Implementation of an antimicrobial stewardship program for urinary tract infections in long-term care facilities: a cluster-controlled intervention study.

BACKGROUND: Widespread inappropriate use of antimicrobial substances drives resistance development worldwide. In long-term care facilities (LTCF), antibiotics are among the most frequently prescribed medications. More than one third of antimicrobial agents prescribed in LTCFs are for urinary tract infections (UTI). We aimed to increase the number of appropriate antimicrobial treatments for UTIs in LTCFs using a multi-faceted antimicrobial stewardship intervention. METHODS: We performed a non-randomized cluster-controlled intervention study. Four LTCFs of the Geriatric Health Centers Graz were the intervention group, four LTCFs served as control group. The main components of the intervention were: voluntary continuing medical education for primary care physicians, distribution of a written guideline, implementation of the project homepage to distribute guidelines and videos and onsite training for nursing staff. Local nursing staff recorded data on UTI episodes in an online case report platform. Two blinded reviewers assessed whether treatments were adequate. RESULTS: 326 UTI episodes were recorded, 161 in the intervention group and 165 in the control group. During the intervention period, risk ratio for inadequate indication for treatment was 0.41 (95% CI 0.19-0.90), p = 0.025. In theintervention group, the proportion of adequate antibiotic choices increased from 42.1% in the pre-intervention period, to 45.9% during the intervention and to 51% in the post-intervention period (absolute increase of 8.9%). In the control group, the proportion was 36.4%, 33.3% and 33.3%, respectively. The numerical difference between intervention group and control group in the post-intervention period was 17.7% (difference did not reach statistical significance). There were no significant differences between the control group and intervention group in the safety outcomes (proportion of clinical failure, number of hospital admissions due to UTI and adverse events due to antimicrobial treatment). CONCLUSIONS: An antimicrobial stewardship program consisting of practice guidelines, local and web-based education for nursing staff and general practitioners resulted in a significant increase in adequate treatments (in terms of decision to treat the UTI) during the intervention period. However, this difference was not maintained in the post-intervention phase. Continued efforts to improve the quality of prescriptions further are necessary. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov NCT04798365.

Factors associated with pressure ulcer and dehydration in long-term care settings in Ontario, Canada.

Pressure ulcers and dehydration are common conditions among residents of long-term care facilities that result in negative health effects. They have been associated with signs of neglect and increased 30-day mortality among LTC residents. However, they are both preventable and with proper care can be effectively managed and treated. We conducted a retrospective cohort study to examine factors associated with pressure ulcers and dehydration among long-term care residents in the province of Ontario, Canada. Results indicated that close to one-fifth of residents were dehydrated (17.3%) or had a pressure ulcer (18.9%) during the study period. Advanced age was significantly associated with the presence of pressure ulcers and dehydration for both men and women. However, men were more likely to present with a pressure ulcer while women were more likely to exhibit symptoms of dehydration. Study findings also demonstrate the presence of both conditions being higher in municipal and not-for-profit homes compared to for-profit homes. The significant differences observed in relation to home ownership which require further investigation to identify the most relevant factors in explaining these differences. Overall, pressure ulcers and dehydration are preventable conditions that warrant attention from policymakers to ensure quality of care and resident safety are prioritized.

Changing genomic epidemiology of COVID-19 in long-term care facilities during the 2020-2022 pandemic, Washington State.

BACKGROUND: Long-term care facilities (LTCFs) are vulnerable to disease outbreaks. Here, we jointly analyze SARS-CoV-2 genomic and paired epidemiologic data from LTCFs and surrounding communities in Washington state (WA) to assess transmission patterns during 2020-2022, in a setting of changing policy. We describe sequencing efforts and genomic epidemiologic findings across LTCFs and perform in-depth analysis in a single county. METHODS: We assessed genomic data representativeness, built phylogenetic trees, and conducted discrete trait analysis to estimate introduction sizes over time, and explored selected outbreaks to further characterize transmission events. RESULTS: We found that transmission dynamics among cases associated with LTCFs in WA changed over the course of the COVID-19 pandemic, with variable introduction rates into LTCFs, but decreasing amplification within LTCFs. SARS-CoV-2 lineages circulating in LTCFs were similar to those circulating in communities at the same time. Transmission between staff and residents was bi-directional. CONCLUSIONS: Understanding transmission dynamics within and between LTCFs using genomic epidemiology on a broad scale can assist in targeting policies and prevention efforts. Tracking facility-level outbreaks can help differentiate intra-facility outbreaks from high community transmission with repeated introduction events. Based on our study findings, methods for routine tree building and overlay of epidemiologic data for hypothesis generation by public health practitioners are recommended. Discrete trait analysis added valuable insight and can be considered when representative sequencing is performed. Cluster detection tools, especially those that rely on distance thresholds, may be of more limited use given current data capture and timeliness. Importantly, we noted a decrease in data capture from LTCFs over time. Depending on goals for use of genomic data, sentinel surveillance should be increased or targeted surveillance implemented to ensure available data for analysis.

