemic heart disease (inadequate supply of blood to the heart). A review of the annual Minimum Data Set (MDS), an assessment tool dated 03/08/2022, indicated a Brief Interview for Mental Status (BIMS) score at 00 out of 15, which indicated the resident had severe cognitive impairment. A review of the quarterly MDS dated [DATE] revealed that the resident had a stage 2 pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). A review of the 8/17/22 physician's telephone order revealed an order to clean the left buttock wound with normal saline, apply alginate and cover with bordered foam gauze, and apply zinc oxide to the peri-wound twice a day and when needed for 7 days. The same physician's order was also noted on the August 2022 Treatment Administration Record (TAR). On 08/25/22 at 9:00 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment for Resident # 81's facility acquired Stage 2 pressure ulcer to the left buttock. The surveyor observed the LPN wash her hands for 45 seconds. She donned (put on) gloves and cleaned the overbed table with disinfectant sanitizing wipes. The surveyor observed the LPN place a barrier on the table and taped a plastic bag on the side of the table. The LPN then placed an open pack of 4 x 4 gauze, two (2) border gauze, one (1) bottle of normal sterile saline (NSS), and a pair of metal scissors on the barrier. The LPN doffed (removed) her gloves and performed hand washing for 30 seconds, then donned a new pair of gloves and assisted the resident onto their left side. The Certified Nursing Assistant (CNA) was also present and assisted the resident during wound care. The wound was exposed, and no dressing was present because the CNA reportedly had performed care prior

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of pertinent documents, it was determined that the facility failed to ensure: a.) a process was followed to initiate immediate action, and conduct COVID-19 testing upon the identification of a single COVID-19 positive result, b.) that staff who were exposed were COVID-19 tested prior to working at the facility, c.) Federal, State and infection control guidelines were followed, and d.) the facility Infectious Disease Outbreak Response Plan was followed to prevent exposure and mitigate the spread of COVID-19, a deadly highly transmissible infectious disease. The facility's system wide failure to immediately conduct COVID-19 testing upon the identification of a single new case of a COVID-19, posed a serious and immediate risk to the health and well-being of all staff and residents who resided at the facility and who were placed at risk for contracting a contagious infectious and potentially deadly virus. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 09/01/22 at 2:37 PM. The removal plan was verified as implemented by the survey team during an onsite visit conducted on 09/06/22 at 4:31 PM. The evidence was as follows: Refer to 880L On 08/16/22 at 10:24 AM, during the entrance conference held with the Administrative team. The survey team was informed that the facility was currently experiencing an outbreak of COVID-19 which began on 11/23/21. The surveyor requested the contact tracing (process to identify people who have come in contact with someone diagnosed with an infectious disease) for seven residents and four staff members. The surveyor reviewed what the facility Infection Preventionist Registered Nurse (IP/RN) provided, Resident & Staff COVID-19 Incident Reports updated 04/21, which included but was not limited to please be as detailed as possible and type all responses, 9. Explain contact tracing that has been completed in detail, and 10. Describe action(s) taken. The review was as follows: #444 who was fully vaccinated and resided on Old [NAME] unit, presented symptomatic with a cough, and sneezing and tested positive on 12/28/21. The contact tracing section failed to list any staff or residents who may have been a close contact. #446 who was fully vaccinated and resided on Eagle unit, presented symptomatic with a cough, and tested positive on 01/4/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #445 who was fully vaccinated and resided on Freedom unit, presented symptomatic with fever and shortness of breath, and tested positive on 01/30/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #447 who was fully vaccinated and resided on Freedom unit, presented symptomatic with a fever and shortness of breath, and tested positive on 02/3/22. Resident #447 was noted to be transported to hemodialysis three days a week. The contact tracing section failed to list any facility staff, hemodialysis staff, transport staff, visitors, or residents who may have been a close contact. #46 who was fully vaccinated and resided on Freedom unit, presented symptomatic with a cough, and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #76 who was fully vaccinated and resided on Freedom unit, was asymptomatic and tested positive on 08/11/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #179 who was fully vaccinated and resided on Freedom unit, was