**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff, Health Department Nurse, and Physician interviews, the facility failed to implement the facility's infection control policy and procedures in accordance with current Centers for Disease Control and Prevention (CDC) guidance. The facility had been in outbreak status since 1/18/25 when 2 staff members tested positive and only residents and staff with COVID symptoms and staff that requested were tested for COVID. The facility failed to initiate contact tracing COVID testing for staff and residents on 1/18/25 after 2 staff members tested positive for COVID and failed to initiate broad-based approach COVID testing when a resident on the 200 hall and the 400-hall tested positive for COVID. No contact tracing or broad-based COVID testing was initiated until after surveyor intervention on 2/4/25. Before broad-based COVID testing was implemented on 2/4/25, a total of 9 staff members and 7 residents tested positive for COVID. Results of the broad-based testing from 2/4/25 through 2/7/25 resulted in 1 resident and 1 staff member positive for COVID on 2/4/25, 1 resident positive for COVID on 2/5/25, and 1 resident positive for COVID on 2/7/25. Additionally, the facility failed to implement staff source control to help prevent transmission and facility staff failed to wear all personal protection equipment (PPE) required according to CDC guidance when they entered resident rooms under transmission-based precautions (TBP) for COVID. The facility also failed to restrict staff from returning to work after testing positive for COVID in accordance with current CDC guidance. The resident census at the time of the survey was 123 and 62% of the residents were vaccinated for COVID. These cumulative practices and system failures occurred during a COVID-19 outbreak and had the high likelihood of continued transmission of COVID-19 to residents and staff and a serious adverse outcome. Immediately Jeopardy began on 1/18/25 when 2 staff members tested positive for COVID, and the facility failed to implement contact tracing COVID testing. Immediate Jeopardy was removed on 2/7/25 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of E (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: On 2/3/25 a request was made for the facility's infection control policy and procedures for COVID testing, transmission-based precautions, masking for source control during a COVID outbreak, and return to work guidelines for staff after testing positive for COVID. The Infection Preventionist (IP) provided the CDC guidance and reported the facility utilized the CDC guidance for their policy and procedures. 1. The facility provided CDC COVID testing guidance, with a review date of 11/20/24 read, in part: Newly identified COVID positive staff or resident in the facility can identify close contacts: test the staff, regardless of vaccination status, that had a higher-risk exposure with a COVID positive individual. If negative, test again 48 hours later, and if negative, 48 hours after the 2nd test. Test the residents, regardless of vaccination status, then had close contact with a COVID positive individual. If negative, test again 48 hours later, and if negative, 48 hours after the 2nd test. Newly identified COVID positive staff or resident in a facility that is unable to identify close contacts: Broad Based approach. Test all staff regardless of vaccine status, if staff are assigned to a specific location where the new case occurred (unit, floor, or other specific areas of the facility). If negative, test again 48 hours later and if negative, 48 hours after the 2nd test. In general, testing should continue every 3-7 days until 14 days have passed without any new cases. Test all residents, regardless of vaccination status, facility-wide or at a group level (unit, floor, or other specific areas of the facility). If negative, test again 48 hours later and if negative, 48 hours after the 2nd test. In general, testing should continue every 3-7 days until 14 days have passed without any new cases. Test results will be tracked and reported as required by local, state, and federal entities. The CDC guidance Outbreak Response when a new facility-onset case of COVID is identified with a date of 2/2022 was reviewed and read in part: Does the facility have the expertise, resources, or ability to identify all close contacts? If yes: Perform individual contact tracing by identifying staff with higher-risk exposure and residents with close contact to the individual with COVID. Close contacts should be tested immediately (but not sooner than 24 hours after exposure) and if negative, again 48 hours later, again 48 hours after the 2nd negative test. If testing reveals additional residents or staff with COVID, contact tracing should continue to identify residents with close contact or staff with higher-risk exposure to the newly identified individuals. Strong consideration should be given to shifting to the broad-based approach if additional cases are identified. If no: Perform broad-based testing: test all staff and residents immediately but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the 1st negative test and, if negative again 48 hours after the 2nd negative. Were new cases identified: if Yes: testing should continue every 3-7 days until there are no new cases for 14 days. A broad-based approach should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Outbreak response: residents and staff should wear source control; consider implementing universal PPE use, visitors should wear source control and only go to and from resident's room or a designated visiting area; communal activities may continue but source control should be used, and physical distancing maintained whenever possible, unless otherwise directed by public health. The infection control line listing for December 2024 and January 2025 for the facility was reviewed and included the following information. The outbreak started on 1/18/25 when the Maintenance Director and the Maintenance Assistant tested positive for COVID. - Maintenance Assistant tested positive for COVID on 1/18/25. - The Maintenance Director also tested positive for COVID on 1/18/25. - Resident #78 (200 hall) tested positive for COVID on 1/19/25. - Resident #14 (400 hall) tested positive for COVID 1/20/25. - The Rehabilitation Director tested positive for COVID on 1/20/25. - The Director of Nursing tested positive for COVID on 1/20/25. - The Admissions Director tested positive for COVID on 1/20/25. - Resident #42 (200 hall) and tested positive for