**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's Advocate (brand) glucometer manufacturer's instructions, undated, revealed the meter was to be cleaned and disinfected before use. The review revealed a commercially available disinfectant towelette could be used on the device for sanitizing. Continued review revealed the meter was to be wiped down and allowed to air dry; after air-drying the disinfection process for the meter was to be followed. Further review revealed the disinfection steps included to: discard the used disinfectant towelette; and obtain a new disinfectant wipe to wipe down the body of the meter enough to thoroughly wet the surface. Further review revealed the disinfection process included continuing to wipe the meter six (6) times, three (3) passes horizontally and three (3) passes vertically, and allow the devices to remain wet for a 2 minute-contact time. Additionally, the review revealed the used disinfectant wipe was to be discarded in the trash, and the user was to wash their hands thoroughly with soap and water after handling the meter. Review of the Professional Disposables International (PDI) Sani-Hands wipes use and directions, revealed it was intended for handwashing to decrease bacteria on the skin. Further review revealed the wipe was for a single use and was to be removed from the packet, used once, and then discarded in a trash receptacle. Review of the Super Sani-Cloth germicidal disposable wipe directions revealed each wipe was to be used as directed and discarded after a single use. Continued review of the wipe directions revealed the wipes were to be used for disinfecting non-food contact surfaces only. Further review revealed the user was to unfold a clean wipe to thoroughly wet the non-food contact surface, allow the treated surface to remain wet for a full two (2) minutes, and then allow the treated surface to air dry. Observation, on 01/11/2022 at 11:46 AM, of Licensed Practical Nurse (LPN) #1, while performing a pre-meal blood glucose test, revealed she failed to wash her hands before donning gloves to conduct the testing. Continued observation, after the test was done, revealed after removing her gloves and washing her hands, LPN #1 placed the glucometer on a barrier towel she laid on the medication cart. Observation revealed LPN #1 cleaned the glucometer with a PDI Sani-Hands 70% Alcohol towelette (sanitizing towelettes), wrapped the wipe around the glucometer, placed it on the barrier towel and wrapped the same barrier towel around the wipe covered glucometer. Interview, at the time of observation, revealed LPN #1 stated the facility's policy was to clean multi-use equipment with a sanitizing wipe, then leave the glucometer wrapped in the sanitizing towelette for 5-10 minutes before putting it away in the cart. Further observation revealed LPN#1 failed to allow the glucometer to air dry before storing. Observation, on 01/12/2022 at 8:25 AM, of LPN #1 after performing a pre-meal blood glucose testing prior to the morning meal, revealed she placed the glucometer on the barrier towel while she obtained a Sani Wipe from the container with which to clean the meter. Observation revealed the LPN cleansed the glucometer with the Sani Wipe, wrapped the meter in the same Sani Wipe and placed it on the same barrier towel. Continued observation revealed LPN #1 wrapped the barrier towel around the Sani Wipe, covered the glucometer and placed the meter on the cart. Further observation revealed LPN #1 left the meter on the medication cart to go administer the resident's scheduled insulin dose. Observation further revealed LPN #1 returned to the cart after approximately four (4) minutes, and removed the glucometer from the barrier towel and sanitizing wipe, disposed of those items and placed the glucometer in the medication cart drawer failing to allow the meter to air dry as required. Interview with the Director of Nursing (DON), on 01/12/2022 at 5:18 PM and, on 01/13/2022 at 12:02 PM, revealed Sani Cloth wipes were located on all the medication carts and were to be used by staff to clean multi-use equipment, such as glucometers or blood pressure cuffs. She stated the facility's policy was to disinfect the equipment by wiping it down and cleaning it well with a sani wipe. Continued interview revealed the equipment was to then be left sitting for two (2) minutes to dry before using it again. Per the DON, multi-use equipment, such as a blood pressure cuff should be sanitized with a sani wipe, allowed to air dry for ninety (90) seconds, then be placed in a case before it was stored away. Further interview revealed for glucometers staff should follow the process for sanitizing the meter, allow it to air dry, and place the meter in a case or bag before storing it in the medication cart. The DON revealed she was not sure how staff referenced the facility's policies regarding sanitizing multi-use equipment. She further stated she believed there was a policy book staff could use; however, she was not sure where it was stored. 