Every finding on record at St Elizabeth Edgewood SNF

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices for 4 out of 14 sampled residents, Resident (R) 4, R11, R40, and R44. The deficient practice had the potential to affect the whole facility with a census of 28.Four observations on 02/11/2026 revealed a physician entered two residents' rooms without wearing the required personal protective equipment (PPE). One of the residents was on Contact Plus isolation precautions, and one of the residents was on Airborne isolation precautions. Another observation revealed a Nutrition Ambassador (NA), after delivering a meal tray to a resident in Contact isolation precautions, continued to wear the contaminated PPE down the hallway, did not perform hand hygiene after removing the PPE, and continued her meal service. Further observation revealed a Registered Nurse (RN), after administering medication to a resident in Contact Plus isolation precautions, touched the door handles in the room and failed to wash her hands with soap and water after exiting the room.The findings include:Review of the Centers for Disease Control and Prevention's (CDC) guidance, Clinical Guidance for C. diff Infection Prevention in Healthcare Facilities, reviewed 08/2024, revealed C. difficile (Clostridioides difficile, C. diff) was a spore forming organism transmitted by contact with contaminated hands and environmental surfaces. The CDC stated alcohol-based hand sanitizers were not effective against C. diff spores, and hand hygiene with soap and water was required after contact with residents on C. diff precautions to prevent transmission. The CDC further recommended healthcare personnel must adhere to appropriate use of personal protective equipment (PPE) and hand hygiene to prevent transmission. Per the CDC, failure of staff to properly remove contaminated PPE, perform hand hygiene with soap and water after exiting the room, and prevent movement through the hallway while wearing contaminated PPE created the potential transmission of infection to other residents within the facility.Review of the facility's policy titled, Standard and Transmission-Based Precautions [TBP], Inf-Cntrl-S-09, revised 07/2024, revealed standard precautions were applied to all residents in all healthcare settings, based on the principle they were treated as potentially infectious. The policy recommended hand hygiene before and after contact with a resident or the resident's environment, and gloves were not a substitute for hand hygiene. Per the policy, Contact and Contact Plus Precautions for diseases transmitted through direct contact with the resident or the resident's environment, such as C. diff., required the use of gowns and gloves when entering the resident care area beyond the designated safe zone, with removal of PPE and performance of hand hygiene before exiting. The policy stated Airborne Precautions were used for COVID-19, and required at a minimum a N95 respirator, gown, and gloves. Further review revealed Enhanced Barrier Precautions (EBP) were implemented in conjunction with standard precautions to reduce transmission of multidrug-resistant organisms and included the use of gown and gloves during high-contact resident care activities.Review of the facility's policy titled, Hand Hygiene Practice, Inf-Cntrl-H-01, revised 06/2024, revealed hand hygiene was identified as one of the most important measures to prevent the spread of infection. The policy stated healthcare workers should perform hand hygiene before and after touching the resident and after contact with inanimate objects in the resident's immediate environment. Per the policy, hand hygiene should be performed using soap and water or alcohol-based hand rub (ABHR). The policy specified that soap and water must be used when caring for residents with confirmed or suspected C. diff. Review of an admission Record, found in R4's electronic medical record (EMR), revealed the facility admitted the resident on 01/20/2026 with diagnoses including non-traumatic rhabdomyolysis, urinary tract infection, and pneumonia.Review of R4's admission Minimum Data Set [MDS], with an Assessment Review Date (ARD) of 01/20/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, which indicated the resident was cognitively intact.Review of an Order Summary Report, found in R4's EMR, revealed on 01/20/2026 he was placed on transmission-based precautions under Contact Isolation related to wounds and multi-drug-resistant organism (MDRO) in urine.Review of the Comprehensive Care Plan [CCP], found in R4's EMR, revealed the resident was assessed on 01/20/2026 for isolation precautions related to MDRO and wounds. Goals initiated included staff to use appropriate isolation precautions to include required PPE to prevent transmission of disease within the facility.Review of an admission Record, found in R11's EMR, revealed the facility admitted the resident on 02/02/2026 with diagnoses including C. diff. colitis, congestive heart failure, and atrial fibrillation. Review of R11's admission MDS, with an ARD of 02/02/2026, revealed the resident had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact.Review of an Order Summary Report, found in R11's EMR, revealed on 02/02/2026, she was placed on transmission-based precautions under Contact Plus Isolation related to C. diff colitis.Review of the CCP, found in R11's EMR, revealed the resident was assessed on 02/02/2026 for isolation precautions related to C. diff. colitis. Goals initiated included staff to use appropriate isolation precautions to include required PPE to prevent transmission of multi-drug organisms within the facility.Review of an admission Record, found in R40's EMR, revealed the facility admitted the resident on 02/06/2026 with diagnoses of COVID-19, atrial fibrillation, and type 2 diabetes mellitus.Review of R40's admission MDS, with an ARD of 02/06/2026, revealed the resident had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact.Review of an Order Summary Report, found in R40's EMR, revealed he did not have a provider's order to be placed on transmission-based precautions under Airborne Isolation for COVID-19.Review of the CCP, found in R40's EMR, revealed the resident was assessed on 02/06/2026 for isolation precautions related to COVID-19. Goals initiated were Airborne Isolation, which included staff to use appropriate isolation precautions to include required PPE and hand hygiene to prevent transmission of COVID-19 within the facility.Review of an admission Record, found in R44's EMR, revealed the facility admitted the resident on 02/10/2026 with diagnoses including C. diff. colitis, C. diff. infection, and type 2 diabetes mellitus.Review of R44's baseline MDS, with an ARD of 02/02/2026, revealed the resident's BIMS score was not assessed.Review of an Order Summary Report, found in R44's EMR, revealed on 02/10/2026 she was placed on isolation precautions related to C. diff. colitis. Goals initiated included staff to use appropriate isolation precautions to include required PPE and hand hygiene to prevent transmission of MDROs within the facility.1. Observation on 02/11/2026 at 8:06 AM revealed Attending Physician 1 entered R11's room, a transmission-based precaution room designated for Contact Plus precautions due to the resident's diagnosis of C. diff. Observation revealed the physician at the bedside without wearing the required PPE. Per the resident's isolation signage, staff was required to don (put on) a gown and gloves.2. Observation of R40 on 02/10/2026 at 12:35 PM revealed he was not wearing any PPE, and neither were his two family members. R40 was not exhibiting any overt respiratory symptoms. The State Survey Agency (SSA) Surveyor was not aware of any infection control precautions implemented for R40 because she did not see any signage. Observation on 02/11/2026 at 8:15 AM revealed Attending Physician 1 entered R40's room, which was designated a transmission-based precaution room for Contact and Airborne precautions related to the resident's COVID-19 status. Continued observation revealed the physician at the bedside without wearing required PPE. Per R40's isolation signage, the required PPE included a gown, gloves, protective eyewear, and an N95 respirator.Observation on 02/11/2026 at 8:28 AM revealed the Infection Preventionist attached a vinyl STOP sign outside of R40's door. During an interview with Attending Physician 1 on 02/12/2026 at 8:20 AM, he stated he believed he was compliant because he was not performing direct patient care. He stated further that wearing PPE was important to prevent spreading infection. 3. Observation on 02/11/2026 at 8:30 AM revealed Registered Nurse (RN) 3 administered medication to R44, who was in Contact Plus isolation for C. diff. After doffing (removing) her PPE, RN3 went to the sink in the resident's bathroom to wash her hands. She then touched the door handle to the bathroom and the door to the hallway and failed to wash her hands with soap and water after exiting the room. In an immediate interview on 02/11/2026 at 8:30 AM, RN3 stated she washed her hands with soap and water in the resident's bathroom and used hand sanitizer. She further stated she believed the hand sanitizer was sufficient after touching the door handles in R44's room. RN3 showed the SSA Surveyor a sink in the resident's shower room where staff could wash their hands with soap and water after exiting a Contact Plus isolation room. However, RN3 did not wash her hands and continued with medication administration.4. Observation on 02/11/2026 at 5:00 PM revealed Nutrition Ambassador (NA) 1, entered R4's room, a transmission-based precaution room designated for Contact precautions related to the resident's diagnoses of multi-drug-resistant organism in the urine and wounds. She donned a gown and gloves to deliver a meal tray. However, upon exiting the room, NA1 failed to doff her PPE and walked several doors down the hallway wearing contaminated PPE. She then returned to R4's room, doffed PPE and exited; however, she failed to perform hand hygiene upon exit. NA1 subsequently proceeded down the hallway and resumed meal service from the nutrition cart.During an interview with NA1 on 02/11/2026 at 5:05 PM, she stated she forgot about doffing her contaminated PPE and stated she should have removed the PPE to protect both herself, residents, and staff from infection. Furthermore, NA1 stated she should have performed hand hygiene immediately after doffing her contaminated PPE. The NA stated she had received infection prevention and control (IPC) training upon hire to