Based on record review and interview conducted during the recertification survey from 8/26/24 to 8/29/24, the facility did not ensure infection prevention and control standards were maintained. This was evident during the Infection Prevention and Control Program review. Specifically, the facility water management plan was dated May 2022 and there was no documented evidence that it had been reviewed or updated annually. The facility lacked the required facility Risk Assessment. The findings are: A review of the Legionella Control and Surveillance policy dated 8/1/2005 and last revised 11/01/2021 documented Blythedale Children's Hospital adheres to the Centers of Disease Control and New York State Department of Health recommendations regarding prevention, treatment and control of the hospital acquired Legionella. On 8/29/24 at approximately 2:00 PM, a request was made to see the facility's Water Management Plan and Risk Assessment. The facility produced a binder with a Water Management Plan dated May 2022 and no facility Risk Assessment was documented. During interview on 8/29/24 at 3:00 PM, a review was conducted of the facility Legionella binder with the Chief Operating Officer. There was no documented evidence of a facility Risk Assessment included in the Legionella binder. The Water Management Plan documented a date of May 2022. The Chief Operating Officer stated they had a water safety committee meeting on 7/24/24 during which they reviewed and updated the facility Risk Assessment and Water Management Plan. The Chief Operating Officer provided an electronic document of the facility Risk Assessment and Water Management Plan to the surveyors which was dated with the current date of 8/29/24. The Chief Operating Officer stated they do not print the documents. They stated the forms are live and when they view the forms, they will have the current date. The Chief Operating Officer stated they reviewed the documentation from the past two meetings and did not find documentation that the Risk Assessment and Water Management Plan was reviewed and updated. 10 NYCRR 415.19

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that staff followed proper gloving and hand hygiene to prevent cross contamination and the spread of infection for 1 of 2 residents reviewed for respiratory care. (Resident #3). Specifically, 1 of 3 Registered Nurses observed did not perform proper hand hygiene while administering tracheostomy care. The findings are: Resident #3 was admitted on [DATE] with diagnoses of Chronic Lung Disease and Respiratory Failure. The Quarterly Minimum Data Set (MDS: a resident assessment tool) dated 4/3/19 documented the resident is ventilator dependent for respiratory care, receives tracheostomy (trach) care and is dependent on staff for all activities of daily living (ADLs). The resident's plan of care dated 7/31/18 documented the resident will be free from signs and symptoms of infection. Interventions included; to assess for signs and symptoms of infection. A care plan progress note dated 6/29/19 documented sputum culture positive for pseudomonas- trachea, resistant to antibiotic. Multi Drug Resistant Organisms (MDRO) precautions initiated 6/20, care providers with potential exposure to sputum need mask, gown, gloves. Will continue to monitor for signs and symptoms of active infections and intervene as needed. A Critical Labs Progress note dated 6/24/19 and signed by the resident's Physician documented that on 6/20/19 Sputum culture-MDRO: Pseudomonas resistant to multiple antibiotics. MDRO precautions initiated. Care givers with potential exposure to sputum need mask, gown, glove. Physicians order dated 6/24/19 documented MDRO precautions, Pseudomonas, trachea, specifics; mask, gown, gloves for potential contact with sputum. A facility policy and procedure dated 9/2016 and revised in 2018, entitled Identification of Residents with Multidrug Resistant Organisms (MDRO) documented: it is the policy of the facility to provide treatment to residents with colonization of MDRO in a manner which minimizes the spread to other residents, staff and visitors. In addition to Standard Precautions, enhanced MDRO precautions are used for those residents identified with an MDRO. Procedures include Personal protective Equipment (PPE) (gowns, gloves) are utilized while providing care when contact with colonized bodily fluid is anticipated. A facility policy dated 5/89, revised April 2019 entitled Hand Hygiene documented: The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. During an observation of the resident's trach care on 7/11/19 at approximately 9:50 AM, after performing hand hygiene and donning PPE, RN #1 was observed holding a staff hand held phone. Subsequently, RN#1 proceeded to assist in the residents' trach care without performing hand hygiene. RN #1 was interviewed on 7/11/19 at 10:17 AM and reported she should have removed her gloves, washed her hands and put on new gloves before providing care. 415.19(b)(4)