COVID on 1/21/25. - Physical Therapy Aide #1 tested positive for COVID on 1/21/25. - Resident #97 (400 hall) tested positive for COVID on 1/23/25. - Physical Therapy Aide #2 tested positive for COVID on 1/23/25. - NA #6 tested positive for COVID on 1/26/25. - Laundry Aide #1 tested positive for COVID on 1/26/25. - Resident #79 (400 hall) tested positive for COVID on 1/27/25. - Resident #69 (100 hall) tested positive on 1/27/25. No contact tracing or broad-based COVID testing was initiated until after surveyor intervention on 2/4/25. - Resident #170 (100 hall) tested positive for COVID on 2/4/25 - Kitchen Staff #1 tested positive for COVID on 2/4/25 outside of the facility. - Resident #112 (100 hall) tested positive for COVID on 2/5/25. - Resident #98 (100 hall) tested positive for COVID on 2/6/25. The Infection Preventionist (IP) was interviewed on 2/3/25 at 2:12 PM. The IP reported she was the infection control nurse and the Assistant Director of Nursing for the facility and had been in her position for almost 9 months. The IP reported that she emailed the Health Department on 1/21/25 to notify the Senior Nurse about the COVID cases. The IP explained the facility was not testing all residents and staff for COVID and they were testing only contacts of the residents who were positive for COVID. The IP noted because the residents who had symptoms of COVID before they tested positive and were placed on TBP she had not tested contacts for the residents because they were under TBP and would not have exposed anyone. The IP reported the facility was only testing symptomatic residents and staff. An email from the Senior Nurse at the Department of Health/Communicable Disease (Health Department Nurse) sent to the IP dated 1/21/25 was reviewed and read, in part: I have attached the monitoring log for reporting .regarding when to test residents and staff, I copied this section for you from the (CDC) website: 'If additional cases are identified, strong consideration should be given to shifting to the broad-based approach (regarding testing for COVID) if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3 to 7 days until there are no new cases for 14 days .' Included in the email were links to the CDC website for additional guidance regarding infection control and guidance for risk assessment. The Health Department Nurse was interviewed by phone on 2/5/25 at 11:31 AM. The Nurse reported the IP had emailed her on 1/21/25 with the report of 3 resident positive COVID cases on the 200 hall, and 1 resident positive case on the 400 hall. The Health Department Nurse explained she had sent the IP CDC guidance for testing residents and staff using broad-based testing, quarantining residents, and how long staff should stay out of work. The IP was interviewed again on 2/5/25 at 12:02 PM and she reported when she received the email from the Health Department Nurse, she missed the part of the email about broad-based testing. The IP and the Director of Nursing were interviewed on 2/4/25 at 8:32 AM. The IP reported she provided infection control surveillance for the facility and monitored all new infections. The IP explained residents with any respiratory symptoms were placed on droplet precautions and a chest x-ray was ordered if they were coughing. The IP reported she tracked the infections and the residents with signs and symptoms on a respiratory tracking form. The IP further explained she had multiple forms for tracking infections in the facility, including event tracking in the electronic documentation system, a spreadsheet, and a facility map that she color-coded to identify trends and outbreaks of infections. The IP reported she had noticed the COVID infections were popping up on different halls, but didn't occur to her the facility was in outbreak status. The IP explained when a resident had sign or symptoms of a respiratory infection, they were placed on droplet precautions immediately and she thought because the resident was isolated, there was no need to conduct contact testing. The DON stated the IP was exclusively responsible for the infection control data, but the other nursing department heads assisted with monitoring the staff for correct PPE use, but the facility had not conducted monitoring. The DON reported she had tested positive for COVID on 1/20/25 and was out of work until 1/30/25 and she was not available during the first part of the outbreak. The DON reported she was not aware the facility was testing only symptomatic residents, and the facility should have initiated broad-based COVID testing for residents and staff. The Administrator was interviewed on 2/5/25 at 1:20 PM. The Administrator explained the IP had misunderstood the guidance from the CDC website did not know that broad-based testing should have started on 1/20/25. The Administrator reported the broad-based testing was not initiated by the IP when the residents tested positive on 1/19/25 and he expected COVID guidelines to be followed. The Administrator reported he was aware the IP was testing only symptomatic residents and staff, and he thought that was the guidance she had received from the Health Department. The Physician was interviewed on 2/5/25 at 9:20 AM. The Physician reported he was not aware the facility was not conducting broad-based testing for residents and there was a risk of COVID spreading throughout the facility and infecting many residents. The Physician explained the residents who were positive for COVID did not have severe illness and only one resident was hospitalized per her family request. 2. The facility policy for Transmission-based precautions and Isolation Policy dated 1/2014 and revision date of 4/15/24 was reviewed and it read, in part: Droplet Precautions: intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances, special air handling and ventilation are not required to prevent droplet transmission; a single patient room is preferred but not required; a mask is worn for close contact with infectious resident; gloves, gown, eye protection are worn adhering to standard precaution guidelines. Airborne Precautions: prevent transmission of the infectious agents that remain infections over long distances when suspended in the air; a respiratory protection program that includes N95 (masks), resident should be placed in a private room with the door closed and the healthcare staff provided with N95 or higher respirators; gloves, gown, and eye protection are worn adhering to Standard Precaution guidelines. Facility staff providing care for the residents will be notified by the facility infection