**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to follow the COVID policies regarding how to contain the COVID virus and prevent the spread, in that the policies indicated 1; the door to the COVID positive residents' rooms were to be kept closed and that staff were to wear Personal Protective Equipment (PPE) of a gown, mask, face shield and gloves when upon entering resident's room to provide care to residents positive for COVID; 2. to ensure transported dishes from COVID positive residents were covered and dishes were washed at 120 degrees Fahrenheit (F) temperature to sanitize, and 3. infection control measures during medication pass were to be followed for one resident (R52). The facility failed to ensure room doors remained closed for the residents who had tested positive for COVID-19 nine of 16 residents in the long (male) 100 hallway (Resident (R)81, R20, R35, R58, R43, R33, R65, R31, and R50) and the short (female) 100 hallway failed to ensure doors were closed for five of 15 residents (R19, R36, R47, R2, and R1). Staff failed to apply proper PPE when in a COVID-positive resident's room (R35, R58, R43, and R33). The facility failed to ensure dishes removed from COVID-positive resident rooms were covered for transport to the kitchen and cleaning was done at the manufacturer's recommended temperatures. On 1/7/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 1/7/2025, at 10:20 am. The noncompliance related to the IJ was identified to have existed on 12/28/2024. An Acceptable Removal Plan was received on 1/9/2025. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 1/9/2025. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of the facility staff's conformance with the facility's policies and procedures governing infection control. Findings included: 1. An observation on 1/6/2025 at 10:46 am, on the long (male) 100 hallway revealed doors were open for five rooms housing R81, R20, R35, R58, R43, R33, R65, R31, and R50 and the doors had signs stating the doors were to be closed due to special droplet precautions being in place. a. A review of R81's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed an admission date of 10/17/2024 and readmission on [DATE], with medical diagnoses that included sepsis and 2019-nCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R81 tested positive for COVID-19 on 1/4/2025. b. A review of R20's Face Sheet located in the EMR under Face Sheet revealed an admission dated 3/2/2022 and readmission on [DATE] with medical diagnoses that included contact with and (suspected) exposure to other viral communicable diseases, wheezing, and 2019-nCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R20 tested positive for COVID-19 on 1/4/2025. c. Review of R35's Face Sheet located in the EMR under Face Sheet revealed an admission dated 1/2/2017 and readmission on [DATE] with a medical diagnosis that included pneumonia. A review of the EMR CCD-Continuity of Care Document revealed that R35 tested positive for COVID on 1/4/2025. d. A review of R58's Face Sheet located in the EMR under Face Sheet revealed an admission dated 8/30/2023 and readmission on [DATE] with medical diagnoses that included diabetes Type II, and 2019-nCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R58 tested positive for COVID-19 on 1/4/2025. e. A review of R43's Face Sheet located in the EMR under Face Sheet revealed an admission dated 7/17/2024 and readmission on [DATE] with a medical diagnosis that included unspecified dementia. A review of the EMR CCD-Continuity of Care Document revealed that R43 tested positive for COVID-19 on 1/4/2025. f. A review of R33's Face Sheet located in the EMR under Face Sheet revealed an admission dated 8/22/2018 and readmission on [DATE] with medical diagnoses that included pneumonia, acute respiratory failure, and 2019-nCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R33 tested positive for COVID-19 on 1/4/2025. g. A review of R65's Face Sheet located in the EMR under Face Sheet revealed an admission dated 02/11/23 and readmission on [DATE] with medical diagnoses that included diabetes Type II, and 2019-nCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R65 tested positive for COVID-19 on 1/1/2025. h. A review of R31's Face Sheet located in the EMR under Face Sheet revealed an admission dated 3/25/2015 and readmission on [DATE] with medical diagnoses that included pneumonia, and 2019-NCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R31 tested positive for COVID-19 on 1/1/2025. i. A review of R50's Face Sheet located in the EMR under Face Sheet revealed an admission dated 8/10/2023 and readmission on [DATE] with medical diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R50 tested positive for COVID-19 on 1/1/2025. An observation on 1/6/2025 at 10:48 am of the short (female) 100 hallway, revealed doors were open for three rooms housing R19, R36, R47, R2, and R1 and the doors had signs stating the doors were to be closed due to special droplet precautions being in place. j. A review of R19's Face Sheet located in the EMR under Face Sheet revealed an admission dated 10/16/2024 and readmission on [DATE] with medical diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R19 tested positive for COVID-19 on 12/28/2024. k. A review of R36's Face Sheet