asymptomatic and tested positive on 08/16/22. The contact tracing section failed to list any staff or residents who may have been a close contact. Licensed Practical Nurse (LPN) #2 was asymptomatic and tested positive on 08/1/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN #3 presented symptomatic with cough, body aches and congestion and tested positive 08/1/22 and the last day worked at the facility was 07/28/22. An Administrative staff member presented symptomatic with nasal congestion and an itchy throat and tested positive 08/6/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN #1 presented symptomatic with a runny nose and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. On 08/29/22 at 8:39 AM during an interview with the surveyor, the facility IP/RN was asked to provide contact tracing for eight residents reviewed between 12/28/21 through 08/16/22 and for six staff members reviewed from 08/01/22 through 08/16/22, all were noted on the facility line-list as have been tested COVID-19 positive. The IP/RN stated that when someone was exposed, she would do the contact tracing but would not list the staff or residents. She stated she would not be able to provide any documentation of staff or residents who may have been exposed because she kept that information in a personal notebook. She further stated that she was alone, no secretary, no help and that she did not document the exposed people. The IP/RN stated that she also followed the facility's Outbreak Response Plan. On 08/29/22 at 9:32 AM, during an interview with the surveyor, a Licensed Practical Nurse Unit Manager (LPN/UM) on Liberty Unit stated that if a resident tested COVID-19 positive, the IP/RN would isolate the resident and do the investigation. She further stated that if a staff member tested COVID-19 positive, they would be sent home and the IP/RN would do all the paperwork. The LPN/UM further stated that she was not sure if testing was done when someone was exposed, but she knew the facility had a team to do routine testing of the residents and staff. On 08/29/22 at 9:40 AM during an interview with the surveyor, the RN Employee Health Nurse stated that she was only responsible to test the staff and residents routinely and upon return to the facility if the resident had gone out. The RN Employee Health Nurse further stated that contact tracing was important to warn others who were exposed so they may be tested as there was a 2 to 14 day incubation period for COVID-19. On 08/29/22 at 11:27 AM, the IP/RN provided incomplete facility, Contact Tracing Forms for the six requested COVID-19 positive staff. The IP/RN stated there was no policy for contact tracing so she would use the Center for Disease Control and Prevention (CDC) guidance and stated she would provide that information. On 08/30/22 at 10:58 AM during an interview with the surveyor, the IP/RN stated that the facility had enough testing supplies to perform facility wide COVID-19 testing. The IP/RN had provided the CDC guidance, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 02/02/22. The surveyor reviewed the guidance with the IP/RN and asked about the directive that asymptomatic residents with close contact to someone COVID + (positive), regardless of vaccination status, should have two viral tests. Testing is recommended immediately and if negative, in 5-7 days after the exposure. The surveyor asked the IP/RN to provide documentation of the tests and follow up tests. The IP/RN stated she would talk to the staff but did not write things down. She again stated that she had kept the information in a personal notebook and would throw out that information when the case was resolved. The IP/RN stated she was unaware of any formal documentation or form to use and retain so she would not be able to inform the surveyor of the exposed staff or residents or their COVID-19 testing in response. The IP/RN stated that contact tracing would be used to prevent the spread of infection in the facility. A review of the facility provided, Outbreak Response Plan revised 02/22, included but was not limited to the following: Purpose - to protect our residents, families, and staff from harm resulting from an outbreak of an infectious disease organism; the IP would be responsible for conducting routine audits of Infection Control in the facility, establish and implement policies and procedures for screening for exposure, will collaborate with facility medical director, public health authorities, regarding interventions to implement responses; Contact Tracing Form - to include name of interview/contact tracer, date of interview, name of resident, history prior positive COVID, date of a + (positive) COVID, date of symptoms/asymptomatic subtract 2 days prior to test result date or symptoms listed (this is the contact tracing date), known exposures, staff in close contact, activities/locations/shift times visited, breaks/meals contacts, outside employment, actions taken by the facility, and reviewed by the Infection Control nurse; Conduct control activities such as management of