Based on observation, interviews, medical record review and other pertinent facility documentation, it was determined that the facility's Administrator failed to ensure that the facility was in compliance with the following regulatory requirements, which affected the safety of all the residents in the facility. The Administrator failed to ensure: 1.) immediate action was taken to initiate contact tracing upon the identification of a COVID positive staff member, Registered Nurse #1 (RN #1), who was symptomatic and provided care to 9 residents on 1 of 2 units and tested positive for COVID-19 while at work on 12/24/22, 2) conduct contact tracing to identify residents and staff who had close contact with symptomatic COVID-19 positive residents (Resident #33 and #235), 3.) a process was in place to conduct immediate resident and staff testing upon identification of a COVID-19 positive staff and residents, 4.) COVID-19 surveillance and monitoring were completed for the residents, 5.) the facility followed the relevant Centers for Disease Control and Prevention (CDC), Federal, and State guidance for infection control, and 6.) the facility's Outbreak Plan and COVID-19 policies were followed to prevent exposure and mitigate the spread of COVID-19, a deadly highly transmissible infectious disease. The Administrator's failure to ensure facility wide infection control prevention standards, policies and procedures were implemented and immediately conduct contact tracing and testing upon the identification of COVID-19-positive 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 1/11/23. The removal plan was accepted and verified as implemented by the survey team during an onsite visit conducted on 1/12/23. The IJ began on 11/15/22 when the former Director of Nursing (DON) who was primarily responsible for infection control left the facility without notice. On 12/24/22 at 7:00 PM, RN #1 reported to work while sick with fever and cough, proceeded to provide care for 9 residents in 1 of 2 resident units, and tested positive for COVID-19 on 12/24/22 at 10:00 PM. The Infection Preventionist (IP) stated that the contact tracing policy was never initiated for the 9 residents on the RN's assignment. Three residents on the RN's assignment were immunocompromised and had a diagnosis of Human Immunodeficiency Virus (HIV) with prednisone (a glucocorticoid medication used to suppress the immune system and decrease inflammation) use, Sickle Cell Anemia (an inherited disease in which the red blood cells have an abnormal crescent shape, and block small blood vessels), Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways), 1 of the 3 immunocompromised residents was not vaccinated for COVID-19. Three additional residents were not vaccinated for COVID-19. Additionally, two symptomatic residents tested positive in the facility on 1/1/23 and 1/2/23. There was no contact tracing or subsequent resident testing performed. There were no consistent COVID-19 surveillance/assessments completed for the residents. The IP stated that she did not have a line list or notify the local health department of the positive cases. There was no screening or education provided to visitors entering the facility. The IP stated she was following the direction and guidance of the Administrator. The Administrator stated that she assumed that the IP was aware of her responsibilities and fulfilling her role as the IP. Refer to F880L and F886L as it pertains to the facility's failure to ensure the implementation of infection control practices and precautions during an identified COVID-19 outbreak. This deficient practice was evidenced by the following: A review of the Administrator's job description provided by the facility revealed the following: Manages all business related activity to achieve the organization's vision and supporting strategies and assures that the company image as an ethical and high quality provider of health services is maintained. Communicates new Policy and Procedures and regulations to staff to ensure compliance. Ensures that facility operations comply with local, state, and federal standards, laws, and licensing and certifying bodies. Understands and uses company policies, procedures and compliance program to promote quality of care. Develops all facility policies consistent with corporate guidelines. During the entrance conference on 1/3/23 at 11:00 AM, the Infection Preventionist (IP), along with the DON, informed the surveyors there were two COVID-19-positive residents (Resident #33 and Resident #235) in the facility on the 2nd-floor unit. The IP stated she started in the facility in November and was responsible for staff development and infection control. The IP stated that the Administrator was currently on vacation. On 1/4/23 at 9:18 AM, Surveyor #2 asked the DON for the facility line list (a table that contains key information about each case in an outbreak). The DON stated that there was no line list and that it had not been done since the prior DON had left. She stated she had started at the facility in December and was not aware there wasn't a line list until yesterday (1/3/23). On 1/4/22 at 10:00 AM, Surveyor #1 reviewed the facility's COVID tracker (an internal tool that documents COVID-19 positive staff) titled COVID-19 Employee Detail, which revealed RN #1 was positive for COVID-19 on 12/24/22. An additional review revealed that the onset of symptoms was on 12/22/22 and the last day RN #1 worked was 12/24/22. Surveyor #1 reviewed the COVID Tracker that included RN #1 with the DON and IP. The DON stated RN #1 tested positive for COVID-19 at work on 12/24/22 and had allergy symptoms that included sinus symptoms and headache, for a couple of days before. The DON stated RN #1 did not work on 12/22/22 and 12/23/22 and worked on 12/24/22 for the 7 pm to 7 am shift on the 2nd-floor unit. The DON further stated RN #1 should not have come in sick to work and should have tested before her shift. The DON stated she did not do contact tracing and would have to check the documentation for residents tested. The surveyor asked the IP about the line list for COVID-19 cases in the facility. The IP stated she was new, did not have access to everything, and was not sure of the line list. The IP confirmed the line list was not completed and was following up with the LHD about it. The IP stated the previous DON was completing the line list and was not sure of the date the previous DON had left. During a telephone interview with Surveyor #1 On 1/4/23 at 11:57 AM, RN #1 stated she started feeling sick on 12/22/22 and called out sick to the Registered Nurse Supervisor (RNS) on 12/22/22 and 12/23/22. RN #1 stated she was running temperatures, had a cough, and reported to the RNS that she was not feeling well. She stated the RNS stated, ok and did not ask any further questions. RN #1 stated it was holiday time and if you call out before the holiday, you don't get time and a half. RN #1 stated she went back to work on 12/24/22 and thought she was ok since she called her primary doctor who gave her antibiotics, and she also took Tylenol. RN #1 stated she still had a fever and cough symptoms when she went to work. RN #1 said she received report from the outgoing nurse, checked on her residents, and did her first medication administration pass before testing herself at 10:00 PM and tested positive for COVID-19. The surveyor asked if she had told anyone that she was not feeling well or about her symptoms on 12/24/22. RN #1 stated, Who was I gonna tell .there was no one . only nurses and she had called the DON at 10:00 PM after testing positive. RN#1 stated the DON told her that she had to go home and could not work as she tested positive for COVID-19. RN #1 said she gave report