3. Review of Resident #217's medical record revealed the facility admitted the resident, on 12/15/2021, with diagnoses which included Displaced Intertrochanteric Fracture, Major Depression and Anxiety, and Shingles. Continued review revealed Resident #217 was placed on transmission based precautions (TBP) on admission related to the diagnosis of Shingles. Interview with the Registered Nurse (RN) Infection Preventionist (IP), on 01/11/2022 at 8:45 AM, confirmed Resident #217, who resided in room [ROOM NUMBER], had a diagnosis of Shingles. Observation, on 01/11/2022 at 9:30 AM, revealed Resident #217's room had a sign posted on the door to, See the nurse prior to entering the room. Continued observation revealed a three (3) drawer container, with various PPE stored in it, located next to the door of room [ROOM NUMBER]. Observation of CNA #3, on 01/11/2022 at 12:05 PM, revealed she entered Resident #217's room, who was on TBP, without donning gloves. Continued observation revealed she washed her hands, doffed her gown and rolled it inside out. She then washed her hands again. Continued observation of CNA #3, on 01/12/2022 at 8:30 AM, revealed she took the breakfast tray into Resident #217's room. CNA #3 did not don any type of PPE before entering the room. Interview with CNA #3, on 01/11/2022 at 12:08 PM and, on 01/12/2022 at 8:32 AM, revealed she was not wearing gloves and was just trying to assist with giving water to the resident. However, she stated she should have donned gloves because she touched a wash cloth to take to the soiled linen. CNA #3 stated she was told Resident #217 was removed from TBP precautions, and it was okay to just take the tray in and leave the tray without donning or doffing any PPE. She further explained she just asked the nurse what the needed precautions were, per the sign posted on the door. Observation of Kentucky Medication Aide (KMA) #2, on 01/11/2022 at 12:30 PM, during medication administration on the 100 Hall revealed KMA #2 entered TBP Resident #217's room to give medications and did not don gloves. Interview with KMA #2, on 01/11/2022 at 12:32 PM, revealed she should have worn gloves to give medication. She stated KMA's just ask the nurse about the required PPE for that room/patient. Interview with the DON, on 01/12/2022 at 12:09 PM, on 01/13/2022 at 12:03 PM, and on 01/15/2022 at 6:02 PM, revealed Resident #217 should remain in TBP until the Medical Doctor cleared it and provided an order to do so. She stated the CNA and KMA should have donned PPE including a gown, mask, gloves, face shield or goggles while taking in the breakfast tray and to administer medication. The DON revealed her expectation was for staff to don PPE prior to entering the TBP room along with a proper sign on the door to explain PPE precautions and how to don/doff PPE. Interview with the Administrator, on 01/15/2022 at 6:04 PM, revealed his expectation was that staff would follow the recommended guidelines for infection control related to TBP and COVID precautions. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 01/14/2022, that alleged removal of the Immediate Jeopardy (IJ) on 01/15/2022. The facility implemented the following: 1. On 01/12/2022 at 9:00 AM, Resident #218 was determined to have a positive COVID test. Residents in room [ROOM NUMBER] were moved to other rooms and Resident #218 was moved into room [ROOM NUMBER]. Per interview with the DON, room [ROOM NUMBER] was chosen because it was at the end of the hall and near the exit door that could be used for entry/exit by staff. 2. Staff, including agency personnel, were re-educated by nurse management on appropriate usage of PPE to include gloves, gown, eye protection, and face masks. This included return demonstration to ensure understanding. Education was conducted, on 01/12/2022 through 01/14/2022. 3. Staff, including agency personnel, were re-educated by nurse management on transmission based precautions (TBP) including signage, usage of PPE, proper handwashing, and donning and doffing of PPE. This included return demonstration to ensure understanding. Education was done, on 01/12/2022 through 01/14/2022. 