b. A review of the facility's 2020 COVID-19 Infection Control Prevention policy revealed: Staff will encourage and assist residents with hand hygiene prior to and after each meal . Resident 55 was admitted to the facility in 2/2022 with diagnoses including calculus of the bile duct with acute cholecystitis without obstruction (a condition characterized by stones in the pathway connecting the liver with the small intestine). Resident 49 was admitted to the facility in 12/2022 with diagnoses including cerebral stroke. On 1/12/23 at 11:47 AM Staff 18 (CNA) was observed delivering lunch plates to Residents 55 and 49 in their shared room. Staff 18 entered the residents' room without performing hand hygiene, adjusted Resident 55's bedding and call light and then cleared and repositioned her/his tray table. Staff 18 then exited the room, collected Resident 55's plate from the cart in the hallway, returned to place it on her/his table and removed the plastic cling wrap covering the food. Without performing hand hygiene, Staff 18 approached Resident 49's bedside and cleared and adjusted her/his tray table. Staff 18 exited the room, collected Resident 49's plate from the cart in the hallway and returned to place it on her/his tray table. Without performing hand hygiene, he removed the cling wrap covering the plate. He then returned to the cart in the hallway, collected two sets of cutlery wrapped in napkins, returned to the room and placed them on the Residents' tray tables. Staff 18 did not perform hand hygiene during this process nor did he offer assistance to Residents 49 and 55 to perform hand hygiene. Staff 18 confirmed he sometimes performed hand hygiene during this process but did not do it today. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information. c. On 1/8/23 at 12:04 PM Staff 30 wore gloves as she pushed a lunch cart on the east hallway. Staff 30 removed plastic wrap on the lunch plates and delivered the plates to four of four rooms with no hand hygiene or change of gloves. On 1/13/23 2:32 PM Staff 30 confirmed she did not perform hand hygiene or change gloves when she passed the lunch plates. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information. 3. Based on observation and interview, it was determined the facility failed to process laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible for 2 of 2 laundry washing machines reviewed for infection control. This placed residents at risk of contaminated laundry. The findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D: -Do not leave damp textiles or fabrics in machines overnight. On 1/10/23 at 9:12 AM Staff 9 (HK/Laundry Supervisor) stated the laundry staff removed the final load of laundry from the washers and placed it in wire baskets at the end of every evening shift at approximately 10:00 PM. She reported housekeeping staff loaded wet laundry into the dryers at 6:30 AM the following morning. On 1/11/23 at 10:58 PM Staff 38 (LPN) provided access to the locked laundry facility using her key. No laundry staff were working and this part of the facility was locked for the night. Wet laundry was observed in two wire baskets covered with sheets and stationed adjacent to the two dryers. The sheets that covered the baskets were observed to be wet. Staff 38 confirmed the laundry was clean and wet and stated laundry should not be stored wet because mold and mildew could grow under these conditions. On 1/12/23 at 8:46 AM Staff 9 confirmed the wet laundry that was observed in the baskets on 1/11/23 at 10:58 PM was loaded into the dryers by laundry staff this morning without being rewashed. She stated this was how the laundry was handled every day. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information. 4. Based on interview and record review, it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water borne pathogens. This placed all residents at risk for exposure to water borne pathogens. Findings include: On 1/17/23 at 2:25 PM Staff 8 (Maintenance Director) reported he did not complete a thorough analysis of the facility's water systems to identify and address the risk of water borne pathogens such as legionella. He reported his current plan to limit the risk of exposure to potentially harmful water borne bacteria involved flushing the eye wash stations regularly. He reported he did not complete regular testing of the facility's water supply nor did the facility contract with an agency to conduct a risk assessment or testing of the water supply on their behalf. Staff 8 confirmed the absence of a sustainable plan to mitigate the risks associated with the potential growth of water borne pathogens within the facility's water system. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information. 1. Based on observation, interview, and record review it was determined the facility failed to implement infection control measures for a resident with exposed blood and bloodborne pathogens including Viral Hepatitis C for 1 of 1 sampled resident (#52) reviewed for infection control. This failure resulted in an immediate jeopardy situation. Resident 52 walked throughout the facility with an open bleeding head wound, touched various surfaces in common areas and held a bloodstained blanket with bloodstained hands. This placed all residents and staff at risk to contract Viral Hepatitis C, a life-threatening virus. Findings include: According to the CDC website, section titled, Hepatitis C Review, dated 7/28/20, Viral Hepatitis C is highly infectious and is spread through contact with blood from an infected person and inadequate infection control. Viral Hepatitis C can remain active on dry surfaces and equipment for up to