**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to follow appropriate infection control practices during a COVID-19 outbreak for 2 of 4 halls reviewed for infection control. This deficient practice was determined to be an immediate jeopardy situation and placed residents at risk for contracting COVID-19. Findings include: The CDC's 3/6/24 Preventing Transmission of Viral Respiratory Pathogens in Healthcare Settings website, https://www.cdc.gov/infection-control/hcp/viral-respiratory-prevention/index.html, specified health care personnel are advised to apply appropriate Transmission-Based Precautions when providing care to a patient with known or suspected respiratory infection. Infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection included to use Droplet Precautions with patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing or talking. Use an approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection worn during all patient care encounters. Remove face protection before room exit. The CDC's 9/2024 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings website, https://www.cdc.gov/infection-control/hcp/isolation-precautions/index.html, and the facility's 3/2024 Policy for Isolation - Categories of Transmission Based Precautions specified in all healthcare settings, providing patients who are on Transmission-Based Precautions with dedicated noncritical medical equipment (e.g., stethoscope, blood pressure cuff, electronic thermometer) has been beneficial for preventing transmission. When this is not possible, adequately clean and disinfect the items after each use and before use for another resident. On 1/27/25 and 1/28/25 between the hours of 6:59 AM and 4:24 PM the following observations and interviews occurred: - Rooms 302, 305, 307, 312, 315, 404, 405, 413, 414 and 417 were identified as Transmission Based Precautions (TBP) rooms where COVID-19 positive residents resided. - Staff 20 (CNA) exited room [ROOM NUMBER] with a respirator on her face and goggles on top of her head. Staff 20 removed the goggles with bare hands, placed the goggles in a pocket, removed the respirator and crinkled it into her hand, obtained a new respirator from a package of unused respirators while holding the contaminated respirator in the same hand, and donned the clean respirator. Staff 20 did not perform hand hygiene during the process. - While preparing to enter room [ROOM NUMBER], Staff 23 (LPN) donned a gown and gloves and did not don a new respirator and did not don eye protection. Staff 23 entered room [ROOM NUMBER] and provided close-contact direct care. Staff 23 exited the room, doffed the gown and gloves and did not doff the respirator. Staff 23 stated she was unsure if she needed eye protection during care for a resident known to be infected with COVID-19. Staff 23 stated she did not believe she needed to remove the respirator upon exit of a TBP room and stated the mask needed to be changed only when visibly soiled. - Staff 23 entered room [ROOM NUMBER] with gown, gloves, respirator and face shield. Upon exit, Staff 23 held the used face shield in her bare hands, did not remove or change the respirator and walked down the hall to the treatment cart. Staff placed the used face shield on the treatment cart without a barrier and did not disinfect the shield. Without changing the respirator used in room [ROOM NUMBER], Staff 23 entered room [ROOM NUMBER], a non-COVID-19 room, and provided close contact care. - Staff 24 (CNA) approached room [ROOM NUMBER] with a respirator and eye glasses donned. Staff 24 donned a gown and gloves and picked up a clear plastic bag from the floor which contained a blood pressure cuff, stethoscope, thermometer and oximeter (used to measure blood oxygen levels). Staff 24 entered room [ROOM NUMBER], removed the vitals equipment from the bag and placed the pieces directly on the resident's bed. Staff 24 obtained the resident's vital signs using the various pieces of equipment, placed the thermometer, oximeter and cuff back into the bag and placed the stethoscope around her neck. Staff 24 did not disinfect the equipment at any time during the process. Staff 24 exited the room after doffing the gown and gloves, did not remove the N95 or eye glasses and had the stethoscope draped around her neck. Staff 24 walked down the hall to the nursing station, placed the bag of vitals equipment directly on the counter, donned gloves and wiped the oximeter and thermometer with an alcohol prep pad. Staff 24 did not remove and disinfect the stethoscope and did not change the respirator. Staff 24 stated she did not remove the glasses between resident cares and left them on throughout the entire shift. Staff 24 stated she used the same vitals equipment for all of the residents on the 400 hall, including those residents not infected with COVID-19. - Staff 25 (RN) doffed his respirator, did not perform hand hygiene, donned a new respirator, did not don eye protection and then entered room [ROOM NUMBER]. Staff 25 stated he forgot to don eye protection and stated when he wore