Based on policy review, job description review, Center for Disease Control and Prevention (CDC) guidelines, observation and interview, the facility Administration failed to administer the facility in a manner that provided a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Administration failed to provide oversight and a sanitary environment for all residents when meal delivery carts containing meal trays from COVID-19 positive resident rooms were not cleaned with an Environmental Protection Agency (EPA) approved disinfectant to kill COVID-19 prior to using the trays for the next meal delivery service to COVID-19 positive and non-COVID-19 positive residents and staff failed to wear the appropriate Personal Protective Equipment (PPE) in rooms of COVID-19 positive residents. These failures resulted in Immediate Jeopardy when Dietary Staff #1 was observed cleaning a dietary meal delivery cart that had contained trays removed from rooms of residents that were positive for COVID-19 as well as non-COVID-19 positive resident rooms with a disinfectant that was not EPA approved to kill COVID-19; when staff were observed entering COVID-19 positive resident rooms without wearing proper Personal Protective Equipment (PPE); when the Activity Assistant was observed in a resident care area wearing a cloth mask; and when Certified Nursing Assistant (CNA) #3 was observed removing a soiled meal tray from a COVID-19 positive resident's room and delivering it to the kitchen with her bare hands. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The [NAME] President, Regional Nurse Consultant, Regional Registered Nurse (RN), and Director of Nursing (DON) were notified of the Immediate Jeopardy on 2/7/2022 at 1:23 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-835, F-867, and F-880 at a scope and severity of L. The Immediate Jeopardy existed from 1/31/2022 through 2/7/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2022 at 4:06 PM, and was validated onsite by the surveyors on 2/6/2022 through 2/8/2022 through review of in-service records, policies and procedures, and staff interviews. The findings include: Review of the facility's Administrator job description dated 4/2013, revealed, .Lead and direct the overall operation of the facility as to maintain excellent care for the residents .Monitor each department's activities, communicate policies, evaluate performance, provide feedback .Conduct regular rounds to monitor delivery of nursing care .ensure universal precautions and infection control .isolation .and sanitation practices .procedures are followed. Maintain a working knowledge and ensure compliance with all governmental regulations and quality assurance standards .ensure .appropriate orientation, training and staff education. Supervise, conduct, and participate in department and facility education activities and staff meetings .Monitor environment for .infection control and all other departmental policies and procedures are followed . Review of the facility's Director of Nursing job description dated 4/2013, revealed, .To manage overall operation of the nursing services department .Work with the administrator, consultants, and facility staff in planning all aspects of nursing services .Monitor department activities, communicate policies, evaluate performance .ensure universal precautions and infection control, isolation .and sanitation procedures are followed .Conduct regular rounds to monitor .care activities .to ensure the delivery of nursing care according to .established standards .Ensure compliance with State, Federal, and company PI [Performance Improvement] standards .Ensure current .training, and staff education .ensure that established safety rules and regulations are followed at all times. Monitor environment for established .infection control and all other departmental policies and procedures are followed; and to ensure cleanliness and safety of work and treatment areas . The facility's Performance Improvement Nurse Registered Nurse (RN)/Licensed Practical Nurse (LPN) job description dated 4/2013, revealed .To manage and coordinate a performance improvement plan of care .in accordance with company policies, standards of nursing practices and government regulations, so as to maintain excellent care of all the residents' needs .Work with or support .administrator in planning all aspects of nursing services to include interface with other disciplines and departments .assist .in managing nursing care to monitor day-to-day operation of nursing functions .ensure compliance with State, Federal, and PI standards, to include alerting management to potential non-compliance issues and preparation of correction plans .Monitor environment for established .infection control and all other departmental policies and procedures are followed; and to ensure cleanliness and safety of work and treatment areas . Review of the facility's policy titled, Policies and Practices-Infection Prevention and Control, dated 4/2012, revealed .This facility's infection prevention and control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .The Quality Assurance and Performance Improvement Committee, through the Infection Prevention and Control Committee, shall oversee implementation of infection prevention and control policies and practices, and help department heads and managers ensure that they are implemented and followed .The Administrator or Governing Body, through the Quality Assurance and Performance Improvement Committee and the Infection Prevention and Control Committees, has adopted our infection prevention and control policies and practices, as outlined herein, to reflect the facility's needs and operational requirements for preventing transmission of infections and communicable diseases as set forth in current OBRA [Omnibus Budget Reconciliation Act], OSHA [Occupational Safety and Health Administration], and CDC [Centers for Disease Control] guidelines and recommendations . Review of the CDC website document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection [the virus that causes COVID-19] .HCP [Healthcare Providers] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH [National Institute for Occupational Safety and Health]-approved N95 [a particulate-filtering facepiece respirator] or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . Observations of staff during the survey revealed the following: a. On 1/31/2022 at 11:09 AM, CNA #1 failed to don eye protection prior to entering Resident #37's (a COVID-19 positive resident) room with bed linens. At 11:18 AM, CNA #2 failed to don eye protection prior to entering the Resident #37's room to deliver the meal tray. b. On 1/31/2022 at 11:24 AM, staff were going from COVID-19 positive to non-COVID-19 