located in the EMR under Face Sheet revealed an admission dated 7/1/2020 and readmission on [DATE] with medical diagnoses that included chronic obstructive pulmonary disease (COPD), and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R36 tested positive for COVID-19 on 12/28/2024. l. Review of R47's Face Sheet located in the EMR under Face Sheet revealed an admission dated 01/27/23 and readmission on [DATE] with medical diagnoses that included wheezing and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R47 tested positive for COVID-19 on 12/30/2024. m. A review of R2's Face Sheet located in the EMR under Face Sheet revealed an admission dated 11/21/2022 with medical diagnoses that included pneumonia, and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R2 tested positive for COVID-19 on 12/28/2024. n. Review of R1's Face Sheet located in the EMR Face Sheet revealed an admission dated 12/24/2011 and readmission on [DATE] with medical diagnoses that included spastic quadriplegic cerebral palsy, and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R1 tested positive for COVID-19 on 12/28/2024. An observation on 1/6/2025 at 11:37 am revealed a Certified Nursing Assistant (CNA)3 was inside the room for R35 who was on special droplet precautions providing care by taking the resident's vital signs. CNA3 was using PPE by wearing an N95 mask and gloves only. During an interview on 1/6/2025 at 11:44 am, when questioned about wearing PPE for the care provided to R35, CNA3 said had not read the signs posted on the door that read All personnel to follow the directions below: prior to entering the room, wash hands, wear a gown and remove before exiting the room, wear an N95 mask, protective eyewear, and gloves to remove before exiting the room. An observation on 1/6/2025 at 11:30 am revealed that housekeeper (HK) 1 was cleaning the room for R43 and R33 who were on special droplet precautions. The housekeeper was using PPE by wearing an N95 mask and gloves only. During an interview on 1/6/2025 at 11:30 am, HK1 explained being told the room for R43 and R33 was not an isolation room and therefore did not wear proper PPE and did not read the signs posted on the outside of the door. During an interview on 1/6/2025 at 11:53 am, Licensed Practical Nurse (LPN)1 confirmed staff entering resident rooms who were positive for COVID were to wear proper PPE including N95 mask, gloves, gown, and eye protection. During an interview on 1/9/2025 at 12:38 pm, the Infection Control Preventionist confirmed when staff entered the resident room who was on special droplet precautions PPE to wear was an N95 mask, gloves, gown, and eye protection. A review of the facility policy titled COVID-19 Isolation and Cohorting Process, revised 11/13/2023 revealed, Ideally, residents suspected or confirmed to have COVID-19 infection should be placed in single-person room on Transmission-Based Precautions but if limited single rooms are available or numerous residents are simultaneously identified, residents should remain in their current room on Transmission-Based Precautions. The door should remain closed and ideally, they should have a dedicated bathroom. At the entrance to the resident room door, there must be Proper Signage on the door indicating Transmission-Based Precautions. STOP and only enter if Necessary and in Proper PPE. PPE will be used in each Transmission-Based Precautions room. A review of the CDC guidance titled Infection Control Guidance: SARS-CoV-2, dated 6/24/2024, found on the website: https://www.cdc.gov/covid/hcp/infection-control/index.html, revealed, Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. Health Care Personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 2. During an interview on 1/6/2025 at 10:06 am, the Dietary Manager (DM) was asked about COVID-19 procedures in the kitchen. The DM stated they used normal delivery, but the consumed meal trays were bagged at pickup and brought back to the kitchen. On 1/6/2025 at 1:34 pm, the lunch cart containing consumed trays was observed coming off the 100 COVID hall and pushed to the kitchen. None of the trays were bagged. Certified Nurse Assistant (CNA)1 was asked if trays were to be bagged and CNA1 stated, No. During a follow-up interview on 1/6/2025 at 1:38 pm, the DM was asked if the COVID-positive trays on the 100 COVID hall cart should be bagged. The DM confirmed the trays were not bagged and thought they should be. A review of the facility policy titled Dishwashing, revised 8/3/2017, provided by the facility revealed, Temperature Guide: Adhere to the Manufacturer's guidelines for appropriate temperature ranges. On 1/6/2025 at 10:07 am, the dish machine was observed with the Dietary Manager (DM) while in use. The wash cycle measured 104 degrees Fahrenheit (F), and the rinse cycle measured 110 degrees F. Dietary Aide (DA)2 was asked if the temperatures of the dish machine should be higher. DA2 stated maintenance checked the machine at the beginning of use and the temperatures were good. DA2 went on to say, As the machine is used, temperatures drop. A review of the January 2025 dish machine log, for dates 1/1/2025 through 1/6/2025 located on the wall revealed the wash cycle temperature ranged from 120 degrees F to 125 degrees F and the rinse cycle temperature ranged