include proper use of PPE, transmission-based precautions, and hand hygiene. NA1 stated following infection prevention and control procedures was important to prevent the spread of infection and to keep residents safe.During an interview with Licensed Practical Nurse (LPN) 1 on 02/12/2026 at 2:05 PM, she stated she received ongoing IPC education online and annually. She stated she was also trained in infection control best practices in orientation. LPN1 stated resident specific isolation precautions were shared by in-person shift communication, the banner in Epic (health information software), signage at the door, and PPE available outside the room. She stated if staff members had any questions or concerns regarding the isolation precautions or PPE required for the room, they were to ask another staff member or their supervisor. She further stated, while there were no formal audits, staff monitored one another and provided on the spot education if an infection control breach was observed.During an interview with the Infection Preventionist (IP) on 02/11/2026 at 2:34 PM, she stated the facility provided infection prevention education at orientation every two months, with ongoing audits, real-time coaching, and a monthly newsletter to reinforce hand hygiene, transmission-based precautions, enhanced barrier precautions, and environmental cleaning. Additionally, the IP stated the facility followed the American Hospital Association's (AHA) red zone protocol, which used a three-foot doorway safe zone for Contact and Contact Plus precaution rooms. The IP stated staff must wear PPE when crossing the three-foot zone, remove gown and gloves inside the room, and perform hand hygiene. She stated alcohol-based hand rub might be used if soap and water were not available. She stated the red zone practice was not a CDC recommendation, and CDC guidance for transmission-based precautions required appropriate donning and doffing of PPE. She stated it also required hand hygiene when entering and exiting the room of a resident on Contact and Contact Plus isolation. Additionally, the Infection Preventionist stated she relied on information from the CDC's Morbidity and Mortality Weekly Report, dated 10/25/2002, which indicated at the time that alcohol-based hand rub could be used after removing gloves when caring for patients with C. difficile.During continued interview with the Infection Preventionist (IP) on 02/11/2026 at 2:34 PM, she stated hand hygiene was expected, after glove removal and before exiting if PPE was removed inside the room, with alcohol-based hand rub or handwashing unless hands were visibly soiled or during outbreaks when handwashing was required. She further stated environmental controls for isolation rooms included door signage identifying precaution type, magnetic stop signs as visual reminders, and distinct isolation carts to differentiate enhanced barrier from transmission-based precautions. The IP stated it was her expectation that all staff would wear the required PPE according to policy guidelines and CDC recommendations to protect themselves and residents from organism transmission.During continued interview with Attending Physician 1 on 02/12/2026 at 8:20 AM, he stated it was his expectation for all staff to wear PPE to prevent the spread of infection. He further stated he believed the staff was doing a good job adhering to IPC practices. During an interview with the Director of Nursing (DON) on 02/12/2026 at 4:00 PM, he stated all staff members, regardless of department, were expected to follow transmission-based precautions (TBP) as indicated for each resident. He stated signage, including door postings and visual cues, were used to alert staff and visitors and prompt consultation with nursing staff before entry into TBP rooms. Additionally, the DON stated there were concerns related to infection control practices, including placement of waste receptacles and hand hygiene processes for residents on contact precautions for C. difficile. He stated there were opportunities for process improvement to ensure consistency with CDC guidance. The DON stated following the facility's IPC policies was important for resident safety and for preventing the spread of disease among residents, staff, and visitors.During an interview with the Administrator on 02/12/2026 at 4:15 PM, she stated infection control compliance was monitored through observational audits conducted by the Infection Control department and monthly peer audit tools completed by staff. She stated those audits included PPE compliance measures and were submitted to leadership for review. She stated the unit frequently managed residents on Contact and Contact Plus precautions, while Airborne and Droplet precautions occurred less frequently. She stated when higher-level precautions were required, managers, team leaders, or infection control nurses provided refresher education to ensure staff compliance. During continued interview with the Administrator on 02/12/2026 at 4:15 PM, when asked about Attending Physician 1's failure to follow IPC protocols, she stated the physician believed he was compliant because he was not performing direct patient care. She stated education was provided clarifying that PPE requirements applied regardless of direct care activities, including masking requirements for COVID-related precautions. She further stated the facility followed CDC recommendations for PPE and transmission-based precautions and consulted with the Infection Control department when clarification was needed. The Administrator stated it was her expectation that all staff followed facility policies related to infection prevention and control practices. She stated adherence was important to prevent the spread of infection for the safety and well-being of all residents, visitors, and staff.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 out of 2 sampled residents, Resident (R) 5. Observation on 01/07/2025 revealed a staff member entered R5's room, a Contact Plus Isolation room, to perform resident care without donning (putting on) personal protective equipment (PPE). The findings include: Review of the facility's policy titled, Standard and Transmission-Based Precautions, Inf-Cntrl-s-09, revised 07/22/2024, revealed Contact Plus Isolation (in addition to Standard Precautions) was used for diseases transmitted by contact with the patient or the patient's environment, such as Clostridium difficile or norovirus. The policy stated the only time no PPE was required was in the Safe Zone, which was approximately three feet of entry into the resident's room. Per the policy these activities included answering call lights, asking questions, visualizing patient, or performing hourly rounding checks; however, any activity while in the resident care environment required donning PPE. These activities included approaching the resident or touching any item, surface, or piece of equipment within the resident's environment. The policy stated a gown and gloves were required when entering the room beyond the Safe Zone to protect exposed skin or clothing. Observation on 01/07/2025 at 4:13 PM revealed Contact Plus Precautions signage was visible outside R5's room, which stated in addition to standard precautions, staff must wear gown and gloves when interacting with the resident. Continued observation revealed Registered Nurse (RN) 1 entered R5's room to perform resident care without donning a gown or gloves, which were readily available in the PPE bin outside of the room. Review of R5's Face Sheet, located in the electronic medical record (EMR), revealed the facility admitted the resident on 12/18/2024 with diagnoses to include endocarditis (an infection of the heart's inner lining). Review of R5's laboratory results, taken during R5's previous admission to the facility and located in the EMR, dated 11/24/2024, revealed R5's C Diff [Clostridium difficile, a highly contagious bacterium that affected the colon] Toxin was positive. On 10/16/2025, R5's blood culture resulted with Klebsiella oxytoca detected. Review of R5's Physician Orders, located in the EMR and dated 12/18/2024, revealed orders for continuous Contact Plus Isolation: 1. Proper equipment, Gloves, Gown, Sporicidal agent (bleach wipes). 2. Provide patient and family education: Regarding isolation, proper PPE and hand hygiene, avoid visiting public areas while in isolation (Cafeteria / Gift Shop). 3. Disinfect: Clean and disinfect reusable equipment upon removal from room. 4. Transport: Place a clean gown or clean cover on patient. 5. Remember proper hand hygiene. Review of R5's Care Plan, dated 12/18/2024, revealed R5 was care planned for isolation precautions to prevent transmission of multi-drug organisms within the facility. During an interview with Certified Nursing Assistant (CNA) 1 on 01/07/2025 at 2:51 PM, she stated precaution signs were outside of doors and PPE was available outside the room. She stated she donned gown and gloves anytime she entered any isolation room because the resident usually required care that required contact. During an interview with RN1 on 01/07/25 at 4:13 PM, she stated she did not don PPE when providing care to R5, stating, Sorry, I just forgot. PPE should have been donned prior to entering the room. She stated she washed her hands with soap and water in R5's bathroom prior to exiting the room. She stated using appropriate PPE was important to keep the residents and staff safe and preventing the potential spread of C-diff. During an interview with the Infection Preventionist (IP) on 01/08/2025 at 1:35 PM, she stated any residents on precautions were tracked via Epic Dashboard that was specific for each unit on a daily basis. She stated if any resident had an organism detected by the lab, then an automatic notice was sent via Epic to the resident's chart and to the care providers to notify them. She stated staff received education on an annual basis by computer-based learning (CBL) and as needed on infection control topics. She also stated any changes would be mentioned in their daily staff meetings. The IP stated her expectation was that staff should be following protocols/policies and donning PPE when leaving the Safe Zone of the room. During an interview with the Interim Director of Nursing (IDON) on 01/08/2025 at 3:35 PM, she stated PPE was supplied by the materials department for the hospital, and there had never been an issue with getting what was needed. She stated staff was made aware of precautions and what PPE was needed by signage that was placed outside of the resident's room. The IDON stated her expectation was very high for staff following protocols that are laid out for us; we need to follow policy's/protocols. She stated audits on the floor were done often, and staff was expected to hold each other accountable as well. She stated this was important to prevent any kind of infection spread and to have good outcomes for the residents. During an interview with the Administrator on 01/09/2024 at 10:10 AM, she stated it was her expectation that staff wear PPE. She stated this was important to protect the staff, as well as the resident, by decreasing the risk of spreading infection as much as possible.