**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure that all nursing staff possess the competencies and skills necessary to protect residents from exposure to COVID-19 during an outbreak by maintaining proper infection control practices, and to provide care to residents based on their individual medical care needs. The lack of staff training and competency in infection prevention and control placed the residents in immediate jeopardy of harm and/or death related to exposure to COVID-19. Findings include: 1. During observation on 10/9/2022 at approximately 9:15 PM a Licensed Nursing Assistant (LNA) assigned to 3 South was observed entering the room of a COVID-19 positive resident (room [ROOM NUMBER]) without applying a gown or gloves. A sign on the door indicated that Transmission Based Precautions should be followed when entering the room to include the donning of a gown and gloves. When asked if the residents in room [ROOM NUMBER] were Covid positive the LNA stated I don't know. When directed to the sign on the door that indicated the use of Personal Protective Equipment (PPE), the LNA confirmed that s/he should have used PPE when entering the room. The LNA was asked if anyone from the facility had shown her/him how and when to don PPE s/he stated No. 2. Per interview with 3 agency LNAs on 10/11/2022 at approximately 9:30 AM they had been assigned to the facility due to the Covid 19 outbreak. They all confirmed that they had not received any training prior to beginning their assignment nor had the facility assessed them for competency in proper use of PPE and hand hygiene. During interview on 10/13/2022 at 10:46 AM the staff educator confirmed that the facility had not provided the emergency staff with training related to infection control such as proper use of PPE nor were they assessed by the facility for the skills necessary to prevent the spread of COVID-19 prior to their assignment. Review of a list provided by the facility of emergency response staff, there were 15 emergency response staff which included 7 nurses and 8 LNAs scheduled during the current Covid outbreak. Of the 15 emergency responders the there was no evidence that they received training or were assessed for competency related to proper use of PPE and other infection control practices prior to assuming a resident assignment. 3. On 10/12/2022 at 12:00 PM a LNA who was observed entering and exiting a room while wearing the following PPE: a plastic uniform covering gown, gloves, N95 mask and eye protection. They identified themself as agency staff and admitted to not knowing when to wear PPE or how to dispose of it. Per interview with the RN (registered nurse) Staff Educator and the RN Infection Control Preventionist on 10/11/22 at 10:30 AM agency/contract staff were not evaluated or trained prior to assuming an assignment to ensure their competencies and skills to care for the facility's resident population during the current Covid-19 outbreak. Per the Infection Preventionist aside from getting them computer access we don't even know who they are. Per the Staff Educator who had been working on the unit and was relieved by one agency staff nurse, I reviewed the medication room location, door codes, personal protection equipment location, I did not review any competencies. On 10/13/2022 at 10:46 AM during a subsequent interview with the Staff Educator it was further clarified that when nursing staff are obtained through a staffing agency it is the expectation of the facility that all competencies are completed by the staffing agency. When asked to provide facility documentation to review required competencies for agency/contract staff, the facility contacted the staffing agency and obtained evidence of staff self-evaluations and check lists indicating training provided by the staffing agency. 4. Review of the Resident Roster Matrix and the nursing assignment sheet for the second floor, revealed that Resident #52 had a midline IV (Intravenous) for antibiotic administration related to a diagnosis of an infected wound. Review of the residents TAR (Treatment Administration Record) revealed that the resident had an order for a wound vac (a treatment that promotes vacuum-assisted closure of a wound) to her/his left thigh related to a community acquired stage 4 pressure ulcer that was surgically debrided. Interview on 10/10/22 at 10:05 AM with the LPN Rapid Response nurse who stated she had not received any training or competencies specific to the care and medication administration of the Midline IV or the wound vac. Review of Resident #52's 10/1/2022 - 10/31/22 MAR (Medication Administration Record) revealed