to the other nurse and went home. The surveyor asked RN #1 why she tested herself at 10:00 PM and not before that time. RN #1 replied that the outgoing nurses wanted to give report to go home, and she did not want to keep them waiting. RN #1 stated that no one from the facility had called her to ask about contact tracing including residents she had contact with. RN #1 stated she had education about COVID-19 in 2020 and 2021 and acknowledged that the facility had stated if a staff member had symptoms or was COVID-19 positive that the staff member should not come to work. On 1/4/23 at 11:54 AM, the IP provided the surveyor RN#1's timecard which revealed RN #1 worked on Saturday 12/24/22, clocked in at 7:00 PM, and clocked out at 10:45 PM. On 1/4/23 at 12:38 pm, the IP provided the surveyor with the assignment of RN #1 on 12/24/22, which included 9 residents (Resident #236, #69, #239, #47, # 80, #63, #240, #238 and #52). The IP stated that the residents who were exposed were not tested and there was no documentation that the residents were tested. The IP stated she was new in training, but that she was responsible to ensure they were doing the correct thing and the residents should have been tested. Additionally, the IP stated that the contact tracing policy was not initiated. A review of the medical records for the 9 residents that were assigned to RN #1 on 12/24/22, included three immunocompromised residents: Resident #236 who had a diagnosis that included HIV, was receiving dialysis, and prednisone (a corticosteroid medication that suppresses the immune system and decreases inflammation) treatment; Resident #240 who had a diagnosis that included Sickle Cell Anemia; and Resident #238, who had a diagnosis that included COPD. Four of the residents (Resident #236, #69, #239, and #47) were unvaccinated and 5 residents (Resident # 80, #63, #240, #238, and #52) were fully vaccinated according to the facility's resident COVID-19 vaccination matrix. The COVID-19 Surveillance Assessment and progress notes relating to COVID-19 surveillance and monitoring for the 9 residents' electronic medical records were not consistent and were not completed every shift as per the facility's COVID-19 Clinical Monitoring and Measures Plan policy. The policy indicated a Screening UDA [User Defined Assessment] which included vital signs was to be completed every shift for residents in the affected unit (where a resident tested positive or positive employee worked). On 1/4/23 at 12:53 PM, the IP provided to the surveyor a copy of the facility's Contact Tracing Worksheet, dated 10/05/2022, and COVID-19 Outbreak and Contact Tracing Tool, dated 10/19/22. The IP confirmed this was not initiated after positive staff and resident cases in the facility. The Contact Tracing Worksheet indicated the process for contract tracing when a positive COVID-19 case was identified, which included recording COVID-19 positive demographic and exposure data on the COVID-19 Outbreak and Contact Tracing Tool, identifying the first day of symptoms, determining where the symptomatic individual visited and others who were in close contact with the COVID-19 positive individual. The COVID-19 Outbreak and Contact Tracing tool was to be completed for staff and residents, included the COVID-19-positive individual's date of symptom onset, assignment for staff, room number for resident, potentially exposed individuals, if they were in close contact, for how long, and PPE (personal protective equipment, clothing or equipment worn to protect the person from infection) used during contacts. On 1/4/23 at 1:05 PM, Surveyor #1 and Surveyor #2 interviewed the IP and the DON about the process of testing residents and staff, after a positive case. The IP stated testing should be twice a week, positive COVID results are logged in the computer's COVID tracker and there was a surveillance log in which results were written for staff testing. The IP stated there was no log for residents, positive results were found on the resident's medical record, and was not sure where negative results would be documented. The DON stated resident testing, whether positive or negative results, should be documented in the electronic medical record's progress notes. The surveyor requested from the DON and IP documentation of any resident testing conducted. On 1/4/23 at 1:55 PM, Surveyor #1 interviewed the IP about the two COVID-19-positive residents in the facility. The IP stated the two residents were tested because they had symptoms. The IP stated she would check and provide information on contact tracing and resident testing. A review of the progress notes provided by the IP revealed that Resident #235 had chills, muscle aches, cough, and tested positive for COVID-19 on 1/1/23, and Resident #33 had a sore throat with post-nasal drip and tested positive for COVID-19 on 1/2/23. During a follow-up interview with Surveyor #2 on 1/5/23 at 10:58 AM and 12:03 PM, the IP stated there was no process in place to ensure resident testing was done. The IP stated contact tracing should have been done for COVID-19-positive residents and testing of residents in contact but was not done. The surveyor asked for the contact information of the LHD, and the IP handed an email address to the surveyor and stated that she did not have a phone number for the LHD and had not notified the LHD of any of the positive cases. She stated after the former DON left the facility, she was pulled into so many directions and was following the direction and guidance of the Administrator. On 1/11/23 at 9:35 AM, the surveyor interviewed the DON who provided the infection control policy. The policies for isolation precautions, PPE, Infection Surveillance, outbreak investigations, and antibiotic stewardship had a review date of 7/2021. The DON stated she could not find the policy reviewed for the year 2022 and that the infection control policy was reviewed and approved in January 2023. The DON provided policies with an Annual Review page signed by the DON, Administrator, IP, and Medical Director, dated 1/9/2023. During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated that the former DON had left without notice in November and the IP had a solid week of training and spent a day with the Quality Assurance Consultant. She stated when the DON left, she had assigned the IP to be a Unit Manager on one of the units for oversight and she (the IP) should have been juggling everything. The Administrator stated she would let the IP know if something needed to be addressed and the IP was responsible for in-services, following up with tracking of covid positive residents, ensuring testing was being done, completing surveillance after a positive case, and checking the residents on the assignment after a positive staff case. The Administrator stated she could not recall a positive staff case on 12/24/22. The surveyor informed the Administrator of RN #1, COVID-19 surveillance, and contact tracing concerns. The Administrator stated after a positive COVID-19 case, it was expected for the residents to be tested for COVID-19 and that staff was instructed not to come in to work when sick and to test before starting their shift. The Administrator further stated the LHD should have been notified after the first positive COVID-19 case and that the IP had a contact in the LHD but was not sure who. The Administrator acknowledged the facility's infection control policies and procedures should be reviewed annually and could not recall if the policy was reviewed in 2022. The Administrator stated the DON and herself were responsible for ensuring policies were reviewed. The Administrator stated she was not aware that there was no line list and that there was no contact with the LHD. The