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to prepare food under sanitary conditions. Observations on 11/07/2023 and 11/08/2023 revealed Cold Food Server #1 moved about in the kitchen production area with her hair not restrained by the hairnet. The findings include: Review of facility's policy titled, Uniforms, Health and Personal Hygiene, not dated, revealed uniform guidelines to include hair restraints were required in all food production, food service, and dish handling areas. Observation of Cold Food Server #1, on 11/07/2023 at 12:40 PM, revealed she wore the hairnet on top of her head with her hair loose and hanging down, while she worked in the food production area. Observation of Cold Food Server #1, on 11/08/2023 at 11:05 AM, revealed her hair was not fully covered by the hairnet as she walked about the kitchen, wrapped the cold food, and placed it in the refrigeration unit. During an interview with Cold Food Server #1, on 11/08/2023 at 11:05 AM, she stated the policy was to cover all hair to prevent hair from getting into the food. During an interview with the Nutrition Supervisor, on 11/09/2023 at 9:13 AM, she stated staff were to have their hair covered. The Nutrition Supervisor stated men were to wear beard guards. She stated staff were educated that their hair could fall into the food. In addition, she stated staff were re-educated related to not wearing hairnets properly. During an interview with the Retail Food Service Manager, on 11/07/2023 at 12:40 PM and 11/09/2023 at 9:46 AM, she stated when staff entered the kitchen all of their hair was to be secured under the hairnet throughout the kitchen and in the food production area. She stated it was important to wear a hairnet to prevent contamination from occurring with the food. During an interview with the Director of Nursing (DON), on 11/09/2023 at 11:20 AM, she stated her expectation was for staff to follow the facility's policy for hairnets being worn properly, and to change them as needed to prevent cross contamination. During an interview with the Administrator, on 11/09/2023 at 11:30 AM, she stated staff should wear hairnets according to policy for sanitary reasons and to prevent possible food contamination.

Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Disease Control and Prevention Reference: Guidelines for Hand Hygiene in Healthcare settings, it was determined the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe environment; and to help prevent the development and transmission of communicable diseases for five (5) of fourteen (14) sampled residents. The failures were related to improper cleaning of the residents' shared glucometers, improper hand hygiene, and improper handling of resident's medication. The residents affected were Resident #1, Resident #7 and Resident #8, Resident #207, and Resident #257. The facility failed to implement the manufacturer's recommendations for cleaning and disinfecting the Nova Stat Strip Point of Care System blood glucose glucometers. These glucometers were used on multiple residents. The facility also failed to follow the manufacture's recommendation on the Sani-Cloth disinfectant wipes when cleaning the monitors after resident use for three (3) of four (4) total residents requiring blood glucose monitoring (Residents #1, #7, and #8). The facility failed to implement the facility's Hand Hygiene Practices, Inf-Cntrl-H01 policy. A staff member failed to perform hand hygiene after removing gloves, after administering a suppository to Resident #207. In addition, the facility failed to implement the facility's Standard and Transmission-Based Precautions, Inf-Cntrl-S-09 policy and the Medication Storage/Security, Rx MM ST-MO1 policy. A staff member stored a medication in his pocket and returned the medication to the Pyxis (an automated medication dispensing system) after Resident #257 refused the medication. The findings include: 1. Review of the manufacturer's recommendations for cleaning and disinfecting the Nova Stat Strip Point of Care System dated 04/26/2017 revealed after use the meter should be disinfected using a Super Sani Cloth wipe. The user should wipe the external surface thoroughly, then observe the two (2) minute wet time. Review of the facility's orientation and yearly training on the Nova Stat Strip Point of Care System revealed after using the Nova Stat meter, the meter must remain visibly wet for the product's wet time which was two (2) minutes using the Super Sani Cloth wipes. Review of the directions for use on the Super Sani Cloth wipes revealed the user should thoroughly wet the surface, and allow the surface to remain wet for two (2) minutes. Review of the facility's Management of Equipment Cleaning and Disinfection, ACLIN-M-02 policy last revised 02/21/2023 revealed, reusable medical equipment should be cleaned based on the manufacturer's recommendations for use, including dwell or contact time. 1a. Review of Resident #8's clinical record revealed the facility admitted the resident on 10/17/2023 with diagnoses of acute on chronic systolic heart failure and diabetes. Review of Resident #8's Physician's Orders, dated 10/17/2023, revealed an order to complete blood glucose monitoring at 7:00 AM, 11:00 AM, 5:00 PM, and 8:00 PM. Observation on 11/08/2023 at 12:05 PM, revealed Licensed Practical Nurse (LPN) #1 completed the blood sugar check on Resident #8. LPN #1 then wiped the Nova Stat Strip monitor with the Sani-Cloth for approximately twenty (20) seconds then placed it on a paper towel to air dry. During interview at the time of observation, LPN #1 stated she should have wiped it for one (1) minute before air drying. 1b. Review of Resident #7's clinical record revealed the facility admitted the resident on 10/24/2023 with diagnoses of acute cerebrovascular accident and diabetes. Review of Resident #7's Physician's Orders, dated 10/24/2023 revealed an order to complete blood glucose monitoring at 7:00 AM, 11:00 AM, 5:00 PM, and 8:00 PM. Observation, on 11/09/2023 at 12:03 PM, revealed Certified Nursing Assistant (CNA) #4 performed a blood glucose check on Resident #7. Upon completion of the blood glucose check, CNA #4 wiped the monitor with a Sani-Cloth wipe for approximately twenty-five (25) seconds, then placed the monitor on a paper towel and allowed it to dry for approximately sixty (60) seconds. During an interview with CNA #4, on 11/09/2023 at 12:12 PM, she stated this was the first time she had performed a blood glucose check at this facility as she was recently hired. She further stated she was educated upon hire to wipe the glucometer for two (2) minutes and allow it to dry for four (4) minutes. CNA #4 stated she was in a rush to get to the next resident to perform a blood glucose check. She stated it was important to wipe the glucometer for two (2) minutes to ensure the effectiveness of the cleaning process to prevent the spread of germs to herself and residents and to avoid infection transmission. 1c. Review of Resident #1's clinical record revealed the facility admitted the resident on 11/01/2023 with diagnoses of left hip fracture and diabetes. Review of Resident #1's Physician's Orders, dated 11/01/2023, revealed an order to complete blood glucose monitoring at 7:00 AM, 11:00 AM, 5:00 PM, and 8:00 PM. Observation on 11/09/2023 at 12:04 PM, revealed CNA #5 picked up the blood glucose monitor from the docking station and did not clean the monitor prior to completing the blood sugar check on Resident #1. After the blood glucose check, CNA #5 wiped the monitor with a Sani-Cloth wipe for approximately five (5) seconds then placed it on a paper towel at the nurses' station to allow it to dry. During interview with CNA #5, at the time of the observation, she stated she thought she needed to wipe the monitor for forty-five (45) seconds and that was what the policy required. She further stated it was important to follow the policy to prevent the spread of infection. Also, the CNA stated she did not know why she did not wipe the glucometer for forty-five (45) seconds. During interview on 11/08/2023 at 2:01 PM with the Infection Preventionist, she stated there had not been any infectious outbreaks in the facility in the past year. She further stated she had taught staff to clean the glucometers with a Sani cloth, wiping the glucometer for two (2) minutes. 2. Review of the facility's Standard and Transmission-Based Precautions, Inf-Cntrl-S-09 policy revealed, hand hygiene should be preformed immediately after removing gloves. Review of the Centers for Disease Control and Prevention Reference: Guidelines for Hand Hygiene in Healthcare settings [PDF - 496 KB];5, 16,17. dated 2002 revealed, C difficile forms spores that are not killed by an alcohol-based hand sanitizer. Review of Resident #207's clinical record revealed the facility admitted the resident on 11/01/2023 with diagnoses that included hematoma of the left leg. Observation on 11/07/2023 at 3:29 PM, revealed after LPN #1 administered a rectal suppository for Resident #207, she removed her gloves and then touched the mouse on the computer without sanitizing her hands. During interview with LPN #1 on 11/07/2023 at 3:33 PM, she stated she didn't sanitize her hands after removing the gloves because she had put on two (2) pairs of gloves. 