Health inspection·April 2, 2021

F880 §483.80 Infection Control The facility must 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. (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; (a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. (a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. On 6/25/20, at 9:52 AM, an unannounced COVID-19 (Coronavirus potentially severe respiratory illness spread person to person characterized by fever, coughing, and shortness of breath) Infection Control Survey was conducted at the facility. The facility failed to follow CDC recommended practices (Preparing for COVID-19 in Nursing Homes...Cloth face coverings [cloth mask] are not considered PPE [Personal Protective Equipment] and should only be worn by HCP for source control, not when PPE is indicated) in the use of PPE when: a. One Receptionist (1) was not wearing a facemask during screening of staff. b. One Graduate Vocational Nurse (GVN) 1 and one Licensed Vocational Nurse (LVN) 1 were wearing cloth masks (textile [cloth] covers are intended to keep the person wearing one from spreading respiratory secretions when talking, sneezing or coughing) inside the facility, next to the nurses station. c. One Physical Therapist (PT) 1 was wearing a cloth covering while providing resident care. d. One Certified Nursing Assistant (CNA) 1 was not wearing a facemask while providing resident care. These failures had the potential to result in the continued spread of infection (COVID-19) for 12 residents, staff, and visitors. a. During a concurrent observation and interview on 6/30/20, at 10 AM, with Receptionist 1, in the front lobby, Receptionist 1 had no facemask while screening staff for COVID-19 symptoms and obtaining staff temperature. Receptionist 1 stated it was her job duty to screen all staff and visitors prior to entering the facility. Receptionist 1 stated, she "only interact with staff" and was not required to wear any face covering when she was at her desk area performing her job duties in screening all staff and visitors. b. During a concurrent observation and interview on 6/30/20, at 10:04 AM, with GVN 1, GVN 1 was observed wearing a cloth mask. GVN 1 stated, staff informed her that it was "ok" to use cloth mask while in the facility. During a concurrent observation and interview on 6/30/20, at 10:06 AM, with LVN 1, LVN 1 was observed wearing a cloth mask. LVN 1 stated she currently works with COVID-19 recovered residents and was given the option to wear either a (medical) facemask (designed to protect the patient from the wearer's respiratory emissions) and/or cloth mask. c. During a concurrent observation and interview on 6/30/20, at 10:07 AM, with PT 1, PT 1 exiting a resident room wearing a cloth mask. PT 1 stated, she had just provided physical therapy to a resident and was told any face covering was acceptable to use while providing care to residents. d. During a concurrent observation and interview on 6/30/20, at 10:09 AM, with CNA 1, in Resident 1's room, CNA 1 was braiding Resident 1's hair. CNA 1 was not wearing any facemask. CNA 1 stated, she was required to wear a facial mask at all times but did not know where she had placed her mask. CNA 1 stated, "I get busy, it gets hot and sweaty, I take it off and I lose track of it." During a concurrent interview and record review on 6/30/20, at 10:14 AM, with Director of Nursing (DON) and Minimum Data Set Coordinator (MDSC), DON stated, the facility currently had no facemask shortage. DON stated, the Receptionist should be wearing facemask at all times during her work hours and stated, the facility practice was for all staff to wear facemask. DON stated, for the month of June, 2020 the facility has had a total of seven staff tested positive for the COVID-19 virus and a cumulative of 73 residents have tested positive for the COVID-19 virus. DON stated, there were currently two Infection Preventionist (IP's - person who specializes in preventing infections) in the facility and they "are always going around making sure everyone is washing their hands, wearing appropriate PPE." DON was unable to provide documented evidence the IP's had completed staff monitoring on proper PPE use. During a review of the facility's mitigation plan titled, "Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities" [undated], the mitigation plan indicated, "a. FACEMASKS vi. Homemade masks are not considered PPE, since their capability to protect staff is unknown..." During a review of the Centers For Medicare & Medicaid Services (CMS) guidelines titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" updated on 6/19/20, indicated, "HCP [Healthcare Personnel] should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. To reduce the number of times HCP must touch their face and potential risk for self-contamination, HCP should consider continuing to wear the same respirator or facemask (extended use) throughout their entire work shift, instead of intermittently switching back to their cloth face covering." This violation had a direct or immediate relationship to health, safety, or security of patients or residents and constitutes a class "B" citation.