Health inspection·August 1, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy and procedure review, the facility's failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow isolation guidelines for COVID 19 for five (Residents #1, #2, #3, #4, and #5) of seven residents who were positive for COVID 19, from a total sample of 9 residents. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants. Residents Affected - Some The findings include: On 7/29/24 at 10:00 am, Licensed Practical Nurse (LPN) A was observed passing medication to Resident #1. A sign on the door noted Resident #1 was on droplet precaution. LPN A was observed wearing a surgical mask below her chin and had no gown or gloves. She was standing at the door interacting with Resident #1 who was sitting in his chair near the door less than one foot from LPN A. When LPN A, realized she was being watched, she pulled up her mask to cover her nose and mouth. During an interview on 7/29/24 at 10:10 am with LPN A, she was asked why Resident #1 was on isolation. She stated that she was not sure and had to look it up. After reviewing Resident #1's physician orders, she stated that the resident had tested positive for Covid on 7/20/24. When asked what personal protective equipment (PPE) she was supposed to use. She said, N95 respirator mask, face shield, gloves and gown. When LPN A was asked if the facility had enough PPE, she said, Yes. She went on to confirm that she should have been wearing a N95 when interacting with Resident #1, who was less than 5 feet away from her. On 7/29/24 at 10:20 am, Resident #2 was observed in room [ROOM NUMBER] sitting on Resident #3's bed. A sign on the door for room [ROOM NUMBER] indicated that Resident #3 was on Droplet precaution. On 7/29/24 at 10:25 am, an interview was conducted with Personal Care Attendant (PCA) B. She was asked if Resident #2 belonged to room [ROOM NUMBER]. She said no and entered room [ROOM NUMBER] to assist Resident #2 out of the room. PCA B was wearing a KN95 mask and did not don gloves or gown. She stated that Resident #2 was in room [ROOM NUMBER] and she was not on isolation (PCA B did not perform hand hygiene after exciting isolation room [ROOM NUMBER]). She was again asked if Resident #3 had a roommate, she said, Yes, Resident #4 is his roommate and is in activities. On 7/29/24 at 10:30 am, PCA A was observed entering room [ROOM NUMBER] A. She was wearing a KN95 mask and did not don gloves or gown. There was a sign on the door indicating that residents were on Droplet precaution. The PPE bag that was hanging on the door had no PPE. PCA A assisted Resident #5 to put on his pants. After dressing the resident, she walked outside the resident room holding Page 1 of 5 105402 105402 08/01/2024 Bridgeview Center 350 S Ridgewood Avenue Ormond Beach, FL 32174