3. Review of the facility's Medication Storage/Security, Rx MM ST-M01 policy last reviewed 03/28/2023 revealed, medications should not be transported in pockets. Also, unused medications should be placed in the designated pharmacy return bin. Review of Resident #257's clinical record revealed the facility admitted the resident on 11/02/2023 with diagnoses of acute on chronic diastolic congestive heart failure and excessive fluid. Observation on 11/07/2023 at 4:27 PM revealed, Registered Nurse (RN) #1 gave a potassium tablet to Resident #257, he then asked the resident #257 if she/he wanted the laxative, the resident declined the laxative. RN #1 then removed his gloves and sanitized his hands. He then went to the medication room and opened the Pyxis. The RN removed the laxative out of his right pocket and put it back in the Pyxis in a compartment containing the same medication and closed the drawer. During interview on 11/07/2023 at 4:34 PM with RN #1, he stated he always puts medications he was going to return in his right pocket then put them back in the Pyxis. During interview on 11/09/2023 at 1:55 PM with the Infection Preventionist (IP), she stated staff education was done by the facility's training and education center. She stated they educated the new hires on glucose monitor cleaning. The IP stated the education included training that the glucometers needed to stay wet for two (2) minutes. She stated that she assured that the glucometers were cleaned correctly by relying on the educators. The IP stated they educated the staff and then have the staff complete return demonstration. During interview on 11/09/2023 at 11:10 AM with the Director of Nursing (DON), she stated she expected staff to follow the facility's policies on glucometer cleaning, medication administration and hand hygiene. She stated this included sanitizing their hands before and after wearing gloves. The DON stated after caring for a resident who had a clostridium difficile (C-diff) infection staff were to wash hands with soap and water. She stated she consulted with the Infection Preventionist if she had a question. During continued interview, the DON stated there had not been any infection outbreaks in the past year. The DON stated they followed the guidelines from the Centers for Disease Control and Prevention for hand hygiene. She stated she monitored staff to assure they were using proper hand hygiene. The DON stated if she observed a staff not using proper hand hygiene, she verbally reminded the staff. She stated the second time she used written education. The DON stated she may terminate if the staff was not able to comply. During interview on 11/09/2023 at 1:39 PM with the DON, she stated staff were trained on the use and cleaning of the glucometer during orientation and once a year. She stated there was extra training if staff had questions. The DON stated she showed them the policy and explained the policy to the staff. She further stated it was her expectation that staff followed the facility's policies. During interview on 11/09/2023 at 11:34 AM with the Administrator she stated she audited hand hygiene periodically. She stated she worked with the Infection Preventionist to ensure staff were following the facility's policies. The Administrator stated her expectation was that staff used proper hand hygiene, used the appropriate personal protection equipment, and followed the facility's policies. She stated it was important for staff to clean equipment correctly and use proper hand hygiene to prevent the spread of infection. 47852

Based on observation, interview, record review, review of the Food and Drug Administration (FDA) website, review of the Centers for Disease Control and Prevention (CDC) website, review of the Food Safety website, and review of the facility's policy, it was determined the facility failed to prepare food under sanitary conditions in accordance with professional standards for food service safety. Observation of the kitchen, on 08/03/2022, revealed Cook #1 wore a hair net inappropriately around food and touched her mask with gloved hands repeatedly without changing gloves with hand hygiene. This deficient practice affected all fifteen (15) residents receiving their food from the kitchen on 08/03/2022. The findings include: Review of the facility's policy and procedure titled, Infectious Control Guidelines, dated 03/29/2021, revealed the purpose was to prevent and control contamination of foodstuffs and foodborne bacteria and the spread of infection within the department and medical center. Further review revealed procedures for the handling, preparation, and serving of food shall meet the standards of all regulatory bodies. Review of the FDA website, https://www.fda.gov, revealed all persons working in direct contact with food, food-contact surfaces, and food-packaging materials shall conform to hygienic practices while on duty to the extent necessary to protect against contamination of food. The methods for maintaining cleanliness included, but were not limited to: 1) washing hands thoroughly (and sanitizing if necessary to protect against contamination with undesirable microorganisms) when the hands might have become soiled or contaminated; 2) maintaining gloves, if they were used in food handling, in an intact, clean, and sanitary condition; and 3) wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, or other effective hair restraints. Review of the CDC website, https://www.cdc.gov, revealed a documented titled, Wear a Mask the Right Way, undated, which stated to properly wear a mask, the individual must first, wash hands before donning (putting on) the face mask. It also stated the mask must cover the nose, mouth, and fit under the chin. Per the document, the mask must fit snugly on the face. Review of the Food Safety website, https://www.statefoodsafety.com, revealed a document titled, Wearing Gloves for Food Safety, undated, which stated gloves should be changed often, as wearing gloves did not guarantee that pathogens would not be transferred during food preparation. It stated gloves could easily be contaminated with pathogens just as hands could be. It gave instructions on ensuring pathogens were not spread by changing gloves: 1) if they became damaged; 2) if they became contaminated; 3) at least every four (4) hours; and 4) when switching tasks. Further review revealed washing hands should always occur before putting on a new pair of gloves. Observation, on 08/03/2022 at 3:15 PM, of the kitchen food preparation area, revealed Cook #1 had not been wearing a hair net correctly, which allowed her hair to be exposed on top and strands of her hair hanging from the sides. Per the observation, Cook #1 wore gloves during the food temperature checks. However, her mask continuously dropped below her nose. When this happened, multiple times she used gloved hands to pull her mask back over her nose, without hand washing or changing gloves after touching her mask. Telephone interviews with Cook #1, on 08/04/2022 at 10:08 AM and on 08/04/2022 at 11:26 AM, were attempted by the State Survey Agency (SSA) Surveyor but were unsuccessful. Voice messages were left requesting a call back. The SSA Surveyor was informed by the Administrator that Cook #1 had time off and would be traveling. Interview with Cook #2, on 08/04/2022 at 10:20 AM, revealed he received training for infection control and hygienic practices, and he stated masks were a requirement for protection against Covid-19 and for handling food safely. He revealed hair nets were required to prevent hair from falling into the resident's food and should cover as much hair as possible. Cook #2 stated handwashing was a standard he practiced on a regular basis and especially when handling food items. He stated he understood that gloves were to be changed when soiled, when changing kitchen work areas, and when working with different food sources. He stated handwashing was required between glove changes. Further, he stated these procedures were necessary to prevent cross-contamination and to promote resident safety. Interview with the Kitchen Supervisor, on 08/03/2022 at 1:00 PM, revealed the facility had no specific policy on mask and hair net wearing but stated the facility followed all local, state, and federal regulatory guidelines. She stated masks were not mandated in dietary, but due to Covid-19 guidelines, the facility preferred masks be worn. The Supervisor stated concerns with hair falling and contaminating foods had always been a potential hazard, even when properly wearing masks. She stated a source at the local health department explained hair had not been considered a contaminant, but the facility had enforced procedures for prevention. The Supervisor stated the unhygienic practice by Cook #1, with hair exposed, mask falling below nose multiple times, and using her gloved hands to pull mask back without washing hands or changing gloves had been a circumstance which warranted a follow-up observation and re-education. She stated she would address this concern with all dietary staff. Interview with the Infection Control Manager, on 08/03/2022 at 4:10 PM, revealed expectations for dietary staff regarding wearing masks were that all staff should be wearing well-fitting masks and should not have to keep re-adjusting them. She stated less than two (2) months ago the Dietary Administrative staff had completed a unit huddle with all staff which highlighted training specific to Infection Control education. She revealed the potential for cross-contamination was always there, but she believed precautions that were currently in place were being implemented correctly by all staff members. She stated these precautions included hair nets covering as much hair as possible, handwashing techniques being utilized as required and per guidelines, and masks being well-fitted and not falling frequently. She stated, then in theory, the potential risk of cross contamination should be reduced significantly or potentially eliminated. Interview with the Director of Senior Services (Administrator), on 08/04/2022 at 11:35 AM, revealed staff expectations were to follow the basic hygienic practices as well as Food Safety and ServSafe (a food and beverage safety training and certificate program) certification guidelines. She revealed staff members should be wearing their masks correctly by covering both nose and mouth, and if the mask did not fit correctly and prompted staff to continually re-adjust, then staff should dispose of the mask, wash hands, and replace it. The Administrator stated the same concerning hair nets: they should be properly worn and cover as much hair as possible. Per the interview, she stated handwashing and changing gloves was a standard that should be followed by all staff and not just dietary. She said it should be practiced in the kitchen, when handling food, to prevent potential negative outcomes such as cross contamination. Further, she explained this concern had been a challenge, but the Kitchen Supervisor should be checking the kitchen and making staff observations regularly to address potential concerns. The Administrator stated she believed, by implementing daily rounds and staff observations, teachable moments would be discovered for staff education going forward.

