**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, documentation, observations, resident and staff interviews and state and federal guidance it was determined that the facility failed to implement COVID and Influenza monitoring, tracking, and testing in accordance with state and federal guidance for 95-101 residents from 11/29/24, through 1/15/25. The facility failed to adhere to state return to work guidance for staff. These failures placed all residents in the facility in an Immediate Jeopardy situation. Review of the facility Infection Prevention and Control Program Policy dated 4/16/18, last revised 9/11/23, indicated it is the facility's policy to maintain an organized, effective facility-wide program designed to systemically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and contract healthcare workers, to conduct surveillance of communicable disease and infectious outbreaks, and to monitor employee health. It was indicated employees must follow return to work guidance. Review of the Pennsylvania Department of Health Influenza Outbreaks in Long-Term Care Facilities: Toolkit for Facilities dated 2023-2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following: -As soon as a respiratory outbreak is suspected, the response should include laboratory testing (i.e., rapid antigen testing, PCR, and/or viral isolation) to evaluate residents and staff and determining the etiology of the outbreak. Specimens should be collected within the first 24-72 hours after symptoms onset and no later than 5 days after symptom onset. -Upon identification of an outbreak, a line listing (designed to collect information about all ill cases for residents and staff during an outbreak of influenza in a long-term care facility) should be utilized to collect and organize information. Information should be updated periodically during the outbreak for all cases. -During an outbreak, conduct daily active surveillance for ILI (influenza-like illness-fever greater than 100F plus cough or sore throat) among residents, staff and visitors to the facility until at least one week after the last confirmed influenza case occurred. -All residents and staff with ILI should receive antiviral treatment immediately; treatment should NOT be delayed while waiting for laboratory confirmation. Review of the Pennsylvania Department of Health COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care Version 1.1 dated February 2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following: During the Outbreak: COVID-19 Outbreak Management and Control Measures included: -Identify and Isolate First Case. -Identify Additional Cases and Exposures. -Exposed asymptomatic residents and HCP (health care professional) should be tested with a series of up to three viral tests. -Determine approach (contact-tracing, unit-based, facility-based). -Identify exposures because of close contact. -Test exposures immediately (but not within 24 hours of exposure) and if negative, another test at 48 hours, and if negative another test 48 hours later. -Returning to Routine Operations -The facility can return to routine operations when the outbreak has been deemed as complete, which occurs after 14 days without new cases. -Evaluation and Monitoring of Residents -It is important to assess for the following symptoms and implement prompt isolation and further evaluation for COVID · Fever or chills · Cough · Shortness of breathe · Fatigue · Muscle or body aches · Headache · New loss of taste or smell · Sore throat · Congestion or runny nose · Nausea or vomiting · Diarrhea -Return to Work Criteria for Healthcare Personnel (HCP) who are NOT moderately to severely immunocompromised · At least seven days have passed since symptoms first appeared; AND a negative antigen (test used to determine current or recent infection) or Nucleic Acid Amplification Test (NAAT-detects one or more RNA sequences of SARS-CoV-2 and is considered the gold standard for clinical testing. If someone with prior COVID infection within 90 days, antigen testing is recommended) ) is obtained within 48 hours prior to returning to work OR 10 days have passed if testing is not performed or the HCP tests positive at day 5-7; · At least 24 hours have passed since last fever without the use of fever-reducing medications; AND · Symptoms (e.g., cough, shortness of breath) have improved. Review of resident clinical records and facility documents revealed: Review of Resident R11's clinical record indicated an admission date of 12/13/19, and readmitted [DATE], with diagnoses of heart failure (occurs when the heart muscle doesn't pump blood as well as it should), myopathy (disorders of the muscles that cause them to function less effectively), and chronic kidney disease (disease that involves a gradual loss of kidney function). Review of a report submitted to the Department of Health dated 11/30/24, indicated Resident R11 tested positive for