Staff's insights into fall prevention solutions in long-term care facilities: a cross-sectional study.

BACKGROUND: Falls are one of the most common and serious health issues in long-term care facilities (LTCFs), impacting not just residents, but staff and the healthcare system. This study aimed to explore LTCF staff's current practices around falls prevention, and their suggested solutions for better falls prevention. METHODS: In the southwest of Ireland, a descriptive cross-sectional study was conducted in 13 LTCF sites, across a range of provider types and facility sizes. A survey, measuring staff knowledge, skills and attitudes, was distributed in physical and online formats. Staff suggestions for prioritising fall and fall-related injury prevention activities, and current staff practices regarding fall incidents were also sought. Content analysis was used to analyse responses, mapping categories and subcategories to the refined theoretical domains framework (TDF) and to an existing fall prevention guideline. RESULTS: There were 155 respondents (15% response rate), from staff of the LTCFs. Environmental reviews and modifications (aligned to the TDF environmental context and resource domain) were the most common suggestions for preventing both falls and fall-related injuries. Other common suggestions for preventing falls were staff education, monitoring of residents, and using alarm/calling systems, while few staff members, across all roles, reported assessing residents, exercises, reviewing medications, and vitamin D supplements. For preventing fall-related injuries, suggestions included protective equipment, hip protectors and alarm/calling systems. Staff used a standardised approach when responding to a fall incident, with intensive and holistic post-fall control measures. HCAs focussed on transferring residents safely, while nurses of all grades focused more on post-fall assessment. Respondents believed that staff education, communication, increasing staffing levels and enhancing specialist care could support their practice. CONCLUSION: Noting the low response rate, the results suggest an awareness gap regarding some evidence-based, resident-focussed falls prevention solutions, such as pro-active fall-risk assessment, exercise, medication review, and Vitamin D supplements. These aspects should be included in future fall prevention education programmes in LTCFs.

Association Between Falls, Head Impacts, and Mortality Among Older Adults in Long-Term Care.

OBJECTIVES: Residents in long-term care (LTC) are at high risk for falls, and falls in LTC often result in impact to the head, with clinical consequences that may be challenging to detect. We examined whether the survival of LTC residents associates with falls and fall-related head impacts. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: This study was conducted in 2 Vancouver-area LTC homes where falls were captured on video from surveillance cameras. A total of 232 participants (133 females, 99 males) experienced at least 1 fall captured on video, among whom 84% (n = 194) died between January 2011 and January 2020. The mean age at death was 86.5 (SD = 8.5) years, and the mean survival time after enrollment to this study was 3.8 (SD = 2.1) years. METHODS: Univariable and multivariable models were used to determine how survival time depended on the rate of falls (falls per 365 days), the percentage of falls on video involving head impact, sex, age at death, and baseline physical and cognitive status. RESULTS: On average, participants experienced 6.2 (SD = 7.0) falls per 365 days, and 36.9% (SD = 36.3) of video-captured falls resulted in head impact. In multivariable analyses, an increase of 1 fall per 365 days resulted in a 4.2% higher risk of death [hazard ratio (HR) = 1.042, 95% CI 1.023-1.062, P < .001]. A 1% increase in falls involving head impact resulted in an 0.5% higher risk of death (HR 1.005, 95% CI 1.001-1.010, P = .015). Participants who experienced head impact in all video-captured falls had a 50% higher risk for death than those who always avoided head impact. CONCLUSIONS AND IMPLICATIONS: Survival in LTC is associated with the rate of falls and percentage of falls involving head impact. Improved efforts are required to prevent falls in LTC, and reduce the frequency and consequences of head impacts during falls (eg, through compliant flooring).

Relationship between oral frailty, health-related quality of life, and survival among long-term care residents.