the following orders: Biopatch on Midline, change with weekly and prn [as needed] dressing changes one time a day every 7 day(s) for IV Care with a start date of 10/01/2022 - this order was signed off as being done on 10/8/22; Ertapenem Sodium Solution Reconstituted 1 GM [gram] Use 1 gram intravenously one time a day for Infected Wound for 28 Days SASH [saline antibiotic saline heparin] FLUSH via MIDLINE with a start date of 10/01/2022 - this order was signed off as being done every day from 10/1/22 - 10/13/22; Heparin Lock Flush Solution 10 UNIT/ML [milliliter] (Heparin Lock Flush) Use 3 ml [milliliter] intravenously two times a day for SASH technique for 28 Days after administration of saline with a start date of 10/01/2022 - this order was signed off every day from 10/1/22 - 10/13/22 at 1000 hours and every evening from 10/1/22 - 10/5/22 and 10/7/22 - 10/8/22, and 10/10/22 - 10/12/22 at 2100 hours; IV: Change Midline Needless Connector one time a day every 7 day(s) for IV Care weekly with a start date of 10/1/2022 at 0900 hour - this order was signed off on 10/8/22 (Monday, 10/1/22 was not signed as being completed); Normal Saline Flush Solution Use 10 ml Intravenously one time a day for SASH/SAS [saline antibiotic saline] technique after med administration with a start date of 10/01/2022 at 1000 hour - this order was signed off every day from 10/1/22 - 10/13/22; Normal Saline Flush Solution Use 10 ml Intravenously one time a day for SASH/SAS technique prior to med administration with a start date of 10/01/2022 - this order was signed off every day at 0900 hours from 10/1/22 - 10/13/22. Review of Resident #52's 10/1/2022 - 10/31/2022 TAR revealed the following orders: Negative Pressure Wound Therapy To LLE SET Unit to 125 mmhg [millimeter of mercury] specify CONTINUOUSLY Cleanse with (NSS[Normal Sterile Saline]/Wound Cleanser/other) Place black foam into wound. Apply skin prep to intact skin around the wound Cover with occlusive dsg [dressing] and secure tubing per manufacturer guide as needed for Surgically Debrided Stage IV [4] PU [pressure ulcer] if NWPT [Negative Wound Pressure Therapy] needs to be turned off for any care, tests/procedures (Bathing, MRI, etc), or for transport; remove dsg entirely, cleanse wound (NSS/Skinintegrity [sic]) and apply hydrogel gauze and secure with ABD [abdominal pad] with a start date of 09/30/2022 at 1711 hours - this order was indicated as completed on 10/11/22. Negative Pressure Wound Therapy To LLE SET Unit to 125 mmhg [millimeter of mercury] specify CONTINUOUSLY Cleanse with (NSS[Normal Sterile Saline]/Wound Cleanser/other) Place black foam into wound. Apply skin prep to intact skin around the wound Cover with occlusive dsg and secure tubing per manufacturer guide every day shift every Mon, Wed, Fri for Debrided Stage IV PU prior to admission - with a start date of 10/03/2022 at 0700 - this order was indicated as completed on Monday 10/3/22 and Wednesday 10/5/22. There was no documentation to represent the the order was implemented/completed on 10/7/22, 10/10/22 or 10/12/22. Interview on 10/14/22 at 10:30 AM with the Infection Control Preventionist (ICP) regarding when and how nurses receive training and competencies to ensure residents are receiving the correct care and treatment of midline IV's and wound vacs. The ICP stated she/he could not find any competencies or policy and procedures regarding trainings for nurses specific to these specialty services. The ICP agreed that nurses are not typically trained to provide care of these specialties unless there was a need in the building. Since there is a wound vac and a midline in the building, he confirmed that training should have been provided as well as competencies on those who are providing care to the midline and the wound vac. There has been no training provided to any of the nurses, per the ICP. Interview on 10/14/22 at 1:05 PM with the Market President for Genesis, which is the owner/licensee of the facility, confirmed that there were no trainings or competencies provided to the facility staff or the emergency response staff for midline IV's or wound vacs. A Google search at www.cdc.gov under Infection Control, subtitled: Guidelines for the prevention of Intravascular Catheter-Related Infections, (2011) under section 1, titled, Education, training and staffing revealed the following guidance: '1. Education, Training and Staffing Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of documentation, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of COVID-19 and other communicable diseases and infections. The deficient practices related to lack of infection control