Based on interview, record review, and review of pertinent documentation on 01/03/24, 01/05/24, and 01/08/24, it was determined that the facility was in an active COVID-19 outbreak status on 10/2/23, failed to prevent the spread of COVID-19, a highly contagious virus for the following: a.) failing to perform contact trace (CT) of the employees and residents who were exposed to COVID-19 virus, b.) failing to consistently test exposed residents and employees. c.) failing to ensure that the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance were implemented to limit the spread of the infectious disease, and to put into effect the facility's policy titled Emergent Infectious Disease (COVID-19) Outbreak Plan V11 to prevent the spread of Covid-19 which is a highly contagious virus. Reference: CDC, COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated May 8, 2023, indicated the following .Perform SARS-CoV-2 Viral Testing, Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test [rapid test] instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period . Testing considerations for healthcare facilities with an outbreak of SARS-CoV-2 are described below. The yield of screening testing for identifying asymptomatic infection is likely lower when performed on those in areas with lower levels of SARS-CoV-2 community transmission. However, these results might continue to be useful in some situations (e.g., when performing higher-risk procedures, admitting/caring for patients who are moderately to severely immunocompromised, or for the HCP [Health Care Provider] caring for such patients) to inform the type of infection control precautions used (e.g., room assignment/cohorting, or PPE used) and prevent unprotected exposures. If implementing a screening testing program, testing decisions should not be based on the vaccination status of the individual being screened. To provide the greatest assurance that someone does not have SARS-CoV-2 infection, if using an antigen test instead of a NAAT, facilities should use 3 tests, spaced 48 hours apart, in line with FDA recommendations. In general, performance of pre-procedure or pre-admission testing is at the discretion of the facility. Performance of expanded screening testing of asymptomatic HCP without known exposures is at the discretion of the facility . Create a Process to Respond to SARS-CoV-2 Exposures Among HCP and Others Healthcare facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. If healthcare-associated transmission is suspected or identified, facilities might consider expanded testing of HCP and patients as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. For example, in an outpatient dialysis facility with an open treatment area, testing should ideally include all patients and HCP. Depending on testing resources available or the likelihood of healthcare-associated transmission, facilities may elect to initially expand testing only to HCP and patients on the affected units or departments, or a particular treatment schedule or shift, as opposed to the entire facility. If an expanded testing approach is taken and testing identifies additional infections, testing should be expanded more broadly. If possible, testing should be repeated every 3-7 days until no new cases are identified for at least 14 days. Guidance for outbreak response in nursing homes is described in setting-specific considerations below. Healthcare facilities responding to SARS-CoV-2 transmission within the facility should always notify and follow the recommendations of public health authorities . Nursing Homes .The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period . According to the progress note in the medical record, it revealed that on 10/02/23, Resident #1, who resided on the second floor, had signs and symptoms of lethargy, generalized weakness and loss of appetite. The resident was given a Rapid COVID-19 test on the same day and the result was positive. According to the CDC guidelines and the Local Health Department (LHD) facility was to initiate the 3 series of viral tests on 10/02/23. a.) The facility's Infection Control Preventionist (ICP#1) identified that nine staff members were exposed to Resident #1 prior to the resident testing positive for COVID-19 on 10/2/23. The staff members were Licensed Practical Nurses (LPNs) #2, #3, and #5, and Certified Nursing Assistants (CNA) #2, #3, #4, #5, #6, and #7. All 9 staff members were rapid tested for COVID-19 on 10/03/23 and 10/04/23, however, testing was not repeated on Day 3 and Day 5 post exposure and so the 9 staff members continued to provide care to other residents. On 12/12/23, facility conducted Broad Based Approach Testing (BBAT) but failed to complete the 3 series of CDC testing recommendations for all residents on Day 1, 3, and 5 for COVID-19. b.) When Residents #2 , #3, #4, #5, and #6 tested positive for COVID -19 virus on 10/7/23, 10/8/23, 10/9/23, 10/11/23 and 10/13/23, the facility failed to initiate CT to identify staff who provided care for 5 residents on the second floor to prevent the spread of COVID-19 virus, In addition, the facility failed to CT and test exposed residents from COVID-19 virus when on 11/01/23, 11/06/23, and 11/24/23, 2 staff members, LPN #3 and #4, who provided care on the second floor and one rehab staff (Rehab #1) received rapid testing and results were positive for COVID-19. The facility had a total of 55 residents and 34 staff who tested positive for COVID-19 virus that started on 10/02/23. The facility failure to complete the recommended series of 3 viral tests, conduct contact tracing upon the identification of COVID-19 positive for staff and residents to prevent the spread of COVID-19, a contagious infectious and potentially deadly virus, posed a serious and immediate risk to the health and well-being of all staff and residents for contracting COVID-19. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 1/3/24 at 6:30 p.m. The removal plan was accepted and verified as implemented by the survey team during an onsite visit on 1/8/24. The IJ situation began on 10/05/23, when nine staff members who were exposed from Resident #1 who exhibited lethargy, general weakness, and no appetite were rapid tested for COVID-19 on Day 1 (10/03/23) and (10/04/23) Day 2 but no evidence of testing after this date. The non-compliance remained on 1/3/24 for F880 at level E, with no actual harm with the potential for more than minimum harm that is not immediate jeopardy. On 1/3/24 at 8:51 a.m., during the entrance conference, the Director of Nursing (DON) and Nurse Educator (NE) informed the surveyors that the facility was experiencing an outbreak of COVID-19 which began on 10/2/23. The facility currently had 3 positive COVID-19 residents. The DON stated that the facility had been communicating with the LHD and had been receiving and following the LHD's recommendation. The surveyors were provided with the facility's ongoing line listing (LL), a document that is transmitted to the Department of Health and lists all COVID-19 cases during an outbreak, and a copy of the CT for Resident #1 who tested positive for COVID-19 on 10/2/23. The LL indicated a total of 55 residents and 34 employees were tested positive for COVID-19. The surveyors reviewed the CT provided by the facility on 1/3/24. The CT revealed that LPNs #2, #3, and #5, CNAs #2, #3, #4, #5, #6, and #7 were exposed from Resident #1 and tested on Day 1. The CT did not indicate that the aforementioned CNAs and LPNs continued to be tested and this was not in accordance with the LHD recommendation, CDC guidelines, and facility policy. The surveyors conducted an interview with the DON, Regional ICP (RICP) and ICP #2 on 01/3/24 at 4:08 p.m., the ICP #2 stated that she started working with facility on the first week of September 2023 in the title of a staff nurse and started in the present title as an ICP on 10/28/23 after she took Infection Control classes from 10/23/23 to 10/27/23. ICP #2 further stated that ICP #1 last day was 10/3/23. DON stated that she was ICP certified and that she was overseeing the infection control and prevention after ICP #1 left (started on 10/4/23). The DON and ICP #2 stated that the CT was initiated on 10/3/23 by ICP #1. The DON and ICP #2 were unable to explain the reason why the 3 series of testing was not completed to the exposed staff from 10/2/23. The DON and ICP #2 revealed that the CT was not performed when Residents #2, Resident #3, Resident #4, Resident #5, and Resident #6 tested positive on 10/7/2023, 10/8/23, 10/9/23, 10/11/23 and 10/13/23, and when 3 staff members on 11/01/23, 11/06/23, and 11/24/23 tested positive for COVID-19. According to the DON everything fell into the cracks, I thought the staff, Unit Managers would know and would do the testing and contact tracing. The DON admitted that when the staff who were exposed on 10/2/23 were tested on day 1, there were no further testing was done. In addition, the DON stated that there was no documented evidence that the CT was done when 5 residents (Residents #2, #3,#4, #5 and #6) tested positive on 10/7/2023, 10/8/23, 10/9/23, 10/11/23 and 10/13/23. The DON and RICP stated it is important to CT and to test the identified exposed resident/staff to stop further exposure and eliminate transmission of Covid-19 among residents and staff. The DON and ICP #2 were aware that on 11/1/23, 11/6/23, and 11/24/23, three facility employees respectively tested positive for Covid-19, the DON stated, contact tracing and testing was done but there's no documentation to prove that it was done. The surveyors conducted an interview with ICP #2 on 1/3/24 and 1/5/24. The ICP confirmed the aforementioned cases of COVID-19. The ICP was unable to provide documented evidence that the staff who were exposed from Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were CT and tested for COVID-19 in the accordance with the CDC guidelines and the facility policy. In addition, during the interview with the ICP on 1/5/23 at 10:05 a.m., she explained that BBAT was initiated for the whole building (for all staff and resdients) because they were unable to perform CT. On 12./11/23, there were many staff and residents who tested positive, so CT was not done at this time. According to the ICP, the staff had been educated to test for COVID-19, however, the testing was not consistently done to detect the virus before providing care to the residents. The electronic-mail (e-mail) communication from LHD