positive residents' rooms. c. On 1/31/2022 at 11:29 AM, CNA #2 was feeding Resident #4, a non-COVID-19 positive resident (this was after the CNA had failed to don eye protection in a COVID-19 positive resident's (Resident #37) room). d. On 2/01/2022 at 8:20 AM, Housekeeper #1 entered Resident #7's room (a COVID-19 positive resident) and was wearing 3 surgical masks, an isolation gown, gloves, and no eye protection. Housekeeper #1 exited the room, entered the hallway, and failed to remove the PPE or perform hand hygiene. Housekeeper #1 returned to Resident #7's room wearing the same 3 surgical masks, isolation gown, gloves and no eye protection. e. On 2/1/2022 at 8:40 AM, the Activity Assistant was wearing a cloth mask (not a surgical mask) in Resident #60's (a non-COVID-19 positive resident) room and in the hallway outside the residents' rooms. f. On 2/1/2022 at 2:46 PM, the Activity Assistant was wearing a cloth mask, leaning over 3 residents, while assisting them to play bingo. g. On 2/4/2022 at 1:47 PM, CNA #3 received a meal tray with her bare hands. The meal tray contained soiled dishes from Resident #68's room (a COVID-19 positive resident), walked down the hall to the kitchen with the meal tray in her bare hands, and handed the meal tray through the kitchen window to the dietary staff. CNA #3 failed to don gloves before handling Resident #68's meal tray. During an interview on 1/31/2022 at 9:30 AM, LPN #4 confirmed that Residents #7 and #37 were in Droplet Precautions isolation for COVID 19. LPN #4 was asked if staff should wear eye protection in a resident's room that was on Droplet Precautions. LPN #4 stated, .KN95 or N95 mask, gloves, gown and goggles or face shield . During an interview on 2/2/2022 at 11:43 AM, the DON confirmed the facility did not have a Performance Improvement (PI)/Infection Control Preventionist (ICP) nurse and she was fulfilling those responsibilities. The DON was asked whose responsibility it was to ensure staff wore the proper PPE when entering COVID-19 positive rooms and non-COVID-19 positive rooms. The DON stated, .the PI nurse .that would be me . During an interview on 2/4/2022 at 10:31 AM, the DON confirmed she had been the PI nurse from 1/2021 to 6/2021 and took on the responsibilities of the PI nurse from 10/2021 to 1/31/2022 during the absence of a PI nurse in the facility. The DON confirmed her responsibilities as PI nurse included educating staff on infection control policies and procedures and arranging the Quality Assurance Performance Improvement (QAPI) meetings. The DON confirmed that all staff should wear N95 masks, a gown, gloves and either goggles or a face shield when entering a COVID-19 positive room. During an interview on 2/4/2022 at 10:54 AM, the DON confirmed staff should wear a surgical mask or a KN95 mask in resident care areas and when assisting residents. During a telephone interview on 2/6/2022 at 2:02 PM, the Administrator was asked what her job responsibilities were. The Administrator stated, Overseeing all department heads .but I do not know what they are supposed to do . The Administrator confirmed the facility did not have anyone in the position as PI and the DON was taking on those responsibilities. The Administrator was asked if she attended the in-services conducted in the facility and she stated, .some are strictly for nurses .so I did not even look at them to be honest . The Administrator confirmed she is responsible for oversight of the facility and the staff. During a telephone interview on 2/7/2022 at 9:16 AM, the Administrator was asked who was responsible for the QAPI meetings. The Administrator confirmed she did not know the difference between a Performance Improvement Project (PIP) and QAPI. The Administrator stated, .we haven't actually done that since I have been here .since I have been here that is something that I am lacking in . Refer to F-835, F-867, and F-880. The surveyors verified the Removal Plan by: 1. The Corporate Director of Operations, who is also a licensed nursing home Administrator, will work with the facility Administrator to provide additional training and oversight regarding infection control and prevention on a weekly basis for 3 months. The surveyors interviewed the Corporate Director of Operations and the facility Administrator. 2. The Corporate Clinical Staff will provide additional training and oversight regarding infection Control and Prevention for the facility leadership weekly for 3 months. The surveyors interviewed the Corporate RN and the Regional Nurse Consultant, DON, and Administrator. 3. The Corporate Director of Operations and the Corporate Clinical Staff will provide guidance and oversight for Administration to provide a safe and sanitary environment and ensure procedures are followed to prevent the spread of infection. The surveyors interviewed the Chief of Operations, Corporate RN, Regional Nurse Consultant, and the Administrator. 4. The Governing Body will monitor the training and performance of the facility administration weekly for 8 weeks and monthly thereafter. The surveyors interviewed the Corporate Director of Operations, Corporate [NAME] President, Administrator, DON, Dietary Manager, Housekeeping/Laundry Supervisor, Social Service Director, and Rehabilitation Director. The facility's noncompliance at F-835 continues at a scope and severity of F for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, Quality Assurance (QA) document review, observation, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that identified opportunities for improvement related to infection control, failed to implement corrective action or performance improvement activities for infection control in order to provide a safe and sanitary environment for residents, prevent the spread of infections and communicable disease, and ensure systems and processes were in place that were consistently followed by staff and administration. The QAPI committee failed to ensure the facility was administered in a manner that enabled it to identify quality care issues and ensure systems and procedures were in place and being followed placed the 75 residents residing in the facility in Immediate Jeopardy when dietary staff failed to clean dining carts containing meal trays from COVID-19 positive residents' rooms with an Environmental Protection Agency (EPA) approved disinfectant to kill COVID-19, prior to using them for the next meal service delivery of trays to COVID-19 positive and non-COVID-19 positive residents and when staff failed to put on Personal Protective Equipment (PPE) in COVID-19 positive resident rooms. These facility failures resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The [NAME] President, Regional Nurse Consultant, Regional