Based on interview and review of facility documentation as indicated, it was determined that the facility failed to implement their infection control program for COVID-19 after a resident on 8/4/23 tested positive and subsequent positives were identified on 8/15/23 and 8/19/23, putting residents at risk for a severe adverse outcome. On 8/22/23 at 4:40 PM, an Immediate Jeopardy (IJ) was called. Based on review of the facility's corrective actions, the IJ was abated on 8/23/23 at 3:00 PM. Additionally, the facility failed to maintain laundry services in a sanitary manner. Findings include:
The facility's policy and procedure entitled COVID-19, dated 5/10/23, stated, . 5. Containment/Management: a. …
D · No harm, potential for more than minimal, isolatedJune 26, 2026
Based on observations, interviews and record reviews, it was determined that for two (R4 and R56) of seven residents reviewed for infection control, the facility failed to implement an effective infection prevention and control program. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) for R4 during incontinent care and a wound dressing change despite an active physician's order and posted EBP signage. For R56, a resident with a multidrug-resistant organism (MDRO), the facility also failed to implement Enhanced Barrier Precautions during medication patch administration.The facility's Enhanced Barrier Precautions (EBP) policy, revised February 2025, stated that Enhanced Barrier Precautions are an infection prevention measure intended to reduce the… …
C · No harm, potential for minimal, widespreadJuly 1, 2019
Based on review of facility documents and interview it was determined that the facility failed to conduct an annual review of their Infection Control and Prevention Policies, and to update the program as necessary. Findings include:
6/28/19 and 7/1/19 - Review of the Infection Prevention and Control Program policies and procedures revealed:
1. The following policies and procedures had no documented review since signed by E2 (DON) on 11/28/17:
- Assessment of Facility Strengths and Weaknesses to Initiate and Maintain an Antimicrobial Stewardship program;
- Engagement of Residents and Family members in Antimicrobial Use;
- Establishment of an Antibiotic Stewardship Program;
- Measurement of Antibiotic Use and Antibiotic Stewardship Activities;
- Microbiology Testing;
- Communication of… …
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