infectious wastes, terminal cleaning of the isolation room, contact tracing of exposed individuals, and monitoring for additional cases under the guidance of local health authorities, and in keeping with guidance from the CDC; and will test any resident symptomatic for the Infectious organism and will conduct additional testing of residents and staff in accordance with applicable DOH (Department of Health), CDC and CMS (Centers for Medicare & Medicaid Services) guidance. On 08/31/22 at 9:37 AM, the IP/RN provided incomplete contact tracing forms for the eight requested COVID-19 positive residents reviewed and the six COVID-19 positive staff who were reviewed. The incomplete contact tracing forms revealed the following: Resident (R) #444 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposure to residents, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #446 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, no exposure to residents, date of symptoms, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #3 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposures to residents, and reviewed by facility Infection Control Nurse. R #445 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, areas for breaks/meals, known exposure to residents, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #447 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, known exposures to residents, and reviewed by facility Infection Control Nurse. R #46 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, date of start of symptoms, known exposures to residents, and reviewed by facility Infection Control Nurse. R #76 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposures to residents, area for breaks/meals, and reviewed by facility Infection Control Nurse. R #179 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, date of positive COVID-19 test result, known exposures to residents, and reviewed by facility Infection Control Nurse. LPN #2 no: area left blank, known exposures to residents or staff noted. LPN #3 noted to be symptomatic with cough, body aches, and congestion on 08/01/22. Possible exposures were not identified from the date of symptoms back 48 hours. Administrative staff member: area left blank of names of those who were in close contact with since contact tracing date of 08/04/22. LPN #1 no: name of residents (only one set of initials noted), reviewed by facility Infection Control nurse. Food Service Worker #2: area left blank action taken by facility, contact tracing notes asymptomatic and corresponding Incident Report noted symptomatic with cough, headache, runny nose, and vomiting. Food Service Worker #1: area left blank, actions taken by facility. On 08/31/22 at 11:21 AM during an interview with the surveyor, the IP/RN stated the contact tracing forms she had provided were all filled out yesterday (08/30/22) based on memory. When asked about additional staff who may have been a close contact such as the nurses caring for the residents who tested COVID-19 positive, the IP/RN stated the nurses were not with the residents long enough to be considered a close contact. The IP/RN stated that an exposure would be traced 48 hours prior for someone within six feet for 15 minutes or more. She further stated, I know from memory that none of the nurses were (with the residents for 15 minutes or more consecutively in a 24 hour period). The IP/RN stated that the facility implemented routine broad based COVID-19 testing back in December 2021 where the staff were tested three times a week and the residents were tested on ce or twice a week. The IP/ RN stated that close contacts were not all tested when identified as exposed. The IP/ RN further stated that testing of close contacts would depend on what time a person tested positive. She stated sometimes staff would have gone home and so testing would be, as soon as possible. The IP/RN acknowledged that the forms should have been complete. On 08/31/22 at 1:12 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated they were familiar with the process of contact tracing. At 1:14 PM, the IP/RN joined the interview and stated that it was facility process for her to keep her own notes and that the facility would test everyone weekly. The IP/RN further stated that she remembers from December 2021 on that none of the nurses who cared for the COVID-19 positive residents spent over 15 minutes with the residents and that there were no treatments done either. The LNHA stated that was incorrect and the facility did require formal tracking (contact tracing). The LNHA further stated that the IP/RN should have conducted the contact tracing at the time of the exposure and not from memory. The LNHA stated that the IP RN's statement that the nurses did not spend more than 15 minutes with the residents was not fully accurate. Based on interviews and a review of pertinent documents, it was determined that the facility failed to ensure: a.) a process was followed to initiate immediate action and conduct COVID-19 testing upon the identification of a single COVID-19 positive result, b.) that staff who were exposed were COVID-19 tested prior to working at the facility, c.) Federal, State and infection control guidelines were followed, and d.) the facility Infectious Disease Outbreak Response Plan was followed to prevent exposure and mitigate the spread of COVID-19, a deadly, highly transmissible infectious disease. The facility's system wide failure to immediately conduct COVID-19 testing upon the identification of a single new case of COVID-19, posed a serious and immediate risk to the health and well-being of all staff and residents who resided at the facility and who were placed at risk for contracting a contagious infectious and potentially deadly virus. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 09/01/22 at 2:37 PM. The survey team verified the removal plan during an on-site visit conducted on 09/06/22 at 4:31 PM. The evidence was as follows: Refer to 880L On 08/16/22 at 10:24 AM, during the entrance conference held with the Administrative team. The survey team was informed that the facility was currently experiencing an outbreak of COVID-19, which began on 11/23/21. The surveyor requested contact tracing (a process to identify people who have come in contact with someone diagnosed with an infectious disease) for seven residents and four staff members. The surveyor reviewed what the facility Infection Preventionist Registered Nurse (IP/RN) provided, Resident & Staff COVID-19 Incident Reports, updated 04/21, which included but was not limited to please be as detailed as possible and type all responses, 9. Explain contact tracing that has been completed in detail, and 10. Describe action(s) taken. The review was as follows: #444 who was fully vaccinated and resided in the Old [NAME] unit, presented symptomatic with a cough and sneezing and tested positive on 12/28/21. The contact tracing section failed to list any staff or residents who may have been a close contact. #446, who was fully vaccinated and resided in the Eagle unit, presented symptomatic with a cough and tested positive on 01/4/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #445, who was fully vaccinated and resided in the Freedom unit, presented symptomatic with fever and shortness of breath and tested positive on 01/30/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #447, who was fully vaccinated and resided in the Freedom unit, presented symptomatic with a fever and shortness of breath and tested positive on 02/3/22. Resident #447 was noted to be transported to hemodialysis three days a week. The contact tracing section failed to list any facility staff, hemodialysis staff, transport staff, visitors, or residents who may have been a close contact. #46 was fully vaccinated and resided in the Freedom unit, presented symptomatic with a cough, and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #76, who was fully vaccinated and resided in the Freedom unit, was asymptomatic and tested positive on 08/11/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #179, who was fully vaccinated and resided in the Freedom unit, was asymptomatic and tested positive on 08/16/22. The contact tracing section failed to list any staff or residents who may have been a close contact. Licensed Practical Nurse (LPN) #2 was asymptomatic and tested positive on 08/1/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN #3 presented symptomatic with cough, body aches, and congestion and tested positive on 08/1/22 and the last day worked at the facility was 07/28/22. An Administrative staff member presented symptomatic with nasal congestion and an itchy throat and tested positive on 08/6/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN #1 presented symptomatic with a runny nose and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. On 08/29/22 at 8:39 AM, during an interview with the surveyor, the facility IP/RN was asked to provide contact tracing for eight residents reviewed between 12/28/21 through 08/16/22 and for six staff members reviewed from 08/01/22 through 08/16/22, all were noted on the facility line-list as have been tested COVID-19 positive. The IP/RN stated that when someone was exposed, she would do the contact tracing but would not list the staff or residents. She stated she could not provide any documentation of staff or residents who may have been exposed because she kept that information in a personal notebook. She further stated that she was alone, no secretary, no help and that she did not document the exposed people. The IP/RN stated that she also followed the facility's Outbreak Response Plan. On 08/29/22 at 9:32 AM, during an interview with the surveyor, a Licensed Practical Nurse Unit Manager (LPN/UM) in Liberty Unit stated that if a resident tested COVID-19 positive, the IP/RN would isolate the resident and do the investigation. She further stated that if a staff member tested COVID-19 positive, they would be sent home, and the IP/RN would do all the paperwork. The LPN/UM further stated that she was unsure if testing was done when someone was exposed, but she