**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident received proper treatment and care to maintain good foot health for 1 (Resident #1) of 4 residents reviewed for foot care. (1) The facility failed to ensure Resident #1 who had a diagnosis of atherosclerosis of the extremities (A disease of the peripheral blood vessels characterized by narrowing and hardening of the arteries that affect blood supply to the legs and feet) (The peripheral vessels consist of the veins and arteries not in the chest or abdomen i.e., in the arms, hands, legs and feet) and peripheral vascular disease (a progressive circulation disorder that involves the narrowing, blockage, or spasms in the blood vessels as a result of arteriosclerosis) and was at risk for impaired blood flow to his feet, received assessments of his feet. (2) The facility failed to ensure consistent and timely skin assessments were provided. Resident #1's 09/05/23 scheduled weekly skin assessment was not provided. (3) Resident #1 was seen by the Podiatrist on 08/29/23 and placed a protective sleeve on the second toe of the left foot, gave orders to check the resident's feet daily and monitor for any new wounds/ulcerations. The facility failed to ensure podiatry orders were followed for Resident #1. On 09/10/23 Resident #1 was discovered with a discolored bandage on the second toe of the left foot, an open wound on the second toe of the left foot with bright red blood and yellow purulent (pus) drainage. An Immediate Jeopardy was identified 09/15/23 at 11:45 a.m. The IJ template was provided via email at 11:48 a.m. While the IJ was removed on 09/15/23, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and at a scope of pattern due to all staff had not been trained on reporting changes in skin condition, new procedure for Podiatrist to exit with DON, the importance of carrying out orders timely, importance of completing weekly skin assessments, identifying skin impairments, notifying the physician for wound orders, documentation of assessments and approaches to aid in the prevention of skin breakdown. These failures placed all residents at risk of not receiving foot care consistent with professional standards of practice and complications from impaired circulation which could lead to possible infection, hospitalization, amputation, and death. Findings included: Review of Resident #1's physician's orders dated 09/2023 revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included atherosclerosis of the extremities and peripheral vascular disease. Review of Resident #1's significant change MDS assessment dated [DATE] revealed a BIMS of 5 indicating severely impaired cognition. The MDS assessment reflected the resident was always incontinent of bowel/bladder, totally dependent on two people for transfers, required extensive physical assistance of one person for bed mobility, dressing and personal hygiene. Review of Resident #1's care plan revised 08/30/23 revealed hospice services and diagnoses of hyperlipidemia (Elevated level of lipids such as cholesterol and triglycerides in the blood linked to atherosclerosis (hardening of the arteries) was addressed. Interventions included assessing skin integrity to help identify potential areas for skin breakdown, assessing for signs and symptoms of hyperlipidemia such as the color of the skin, skin turgor, peripheral circulation, and pedal pulses. Review of Resident #1's weekly skin assessments revealed a skin assessment dated [DATE] reflecting the resident's skin was clear. There was no subsequent weekly skin assessment for 09/05/23. Review of physician's orders, MARs/TARs dated 09/2023 reveled no Podiatry orders had been transcribed related to the visit on 08/29/23. Review of hospital records revealed Resident #1 admitted on [DATE] with diagnoses to include sepsis and cellulitis (Bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin. If untreated, it can spread and cause serious health problems) of the second toe on the left foot. The records reflected the resident was assessed on admission with erythema (redness), blistering, purulent draining, and peeling skin to the second toe of left foot with bone exposed. The records reflected the left foot second toe amputation was scheduled for 09/14/23. Interview on 09/13/23 at 9:19 a.m. the DON stated Resident #1 was noted with redness to his left foot, second toe on 09/10/23. LVN B notified the resident's hospice and orders were received for antibiotic treatment. The facility staff were unaware the Podiatrist had visited the facility on 08/29/23 or that the Podiatrist had placed a protective sleeve on the resident's second toe of the left foot. The DON stated the Podiatrist left no orders with the nurse on 08/23/23. The DON stated LVN C was on duty on 08/29/23 when the Podiatrist visited and denied receiving any orders or instructions from the Podiatrist for Resident #1. LVN C told the DON she had performed a weekly skin assessment for Resident #1 on 08/29/23, noted a wrap on the second toe of the resident's left foot, but did not remove the wrap or assess the resident's toe underneath. The