COVID on 11/29/24, while at the hospital. It was indicated as a follow-up action, the facility tested staff prior to the start of their shifts. The COVID Tool Kit will be followed, and a line listing will be developed for tracking purpose. We will also assess any resident, staff, visitors that would be symptomatic during our COVID testing. Review of the facility's COVID tracking log indicated Resident R11 tested positive at the hospital on [DATE]. The facility failed to accurately track when the COVID outbreak started. Review of Resident R9's clinical record indicated an admission date of 9/20/23, and readmitted [DATE], with diagnoses of Chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), high blood pressure, and bipolar disorder (a mental health condition that causes extreme mood swings). Review of the facility's COVID tracking log revealed Resident R9 tested positive at the hospital on [DATE]. Review of the facility documents and resident's clinical records revealed residents tested negative on Day 1, Day 3, and Day 5. The facility failed to provide evidence that all residents were monitored for signs and symptoms of COVID after Day 5 (12/15/24) of testing. Review of the facility documents revealed Nurse Aide, Employee E8 tested positive for COVID on 12/25/24. Review of the facility document titled COVID Dec/[DATE] Contact Tracing indicated contact tracing was completed for Nurse Aide, Employee E8 and Residents (R5, R6, R8, R9, R12, R13, R21, R26, R27, R33, R38,R43, R44, R47, R52, R53, R57, R62, R68, R70, R73, R87, R92, R94 R199, R201, R248, R249) were tested on Days 0, 3, and 5 and they were all negative. Review of the facility testing log revealed the facility failed to test residents on Day 1, 12/26/24. Review of the facility documents revealed Infection Preventionist, Employee E1 tested positive for COVID on 1/8/25. During an observation on 1/14/25, at 11:30 a.m. the signage posted at the facility's entrance stated if staff test positive for a respiratory illness (COVID, Flu, RSV) in the last 10 days, do not enter resident care areas. It was indicated to wait 10 days after the date of the positive test, symptom onset, or exposure to return work. During an interview on 1/14/25, at 12:52 p.m. Infection Preventionist, Employee E1 stated during a COVID outbreak residents are tested on Day 0, 1, 3, and 5. IP, Employee E1 stated if staff members are positive for COVID, they can return to work on the 5th day if they test negative. IP, Employee E1 confirmed she tested positive for COVID on 1/8/25, and returned to work on 1/13/25. IP, Employee E1 confirmed she failed to wait at least seven days since symptoms first appeared and test negative 48 hours prior to returning to work or wait at least 10 days since she tested positive to return to work. During an interview on 1/14/25, at 1:26 p.m. the NHA and Regional Director of Clinical Services, Employee E5 confirmed Infection Preventionist, Employee E1 failed adhere to return to work guidelines. During an interview on 1/15/25, at 10:54 a.m. IP, Employee E1, NHA, and RDCS, Employee E5 confirmed the facility failed to accurately track, test, and monitor resident's during the COVID outbreak. Review of Resident R9's clinical record indicated on 1/3/25, Resident R9 was ordered Guaifenesin (medication used for cough) for a cough. Review of clinical record failed to indicate he was monitored for ILI symptoms or tested for Influenza. Review of Resident R9's progress note dated 1/5/25, indicated Resident R9 requested Robitussin (medication used for cough) for his cough. Review of Resident R9's progress note dated 1/10/25, at 5:15 p.m. indicated Resident R9 was demanding to have an ambulance called to be taken to the emergency room for cold symptoms. The facility staff informed him that the ER is for life-threatening emergencies and that his cold could be treated in house. Resident R9 then requested a breathing treatment. Review of Resident R9's progress note dated 1/11/25, indicated he was sent out to the hospital for behaviors. The resident tested positive for Influenza A at the hospital. Review of Resident R27's clinical record indicated an admission date of 11/27/24, with diagnoses of heart failure, intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), and pneumonia (infection that affects the lungs). Review of Resident R27's progress note dated 1/6/25, indicated the resident complained of stomach pain and hyperemesis (severe nausea and vomiting) that was dark green in color. Resident R27 was sent to the hospital for further evaluation. The facility failed to assess the resident for ILI symptoms and test for Influenza. Review of Resident R27's progress note dated 1/7/25, indicated on 1/6/25, the resident returned to the facility and was diagnosed with Influenza A. Review of Resident R52's clinical record indicated an admission date of 3/13/21, and readmitted [DATE], with diagnoses of