**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28. On 7/16/21 at 1:17 PM, resident 186, who was on isolation, walked outside of her room to place an old, dirty lunch tray on the plastic folding table near her front door. [Note: This plastic folding table was present outside of resident 186's room was used to assist staff with donning and doffing PPE.] On 7/16/21 at 1:45 PM, CNA 7 gathered the used meal tray from the plastic folding table outside of 186's room. CNA 7 walked down the 100 hall with the uncovered, used food tray and placed the used tray on a table in dining area. On 7/16/21 at 1:46 PM, CNA 7 collected three, used meal trays from 185's room, who was also on isolation precautions. CNA 7 placed all 4 used trays on one table in dining area. At this time the used meal trays from isolation rooms were not covered and included used plates with lids, Styrofoam cups, napkins, utensils, and an empty yogurt containers. On 7/16/21 at 1:47 PM, CNA 7 rolled an open sided food cart to the dining area near the 100 hall and placed the 4 used trays, from isolation rooms, on the open cart. CNA 7 took the cart from the 100 hall to the kitchen through the door at the end of the hall. CNA 7 brought the cart with used meal trays from the isolation rooms into the kitchen through the door next to the stove. On the stove at that time were three pots currently uncovered and simmering. The cart, containing used, isolation room meal trays, sat in the doorway near stove for 1 minute. Diet Aide 4 then walked the open-sided cart, containing used meal trays from isolation rooms, through the kitchen to the dish room. 29. On 7/18/21 at 8:41 PM, CNA 5 was observed to answer a call light for resident 185, who was on isolation precautions. Resident 185 asked CNA 5 to take his meal tray away. CNA 5 exited the room, and did not clean her face shield after exiting. CNA 5 emerged from the room holding the meal tray with her bare hands. There were several uncovered items on the tray, including a bowl and cup. CNA 5 walked directly to the back hallway, opened the door, and then used her bare hands to put the items in various containers outside of the kitchen door. CNA 5 then walked out of the back hallway, and out to the nurses station without sanitizing her hands. At no time during the observation, did CNA 5 perform hand hygiene. 30. On 7/18/21 from 8:15 PM to 9:56 PM, there was a face shield placed on a treatment cart in the 100/200 nurses station. The face shield appeared to be soiled, and was not labeled. 31. On 7/18/21 from 9:54 PM to 9:56 PM, CNA 5 was observed to be walking throughout the 100 hall with her surgical mask below her nose. 32. Resident 85 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, malignant neoplasm of the colon, chronic kidney disease, diabetes mellitus, heart failure, rhabdomyolysis, and weakness. Resident 85's medical record was reviewed on 7/19/21. Resident 85's progress notes indicated that resident 85 was unvaccinated and taken off of isolation precautions after 7 days. 33. Resident 86 was admitted on [DATE] with diagnoses that included cerebral palsy, cellulitis of lower left and right lower limb, severe protein calorie malnutrition, lymphedema, anemia, electrolyte and fluid disorder, lack of coordination, and weakness. Resident 86's medical record was reviewed on 7/12/21. A progress note for resident 86 dated 6/10/21 indicated that resident 86 was taken off of isolation precautions, even though he was admitted on [DATE] and was unvaccinated. 34. On 7/14/21 at 10:45 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated that he had started working as the IP at the facility the previous week. The IP stated that if a resident had not been vaccinated, they were put on isolation for up to 7 days to see if they have symptomsof COVID-19. The IP stated that after 7 days, if a resident tested negative for COVID-19, the resident could go off of isolation. The IP stated that they would not test residents during the 7 days for COVID-19 unless they showed symptoms of COVID-19. The IP stated that if a resident had a CPAP machine in use, then staff members needed to don full PPE (gowns, gloves, face shields, and N95 masks before entering the resident's room. The IP stated that as soon as the CPAP was turned off, staff could enter the resident's room without PPE. The IP stated that if a resident was using a nebulizer on a scheduled basis, then staff would need to don full PPE. The IP stated that if a resident was using a nebulizer on an as needed basis, then PPE was not required, nor were signs placed on the resident's door. The IP stated that if a resident was on isolation precautions for possible COVID-19, then all staff should be donning full PPE, even if they were just delivering trays for dietary. The IP stated that after a staff member came out of an isolation room, they should doff gowns and gloves inside the resident room, and then wash and sanitize their hands. The IP stated that staff should not use the same face shields in the isolation