PURPOSE: We evaluated oral frailty (OFr) and its association with health-related quality of life (HRQoL), energy and protein intake, and survival among older long-term care residents. METHODS: This cross-sectional study with a 3-year follow-up for survival assessed 349 residents in long-term care facilities (73% female, mean age 82 years). We defined OFr with six signs (dry mouth, food residue on oral surfaces, unclear speech, inability to keep mouth open or pain expression during the clinical oral examination, diet pureed/soft) and OFr severity was categorized as Group 1, (mild) = 0-1 signs, Group 2 (moderate) = 2-4 signs, and Group 3 (severe) = 5-6 signs. We measured HRQoL with 15D instrument, and energy and protein intake by a 1- to 2-day food record. Mortality was retrieved from central registers on March 2021. RESULTS: Of the residents, 15% had 0-1, 67% 2-4 and 18% 5-6 OFr signs. HRQoL decreased linearly from Group 1 to Group 3. OFr correlated with such dimensions of HRQoL as mobility, eating, speech, excretion, usual activities, mental function, and vitality. We found no association between OFr categories and energy and protein intake. Survival decreased linearly from Group 1 to Group 3. CONCLUSIONS: OFr was common among older long-term care residents and OFr severity predicts poorer outcomes. The six oral signs denoting OFr may be used at the bedside to screen residents at risk for OFr.

Reparations for people living with dementia: Recognition, accountability, change, now!

There is a significant and longstanding problem of harm to people living with dementia in long term care institutions ('LTC institutions', referred to by others as 'care homes', 'nursing homes', 'long term care', 'residential aged care facilities'), along with a failure to redress the harm or hold people accountable for this harm. This article reports on an Australian project that found reparations must be a response to harm to people living with dementia in residential aged care. Using a disability human rights methodology, focus groups were conducted with people living with dementia, care partners and family members, advocates and lawyers to explore perspectives on why and how to redress harm to people living with dementia in Australian LTC institutions. Researchers found four key themes provide the basis for the necessity and design of a reparative approach to redress - recognition, accountability, change, now. The article calls for further attention to reparations in dementia scholarship, with a particular focus on the role that can be played in the delivery of reparations by the LTC industry, dementia practitioners, and dementia scholars. Ultimately, this article provides a new understanding of responses to violence, abuse, neglect and other harms experienced by people living with dementia in LTC institutions, which centres justice, rights, and transformative change.

The RESPECT-tool as a facilitator for person-centered medication reviews for nursing home residents: tool development and pilot study.

BACKGROUND: Although support is needed, no method exists to elicit and integrate personal goals into medication optimization interventions for nursing home residents. AIM: To develop and evaluate a tool to (1) elicit and evaluate residents' personal goals during medication optimization, and (2) elicit involvement preferences regarding medication decision-making. METHOD: A draft was composed by the research team, on which feedback was collected through four focus groups with healthcare professionals (n = 23) and pilot interviews with residents (n = 6). The tool was then pilot tested in 11 nursing homes as means to facilitate person-centered medication reviews, focusing on feasibility, appropriateness, and meaningfulness. Evaluation was performed through interviews and focus groups with residents and healthcare professionals, and reports for executed medication reviews. Interview summaries and reports were analyzed inductively. RESULTS: The RESident's Participation in the Evaluation and Customization of Therapy tool (RESPECT-tool) was drafted as a modular approach of five modules. Pilot study results showed that the tool supported the formulation of personal goals. Goals resulted in changes in all aspects of the nursing home stay, indicating the tool's potential to promote person-centered care. The RESPECT-tool showed value in the context of medication optimization as it allowed to determine potential links between residents' personal goals and medication plans, and its use regularly led to medication changes. CONCLUSION: A person-centered medication review facilitated by the RESPECT-tool holds a promising approach to medication optimization in nursing homes. Further research should assess impact on relevant outcomes like goal attainment, appropriateness of prescribing and quality of life.

Association between meaningful activities at home and subjective well-being in older adults with long-term care needs: A cross-sectional study.

For this study, we examined whether engaging in meaningful activities at home is associated with subjective well-being (SWB) in older adults with long-term care needs according to their preference for going out. We distributed a self-administered questionnaire to long-term care facilities in Japan and performed a linear mixed-effects model regression analysis of the responses. The dependent variable was SWB, and the independent variables were the number of meaningful home activities, preference for going out, and the interaction between them. In our survey (n = 217), we found that both number of meaningful home activities (B = 0.43; 95%CI: 0.17, 0.70) and its interaction with preference (B = -0.43; 95%CI: -0.79, -0.08) were associated with SWB. These results suggest the importance of engaging in meaningful activities at home for older adults who do not prefer going out. We should encourage older adults to participate in activities that match their preference.