knew the facility had a team to do routine testing of the residents and staff. On 08/29/22 at 9:40 AM, during an interview with the surveyor, the RN Employee Health Nurse stated that she was only responsible for routinely testing the staff and residents and, upon return to the facility, if the resident had gone out. The RN Employee Health Nurse further stated that contact tracing was important to warn others who were exposed so they may be tested as there was a 2 to 14 day incubation period for COVID-19. On 08/29/22 at 11:27 AM, the IP/RN provided the incomplete facility, Contact Tracing Forms, for the six requested COVID-19 positive staff. The IP/RN stated there was no policy for contact tracing so she would use the Center for Disease Control and Prevention (CDC) guidance and stated she would provide that information. On 08/30/22 at 10:58 AM, during an interview with the surveyor, the IP/RN stated that the facility had enough testing supplies to perform facility wide COVID-19 testing. The IP/RN had provided the CDC guidance, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 02/02/22. The surveyor reviewed the guidance with the IP/RN and asked about the directive that asymptomatic residents with close contact to someone COVID + (positive), regardless of vaccination status, should have two viral tests. Testing is recommended immediately and if negative, in 5-7 days after the exposure. The surveyor asked the IP/RN to provide documentation of the tests and follow up tests. The IP/RN stated she would talk to the staff but did not write things down. She again stated that she had kept the information in a personal notebook and would throw out that information when the case was resolved. The IP/RN stated she was unaware of any formal documentation or form to use and retain, so she would not be able to inform the surveyor of the exposed staff or residents or their COVID-19 testing in response. The IP/RN stated that contact tracing would be used to prevent the spread of infection in the facility. A review of the facility provided, Outbreak Response Plan revised 02/22, included but was not limited to the following: Purpose - to protect our residents, families, and staff from harm resulting from an outbreak of an infectious disease organism; the IP would be responsible for conducting routine audits of Infection Control in the facility, establish and implement policies and procedures for screening for exposure, will collaborate with facility medical director, public health authorities, regarding interventions to implement responses; Contact Tracing Form - to include name of interview/contact tracer, date of interview, name of resident, history prior positive COVID, date of a + (positive) COVID, date of symptoms/asymptomatic subtract 2 days prior to test result date or symptoms listed (this is the contact tracing date), known exposures, staff in close contact, activities/locations/shift times visited, breaks/meals contacts, outside employment, actions taken by the facility, and reviewed by the Infection Control nurse; Conduct control activities such as management of infectious wastes, terminal cleaning of the isolation room, contact tracing of exposed individuals, and monitoring for additional cases under the guidance of local health authorities, and in keeping with guidance from the CDC; and will test any resident symptomatic for the Infectious organism and will conduct additional testing of residents and staff in accordance with applicable DOH (Department of Health), CDC and CMS (Centers for Medicare & Medicaid Services) guidance. On 08/31/22 at 9:37 AM, the IP/RN provided incomplete contact tracing forms for the eight requested COVID-19 positive residents reviewed and the six COVID-19 positive staff who were reviewed. The incomplete contact tracing forms revealed the following: Resident (R) #444 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposure to residents, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #446 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, no exposure to residents, date of symptoms, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #3 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposures to residents, and reviewed by facility Infection Control Nurse. R #445 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, areas for breaks/meals, known exposure to residents, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #447 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, known exposures to residents, and reviewed by facility Infection Control Nurse. R #46 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, date of start of symptoms, known exposures to residents, and reviewed by facility Infection Control Nurse. R #76 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposures to residents, area for breaks/meals, and reviewed by facility Infection Control Nurse. R #179 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, date of positive COVID-19 test result, known exposures to residents, and reviewed by facility Infection Control Nurse. LPN #2 