preventionist and/or charge nurse regarding needed precautions based on the infectious agent or condition. Signage indicating the appropriate types of precautions and indicating that visitors should stop at the nurse's station before entering will be placed on the resident's door. Handle resident care equipment and instruments/devices, laundry, dishware, or eating utensils and environmental cleaning with Standard Precautions unless more stringent disinfection is indicated. Staff will educate visitors regarding donning appropriate PPE. Transmission-based precautions will remain in effect while the risk of transmission of the infectious agent persists or for the duration of the illness. Isolation and resident placement decisions will be determined based on the potential for transmission of (the illness). Isolation/patient placement decisions will be determined based on the potential for transmission of infectious agents and will include the following: route of transmission, risk factors for transmission in the infected patient, risk factors for adverse outcomes resulting from a healthcare-associated infections in the area or room being considered for patient placement, the availability of single patient rooms, and patient options for room-sharing. Refer to the CDC Types and Duration of Precautions for further information. The CDC guidance for Outbreak Response when a new facility-onset case of COVID is identified with a date of 2/2022 was reviewed and read in part: Outbreak response: residents and staff should wear source control; consider implementing universal PPE use, visitors should wear source control and only go to and from resident's room or a designated visiting area; communal activities may continue but source control should be used, and physical distancing maintained whenever possible, unless otherwise directed by public health. A continuous observation was conducted on 2/2/25 at 12:47 PM to 12:51 PM of Nursing Assistant (NA) #1 assisting Resident #69. Resident # 69 had signage on her door notifying she was on special droplet precautions. A caddy was outside of the door with personal protective equipment (PPE), including gowns, gloves, N95 masks, and eye protection. Instructions on the signage included hand hygiene, applying gloves, protective gown, N95 mask, and eye protection before entering the room. NA #1 was observed wearing only a KN95 mask as she took Resident #69's lunch tray into the room. NA #1 did not perform hand hygiene, did not apply gloves, a gown, eye protection, or change her mask to a N95. NA #1 exited the room at 12:51 PM and did not remove her KN95 mask or perform hand hygiene. NA #1 was interviewed on 2/2/25 at 12:51 PM and when asked why she had entered the room without PPE, NA #1 reported she had been off work for a few days and had not noticed the sign on the door. NA #1 was interviewed by phone on 2/4/25 at 11:05 AM. NA #1 reported she was not aware she had to apply full PPE to deliver a meal tray. NA #1 explained after the observation on 2/2/25, she took a break and changed her mask after her break. During an interview with the Infection Preventionist nurse (IP) on 2/4/25 at 8:32 AM, the IP reported that NA #1 should have applied full PPE to deliver the meal tray to Resident #69 and she would have expected her to change her mask and perform hand hygiene after removing the PPE. Review of NA #1's education revealed NA #1 received infection control education and use of standard precautions on 4/23/24. NA #1 additionally had a skills review that was completed 8/10/24 which included demonstration of infection control and prevention and demonstrated adherence to the infection control policies. On 2/2/2025 at 4:45 pm NA #2 was observed in Resident #79's room from the hall. Resident #79 had signage on her door for special droplet precautions. A caddy was outside of the door with PPE, including gowns, gloves, N95 masks, and eye protection. Instructions on the signage included completing hand hygiene, applying gloves, protective gown, N95 mask, and eye protection before entering the room. Resident #79 was upset and yelling and NA #2 was observed standing beside Resident #79's bed, within 2 feet of Resident #79, with her N95 mask pulled below her nose, attempting to calm her. NA #2 was not wearing eye protection, a gown, or gloves. NA #2 made eye contact with the surveyor and pulled her mask up over her nose. NA #2 was observed to leave NA #2 did not remove the N95 mask or replace the N95 mask when she exited Resident #79's room. NA #2 was interviewed on 2/2/2025 at 4:46 pm and she stated she saw the Special Droplet and Contract Precautions sign on Resident #79's door but thought Resident #79 was off precautions because she was told the resident tested negative for COVID. NA #2 stated she did not remember who told her Resident #79's precautions were removed. NA #2 stated she should have worn eye protection, a gown and gloves and kept her mask over her nose and mouth. Review of NA #2's education revealed NA #2 received infection control education and use of standard precautions on 5/31/24. NA #1 additionally had a skills review that was completed 8/12/24 which included demonstration of infection control and prevention and demonstrated adherence to the infection control policies. During an interview with the IP on 2/2/2025 at 4:47 pm she stated Resident #79 should still be on Special Droplet and Contact Precautions because she had not completed the required isolation period since she had tested positive. The IP further stated she would have taken the precautions sign from Resident #79's door if she was off precautions and NA #2 should have worn a gown and gloves, and NA #2 would be required to always wear a mask that covered her nose and mouth. The DON was interviewed on 2/7/2025 at 1:04 pm and she stated NA #2 should have worn her mask over her nose and put on eye protection, a gown and gloves on before entering Resident #79's room on 2/2/2025 since the resident was on Special Droplet and Contact Isolation. On 2/7/2025 at 1:09 pm the Administrator was interviewed and stated NA #2 should have worn eye protection, a gown and gloves and worn her mask over her nose while entering a room that was on Special Droplet and Contact Isolation. An observation of Nurse #4 without a mask on during a medication administration observation was made on 2/4/2025 at 7:45 am on the 300 hall. Nurse #4 had prepared medications for Resident #278 and was getting ready to enter his room, when she was stopped and asked if she should be wearing a mask. Nurse #4 stated she was not required to