Health inspection·February 17, 2022

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. §483.80(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: §483.80(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. §483.80(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. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The Department received a complaint on 12/13/21 regarding an unrelated allegation of resident neglect. On 12/23/2021, an unannounced visit was made to the facility. The facility failed to maintain an effective infection prevention and control program to prevent the development and transmission of COVID-19 (disease caused by a virus called SARS-CoV-2, a coronavirus) throughout the facility including but limited to: 1. Ensure Certified Nurse Assistant 4 (CNA 4) and Registered Nurse 1 (RN 1) wore the appropriate personal protective equipment ([PPE] equipment worn to minimize exposure to infectious diseases and hazards) while transporting Residents 3, 4, and 5, who were potentially exposed to COVID-19. 2. Ensure CNA 1 and RN 2 wore the appropriate PPE while providing care to Residents 6 and 7, who were in the yellow zone (a zone where residents reside if they are potentially COVID-19 positive), and to ensure the PPE cart was set up directly outside of the dining room converted to a yellow zone for staff use. 3. Ensure CNAs 1 and 4, and RN 2 were fit tested for an N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles, including those from SARS-CoV-2) respirator. As a result, 93 residents (14 residents in the yellow zone and 79 residents in the green zone (a zone where residents reside if they do not have COVID-19), 120 staff, and the community were placed at risk for the transmission and spread of COVID-19 virus. a. During a review of Resident 2's Admission Record dated 12/21/2021, the Admission Record indicated Resident 2 was admitted to the facility on 12/16/2021 with diagnoses including hypertension (high blood pressure), anemia (a condition in which the blood doesn't have enough healthy red blood cells), and hyperlipidemia (high levels of fat in the blood). The Admission record indicated Resident 2 had a positive COVID-19 test dated 12/19/2021. During a review of Resident 2's Admission Assessment, dated 12/16/2021, the Admission Assessment indicated the resident was alert with periods of confusion, had a clear speech, and was able to follow simple commands. During a review of Resident 3's Admission Record dated 12/23/2021, the Admission Record indicated the resident was admitted to the facility on 7/27/2017 with diagnoses including coronary artery disease ([CAD] damage or disease in the heart's major blood vessels), hyperlipidemia (high fats in the blood), and dementia (group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/04/2021, the MDS indicated Resident 3 had the ability to make herself understood and understood others, and required supervision from staff for bed mobility, transfer, walking, and locomotion (moving from place to place), and extensive assistance with personal hygiene, and bathing. During a review of Resident 4 ' s Admission Record, the Admission Record indicated the resident was admitted to the facility on 12/20/2018, with diagnoses including hypertension, hyperlipidemia, and osteoporosis (a condition in which bones become weak and brittle). During a review of Resident 4's MDS, dated 9/30/2021, the MDS indicated the resident had the ability to make herself understood and understood others, and required limited assistance from staff with bed mobility, and extensive assistance from staff for transfer, walking, locomotion, personal hygiene, and bathing. During a review of Resident 5's Admission Record, the Admission Record indicated the resident was admitted to the facility on 8/30/2020 with diagnoses including hypertension, anemia (condition in which the blood doesn't have enough healthy red blood cells), and hyperlipidemia. During a review of Resident 5's MDS, dated 10/17/2021, the MDS indicated the resident had the ability to make herself understood and understood others, and required limited assistance from staff for bed mobility, and extensive assistance form staff for and transfer, walking inside and outside the room, locomotion, personal hygiene, and bathing. During an observation on 12/23/2021 at 9:50 a.m., CNA 4 and RN 1 were observed wheeling Resident 3 in her bed from Resident 3's room (in the green zone) to the dining room (converted to a yellow zone). During the transfer, CNA 4 and RN 1 were observed to have close contact with Resident 3 (within 6 