DON further stated Resident #1's weekly skin assessment scheduled for 09/05/23 was not completed by LVN A because the nurse told them she had been overwhelmed. The Administrator stated on 09/11/23 the facility became aware of the Podiatrist's progress notes, that included orders and instructions for the care of Resident #1, had been emailed to the facility on Friday 09/08/23. They stated Resident #1's toe was worse on 09/11/23 and continued to deteriorate. Orders were received to transfer the resident to the hospital on [DATE]. The facility staff were unaware of the Podiatrist's orders/instructions until Monday (09/11/23), 13 days after the Podiatrist visit on 08/29/23. Interview on 09/13/23 at 10:05 a.m. the TN stated on 09/10/23 she was informed by LVN B that there was a problem with Resident #1's left foot. She assessed the resident and discovered his entire left foot was swollen, purple colored and the resident's second toe on the left foot was noted with a small open area. LVN B received orders for wound care and the antibiotic doxycycline 100 milligrams orally two times a day for 7 days. The TN stated she communicated with the Podiatrist on 09/12/23 and he told her his assistant typically left written orders with the charge nurse, but he did not specifically say orders were left for Resident #1. The TN stated she was not aware of the Podiatrist's visit on 08/29/23 or of any orders or instructions related to Resident #1 prior to 09/11/23. Interview on 09/13/23 at 1:08 p.m. the Podiatrist stated he visited Resident #1 on 08/29/23 and noted the resident had a reddened area on the second toe of the left foot. He stated the toe was pre-ulcerative, not open, but on its way to being an ulcer. He stated he placed a gel sleeve on the second toe for padding and protection. His assistant provided written orders to the charge nurse (unable to recall name). He stated he did not keep copies of his orders and had been providing services in the facility for two years in the same manner and never had any issues with nurses implementing his orders before. Interview on 09/14/23 at 2:25 p.m. the Podiatrist stated he expected nursing staff to remove the gel sleeve to assess/monitor Resident #1's toe daily per his orders for any skin breakdown until the redness dissipated. He specifically explained to the charge nurse the resident's toe was at risk for skin breakdown. Review of Resident #1's Podiatry progress notes dated 08/29/23 revealed the resident was assessed with an area of redness to the second toe of the left foot. Pedal pulses (rhythmical throbbing of the arteries that can be felt in the feet) were non-palpable (not found on clinical exam), and findings were consistent with decreased circulation. The notes reflected a gel sleeve was applied and staff had been educated on its use and to check the resident's feet daily and monitor for any new wounds/ulcerations. Interview on 09/13/23 at 3:48 p.m. LVN A stated she did not perform the scheduled weekly skin assessment for Resident #1 on 09/05/23 because she was busy and did not get around to it. She stated she was not aware of any issues with the resident's foot/toe or that the resident had been seen by the Podiatrist or she would have made the skin assessment a priority. She observed Resident #1's toe prior to sending him out to the hospital on [DATE] and it looked terrible. She stated the resident's toe was black colored, but the resident made no complaints of pain. Interview on 09/13/23 at 4:00 p.m. LVN B stated on 09/10/23 she noticed Resident #1 with dried blood-tinged drainage on his left sock. She removed the sock and noted an undated, soiled dressing on the resident's second toe. When she removed the dressing, she discovered the resident's toe was red colored with a dimed sized open area. She cleansed the area, applied a dry dressing, and notified the PA. LVN B stated the PA was in the facility and instructed her to call hospice and when she notified hospice orders were received to start an antibiotic. She stated she was not aware of any problems with Resident #1's toes or that the Podiatrist had seen the resident on 08/29/23. Observation on 09/14/23 at 11:28 a.m. revealed Resident #1 was in the hospital awaiting surgical amputation of his second toe on the left foot. The resident was resting flat in bed, with intravenous lines, bilateral compression boots in place and was mumbling incoherently. The resident's family was at the bedside and stated Resident #1 was cognitively impaired and did not understand what was going on. Observation with the hospital RN revealed the second toe on the left foot was black colored with an open area underneath the toe. The RN stated Resident #1 was receiving intravenous antibiotics and was scheduled for surgical amputation later in the day. Interview on 09/14/23 at 2:43 p.m. LVN C stated she was on duty 08/29/23 and provided care for Resident #1. She stated she did not know the Podiatrist was in the facility until she saw him in a resident's room. She stated the Podiatrist never introduced himself, and no one provided any orders or instructions related