Administrator stated she assumed the IP was doing what she was supposed to do and was not following up with her. She stated there was no team meeting held to discuss RN #1 testing positive on 12/24/22. The Administrator stated that she and the DON would be responsible for ensuring the IP was carrying out her responsibilities. During an interview with Surveyor #1 on 1/13/23 at 8:45 AM, the Human Resource Director confirmed that the last day of the prior DON was on 11/15/22. The surveyor reviewed the IP's competency checklist, a twelve page document, titled Infection Preventionist Orientation Plan and Skills Competency Checklist which was dated 11/4/22. Review of the checklist revealed 84 out of 92 tasks were not completed. A review of the Job Description provided for the IP with a date of hire of 10/22/22 did not indicate her role and responsibilities as an IP. A review of an undated facility's policy titled Outbreak Plan included the following: Under Testing, Refusal of Testing & Isolation/Cohorting, it read ProMedica Piscataway will continue to test healthcare personnel and residents for Covid-19 in accordance with CDC, CMS, and LHD guidelines.; Under Reporting Requirements, it read Any resident or staff suspected or diagnosed according to State-specific criteria shall be promptly reported to appropriate local and/or state health department officials, included but not limited to NHSN. The policies provided did not further address COVID-19 surveillance. A review of the facility's policy titled COVID-19 Clinical Monitoring and Measures Plan, dated 10/10/22, indicated that when any employee tests positive or a resident (who was not previously being cared for in transmission based precautions [TBP]) tests positive for COVID-19, enhanced measures should be implemented. Enhanced measures included but were not limited to, a Screening UDA (User Defined Assessment) consisting of vital signs every shift for residents in the affected unit (where a resident tested positive or positive employee worked), identifying potential staff, visitor, and other resident prolonged exposure, notification to local department of health of any positive COVID-19 test results, and to refer to CDC Work Restrictions for HCP with SARS-CoV-2 Infection and Exposures to determine status of employee. A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 09/23/22, included but was not limited to the definition of Close contact 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 a 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 resident 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 a 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 (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Documentation of testing revealed that 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. A review of CDC guidance Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, revised 9/23/22, indicated 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. The guidance further indicated the following: A single new case of SARS-CoV-2 infection in any healthcare personnel (HCP) or resident should be evaluated to determine if others in the facility could have been exposed; The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts 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 NJAC 8:39- 19.1(a); 19.2(a)(c),8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure: 1.) immediate action was taken to initiate contact tracing upon the identification of a COVID positive staff member, Registered Nurse #1 (RN #1), who was symptomatic and provided care to 9 residents on 1 of 2 units and tested positive for COVID-19 while at work on 12/24/22 2. 2) conduct contact tracing to identify residents and staff who had close contact with symptomatic COVID-19 positive residents (Resident #33 and #235) 3.) COVID-19 surveillance and monitoring were completed for the residents, 4.) the facility followed the relevant Centers for Disease Control and Prevention (CDC), Federal, and State guidance for infection control, and 5.) the facility's Outbreak Plan and COVID-19 policies were 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 contact tracing upon the identification of COVID-19-positive 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 1/5/23 at 3:35 PM. The removal plan was accepted and verified as implemented by the survey team during an onsite visit conducted on 1/6/23. The IJ situation began on 12/24/22 at 7:00 PM, when RN #1 reported to work while sick with fever and cough, proceeded to provide care for 9 residents in 1 of 2 resident units, and tested positive for COVID-19 on 12/24/22 at 10:00 PM. The Infection Preventionist (IP) stated that the contact tracing policy was never initiated for the 9 residents on the RN's assignment. Three residents on the RN's assignment were immunocompromised and had a diagnosis of Human Immunodeficiency Virus (HIV) with prednisone (a glucocorticoid medication used to suppress the immune system and decrease inflammation) use, Sickle Cell Anemia (an inherited disease in which the red blood cells have an abnormal crescent shape, and block small blood vessels), Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways). 1 of the 3 immunocompromised residents was not vaccinated for COVID-19. Three additional residents were not vaccinated for COVID-19. Additionally, two symptomatic residents tested positive in the facility on 1/1/23 and 1/2/23. There was no contact tracing or subsequent resident testing performed. There were no consistent COVID-19 surveillance/assessments completed for the residents. The IP stated that she did not have a line list or notify the local health department of the positive cases. There was no screening or education provided to visitors entering the facility. The IP stated she was following the direction and guidance of the Administrator. This deficient practice was evidenced by the following: Refer to F 886L Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, revised 9/23/22, 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. Reference: Centers for Disease Control and Prevention (CDC) guidance, Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, revised 9/23/22. During the entrance conference on 1/3/23 at 11:00 AM, the Infection Preventionist (IP), along with the Director of Nursing (DON), informed the surveyors there were two COVID-19-positive residents (Resident #33 and Resident #235) in the facility on the 2nd-floor unit. The IP stated she started working in the facility in November and was responsible for staff development and infection control. The IP stated that the Administrator was currently on vacation. On 1/4/23 at 9:18 AM, Surveyor #2 asked the DON for the facility line list. The DON stated that there was no line list and that it had not been done since the prior DON had left. She stated she had started at the facility in December and was not aware there was not a line list until yesterday (1/3/23). On 1/4/23 at 10:00 AM, Surveyor #1 reviewed the facility's COVID tracker (an internal tool that documents COVID-19 positive staff) titled COVID-19 Employee Detail, which revealed RN #1 was positive for COVID-19 on 12/24/22. An additional review revealed that the onset of symptoms was on 12/22/22 and the last day RN #1 worked was 12/24/22. During an interview with Surveyor #1 and Surveyor #2 on 1/4/23 at 11:05 AM, the IP, in the presence of the DON, stated the facility's infection control practice was based on the infection control manual and facility policies based on corporate, CDC guidelines and guidance from the Local Health Department (LHD). The IP stated COVID-19 testing was conducted twice a week and in between that time if someone was symptomatic. The IP stated the residents and staff were tested