4. Staff, including agency personnel, were re-educated by nurse management on proper handwashing performance with a questionnaire and quiz given and reviewed by nurse management to ensure understanding or need for further education. Education began on 01/12/2022. 5. Additional education was provided to staff including agency personnel, by nurse management for proper glove usage and proper donning/ doffing measures. Education began on 01/12/2022. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy Removal Plan as follows: 1. Interview with the DON and the Administrator, on 01/15/2022 at 5:55 PM and 6:25 PM, respectively, revealed they identified that all residents had the potential to be affected by the deficiencies in infection control practices. Observation, on 01/12/2022, at 1:35 PM, revealed the facility created a dedicated COVID-19 Care Unit on the 100 Hall. The COVID-19 Care Unit was physically separated from other rooms by a temporary zippered barrier wall. In addition, the facility was staffing the unit with dedicated staff: one (1) RN or LPN, and one (1) CNA, who would not work on both the COVID-19 Care Unit and other units during the same shift. To the extent possible, there was restricted access of ancillary personnel (e.g., dietary) to the unit. Meals were handed through the plastic barrier. An environmental services (EVS) staff member would be dedicated to the COVID-19 Care Unit. All dedicated staff would enter through a clean area where staff doff PPE. Staff exited the facility through the back door. Observation and interview with LPN #1 and CNA #1, on 01/14/2022, at 1:40 PM, revealed they had been assigned as dedicated staff to the COVID-19 Care Unit. Both stated they received re-education on transmission based precautions (TBP) including signage, usage of PPE, proper handwashing performance, and donning and doffing of PPE. LPN #1 and CNA #1 stated they were required to demonstrate donning and doffing PPE and hand hygiene. Both stated they were educated to not leave the unit during their shift, except on breaks, in which they exited though the back stairwell. Both stated meals were passed through the zippered barrier. Observation revealed both LPN #1 and CNA #1 performed proper hand hygiene technique and were wearing the appropriate PPE. 2. Observation, interview, and record review revealed nursing management completed re-education of all scheduled staff on appropriate usage and storage of PPE to include gloves, gown, eye protection, and face masks. Further observation revealed training by nursing management, which included return demonstration from staff. Education occurred from 01/12/2022 through 01/14/2022. Record review revealed education sheets, sign-in logs, and the post-test were completed by staff during the day and evening shifts prior to being allowed to work to ensure understanding or the need for further education. 3. Interviews with CNA/KMA #2, CNA #3/Billing, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, Resident Assistant (RA) #1, RA #2, LPN #1, LPN #2, RN #1, RN #2 and RN #3, on 01/15/2022 between 10:58 AM and 3:08 PM, revealed they were re-educated by nurse management on transmission based precautions (TBP) including signage, usage of PPE, proper handwashing performance, and donning and doffing of PPE. Interviews were continued with Dietary Aides #1 and #2; [NAME] #1, and the Dietary Manager, on 01/15/2022 between 10:58 AM and 3:39 PM, which revealed they had also received infection control education for COVID and their department. Observations of training by nursing management, on 01/12/2022 through 01/14/2022, revealed they provided re-education and return demonstration of donning and doffing full PPE and hand hygiene. Record review revealed education sheets, sign-in logs, and posttests were completed by day and evening staff, and graded by nursing management, prior to being allowed to work to ensure understanding or the need for further education. 4. Interviews with CNA/KMA #2, CNA #3/Billing, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, Resident Assistant (RA) #1, RA #2, LPN #1, LPN #2, RN #1, RN #2 and RN #3, on 01/15/2022 between 10:58 AM and 3:08 PM, revealed they were re-educated by nurse management on proper handwashing performance with a questionnaire and quiz taken. Record review revealed education sheets, sign-in logs, and posttests were completed by day and evening staff, and graded by nursing management, prior to staff being allowed to work. Interview with the DON, on 01/14/2022 at 1:13 PM, revealed staff, including agency personnel, were re-educated by nurse management on proper handwashing performance, with questionnaire and quiz, and reviewed by nurse management to ensure understanding or the need for further education. 