six weeks, resulting in a longer period for transmission. Potential adverse outcomes of Viral Hepatitis C include cirrhosis, liver cancer and death. According to the CDC website, section titled, Recommendations for Prevention and Control for Viral Hepatitis C dated 8/7/20, included the following guidance: health-care workers should follow universal blood/body fluid precautions, wear gloves if they must touch another person's blood or open sores and avoid sharing and/or touching personal care items that might have blood on them, such as toothbrushes, razors, nail clippers, etc. Resident 52 was admitted to the facility in 6/2021 with diagnoses including moderate vascular dementia with behavioral disturbance, malignant melanoma (skin cancer), and Viral Hepatitis C. Resident 52's 9/9/22 Care Plan indicated the resident was at risk for actual skin impairment/pressure ulcer and had a sebaceous cyst (a type of liquid-filled bump that occurs on the skin) on top of her/his head. The care plan also indicated Resident 52 was resistant to treatment and ADL cares. The care plan lacked person-centered interventions related to the resident's bleeding cyst. The 10/5/22 Quarterly MDS indicated Resident 52 was severely cognitively impaired, required limited assistance with ADL care and was independent with ambulation. She/he was coded as having an open lesion other than ulcers, rashes, cuts (e.g., cancer lesion). On 1/8/23 between the hours of 11:27 AM and 4:23 PM observations were made of Resident 52. Resident 52's head had a golf-ball sized, protruding red nodule which was actively bleeding down both sides of her/his face and neck. Resident 52 was observed lying in her/his bed with bloodstained sheets and a blanket. Resident 52 walked independently throughout the facility and in communal areas, wore blood stained clothing, carried a bloodstained blanket, had an exposed bloody head wound, and touched/handled a communal chair in the dining room. Resident 52's hands were soiled with dried blood the entire time. Resident 52's hands were observed to have blood on each finger pad, on top of and under her/his nails. Interviews on 1/9/23 revealed the following: -12:35 PM Staff 19 (CNA) stated Resident 52 often picked at the exposed head wound and refused hand hygiene. Staff 19 stated Resident 52 often removed the gauze head bandage and discarded the soiled gauze bandage throughout the facility, including the communal bathroom. -12:36 PM Staff 35 (CNA) stated Resident 52 refused bandaging and treatment of her/his head wound. Staff 35 stated Resident 52 discarded the soiled gauze bandage in the dining room and communal bathroom. Staff 35 stated Resident 52 often picked at the exposed head wound and blood dripped down her/his face. Staff 35 stated Resident 52 easily became agitated and often refused hand hygiene. -12:36 PM Staff 5 (RN/IP) stated Resident 52 had a cancerous tumor on her/his head. Staff 5 stated Resident 52 refused treatment and bandaging of the head wound, walked around the facility with the exposed head wound bleeding, and stated it's an ongoing problem. Staff 5 stated Resident 52, can't keep from messing with it, there's nothing much else we can do. -12:36 PM Staff 3 (RNCM) stated Resident 52 could become belligerent and refused bandaging of the exposed head wound. Staff 3 stated Resident 52 often picked at the exposed head wound and had blood run down her/his face. Staff 3 stated it's an infection control issue because Resident 52 bled and walked around the facility. Staff 3 stated Resident 52 often refused hand hygiene and her/his hands were a mess. -12:40 PM Staff 30 (CNA) stated Resident 52 picked at the exposed head wound, removed, and discarded the soiled gauze bandage throughout the facility daily. Staff 30 stated Resident 52 often refused hand hygiene. Resident 52's 1/9/23 physician order indicated: Keep growth on top of head clean, dry, and covered with gauze at all times. To prevent infection and to contain blood. If resident refuses, reapproach in 15 minutes. On 1/9/23 at 2:24 PM Staff 1 (Administrator) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to do the following: - Failure to have a system in place to ensure Resident 52's hands and personal property were clean and free from blood. - Failure to ensure the physician orders were followed to keep growth on top of her/his head clean, dry, and covered with gauze at all times to prevent infection and to contain blood. - Failure to have a system in place to ensure staff followed appropriate infection control practices and standard precautions. - Failure to ensure residents and staff did not contract Viral Hepatitis C. On 1/9/23 at 7:28 PM the facility submitted a removal plan which was reviewed and approved. The IJ removal plan indicated the facility would implement the following actions: - Resident 52 was moved to a private room and was assigned a one-on-one caregiver 24 hours a day seven days a week as of 1/9/23 at 7:00 PM. The resident's room was stocked with uncontaminated furniture and a commode to reduce the use of the communal bathroom. Resident 52's former room was completely disinfected by housekeeping as soon as the resident moved. - The assigned one-on-one caregiver would have gloves, appropriate alcohol-based hand sanitizer, and clean rags and/or paper towels to clean the resident's hands. When the resident's hands become visibly soiled the one-on-one caregiver would take the resident to the sink and wash her/his hands with soap and water. The resident's clothing would also be changed when contaminated. If the resident refused to change clothes or wash her/his hands, she/he would be re-approached by the one-on-one caregiver