Efficacy of COVID-19 control measures on post-vaccination outbreak in Italian Long Term Care Facilities: implications for policies.

Background: Numerous individual and organizational factors can influence the spread of SARS-CoV-2 infection in Long Term Care Facilities (LTCFs). A range of outbreak control measures are still implemented in most facilities involving administrations, staff, residents and their families. This study aims to evaluate which measure could influence the transmission of SARS-CoV-2 infection among residents during the period March 2021-June 2022. Methods: We enrolled 3,272 residents aged ≥60 years. The outbreak control measures adopted to prevent or manage the infection included entry regulations, contact-regulating procedures, and virological surveillance of residents and staff. The association between LTCFs' and participants' characteristics with new cases of COVID-19 infections was analyzed using multilevel logistic regression models. Results: In 33.8% of the facilities 261 cases of SARS-CoV-2 infection were reported. Among participant characteristics, gender and age were not associated with SARS-CoV-2 infection, while having received the vaccine booster dose was protective against infection [Odds Ratio (OR) = 0.34, 95% Confidence Interval (CI) 0.12-0.99, p = 0.048]. In addition, the implementation of protected areas for family visits was associated with a significant reduction of the probability of infections (OR = 0.18, 95% CI 0.03-0.98, p = 0.047). Overall, about 66% of the variability in the probability of SARS-CoV-2 infection during the observational period may be due to facility structure characteristics and 34% to the participant characteristics. Conclusions: These data showed that vaccination booster doses and family visit restriction-control are still needed to make the LTCFs safer against SARS-CoV-2 infection.

Findings in Danish long-term care facilities in the first year of the SARS-CoV-2 pandemic.

PURPOSE: To describe the occurrence of SARS-CoV-2 infections, deaths and outbreaks among residents in Danish long-term care facilities (LTCFs) from February 2020 to February 2021. METHODS: Danish COVID-19 national register data from a newly implemented automated surveillance system was used to describe incidence rate and deaths (per 1000 residents' years), number of tests, SARS-CoV-2 infections and outbreaks among LTCF residents. A case was defined as a LTCF resident with a positive SARS-CoV-2 PCR test. An outbreak was defined as two or more cases in one LTCF within a 14-day period, and considered closed if no new cases had occurred within 28 days. Death was defined as occurring within 30-days of a positive test. RESULTS: A total of 55,359 residents living in 948 LTCFs were included. The median age of the residents was 85 years and 63% were female. There was a total of 3712 cases found among residents across 43% of all LTCFs. Nearly all (94%) cases were linked to outbreaks. Higher numbers of cases and outbreaks were seen in Denmark's Capital Region compared to other regions. Overall, 22 SARS-CoV-2 deaths and 359 deaths (non-SARS-CoV-2) per 1000 resident years were identified in the study period. CONCLUSION: Less than half of LTCFs identified any cases. The majority of cases were linked to outbreaks, emphasizing the importance of preventing introductions of SARS-CoV-2 into the facilities. Furthermore, it highlights the need to invest efforts into infrastructures, routine procedures and monitoring of SARS-CoV-2 in LTCFs to limit the introduction and the spread of SARS-CoV-2.

Facility- and ward-level factors associated with SARS-CoV-2 outbreaks among residents in long-term care facilities: A retrospective cohort study.

OBJECTIVES: Long-term care facilities (LTCFs) have been disproportionately impacted by COVID-19. Yet, the reasons why certain LTCFs are affected more by outbreaks are poorly understood. This study aimed to identify the facility- and ward-level factors associated with SARS-CoV-2 outbreaks among LTCF residents. METHODS: We conducted a retrospective cohort study of multiple Dutch LTCFs (N = 60; with 298 wards providing care for ∼5600 residents) from September 2020 to June 2021. A dataset was constructed linking SARS-CoV-2 cases among LTCF residents to facility- and ward-level factors. Multilevel logistic regression analyses examined the associations between these factors and the likelihood of a SARS-CoV-2 outbreak among residents. RESULTS: During periods of the Classic variant, the mechanical recirculation of air was associated with significantly increased odds of a SARS-CoV-2 outbreak. During periods of the Alpha variant, the factors associated with significantly increased odds included large ward size (≥21 beds), wards providing psychogeriatric care, fewer restrictions on staff movement between wards and facilities, and a greater number of cases among staff (>10 cases). CONCLUSION: Policy and protocols on reducing resident density, staff movement, and mechanical recirculation of air in buildings are recommended to enhance outbreak preparedness in LTCFs. The implementation of low-threshold preventive measures among psychogeriatric residents is important because they appear as a particularly vulnerable group.