to Resident #1's care. She further stated she performed the resident's weekly skin assessment on 08/29/23 but was unable to recall if it was before or after the Podiatrist left. LVN C stated she never saw a bandage or sleeve on Resident #1's toe and there were no issues noted with the resident's skin during her assessment. Additionally, LVN C stated she saw the resident's toe on 09/10/23 after the open area had been identified and the toe was ugly, green/red colored and looked infected. She was not aware of any problems with the resident's toe until she saw it on Sunday 09/10/23. Interview on 09/14/23 at 3:45 p.m. CNA D stated she worked for hospice and provided care for Resident #1 Monday through Friday. She stated she showered the resident every Monday, Wednesday, and Friday. She stated the resident always wore socks and Croc style shoes and she changed his socks daily. CNA D stated she did not notice any issues with the resident's feet or toes and never saw any bandage, sleeve, or other type of dressing until Friday 09/08/23. On 09/08/23 she saw a band aid on one of the resident's toes on his left foot, covered the left foot with a trash bag and provided the shower as usual. When she completed the shower the band aid was still in place. CNA D further stated she was not exactly sure when she saw the band aid on the resident's toe, but whenever it was, she covered the left foot to ensure it did not get wet in the shower. Interview on 09/14/23 and 4:46 p.m. CNA E stated she provided care for Resident #1 prior to the resident's hospice admission [DATE]) and provided showers. She stated she never saw any issues with the resident's foot or toes. The resident always wore socks and shoes and she never removed them since hospice was initiated. Interview on 09/15/23 at 11:00 a.m. the DON and Administrator were queried about procedures to ensure Podiatry orders were received and implemented by nursing staff. The DON stated the Podiatrist just gave the orders to the charge nurses and then emailed his progress notes. The DON was queried about how she ensured orders from Podiatry were transcribed and initiated for resident care. She and the Administrator stated there had been no plan/procedure in place. The Administrator stated the facility had never had any problems with Podiatry orders before. Review of the facility's policy/procedure entitled wound care policies and procedures revised 06/01/15 revealed licensed nurse skin checks was addressed. The policy was that all residents would have a thorough weekly skin evaluations performed by a licensed nurse. An Immediate Jeopardy was identified on 09/15/23 at 11:34 a.m. The Administrator was informed of IJ in the area of quality of care and the IJ template was provided via email at 11:48 a.m. and a POR was requested. The plan of removal was accepted on 09/15/23 at 6:32 p.m. and reflected: Interview on 09/15/23 at 4:26 p.m. the DON stated she had worked at the facility since 2018 and there had never been any training related to foot care and/or residents with impaired LE circulation. The DON stated it was important for weekly skin assessments to be performed to ensure residents with skin issues were treated to prevent further deterioration of the skin issues. She stated it was important to follow orders provided by the Podiatrist and perform assessments of residents with impaired circulation of the lower extremities to prevent infections. Interview on 09/15/23 at 6:05 p.m. CNA K stated she provided care for Resident #1 but did not remove his socks and was not aware of any problems with his foot/toe. Interview on 09/15/23 at 6:35 p.m. the Administrator stated he had communicated with corporate and there was no policy/procedure addressing foot care, podiatry services and/or assessments of residents with impaired circulation of the lower extremities. The plan or removal reflected: Resident #1 was discharged to the hospital on 9/12/23. An audit of notes from the podiatrist's current resident list was completed by The Director of Nursing on 9/13/23 to identify new physician orders. Any orders identified were completed at time of discovery. Assistant Director of Nursing/designee completed a skin audit on current residents to identify wounds and skin integrity issues on 9/12/23. None were identified. Director of Nursing/Designee will follow up via phone on 9/15/23 with the Podiatrist to the validate receipt of email education that was sent on 9/14/23. The education included ensuring a verbal exit with the Director of Nursing/Designee will occur prior to the physician leaving the building, ensuring new orders are identified and carried out timely. Licensed nurses were re-educated by the Director of Nursing/Designee on the exit process for the podiatrist on 9/14/23. Licensed Nurses were re-educated by the Director of Nursing/Designee on completing weekly skin assessments and identifying areas of skin impairment to include: o approaches to aid in prevention of further skin breakdown o documentation with description of any observed changes in skin integrity o notification of physician for new orders as