no: area left blank, known exposures to residents or staff noted. LPN #3 was noted to be symptomatic with cough, body aches, and congestion on 08/01/22. Possible exposures were not identified from the date of symptoms back to 48 hours. Administrative staff member: area left blank of names of those who were in close contact with since contact tracing date of 08/04/22. LPN #1 no: name of residents (only one set of initials noted), reviewed by facility Infection Control nurse. Food Service Worker #2: area left blank action taken by facility, contact tracing notes asymptomatic and corresponding Incident Report noted symptomatic with cough, headache, runny nose, and vomiting. Food Service Worker #1: area left blank, actions taken by the facility. On 08/31/22 at 11:21 AM, during an interview with the surveyor, the IP/RN stated the contact tracing forms she had provided were all filled out yesterday (08/30/22) based on memory. When asked about additional staff who may have been a close contact, such as the nurses caring for the residents who tested COVID-19 positive, the IP/RN stated the nurses were not with the residents long enough to be considered a close contact. The IP/RN stated that an exposure would be traced 48 hours prior for someone within six feet for 15 minutes or more. She further stated, I know from memory that none of the nurses were (with the residents for 15 minutes or more consecutively in a 24 hour period). The IP/RN stated that the facility implemented routine broad-based COVID-19 testing back in December 2021, where the staff were tested three times a week, and the residents were tested on ce or twice a week. The IP/ RN stated that close contacts were not all tested when identified as exposed. The IP/ RN further stated that testing of close contacts would depend on what time a person tested positive. She stated sometimes staff would have gone home and so testing would be as soon as possible. The IP/RN acknowledged that the forms should have been complete. On 08/31/22 at 1:12 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated they were familiar with the process of contact tracing. At 1:14 PM, the IP/RN joined the interview and stated that it was a facility process for her to keep her own notes and that the facility would test everyone weekly. The IP/RN further stated that she remembers from December 2021 that none of the nurses who cared for the COVID-19 positive residents spent over 15 minutes with the residents and that no treatments were done either. The LNHA stated that was incorrect, and the facility did require formal tracking (contact tracing). The LNHA further stated that the IP/RN should have conducted the contact tracing at the time of the exposure and not from memory. The LNHA stated that the IP RN's statement that the nurses did not spend more than 15 minutes with the residents was not fully accurate. On 09/01/22 at 9:22 AM, during an interview with surveyors in the conference room, the IP/RN stated that she consulted with the local health department (LHD) but did not get any guidance on testing close contacts versus broad-based testing. The IP/RN stated, the nurses (facility) I spoke to were in and out (of resident rooms); I should have kept my contact tracing personal notes; I cannot say 100% if the nurses did not stay 15 minutes or more. The surveyor requested communication information from the LHD. A review of the communication with the LHD provided by the IP/RN on 09/02/22 at 9:30 AM, revealed emails sent to the LHD as follows: 01/04/22, the IP/RN asked for a meeting, and the LHD asked for her concerns; 01/25/22 the IP/RN asking for clarification if she needed to test the roommate of a COVID-19 positive resident and would she be required to retest in 48 hours and the IP/RN added according to an attached policy (not provided), she would say no; 04/22/22 the IP RN asking about quarantining residents not up to date with COVID-19 vaccinations in response to COVID-19 positive residents on the same unit, and 07/18/22 regarding staff going on vacation and coming back COVID-19 positive if they would need to be reported. On 09/01/22 at 9:34 AM, during an interview with the surveyors, the IP/RN stated that not all the staff were tested at the facility. She stated some would go elsewhere to get tested, but they would have to let her know. The IP/RN again stated she did not keep the contact tracing or testing documentation. She stated that the documents should have been kept, but most of the contact tracing was done by her, and in December, she was getting like 10 positives (COVID-19) a day. The IP/RN could not provide any documented evidence of COVID-19 testing performed outside of the facility. On 09/02/22 at 9:47 AM, the IP/RN stated that if someone tested COVID-19 positive on a Saturday, she would wait until Monday. She stated, the nurses on the weekend would verbally tell her (who was exposed), but there was no documentation regarding the conversation. The IP/RN acknowledged that close contacts should have included visitors, physicians, and therapy staff b[TRUNCATED]