from 123 degrees F to 124 degrees F. On 1/6/2025 at 3:35 pm, the dish machine was observed with the DM at the end of washing the lunch dishes. The dish machine's wash cycle measured 105 degrees F, and the rinse cycle measured 118 degrees F. The dish machine's manufacturer's requirements posted on the machine were reviewed with the DM. The posted plaque revealed 120 degrees F for the wash cycle and 130 degrees F for the rinse cycle. The DM stated the dish machine company checked the dish machine last month. The DM was asked if the hot water supply was lasting long enough to get through all the dishes. The DM stated she did not know but would ask maintenance. On 1/7/2025 at 3:41 pm, the dish machine was observed in progress. The wash cycle measured 118 degrees F, and the rinse cycle measured 122 degrees F. The DM was asked again about the temperatures. The DM stated the dish machine company would be at the facility on 1/7/2025 to check it. A review of the facility policy titled COVID-19 Infection Prevention and Control Practices, revised 6/25/2024 revealed, Dishware will be sanitized following chemical or temperature guidelines. Used dishware from positive or presumptive units will be transported in covered or closed carts. 3. IC procedures not followed for one of five residents (R52) observed during medication administration: A review of R52's Face Sheet, dated 1/9/2025, and found in the electronic medical record (EMR) under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included a history of stroke, type 2 diabetes, hemiplegia, and hemiparesis following stroke affecting the right dominant side. A review of R52's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/2/2024 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (which indicated the resident was cognitively intact). A review of R52's Active Orders Report, dated 1/9/2025 and found in the EMR under the Orders tab, revealed orders for the resident to receive Lyrica, with an original order date of 6/10/2021, 75 milligrams (MG) by mouth every 12 hours related to control pain, Lantus (insulin), with an original order date of 12/13/2024, 15 units subcutaneously every twelve hours to control blood sugar and blood sugar checks, with an original order date of 10/29/2024, routinely every twelve hours to monitor blood sugar. LPN 4 was observed administering R52's medication on 1/8/2025 at 9:41 am. LPN 4 was observed to have long false nails (approximately half inch in length) applied to most of her fingertips. During the pouring of the resident's medication, LPN4, who was not observed to apply gloves or sanitize her hands prior to pouring the medication, was observed to drop the resident's Lyrica onto the top of the medication cart and then obtain the medication off the medication cart with her bare fingers and put the Lyrica into the resident's medication cup for administration. The medication was administered to R52. In addition, LPN4 did not place a clean barrier on the resident's bedside table prior to placing R52's insulin pen and blood sugar monitor on the table. After administration of the resident's blood sugar check, LPN4 was observed placing the monitor in her pocket to transport it to the medication cart before putting the monitor and the insulin pen back onto the top of the medication cart. During an interview with LPN 4 on 1/8/2025 at 10:01 am, she stated she was attempting to remove her long false fingernails but had only been able to remove a couple of the nails so far. She stated she was aware she was not supposed to be wearing long false nails while providing resident care due to potential infection control and safety concerns. LPN4 stated she was aware she was supposed to place a clean barrier on surfaces in residents' rooms prior to placing any equipment to be returned to the medication cart on the surface. LPN4 additionally stated she was aware she was supposed to perform adequate hand hygiene, such as sanitizing her hands and wearing gloves when touching medication directly, and was aware medications should not be administered after coming into direct contact with the top of the medication cart. During an interview with the Director of Nursing (DON) on 1/9/2025 at 10:28 am, she confirmed her expectation was false nails not be worn while providing direct care/medication administration to residents, hand hygiene was expected to be performed during medication pass/prior to administering and pouring medication, a clean barrier was expected to be placed on any room surface before placing equipment/medications to be returned to the medication cart, and medications were to be discarded and repoured if dropped on the medication cart rather than administered. The facility's Medication Administration: Hand Hygiene Policy dated most recently revised on 10/14/2024, read, in pertinent part, It is the policy of Pruitthealth Pharmacy Services that partners will use appropriate hand hygiene during medication administration. Appropriate hand hygiene reduces the spread of germs and decreases the spread of infections. Additional policies related to infection control procedures with medication administration were requested by the survey team on 1/9/2025 at 12:30 pm, however, these policies were not provided by the facility prior to the survey exit on 1/9/2025.