on 10/3/23 at 11:16 a.m. indicated that the facility was in an outbreak. The LHD email was sent to ICP #1, DON, ICP #2, and the Administrator. The LHD instructed the facility to Conduct contact tracing on all resident and staff cases. Conduct testing of close contacts as appropriate (on days 1, 3, and 5). Be sure to follow all applicable federal and state directives. Included in the email was an Outbreak Management Checklist for COVID-19 in Nursing Homes and other Post-acute Care Settings The checklist under Screening, Testing, & Response Outbreak Intervention 1. Review outbreak response plans for SARS-CoV-2 and other respiratory pathogens to support containment and response efforts . Under Contact Tracing or Broad-based Approach Outbreak Intervention 1. Facilities should perform contact tracing to identify all high-risk staff exposures and close contact encounters with patients/residents .2. Contact tracing approach: Perform SARS-CoV-2 viral testing for all patients/residents identified as close contacts and all staff who have higher-risk exposures, regardless of vaccination status, who have not been previously positive within the past 30 days. Asymptomatic patients/residents and staff with close contact or higher-risk exposures should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately but not earlier than 24 hours after exposure and, if negative, 48 hours after the first negative test. If negative, again 48 hours after the second negative test. This will typically be on days 1, 3, and 5 (where the day of exposure is day 0). 3. Continue performing contact tracing if testing reveals additional cases .5. Broad-based approach: Perform SARS-CoV-2 testing for all patients/residents and staff on the affected unit(s), regardless of vaccination status, who have not been previously positive within the past 30 days, immediately and, if negative, again 48 hours after first negative test, and if negative, again 48 hours after second negative test. 6. If additional cases are identified, testing should continue on the affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days) should be considered . The LL for COVID-19 from 10/2/23 through 12/28/23 revealed the following medical records (MR), Resident #2, who resided on the second floor tested positive for COVID-19 on 10/7/23. Resident #3, who resided on the second floor tested positive for COVID-19 on 10/8/23. Resident #4, who resided on the second floor tested positive for COVID-19 on 10/9/23. Resident #5, who resided on the second floor tested positive for COVID-19 on 10/11/23. There was no documentation to indicate that Residents #2, #3, #4, and #5 were tested to complete the 3 series of viral test from 12/12/23 when the facility performed BBAT for all staff and residents. The medical records revealed the following: Resident #6, who resided on the second floor tested positive for COVID-19 on 10/13/23. On 12/27/23 at 11:24 a.m., documented by the Speech Therapy (ST) that Resident #6 had difficulty swallowing, at 11:25 a.m., documented by LPN #2 Very congested. Productive cough. Stated unable to swallow. Wants med crushed. Temp: 97.3. [Nurse Practitioner] informed. Order received for stat [Now] CXR [Chest X-ray], at 3:36 pm, documented by LPN #2 Appetite poor. On 12/28/23 at 10:24 a.m., documented by ST that Resident #6's diet was changed to chopped solids, at 3:06 p.m., documented by LPN #2 that the CXR results was Right lower lobe infiltrate and NP was made aware. On 12/29/23 at 12:55 p.m., documented by a LPN #1 that Resident #6 was on antibiotic for Upper Respiratory Infections. On 12/31/23 at 3:53 p.m., documented by LPN #2 that the Resident was coughing. On 1/1/24, documented by the Residents Primary Physician (PP) that No specific issue reported by nursing home staff. On 1/2/24 at 9:12 a.m., documented by Unit Manager/LPN (UM/LPN #1) that Resident was congested, and secretions was increased, the NP ordered Duoneb and CXR. On 1/2/24, Resident #6 complaint of sore throat and shortness of breath, at 7:04 p.m., the facility received an order for Levaquin for infiltrate for 7 days. On 1/3/24 at 12:49 p.m., documented by the NP to start intravenous (IV) fluids. At 3:26 p.m., documented by LPN #2 that Resident #6 was on Levaquin for Upper Respiratory Infection (URI), continued coughing and family visited. At 4:07 p.m., documented by LPN #2 Status poor. Increase congestion. Neb [nebulizer] TX [treatment] on going. On LEVAQUIN .VS stable . On 1/5/24 at 4:40 p.m., the resident was tested negative for COVID-19, at 11:15 p.m., Resident #6 was sent to emergency room for having low sodium and chest congestions. Resident #6 was admitted with diagnosis of Respiratory Syncytial Virus. The facility failed to perform CT on the staff who provided care from 10/13/23 and continued to provide care to other residents. In addition, there was no documentation that 3 series of viral test was done from 12/12/23 when the facility performed BBAT to all staff and residents. Furthermore, the facility failed to test the resident for COVID-19 when symptoms manifested from 12/27/23 until 1/5/24. Resident #7, who resided on the second floor tested positive for COVID-19 on 12/16/23. Resident #8, who resided on the second floor tested positive