feet). CNA 4 was observed not wearing a N95 respirator, a gown, and gloves. RN 1 was observed wearing two masks, one on top of the other. During an observation on 12/23/2021 at 9:55 a.m., CNA 4 was observed wheeling Resident 4 in her bed from Resident 4's room (in the green zone) to the dining room. During the transfer, CNA 4 was observed to have a close contact with Resident 4 (within 6 feet) without wearing an N95 respirator, a gown, and gloves. During an observation on 12/23/2021, at 9:59 a.m., CNA 4 was observed wheeling Resident 5 in her bed from Resident 5's room (in the green zone) to the dining room (converted to a yellow zone). During the transfer, CNA 4 was observed to have a close contact with Resident 5 (within 6 feet) without wearing an N95 respirator, a gown, and gloves. During a review of the facility’s census dated 12/17/2021, the census indicated Resident 2, 3 and 4, shared a room and Resident 5 was in the adjacent room to Resident 2, 3, and 4. Resident 2, 3, and 4's room and Resident 5's room shared a bathroom. During a concurrent interview and record review on 12/22/2021 at 10 a.m., the with Infection Preventionist (IP) Nurse, the census, dated 12/22/2021, was reviewed. IP confirmed by highlighting the census, dated 12/22/21, and stated that Residents 3, 4, and 5 were residing in the dining room (yellow zone). During an interview on 12/23/21 at 10:05 a.m., CNA 4 stated when she was transporting Resident 3, 4, and 5 from their room in the green zone to the yellow zone, she was only wearing a surgical mask and eye protection. CNA 4 stated she was transporting Resident 3, 4, and 5 from the green zone to the yellow zone because they were exposed to Resident 2, who was confirmed positive for COVID-19 on 12/19/21. CNA 4 stated that she was in close contact with Resident 3, 4, and 5 (within 6 feet). CNA 4 could not verbalize whether an N95 respirator, gown, and gloves were necessary when transporting and coming into close contact with a resident (Residents 3, 4, and 5) who was potentially exposed to COVID-19. During an interview on 12/23/2021 at 10:30 a.m., IP stated Resident 2, 3 and 4, shared a room in the green zone before Resident 2 was transferred to the general acute care hospital (GACH) on 12/18/2021. IP stated Resident 5 was considered exposed to COVID-19 because she shared a bathroom with Resident 2, 3, and 4. IP stated the GACH had reported to the facility that Resident 2 had tested positive for COVID-19 on 12/19/2021. IP stated the GACH did not provide a documented confirmation of Resident 2 ' s positive COVID-19 test, but the facility was verbally notified over the phone. IP stated that the facility was moving Resident 3, 4, and 5 from the green zone to the yellow zone because they were exposed to Resident 2, who was confirmed COVID-19 positive. IP stated when staff provide care or are in close contact to residents (within 6 feet) who were potentially exposed (Resident 3, 4, and 5), they must wear eye protection, a gown, an N95 respirator, and gloves. IP stated if CNA 4 and RN 1 were not wearing eye protection, a gown, an N95 respirator, and gloves while transporting Resident 3, 4, and 5 from the green to the yellow zone, they can potentially spread COVID-19 to all other residents, staff, and visitors. During an interview on 12/23/2021 at 12:11 p.m., RN 1 stated on 12/23/21, at approximately 10 a.m., RN 1 stated that the mask she was wearing was a KN95 respirator (a respirator not approved by NIOSH) under a surgical mask for "double protection." RN 1 could not verbalize if the KN95 respirator she wore was NIOSH-approved nor whether the facility approved its use. RN 1 stated that she was not fit tested for the KN95 she wore while transporting Resident 3. RN 1 stated she did not know whether all respirators worn by staff must be NIOSH-approved or fit tested prior to its use. RN 1 stated she did not know whether double masking was appropriate and within the current COVID-19 PPE guidelines. RN 1 stated that the "guidelines [COVID-19] keep changing, so I do not know what [PPE] to wear." b. During a review of Resident 6's Admission Record, the Admission Record indicated Resident 6 was admitted to the facility on 8/25/2021 with diagnoses including hypertension, congestive heart failure ([CHF] chronic condition in which the heart doesn't pump blood as well as it should), and coronary artery disease ([CAD] damage or disease in the heart’s major blood vessels). During a review of Resident 6's MDS, dated 12/11/2021, the MDS indicated Resident 6 had the ability to make himself understood and understood others