twice a week on Mondays and Thursdays. Surveyor #1 reviewed the COVID Tracker that included RN #1 with the DON and IP. The DON stated RN #1 tested positive for COVID-19 at work on 12/24/22 and had allergy symptoms that included sinus symptoms and headache, for a couple of days before. The DON stated RN #1 did not work on 12/22/22 and 12/23/22 and worked on 12/24/22 for the 7 pm to 7 am shift on the 2nd-floor unit. The DON further stated RN #1 should not have come in sick to work and should have tested before her shift. The DON stated she did not do contact tracing and would have to check the documentation for residents tested. The surveyor asked the IP about the line list (a table that contains key information about each case in an outbreak) for COVID-19 cases in the facility. The IP stated she was new, and did not have access to everything, and was not sure of the line list. The IP confirmed the line list was not completed and was following up with the LHD about it. The IP stated the previous DON was completing the line list and was not sure of the date the previous DON had left. Surveyor #2 requested the contact information for RN #1, timecards, and residents assigned to RN #1 on 12/24/22. During a telephone interview with Surveyor #1 On 1/4/23 at 11:57 AM, RN #1 stated she started feeling sick on 12/22/22 and called out sick to the Registered Nurse Supervisor (RNS) on 12/22/22 and 12/23/22. RN #1 stated she was running temperatures, had a cough, and reported to the RNS that she was not feeling well. She stated the RNS stated, ok and did not ask any further questions. RN #1 stated it was holiday time and if you call out before the holiday, you don't get time and a half. RN #1 stated she went back to work on 12/24/22 and thought she was ok since she called her primary doctor who gave her antibiotics, and she also took Tylenol. RN #1 stated she still had a fever and cough symptoms when she went to work. RN #1 said she received report from the outgoing nurse, checked on her residents, and did her first medication administration pass before testing herself at 10:00 PM and tested positive for COVID-19. The surveyor asked if she had told anyone that she was not feeling well or about her symptoms on 12/24/22. RN #1 stated, Who was I gonna tell .there was no one .only nurses and she had called the DON at 10:00 PM after testing positive. RN#1 stated the DON told her that she had to go home and could not work as she tested positive for COVID-19. RN #1 said she gave report to the other nurse and went home. The surveyor asked RN #1 why she tested herself at 10:00 PM and not before that time. RN #1 replied that the outgoing nurses wanted to give report to go home, and she did not want to keep them waiting. RN #1 stated that no one from the facility had called her to ask about contact tracing including residents she had contact with. RN #1 stated she had education about COVID-19 in 2020 and 2021 and acknowledged that the facility had stated if a staff member had symptoms or was COVID-19 positive that the staff member should not come to work. On 1/4/23 at 11:54 AM, the IP provided the surveyor RN#1's timecard which revealed RN #1 worked on Saturday 12/24/22, clocked in at 7:00 PM, and clocked out at 10:45 PM. On 1/4/23 at 12:38 PM, the IP provided Surveyor #2 with the assignment of RN #1 on 12/24/22, which included 9 residents (Resident #236, #69, #239, #47, # 80, #63, #240, #238 and #52). The IP stated that the residents who were exposed were not tested and there was no documentation that the residents were tested. The IP stated she was new in training, but that she was responsible to ensure they were doing the correct thing and the residents should have been tested. Additionally, the IP stated that the contact tracing policy was not initiated. A review of the medical records for the 9 residents that were assigned to RN #1 on 12/24/22, included three immunocompromised residents: Resident #236 who had a diagnosis that included HIV, was receiving dialysis, and prednisone treatment; Resident #240 who had a diagnosis that included Sickle Cell Anemia; and Resident #238, who had a diagnosis that included COPD. Four of the residents (Resident #236, #69, #239, and #47) were unvaccinated and 5 residents (Resident # 80, #63, #240, #238, and #52) were fully vaccinated according to the facility's resident COVID-19 vaccination matrix. The COVID-19 Surveillance Assessment and progress notes relating to COVID-19 surveillance and monitoring for the 9 residents' electronic medical records were not consistent and were not completed every shift as per the facility's COVID-19 Clinical Monitoring and Measures Plan policy. The policy indicated a Screening UDA [User Defined Assessment] which included vital signs was to be completed every shift for residents in the affected unit (where a resident tested positive or positive employee worked). On 1/4/23 at 12:53 PM, the IP provided Surveyor #2 a copy of the facility's Contact Tracing Worksheet, dated 10/05/2022, and COVID-19 Outbreak and Contact Tracing Tool, dated 10/19/22. The IP confirmed this was not initiated after positive staff and resident cases in the facility. The Contact Tracing Worksheet indicated the process for contract tracing when a positive COVID-19 case was identified, which included recording COVID-19 positive demographic and exposure data on the COVID-19 Outbreak and Contact Tracing Tool, identifying the first day of symptoms, determining where the symptomatic individual visited and others who were in close contact with the COVID-19 positive individual. The COVID-19 Outbreak and Contact Tracing tool was to be completed for staff and residents, included the COVID-19-positive individual's date of symptom onset, assignment for staff, room number for resident, potentially exposed individuals, if they were in close contact, for how long, and PPE used during contacts. On 1/4/23 at 1:05 PM, Surveyor #1 and Surveyor #2 interviewed the IP and the DON about the process of testing residents and staff, after a positive case. The IP stated testing should be twice a week, positive COVID results are logged in the computer's COVID tracker and there was a surveillance log in which results were written for staff testing. The IP stated there was no log for residents, positive results were found on the resident's medical record, and was not sure where negative results would be documented. The DON stated resident testing, whether positive or negative results, should be documented in the electronic medical record's progress notes. Surveyor #1 requested from the DON and IP documentation of any resident testing conducted. On 1/4/23 at 1:55 PM, Surveyor #1 interviewed the IP about the two COVID-19-positive residents in the facility. The IP stated the two residents were tested because they had symptoms. The IP stated she would check and provide information on contact tracing and resident testing. A review of the progress notes provided by the IP revealed that Resident #235 had chills, muscle aches, cough, and tested positive for COVID-19 on 1/1/23, and Resident #33 had a sore throat with post-nasal drip and tested positive for COVID-19 on 1/2/23. During an interview with Surveyor #1 on 1/5/23 at 10:42 AM, the RNS stated if someone said they were calling out sick or not feeling well, she would ask about their symptoms, how long, and when they last worked. The RNS could not recall if she received any callouts when working on 12/22/22 and 12/23/22. The surveyor asked the RNS if she was aware of a positive COVID-19 staff case on 12/24/22. The RNS stated she knew they had a case but does not know who it was. The RNS stated there was a schedule logbook where callouts are written. During a follow-up interview with Surveyor #2 on 