room as on the hall without cleaning them first. The IP stated that after leaving a room on isolation precautions, masks should be thrown away, and face shields should be cleaned with alcohol wipes or the red-lidded disinfectant wipes. The IP stated that he was responsible for stocking the items in the isolation cart, such as gowns, gloves, disinfectant wipes, etc. The IP stated that after staff had cleaned the face shields, and/or needed to throw their masks away, they were throwing those things away in the garbage by the nurses station. The IP stated that anyone who entered the facility needed to complete the screening process of answering questions, taking their temperature, etc. 35. On 7/14/21 at 11:50 AM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that she had started working at the facility in January of 2021, but was not certified as an IP. The DON stated that the previous IP had been terminated in February and the facility did not have an IP between February and July 2021. The DON stated that when someone was admitted to the facility who was not vaccinated, the resident was placed on isolation and was tested for COVID-19 on days 1, 5, and 7 after their admission. The DON stated that if residents had a negative test on day 7, they were taken off of isolation precautions. The DON was informed of the CDC guidance to place residents on isolation for 14 days. The DON stated she was unaware of that recommendation. The DON stated that if a resident had a CPAP machine in use, then staff members needed to don full PPE (gowns, gloves, face shields, and N95 masks before entering the resident's room. The DON stated that as soon as the CPAP was turned off, staff could enter the resident's room without PPE. The DON stated that staff were not supposed to share face shields, or gowns. The DON stated that full PPE should be donned prior to entering an isolation room. The DON stated that there should be a garbage can next to the isolation carts. The DON stated that staff should be sanitizing their hands after leaving an isolation room. The DON stated that all staff and visitors should complete the screening process upon entrance to the facility. The facility's COVID-19 Policy and Procedure was reviewed, and indicated the following . Screening staff . All staff will be screened at the beginning of their shift for fever and signs and symptoms of illness . . Infection Control .The facility will comply with any new or updated restrictions as provided by the CDC or the Utah health department . . All residents admitted shall be in isolation monitoring for 14 days, which can include their hospitalization days, to assure they are not positive for Covid-19 and have no signs and symptoms before they are allowed to interact with other residents . . For the duration of the state of emergency in Utah, all long-term care facility personnel shall wear a facemask while they are in the facility . . Full PPE shall be worn, per CDC guidelines, for the care of any resident with known or suspected Covid-19; and per CDC guidance for the conservation of PPE . .Cleaning and Disinfecting . Practice proper hand hygiene often . . Dedicated trash bins should be used for Covid-19 positive or suspected cases . . Disposable dishes and utensils shall be used whenever possible and discarded in biohazard bin in residents room after use .For potentially contaminated meal trays and associated dishware: Nursing staff to deliver potentially contaminated meal trays and associated dishware, wrapped and fully contained in a plastic bag . .PPE Status Requirements .Covid-19 suspected PPE requirements: N-95 masks, Goggles or face shields, Gowns and gloves on staff when performing personal cares . .Isolation . Use dedicated equipment for resident in isolation . 3. On 7/12/21 at 11:55 AM, an observation was made of Dietary Aide (DA) 1 delivering lunch trays on the 100 hallway, which was the hallway designated for residents in isolation. DA 1 did not put on a gown or gloves to enter multiple resident rooms on the isolation hall. DA 1 was wearing a face mask and eye protection. DA 1 did not clean her eye protection upon exiting the resident rooms. An interview was immediately conducted with DA 1. DA 1 stated staff were only required to wear gowns and gloves when they anticipated coming in contact with residents. Per review of the CDC guidance at https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html, appropriate PPE donning steps for staff were to: identify and gather the proper PPE to don, perform hand hygiene using hand sanitizer, put on isolation gown, put on NIOSH-approved N95 filtering face respirator or higher, put on face shield or goggles, and put on gloves. The guidance also stated that appropriate doffing steps for staff were to: remove gloves, remove gown, exit patient room, perform hand hygiene, remove face shield or goggles, remove mask, and perform hand hygiene after removing the mask and before putting it on again if the workplace was practicing reuse. 