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #5's hand and directed him to the activities room. Resident #5 was not encouraged to wear a mask. PCA A did not perform had hygiene. Before entering the activities room, she was stopped and asked what precautions Resident #5 was on. She said, I don't know, he is not my resident. She continued to enter the activities room where 15 other residents were seated having activities. In an interview on 7/29/24 at 10:34 am with LPN C, she confirmed that Resident #5 was on droplet precaution. She added that the resident tested positive for Covid on 7/22/24 and should be off of isolation on August 1. When asked if the resident was allowed to leave his room without a mask. She said, Resident are allowed to go anywhere they want we can't restrict them; he does not have any symptoms. She then asked the activities staff to offer a mask to Resident #5. During a follow-up interview on 7/29/24 at 10:45 am with PCA B, she stated that she was hired in May 2024. When asked if she had received any training on infection control and abuse/neglect she said, No. She added that she received video training upon hire. When asked how she identified what type of isolation and appropriate PPE to use, she said, Honestly I don't know. During an interview on 7/29/24 at 12:25 pm with the Assistant Director of Nursing (ADON)/Infection Control Preventionist, she stated that since the facility was in outbreak mode, all staff are supposed to wear surgical masks when in the resident areas and stay home if sick. Residents who are positive for COVID 19 should be encouraged to stay in their rooms or wear mask when they get out of their room. Staff are supposed to follow the standard precaution and isolation precautions. When asked how she ensured that staff implemented the infection control protocol, she said that she conducts random spot checks and hand hygiene observations. When asked how staff are supposed to differentiate isolation precautions, she said that isolation posters were color coded, and each poster included the appropriate PPE to wear. When asked how families and visitors are notified of an outbreak. She said, We are supposed to have an outbreak sign upon entrance, but I noted it was not there when you guys walked in. The ADON confirmed that staff are supposed to perform hand hygiene, don appropriate PPE before entering isolation rooms except when entering rooms on Enhanced barrier precaution (EBP). She stated that COVID 19 isolation requires an N95 mask, Face shield, gown and gloves. When asked how COVID 19 residents in semi-private rooms were isolated. She said, Normally we will get the negative resident out of the room, but residents who are positive for COVID 19 without symptoms can be placed in the same room, it's a case-by-case situation. When asked about Resident #3, she confirmed that resident was on isolation for COVID 19, and his roommate (Resident #4) was not on isolation. When asked why the two residents were not separated. She stated that there was no available bed. The ADON also confirmed that Resident #5 had no roommate. She could not explain why Residents #3 and #5 were not placed in the same room. A review of the facility' policy and procedure titled, Infection Control - Infection Prevention and Control Program - Revised 6/2023 revealed the following: Standard - An infection prevention and control program (IPCP) are established and maintained to provide a safe, sanitary and conformable environment and to help prevent development and transmission of communicable diseases and infections. Guideline- The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is based on accepted national infection prevention and control standards in accordance with local, state and federal regulations and guidelines. 105402 Page 2 of 5 105402 08/01/2024 Bridgeview Center 350 S Ridgewood Avenue Ormond Beach, FL 32174

F 0880 Procedure: Level of Harm - Minimal harm or potential for actual harm Elements (Page 2) Residents Affected - Some 2. The elements of the infection prevention and control program consists of coordination/oversight/policies/procedures, surveillance, data analysis, antibiotics stewardship, outbreak management, prevention of infection, and employee health and safety. Outbreak management (Page 4) 1. Outbreak management is a process that consists of: a. determining the presence of an outbreak; b. managing the affected residents; c. preventing the spread to other residents; d. documenting information about the outbreak; e. reporting the information to appropriate public health authorities; f. educating staff and the public; g. monitoring the recurrences; h. reviewing the care after the outbreak has subsided; and i. recommending new or revised policies to handle similar events in the future. Important facets of infection prevention include: 105402 Page 3 of 5 105402 08/01/2024 Bridgeview Center 350 S Ridgewood Avenue Ormond Beach, FL 32174

F 0880 a. Level of Harm - Minimal harm or potential for actual harm identifying possible infections or potential complications of existing infections; b. Residents Affected - Some instituting measures to avoid complications or dissemination; c. educating staff and ensuring that they adhere to proper techniques and procedures; d. communicating the importance of standard precautions and cough etiquette to visitors and family members; e. enhancing screening for possible significant pathogen; f. immunizing residents and staff to try to prevent illness; g. implementing appropriate isolation precautions when necessary; and h. following established general and disease-specific guideline such as those of the centers for Disease Control (CDC) A review of the facility's policy titled, Infection Control: Transmission Based Precautions - Revised 02/2024 revealed the following: Guideline: All staff receive training on transmission-based precautions upon hire and at least annually. Procedure: 3. Droplet precautionsa. intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing or talking). 105402 Page 4 of 5 105402 08/01/2024 Bridgeview Center 350 S Ridgewood Avenue Ormond Beach, FL 32174

F 0880 b. Level of Harm - Minimal harm or potential for actual harm Make decisions regarding private room on case-by-case basis after considering infection risk to other residents in the room and available alternatives. Residents Affected - Some c. Healthcare personnel wear surgical masks for close contact with infectious resident. d. Residents on Droplet precautions who must be transported outside of their room should wear a surgical mask if tolerated and follow respiratory hygiene/cough etiquette. . 105402 Page 5 of 5