Based on observation, interview, and facility Policy review, it was determined the facility failed to maintain an effective infection control program to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for one (1) resident, (Resident #8). Certified Nursing Assistant (CNA) #1 was observed to perform a blood glucose test for Resident #8. After obtaining the blood sample, CNA #1 placed the used lancet and the soiled glucose meter on the patient's bedside table. The findings include: Review of the facility's policy and procedure titled, Management of Equipment Cleaning and Disinfection, last revised 11/01/18, revealed point of care reusable devices such as glucose meters or other equipment that contacted blood must be cleaned and disinfected after each use. However, the policy did not address the cleaning of surfaces which were contacted by the reusable device. Observation during a blood sugar test on 09/21/19 at 9:43 PM, revealed CNA #1 used a disposable lancet and obtained a blood sample from Resident #8 for a blood sugar test. Continued observation revealed CNA #1 placed the used lancet on Resident #8's bedside table. CNA #1 then used the glucose meter and performed the blood sugar test. When CNA #1 completed the blood sugar test, she was observed to place the used glucose meter on Resident #8's bedside table. Further observation revealed CNA #1 was not observed to sanitize Resident #8's bedside table. Interview with CNA #1, on 09/21/19 at 12:21 PM, revealed she was trained by the facility to perform blood glucose testing for residents. CNA #1 stated she was trained to keep the glucometer in her hand until it was cleaned and was trained to immediately dispose of the lancet in the biohazard/sharps container. CNA #1 stated she normally did not place the lancet or glucometer on the patients table and stated she was just nervous. CNA #1 also stated this was important due to prevent the spread of Infection. Interview with the Director of Nursing (DON), on 09/21/19 at 5:01 PM, revealed the CNA's had been trained to perform blood glucose testing for resident. Further interview with the DON revealed staff were trained to immediately discard any sharps, including lancets, in the biohazard sharps container. In addition, the DON stated CNA #1 should have placed the glucose meter on a barrier or held the meter in her hand until it could have been sanitized. The DON stated by placing the soiled lancet and glucose meter on the resident's bedside table increased the risk of the spread of infection.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to submit Discharge Minimum Data Set (MDS) Assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for three (3) of three (3) residents, Residents #1, #2 and #3. The findings include: Review of the facility's Policy, titled MDS-Completion and Staff Responsibilities, revised date 11/07/17, revealed PPS and Quarterly Assessments will be transmitted within fourteen (14)days of the completion date in Z0500B. Comprehensive assessments will be transmitted in fourteen (14) days of the care plan completion date (V0200C2). The RAI Coordinator will transmit the file and print the initial and final validation report. The RAI Coordinator will facilitate the correction of any fatal errors immediately and retransmit the assessment until an accepted validation report is received. To facilitate receiving validation reports timely, the RAI Coordinator will transmit as frequently as necessary to obtain timely validation of MDS acceptance into the QIES ASAP data base. Review of the RAI 3.0 User's Manual, Version 1.16, dated (MONTH) (YEAR), Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records, information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Entry Tracking Record revealed a completion and transmitted date of 04/01/19. Review of the Admission MDS Assessment revealed a completion and transmitted date of 04/08/19. Review of the facility's SNF Admission and Discharge Log revealed Resident #1 was discharged to home on 04/21/19. The Discharge Tracking Record was completed on 04/22/19; however, the record was not transmitted to CMS. 2. Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Entry Tracking Record revealed a completion and transmitted date of 04/12/19. Review of the Admission MDS Assessment revealed a completion and transmitted date of 04/19/19. Review of the facility's SNF Admission and Discharge Log revealed Resident #2 was discharged to an acute unit on 04/27/19. The Discharge Tracking Record was completed on 05/03/19; however, the record was not transmitted to CMS. 3. Record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Entry Tracking Record revealed a completion and transmitted date of 05/13/19. Review of the Admission MDS Assessment revealed a completion and transmitted date of 05/20/19. Review of the facility's SNF Admission and Discharge Log revealed Resident #3 was discharged to home on 06/01/19. The Discharge Tracking Record was completed on 06/05/19; however, the record was not transmitted to CMS. Interview with the MDS Coordinator, on 09/21/19 at 3:54 PM, revealed the discharge assessments were completed timely; however, they were not submitted to CMS. He/she stated not aware that the discharge assessments were not submitted to CMS. He/she stated these assessments were another payor source (not Medicare or Medicaid) that doesn't automatically transmit to CMS in their system. He/she stated that two (2) MDS Coordinators cover each other when they take off from work; however, they do not audit each other's work to ensure assessments are completed and transmitted timely. Interview with the Administrator, on 09/21/19 at 5:00 PM, revealed that MDS policy states to code and submit the MDS assessments timely. Further interview revealed that the MDS Coordinator did not complete the steps required to submit the MDS to CMS timely. He/she stated their auditing process could be improved and they will add another step to the process to ensure they aren't missed in the future.

Based on observation, interview, and facility policy review, it was determined the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. Observation revealed food stored unsealed and undated and a male kitchen staff with an uncovered beard. The findings include: Review of facility's policy titled, Preparation and Serving of Food, dated 06/21/18, revealed no food will be used beyond the expiration date. Dating food guidelines are posted in all department areas and updated routinely. Review of the facility's policy titled, Uniforms, Health and Personal Hygiene, dated 10/11/17, revealed hair restraints are required in all food production, food service and ish handling areas. Male employees are encouraged to be clean-shaven. Beards must be covered with a beard restraint. Observation of the walk-in freezer in the kitchen, on 09/10/18 at 9:47 AM, revealed one (1) bag of Jimmy Dean Sausage Links and one (1) bag of Jimmy Dean Sausage Patties opened, unsealed and undated. Interview with the Dietary Manager, at 09/10/18 at 9:50 AM, revealed that staff should seal and date foods after opened. Unsealed foods could cause food contamination. Observation a male Room Service Ambassador, on 09/10/18 at 09:23 AM , revealed he walked through the kitchen to the Dietary Manager's office without a beard restraint. Interview with the Room Service Ambassador, on 09/10/18 at 9:30 AM, revealed that he knew to wear the beard restraint but he was in a hurry and forgot to put it on. Interview with the Dietary Manager, on 09/10/18 at 9:33 AM, revealed that the facility policy is to wear hair and beard restraints when in the kitchen. Staff have been educated on the policy. Interview with the Administrator, on 09/11/18 at 12:37 PM, revealed he/she expects the staff to wear hair/beard restraints all of time and food items to be sealed and dated in the kitchen.