1/5/23 at 10:58 AM and 12:03 PM, the IP stated there was no process in place to ensure resident testing was done. The IP stated contact tracing should have been done for COVID-19-positive residents and testing of residents in close contact but was not done. The surveyor asked for the contact information of the LHD, and the IP handed an email address to the surveyor and stated that she did not have a phone number for the LHD and had not notified the LHD of any of the positive cases. She stated after the former DON left the facility, she was pulled into so many directions and was following the direction and guidance of the Administrator. On 1/5/23 at 1:30 PM, the DON provided Surveyor #1 with the call-out log for December 2022. The call-out log was in calendar format, which included the employee's name written on the day the employee called out. RN #1's name was documented on the December 2022 call-out log for 12/22/22 and 12/23/22. There was no further information documented on the call-out log. During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated that the former DON had left without notice in November and the IP had a solid week of training and spent a day with the Quality Assurance Consultant. She stated when the DON left, she had assigned the IP to be a Unit Manager on one of the units for oversight and she (the IP) should have been juggling everything. The Administrator stated she would let the IP know if something needed to be addressed and the IP was responsible for in-services, following up with tracking of covid positive residents, ensuring testing was being done, completing surveillance after a positive case, and checking the residents on the assignment after a positive staff case. The Administrator stated she could not recall a positive staff case on 12/24/22. The surveyor informed the Administrator of RN #1, COVID-19 surveillance, and contact tracing concerns. The Administrator stated after a positive COVID-19 case, it was expected for the residents to be tested for COVID-19 and that staff was instructed not to come in to work when sick and to test before starting their shift. The Administrator further stated the LHD should have been notified after the first positive COVID-19 case and that the IP had a contact in the LHD but was not sure who. The Administrator stated she was not aware that there was no line list and that there was no contact with the LHD. The Administrator stated she assumed the IP was doing what she was supposed to do and was not following up with her. She stated there was no team meeting held to discuss RN #1 testing positive on 12/24/22. The Administrator stated that she and the DON were responsible for ensuring the IP was carrying out her responsibilities. During an interview with Surveyor #1 and Surveyor #2 on 1/13/23 at 9:13 am, the Medical Director, stated he was made aware of the COVID-19 tracking and testing concerns. The Medical Director stated that the facility followed CDC and CMS guidelines for policies and was unaware they were not being followed. The Medical Director stated he was always made aware of positive COVID-19 cases in the facility and testing of residents should be based on contact tracing. The surveyor reviewed the IP's competency checklist, a twelve page document, titled Infection Preventionist Orientation Plan and Skills Competency Checklist which was dated 11/4/22. Review of the checklist revealed 84 out of 92 tasks were not completed. A review of the Job Description provided for the IP with a date of hire of 10/22/22, did not indicate her role and responsibilities as an IP. A review of an undated facility's policy titled Outbreak Plan included the following: Under Testing, Refusal of Testing & Isolation/Cohorting, it read ProMedica Piscataway will continue to test healthcare personnel and residents for Covid-19 in accordance with CDC, CMS, and LHD guidelines.; Under Reporting Requirements, it read Any resident or staff suspected or diagnosed according to State-specific criteria shall be promptly reported to appropriate local and/or state health department officials, included but not limited to NHSN. The policies provided did not further address COVID-19 surveillance. A review of the facility's policy Infection Control Manual, 07/10/2021 included the following: Under Surveillance, Section 4: Outbreak Investigations read, An epidemic or outbreak is an excess over the expected or usual level of a disease within a geographic area. One case may constitute an epidemic and warrant an outbreak investigation .The Infection Preventionist or DON, under the direction of the Medical Director, manages an outbreak investigation. Under Outbreak Strategies, it read Upon identification of a potential outbreak, conduct an outbreak investigation. The objectives of any outbreak investigation are to describe the situation (what is happening), determine the etiology (where did the infection start), what is the agent, where is the source and what is the method of spread. It is important to identify the incubation period (interval between exposure and onset of symptoms). A review of the facility's policy titled COVID-19 Clinical Monitoring and Measures Plan, dated 10/10/22, indicated that when any employee tests positive or a resident (who was not previously being cared for in transmission based precautions [TBP]) tests positive for COVID-19, enhanced measures should be implemented. Enhanced measures included but were not limited to, a Screening UDA [User Defined Assessment] consisting of vital signs every shift for residents in the affected unit (where a resident tested positive or positive employee worked), identifying potential staff, visitor, and other resident prolonged exposure, notification to local department of health of any positive COVID-19 test results, and to refer to CDC Work Restrictions for HCP with SARS-CoV-2 Infection and Exposures to determine status of employee. A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 09/23/22, included but was not limited to the definition of Close contact 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 a 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 resident 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 a 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 (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Documentation of testing revealed that 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. A review of CDC guidance Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, revised 9/23/22, indicated 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. The guidance further indicated the following: A single new case of SARS-CoV-2 infection in any healthcare personnel (HCP) or resident should be evaluated to determine if others in the facility could have been exposed; The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts 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. Part B F880 remains a deficiency at a scope and severity of an F based on the following: Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to: 1) conduct screening or education for visitors entering the facility, 2) review annually the facility's infection control and infection prevention plan and policies, and 3) maintain proper infection control practices identified during the: a) tour of the kitchen b) dining observation, and c) medication administration observation identified on 1 of 2 Nursing Units (Second Floor), and for 1 of 2 nurses (Licensed Practical Nurse #2) observed during the medication pass. This deficient practice was evidenced by the following: 1) On 1/3/23 at 9:05 AM, six surveyors entered the facility and were greeted by the front desk receptionist, who was not wearing a mask. The receptionist after greeting the