5. Interviews with CNA/KMA #2, CNA #3/Billing, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, Resident Assistant (RA) #1, RA #2, LPN #1, LPN #2, RN #1, RN #2 and RN #3, on 01/15/2022 between 10:58 AM and 3:08 PM revealed they were re-educated by nurse management on proper glove usage and proper donning/doffing measures. Record review revealed education sheets and sign-in logs were completed by staff during the day and evening shifts prior to being allowed to work. Interview with the DON, on 01/14/2022 at 1:13 PM, revealed staff that were off would be re-educated prior to his/her shift. No staff member would be allowed to work until all his/her re-education was completed. Based on observation, interview, record review, and facility policy review, it was determined 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 two (2) of eighteen (18) sampled residents (Residents #217 and #218). Observation, on 01/12/2022 at 10:45 AM, revealed Certified Nurse Aide (CNA) #1 walked out of room [ROOM NUMBER], where Resident #218 had been moved, after testing positive for COVID, and walked up the hallway. CNA #1 was observed to be wearing the contaminated full personal protective equipment (PPE) of gown, mask, eye protection, and shoe covers that had been worn while in room [ROOM NUMBER]. Continued observation revealed CNA #1 walked up the hallway and touched the community linen cart with a contaminated gloved hand. Additionally, CNA #1 was observed to wear the contaminated shoe covers from room [ROOM NUMBER] up the hallway and into the community nourishment room. Additional observations, on 01/11/2022 and 01/12/2022, revealed Licensed Practical Nurse (LPN) #1, while performing pre-meal blood glucose tests, either failed to wash her hands before donning gloves to conduct the testing, and/or failed to allow the glucometer to air dry after disinfection, as required before storage. Additional observations, on 01/11/2022, revealed CNA #3 and Kentucky Medication Aide (KMA) #2 failed to don (put on) appropriate PPE when giving care to Resident #217, who was on transmission based precautions (TBP) related to a diagnosis of Shingles. The facility's failure to maintain an infection prevention and control program to prevent unnecessarily exposing residents to COVID-19 has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified, on 01/12/2022, and was determined to exist on 01/12/2022, at 42 CFR 483.80 Infection Prevention and Control (F-880) at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy on 01/12/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 01/14/2022, alleging removal of the IJ on 01/15/2022. The State Survey Agency determined the IJ had been removed on 01/15/2022, as alleged, prior to exit on 01/15/2022. The findings include: Review of the facility's policy titled, Policy and Procedure COVID-19, undated, revealed the facility would follow the current Centers for Disease Prevention and Control (CDC) guidelines for the evaluation, prevention, and treatment of the Novel Coronavirus (COVID-19). Continued review revealed if a resident had a positive COVID-19 test or signs and symptoms of a respiratory viral infection, standard, contact and droplet precautions were to be maintained. Additional review revealed the facility would ensure all its staff were educated on hand hygiene and appropriate donning and doffing (putting on and taking off) of PPE. Review of the facility's Infection Prevention and Control Assessment Tool, undated, revealed the facility had Environmental Protection Agency (EPA) registered, hospital-grade disinfectants with an emerging viral pathogens claim against SAR-CoV-2 (COVID-19) available for frequent cleaning of high-touch surfaces and shared resident care equipment. Continued review revealed the facility's practice was for staff to perform hand hygiene in the following situations: before resident contact, even if gloves were worn; after contact with the resident; after contact with blood, body fluids or contaminated surfaces or equipment; before performing an aseptic task; and after removing PPE. 1. Observation, on 01/12/2022 at 10:45 AM, revealed CNA #1 walking on the 100 Hallway after exiting room [ROOM NUMBER], where Resident #218, who had tested positive for COVID, resided. Per observation, CNA #1 was wearing the full PPE he/she had worn in Resident #218's room, which was