The development of knowledgeable nursing assistants as creative caregivers (KNACC).

Certified nursing assistants (CNAs) provide 80% of direct care in long-term care settings and are critical to maintaining resident well-being. Arts-based approaches to enhancing meaningful engagement have the potential to empower CNA ownership in the process of improving patient-centered care. We held a series of focus groups with CNAs (n = 14) to adapt arts-based creative caregiving (CCG) techniques for use in long-term care. Iterative revisions focused on CCG techniques, factors influencing implementation, and usability. The Knowledgeable Nursing Assistants as Creative Caregivers (KNACC) manual developed from the adapted CCG describes training guidelines and instructions to facilitate CNA use of creative caregiving techniques in direct care.

Pilot testing the knowledgeable nursing assistants as creative caregivers (KNACC) guide.

Knowledgeable Nursing Assistants as Creative Caregivers (KNACC) was developed to train certified nursing assistants (CNAs) to apply arts-based techniques to enhance care and support to older adults in long-term care (LTC) settings. We piloted (n=8) KNACC techniques for use in LTC and assessed its potential for influence on the CNA outcomes of structural empowerment and job satisfaction. During preliminary implementation, CNAs working in memory care units were more open to applying all techniques. The techniques in KNACC have the potential to improve CNA skills in working with long-term care residents.

Predictors of COVID-19 Outcomes Among Residents of Swedish Long-Term Care Facilities-A Nationwide Study of the Year 2020.

OBJECTIVE: We analyzed predictors of SARS-CoV-2 infection and COVID-19 death among residents of long-term care facilities (LTCFs) in Sweden for the pandemic year 2020 and its different waves. METHODS: The study included 99% of Swedish LTCF residents (N = 82,488). Information on COVID-19 outcomes, sociodemographic factors, and comorbidities were obtained from Swedish registers. Fully adjusted Cox regression models were used to analyze predictors of COVID-19 infection and death. RESULTS: For the entirety of 2020, age, male sex, dementia, cardiovascular-, lung-, and kidney disease, hypertension, and diabetes mellitus were predictors of COVID-19 infection and death. During 2020 and the two waves, dementia remained the strongest predictor of COVID-19 outcomes, with the strongest effect on death being among those aged 65-75 years. CONCLUSION: Dementia emerged as a consistent and potent predictor of COVID-19 death among Swedish residents of LTCFs in 2020. These results provide important information on predictors associated with negative COVID-19 outcomes.

COVID-19 Burden in Long-Term Care Facilities in the Omicron Era: Public Health Action Not Yet Redundant.

Since the beginning of the pandemic, public health authorities have provided support to long-term care facilities (LTCFs) for the implementation of risk mitigation measures. Nevertheless, the necessity of these measures has been doubted, especially after vaccines and antiviral treatment became available. Here, we present the burden of COVID-19 infection in LTCFs during the first 9 months of 2022 across Greece. We tested the possible association of LTCF characteristics and public health response with the occurrence of clusters (two or more linked cases in LTCFs) with facilities recording one case as reference. After excluding LTCFs with sporadic cases, we tested the effect of the abovementioned variables on attack rate (cases/total number of persons in the LTCF). The disease burden in LTCFs was high and substantially varied among facilities, with hospitalization and case fatality rates ranging from 2 to 80% (median 14%, IQR 27%) and from 1 to 50% (median 5%, IQR 7%), respectively. The probability of transmission inside the facility increased when notification of public health authorities was delayed (p-Value < 0.001) after adjusting for vaccination status and phase of the pandemic. Results showed that active support from public health authorities is still important in reducing the burden in LTCFs.

Relational Care, Dementia, and Communication Challenges in Long-Term Care: A Meta-Ethnography.

Few studies examine care as a relational process in long-term care, and still fewer describe the participation of residents with dementia. In this article, our objective was to understand the development of knowledge in this area by means of a meta-ethnography. Our search and selection process resulted in six eligible articles. Each documents a qualitative study of resident-staff interactions during care activities in a residential care setting, and includes participants with dementia. Tronto's 4 Phases of Care were used to guide the identification of relational care practices within the articles selected. We identified five translatable concepts across the six studies: (1) doing with versus doing for, (2) staff responsiveness, (3) resident agency, (4) inclusive communication, and (5) time. In our new configuration of relational care, we combine these concepts to delineate an "interactive space" in which the agency of residents and initiative of staff are equally visible.