surveyor applied a surgical mask. The receptionist instructed the surveyors to sign in with their names and date. There was no COVID-19 screening or education. Surveyor #2 interviewed the receptionist about the process of visitor check-in. The receptionist stated visitors sign in who they are visiting, they do not check temperatures anymore, and was not sure if there were COVID-19-positive residents in the facility. The receptionist stated there was no COVID-19 screening of visitors since November 2022. The receptionist further stated previously they would check temperatures and had a form for visitors to fill out. There was a sign on the reception desk for all visitors to always wear a mask in the facility. There was no signage about COVID-19 observed by the main entrance or reception area. On 1/3/23 at 10:29 AM, Surveyor #2 used the elevator, where there was signage observed for visitors about COVID-19, signs and symptoms, and signage that indicated a mask and face shield was required for the 2nd and 3rd-floor units. Signs were also observed in front of the elevators for visitors about COVID, its signs and symptoms, and a small sign was noted behind the reception area that was not visible. On 1/4/23 at 8:59 AM, the surveyors entered the facility, there were no visible signs posted about COVID-19 by the main entrance. On 1/4/23 at 11:05 AM, Surveyors #1 and #2 interviewed the infection preventionist (IP) and the Director of Nursing (DON) about visitor education and screening. The IP stated they did not conduct visitor screening since before she started working there and that the facility cannot close to visitors. The surveyor asked about any COVID-19 education for visitors. The IP stated signs were posted, though she was not sure if any were posted by the main entrance. On 1/4/23 at 11:50 AM, Surveyor #3 interviewed Guest Services/Recreation Director about visitor screening, who stated there used to be a Visitors/Staff Attestation. The Visitor/Staff had their temperature taken, they answered questions about COVID-19 signs and symptoms and then the second form had contact information and verified that the person was aware that the building had Covid positive residents. The Guest Services/Recreation Director stated the Administrator informed the staff in November they would not be using COVID-19 attestation forms and that she sent out an email to staff on November 4, 2022. A copy of the email was provided to the surveyor. During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated in November 2022, the policy of screening visitors changed based on a zoom meeting with the corporate level nurse who provided an update on CDC guidance. The Administrator further stated visitors were given masks and were informed of proper PPE (personal protective equipment, protective clothing or equipment used to protect the body from injury or infection) to use when coming into the facility. A review of an undated facility's policy titled Outbreak Plan included the following: Under Screening & Protective Measures, it read Healthcare personnel and permitted visitors entering ProMedica Piscataway will be screened for COVID-19 illness; Under Notification Plan, it read Signage is posted at entrance doors to alert visitors to Covid-19. A review of the facility's Infection Control Manual policy with a revised date of 07/2021 included the following: Section 2: Precaution Systems, under Visitor Management, it read, Visitor management is the control of access and actions of people visiting for the safety and prevention of disease transmission. The policies provided did not further address COVID-19 visitor screening and education. 2) On 1/11/23 at 9:35 AM, the surveyor interviewed the DON who provided the infection control policy. The policies for isolation precautions, PPE, Infection Surveillance, outbreak investigations, and antibiotic stewardship had a review date of 7/2021. The DON stated she could not find the policy reviewed for the year 2022 and that the infection control policy was reviewed and approved in January 2023. The DON provided policies with an Annual Review page signed by the DON, Administrator, IP, and Medical Director, dated 1/9/2023. During an interview with the surveyor on 1/11/23 at 10:05 AM the Administrator acknowledged the facility's policies and procedures should be reviewed annually and could not recall if the policy was reviewed in 2022. The Administrator stated the DON and herself were responsible for ensuring policies were reviewed. During an interview with the surveyor on 1/13/23 at 9:13 AM, the Medical Director stated he was not sure exactly, but believed the policies were reviewed at the last QAPI meeting in December. The surveyor informed the Medical Director that the DON and the Administrator could not find an annual infection control policy review for 2022. The Medical Director provided no direct response and further stated the interdisciplinary team discussed protocols in morning meetings. 3) On 01/03/23 at 9:52 AM, during the initial tour of the kitchen, the surveyor observed the Dining Services Director (DSD) who touched the lid of a trash can with her bare hands as she attempted to open the lid after the foot pedal feature malfunctioned. The DSD then proceeded to wash her hands for 14 seconds before she began the tour of the kitchen. During an interview with the surveyor on 01/04/23 at 8:40 AM, the DSD stated that when she washed her hands yesterday in the presence of the surveyor, she sang the happy birthday song once to ensure that she washed her hands for what she thought was the appropriate length of time of 20 seconds. The DSD further stated that if she did not wash her hands for at least 20 seconds prior to the tour of the kitchen there was a concern of contamination. During an interview with the surveyor on 01/11/23 at 10:46 AM, the Administrator stated that if the DSD had not washed her hands for at least 20 seconds prior to the tour of the kitchen, She could have passed germs onto the food and all around the kitchen. During an interview with the surveyor on 01/12/23 at 11:35 AM, the Infection Preventionist (IP) stated that the DSD should have washed her hands for 20 seconds prior to the tour of the kitchen to prevent the spread of infectious agents or bacteria. On 01/12/23 at 12:25 PM, during a follow-up visit to the kitchen, the surveyor observed Dietary Aide (DA #1) who washed her hands for 32 seconds at the handwashing sink, left the water running in the sink, dried her hands on a paper towel, removed her hair net, and replaced it with a larger one that provided full coverage, as the one she wore only covered her ponytail, and not the front or top of her head. DA #1 then proceeded to turn off the faucet with her bare hands. When interviewed at that time, DA #1 stated that she knew that she should have used a paper towel to turn off the faucet, but she had forgotten to. The DSD who was present stated that there was a potential for contamination since DA #1 touched her hair, then touched the faucet with her bare hands. The DSD stated that DA #1's responsibilities included plating food on the food service line, which was in process during the time of the observation. During an interview with the surveyor on 01/13/23 at 9:46 AM, the IP stated that DA #1 should have used a paper towel to turn off the faucet after she washed her hands because she re-contaminated her hands and that could have transferred to the faucet which had a potential for the spread of infection. 