Based on observation, interview and record review and facility policy review, revealed the facility failed to ensure each resident was treated with dignity and respect for two (2) of two (2) residents with catheters (Resident #2 and #3). Observations on 09/10/18 and 09/11/18, revealed Resident #2 and #3's urinary catheter bags were not covered in dignity bags. The findings include: Review of the facility's admission packet, revealed the the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and ouside the facility. Further review revealed the resident has a right to be treated with respect and dignity. Review of the facility's training policy titled Urinary Catheter: Indwelling (Foley) Catheter/Emptying a Urinary Drainage Bag, dated (YEAR), revealed to hang the Foley drainage bag securely to the bed frame or appropriate securement area depending on bed/stretcher type. However, the policy did not address covering the urinary drainage bag. 1. Record review revealed the facility admitted Resident #2 on 09/10/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 08/29/18, revealed the facility coded Resident #2's Brief Interview for Mental Status (BIMS) score as 15, which indicated the resident was cognitively intact and interviewable. Observations of Resident #2 on 09/10/18 at 12:30 PM and 4:14 PM, and 09/11/18 at 10:24 AM, revealed the resident's catheter drainage bag was not in a dignity bag and was facing the doorway, visible to any residents, staff or visitors passing by the door. 2. Record review revealed the facility admitted Resident #3 on 08/03/18 with [DIAGNOSES REDACTED]. Review of the PPS 30-day MDS assessment, dated 08/15/18, revealed the facility coded Resident #3's BIMS score as 13, which indicated the resident was cognitively intact and interviewable. Observations of Resident #3 on 09/10/18 at 12:35 PM and 09/11/18 at 9:45 AM, revealed the resident's catheter drainage bag was not in a dignity bag and was facing the doorway, visible to any residents, staff or visitors passing by the door. Interview with Certified Nursing Assistant (CNA) #1, on 09/11/18 at 10:30 AM, revealed the catheter bag should be hung on the opposite of the bed facing the wall. He/she stated that they did not have dignity covers for bags at the hospital. He/she further stated that it was a dignity issue if visitors could see the catheter bag from the hallway. Interview with CNA #3, on 09/11/18 at 10:37 AM, revealed he/she was not trained to cover or place the catheter bag where it could not be seen by visitors. Interview with Licensed Practical Nurse (LPN) #1, on 09/11/18 at 11:12 AM, revealed that the urinary bag should be covered or placed on the other side of the bed where it could not be seen when the Resident's door was open. Interview with Registered Nurse (RN) #1, on 09/11/18 at 11:22 AM, revealed CNAs were trained to place urinary drainage bags on the other side of the bed not facing the hallway. Interview with the Director of Nursing (DON), on 09/11/18 at 11:29 AM, revealed that staff were trained and he/she expects staff to ensure that uncovered urinary drainage bags were kept out of sight. Interview with the Nurse Manager, on 09/11/18 at 11:57 AM, revealed the facility did not have dignity bags to cover the drainage bag. He/she stated staff should follow policy on foley catheters to place it below the bladder and on the bedframe where it could not be seen by visitors. Interview with the Administrator, on 09/11/18 at 12:40 PM, revealed that the foley catheter policy did not address covering the urinary catheter bags. He/she stated that the hospital would not order them for the nursing facility. He/she stated that staff were not trained on this in orientation by the hospital.

Based on observation, interview, and review of facility policy, it was determined the facility failed to maintain proper temperatures for cold food items in the kitchen. Observation on 01/27/16, revealed one (1) Mighty Shake, two (2) Applesauce's, one (1) Cottage Cheese and one (1) Chocolate Pudding were at temperatures above forty-one (41) degrees Fahrenheit (F). The findings include: Review of the facility's policy titled, Preparation and Serving of Food, revised 12/04/13, revealed foods would be prepared and served in a manner to ensure food safety, promote highest quality, flavor, and appearance and to preserve nutritive value. Continued review of the policy, revealed time and temperature measures were used for foods that were held for service or immediate consumption. (A) Hot foods would be maintained above one hundred thirty-five (135) degrees Fahrenheit (F) and cold foods would be maintained below forty-one (41) degrees F. Review of the A LA Cart Dual Temp 120 information guide, dated 06/14, revealed the Dual Temp's indefinite hot and cold holding capacity allowed for the assembly of meal trays as much as an hour in advance of serving and the hold hot capacity was indefinite. Observation, on 01/27/16 at 11:20 AM, revealed the residents' trays were already stored on the cart, titled A La Cart Dual Temp 120. Interview with the Dietary Manager (DM) during the observation, at 11:20 AM, revealed the residents' trays were stored inside of the cart and was holding for at least one (1) hour and fifteen (15) minutes before the trays were sent to the unit. Further observation with the DM, on 01/27/16 at 12:20 PM, revealed random trays were selected for temperatures from the cart and the temperatures obtained revealed one (1) Mighty Shake at fifty (50) degrees F, two (2) Applesauces at fifty-two (52) degrees F, and at forty-eight (48) degrees F, one (1) Cottage Cheese at forty-seven point eight (47.8) degrees F, and a Chocolate Pudding at forty-seven point six (47.6) degrees F. Interview with the Kitchen Lead, on 01/28/16 at 11:33 PM, revealed staff took the temperature of the residents' food before they were put it into the cart and random trays were selected and tempted before taking the cart to the unit. The Kitchen Lead stated, it was important that the food remained at a certain temperature so bacteria would not set in the food, in order to prevent food poisoning and so that no one would get sick. Interview with the DM, on 01/28/16 at 12:15 PM, revealed she noticed the cold foods were not remaining cold, after obtaining food temperatures with the surveyor. She stated, the compressor/gauge on the cart was broken and Maintenance was called to repair the cart. Continued interview, revealed the kitchen staff did test trays on the food to determine if the cart was maintaining proper temperatures three (3) times a week. She stated it was important for food temperatures to stay out of the danger zones, because food borne illness could set in. She stated, bacteria would grow in the food and added there was also a matter of the quality of food and the overall taste of the food if served at the wrong temperatures.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the Interim Care Plans was sufficient to meet the needs of newly admitted residents for one (1) of eight (8) sampled residents (Resident #4). Resident #4's Interim Care Plan did not reflect accurate interventions needed to prevent falls. The findings include: Review of the facility's policy titled, Fall Protection/Prevention Program, revised 08/10/15, revealed customized safety and fall risk interventions were implemented on residents that were identified at high risk for falls. The purpose was to minimize the risk of falls without compromising patient mobility and functional independence. Review of the facility's policy titled, Patient (Resident) Care Services, revised 09/11/15, revealed the Licensed Practical Nurse (LPN), with the support of the Minimum Data Set (MDS) Coordinator (RN), would develop and implement the initial individualized care plan for each resident based on subjective and objective assessment/history data obtained during the admission process. Continued review of the policy revealed the purpose of the care plan was to provide guidelines for the healthcare team in delivery of consistent, quality resident care. Review of Resident #4's medical record revealed the facility admitted the resident on 01/18/16 from the hospital with [DIAGNOSES REDACTED]. The facility had not completed a Minimum Data Set Assessment yet, due to the resident being a new admission. Review of the Brief Interview for Mental Status (BIMS) List provided by the facility, revealed the facility assessed the resident as having a BIMS of a fifteen (15) out of fifteen (15) indicating the resident had no cognitive impairment. Review of the resident's Active Interim Care Plan related to Fall Risk dated 01/18/16, revealed the resident's goal was to remain free of falls and injury. He/She was care planned to Consider use bed/chair/toilet alarm, Consider floor mat, Pomeroy chair cushion, hip protectors, and apply yellow armband for a fall during current admission or admission related to fall. Interview with Resident #4, on 01/27/16 at 8:00 AM, revealed he/she pressed his/her call light to assist with warming his/her tea. Observation at the time of the interview, revealed Resident #4 did not have a fall mat on the floor, a Pomeroy chair cushion, hip protectors, a chair or toilet alarm, nor a yellow armband. The resident revealed he/she knew there was a bed alarm because it went off when he/she got out of bed. Interview with Certified Nursing Assistant (CNA) #1, on 01/28/16 at 4:00 PM, revealed Resident #4 was alert and oriented and could make his/her wants and needs known. CNA #1 further revealed, the resident had a bed alarm, but she did not use the bed alarm on Resident #4 because the resident could use the call light and could tell staff when he/she needed to get up out of bed or needed assistance to go to the restroom. Continued interview, revealed the residents were given a yellow arm band if they had a fall at the hospital prior to admit or may be at risk for falls. CNA #1 revealed, Resident #4 did not have a yellow arm band, so she did not believe the resident was a fall risk. Further interview with CNA #1, revealed