and required a limited to extensive assistance from staff for transfer, locomotion, toilet use, personal hygiene, and bathing. During a review of Resident 7's Admission Record, the Admission Record indicated the resident was admitted to the facility on 10/9/2021 with diagnoses including hypertension, CHF, and CAD. During a review of Resident 7's MDS, dated 12/20/2021, the MDS indicated Resident 7 had the ability to make himself understood and understood others and required a limited assistance from staff with bed mobility, and extensive assistance from staff members for transfer, locomotion, toilet use, personal hygiene, and bathing. During a concurrent interview and record review on 12/22/2021 at 10 a.m., with IP, the census, dated 12/22/21, was reviewed. IP stated and confirmed by highlighting the census, dated 12/22/21, that Residents 6 and 7 were residing in the dining room (yellow zone). During an observation on 12/23/2021 at 10:10 a.m., CNA 1 and RN 2 were observed not wearing N95 respirators, gown, and gloves while providing care in the dining room converted to a yellow zone. CNA 1 was observed tucking Resident 6's sheets into the resident's bed while being within six feet of Resident 6. RN 2 was observed giving Resident 7 medications while being within 6 feet of the resident. During an interview on 12/23/2021 at 10:12 a.m., CNA 1 confirmed she was in close contact with Resident 6 when she was tucking the resident's bed sheets CNA 1 confirmed she was only wearing a surgical face mask and a face shield. CNA 1 stated he should have worn an N95 respirator, a gown, and gloves. CNA 1 stated he did not wear a N95, a gown, and gloves because the PPE cart containing all required PPE was not set up outside of the dining room. CNA 1 stated he could spread COVID-19 because he did not wear all PPE as required when providing care to a resident in the yellow zone, which included an N95 respirator, gown, eye protection, and gloves. During an interview on 12/23/2021 at 10:15 a.m., with RN 2, RN 2 stated she was passing medications to Resident 7 at approximately 10 a.m. on 12/23/2021. RN 2 stated she came into close contact with Resident 7. RN 2 confirmed she was only wearing a surgical face mask and a face shield when she administered medications to Resident 7. RN 2 stated she should have worn "full PPE" which included an N95 respirator, a gown, gloves, and eye protection because Resident 7 was in the yellow zone. RN 2 stated she did not wear full PPE because the PPE cart was not set up directly outside of the room in the yellow zone. RN 2 stated she should be wearing full PPE in the yellow zone and when providing resident care to prevent the spread of COVID-19. During a review of the facility's census dated 12/22/2021, indicated there were 14 residents residing in the yellow zone and 79 residents were in the green zone. A review of the facility's COVID-19 Vaccination Daily Tracking Log for Healthcare Personnel (HCP) indicated the facility had a total of 120 HCP staff. During an interview with the Director of Nursing (DON) on 12/23/2021 at 1:30 p.m., the DON confirmed that the facility had 14 residents in the yellow zone and 79 in the green zone. The DON stated when staff provide residents' care and come into close contact with residents, within 6 feet or closer, they must wear full PPE, which includes eye protection, an N95 respirator, a gown, and gloves. The DON stated if the staff do not wear required PPE when providing residents' care or coming into close contact with residents, they can potentially spread COVID-19 virus to other residents throughout the facility, staff, visitors, and the community. DON confirmed there was no PPE cart set up outside of the dining room converted to a yellow zone, because they "were barely setting up the converted dining room to a yellow zone room." c. During an interview on 12/23/21 at 10:05 a.m., CNA 4 stated she could not remember if she was fit tested for an N95 respirator. CNA 4 could not verbalize if N95 respirators must be fit tested prior to its use with residents who were potentially exposed to COVID-19. During an interview on 12/23/2021 at 10:12 a.m., CNA 1 stated he was not fit tested for an N95 respirator. During an interview on 12/23/2021, at 10:15 a.m., RN 2 stated she was not fit tested for an N95 respirator. During a record review of the assignment and sign-in sheet dated 12/23/2021, the assignment and sign-in sheet indicated CNA 1 and RN 2 were assigned to work in the yellow zone. During an interview with the Director of Staff Development (DSD) on 12/23/2021 at 2:45 p.m.,