Registered Nurse (RN), and Director of Nursing (DON) were notified of the Immediate Jeopardy on 2/7/2022 at 1:23 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-835, F-867, and F-880 at a scope and severity of L. The Immediate Jeopardy existed from 1/31/2022 through 2/7/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2022 at 4:06 PM and was validated onsite by the surveyors on 2/6/2022 through 2/8/2022 through review of in-service records, policies and procedures, and staff interviews. The findings include: Review of the facility's policy titled, Performance Improvement Committee, revised 12/2009, revealed .This facility shall establish and maintain a Performance Improvement Committee that oversees the identification and handling of quality issues .The Administrator shall delegate the necessary authority for actions and processes to the Performance Improvement Committee .The committee shall be a standing committee of the facility, and shall provide reports to the Administrator and governing board (body) .To oversee facility systems and processes related to improving quality of care and services .To promote consistent facility systems and processes and appropriate practices in resident care .The Performance Improvement Coordinator shall coordinate the activities of the Performance Improvement Committee .The following individuals will serve on the committee .Committee Chairperson .Administrator .Director of Nursing .Medical Director .Dietary Representative .Social Services Representative .Activities Representative .Environmental Services Representative .Infection Control Representative .Rehabilitative/Restorative Services Representative .Staff Development Representative .and Safety Representative .The committee will oversee the development and implementation of actions to correct quality concerns and promote overall quality of care and services in the facility . Review of the facility's policy titled, Policies and Practices-Infection Prevention and Control, dated 4/2012, revealed .This facility's infection prevention and control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .The Quality Assurance and Performance Improvement Committee, through the Infection Prevention and Control Committee, shall oversee implementation of infection prevention and control policies and practices, and help department heads and managers ensure that they are implemented and followed .The Administrator or Governing Body, through the Quality Assurance and Performance Improvement Committee and the Infection Prevention and Control Committees, has adopted our infection prevention and control policies and practices, as outlined herein, to reflect the facility's needs and operational requirements for preventing transmission of infections and communicable diseases as set forth in current OBRA [Omnibus Budget Reconciliation Act], OSHA [Occupational Safety and Health Administration], and CDC [Centers for Disease Control and Prevention] guidelines and recommendations . Review of the facility's Administrator job description dated 4/2013, revealed .Lead and direct the overall operation of the facility as to maintain excellent care for the residents .Monitor each department's activities, communicate policies, evaluate performance, provide feedback .ensure universal precautions and infection control .isolation .and sanitation practices .procedures are followed. Maintain a working knowledge and ensure compliance with all governmental regulations and quality assurance standards .ensure .appropriate orientation, training and staff education. Supervise, conduct, and participate in department and facility education activities and staff meetings .Monitor environment for .infection control and all other departmental policies and procedures are followed . Review of the facility's Director of Nursing (DON) job description dated 4/2013, revealed .To manage overall operation of the nursing services department .Work with the administrator, consultants, and facility staff in planning all aspects of nursing services .Monitor department activities, communicate policies, evaluate performance .ensure universal precautions and infection control, isolation .and sanitation procedures are followed .Conduct regular rounds to monitor .care activities .to ensure the delivery of nursing care according to .established standards .Ensure compliance with State, Federal, and company PI [Performance Improvement] standards .Ensure current .training, and staff education .ensure that established safety rules and regulations are followed at all times. Monitor environment for established .infection control and all other departmental policies and procedures are followed; and to ensure cleanliness and safety of work and treatment areas . Review of the facility's Performance Improvement Nurse/Registered Nurse (RN)/Licensed Practical Nurse (LPN) job description dated 4/2013, revealed .To manage and coordinate a performance improvement plan of care .in accordance with company policies, standards of nursing practices and government regulations, so as to maintain excellent care of all the residents' needs .Work with or support .administrator in planning all aspects of nursing services to include interface with other disciplines and departments .assist .in managing nursing care to monitor day-to-day operation of nursing functions .ensure compliance with State, Federal, and PI [Performance Improvement] standards, to include alerting management to potential non-compliance issues and preparation of correction plans .Participate in educational training, assist in implementing orientation programs and jobs skills training, maintain professional compliance .Monitor environment for established .infection control and all other departmental policies and procedures are followed; and to ensure cleanliness and safety of work and treatment areas . Review of the facility's document titled, Performance Improvement Project Information, updated 1/25/2021, revealed .Team Members .RN QAPI, LPN, PCC [Patient Care Coordinator], RN, DON, RN ADON [Assistant Director of Nursing], LPN, PCC [Point Click Care], LPN Staffing Coordinator . Review of the facility's document titled, [Named Facility] QA [Quality Assurance] Program, dated 7/29/2021, confirmed the facility's Medical Director was not in attendance. Observation on the North Hall on 1/31/2022 at 8:36 AM, revealed a sign on the door of Resident #37's room, a COVID-19 positive resident, that revealed, .DROPLET PRECAUTIONS .EVERYONE MUST .Make sure their eyes, nose and mouth are fully covered before room entry . Observation on the North Hall on 1/31/2022 at 8:39 AM, revealed a sign on the door of Resident #7's (COVID-19 positive resident) room that revealed, .DROPLET PRECAUTIONS .EVERYONE MUST .Make sure their eyes, nose and mouth are fully covered before room entry . Observation of the North Hall on 1/31/2022 at 11:09 AM, revealed CNA #1 failed to don eye protection and entered Resident #37's (a COVID-19 positive resident) room with bed linens. Observation on the North Hall on 1/31/2022 at 11:18 AM, revealed CNA #2 failed to don eye protection and entered Resident #37's room to deliver his meal tray. Observation in the North Hall on 1/31/2022 at 11:24 AM, revealed staff were going from COVID-19 positive to non-COVID-19 positive residents' rooms. Observation in the resident's room on 1/31/2022 at 11:29 AM, revealed CNA #2 feeding Resident #4, a non-COVID-19 positive resident (this was after the CNA had failed to don eye protection in a COVID-19 positive resident's (Resident #37) room). Observation of the North Hall on 2/1/2022 at 8:20 AM, revealed Housekeeper #1 entered Resident #7's (a COVID-19 positive resident) room wearing 3 surgical masks, an isolation gown, gloves, and no eye protection. Housekeeper #1 failed to don an N95 mask (or equivalent) or protective eye wear. Housekeeper #1 exited the room and entered the hallway and failed to remove the PPE or perform hand hygiene. Housekeeper #1 then returned back to Resident #7's room wearing the same 3 surgical masks, isolation gown, gloves, and no eye protection. Observation of the North Hall on 2/1/2022 at 8:40 AM, revealed the Activity Assistant wearing a cloth mask (not a surgical mask) in Resident #60's (a non-COVID-19 positive resident) room and in the hallway outside the residents' rooms. Observation in the South Hall on 2/1/2022 at 2:46 PM, revealed the Activity Assistant wearing a cloth mask, while leaning over 3 residents, and assisting them to play bingo. Observation on 2/1/2022 at 3:42 PM, revealed Dietary Staff #1 removed the dirty trays from the meal carts, that contained COVID-19 positive and non-COVID-19 meal trays. After the meal cart was empty, Dietary Staff #1 sprayed the inside of the meal cart with a (Named disinfectant) and wiped the inside of the cart with a cloth she had picked up off the countertop. Dietary Staff #1 failed to use an approved EPA that kills COVID-19 and was not observed using a bleach solution to clean the cart. During an interview on 2/2/2022 at 8:55 PM, the Registered Dietary Manager (RDM) confirmed that the (Named disinfectant) did not kill COVID-19 and stated, .it was not approved for viruses .it killed bacteria not viruses .have another product they received last week called [Named Disinfectant] which does kill viruses. The kitchen did not have it until now .the kitchen staff are supposed to use bleach solution first . During an interview on 2/4/2022 at 10:33 AM, the DON was asked who the members of the QAPI team were. The DON stated, .Me, [named the Administrator], and [named the ADON] get together and discuss infections, antibiotics .if we need to isolate [a resident] where is the best place to put them. The DON was asked when was the last time the Medical Director attended a QAPI meeting. The DON stated, The beginning of the year .2021. The DON was asked if only three people attend the QAPI meetings. The DON stated, There are other members as well .the Medical Director, people from Corporate, the Housekeeping Supervisor .it's all on the sign in sheet. The DON was asked how often those meetings are held. The DON stated, Quarterly. The DON was asked when the last Quarterly QAPI meeting was. The DON stated, We did not have an actual QAPI meeting .[in December 2021] we did the minutes for the last quarter, but we did not get to have the meeting .We had a lot of people having symptoms [of COVID] so we just kind of held up . The DON was asked what are some things that are reviewed in QAPI. The DON stated, We have been working on COVID, consistently we have been tracking the proper use of the mask, keeping the mask up, and COVID .[the Medical Director] has not been with us since the first quarter because of COVID. We take information to him and he signs it . The DON was asked if the Medical Director should be involved in the QAPI meetings. The DON stated, He should. Observation of the South Hall on 2/4/2022 at 1:47 PM, revealed a Droplet Precautions sign on Resident #68's room. Resident #68 was positive for COVID-19. While standing outside the room, CNA #3 was handed a meal tray containing soiled dishes from the room, carried the meal tray with her bare hands to the kitchen window, and handed it to the dietary staff. CNA #3 failed to don gloves before handling Resident #68's meal tray. During an interview on 2/4/2022 at 10:31 AM, the DON was asked when QAPI meetings should be held and confirmed QAPI meetings should be held at least quarterly. The DON confirmed she failed to set up QAPI meetings and the last QAPI meeting was held in 7/2021. During an interview on 2/6/2022 at 9:20 AM, the DON confirmed there have been no official QAPI meetings which included the QAPI team and Medical Director since 1/28/2021. The DON confirmed that no Performance Improvement Project (PIP) or QAPI meetings were held related to an outbreak of COVID 19 in December 2021. During an interview on 2/6/2022 at 12:01 PM, the Chief of Operations confirmed that he attends QAPI meetings when he is around and available. The Chief of Operations was asked how often the facility was supposed to have QAPI meetings. The Chief of Operations stated, .quarterly . The Chief of Operations was asked when the last QAPI meeting was held. The Chief of Operations stated, I'm going to say about a year and a half ago . The Chief of Operations was asked who was responsible for making sure the QAPI meetings were held. The Chief of Operations stated, The Administrator . During an interview on 2/6/2022 at 12:41 PM, the Medical Director was asked when was the last QAPI meeting that he had attended. The Medical Director stated, .4 to 6 months . During a telephone interview on 2/6/2022 at 2:02 PM, the Administrator confirmed she was responsible for the QAPI program but the PI nurse is responsible for the quarterly meetings. The Administrator was asked when was the facility's last QAPI meeting. The Administrator stated, .I think it was in July 2021 and one should have been held in October, but it wasn't. The Administrator confirmed she is responsible to provide oversight of the facility, the staff, the operations, and functions of the facility. During an interview on 2/6/2022 at 3:19 PM, the DON confirmed the December QAPI minutes had not been sent to the Medical Director. The DON stated, We sent it to Corporate for them to review and make any changes . During a telephone interview on 2/7/2022 at 9:16 AM, the Administrator was asked who was responsible for the QAPI meetings. The