wear a mask if she was not in a room with precautions in place. An attempt was made to interview Nurse #4 again, but she had left the facility and did not return phone calls with requests for an interview. Nurse #4 received infection control education and use of standard precautions during orientation to the facility on 7/274/24. Nurse #4 additionally had a skills review that was completed 8/21/24 which included demonstration of infection control and prevention and demonstrated adherence to the infection control policies. The IP was interviewed on 2/4/2025 at 8:32 am and she reported she was educating all the nursing staff on PPE use because of the observations of NA #1 and NA #2 not wearing the PPE required for Special Droplet and Contract Precautions made on 2/2/25. The IP explained all staff should be wearing masks during the COVID outbreak. The IP stated Nurse #4 received in-service education regarding personal protective equipment yesterday and was not compliant with wearing a mask for source control today. The IP was unable to answer why Nurse #4 was not wearing her mask after receiving education on 2/3/25. The IP explained she conducted surveillance for PPE use and hand hygiene in the facility but had not conducted any surveillance during the outbreak until 2/2/25. The IP reported the process for monthly PPE surveillance was she typically watched 3 staff members apply and remove PPE and provided education if they had problems. The IP explained she did not keep records of the surveillance of PPE. The Director of Nursing (DON) was interviewed with the IP on 2/4/25 at 8:32 AM. The DON explained she and other nurse managers had not routinely assisted with PPE surveillance, but the unit managers had started to monitor staff PPE use since 2/2/25. The DON reported she expected all staff to follow the guidelines for PPE use for residents on special droplet precautions. The DON was interviewed on 2/7/2025 at 1:04 pm and DON and stated Nurse #4 should have been wearing a mask at all times due to the outbreak status of the facility. The Physician was interviewed on 2/5/25 at 9:20 AM. The Physician reported PPE use was important source control to prevent the spread of COVID and he would expect all staff to adhere to PPE guidelines. 3. The Centers for Disease Control and Prevention (CDC) guidance for Health Care Personnel (HCP) returning to work updated 9/23/22 was reviewed and read, in part: HCP with mild to moderate illness who are not immunocompromised could return to work after the following criteria is met: 7 days since symptoms first appeared if a negative (COVID) test is obtained 48 hours prior to returning to work (or 10 days if testing is not performed), 24 hours since the last fever and symptoms (shortness of breath, cough) have improved. (Either NAAT [Nucleic Acid Amplification Test] (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later). HCP who were asymptomatic throughout their infection and not moderately to severely immunocompromised could return to work after the following criteria is met: at least 7 days have passed since the date of their first positive viral test if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed). (Either NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later). HCP with severe to critical illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: at least 10 days and up to 20 days have passed since symptoms first appeared, and at least 24 hours have passed since the last fever without the use of fever-reducing meds, and symptoms (shortness of breath, cough) have improved. HCP who are symptomatic could return to work after the following criteria are met: resolution of fever without the use of fever-reducing medications, improvement in symptoms, results are negative from at least 2 consecutive respiratory specimens collected 48 hours apart. The infection control line listing for December 2024 and January 2025 for the facility was reviewed for staff. The Maintenance Assistant tested positive for COVID on 1/18/25 and returned to work on 1/24/25. There was no negative COVID test documented on the line listing. An interview was conducted with the Maintenance Assistant on 2/5/25 at 9:53 AM. The Maintenance Assistant reported he left work on 1/17/25 because he felt bad and he tested at home for COVID on 1/18/25 and it was positive. The Maintenance Assistant reported he worked in all areas of the building prior to becoming sick. The Maintenance Assistant reported he returned to work on 1/24/25 and he had not retested for COVID prior to returning to work. The Maintenance Assistant explained he was told to stay out of work for 7 days by the Infection Preventionist (IP). The Maintenance Director tested positive for COVID on 1/18/25 at home and 1/22/25 at the facility and returned to work on 1/23/25. There was no negative COVID test documented on the line listing for the Maintenance Director. The Maintenance Director was interviewed on 2/5/25 at 9:41 AM. The Maintenance Director reported he started feeling bad at home on Saturday 1/18/25 and he tested on [DATE] and it was positive. The Maintenance Director reported the week before he was sick, he worked in all areas and halls of the building. The Maintenance Director reported he notified the facility on 1/19/25 that he was positive and stayed out of work until 1/23/25 when he came to facility briefly to put salt on the pavement in preparation for a winter storm. The Maintenance Director reported he was told to stay out of work for 5 days by the IP and returned to work on 1/24/25. The Admissions Director tested positive for COVID on 1/20/25 and returned to work on 1/28/25. There was no negative COVID test documented on the line listing for the Admissions Director. An interview was conducted with the Admissions Director on 2/5/25 at 11:49 AM. The Admissions Director explained she tested positive on 1/20/25 and returned to work on 1/28/25. The Admissions Director reported she was not vaccinated for COVID, and she was told to stay out of work for 7 days by the IP. The IP was interviewed on 2/3/24 at 11:24 AM and she reported she was not aware of the CDC guidance for staff to stay out of work for 10 days if they did not test negative for COVID 48 hours before their return. The IP reported she thought the CDC guidance instructed staff to stay out of work for 7 days after testing positive for COVID. The Director of Nursing (DON) was interviewed on 2/4/25 at 8:32 AM. The DON reported she had tested positive for COVID on 1/20/25 and was out of work until 1/30/25 and she was not available during the first part of the outbreak. The DON reported she was not aware staff were not staying out of work for 10 days. A facility Nurse Consultant was interviewed on 2/5/25 at 11:32 AM and reported contingency staffing protocols were used by the facility for returning to work after COVID. A follow-up interview was conducted with the facility Nurse Consultant on 2/5/25 at 12:25 PM and she reported she was not aware the contingency staffing protocol was no longer applicable. The Physician was interviewed on 2/5/25 at 9:20 AM and he reported staff should follow the CDC guidance for returning to work after COVID. The Administrator was notified of Immediate Jeopardy on 2/4/25 at 12:26 PM. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to operationalize infection control policy and procedures in accordance with current Centers for Disease Control and Prevention (CDC) guidance for COVID testing, transmission-based precautions and return to work criteria for Healthcare Personnel during a COVID outbreak. On 1/17/25 Resident #78 (200 hall) reported symptoms of not feeling well (weakness, malaise, and productive cough); chest XRAY was ordered and Resident placed on precautions for rule out of COVID. COVID test on 1/17/25 was negative. Resident was tested on [DATE] as part of the Day 1, 3, 5 testing recommendation, result was positive on Day 3. Because the Resident was in a private room with isolation measures in place, contact tracing for COVID testing was not initiated. The Maintenance Assistant felt bad on 1/17/25 (Friday) and left work and tested positive for COVID at home on 1/18/25. The Maintenance Assistant worked on all halls the weekdays prior to feeling sick. On 1/18/25 (Saturday) the Maintenance Director started feeling bad at home and tested positive for COVID. He was exposed to COVID by a family member the week before. The Maintenance Director worked on all halls the weekdays prior to feeling sick. On 1/20/25 Resident #42 (200 hall) and 3 staff members tested positive for COVID. On 1/23/25 Resident #97 (400 hall) tested positive for COVID. Broad-based COVID testing was not initiated by the facility policy and Center for Disease Control and Prevention (CDC). Contract tracing or broad-based approach COVID testing was not initiated until 2/04/25 after surveyor intervention. Facility policy/procedure was not implemented for testing. Contact tracing or broad-based COVID testing was not completed; staff and residents were not tested per facility policy and CDC guidance. Therefore, Infection Preventionist failed to follow facility policy/procedure for testing and current CDC guidance. On 2/2/25 NA #1 was observed entering a COVID positive room wearing only a KN95 mask. NA #1 was observed assisting the resident to sit up in bed and setting up the resident's meal tray. NA #1 exited wearing the KN95 mask and did not perform hand hygiene. On 2/2/25 NA#2 was observed in a COVID positive room assisting the resident wearing only an N95 mask which was positioned below her nose. NA #2 exited the room wearing the N95 mask. On 2/4/25 Nurse #1 was observed on the hall not wearing a mask for source control while administering medications and stated during interview she only wore a mask into rooms if a resident was on precautions. The facility did not implement policy and procedures for return-to-work criteria for Healthcare Personnel per facility policy and current CDC guidance. The Maintenance Director tested positive for COVID on 1/18/25 and returned to work on 1/23/25. The Maintenance Assistant tested positive for COVID on 1/18/25 and returned to work on 1/24/25. The Admissions Coordinator tested positive for COVID on 1/20/25 and returned to work on 1/28/25. Residents who did not receive the COVID vaccine are most susceptible to serious illness. Residents who are not up to date and Residents who did not test positive may be affected. On 2/4/2025 the Director of Nursing notified the Medical Director of the need for broad-based COVID testing. On 2/4/2025 Residents and/or Responsible Party were notified of the outbreak and the need for the broad-based testing. The management team, which includes the nurse managers, admissions managers, activities manager, and social workers made calls on 2/04/25 to the responsible parties of all residents to inform them of the COVID outbreak and broad-based testing. Communication was in person or via telephone. On 2/4/25, upon awareness of noncompliance with COVID testing guidelines, the[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident, staff, physician and family interviews, the facility failed to protect a resident's (Resident #1) rights to be free from physical abuse when Resident #2 yelled for his roommate, Resident #1 (who was severely cognitively impaired), to leave his stuff alone and then hit Resident #1 3 times with a closed fist on the back of Resident #1's head and neck. This resulted in Resident #1 being transported to the local emergency department (ED) on 7/13/24, where a computerized tomography (CT) scan of the head determined that Resident #1 had a 4-millimeter (mm) hyperdense focus (increased area of density that could indicate bleeding or a stroke) in the right frontal region of his brain that was questionable for focal hemorrhage, subarachnoid (space between the brain and membrane covering the brain) bleeding, or contusion. Resident #1's Glasgow Coma Scale (GCS) was 15 (mild head injury). Resident #1 was transferred to a trauma center, where he was hospitalized on [DATE]. Resident #1 received a repeat CT of the head 6 hours after the original CT, neuro checks every 4 hours, and deep vein thrombosis prophylaxis. Resident #1 was discharged from the hospital to another skilled nursing home on [DATE] with orders to follow up with his primary care physician in 1 to 2 weeks. A reasonable person would be traumatized by this type of physical abuse. This was for 2 of 4 residents reviewed for abuse. The findings included: Resident #1, who was [AGE] years old, was admitted to the facility on [DATE], with diagnoses to include dementia, cognitive communication deficit, anxiety disorder, and generalized muscle weakness. Resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired with fluctuating inattention and disorganized thinking. The MDS also revealed behaviors were present, but no physical or verbal behaviors were exhibited. According to the MDS, Resident #1 had clear speech, adequate vision and hearing. Resident #2, who was [AGE] years old, was admitted to the facility on [DATE], with diagnoses to include abnormalities of gait and mobility, muscle