contaminated. Observation revealed CNA #1 walked to the linen cart where the CNA touched the top right corner of the community linen cart with his/her contaminated gloves. Further observation revealed the Director of Nursing (DON), instructed CNA #1 to go back down the hallway to room [ROOM NUMBER], which was being used as the nurse's station for the COVID area of the facility, and remove the contaminated PPE. Continued observations on 01/12/2022 from 10:45 AM until 11:32 AM, revealed the door to room [ROOM NUMBER] remained open until 11:29 AM, with no protective barrier in place to prevent transmission of the COVID virus. Additional observation revealed the Housekeeping Director exited COVID positive room [ROOM NUMBER] which he had been assisting with cleaning (room [ROOM NUMBER] was where Resident #218, the COVID positive resident, resided prior to being moved to room [ROOM NUMBER]). Further observation revealed the Housekeeping Director obtained linen from the linen cart that CNA #1 had previously contaminated and walked toward the clean room. However, the Housekeeping Director was stopped by the State Survey Agency (SSA) Surveyor, prior to re-entering room [ROOM NUMBER], which had been cleaned. Interview with the Housekeeping Director, on 01/12/2022 at 11:32 AM, revealed he did not know the linen cart had been contaminated by CNA #1, as he was in room [ROOM NUMBER], assisting to clean that room. The Housekeeping Director stated if he had known the cart had been contaminated, he would have ensured the cart and linens on it were taken out of service and disinfected appropriately. Interview with CNA #1 on 01/12/2022 at 10:57 AM, revealed the CNA had exited Resident #218's room wearing contaminated PPE. Per the CNA, while wearing the contaminated PPE, which included gloves, he/she had touched the community linen cart contaminating it. Observation, on 01/12/2022 at 10:57 AM, revealed CNA #1 entered Resident #218's room, the COVID positive resident, and pulled the room curtain back without wearing the required gloves. Observation, on 01/12/2022, at 12:32 PM, revealed CNA #1 exited room [ROOM NUMBER] and walked up the 100 Hallway with contaminated shoe covers and face shield still in place. Continued observation revealed CNA #1 entered the community nourishment room wearing the contaminated shoe covers and face shield. The DON was notified of this information by the State Survey Agency (SSA) Surveyor performing the observation. Further observation revealed the DON immediately went to the nourishment room where CNA #1 was located. Interview, on 01/14/2022 at 1:40 PM, with CNA #1, via telephone, revealed on 01/12/2022, he/she had not realized he/she had come out of room [ROOM NUMBER], which was COVID positive, wearing contaminated PPE. Per the interview, CNA #1 stated he/she had not realized he/she touched the linen cart while wearing the contaminated PPE on that date. Further, the CNA stated he/she was unaware his/her contaminated shoe covers were still in place when he/she went to the nourishment room. The CNA stated staff had recently, in December 2021, received Infection Control education that covered everything from proper hand hygiene, donning/doffing PPE, to appropriate door signage for the type of isolation for the resident. Interview with the DON, on 01/12/2022 at 12:45 PM and 2:12 PM, revealed she had re-educated CNA #1 on the facility's infection control protocol, when she went into the community nourishment room where the CNA had been wearing contaminated PPE. The DON stated it never occurred to her, that instead of waiting on Maintenance to erect a barrier, the most immediate solution would have been to ensure Resident 218's door, remained closed. Additional interview with the DON, on 01/15/2022 at 5:55 PM, revealed it was her expectation that staff adhered to all components of the facility's infection control policy. The DON stated the facility's Infection Preventionist (IP) had quit on 01/13/2022. Further interview revealed, until 01/12/2022, there had not been a COVID positive resident in the facility since October 2021. Interview with the Administrator, on 01/15/2022 at 6:25 PM, revealed his involvement with infection control had been to direct all the facility's Department Heads to come together to create an after action plan regarding the errors that occurred during the establishment of the COVID Unit that week (01/12/2022) and to address what would be done to correct those errors. He stated it was his expectation all staff would follow the recommended guidelines for infection control and isolation.