depression, anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and dorsalgia (back pain). Review of Resident R52's progress note dated 1/7/25, indicated the resident went to the hospital for a CT scan. RN, Employee E3 received a call from the emergency room that indicated while the resident was at her appointment she became short of breath and had a cough. She was taken to emergency room and tested positive for Influenza A. During an interview on 1/15/25, at 10:48 a.m. Resident R52 stated I was sick for a couple of days before the hospital with nausea and coughing, I don't think they gave me anything for it. I told the nurses I didn't feel well, I had an appointment out of the building and the doctor sent me to ER and that's when they tested me for flu. Review of Resident R52's clinical record failed to indicate the facility assessed the resident for ILI symptoms and test for influenza. Review of Resident R42's clinical record indicated an admission date of 1/10/22, and readmitted [DATE], with diagnoses of heart failure, hypoxemia (low levels of oxygen in your blood, and anemia. Review of Resident R42's progress note dated 1/11/25, at 9:45 a.m. indicated the resident had fever of 102.5 Fahrenheit, audible wheezing, and oxygen saturation was 78% on room air. The facility failed to conduct Influenza testing. Review of Resident R42's progress note dated 1/11/25, at 2:15 p.m. indicated the resident was transferred to the hospital and tested positive for Influenza. Review of facility's Flu [DATE] line listing report for Influenza, revealed Resident R27 tested positive for Influenza A on 1/6/25. Resident R52 tested positive on 1/7/25. The last reported positive cases were on 1/11/25 (Resident R9, R42, and Housekeeper, Employee E9.) The facility was in an Influenza outbreak as of 1/11/25. During an observation on 1/14/25, at 11:30 a.m. the signage posted at the facility's entrance failed to indicate the facility was in an Influenza outbreak. During an interview on 1/14/25, at 11:32 a.m. the Nursing Home Administrator confirmed the signage posted at the entrance of the facility failed to indicate the facility was in an Influenza outbreak. During an interview on 1/14/25, at 12:58 p.m. IP, Employee E1 stated Resident R27 was sent to the hospital and tested positive for Influenza on 1/6/24. IP, Employee E1 confirmed Resident R52 was sent out for routine visit and was transferred to hospital for a change in condition and tested positive for Influenza. IP, Employee E1 stated we didn't know she had flu until we sent her and stated she was aware she had respiratory symptoms the whole week prior to sending her out to her appointment. IP, Employee E1 stated she would only test for Influenza if the physician was notified, and it was ordered. IP, Employee E1 confirmed the facility failed to monitor residents for ILI symptoms during an Influenza outbreak and test 4 of 4 Residents who had signs and symptoms of Influenza (Resident R9, R27, R42, and R52). During an interview on 1/15/25, at 11:07 a.m. the NHA and RDCS, Employee E5 confirmed the facility failed to test four of four residents for Influenza who had symptoms (Resident R9, R27, R42, and R52). The NHA confirmed no residents were tested for Influenza in the facility. During an interview on 1/15/25, at 2:49 p.m. the Nursing Home Administrator (NHA), Director of Nursing (DON), and RCDS Employee E5 were made aware that an Immediate Jeopardy (IJ) existed. The NHA was provided the IJ Template and at that time a corrective action plan was requested. On 1/15/25, at 5:47 p.m. an acceptable Corrective Action Plan was received, which included the following interventions: Issue #1 -Facility immediately initiated monitoring signs and symptoms for residents with COVID. IP/Designee will conduct house audit of residents with signs and symptoms of COVID by EOD 1/16/25. -Regional Director of Clinical Services will conduct in-service regarding Infection Control and Outbreak Response to facility Infection Preventionist and Director of Nursing by 1/16/25. -IP/Designee will conduct education to all staff regarding infection control measures and monitoring at their start of shift beginning 1/15/25 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct audits to monitor for resident's signs and symptoms for COVID, daily x5 days for 14 days , then weekly for 4 weeks then monthly x2. -Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Issue #2 -Effective 1/15/25, facility will ensure that COVID testing occurs on Day 1 following a positive result in accordance with PA DOH COVID 19 Infection Control Outbreak Response Toolkit for Long Term Care. -IP/Designees will conduct house audit of all COVID testing to ensure Day 1 testing complete upon positive result by EOD 1/16/25. -Regional Director of Clinical Services will conduct in-service regarding Infection Control and Outbreak Response testing procedures to facility Infection