indicated DON/designee will reeducate CNAs to report any change of condition related to skin integrity immediately to the charge nurse. The reeducation will be completed 9/16/2023. This reeducation will be completed by 9/15/23 by Director of Nursing/Designee. Licensed nurses and agency nurses who have not received the re-education by this date will receive it prior to their next scheduled shift and will be presented in New Hire and agency orientation by the Director of Nursing/Designee. The Director of Nursing/Designee will review weekly skin assessments Monday - Friday in clinical morning meeting to validate compliance. This began on 9/12/23. Director of Nursing/Designee will review wound consulting physician notes Monday - Friday in clinical morning meeting to validate orders are transcribed as written. This began on 9/15/23. Ad Hoc QAPI will be held on 9/15/23. The Medical Director was notified of the Immediate Jeopardy on 9/15/23. Review of in-service training material and training logs dated 09/12/23 and 09/15/23 revealed education was provided to licensed nurses and CNAs related to reporting any changes in skin condition, Podiatrist to exit with DON, the importance of carrying out orders timely, importance of completing weekly skin assessments, identifying skin impairments, notifying the physician for wound orders, documentation of assessments and approaches to aid in the prevention of skin breakdown. Interviews conducted with facility nurses and CNAS across multiple shifts on 09/15/23 from 5:35 p.m. to 6:20 p.m. revealed they verbalized comprehension of the in-service training. Staff interviewed were CNA F, LVN G, LVN H, CNA I, CNA J, CNA K, CNA L, LVN M, CNA N, RN O, RN P and CNA Q. The Administrator was notified on 09/15/23 at 7:16 p.m. that the Immediate Jeopardy was removed. However, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program with a system for preventing, identifying, and controlling infections and communicable diseases for all residents, staff, visitors, and other individuals providing services based upon the facility assessment and following accepted national standards for four of four halls reviewed for infection control. The facility failed to have an effective protocol in place to prevent the spread of COVID-19 that followed nationally accepted standards for contact tracing testing or broad-based testing. Resident #1 had a change in condition on [DATE], and he was sent to the hospital where he tested positive for COVID-19. Prior to being sent out to the hospital, Resident #1 visited his family member (Resident #2) daily, who also resided at the facility on another hall. Staff and residents were only tested if they were showing signs/symptoms of COVID-19 per their policy. The facility had not implemented contact trace testing or broad-based testing to identify others who may have been exposed. As of [DATE], 26 residents and 5 staff members had tested positive for COVID-19. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:37 PM. While the IJ was removed on [DATE], the facility remained out of compliance of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a severity level of pattern because all staff had not been trained on testing during a COVID-19 outbreak. These failures placed residents at risk of exposure of COVID-19 virus which could result in serious illness, hospitalization, and/or death. Findings included: Interview on [DATE] at 9:00 AM with the Administrator revealed the facility had six residents that were COVID-19 positive. Review of Resident #1's MDS dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included coronary artery disease, heart failure, hypertension, end stage renal disease, diabetes, and respiratory failure. Resident #1 had a BIMS of 15 (cognition intact) and was able to ambulate with supervision and setup only. Review of Resident #1's progress notes dated [DATE] entered by RN A revealed the following: resident had c/o chest pain .resident described chest pain as someone standing on his chest, and it hard for him to breath, stated pain was 4/10, and that the pain was not sharp Resident was sent to [Hospital] Review of Resident #1's clinical record revealed the resident had not been showing any signs or symptoms of COVID-19 prior to [DATE] Review of Resident #2's MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included atrial fibrillation, heart failure, hypertension, non-Alzheimer's dementia, and type 2 diabetes. Resident #2 had severe cognitive impairment with a BIMS score of 3 and required total care of staff for all ADLs. The MDS further reflected Resident #2 was on hospice care. Review of Resident #2's progress notes revealed the following: [DATE] - Resident was weak, Coughing and had a Fever 101.4, Hospice was notified and ordered a COVID test. Result came back positive for Covid Resident on contact isolation [DATE] - Resident continues on COVID-19 isolation precautions. Unable to make needs known, wheezing noted on Chest Auscultation, SOB noted Hospice notified and wants Comfort Medication to be given as needed with Breathing Treatment [DATE] - Resident