weakness, intellectual disabilities, and a cognitive communication deficit. Resident #2's most recent MDS dated [DATE] indicated that Resident #2 was cognitively intact, with no physical, verbal, and/or cognitive behaviors exhibited. He was independent for self-care and used a manual wheelchair for mobility. A review of Nurse #1's progress note for Resident #1 dated 07/13/24 at 8:15 pm revealed that Nursing Assistant (NA) #2 informed him that Resident #2 was assaulting Resident #1. Nurse #1 heard Resident #2 yelling as he approached the room. Upon entering the room, he observed Resident #2 behind the privacy curtain and Resident #1 hitting him in the back of the head. Nurse #1 intervened by holding Resident #2's arms, asking NA #2 to take Resident #1 out and away from Resident #2, and asking other staff members to call 911. Nurse #1 documented a small tear on the right side of Resident #1's head, with stable vital signs, and noted the need to send Resident #1 to the hospital for assessment. Nurse #1 notified Resident #1's family, the on-call provider, the Director of Nursing (DON), and the Administrator. Staff continued to monitor. A review of Nurse #1's progress note for Resident #2 dated 07/13/24 at 8:15 pm documented that Nurse #1 assessed Resident #2 who verbalized no complaints of pain or discomfort, and noted no cuts or bruises. Nurse #1 documented that Resident #2 stated that he snapped because Resident #1 was going through my clothes. Resident #2, who was educated and encouraged to report concerns to a staff member, was transferred to an alternate room on another hall. Nurse #1 notified Resident #2's family, the on-call provider, the DON, and the Administrator. Staff continued to monitor. A review of the Incident Report dated 07/13/24 was completed by Nurse #1 and revealed that Resident #2 exhibited physical aggression towards Resident #1, causing cuts/skin tear on the right side of Resident #1's head. A telephone interview was conducted with NA #3 on 07/31/24 at 9:49 am. She recounted that she was at the nursing station when she heard Resident #2 yelling that he told another person Not to mess with my stuff; then, she ran to the room's doorway where she saw Resident # 1 and Resident #2 behind the privacy curtain. NA #3 stated that she remained halfway in the residents' room and halfway out of the room, and did not enter the room for her safety. NA #3 stated that she asked NA #2, who arrived behind her, to call for assistance. NA #3 stated that Nurse #1 arrived and bear-hugged Resident #2, who was standing, as he pulled Resident #2 away from Resident #1, while NA #2 pushed Resident #2, who was in his wheelchair, to the nursing station. NA #3 stated that she heard punches from the hallway at the time that Nurse #1 entered the room and approached Resident #2, but was unsure of how many punches she heard. NA #3, who did not recall any conflicts between Resident #2 and Resident #1 (or any residents), stated that Resident #2 was concerned that his family would think that Resident #2 did not appreciate the new clothes they had given to Resident #2 if they saw Resident #1 wearing the clothes. During a telephone interview with NA #2 on 07/31/24 at 10:18 am, he stated that he was in another resident's room when he heard Resident #2 talking loudly to Resident #1, so went to check on them. NA#2 did not report hearing Resident #2 hitting Resident #1. Upon his arrival to the entryway of the room, NA #2 found NA #3 standing in the doorway, and Resident #2 standing behind Resident #1 who was seated in his wheelchair. He stated that he did not see Resident #2 hitting Resident #1, and did not notice Resident #1 guarding himself. NA #2 left NA #3 to monitor the residents while he ran to get the assistance of Nurse #1. NA #2 stated that he never noticed Resident #1 looking through Resident #2's clothing, but would not rule it out. A telephone interview was conducted with Nurse #1 on 07/31/24 at 11:14 am, at which time he explained he thought NA #2 was kidding when he beckoned Nurse #1 to assist with an altercation between Resident #1 and Resident #2 on 07/13/24. Nurse #1 stated that he ran to the room to find Resident #1 seated in his wheelchair, between Resident #1's bed and the window. Nurse #1 stated that Resident #2, whose wheelchair was on the other side of the room near Resident #2's bed and the door, was standing behind Resident #1, hitting Resident #1 in the back of his head/neck area 3 times. Nurse #1 stated he bear-hugged Resident #2 and instructed NA #2 to push Resident #1 to the nursing station for safety, then to have staff call for medic and police dispatch. Nurse #1 stated Resident #1 was transferred to the ED; however, Resident #2, who denied injuries, agreed to be assessed but refused medic transport to the hospital. Nurse #1 shared that Resident #1 was sometimes confused. To ensure Resident #1's safety, Nurse #1 moved Resident #2 to an alternate room on another hallway where there were no other residents who may have wandered into Resident #2's room. A review of the Police Department Report dated 07/13/24 indicated that Resident #1, who appeared confused, stated he did not know why Resident #2 punched him. The report continued, Resident #2 informed the officer that Resident #1 was trying to steal his clothing, didn't stop doing so when asked, thus Resident #2 began hitting Resident #1 in the back of his head to defend my property. The report noted that Resident #1 was transported by emergency medical services (EMS) to the ED and Resident #2 was evaluated on scene by EMS, however his injury did not necessitate transfer to the ED. The report stated that the Officer declined to cite Resident #2 for the assault due to his physical condition and his reliance on medical staff. A review of Resident #1's ED records dated 07/13/24 at 10:17 pm included CT scans of his head and his facial bones with impressions of tiny potential focus of hemorrhage in the high right frontal region, and a recommendation for follow-up. CT scans of Resident #1's facial bones without contrast and cervical spine indicated no CT evidence of facial injury and no CT evidence of cervical injury, respectively. The physician assistant's (PA's) physical exam noted abrasions to the face of Resident #1. The PA's discussion with the neuro intensive care unit resulted in the recommendation that Resident #1 be transferred to another hospital equipped with trauma services for examination and observation. A review of the EMS run sheet dated 07/14/24 revealed that Resident #1 was transported by critical care transport from