4. On 7/13/21 at approximately 12:00 PM, an observation was made on the 100 hallway outside of room [ROOM NUMBER]. A disposable gown was observed draped over the Personal Protective Equipment (PPE) cart and on top of a box of clean gloves. There was a glove on the floor next to the PPE cart. No disinfectant or alcohol based hand rub (ABHR) was observed to be on the PPE cart. There were 2 face shields tucked in the hand railing behind the PPE cart. There were no additional disposable gowns in the PPE cart, and no extra face masks. Another PPE cart in the same hallway had extra PPE in the cart. On 7/13/21 at approximately 12:15 PM an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated the gown on the cart was for donning before entering the resident's room. CNA 6 stated the gown outside the resident room was used by any staff that went into the resident's room. CNA 6 stated the visors were shared by staff. CNA 6 stated staff were not required to change their mask when going into the resident room. CNA 6 stated resident meal trays were delivered by kitchen staff and CNAs. CNA 6 stated whoever does the 100 hallway has to put on the gown. CNA 6 stated after delivering the meal trays the staff member would have to reach inside the resident's room for hand sanitizer. CNA 6 stated one disposable gown was used for the whole shift. CNA 6 stated clean gowns were kept in the storage room and either the CNAs or the nurses stocked the PPE carts. CNA 6 stated extra masks were kept in the medication room or the stock room. CNA 6 stated she cleaned her goggles with wipes after leaving an isolation room. CNA 6 stated she had worked at the facility for 3 months and was trained by another CNA. CNA 6 stated the Infection Preventionist did a little bit of the training on the floor. CNA also stated she received some training from the Director of Nursing (DON). CNA 6 stated she would go ask a nurse if she didn't know what to do. On 7/13/21 at 1:08 PM, an observation was made of CNA 6 donning the gown outside of room [ROOM NUMBER] that was draped over the PPE cart. CNA 6 entered the resident's room to answer the call light. Soon after she exited the resident's room. CNA 6 doffed the disposable gown and placed it back over the clean gloves on the PPE cart. CNA 6 did not change her mask, and was not observed sanitizing her hands after doffing the used gown. Review of Centers for Disease Control and Prevention (CDC) guidance on Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes documented under Personal Protective Equipment that Facilities should have policies and procedures addressing: Which PPE is required in which situations (e.g., residents with suspected or confirmed SARS-CoV-2 infection, residents placed in quarantine) and Recommended sequence for safely donning and doffing PPE. Additionally, Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. The guidance further recommended under Implement Universal Use of Personal Protective Equipment that HCP (Health Care Personnel) working in areas with minimal to no community transmission should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other PPE. The guidance also recommended under New Admissions and Residents who Leave the Facility documented, In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The guidance was last updated on March 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#ppe Review of the CDC guidance on Strategies for Optimizing the Supply of Isolation Gowns, documented under Crisis Capacity Strategies that The risks to HCP and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be re-used, and reusable gowns should NOT be reused before laundering, because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits. Similar to extended gown use, gown reuse has the potential to facilitate transmission of organisms (e.g., C. auris) among patients. However, unlike extended use, repeatedly donning and doffing a contaminated gown may increase risk for HCP self-contamination. If reuse is considered, gowns should be dedicated to care of individual patients. Any gown that becomes visibly soiled during patient care should be disposed of or, if reusable, laundered. The guidance further stated, Once gown availability returns to normal, healthcare facilities should promptly resume conventional practices. The guidance was last updated on January 21, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html# Review of the United States Food and Drug Administration (FDA) guidance on Personal Protective Equipment documented on questions about PPE, In general, most PPE cleared by the FDA is intended to be used only one time and by one person. Sharing PPE is not advised. The protective capabilities of single use PPE cannot be assured when it is reused by the same person or used by more than one person. Sharing PPE that is intended for single use may expose another person to infectious materials. PPE should be removed promptly after use and disposed of properly. The content was current as of March 11, 