expired, [Hospice] Nurse pronounced death Review of Resident #3's MDS dated [DATE] revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heat failure, hypertension, end-stage renal disease, diabetes, CVA (stroke), and malignant neoplasm of colon. Review of Resident #3's progress notes for the following dates revealed: [DATE]: Observed resident lying in bed, stated that her body was aching and had a sore throat, resident also appear to hoarse when taking. Assessed vital: B/P 178/97 Administer PRN clonidine, tramadol, placed cool towel on head, notified the [Doctor], N/O for covid testing Performed covid test and resident have a positive result [DATE]: Resident remains of airborne isolation as she tested positive for COVID 19 virus Lungs auscultated and lower lobes are very diminished, upper lobes sounded very congested [DATE]: Resident presents no s/s of COVID-19 Review of Resident #4's MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, hypertension, diabetes, and COPD. Review of Resident #4's progress notes on the following dates revealed: [DATE]: Resident asked this writer if He could be tested for COVID, I asked if He had any symptoms and he Stated He did not feel to well and was not sure if it was Covid or an Allergy. Notified [Doctor] and She said Resident should be tested for COVID, Resident was tested and Results was positive. Resident was moved to room [ROOM NUMBER] and put on COVID Isolations precaution [DATE]: Resident continues on COVID-19 isolation precautions. Alert and can make needs known. No complaints or pain or discomfort noted. Vitals within normal range. No congestion or chest pains noted Review of Resident #5's MDS dated [DATE] revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension and non-Alzheimer's dementia. Review of Resident #5's progress notes for the following day revealed: [DATE]: Resident c/o headache/vertigo/low grad temp 99.6, MD notified and ordered covid test, results returned positive and patient transferred to room [ROOM NUMBER]B [DATE]: Resident continues on Isolation related to covid. Denies no complain Temp 97.8 Review of Resident #6's MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart failure, end stage renal disease, Parkinson's disease, COPD, and respiratory failure. Review of Resident #6's progress for the following dated revealed the following: [DATE]: .Complaints of pain to lower back and congestion noted .MD was also notified of SOB and wheezing noted [DATE]: MD notified and gave orders for covid test. Test results were positive and orders were given to start isolation precautions [DATE]: Continues on COVID-19 isolation precautions. Alert and can make needs known. No complaints of pain or discomfort noted Interview on [DATE] at 9:34 AM with LVN B revealed Resident #1 was independent with most ADLs and was alert and oriented to person, place, time and situation. LVN B said Resident #1 would attend therapy daily and spend the rest of his day getting coffee and visiting his family member (Resident #2) who resided on the 100 hall. LVN B further stated they asked management about testing for staff and residents after Resident #1 tested positive for COVID-19, and they were told they were not testing per their facility policy. LVN B further stated she had not noticed any signs/symptoms of COVID-19 while caring for the resident. Interview on [DATE] at 9:50 AM with CNA C revealed she worked with Resident #1. CNA C stated the resident was independent with most ADLs. CNA C stated Resident #1 visited his family member, Resident #2, daily on the 100 hall. CNA C further stated she was not asked to test for COVID-19 after being around Resident #1 and she had not noticed Resident having any signs/symptoms of COVID-19 while she care for the resident. Interview on [DATE] at 10:38 AM with CNA D revealed she worked with Resident #2. CNA D stated Resident #1 visited Resident #2 daily and spent most of his day with her in her room. After Resident #1 tested positive, the staff were asked to wear surgical masks, but no one was asked to test. CNA D further stated she was not asked to test for COVID-19 after being around Resident #1 and she had not noticed Resident having any signs/symptoms of COVID-19 while she care for the resident. Interview on [DATE] at 10:38 AM with CNA J revealed she worked with Resident #2, and she appeared to be slowly declining prior to the resident passing away (did not specify the timeframe). The resident's family member, Resident #1, would visit her daily and stay in her room for long periods of time. CNA J stated some time after Resident #1 discharged to the hospital, Resident #2 began to sleep more and got a nasty cough. CNA J also said she or none of the other staff were asked to test for COVID-19 and they were only told to begin to wear masks again after Resident #1 tested positive for COVID-19 ([DATE]). Interview on [DATE] at 2:03 PM with the DON revealed Resident #1 was sent to the hospital ([DATE]) for a change in condition where he tested positive for COVID-19. After they were informed Resident #1 tested positive, they were only testing staff/residents that