or nurse every 15 minutes until the task (washing hands or changing clothes) was completed. - The one-on-one caregiver would have separate red biohazard bags and garbage bins available in the resident's room, one for any waste, another for laundry, washable linen, and clothes. The one-on-one caregiver would have virucidal disinfectant to clean the surfaces in the resident's room when she/he was contaminated with blood. Housekeeping would clean the resident's room once each day shift and evening shift. PPE supplies would be set up in three drawer infection control bins accessible to staff. The supplies would be used in the room and on the portable tote, stocked with appropriate disinfectants and used by the one-on-one caregiver when the resident was up and ambulating. - The IP, RN Educator, or Staffing Coordinator would educate each CNA prior to becoming a one-on-one caregiver. If education was needed after hours, the charge nurse would provide the education. The education would be provided verbally and with a handout for reference. A copy of this education would be kept in the three-drawer bin located in the resident's room. This education would include disinfectant wipes, contact time, standard precautions, and what to do when the resident was mobile. The education would also include the duties expected of the one-on-one caregiver. There would be a sign off sheet when the education was completed for each CNA. Housekeeping would disinfect all community high touch areas four times a day and as needed. This would be done after breakfast and lunch, before dinner, and at bedtime. - A clarification was added to the physician order on the TAR as follows: if resident refuses the dressing changes per MD order re-approach in 15 minutes (one-on-one caregiver will stay with the resident to clean anything she/he touches). - An order was obtained from the physician to start hydroxyzine (anti-itch medication) TID to reduce the resident's anxiety, itching, and picking at wounds. - Hand hygiene will be done for each resident before and after each meal in addition to morning and bedtime routine and as needed for the bathroom/sneezing/touching nose and mouth or any other contamination. A portable tote with appropriate virucidal disinfectant for the one-on-one caregiver would be supplied when the resident was up and ambulating. - A stat lab order was received and sent to the lab to confirm whether the resident had Viral Hepatitis C. If the resident's lab results showed the resident was positive there would be an order to treat if clinically appropriate. An order was received to test and treat all residents and staff for Hepatitis C, if the resident's lab results came back positive. Resident 52's Viral Hepatitis C diagnosis was from 2014. The facility would seek clarification if the Viral Hepatitis C was treated at that time. The resident was placed on alert charting for the nurse to check in with the resident and her/his one-on-one caregiver every hour to ensure the resident was free of blood on her/his clothing or body. On 1/10/23 at 10:00 AM the survey team determined all components of the IJ removal plan were in place and the immediacy was removed. Following the removal of the immediacy, noncompliance remained at isolated with no actual harm with potential for more than minimal harm that is not IJ. 2. Based on observation, interview and record review it was determined the facility failed to ensure proper infection control practices were followed during meal service for 2 of 3 hallways. This placed residents at risk for infections. Findings include: a. Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Resident 59's 11/18/22 admission MDS indicated the resident was cognitively intact. On 1/13/23 at 11:47 AM Staff 3 (RNCM) and surveyor were with Resident 59 when Staff 31 (CNA) brought Resident 59's lunch into her/his room. Staff 31 removed the plastic wrap from Resident 59's plate then set the plate followed by cups of liquid on the bedside table approximately one inch from Resident 59's partially filled urinal. Staff 3 observed Staff 31 place the uncovered food and cups of liquid next to and near Resident 59's partially filled urinal and in approximately two to three minutes, Staff 3 left the room and returned with Staff 31. Staff 3 asked Staff 31 to remove the urinal from the bedside table, remove and discard the food and liquids from the bedside table, disinfect the bedside table and provide the resident with a new plate of food and liquids once the bedside table was disinfected. Staff 3 confirmed this practice was an infection control problem. On 1/17/23 at 2:13 PM Resident 59 stated staff frequently placed her/his food and liquids on the bedside table next to or near the urinal. Resident 59 stated she/he did not like staff putting her/his food and liquids next to the urinal, she/he asked staff to move the urinal but it was always a major issue to get anything done. Resident 59 stated sometimes she/he was laying in bed and staff put the nearly full urinal right by her/his plate of food then placed the bedside table over her/him so she/he could eat. Resident 59 stated her/his urinal sometimes sloshed over and spilled on her/his bedside table or bed linens and smelled. The resident stated the urinal often left a ring on the bedside table and staff put her/his silverware in the dirty area. Resident 59 stated she/he would not have pee sitting on her/his dining room table at home and did not want that done at the facility, either. On 1/18/23 at 11:19 AM Staff 1 (Administrator) and Staff 2 (DNS) were provided with the findings of this investigation and acknowledged this practice was an infection control concern.