4) On 01/03/23 at 12:10 PM, the surveyor observed that a Dietary Aid (DA) delivered the food truck to Hall A of the Second Floor Nursing Station and proceeded to leave the unit. At 12:11 PM, the surveyor observed Certified Nursing Assistant (CNA #4) as she approached the food truck and removed the first meal tray without first performing hand hygiene before she delivered the tray to Unsampled Resident #1. The resident requested a plastic cup. CNA #4 returned to the food truck, obtained a plastic cup, and provided it to the resident as requested. CNA #4 then exited the resident's room without first performing hand hygiene. At 12:12 PM, the surveyor observed CNA #4 as she approached the food truck and reviewed Unsampled Resident #2's meal ticket before she poured coffee from a carafe into a coffee cup and placed it on the resident's tray. CNA #4 then proceeded to deliver the meal tray to the resident without first performing hand hygiene. The surveyor observed that CNA #4 did not offer to assist the resident with hand hygiene prior to the meal service. CNA #4 then exited the resident's room without first performing hand hygiene. At 12:13 PM, the surveyor observed CNA #4 who removed Unsampled Resident #3's tray from the food truck without first performing hand hygiene. The resident was asleep when she entered the room and she attempted to wake the resident by calling the resident's name without success. CNA #4 left the tray at the bedside and exited the res[TRUNCATED]

Based on interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure: 1.) a symptomatic Registered Nurse #1 (RN #1) notified the supervisor, prior to the start of her shift on 12/24/22 that she was ill, 2.) a process was in place to conduct immediate resident and staff testing upon identification of a COVID-19 positive staff member (RN #1) who provided care to 9 residents on 1 of 2 units while working on 12/24/22, and for two residents who tested positive for COVID-19 (Residents #33 and #235) 3.) the facility followed the relevant Centers for Disease Control and Prevention (CDC), Federal, and State guidance for infection control, and 4.) the facility's Outbreak Plan and COVID-19 policies were 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 COVID-19-positive 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 1/5/23 at 3:35 PM. The removal plan was accepted and verified as implemented by the survey team during an onsite visit conducted on 1/6/23. The IJ situation began on 12/24/22 at 7:00 PM, when RN #1 reported to work while sick with fever and cough, proceeded to provide care for 9 residents in 1 of 2 resident units, and tested positive for COVID-19 on 12/24/22 at 10:00 PM. The Infection Preventionist (IP) stated there was no process in place to test the residents and staff. There was no evidence that the facility tested the 9 residents the RN had on her assignment. Three residents on the RN's assignment were immunocompromised and had a diagnosis of Human Immunodeficiency Virus (HIV) with prednisone use, Sickle Cell Anemia, and Chronic Obstructive Pulmonary Disease (COPD). 1 of the 3 immunocompromised residents was not vaccinated for COVID-19. Three additional residents were not vaccinated for COVID-19. Additionally, two symptomatic residents tested positive in the facility on 1/1/23 and 1/2/23. There was no subsequent resident testing performed. This deficient practice was evidenced by the following: Refer to 880L Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, revised 9/23/22, 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 During the entrance conference on 1/3/23 at 11:00 AM, the IP, along with the Director of Nursing (DON), informed the surveyors that there were two COVID-19-positive residents (Resident #33 and Resident #235) in the facility on the 2nd-floor unit. The IP stated she started in the facility in November and was responsible for staff development and infection control. The IP stated that the Administrator was currently on vacation. On 1/4/22 at 10:00 AM, Surveyor #1 reviewed the facility's COVID tracker (an internal tool that documents COVID-19 positive staff), titled COVID-19 Employee Detail which revealed RN #1 was positive for COVID-19 on 12/24/22. An additional review revealed that the onset of symptoms was on 12/22/22 and the last day the RN #1 worked was 12/24/22. During an interview with Surveyor #1 and Surveyor #2 on 1/4/23 at 11:05 AM, the IP, in the presence of the DON, stated the facility's infection control practice was based on the infection control manual and facility policies based on corporate, CDC guidelines and guidance from the Local Health Department (LHD). The IP stated COVID-19 testing was conducted twice a week and in between that time if someone was symptomatic. The IP stated the residents and staff were tested twice a week on Mondays and Thursdays. Surveyor #1 reviewed the COVID Tracker which included RN #1 with the DON and IP. The DON stated RN #1 tested positive for COVID-19 at work on 12/24/22 and had allergy symptoms that included sinus symptoms and headache, for a couple of days before. The DON stated RN #1 did not work on 12/22/22 and 12/23/22 and worked on 12/24/22 for the 7 pm to 7 am shift on the 2nd-floor unit. The DON further stated RN #1 should not have come in sick to work and should have tested before her shift. The DON stated she did not do contact tracing and would have to check the documentation for residents who were tested. During a telephone interview with Surveyor #1 On 1/4/23 at 11:57 AM, RN #1 stated she started feeling sick on 12/22/22 and called out sick to the Registered Nurse Supervisor (RNS) on 12/22/22 and 12/23/22. RN #1 stated she was running temperatures, had a cough, and reported to the RNS that she was not feeling well. She stated the RNS stated, ok and did not ask any further questions. RN #1 stated it was holiday time and if you call out before the holiday, you don't get time and a half. RN #1 stated she went back to work on 12/24/22 and thought she was ok since she called her primary doctor who gave her antibiotics, and she also took Tylenol. RN #1 stated she still had a fever and cough symptoms when she went to work. RN #1 stated she received report from the outgoing nurse, checked on her residents, did her first medication administration pass before testing herself at 10:00 PM, and tested positive for COVID-19. The surveyor asked if she had told anyone that she was not feeling well or about her symptoms on 12/24/22. RN #1 stated, Who was I gonna tell .there was no one .only nurses and she had called the DON at 10:00 PM after testing positive. RN#1 stated the DON told her that she had to go home and could not work as she tested positive for COVID-19. RN #1 said she gave report to the other nurse and went home. The surveyor asked RN #1 why she tested herself at 10:00 PM and not before that time. RN #1 replied that the outgoing nurses wanted to give report to go home, and she did not want to keep them waiting. RN #1 stated that no one from the facility had called her to ask about contact tracing including residents she had contact with. RN #1 stated she had education about COVID-19 in 2020 and 2021 and acknowledged that the facility had stated if a staff member had symptoms or was COVID-19 positive that the staff member should not come to work. On 1/4/23 at 11:54 AM, the IP provided the surveyor RN #1's timecard which revealed RN #1 worked on Saturday 12/24/22, clocked in at 7:00 PM, and clocked out at 10:45 PM. On 1/4/23 at 12:38 PM, the IP provided the surveyor with the assignment of RN #1 on 12/24/22, which included 9 residents (Resident #236, #69, #239, #47, # 80, #63, #240, #238 and #52). The IP stated that the residents who were exposed were not tested and that there was no documentation that the residents were tested. The IP stated she was new in training, but that she was responsible to ensure they were doing the correct thing and the residents should have been tested. A review of the medical records for