Preventionist and Director of Nursing by 1/16/25. -IP/Designee will conduct education to all staff regarding Infection Control and Outbreak Response testing procedures at their start of beginning 1/15/2025 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct audits to monitor for completion of Day 1 testing for positive COVID results, daily x5 days for 14 days , then weekly for 4 weeks then monthly x2. -Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Issue #3 -Effective 1/15/25, facility will ensure that return to work guidance for a staff member who tested Outbreak Response Toolkit for Long Term Care. -IP/Designee will monitor for any COVID positive staff weekly x4 weeks, monthly x2 months, and ongoing with occurrence, to ensure that return to work guidance for a staff member who tested positive for COVID is followed. -IP/Designee will conduct education regarding return to work guidance for a staff member who tested positive for COVID is followed in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care beginning 1/15/2025 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for COVID positive staff and monitor return to work status, weekly with outbreak occurrence in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care by 1/16/25. -Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Issue #4 -Effective 1/15/2025, IP/Designee to ensure that residents exhibiting signs and symptoms of Influenza are monitored in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care. -IP/Designee will monitor all residents weekly x 4 weeks, monthly x 2 months and ongoing with occurrence for any sign and symptoms of Influenza in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care. -Regional Director of Clinical Services will conduct Inservice regarding identification of Influenza signs and symptoms and testing in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/25. -IP/Designee will conduct education to all staff regarding identification of Influenza signs and symptoms and testing in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care beginning 1/15/2025 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms and testing, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/25. -Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Issue #5 -Effective 1/15/2025, IP/Designee will conduct an initial audit of all residents ' temperatures to ensure that residents exhibiting signs and symptoms of Influenza are monitored in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care. -IP/Designee will monitor all residents ' temperatures weekly x 4 weeks, monthly x 2 months and ongoing with occurrence for any sign and symptoms of Influenza in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care. -Regional Director of Clinical Services will conduct Inservice regarding identification of Influenza signs and symptoms and monitoring in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/25. -IP/Designee will conduct education to all staff regarding identification of Influenza signs and symptoms and monitoring in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care beginning 1/15/25 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/2025. -Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Review of medical records and facility documents on 1/16/25, revealed 98 of 98 residents were assessed for signs and symptoms of Influenza and COVID. No residents exhibited IFI symptoms and required Influenza testing. The facility obtained Influenza tests from hospital and were available for staff to use if needed. Facility wide testing was conducted on all residents and staff prior to the start of their shift for COVID. The DON completed an audit of tests and no positive COVID results were identified. The facility will conduct COVID testing until Day 5, then monitor residents and staff for signs and symptoms of COVID, and test as needed, until Day 14. Review of facility documents revealed the policy for Managing respiratory Illnesses and Outbreaks and Investigating Communicable Outbreaks was created 1/16/25. During an observation on 1/16/25, at 9:02 a.m. the signage posted at the entrance of the facility indicated the facility was currently in an influenza and COVID outbreak. Review of facility documents on 1/16/25, revealed the Regional Director of Clinical Services, Employee E5 conducted an in-service with the Infection Preventionist, Employee E1, and the Director of Nursing on 1/15/25. Review of facility documents on 1/16/25, revealed that the facility had 104 employees and 100% had received education on the facility's COVID-19 and Influenza infection control practices and outbreak response. 48 of these employees received formal education on the facility's COVID-19 infection control practices. 