for COVID-19 on 12/16/23. Resident #9, who resided on the second floor tested positive for COVID-19 on 12/14/23. Resident # 11, who resided on the second floor tested positive for COVID-19 on 12/14/23. Resident #12, who resided on the second floor tested positive for COVID-19 on 12/21/23 when she/he manifested nasal congestion and noted with occasional cough. Resident #14, who resided on the second floor was tested positive for COVID-19 on 12/16/23 after she developed a cough. Residents #7, #8, #9, #11, #12, and #14 had no documentation in the MR to indicate that the residents completed the 3 series of viral test from 12/12/23 when the facility performed BBAT for all staff and residents. During an interview with the surveyor on 1/3/24 at 10:24 a.m., the Respiratory Therapist (RT) revealed that he had been working in the facility and had not been tested for COVID-19 since the beginning of the outbreak on 10/2/23. A follow up interview with the RT at 11:28 a.m., the RT revealed that he was just tested today for COVID-19 and tested negative. He also stated that this was the first time the facility tested him for COVID-19 virus. On 1/3/23 at 2:53 p.m., ICP #2 verified that the RT worked on the following days 12/13/23, 12/18/23, 12/20/23, 12/26/23, and 12/27/23. The ICP confirmed that the RT was not tested on the aforementioned dates and was only tested today, 1/3/24. Review of the form Covid BinaxNow Test Results (CBTR) provided by the facility during the survey on 1/8/24, indicated a list of employees who tested for COVID-19. The form revealed that on 12/13/23, 12/18/23, 12/20/23, 12/26/23, and 12/27/23 the RT was not tested for COVID-19 and provided care on the Ventilator Unit. The facility policy titled Policy for Emergent Infectious Diseases (COVID-19) (Outbreak Plan V11), dated 05/22/23, under ASSUMPTIONS .Every disease is different. The local, state, and federal health authorities will be the source of the latest information and most up to date guidance on prevention, case definition, surveillance, treatment, and skilled nursing center response related to a specific disease threat .GOAL to protect our residents, families, and staff from harming resulting from exposure to an emergent infectious disease while they are in our care center. 2. Local Threat: a. Once notified by the public health authorities at either the federal, state and/or local level that the Emergent Infectious Disease (EID) is likely to or already has spread to the care center's community, the care center will b. activate specific surveillance and screening as instructed by Centers for Disease Control and Prevention (CDC), state agency and/ or the local public health authorities .6: Test Based Prevention Strategy .Testing of nursing home HCP .3 .CMS still expects facilities to conduct SARS-CoV-2 testing in accordance with accepted national standards, such as the CDC recommendations .5. Retesting of HCP will be completed in accordance with the CDC guidance, amended and supplemented .Testing related to (+) COVID-19 exposure and/or symptoms associated with SARS-CoV-2 (Outbreak Testing) 1. An outbreak investigation is initiated when a single new case of Covid-19 occurs among the residents or staff to determine if others have been exposed. Testing during an outbreak would be determined in accordance with CDC guidance .3. Upon the identification of a single new case of Covid-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). The facility has the option to perform outbreak testing through two approaches: contact tracing, or broad-based; 1. Contact tracing approach. Identifies all patients/residents close contacts and staff high-risk exposures. All individuals with close contact and/or high-risk exposure should be tested as described below .testing reveals additional cases, contact tracing will be continued to be performed. 2. Broad-based approach. Testing is performed for all patients/residents and staff on the affected unit(s), regardless of vaccination status, who have not been previously positive within the past 30 days .Testing of Residents and Staff as follows .2. If there is a newly identified COVID-19 positive staff of resident in a facility that can identify close contacts, then: Residents: regardless of vaccination status, who had close contact with the COVID-19 positive individual must be tested. Staff: regardless of vaccination status, that had higher risk exposure with a COVID-19 positive individual must be tested. Testing is completed on Day 1 - Day 3 - Day 5 or in accordance with the recommendations by local health department (LHD). 3. If a newly identified COVID-19 positive staff or residents in a facility that is unable to identify close contacts, then: Residents: regardless of vaccination status, facility wide or at a group level (e.g., unit, floor, or other specific area(s) of the facility) must be tested. Staff: regardless of vaccination status, facility-wide or at a group level if staff are assigned to specific location where the new cases occurred (e.g., unit, floor, or other specific area(s) of the facility) must be tested. Testing is completed on Day 1 - Day 3 - Day 5 or in accordance with the recommendations by local health department (LHD) . N.J.A.C. 8:39-19.4 (a)(e)