Administrator stated, I am not sure what a PIP or QAPI is. The Administrator was asked if the facility had any QAPI meetings. The Administrator stated, .we haven't actually done that since I have been here, since I have been here that is something that I am lacking in . The Administrator stated, I have not done anything with that .since I've been in [Named Facility] [10/18/2021] .it's definitely what I need to focus on .it's probably the most thing lacking .I am learning more during this survey .I'm going to have to take more control . During an interview on 2/7/2022 at 10:17 AM, the DON confirmed she was the PI Nurse from January 2021 until June 2021, when she took the Assistant Director of Nursing (ADON) and then the DON role. The DON confirmed no one has been in the role of PI nurse since November 2021. The DON confirmed that she has been responsible for the QAPI program since November 2021. The DON was asked if she knew what the policies and procedures related to QAPI were. The DON stated, No. The DON stated, There was a meeting in January, then when it came time for the next meeting, I had never written up QAPI minutes, so we did not have a meeting. Then I changed jobs .everyone that I report to knew [that meetings were not being held] .the Administrator and Corporate . Refer to F-880 and F-835 The surveyors verified the Removal Plan by: 1. The facility hired a nurse to fill the position of QAPI nurse on 1/21/2022. The Corporate nurses will train the QAPI nurse on the QAPI program. The QAPI nurse was interviewed. 2. The facility will develop a system for QAPI to monitor departmental performance data and communication, to monitor staff are using the appropriate PPE, and to monitor to ensure the facility is using EPA approved cleaning agents to disinfect all tray carts. The surveyors interviewed administration and made observations. 3. On 2/7/2022, the facility QAPI Committee met to discuss the survey findings related to infection control. The QAPI Committee included the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services Director, Minimum Data Set (MDS) Coordinator, Dietary Supervisor, Activity Director, Restorative Nurse, Maintenance Supervisor, Housekeeping Supervisor, Therapy Representative, Performance Improvement Nurse, and the Corporate leadership team. The QAPI Committee will meet weekly for four weeks, monthly for five months, then at least quarterly. The Corporate leadership team will oversee the QAPI program and report to the Governing Body. The surveyors reviewed the QAPI minutes from 2/7/2022 and interviewed the QAPI Committee. The facility's noncompliance at F-867 continues at a scope and severity of F for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, medical record review, observation, and interview, the facility failed to follow CDC infection control guidelines and ensure practices to prevent the spread of infection were maintained when 4 of 20 staff members (Hostess #1, Housekeeper #1, and Certified Nursing Assistant (CNA) #1 and #2) failed to wear appropriate Personal Protective Equipment (PPE) in COVID-19 positive residents' rooms and were caring for other residents, 1 of 20 staff members (the Activity Assistant) failed to wear appropriate PPE in resident care areas and in resident's rooms, 1 of 15 staff (CNA #3) failed to wear gloves when handling a meal tray from a COVID-19 positive resident's room, 1 of 3 staff members (Dietary staff #1) failed to clean meal carts containing meal trays from COVID-19 positive residents' rooms with an EPA (Environmental Protection Agency) approved disinfectant, to kill COVID-19, prior to using them for the next meal service delivery of trays to COVID-19 positive and non-COVID-19 residents, and when 3 of 4 nurses (LPN #1, #2, and #3) failed to perform hand hygiene and contaminated multidose bottles of eye drops during medication administration. The community positivity rate was 38.7% on 2/4/2022. The facility's failure to wear appropriate PPE in COVID-19 positive residents' rooms and in resident care areas and failure to clean meal carts containing trays from COVID-19 positive residents' rooms with an EPA approved disinfectant, to kill COVID-19, prior to using them for the next meal service delivery of trays to COVID-19 positive and non-COVID-19 residents resulted in Immediate Jeopardy (IJ) and could potentially affect all 75 residents residing in the facility. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The [NAME] President, Regional Nurse Consultant, Regional Registered Nurse (RN), and Director of Nursing (DON) were notified of the Immediate Jeopardy on 2/5/2022 at 12:35 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-880 at a scope and severity of L. The Immediate Jeopardy existed from 1/31/2022 to 2/7/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/5/2022 at 5:20 PM and was validated on site by the surveyors on 2/6/2022 through 2/8/2022 by review of in-service records, observations, and staff interviews. The findings include: Review of the Center for Disease Control and Prevention (CDC) website document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection [the virus that causes COVID-19] .HCP [Healthcare Providers] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH [National Institute for Occupational Safety and Health]-approved N95 [a particulate-filtering facepiece respirator] or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . Review of the CDC's website document titled, Science Brief: SARS-CoV-2 and Surface (Fomite) Transmission for Indoor Community Environments, updated 4/5/2021, revealed .It is possible for people to be infected through contact with contaminated surfaces or objects (fomites) .Surface survival .on non-porous surfaces, viable virus can be detected for days to weeks .Effectiveness of cleaning and disinfection .To substantially inactivate SARS-CoV-2 on surfaces, the surface must be treated with a disinfectant registered with the Environmental Protection Agency's (EPA's) List or technology that has been shown to be effective against the virus .Disinfectant products might also contain cleaning agents, so they are designed to clean by both removing soil and inactivating microbes. Cleaners and disinfectants should be used safely, following the manufacturer guidance .In situations when there has been a suspected or confirmed case of Covid-19 indoors within the last 24 hours, the presence of infectious virus on surfaces is more likely .Conclusion .People can be infected with SARS-Cov-2 through contact with surfaces . Review of the facility's policy titled, Policies and Practices-Infection Prevention and Control, dated 4/2012, revealed .This facility's infection prevention and control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .The Administrator or Governing Body .has adopted our infection prevention and control policies and practices, as outlined herein, to reflect the facility's needs and operational requirements for preventing transmission of infections and communicable diseases as set forth in current OBRA [Omnibus Budget Reconciliation Act], OSHA [Occupational Safety and Health Administration], and CDC guidelines and recommendations . Review of the facility's policy titled, Cleaning and Disinfection of Environmental Surfaces, Resident-Care Items, Equipment and Other Items, revised 8/2010, revealed .Environment surfaces, resident-care items and equipment will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities .items that may come in contact with mucous membranes or non-intact skin .should be free from all microorganisms .Reusable items are cleaned and disinfected or sterilized between residents . Review of the (Named Disinfectant) information sheet revealed .food contact surface sanitizer .ready to use quaternary-based [a non toxic and non corrosive] cleaner, sanitizer and deodorizer .provides light cleaning .can be used as a light duty cleaner on multi-touch surfaces such as refrigerators, drinking fountains .it stops the growth of bacteria . It did not include COVID-19 as one of the organisms killed by the disinfectant. Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia, Aphasia, Dysphagia, and Depression. Review of a Point of Care (POC) Test Result dated 1/24/2022, revealed Resident #7 tested positive for COVID-19. The Medication Administration Record (MAR) dated January 2022, documented, Droplet Precautions .1/26/22 [2022] . Observation on the North Hall on 1/31/2022 at 8:39 AM, revealed a sign on the door of Resident #7's room that revealed, .DROPLET PRECAUTIONS .EVERYONE MUST .Make sure their eyes, nose and mouth are fully covered before room entry . Observation in residents' room on 1/31/2022 at 11:24 AM, revealed staff moving from COVID-19 positive residents to non-COVID-19 positive residents' rooms. Observation of the North Hall on 2/1/2022 at 8:20 AM, revealed Housekeeper #1 entered Resident #7's room wearing 3 surgical masks, an isolation gown, gloves, and no eye protection. Housekeeper #1 failed to don an N95 mask (or equivalent) or protective eye wear. Housekeeper #1 exited the room, entered the hallway and failed to remove the PPE or perform hand hygiene. Housekeeper #1 then returned to Resident #7's room, wearing the same 3 surgical masks, isolation gown, gloves, and no eye protection. Review of the medical record, revealed Resident #37 was admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease, Diabetes, Benign Prostatic Hyperplasia, Polyosteoarthritis, Parkinson's Disease, and Depression. Review of a POC Test Result dated 1/24/2022, revealed Resident #37 tested positive for COVID-19. Review of a Telephone Order dated 1/24/2022, revealed .Droplet Precautions . Observation on the North Hall on 1/31/2022 at 8:36 AM, revealed a sign on the door of Resident #37's room that revealed, .DROPLET PRECAUTIONS .EVERYONE MUST .Make sure their eyes, nose and mouth are fully covered before room entry . Observation of the North Hall on 1/31/2022 at 11:09 AM, revealed CNA #1 failed to don eye protection and entered Resident #37's room with bed linens. Observation on the North Hall on 1/31/2022 at 11:18 AM, revealed CNA #2 failed to don eye protection and entered Resident #37's room to deliver his meal tray. Observation in the resident's room on 1/31/2022 at 11:29 AM, revealed CNA #2 feeding Resident #4, a non-COVID-19 positive resident (this was after the CNA had failed to don eye protection in a COVID-19 positive resident's (Resident #37) room). Observation of the North Hall on 2/1/2022 at 8:40 AM, revealed the Activity Assistant wearing a cloth mask (not a surgical mask) in Resident #60's (a non-COVID-19 positive resident) room and in the hallway outside of residents' rooms. Observation in the South Hall on 2/1/2022 at 2:46 PM, revealed the Activity Assistant wearing a cloth mask while leaning over 3 residents and assisting them to play bingo. Observation and interview in the Dining Room on 2/1/2022 at 3:42 PM, revealed Dietary Staff #1 removed the soiled meal trays from the dining carts which contained the meal trays from COVID-19 positive resident and non-COVID-19 positive residents and placed the plate covers and silverware into a large dish pan filled with liquid. Once all the meal carts were empty, Dietary Staff #1 sprayed the inside of the empty meal cart with a solution, retrieved a cloth from the countertop, and wiped the inside of the meal cart with a cloth. Dietary Staff #1 was asked what dishware and utensils the meals were served on for residents in isolation. Dietary Staff #1 stated, Styrofoam trays .nurses dispose of it in their room, all we get back is the tray that was under the Styrofoam tray . Review of the medical record, revealed Resident #68 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Hypertension, Diabetes Mellitus, and Pneumonia. Review of a POC Test Result dated 2/3/2022, revealed Resident #68 tested positive for COVID-19. Review of a Telephone Order dated 2/3/2022, documented .Droplet Precautions .2/3/2022 . Observation on the South Hall on 2/4/2022 at 1:47 PM, revealed a Droplet Precautions sign on Resident #68's room. While standing outside the room, CNA #3 was handed a meal tray containing soiled dishes from the room, carried the meal tray with her bare hands to the kitchen window, and handed it to the dietary staff. CNA #3 failed to don gloves before handling Resident #68s meal tray. During an interview on 1/31/2022 at 9:30 AM, LPN #4 confirmed that Residents #7 and #37 were in Droplet Precautions isolation for COVID-19. LPN #4 was asked what staff was required to wear in a resident's room that was on Droplet Precaution. LPN #4 stated, .KN95 or N95 mask, gloves, gown and goggles or face shield . During an interview on 2/1/2022 at 3:44 PM, the DON was asked what residents' meals were served on for residents with COVID-19. The DON stated, The first few days, they receive their food on Styrofoam trays, and everything is disposed of in the trash in the room, after 3 or 4 days they receive regular meal trays . During an interview on 2/2/2022 at 9:05 AM, the Certified Dietary Manager (CDM) confirmed residents in isolation get meals served on disposable Styrofoam trays and stated, The nurses dispose of them in their rooms. All we get back is the tray that was under the Styrofoam tray .nurses notify them [dietary staff] of who is in isolation by phone or by using communication forms they [nurses] send to them [dietary staff] to let them know who is in isolation. During an interview on 2/2/2022 at 11:43 AM, the