the local ED to the main hospital's trauma ED for admission to the trauma department. Orders were for a repeat CT of Resident #1's head 6 hours after the original CT, neurological checks every 4 hours, and deep vein thrombosis prophylaxis. A review of Resident #1's hospital records dated 07/14/24 at 3:05 am revealed a Glascow coma scale of 15 (used to score Resident #1's level of consciousness, from 3 to 15, with 15 indicating mild traumatic brain injury (TBI) or a concussion). The repeat CT of the head revealed Resident #1 had a 4 mm hyperdense focus in the right frontal region questionable for focal hemorrhage, subarachnoid, or contusion, which was unchanged from the previous CT scan of the head. The physician concluded that Resident #1's bones were osteopenic (loss of bone density) which limited evaluation and Resident #1 had no acute fractures or dislocations. Hospital treatment included a repeat CT of Resident #1's head 6 hours after the original CT, neuro checks every 4 hours, and deep vein thrombosis prophylaxis. During hospitalization, Resident #1 received neurological surgical consultation that determined no further interventions were needed. Resident #1 was discharged to an alternate nursing facility on 07/24/24 with orders to follow up with his primary care physician in 1 to 2 weeks. New medication orders for Resident #1 included an over-the-counter pain medication, and gabapentin (an antiseizure medication that is used to treat nerve pain) 300 milligrams by mouth as needed to treat neurological pain. During a telephone interview with Resident #1's family on 07/30/24 at 4:03 pm, Family Member #1 reported since the incident on 7/13/24 Resident #1 was more forgetful, much more fearful, and appeared to be afraid of another attack. A review of the physician progress note dated 07/17/24, which included a psychiatric assessment, revealed that Resident #2 was at baseline mental status and functional status with normal behavior and no homicidal ideations. In addition, the physician stated that Resident #2, who was placed on 1:1 observation immediately following the physical abuse of Resident #1, did not need 1:1 observation. An interview was conducted with the residents' physician on 07/31/24 at 11:02 am. The physician described Resident #1 as having major neurocognitive disorder who sometimes strayed from the topic during conversation (but could be redirected) and did a lot of repeating which was consistent with his dementia, though medically stable despite his cognitive deficits. He denied concerns regarding Resident #1's upper extremity range of motion (ROM), and felt that Resident #1 had the ability to guard himself. The physician, who denied observed tension between Residents #1 and #2, stated that neither resident verbalized complaints about one another to him prior to the altercation. The physician shared Resident #2 never appeared to be abusive based on his medical assessment. He stated that his 07/17/24 physical and psychiatric examination of Resident #2 revealed that Resident #2 was alert, awake, calm with no resistance to care. In addition, he denied that Resident #2's intellectual and/or cognitive diagnoses impacted Resident #2's actions. An interview was conducted with Resident #2 on 07/30/24 at 4:30 pm. He stated he did not appreciate Resident #1 going through his clothes. Resident #2 reported that he informed the lady that passed meds that Resident #1 was going through his clothing, but was not sure of her name. He stated that she kinda brushed it off, and told Resident #2, you need to stop doing {hitting} Resident #2 stated that he did report his concern at a Resident Council meeting, but felt that others did not understand and could not relate to his concern. Resident #2 stated that he is normally in the Common Area, but returned to his room on 07/13/24 because he was not feeling well, and found Resident #1 going through his clothing. Resident #2 continued, I got mad, and I hit him with my right hand - with my knuckles. He stated that Resident #1 hollered, then Nurse #1 came into the room, put his arms around me, and I just dealt with it. It kinda clicked in my mind, 'You stop.' On 07/13/24, after hitting Resident #2 shared regret that he hit Resident #1 with Nurse #1. He stated, I'm sorry. And, I hope to handle other conflicts better. I learned my lesson. A review of the Grievance and Complaint Log from 01/01/24 to 07/30/24 revealed no complaints about clothing being taken from Resident #2 and/or other residents. A review of Resident Council Minutes, from 01/01/24 to 07/30/24, had no reported concerns of residents' personal property being disturbed, and revealed that Resident #2 attended the 05/27/24 meeting but noted no reported concerns. During an interview with the DON and the Corporate Consultant on 07/31/24 at 2:34 pm, they stated that they both spoke with Resident #2 after the altercation. The DON and Corporate Consultant said that Resident #2 told them that he overheard Resident #1 speaking with his family over the phone about Resident #1's upcoming discharge. Resident #2, who had given Resident #1 items in the past, was concerned that Resident #1 planned to take Resident #2's clothing home with him. They stated that all staff had been re-educated on policies, which included resident abuse/neglect, resident rights, de-escalation, and reporting allegations. During a telephone interview with the Facility Administrator on 08/01/24 at 1:13 pm, he reported that there were no known prior triggers to indicate that Resident #2 would abuse Resident #1, other residents, or staff, based on the facility's investigation. The facility Administrator was notified of Immediate Jeopardy on 07/31/24 at 4:15 pm. The facility provided the following corrective action plan for immediate jeopardy removal: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 7/13/2024, around 8:15pm, NA #2 and NA #3 heard yelling coming from room [ROOM NUMBER] and observed Resident #2 up behind Resident #1. Resident #2 was yelling for Resident #1 to stop touching his stuff. Resident #2 did not respond to verbal requests to calm down. NA #2 immediately ran to get the Nurse #1 to assist while NA #3 remained with residents in room. Resident #2 started punching Resident #1 and NA #3 was not able to stop attack and seconds later, NA #2 and Nurse #1 returned to room [ROOM NUMBER]. Nurse #1 grabbed Resident #2 in a bear hug to prevent Resident #2 from continuing to punch Resident #1 and instructed NA #2 to remove Resident1 from the room and to notify 911. Facility staff immediately separated residents. Resident #1 and Resident #2 were assessed for injury. Resident #1 noted with blood coming from right side of head. Nurse #1 notified Resident #1's Doctor and received order to transfer Resident #1 to the hospital for evaluation. Responsible Party for Resident #1 and Resident #2 were notified of the altercation and injuries. At approximately 8:20pm, paramedics and police arrived to facility. Resident #1 was assessed by paramedics and Resident1 was transferred to hospital for further evaluation. Resident #2 was relocated to a private room off the unit for close observation. On 7/13/2024, at approximately 8:24pm the Director of Nursing and the Nursing Home Administrator were notified of the Resident-to-Resident altercation. On 7/13/2024, at approximately 10:07pm, The Nursing Home Administrator submitted initial self-reported incident to DHSR. On 7/15/24, Resident #2 was relocated back to room [ROOM NUMBER] and placed on 1:1 observation. 