56 of these employees had received this education via telephone as they had not been working in the building. Staff are to sign that they received this education when they are in the building before the start of their next shift. During staff interviews conducted on 1/16/25, between 2:45 p.m. and 3:02 p.m. 28 employees confirmed that they received education on the facility's COVID-19 and Influenza infection control practices and outbreak response. 21 of these employees had received education in person and seven of these employees had received education over the telephone and signed the training sheet prior to the start of their shift. The Immediate Jeopardy was lifted on 1/16/25, at 5:49 p.m. when the action plan implementation was verified. During an interview on 1/16/25, at 6:39 p.m. the Nursing Home Administrator confirmed that the facility failed to implement COVID and Influenza monitoring, tracking, and testing in accordance with state and federal guidance for 95-101 residents from 11/29/24, through 1/15/25. The facility failed to adhere to state return to work guidance for staff. These failures placed all residents in the facility in an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and documentation, observations, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during a COVID-19 outbreak. The facility failed to perform contact tracing and testing per PA DOH guidelines and cohorted (an infection prevention and control strategy of grouping residents together who are identified with the same organism to confine their care to one area and prevent contact and spread to other residents) residents who were positive for COVID-19 with residents who were not tested and did not have symptoms of COVID-19. This failure placed the facility in an Immediate Jeopardy situation for 35 of 47 residents reviewed (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, and R35). Review of the Pennsylvania Department of Health COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care Version 1.1 dated February 2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following: During the Outbreak: COVID-19 Outbreak Management and Control Measures included: 1. Identify and Isolate First Case. a. Isolate with transmission-based precautions (TBP) on COVID-19 Care Unit in accordance with most up-to-date isolation guidance or provide source control to positive resident and isolate in room (ideally residents should be placed in a single-person room). b. Place TBP signs on the door to indicate to those entering the COVID-19 Care Unit/room of the personal protective equipment (PPE) requirements when providing care to residents with COVID-19. c. Ensure all required PPE is available including N95 or higher-level respirator, gowns, gloves, and eye protection and is worn. d. Reinforce core infection prevention practices among residents, visitors, and healthcare personnel (HCP) including hand hygiene, appropriate use of PPE, environmental cleaning, and disinfection. 2. Identify Additional Cases and Exposures. a. Exposed asymptomatic residents and HCP (health care professional) should be tested with a series of up to three viral tests. b. Determine approach (contact-tracing, unit-based, facility-based). c. Identify exposures because of close contact. d. Test exposures immediately (but not within 24 hours of exposure) and if negative, another test at 48 hours, and if negative another test 48 hours later. 5. Returning to Routine Operations a. The facility can return to routine operations when the outbreak has been deemed as complete, which occurs after 14 days without new cases. Evaluation and Monitoring of Residents included: Early detection of signs and symptoms of COVID-19 is key to minimize transmission throughout the facility, as It enables HCP to implement mitigation strategies early. Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms, and it is important to assess for other symptoms such as: 1. Fever or chills 2. Cough 3. Shortness of breath 4. Fatigue 5. Muscle or body aches 6. Headache 7. New loss of taste or smell 8. Sore throat 9. Congestion or runny nose 10. Nausea or vomiting 11. Diarrhea With identification of any COVID-19 symptoms, implement prompt isolation and further evaluation for COVID-19 infection. Identify a COVID-19 Care Unit Dedicated to Monitor and Care for Residents with Confirmed COVID-10 included: Dedicating an area within the facility to cohort residents on isolation for confirmed COVID-19 during their infectious period is best practice for decreasing the likelihood of transmission. Components of a COVID-19 Care Unit ideally include the following: 1. Physical separation from other rooms and spaces where residents are not confirmed with COVID-19 2. Single-person room(s) with designated bathroom(s); a. Place a resident with suspected COVID-19 in a single-person room. The door should be kept closed, if safe to do so. The resident should have a dedicated bathroom. b. If limited single rooms are available, or if numerous residents are simultaneously identified to have symptoms concerning for COVID-19, residents may remain in their current location until cause of symptoms is determined. c. If cohorting, only residents with the same pathogens should be housed in the same room. Resident Cohorting Guide included: 1. Resident positive for COVID-19 should not be cohorted with a resident with no respiratory symptoms and not in isolation. 