DON confirmed that the facility had N95 masks available. The DON stated, .we should be keeping a better look at the carts, I admit I do not check them regularly . The DON was asked whose responsibility it was to ensure staff were wearing the proper PPE in COVID-19 positive and non-COVID-19 positive resident rooms. The DON stated, .that would be me. During an interview on 2/2/2022 at 11:47 AM, the Housekeeping Supervisor was asked if staff should wear an N95 mask when cleaning COVID-19 positive residents' rooms. The Housekeeping Supervisor stated Yes, sort of, kind of. The Housekeeping Supervisor was asked if she was aware that the housekeeping staff were not using an N95 or equivalent mask when cleaning COVID-19 positive resident rooms. The Housekeeping Supervisor stated, .sort of kind of . During an interview on 2/2/2022 at 8:55 PM, the Regional Dietary Manager (RDM) confirmed that the disinfectant that was used to clean the meal carts on 2/1/2022 did not kill Covid and stated, . it [disinfectant] was not approved for viruses .it killed bacteria not viruses .have another product they [staff] received last week called [named cleaner] which does kill viruses. The kitchen did not have it until now .the kitchen staff are supposed to use bleach solution first . During an interview on 2/4/2022 at 10:54 AM, the DON confirmed that staff should wear a surgical or KN95 mask in resident care areas and when assisting non COVID-19 positive residents. During an interview on 2/5/2022 at 9:22 AM, CNA #4 confirmed COVID-19 positive and non-COVID-19 positive meal trays were put on regular trays and stated, .we picked them up and put them on the regular cart. CNA #4 was asked if the staff in dietary were told that there were trays on the cart from COVID-19 positive residents' rooms. CNA #4 stated, No . During a telephone interview on 2/5/2022 at 9:28 AM, Hostess #2 confirmed COVID-19 positive meal trays were being put back on the meal cart with non-COVID-19 positive resident meal trays and stated, .not usually how it is .was using Styrofoam, throw away when we had our outbreak of 18-20 residents . During an interview on 2/5/2022 at 9:33 AM, CNA #5 was asked how COVID-19 positive resident meal trays were delivered. CNA #5 stated, We are supposed to use Styrofoam, I'm pretty sure you have seen we don't have the Styrofoam right now, we had 27 residents that were COVID-19 positive, we didn't have any, the person over dietary was out with COVID-19, [I] don't know what happened there but we were given regular trays and had to take regular trays in .for a while they were putting them on a metal wire rack covered in plastic. CNA #5 was asked how the trays were delivered on Monday [1/31/2022]. CNA #5 stated, We were just putting them [COVID-19 meal trays] back on the regular buggy. CNA #5 was asked if the COVID-19 positive trays were with the non-COVID-19 meal trays. CNA #5 stated, Yes. CNA #5 was asked if the dietary staff were told there were COVID-19 positive trays on the cart with non-COVID-19 trays when the cart was delivered to the kitchen. CNA #5 stated, No, they knew. During an interview on 2/7/2022 at 8:59 AM, the Medical Director was asked if he would expect staff to remove a meal tray from a COVID-19 positive room with their bare hands and carry it down the hall to the kitchen. The Medical Director stated, No. The Medical Director was asked if staff should follow CDC guidelines and wear proper PPE in COVID-19 positive residents rooms. The Medical Director stated, Yes . The Medical Director was asked if he expected staff to follow CDC guidelines for cleaning, COVID-19 positive contaminated meal carts with the proper CDC and EPA approved disinfectants. The Medical Director stated, Yes. During a telephone interview on 2/7/2022 at 9:12 AM, the Administrator was asked if staff received any in-services or education related to PPE use because of the outbreak of COVID-19 that occurred in December 2021. The Administrator stated, .I do not know that for sure .I personally did not. The Administrator was asked if an in-service should be conducted after a large outbreak. The Administrator stated, I think that I am gonna have to be on top of that more . The Administrator was asked if she would expect staff to go into a COVID-19 positive resident's room wearing only a surgical mask. The Administrator stated, .I would not, they do know they are supposed to wear the N95 . The Administrator was asked if she would expect staff to go into COVID-19 positive residents' rooms without eye protection. The Administrator stated, Well, that's iffy, that's not something they are used to . The Administrator was asked if she would expect staff to follow CDC guidelines regarding COVID-19 PPE procedures. The Administrator stated, Yes, I do . The Administrator was asked if staff should transport a meal tray from a COVID-19 positive resident's room down the hall to the kitchen with their bare hands. The Administrator stated, No . During a telephone interview on 2/7/2022 at 9:16 AM, the Administrator was asked if dietary staff should clean the meal tray carts with an approved EPA disinfectant that kills COVID-19 on the carts that contained COVID-19 positive and non-COVID-19 resident meal trays. The Administrator confirmed dietary staff should have been using the approved EPA disinfectant that kills COVID-19 and stated, I would think they should have been separated .not mixing . During an interview on 2/7/2022 at 10:17 AM, the DON was asked if she would expect staff to go into a COVID-19 positive resident's room wearing only a surgical mask. The DON stated, No. The DON was asked if she would expect staff to go into a COVID-19 positive resident's rooms without eye protection. The DON stated, No. The DON was asked if a staff member should transport a COVID-19 positive tray with their bare hands down the hall to the kitchen. The DON stated, No. During an interview on 2/7/2022 at 10:18 AM, the DON was asked if dietary staff should clean the meal tray carts with an approved EPA disinfectant that kills COVID-19, after commingling the COVID-19 positive and non-COVID-19 residents' meal trays. The DON stated, Yes. Review of the facility's policy titled, Instillation of Eye Drops, revised 10/2010, revealed .Drop the medication into the mid lower eyelid .