2020. https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/questions-about-personal-protective-equipment-ppe 5. On 7/13/21 at 1:18 PM, therapy staff were observed to be in room [ROOM NUMBER]. The therapist was heard asking the resident if he wanted to get dressed, brush his teeth and comb his hair. The therapy staff member said he would get the resident a comb, a razor and a tooth brush. The therapy staff member doffed the gown he was wearing and put it on top of the used disposable gown on the PPE cart. When the staff member returned with the care items, he re-donned the disposable gown and re-entered the resident's room. The therapy staff was wearing a surgical mask and eye protection. Soon after, the same therapy staff member was observed exiting the resident's room again, this time without doffing his gown, and walked down the hall to the storage closet to get the resident some towels. The therapy staff member then re-entered the resident's room and closed the door. 6. On 7/13/21 at approximately 1:25 PM, an observation was made outside of another resident's room on the 100 hallway. There was a used disposable gown laying across the PPE cart outside of room [ROOM NUMBER], and on top of the clean gloves. 7. On 7/13/21 at 3:00 PM, an observation was made of CNA 5 going into room [ROOM NUMBER]. CNA 5 got a clean disposable gown out of the PPE cart. CNA 5 put on clean gloves and then donned the gown up to her elbows and entered the resident's room. The gown was observed not to be donned appropriately, as it only covered the staff member's elbows and part of her lower torso. The gown was not covering the upper rib and chest area of the CNA. 8. On 7/14/21 at 7:30 AM, an observation was made of Registered Nurse (RN) 3 entering the building. RN 3 walked past the front desk in the lobby area where screening was done, without screening in. An interview was conducted with RN 3 at the nursing station on the 300/400 hallway. RN 3 stated she usually waited a few minutes before taking her temperature so it normalized. RN 3 stated staff took their temperatures 3 times per day. RN 3 stated staff do one to two COVID tests weekly depending on the county infection rate. RN 3 stated all staff were supposed to screen at the front desk upon arriving to work. RN 3 stated everyone coming into the building fills out the screening sheet, every day. RN 3 stated if staff left the building for any reason, they were required to re-screen before going to their work stations. RN 3 stated she had been at the facility for 1 year and 9 months. RN 3 stated the screening protocol had changed so much depending on the state requirements. RN 3 stated currently surgical masks and eye protection were required for all staff. RN 3 stated full PPE is required on the 100 hallway. Review of the CDC's guidance on Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented under Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 stated .symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. The guidance further stated to Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 and Properly manage anyone with suspected or confirmed SARS-CoV-2 infection or who has had contact with someone suspected or confirmed with SARS-CoV-2 infection: Healthcare personnel (HCP) should be excluded from work The guidance was last updated on February 10, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html 9. On 7/14/21 at 2:37 PM an observation was made of a used disposable gown laying on a chair outside of room [ROOM NUMBER]. A disposable gown was also hanging inside the doorway at room [ROOM NUMBER], where there were no residents residing. Observations were made of the three PPE carts in the 100 hallway. The cart outside of room [ROOM NUMBER] had masks, gowns, and gloves. There was no hand sanitizer and no disinfectant wipes. There was no garbage receptacle near the cart in which staff could dispose of their used PPE or used disinfectant wipes. A pair of goggles was observed on the floor next to the PPE cart. The cart outside of room [ROOM NUMBER] had no gowns and masks. There was a box of clean gloves sitting on top. No ABHR or disinfectant wipes were observed. The PPE cart outside of room [ROOM NUMBER] had no masks and no gowns. Clean gloves were observed to be on top of the cart, and visors were tucked into the hand railing behind the cart. No garbage receptacle was observed for used PPE. 10. On 7/14/21 at 2:44 PM, an interview with CNA 5 was conducted about donning PPE. CNA 5 stated she first put on gloves, then a gown and stated she already had on a mask and eye protection. When asked if she needed additional eye protection or face shield she stated I already have eye protection on (pointing to her glasses). CNA 5 stated she had hand sanitizer in her pocket and she would put the used gown in the red bin in the resident's bathroom before exiting the room. An observation was then made of CNA 5 donning PPE to enter a resident room. CNA 5 put a gown on, then put gloves on and entered the resident room. Upon exiting the resident's