eye protection, he used the face shield which hung on the treatment cart in the hallway. - Staff 22 (CNA) stated she thought it was okay to store the used face shields in the PPE storage containers which hung on the room door and the face shields were shared with other staff. - Staff 9 (CNA) exited room [ROOM NUMBER], doffed the face shield and placed the used face shield inside the storage container with clean, unused PPE. Staff 9 stated she left the respirator on upon exit and stated she wore the same respirator in and out of resident rooms and at the nursing station. - Staff 26 (Physical Therapy Assistant) entered room [ROOM NUMBER], wore a respirator and did not don a gown, gloves or face shield. Staff 26 stated he was supposed to don PPE before entering but did not because he checked on the resident real quick. Staff 26 did not doff the respirator upon exit and continued to wear the same respirator throughout the hall. - Staff 27 (Physical Therapist) exited room [ROOM NUMBER] with a respirator and face shield donned. Staff 27 walked to a treatment cart at the end of the hall, donned gloves, removed the face shield, cleaned the shield with a disinfectant wipe, doffed the gloves, performed hand hygiene, tucked the used face shield between her side and arm and walked down the hallway. - Used face shields were stored on name placards outside of TBP rooms. - Used face shields were stored inside PPE storage containers, in contact with clean, unused PPE. - Used face shields were stored on medication and treatment carts in the 200, 300 and 400 hallways. On 1/28/25 at 8:29 AM and 9:55 AM Staff 2 (DNS) and Staff 3 (DNS in training) stated if a resident room was identified on TBP for COVID-19, staff were expected to don the required PPE before crossing through the doorway of the room. Staff 2 and 3 stated appropriate PPE included a gown, gloves, respirator and face shield which should be donned prior to entrance and doffed upon exit. Staff 2 and 3 indicated all PPE worn in a TBP room was considered contaminated and was to be discarded upon exit. Staff 2 and 3 stated they expected staff to don a new respirator right away and the same respirator was not worn in other rooms. Staff 2 indicated there was an abundance of face shields readily accessible and available and goggles were not an acceptable form of eye protection in a TBP room. Staff 2 stated she expected face shields were not shared between staff or used between resident care. She stated if face shields were reused by a single staff, she expected staff to disinfect the shield with the appropriate disinfectant between uses and store the used face shield in the PPE container. Staff 2 stated each TBP room was supplied with a dedicated stethoscope stored inside the room and was used on that resident only. She indicated if resident care equipment was shared among residents, the expectation included the equipment was disinfected with the appropriate product between every resident. Staff 2 acknowledged there was a risk of contamination and spread of infection if staff did not remove potentially contaminated PPE after resident care in a TBP room. Staff 2 stated the facility's first case of COVID-19 was identified on 1/9/25. On 1/28/25 at 12:00 PM Staff 1 (Administrator), Staff 2, Staff 3 and Staff 28 (Administrator in training) were informed the facility's failure to implement appropriate infection control during a COVID-19 outbreak constituted an Immediate Jeopardy situation. An IJ removal plan was requested. On 1/28/25 at 3:21 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: 1. Immediate staff training was initiated by the DNS and Administrator on COVID transmission protocols, proper use of PPE (donning, doffing and reuse), storage and handling of PPE, disinfecting and use of equipment. 2. Staff who received training included CNAs, nurses, housekeeping, laundry, maintenance, administrative staff, agency staff and contracted staff. 3. Staff training was done immediately for all staff in the facility then at each shift change on 1/28/25. 4. Documentation of training would include a sign in sheet and a PPE competency validation form. 5. Continued training would be conducted at each shift change and/or 1:1 until all staff received training. 6. For staff who were on leave, training would be provided prior to returning to work. 7. Facility will have a quality assurance meeting with the committee (Medical Director, Infection Preventionist, DNS, Administrator and other interdisciplinary members) on 1/28/25 to review policies and procedures on TBP and COVID-19 precautions, including proper use of PPE, storage and equipment use. 8. DNS and Infection Preventionist will conduct visual audits every shift for three days, then weekly for four weeks, then monthly ongoing to ensure continued compliance with COVID and TBP requirements. 9. Audits will be reviewed by the quality assurance team monthly for six months to ensure ongoing compliance. On 1/29/25 at 9:54 AM it was determined the immediacy was removed after verification of completion of the IJ removal plan.