the 9 residents that were assigned to RN #1 on 12/24/22, included three immunocompromised residents: Resident #236 who had a diagnosis that included HIV, was receiving dialysis, and prednisone (a corticosteroid medication that suppresses the immune system and decreases inflammation) treatment; Resident #240 who had a diagnosis that included Sickle Cell Anemia; and Resident #238, who had a diagnosis that included COPD. Four of the residents (Resident #236, #69, #239, and #47) were unvaccinated and 5 residents (Resident # 80, #63, #240, #238, and #52) were fully vaccinated according to the facility's resident COVID-19 vaccination matrix. On 1/4/23 at 1:05 PM, Surveyor #1 and Surveyor #2 interviewed the IP and the DON about the process of testing residents and staff, after a positive case. The IP stated testing should be twice a week, positive staff COVID results are logged in the computer's COVID tracker and there was a surveillance log in which results were written for staff testing. The IP stated there was no log for residents, positive results were found on the resident's medical record, and she was not sure where negative results would be documented. The DON stated resident testing, whether positive or negative results, should be documented in the electronic medical record's progress notes. The surveyor requested from the DON and IP documentation of any resident testing conducted. On 1/4/23 at 1:55 PM, Surveyor #1 interviewed the IP about the two COVID-19-positive residents in the facility. The IP stated the two residents were tested because they had symptoms. The IP stated she would check and provide information on contact tracing and resident testing. A review of the progress notes provided by the IP revealed that Resident #235 had chills, muscle aches, and cough, and tested positive for COVID-19 on 1/1/23, and Resident #33 had a sore throat with post-nasal drip and tested positive for COVID-19 on 1/2/23. During an interview with Surveyor #1 on 1/5/23 at 10:42 AM, the RNS stated if someone said they were calling out sick or not feeling well, she would ask about their symptoms, how long, and when they last worked. The RNS could not recall if she received any callouts when working on 12/22/22 and 12/23/22. During a follow-up interview with Surveyor #2 on 1/5/23 at 10:58 AM and 12:03 PM, the IP stated there was no process in place to ensure resident testing was done. The IP stated contact tracing should have been done for the COVID-19-positive residents and testing of residents in contact but was not completed. She stated after the former DON left the facility, she was pulled into so many directions and was following the direction and guidance of the Administrator. During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated that the former DON had left without notice in November and the IP had a solid week of training and spent a day with the Quality Assurance Consultant. She stated when the DON left, she had assigned the IP to be a Unit Manager on one of the units for oversight and she (the IP) should have been juggling everything. The Administrator stated she would let the IP know if something needed to be addressed and the IP was responsible for in-services, following up with tracking of covid positive residents, ensuring testing was being done, completing surveillance after a positive case, and checking the residents on the assignment after a positive staff case. The Administrator stated she could not recall a positive COVID-19 staff case on 12/24/22. The surveyor informed the Administrator of RN #1, COVID-19 surveillance, and contact tracing concerns. The Administrator stated after a positive COVID-19 case, it was expected for the residents to be tested for COVID-19 and that staff was instructed not to come in to work when sick and to test before starting their shift. The Administrator stated she assumed the IP was doing what she was supposed to do and was not following up with her. She stated there was no team meeting held to discuss RN #1 testing positive on 12/24/22. The Administrator stated that she and the DON would have been responsible for ensuring the IP was carrying out her responsibilities. During an interview with Surveyor #1 and Surveyor #2 on 1/13/23 at 9:13 AM, the Medical Director stated he was made aware of the COVID-19 tracking and testing concerns. The Medical Director stated that the facility followed CDC and CMS guidelines for policies and was unaware they were not being followed. The Medical Director stated he was always made aware of positive COVID-19 cases in the facility and testing of residents should be based on contact tracing. The surveyor reviewed the IP's competency checklist, a twelve page document, titled Infection Preventionist Orientation Plan and Skills Competency Checklist which was dated 11/4/22. Review of the checklist revealed 84 out of 92 tasks were not completed. A review of the Job Description provided for the IP with the date of hire of 10/22/22, did not indicate her role and responsibilities as an IP. A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 09/23/22, included but was not limited to the definition of Close contact 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 a 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 resident 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 a 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 (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Documentation of testing revealed that 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. A review of an undated facility's policy titled Outbreak Plan included the following: Under Evidence-Based Outbreak Response Measures, it revealed, if a new/reemergence of an infectious disease is detected, ProMedica Piscataway will follow its Infection Control policies and the measures and procedures set forth by the CDC, CMS, and LHD for guidelines and directives. Under Testing, Refusal of Testing & Isolation/Cohorting, it read ProMedica Piscataway will continue to test healthcare personnel and residents for Covid-19 in accordance with CDC, CMS, and LHD guidelines.; Under Reporting Requirements, it read Any resident or staff suspected or diagnosed according to State-specific criteria shall be promptly reported to appropriate local and/or state health department officials, included but not limited to NHSN. The policies provided did not further address COVID-19 surveillance. A review of the facility's policy titled COVID-19 Clinical Monitoring and Measures Plan, dated 10/10/22, indicated that when any employee tests positive or a resident (who was not previously being cared for in transmission based precautions [TBP]) tests positive for COVID-19, enhanced measures should be implemented. Enhanced measures included but were not limited to, a Screening UDA [User Defined Assessment] consisting of vital signs every shift for residents in the affected unit (where a resident tested positive or positive employee worked), identifying potential staff, visitor, and other resident prolonged exposure, notification to local department of health of any positive COVID-19 test results, and to refer to CDC Work Restrictions for HCP with SARS-CoV-2 Infection and Exposures to determine status of employee. A review of the facility's policy titled Testing Criteria Summary, dated 10/05/22, for newly identified COVID-19 positive staff or resident (not in TBP) in a facility/community that can identify close contacts included: For newly identified COVID-19 positive staff or resident 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 a close contact with a COVID-19 positive individual and testing frequency should be performed Day 1, 3, and 5 unless a positive result is obtained. NJAC 8:39- 19.1(a); 19.2(a)(c)