(Note: Do not touch the eye or eyelid with the dropper) . Review of the facility's policy titled, Administer Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, revealed .The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .When treatment is complete, turn off nebulizer and disconnect .Perform hand hygiene .Cleanse the nebulizer equipment .Perform hand hygiene . Observation in the resident's room on 2/1/2022 at 12:53 PM, revealed LPN #1 prepared to administer a nebulizer treatment to Resident #55. LPN #1 donned gloves, placed the aerosol solution in the nebulizer canister of the mask, and placed the mask on Resident #55. LPN #1 then plugged the machine in and turned it on, repositioned the nebulizer mask on Resident #55's face, and placed her hands on the siderail. LPN #1 then adjusted her KN95 mask, which had fallen below her nose, adjusted the bed with the bed crank, adjusted the resident's blankets, repositioned Resident #55's nebulizer mask without removing her gloves and performing hand hygiene, and returned her hands to the siderail. LPN #1 turned the nebulizer machine off, removed the nebulizer mask, took it across the hall to a bathroom, and failed to remove her gloves or perform hand hygiene. LPN#1 turned on the water faucet, and washed the mask with water, dried it with paper towels, turned the water off and returned to Resident #55's room to return the mask before she removed her gloves and exited the room. Observation in the resident's room on 2/1/2022 at 4:00 PM, revealed LPN #2 administered eye drops to Resident #41. LPN #2 administered 1 drop of Brimonidine (a medication used to lower pressure in the eyes) into Resident #41's right eye, touched the eye lid with the dropper, replaced the cap, and returned the multidose bottle to the medication cart. Observation in the resident's room on 2/2/2022 at 9:25 AM, revealed LPN #3 administered eye drops to Resident #29. LPN #3 administered 1 drop of lubricating eye drops to Resident #29's left eye, touched the eye lid with the dropper, replaced the cap and returned the multidose bottle to the medication cart. During an interview on 2/4/2022 at 10:54 AM, the DON confirmed that staff should perform hand hygiene after administering a nebulizer treatment, before cleaning the nebulizer mask, that masks worn by staff should cover the mouth and nose when in a resident's rooms, that staff should not touch a resident's eye or eye lid with the dropper during eye drop administration, and that contaminated bottles of eye drops should be replaced. The surveyors verified the Removal Plan by: 1. On 2/2/2022 The Dietary Manager immediately removed the sanitizer in question and an EPA-approved disinfectant was obtained by the Dietary Manager. The dietary staff members on duty were instructed by the Dietary Manager on the proper use of the EPA-approved disinfectant. The surveyors made observations and interviewed staff on all shifts. 2. On 2/3/2022 and 2/4/2022, the Dietary Manager in-serviced the remaining dietary staff members, regarding the use of EPA-approved disinfectants and infection control practices. The surveyors reviewed education records and interviewed staff on all shifts. 3. On 2/4/2022, the facility Leadership/Quality Assurance Team, consisting of the Administrator (via phone), Dietary Manager, DON, Assistant DON, the Housekeeping Supervisor, the Performance Improvement Nurse, the Regional Dietary Manager, and the Corporate Registered Dietitian/Vice-President met to discuss and develop an education plan for the staff regarding the appropriate use of PPE and best practices for infection control and prevention. Instruction was then provided to on-duty staff regarding removing meal trays from COVID positive resident rooms. The surveyors reviewed the education records and interviewed staff on all shifts. 4. On 2/5/2022, all staff members on duty were in-serviced by their respective department managers on the proper use of only EPA-approved disinfectants. All facility staff members will be in-serviced by their respective department managers on the proper use of EPA-approved disinfectants prior to returning to work on his/her next scheduled work shift. The use of only EPA-approved disinfectants will be monitored by the Dietary Manager or the Head Cook, daily for two weeks; weekly for 2 weeks; and monthly thereafter to ensure only EPA-approved disinfectants are used. The surveyors made observations, reviewed education records, and interviewed staff on all shifts. 5. On 2/5/2022, all facility staff members on duty were in-serviced by their respective department managers on the proper use of appropriate PPE for COVID-19 positive residents. All remaining facility staff members will be in-serviced by their respective department managers on the proper use of appropriate PPE for COVID-19 positive residents, prior to returning to work on his/her next scheduled work shift. The DON and ADON will be responsible for assuring that there is adequate PPE available to the staff and to monitor compliance. As adopted above, the DON or Assistant DON will monitor the clinical staffs' use of PPE and appropriate infection control techniques, daily for two (2) weeks; weekly for two (2) weeks; and monthly thereafter to ensure compliance. The surveyors reviewed education records and interviewed staff on all shifts. 6. As of 2/5/2022, all active and on duty staff members have received updated education on the appropriate use of PPE and to assure that any disinfectants being used to sanitize environmental hard services are to be EPA Approved for the prevention of COVID related transmission. The remaining scheduled off/PRN/LOA/Vacation staff members have been called or texted and informed that they can't return to work until they have received the appropriate training regarding the updated protocols. A notice was also placed on the time clock to alert each of these employees to receive an in-service session before proceeding with their assignments. The remaining staff members will be in-serviced as they move back on the active work schedule. The surveyors made observations, reviewed education records, and interviewed staff on all shifts. 7. On 2/5/2022 the facility Medical Director, was apprised of the cited deficiencies and has agreed to expand his oversight & supervision of the facility's Infection Control protocols. In addition to his routine responsibilities, the Medical Director will participate with the Safety & Quality Committee to ensure policies are in place and being followed relative to staff supervision and infection control practices. The surveyors interviewed the Medical Director and interviewed staff on all shifts. 8. As of 2/6/2022, the Facility Leadership Team/Quality Assurance Team met to discuss serving COVID positive residents' meals on disposable dishes. All facility staff will be educated on this new process. In servicing of the new process will be initiated on 2/6/2022, with in servicing continuing until all facility staff have been in serviced. The surveyors made observations and interviewed staff on all shifts. The facility's noncompliance at F-880 continues at a scope and severity of F for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.