2. Resident positive for COVID-19 should only be cohorted with another resident positive for COVID-19. Review of facility policy Guidelines in Managing Respiratory Illness & Outbreaks dated 1/2/24, indicated one case of COVID-19 is considered an outbreak. The facility is to isolate symptomatic residents as appropriate. Only cohort symptomatic residents with same pathogen confirmed via testing. Conduct contact tracing to determine high risk exposures, perform testing and symptom monitoring as required. Conduct daily symptom surveillance until all cases resolved. The facility must follow mandated testing requirements for COVID, test ALL residents with respiratory symptoms and identified high risk exposures for COVID-19 on days 1, 3, and 5. During an interview on 9/11/24, at 12:38 p.m. when asked how she determines how to handle a communicable disease outbreak, Infection Preventionist Employee E1 stated, I go by what the CDC guidelines are, that's pretty much how I handled the situation, whatever the CDC guidelines say. I do reference the PA HAN as well. When asked if roommates of confirmed positive COVID-19 residents were tested, Infection Preventionist Employee E1 stated, The roommate stayed in the room with the positive resident, we treated them as if they were exposed, but all the residents still had the right to come out of their room, we just encouraged masking. I did not perform contact tracing or testing. I think they did before, but the regulations have changed since the beginning of COVID. We only tested residents if they showed symptoms of COVID or if they requested to be tested. During an interview on 9/11/24, at 12:42 p.m. when asked if the facility cohorted COVID-19 positive residents with residents who had not been tested or displaying symptoms, Infection Preventionist Employee E1 stated, No, we did not split the residents, in the past we did. What I observed is that it [COVID-19] would spread when we would move residents room to room. Review of resident clinical records and facility documents revealed: Resident R1 had symptoms of a sore throat and decreased appetite on 8/5/24, and tested positive for COVID-19 on 8/6/24. Resident R1 remained in the same room with Resident R2, who was not tested. Resident R3 tested positive on 8/7/24, and had symptoms of not feeling well, sweating, and congestion, and remained with roommate Resident R4, who was not tested. Resident R5 tested positive on 8/8/24, and had symptoms of dry cough, and remained with roommate Resident R6, who was not tested. Resident R7 tested positive on 8/10/24, and had symptoms of cough and congestion, and remained with roommate Resident R8, who was not tested. Resident R9 tested positive on 8/13/24, and had symptoms of a fever, sore throat, congestion, and sweating, and remained with roommate Resident R10, who was not tested. Review of a nursing progress note dated 8/13/24, stated, Resident R10 was notified that his roommate has COVID-19. Resident R10 denied having any symptoms. It was explained to Resident R10 that because he has already been exposed to the virus he would need to wash his hands and wear a mask when outside his room. Resident R10 states he understands this but is refusing to re-enter the room. Resident R10 states he hasn't been exposed and spent the night on the dayroom couch. Review of Resident R10's clinical record indicated he was moved to a different room on 8/13/24, upon his request. Resident R11 tested positive on 8/17/24, and had symptoms of congestion and a head cold, and remained with roommate Resident R12, who was not tested. Resident R13 tested positive on 8/17/24, and had no symptoms documented, and remained with roommate Resident R14, who was not tested. Resident R15 tested positive on 8/21/24, and had symptoms of an elevated temperature, and remained with roommate Resident R16, who tested positive on 8/28/24, and had symptoms of a low-grade temperature and feeling flushed. Resident R17 tested positive on 8/24/24, and had symptoms of not feeling well and a low grade temperature, and remained with roommate Resident R18, who was not tested. Resident R19 tested positive on 8/24/24, and had no documented symptoms, and remained with roommate Resident R20, who tested positive on 8/25/24, and had no documented symptoms. Resident R21 tested positive on 8/25/24, and had symptoms of hypoxia (not enough oxygen in the blood). Resident R21 ceased to breathe on 8/26/24. Resident R21 remained with roommate Resident R22, who tested positive on 8/26/24, and had symptoms of hypoxia, altered mental status, and