if the resident was at risk for falls, she would need to know. Interview with Registered Nurse (RN) #2/Unit Manager, on 01/28/16 at 4:36 PM, revealed care plans were completed upon admission and it was important for the care plans to be accurate because it was a guide for staff to provide care to the residents. She stated, the initial care plans could be completed and revised as needed by the staff nurses, or the MDS Coordinator. Further interview with RN #2, revealed she was aware Resident #4 was a fall risk. She stated staff monitored the bed alarm closely. She further stated, the resident would not allow a chair or toilet alarm. Continued interview with RN #2, revealed after looking at the care plan, she was not certain if the resident used a chair cushion but knew the fall mat should have been removed from the resident's care plan because the resident was not using a fall mat. She further stated, she was not sure if the yellow arm band and hip protectors needed to be in place or needed to be care planned. Continued interview with RN #2, revealed she understood Resident #4's care plan should be reflective of what care staff provided for the resident. Interview with the Director of Nursing (DON), on 01/28/16 at 5:19 PM, revealed Resident #4's care plan should have been accurate after staff had completed their initial assessment of the resident and should have been revised if the resident had changes in his/her cognitive or functional ability after admission. Interview with the Administrator, on 01/28/16 at 5:09 PM, it was her expectation for the care plans to accurately reflect the care needs of the resident.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for one (1) of twelve (12) sampled residents (Resident #3). Observation revealed the nursing staff used improper hand decontamination and gloving technique during the skin assessment for Resident #3. In addition, observation on the initial tour of the facility revealed a bedpan unbagged and unlabeled hanging on the handrail in a shared bathroom for room [ROOM NUMBER]. The findings include: 1. According to the facility's Hand Hygiene Practices policy, reviewed 05/01/15, revealed the facility considered hand hygiene the primary means to prevent the spread of infection. To minimized the risk of cross contamination via the hands of healthcare workers, hand hygiene was performed with either soap and water, hand wash, or alcohol hand foam. According to the policy, hand hygiene was to be performed after removing gloves or other personal protection equipment (PPE). Review of Resident #3's medical record revealed the facility admitted the resident on 01/20/16 with [DIAGNOSES REDACTED]. Observation, on 01/27/16 at 12:55 PM, during Resident #3's skin assessment conducted by Registered Nurse (RN) #2, revealed the nurse washed her hands and applied gloves. During the skin assessment the nurse then applied a topical (skin) cream to the resident's feet. The nurse removed her gloves and reapplied clean gloves, but did not sanitize her hands with soap and water or use sanitizing gel before reapplying clean gloves. The nurse then proceeded to remove the glove from her right hand, to use the mouse on the computer on wheels. The nurse reapplied the glove to her right hand but did not perform hand hygiene prior to applying the glove, and proceeded with the skin assessment touching the resident's left ear. Interview with RN #3, on 01/27/16 at 1:30 PM, revealed she realized she had not sanitized her hands between gloves changes, possibly two (2) times during the skin assessment. The nurse stated, she was supposed to sanitize her hands between gloves changes to prevent the spread of disease and infection. Interview, with the Infection Control Preventist (ICP) on 01/28/16 at 3:45 PM, revealed whenever staff removed gloves, hands should be washed or sanitized before applying clean gloves. The ICP stated, not following proper infection control hand hygiene could result in cross contamination. Interview, on 01/16/16 at 4:20 PM, with the Director of Nursing (DON), revealed she had been in the DON position with the facility about six (6) months and she would need to pull the facility's actual policy on hand hygiene to comment. The DON further stated, she thought it was the facility's policy to wash hands between every glove change but she would have to check. She stated, ideally, the nurse should have sanitized with gel or washed her hands between glove changes. The DON stated, not doing this could cause an infection control issue and spread different organisms to different places and people. 2. Observation during tour, on 01/26/16 at 12:00 PM, revealed one (1) bed pan was uncovered and unlabeled located on the handrail of a shared bathroom, room [ROOM NUMBER]. Interview with Certified Nursing Assistant (CNA) #2, on 01/28/16 at 3:44 PM, revealed bed pans should be placed in the resident's shower room and labeled with the resident's name and room number. She stated, the bed pans should also be bagged. Further interview revealed this was important for infection control, adding, we don't want to mix the resident's items up. Interview with Registered Nurse (RN) #2, on 01/28/16 at 4:36 PM, revealed the bed pans should be stored, bagged, and labeled. RN #2 stated, this was important to prevent any contamination. Interview with the Administrator and the Director of Nursing (DON), on 01/28/16 at 5:19 PM, revealed it was their expectation that the bed pans would be stored in the shower area, bagged and labeled. They revealed this was important for infection control.

Based on observation, interview, record review and review of facility's policy it was determined the facility failed to ensure a Comprehensive Plan of Care was developed for each resident to meet the resident's medical needs that was identified in the comprehensive assessment for one (1) of eight (8) sampled residents (Resident #4). The facility failed to care plan and have interventions in place to address Resident #4's lower extremity [MEDICAL CONDITION] which progressively worsened during their stay at the facility. The findings include: Interview, on 04/26/13 at 3:10 PM, with the Minimum Data Set (MDS) Coordinator revealed the purpose of a care plan was try to identify problems and put interventions in place for staff to follow and manage the problems identified. Observation of Resident #4 on 04/25/13 at 11:25 AM, 12:45 PM and 4:30 PM revealed the resident was seated in a wheel chair with his/her legs down and observed to have bilateral lower extremity [MEDICAL CONDITION]. Observation of a skin assessment performed on Resident #4, on 04/26/13 at 9:20 AM, by Licensed Practical Nurse (LPN) #1 revealed the resident had bilateral lower extremity [MEDICAL CONDITION]. LPN #1 assessed the resident's bilateral lower extremity [MEDICAL CONDITION] as +2. Interview, on 04/26/13 at 3:00 PM, with LPN #1 revealed Resident #4 had no care plan for their [MEDICAL CONDITION] and should have been careplanned. There should have been interventions in place to keep his/her legs elevated. Review of Resident#4's medical record revealed the resident was admitted by the facility on 04/02/13 with [DIAGNOSES REDACTED]. Review of 04/15/13 admission MDS revealed the resident had moderate cognitive impairment. In addition, the resident required extensive assistance of two (2) staff with bed mobility, transfers, and to be walked in the room. Review of Resident #4's medical record under the Peripheral Vascular Assessment revealed upon admit, 04/02/13, the resident had a trace amount of [MEDICAL CONDITION] in the lower extremities. Continued review of the resident's Lower Extremity Peripheral Vascular Assessment revealed: from 04/03/13 thru 04/06/13 assessed as 2+ [MEDICAL CONDITION]; 04/07/13 thru 04/10/13 assessed as 2+ [MEDICAL CONDITION]; from 04/11/13 thru 04/25/13 the resident was assessed as having 2+ or 3+ [MEDICAL CONDITION] in their lower extremities. Review of Resident #4's Plan of Care (POC) revealed no care plan related to the assessed [MEDICAL CONDITION] in the resident's lower extremities. Interview, on 04/26/13 at 8:50 AM, with Certified Nursing Assistant (CNA) #1 revealed she occasionally takes care of Resident #4 and was not aware of any care plan interventions related to the [MEDICAL CONDITION]. Interview, on 04/26/13 at 8:40 AM and 2:15 PM, with Registered Nurse (RN) #4 revealed care plans were used to identify medical issues/problems and the purpose was to provide interventions for care of the resident's problems and monitor the outcome. She further stated the care plan was to provided standardized interventions. The RN stated the resident had [MEDICAL CONDITION], but there was no specific care plan in place with interventions to reduce the resident's [MEDICAL CONDITION]. Further interview, on 04/26/13 at 3:10 PM, with the MDS Coordinator revealed when Resident #4 was admitted the resident had a trace of [MEDICAL CONDITION] to their lower extremities, but over the course of the assessment period the resident's [MEDICAL CONDITION] was assessed as +2 and +2 [MEDICAL CONDITION]. She stated the [MEDICAL CONDITION] should have been addressed in the resident's care plan with goals to monitor the outcome and update the care plan if needed. She further stated the care plan could have addressed the resident's refusal with interventions if non-compliance was an issue. Interview, on 04/26/13 at 3:45 PM, with the Director of Nursing (DON) revealed Resident #4's [MEDICAL CONDITION] should have been addressed in a care plan with appropriate interventions such as elevating legs when up in a chair. The DON stated staff was probably doing this at times, but was not an intervention to be monitored. She stated the purpose of the care plan was to identify what care was needed for the resident. She further stated the resident's [MEDICAL CONDITION] worsened during his/her stay.