were showing signs and symptoms of COVID-19 per their facility policy. Interview on [DATE] at 3:11 PM with the Infection Control Preventionist revealed they had not conducted contact or widespread testing after Resident #1 was positive for COVID-19 because they were following their facility COVID-19 policy. The Infection Control Preventionist stated per their policy they were only doing symptom-based testing. Review of the facility's policy titled Infection Prevention and Control Policies and Procedures revised on [DATE] reflected the following: CORONAVIRUS DISEASE (COVID-19) Continue .Procedures: .3 Facility staff may test residents for COVID-19 when respiratory symptoms appear to identify positive cases Review of the facility's COVID Positive Residents/Staff List revealed the following: [DATE] - 1 resident [DATE] - 1 resident [DATE] - 1 staff [DATE] - 4 residents [DATE] - 2 residents [DATE] - 1 staff [DATE] - 1 resident [DATE] - 1 staff [DATE] - 2 residents and 1 staff [DATE] - widespread testing was conducted - 15 residents and 1 staff Interview on [DATE] at 11:33 AM with the Administrator revealed he contacted the local health department on [DATE]. The Administrator said he did not contact the local health department after Resident #1 tested positive for COVID-19, [DATE], because he had been told by the local health department to only send them a line listing of COVID-19 positive cases once a week. The Administrator further stated they facility was only doing symptoms based testing after Resident #1 tested positive for COVID-19 ([DATE]). Interview on [DATE] at 12:22 PM with the local health department revealed they wanted to know as soon as possible when a resident tested positive for COVID-19. The local health department also stated they continued to recommend testing of staff and residents per CDC recommendations. They further stated they also continued to recommend the facility conducted contact or widespread testing to help prevent the spread of COVID-19. Interview on [DATE] at 10:07 AM with the Medical Director revealed he was not aware the facility COVID-19 policies did not have prevention protocols in place or that the health department had not been contacted after their first COVID-19 positive resident. The Medical Director further stated moving forward they would relook at the infection control guidelines and adjust to CDC standards for prevention. Interview on [DATE] at 3:22 PM with the Health Department revealed they had just received an updated list from the facility of resident/staff positives for COVID-19, and the total was up to 55. Review of the facility's current Infection Prevention and Control Policies and Procedures, revised [DATE], reflected the following: Policy: In the event of a suspected or actual case of SARS-CoV-2/COVID-19, the Facility provides notification to the Clinical Services Director and Regional [NAME] President and initiates involvement of federal, state, and local health agencies for direction regarding current recommended strategies for prevention of spread of the disease and treatment methods .4. Facility staff shall notify its local/state health departments upon discovery of any positive cases of COVID-19 Review of the CDC's website, Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC accessed on [DATE], revealed: .Nursing Homes .Stay connected with the healthcare-associated infection program in your state health department, as well as your local health department, and their notification requirements. Report SARS-CoV-2 infection data to National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 Module. See Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting requirements. Managing admissions and residents who leave the facility: admission testing is at the discretion of the facility. Pros and cons of screening testing are described in Section 1. Residents who leave the facility for 24 hours or longer should generally be managed as an admission. Empiric use of Transmission-Based Precautions is generally not necessary for admissions or for residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings) and do not meet criteria described in Section 2. Placement of residents with suspected or confirmed SARS-CoV-2 infection Ideally, residents should be placed in a single-person room as described in Section 2. If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. Responding to a newly identified SARS-CoV-2-infected HCP or resident When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP are not generally necessary unless residents meet the criteria described in Section 2 or HCP meet criteria in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested. In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach 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 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered On [DATE] at 4:24 PM the Administrator, DON, and the Infection Control Preventionist were notified an Immediate Jeopardy was identified and a Plan of Removal was requested. The IJ template was provided. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] at 9:52 AM and reflected the following: The 6 identified residents are in transmission-based precautions for COVID-19. Resident #1 no longer resides in the facility. Residents and/or employees who had close contact identified by root cause, contact tracing and have high risk exposure with the identified 6 COVID 19 positive residents and the 3 COVID 19 positive employees will be and tested for COVID 19 by [DATE] Resident who test positive for COVID 19 will be placed in transmission based precautions. Employees who test positive for COVID 19 will be sent home and return to work when the following criteria are met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and 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. Resident and employees that do not test positive will don source control for 10 days and be tested every 3 days until there are no new cases for 14 days Director of nursing, Infection Preventionist and administrator were re-educated by the Regional [NAME] President of Operations and the Clinical Consultant on [DATE] on Implementing Infection Control Measures to prevent the spready and development of COVID 19 including: Any single new case of COVID 19 infection in any employee or resident should be evaluated to determine if others in the facility could have been exposed. Perform testing for all residents and employee identified as close contacts who have not tested positive for COVID 19 in the last 30 days. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Daily monitoring of residents for signs and symptoms of COVID 19 a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach will be initiated if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission contact tracing and root cause analysis in infection control to prevent the spread of any infection The Director of Nursing / designee will re-educate licensed nurses on [DATE] on Implementing Infection Control Measures to prevent the spread and development of COVID 19 Any single new case of COVID 19 infection in any employee or resident should be evaluated to determine if others in the facility could have been exposed. Perform testing for all residents and HCP identified as close contacts who have not tested positive for COVID 19 in the last 30 days. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Daily monitoring of residents for signs and symptoms of COVID 19 a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach will be initiated if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission Any licensed nurse not receiving this information by [DATE] will receive prior to their next scheduled shift, this will include any staff on FMLA, sick days or vacation. This information will also be presented to agency staff before reporting to assigned area. Staff will be screened prior to work for signs and symptoms of illness and not be allowed to work until symptoms are resolve. Residents will be screened daily for signs and symptoms of COVID 19 and placed in transmission-based precautions and or tested as necessary If a resident or employee tests positive for COVID 19, a root cause analysis will be completed to identify additional testing or screening that should be completed. The Medical Director was notified on [DATE] of the Immediate Jeopardy. Ad Hoc Quality Assurance Performance Improvement Meeting with the Administrator, Director of Nursing and Clinical Consultant and medical director was held on [DATE] to discuss contents of this plan and will be reported by the administrator to Quality Assurance Performance Improvement committee monthly for review and recommendations. The administrator will ensure implementation and monitoring of this plan of removal. Monitoring of the POR included: Review of the facility's COVID Positive Residents/Staff List provided by the Administrator on [DATE] revealed facility conducted widespread testing was conducted on [DATE] to [DATE] and there were an additional 15 resident and 1 staff that were positive for COVID-19. All residents were cohorted/isolated according to CDC recommendations. New staff identified were sent home to isolated. Observation on [DATE] through [DATE] revealed the facility had placed the proper PPE outside each isolation room for staff to don and doff. Interviews were conducted on [DATE] starting at 10:38 AM and completed on [DATE] at 10:20 AM with 14 staff members (Administrator, DON, Infection Control Preventionist, ADON, RN A, LVN B, LVN E, LVN I, LVN K, LVN L, RN M, LVN N, LVN O, LVN P) from various shifts regarding in-services which included testing after a COVID-19 outbreak. The staff members were able to explain the process when there is an COVID-19 outbreak. Testing will be conducted with residents and health care personnel identified as close contact. Testing will be done at day 1, 3 and 5. Staff were also in-serviced on the monitoring of residents for signs and symptoms of COVID-19. Record review of residents revealed newly identified residents with COVID-19 were being monitored every shift and COVID-19 negative residents were being monitored daily. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.