hypoxia. Resident R23 tested positive on 8/27/24, and had flu-like symptoms, and remained with roommate Resident R24, who was not tested. Resident R25 tested positive on 8/27/24, and had symptoms of being flushed, sweaty, emesis, and liquid stools, and remained with roommate Resident R26, who was not tested. Resident R27 tested positive on 8/28/24, and had symptoms of coughing, congestion, sneezing, and malaise (feeling tired), and remained with roommate Resident R28, who was not tested. Resident R29 tested positive on 8/28/24, and had symptoms of coughing, congestion, sneezing, and malaise, and remained with roommate Resident R10, who was not tested. Resident R30 tested positive on 8/29/24, and had symptoms of wheezing and rhonchi (coarse lung sounds caused by constricted airways), and remained with roommate Resident R31, who was not tested. Resident R32 tested positive on 8/30/24, and had symptoms of a fever, and remained with roommate Resident R33, who tested positive on 8/31/24, and had no documented symptoms. Resident R34 tested positive on 9/1/24, and had symptoms of not feeling well, and a low-grade temperature, and remained with roommate Resident R35, who was not tested. During an interview on 9/11/24, at 3:32 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware that an Immediate Jeopardy (IJ) existed. The NHA was provided the IJ Template and at that time a corrective action plan was requested. On 9/11/24, at 6:11 p.m. an acceptable Corrective Action Plan was received, which included the following interventions: - Per PA Department of Health COVID Response Tool Kit, the facility will perform COVID testing for all residents and healthcare providers identified as exposed regardless of vaccination status. - If negative, the facility will test again in 48 hours, after the second negative test (typically day 1, 3, and 5) if additional cases are identified testing should continue on affected units or facility-wide every 3 - 7 days until there are no new cases for 14 days. - The facility is with limited rooms available, residents will remain in their current location until cause of symptoms are determined. - The Medical Director was notified and resident care plans were updated. - All staff will be in-serviced on COVID-19 infection control practices. If any identified COVID infections are noted, the responsible party will be notified. - Education will be completed in person, if staff are not working, phone calls will be made. - To monitor and ongoing compliance, the DON/designee will complete COVID testing. - If COVID positive resident is confirmed, we will shelter in place and pull privacy curtains between both residents, masks will be worn by both residents. - To monitor ongoing compliance, the DON/designee will complete COVID testing according to the PA DOH COVID infection control outbreak response weekly x 4 weeks, then monthly x 2 months. - Results of the audits will be forwarded to the facility Quality Assurance Performance Improvement Committee for review upon completion and recommendations. Review of medical records on 9/12/24, indicated that 101 residents that were not previously tested for COVID-19 were tested on [DATE], all with negative results. 84 staff members who had not previously tested positive for COVID-19 were tested, all with negative results. Review of facility documents on 9/12/24 and 9/13/24, revealed that the facility had 105 employees and 100% had received education on the facility's COVID-19 infection control practices. 57 of these employees received formal education on the facility's COVID-19 infection control practices. 48 of these employees had received this education via telephone as they had not been working in the building. Staff are to sign that they received this education when they are in the building before the start of their next shift. During staff interviews conducted on 9/12/24, between 10:15 a.m. and 2:00 p.m. 22 employees confirmed that they received education on the facility's COVID-19 infection control practices. 13 of these employees had received education in person and nine of these employees had received education over the telephone and signed the training sheet prior to the start of their shift. During an interview on 9/12/24, at 10:07 p.m. Nurse Aide Employee E3 stated, I was told we were cited for not doing the right thing. I figured that was coming. They [administration] don't put too much thought and effort into things. We have been telling them they need to do something. The Immediate Jeopardy was lifted on 9/13/24, at 10:54 a.m. when the action plan implementation was verified. During an interview on 9/13/24, at 11:00 a.m. the DON confirmed that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during a COVID-19 outbreak. This failure placed the facility in an Immediate Jeopardy situation for 35 of 47 residents reviewed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.