1:1 observation will remain in place. The discontinuation of 1:1 observation will be determined by QAPI committee and psychiatric services. On 7/15/24, the nursing home administrator notified Adult Protective Services. On 7/15/2024, the social worker notified the consulting psychiatrist and consent was obtained for Resident #2 to be evaluated by psychiatric services. On 7/15/2024, Resident #2 was evaluated by Nurse Practitioner. No new orders. On 7/15/2024, Regional Director of Clinical Services, Director of Nursing and Nursing Home Administrator completed Root Cause Analysis. Root cause determined as roommate incompatibility. Root Cause Analysis reviewed by QAPI committee. On 7/17/2024, Resident #2 was evaluated by Attending Physician. No new orders. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 7/15/2024, to identify other potential like residents, current residents with a BIMS of 12 and above were interviewed by facility social worker related to roommate compatibility, safety, and overall well-being. Three rooms were identified with potential roommate compatibility issues. Room(s) 114, 130, 106 On 7/15/2024, Social worker contacted resident family for Resident 114, family declined room change. On 7/15/2024, social worker contacted Responsible Party for resident's residing in room [ROOM NUMBER]. Both resident Responsible Party's declined changing a room. On 7/15/2024, social worker offered a room change to Resident in 106b. Resident declined a room change. On 7/15/2024, The RN Unit Manager performed head to toe skin assessments on all residents that had a BIMS score less than 12. No adverse findings. On 7/15/2024, the Regional Director of Clinical Services and facility Clinical Quality Specialist reviewed all facility progress notes and care plans for the past 30 days to identify residents with documented behaviors and to ensure resident care plans were up to date On 7/15/2024, the MDS coordinator reviewed all resident medical records with similar diagnoses to ensure behaviors indicated were care planned appropriately with interventions. No concerns found. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 7/15/24, the Director of Nursing/designee re-educated current staff on the abuse policy and procedure, including providing quality of care and services to each resident based on the plan of care and potential trigger behaviors and de-escalation techniques/process. The Director of Nursing will ensure that newly hired employees will receive education during facility orientation on the facility abuse policy and procedure, including quality of care and services to each resident based on the plan of care and potential trigger behaviors and de-escalation techniques. On 7/15/2024, the Nursing home administrator and the Director of Nursing were re-educated by the Regional Director of Clinical Services on the revisions made to the orientation education detailed above. On 7/15/24, the Regional Director of Clinical Services educated IDT on Grievance Process to ensure resident grievances are followed up with appropriately and timely. On 7/15/2024, an Ad Hoc QAPI was completed. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On 7/15/2024, to monitor and maintain ongoing compliance the facility social worker/designee will conduct 5 resident interviews weekly for 4 weeks, then monthly for 2 months to ensure there are no issues with behaviors, abuse/neglect, or roommate compatibility issues. Any concerns identified will be reported immediately to the Administrator. Interview results will be submitted to the QAPI committee for further review and recommendation. On 7/15/2024, to monitor and maintain ongoing compliance the facility director of nursing/designee will conduct 5 staff interviews weekly for 4 weeks then monthly for 2 months to ensure there are no issues with behaviors, abuse / neglect, or roommate compatibility issues. Any concerns identified will be reported immediately to the Administrator. Interview results will be submitted to the QAPI committee for further review and recommendation. On 7/15/2024, to monitor and maintain ongoing compliance the facility Interdisciplinary Team, to include Administrator, admission Coordinator, Director of Nursing, Social worker, will review potential admissions for roommate compatibility prior to accepting patient. Criteria to determine compatibility was explained to social worker and admission coordinator by the Administrator on 7/15/2024. Roommate compatibility is a multifactorial determination based on medical diagnoses affecting cognition and inappropriate behaviors. Above responsibilities were discussed during Ad-hoc QAPI completed on 7/15/2024. Alleged Compliance date: 7/16/24 The corrective action plan was reviewed onsite and validated on 08/02/24. Interviews with current staff revealed they received education and training on resident-to-resident abuse, resident rights, de-escalation, and reporting abuse. Staff education was reviewed. Monitoring of staff interviews was reviewed. Roommate compatibility was reviewed. The audits conducted on 07/15/24 revealed that residents were interviewed about abuse and concerns with roommates, and skin assessments were completed on non-interviewable residents. The education provided to the Administrator by the Regional Director of Clinical Services, audits conducted by the Regional Director of Clinical Services and the Ad Hoc QAPI meeting notes from 7/16/2024 were reviewed. The Administrator, Director of Nursing, and Regional Director of Clinical Services were interviewed. The facility compliance date of 07/16/24 was validated. Immediate jeopardy was removed 7/16/24.