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being for one (1) of eight (8) sampled residents (Resident #4). The facility failed to ensure interventions were in place to address Resident #4's lower extremity [MEDICAL CONDITION] which progressively worsened during their stay at the facility. The findings include: Review of Resident #4's medical record revealed the resident was admitted by the facility on 04/02/13 with [DIAGNOSES REDACTED]. Review of 04/15/13 admission MDS revealed the resident had moderate cognitive impairment. In addition, the resident required extensive assistance of two (2) staff with bed mobility, transfers, and to be walked in the room. Interview, on 04/26/13 at 3:10 PM, with the Minimum Data Set (MDS) Coordinator revealed the purpose of a care plan was try to identify problems and put interventions in place to manage the problems. Observation of Resident #4, on 04/25/13 at 11:25 AM, revealed the resident was seated in a wheel chair with his/her legs down. Observation revealed the resident to have bilateral lower extremity [MEDICAL CONDITION]. Continued observation, on 04/25/13 at 12:45 PM and 4:30 PM and on 04/26/13 at 8:30 AM, revealed the resident was seated in his/her wheel chair with his/her legs down. Observation of a skin assessment performed on Resident #4, on 04/26/13 at 9:20 AM, by Licensed Practical Nurse (LPN) #1 revealed the resident had bilateral lower extremity [MEDICAL CONDITION]. LPN #1 assessed the resident's bilateral lower extremity [MEDICAL CONDITION] as +2. Review of Resident #4's medical record under the Peripheral Vascular Assessment revealed upon admittion, 04/02/13, the resident had a trace amount of [MEDICAL CONDITION] in the lower extremities. Continued review of the resident's Lower Extremity Peripheral Vascular Assessment revealed: from 04/03/13 through 04/06/13 assessed as 2+ [MEDICAL CONDITION]; 04/07/13 through 04/10/13 the resident was assessed as 2+ [MEDICAL CONDITION]; from 04/11/13 through 04/25/13 the resident was assessed as having 2+ or 3+ [MEDICAL CONDITION] in his/her lower extremities. Review of Resident #4's Plan of Care (POC) revealed no documented evidence of a care plan to the address [MEDICAL CONDITION] in the resident's lower extremities. Interview, on 04/26/13 at 8:50 AM, with Certified Nursing Assistant (CNA) #1 revealed she occasionally took care of Resident #4. She stated the resident's legs looked more swollen yesterday when she was helping to walk the resident and looked a lot worse then she had seen before. She further stated she was not aware of any care plan interventions related to the [MEDICAL CONDITION]. Interview, on 04/26/13 at 8:40 AM and 2:15 PM, with Registered Nurse (RN) #4 revealed the resident had [MEDICAL CONDITION] which they assessed daily, but there was no specific care plan in place with interventions to reduce the resident's [MEDICAL CONDITION]. Further interview, on 04/26/13 at 3:10 PM, with the MDS Coordinator revealed when Resident #4 was admitted the resident had a trace of [MEDICAL CONDITION] to their lower extremities, but over the course of the assessment period the resident's [MEDICAL CONDITION] was assessed as +2 and +2 [MEDICAL CONDITION]. She stated the [MEDICAL CONDITION] should have been addressed and careplanned with interventions to try and manage the problem. She further stated the resident's [MEDICAL CONDITION] had increased to +2 and +3 [MEDICAL CONDITION] during his/her care at the facility. Interview, on 04/26/13 at 3:45 PM, with the Director of Nursing (DON) revealed Resident #4's [MEDICAL CONDITION] progressively worsened during his/her stay and should have been addressed in a care plan. She stated the resident currently had +3 [MEDICAL CONDITION] in their lower extremities, but had not signs of [MEDICAL CONDITION] and the Physician noted the [MEDICAL CONDITION] was a chronic condition.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure personal privacy was provided for one of eight sampled residents (Resident #6). Observation on 06/20/12, at 10:00 AM, revealed Registered Nurse (RN) #3 failed to close the window blinds while performing wound care for Resident #6. Observation revealed the facility was engaged in a major reconstruction/remodeling project and construction scaffolding was observed outside the window of Resident #6's room. The findings include: A review of a booklet given to all residents upon admission to the facility entitled "Welcome to St. Elizabeth Healthcare Skilled Nursing Facility," (dated June 2009) revealed each resident would be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and in care for personal needs. Review of the facility policy/procedure entitled HIPAA Privacy (dated 04/02/12) revealed the facility would protect residents' privacy by keeping curtains pulled and doors closed during examinations and treatments. Observation on 06/20/12, at 10:00 AM, revealed RN #3 (wound care nurse) entered Resident #6's private room to apply negative pressure wound therapy to the resident's upper mid-chest wound. RN #3 was observed to shut the door to Resident #6's private room and pull the privacy curtain that only provided privacy if the door to the hallway was opened. Continued observation revealed construction equipment (scaffolding) was erected outside of Resident #6's window. RN #3 failed to close Resident #6's window blinds, thus failed to ensure visual privacy was maintained during the wound care, and permitted Resident #6's upper chest area to be exposed to any individual, including construction workers, which may have been near the windows. Interview on 06/21/12 at 9:30 AM, with Resident #6 revealed the resident would have been uncomfortable if anyone had been outside the window while the dressing on the resident's chest was changed. An interview conducted with RN #3 on 06/21/12, at 10:40 AM, revealed RN #3 was aware of a major construction/remodeling project at the facility but failed to notice the construction scaffolding erected outside Resident #6's room. RN #3 stated she should have closed the window blinds to ensure Resident #6's privacy during wound care but was nervous and failed to close the window blinds. An interview conducted with the Assistant Nurse Manager (ANM) on 06/21/12, at 11:10 AM, revealed staff was expected to close the door and pull the privacy curtain during any treatment or while providing care to residents. The ANM stated a major construction project was underway throughout the facility and confirmed blinds should be closed to ensure privacy to residents while care was provided.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish and maintain an effective infection control program to prevent the development and transmission of disease and infection for one of eight sampled residents (Resident #6). Observation of wound care on 06/20/12, revealed the wound care nurse (RN #3) failed to wash/sanitize her hands between glove changes. The findings include: A review of two facility policies titled, "Hand Hygiene Practices," (dated 06/15/12) and "PPE: Gloves/Latex Sensitivity" (dated 05/04/12), revealed staff was required to perform hand hygiene with soap and water or use an alcohol hand sanitizer after removing gloves. A review of the medical record for Resident #6 revealed the facility admitted the resident on 06/19/12, with [DIAGNOSES REDACTED]. Observation of wound care for Resident #6 on 06/20/12, at 10:00 AM, revealed Registered Nurse (RN) #3 washed/sanitized her hands and applied gloves prior to wound care. RN #3 was then observed to remove a soiled dressing from a wound to Resident #6's upper mid-chest area, discard the soiled dressing in a biohazard bag, remove her soiled gloves, and apply clean gloves. RN #6 failed to wash/sanitize her hands after removing soiled gloves and prior to applying clean gloves. Continued observation revealed RN #3 cleansed the wound to the resident's mid-upper chest with a wound cleansing solution and gauze sponge. The RN disposed of the soiled gauze sponge in the biohazard bag, removed her gloves, and applied clean gloves but failed to wash/sanitize her hands between glove changes. The RN was then observed to spray a skin barrier to the skin surrounding the mid-upper chest wound and obtained measurements of the wound. RN #3 removed her gloves and placed them in the biohazard bag, applied clean gloves, and then applied strips of clear occlusive dressing to the skin around the wound without washing/sanitizing her hands. Continued observation of the wound care revealed RN #3 used a tongue depressor to position [MEDICATION NAME] mesh (prevents the outer absorbent dressing from sticking to the wound) into the wound bed. Black foam was inserted into the wound and secured with clear adhesive dressing. The wound vac tubing was secured to the wound dressing with the appropriate disk and the pump was activated by the nurse. RN #3 was observed to remove her gloves and discard the gloves in the biohazard bag and wash/sanitize her hands upon exiting Resident #6's room. An interview with the Infection Control Nurse/Preventionist (ICN/P) on 06/20/12, at 4:00 PM, revealed hands should be washed/sanitized any time an employee changes his/her gloves. The ICN/P revealed hand hygiene was a part of all employees' initial orientation and frequent in-services were provided. An interview conducted with RN #3 on 06/21/12, at 10:40 AM, revealed the RN was not aware of the requirement to wash/sanitize hands after every glove removal. The RN stated she always washed/sanitized her hands prior to starting the wound care and again when the wound care had been completed. RN #3 stated she thought changing her gloves had been sufficient and always washed/sanitized her hands prior to starting any wound care and again when the wound care had been completed. An interview conducted with the Assistant Nurse Manager on 06/21/12, at 11:10 AM, revealed employees were expected to follow facility policy and wash/sanitize their hands after changing gloves. The DON revealed frequent in-services were provided related to infection control/proper hand washing and was not aware of any concerns related to staff failing to wash hands between glove changes. The DON confirmed staff was to wash/sanitize their hands after every glove change.