room, she had already taken off her gown and gloves. CNA 5 was not observed sanitizing her hands. CNA 5 left the gown that was lying across the PPE cart where it was and did not throw it away. Review of the CDC guidance regarding eye protection indicated that Workers should understand that regular prescription eyeglasses and contact lenses are not considered eye protection https://www.cdc.gov/niosh/topics/eye/eye-infectious.html Review of the current county positivity rates at https://data.cms.gov/covid-19/covid-19-nursing-home-data, the county positivity rate for the week of 7/6/21 was 9.3 percent in Utah county. Per https://coronavirus.utah.gov/recommendations-for-providers/, in communities with moderate to high transmission, universal eye protection and additional precautions are advised. 11. On 7/14/21 at 2:52 PM, an observation was made of the facility Infection Preventionist (IP) exiting room [ROOM NUMBER] with a container of vitals equipment. When exiting the resident room the IP put his visor on the hand railing with the other visors outside the resident's room, without cleaning it. The IP then walked over the nurse's station, removed his mask, put the vitals container on the counter and went to the sink to wash his hands. The IP was not observed to clean the vitals equipment that had just been used in room [ROOM NUMBER]. It should also be noted that the PPE cart outside of the resident's room had no cleaning supplies on it, nor did it have ABHR on the cart. 12. On 7/14/21 at 3:08 PM, an observation was made of CNA 5 walking through the 200 hallway to the nurse's desk with her mask below her chin. Review of the CDC guidance on Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic under Implement Universal Source Control Measures stated that Source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose Patients and visitors should wear their own well-fitting form of source control upon arrival to and throughout their stay in the facility. The guidance was last updated on February 23, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html 13. On 7/14/21 at 3:14 PM, an observation was made of RN 2 with her eye protection on top of her head. 14. On 7/14/21 at 3:16 PM, an interview was conducted with RN 2. RN 2 stated when she worked on the 100 hallway she used her eye protection, put on a gown and gloves and entered the room. RN 2 stated when she doffed her gown, she would hang it on the door to use again. RN 2 stated she did not put her name on the gown to know which gown was hers. After exiting the resident's room, RN 2 stated she would put her eye protection back on top of her head because of having poor eyesight. RN 2 stated she put her gloves in the garbage in the hallway. She was asked to show what garbage she was referring to, and she walked over to the 100 hallway and there was no garbage. RN 2 stated there was usually a garbage in the 100 hallway. RN 2 stated residents on the 100 hallway were not allowed to leave their rooms during isolation. 15. On 7/14/21 at 3:46 PM, an interview was conducted with CNA 5. CNA 5 stated she had been in an automobile accident and had been out of the facility for some time. CNA 5 stated upon her return to the facility she was not tested prior to starting work again. CNA 5 stated she was not tested because she did not ask to be tested so it's on me, not the facility. I did not ask to be tested when I came back. 16. On 7/15/21 at 7:49 AM, an observation was made of Dietary Aide (DA) 1 serving breakfast in the 200 hallway. She was observed sanitizing her hands upon exiting each room. DA 1 then pushed the food cart to the 100 hallway. Before entering room [ROOM NUMBER], DA 1 put on a gown and gloves. She had a mask and eye protection on. She brought the meal into the resident room. Upon exiting, DA 1 put the disposable gown she was wearing on the chair outside of the room, where 2 other gowns were already lying across the chair. An interview was immediately conducted with DA 1. DA 1 stated the gown she put on the chair with the other gowns was one that she was going to use later. DA 1 was asked if anyone else would use her gown and she stated no, we know which ones are ours. DA 1 did not change her mask or eye protection, nor did she clean her eye protection upon exiting the room. DA 1 then proceeded to room [ROOM NUMBER] to deliver a meal tray. DA 1 put on a new gown and entered the room. Upon exiting room [ROOM NUMBER] she put her used gown over the PPE cart and went to get the resident a banana from the kitchen. When DA 1 returned, she put the used gown on again, donned new gloves and entered the room. When DA 1 exited the room again, she put her used gown over the PPE cart and rearranged the face shields by the door, then left. The PPE cart was observed to have no ABHR or disinfectant wipes. 