Managing COVID-19 transmission in long-term care: A qualitative study of high performing facilities.

Ever since its emergence, COVID-19 has posed a serious threat to members of the population who are older and have underlying health conditions, with those residing in Long-Term Care Facilities being particularly susceptible. The purpose of this study was to explore initiatives implemented by Long-Term Care Facilities which had lower COVID-19 transmission compared to their regional counterparts. Of the facilities interviewed, the majority implemented a routine testing schedule for residents utilizing both PCR and Rapid Antigen nasal tests, while also separately housing residents who may be at an increased risk. The results of this study could serve as a guidance for other facilities.

A new automated national register-based surveillance system for outbreaks in long-term care facilities in Norway detected three times more severe acute respiratory coronavirus virus 2 (SARS-CoV-2) clusters than traditional methods.

OBJECTIVE: To develop and test a new automated surveillance system that can detect, define and characterize infection clusters, including coronavirus disease 2019 (COVID-19), in long-term care facilities (LTCFs) in Norway by combining existing national register data. BACKGROUND: The numerous outbreaks in LTCFs during the COVID-19 pandemic highlighted the need for accurate and timely outbreak surveillance. As traditional methods were inadequate, we used severe acute respiratory coronavirus virus 2 (SARS-CoV-2) as a model to test automated surveillance. METHODS: We conducted a nationwide study using data from the Norwegian preparedness register (Beredt C19) and defined the study population as an open cohort from January 2020 to December 2021. We analyzed clusters (≥3 individuals with positive SARS-CoV-2 test ≤14 days) by 4-month periods including cluster size, duration and composition, and residents' mortality associated with clusters. RESULTS: The study population included 173,907 individuals; 78% employees and 22% residents. Clusters were detected in 427 (43%) of 993 LTCFs. The median cluster size was 4-8 individuals (maximum, 50) by 4-month periods, with a median duration of 9-17 days. Employees represented 60%-82% of cases in clusters and were index cases in 60%-90%. In the last 4-month period of 2020, we detected 107 clusters (915 cases) versus 428 clusters (2,998 cases) in the last period of 2021. The 14-day all-cause mortality rate was higher in resident cases from the clusters. Varying the cluster definitions changed the number of clusters. CONCLUSION: Automated national surveillance for SARS-CoV-2 clusters in LTCFs is possible based on existing data sources and provides near real-time detailed information on size, duration, and composition of clusters. Thus, this system can assist in early outbreak detection and improve surveillance.

Epidemiological and Genomic Analysis of a Large SARS-CoV-2 Outbreak in a Long-Term Care Facility in Catalonia, Spain.

Limiting outbreaks in long-term care facilities (LTCFs) is a cornerstone strategy to avoid an excess of COVID-19-related morbidity and mortality and to reduce its burden on the health system. We studied a large outbreak that occurred at an LTCF, combining methods of classical and genomic epidemiology analysis. The outbreak lasted for 31 days among residents, with an attack rate of 98% and 57% among residents and staff, respectively. The case fatality rate among residents was 16% (n = 15). Phylogenetic analysis of 59 SARS-CoV-2 isolates revealed the presence of two closely related viral variants in all cases (B.1.177 lineage), revealing a far more complex outbreak than initially thought and suggesting an initial spread driven by staff members. In turn, our results suggest that resident relocations to mitigate viral spread might have increased the risk of infection for staff members, creating secondary chains of transmission that were responsible for prolonging the outbreak. Our results highlight the importance of considering unnoticed chains of transmission early during an outbreak and making an adequate use and interpretation of diagnostic tests. Outbreak containment measures should be carefully tailored to each LTCF. IMPORTANCE The impact of COVID-19 on long-term care facilities (LTCFs) has been disproportionately large due to the high frailty of the residents. Here, we report epidemiological and genomic findings of a large outbreak that occurred at an LTCF, which ultimately affected almost all residents and nearly half of staff members. We found that the outbreak was initially driven by staff members; however, later resident relocation to limit the outbreak resulted in transmission from residents to staff members, evidencing the complexity and different phases of the outbreak. The phylogenetic analysis of SARS-CoV-2 isolates indicated that two closely related variants were responsible for the large outbreak. Our study highlights the importance of combining methods of classical and genomic epidemiology to take appropriate outbreak containment measures in LTCFs.