17, On 7/15/21 at 8:10 AM, an observation was made of the PPE carts on the 100 hallway. The PPE cart next to room [ROOM NUMBER] still did not have any gowns or masks, nor was there any ABHR or disinfectant wipes on the cart. There was no garbage by the door. The PPE cart next to room [ROOM NUMBER] had masks and some gowns, but no ABHR and no disinfectant wipes, and no garbage can. 18. On 7/17/21 at 5:56 AM, an observation was made of RN 6 reporting to her work station. RN 6 was not wearing a mask. 19. On 7/17/21 at 6:05 AM, an observation was made of CNA 8 performing hand hygiene incorrectly. CNA 8 rinsed her hands in the sink without using soap, then she dried her hands and turned the water off. On 7/17/21 at 6:13 AM, another observation was made of CNA 8 performing hand hygiene incorrectly. CNA 8 rinsed her hands off under the water and dried them before turning off the water. 20. On 7/18/21 at 8:35 PM, an observation of RN 2 was made going into a resident room. RN 2 came out soon after and got some gloves off of the wall inside the door and re-entered the room. Upon exiting the room again, RN 2 took off the gloves and tucked them under her arm while she used ABHR. She then took the gloves back into her hands and walked toward the nurse's cart while rolling the used gloves in her hands. When she reached the nurse's cart she threw the gloves into the garbage by the cart. RN 2 then went over to the sink and rinsed her hands under the water, not using soap. RN 2 dried her hands and then turned off the water. At 8:39 PM, RN 2 exited the resident's room again, came into the hallway and donned a gown before going back into the resident's room. 21. On 7/18/21 at 8:40 PM, an observation was made of CNA 9 walking out of the 300 hallway with her mask below her chin. The mask stayed below her chin until she started talking with a resident, at which time she pulled it up over her nose. 22. On 7/18/21 at 8:44 PM, an observation was made of RN 2 coming out of a resident room with the equipment to take vital signs. RN 2 set the equipment down briefly, then picked it up and took it to another resident's room without sanitizing the equipment. Shortly after, she exited the room with gloves on, took the gloves off, went into the medication room and then went back to the resident room. 23. On 7/18/21 at 8:49 PM, an observation was made of CNA 9 improperly washing her hands at the sink. She put soap on her hands, then turned the water on, washed her hands and turned off the water before drying her hands. 24. On 7/18/21 at 8:51 PM, an observation was made of RN 2 exiting a resident room on the 400 hallway with the vitals equipment. RN 2 put the vitals equipment on the dining table and went to the sink to wash her hands. RN 2 then picked up the vitals equipment and took it to the medication room without cleaning it. 25. On 7/18/21 at 9:04 PM, an observation was made of CNA 9 opening the refrigerator in the dining area and took out some sliced meat from a bag with her bare hands. CNA 9 placed the meat on a paper towel and put it in the microwave for a few seconds. CNA 9 then took the meat out and carried it on the paper towel to the resident's room. Upon exiting the resident's room, CNA 9 went to the sink and washed her hands with soap and water. CNA 9 turned off the water and then dried her hands. 26. On 7/18/21 at 9:45 PM, CNA 9 was observed to enter a resident's room that had a sign on the door indicating that PPE should be worn when entering the resident room if the resident was using his Continuous Positive Air Pressure (CPAP) machine. At 9:55 PM when CNA 9 exited the resident's room an interview was conducted. CNA 9 stated she did not know what the sign was for. CNA 9 stated that she read through it. CNA 9 stated that it says to put PPE on, but nobody does. CNA 9 stated that the resident in that room put his CPAP machine on by himself and when the staff did rounds they checked to see if it is on correctly and working. Review of Centers for Disease Control and Prevention (CDC) guidance on Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes documented under Implement Universal Use of Personal Protective Equipment that .HCP should use PPE as described below: N95 respirator or equivalent or higher-level respirators should be used for All aerosol generating procedures The guidance was last updated on March 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#ppe Review of the CDC guidance on Clinical Questions about COVID-19: Questions and Answers, documented under Which procedures are considered aerosol generating procedures in healthcare setting?, stated Some procedures performed on patients are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing. These aerosol generating procedures (AGPs) potentially put healthcare personnel and others at an increased risk for pathogen exposure and infection. The guidance further identified non-invasive ventilation (e.g., BiPAP, CPAP) as AGPs. The guidance was last updated on March 4, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control-faq.html 27. On 7/21/21 at 7:05 AM, an observation was made of one of the facility's van drivers pulling away from the building with a resident in the back. The van driver was not wearing a mask.