measures specifically to source control and containment led to the determination that the residents who resided in the facility were in immediate jeopardy of harm and/or death. At the time that immediate jeopardy was called on 10/11/2022, review of the facility provided list of residents who had tested as COVID-19 positive since the beginning of the facility outbreak that began on 10/1/2022, there were 30 COVID-19 positive residents residing throughout the facility. During the outbreak, there had been three residents who died while COVID-19 positive. Findings include: 1. Per record review Resident # 7 was found by facility staff to be unresponsive on 10/5/2022 and was transferred to the local Emergency Department. Review of the hospital Emergency Department Report written on 10/5/2022 revealed that the admitting diagnoses were acute hypoxic respiratory failure, shock, and COVID-19. Review of Resident #7's [NAME] Certificate of Death states that the primary cause of death was COVID-19 infection. 2. Per observations made during the initial tour of the third floor (Unit 3 North and South) on 10/9/2022 at 8:45 PM, the 3 South Licensed Practical Nurse (LPN) was observed in the hall preparing medications for administration without eye protection. When asked how many of the residents on the South unit were positive for COVID-19 s/he stated, I think three However, there were 11 confirmed COVID-19 positive residents in her/his care. 3. On 10/9/2022 at approximately 9:15 PM a Licensed Nursing Assistant (LNA) assigned to 3 South was observed entering two COVID-19 positive resident's room (#316) without the required personal protective equipment (PPE), a gown or gloves. A sign on the door indicated that Transmission Based Precautions should be followed when entering the room of a COVID-19 positive resident to include the donning of a gown and gloves. When asked if the residents in room [ROOM NUMBER] were Covid positive the LNA stated I don't know. When directed to the sign on the door that indicated the use or PPE, the LNA confirmed that s/he should have used PPE when entering the room. The LNA was asked if anyone from the facility had shown her/him how and when to don PPE s/he stated No. On 10/9/2022 at approximately 9:20 PM the Director of Nursing (DNS) entered the facility. When approached by this surveyor s/he stated that s/he had not been feeling well and that s/he was going to take a COVID test. When this surveyor returned the DNS stated that she was positive for COVID and that s/he was trying to contact the Executive Director. The DNS remained in the facility in her/his office. S/he was there when the surveyors exited the facility at approximately 1:00AM. On 10/9/2022 at approximately 9:45 PM the Infection Control Preventionist (ICP) was informed of the infection control concerns related to the use of PPE (personal protective equipment) and the potential spread of COVID-19 that had been identified. S/He was asked if it was the expectation that staff wear a face shield or goggles as PPE when on the unit the ICP stated yes, it is. At approximately 10:15 s/he was seen on the unit talking with staff. 4. On 10/9/2022 at 10:20 PM an agency LNA assigned to the 3rd North and South Unit was observed exiting a room of a COVID-19 positive resident (room [ROOM NUMBER]), without removing the gown and gloves that s/he had been wearing in the room. The LNA walked down the hall with the contaminated gown and gloves from the COVID-19 positive room, to retrieve incontinence care products. S/he then returned walking back into the resident's room. When asked if s/he should have removed the gown and gloves and washed her hands when s/he exited the room s/he confirmed that s/he should have. 5. Review of the facility list of residents who were Covid-19 positive, provided by the ICP on 10/9/2022, revealed that 7 of the 12 residents residing on the 2nd floor (2 North) were COVID-19 positive, and one additional resident was currently admitted to the hospital with COVID-19. Of the 19 residents on the 3rd floor North Hall, 12 of them were COVID-19 positive. On the 3rd floor South Hall there were 20 residents total with 11 that were COVID-19 positive. On 10/10/2022 at 9:34 AM during interview with the facility Executive Director s/he confirmed the above COVID-19 cases and provided documentation (the facility Heat list On 10/11/2022 the list was updated to reflect two new COVID-19 positive residents on 2nd floor Unit 2). When informed of the multiple concerns identified throughout the facility on 10/9/2022, s/he stated we are in the middle of a COVID outbreak, and we have travelers and emergency staff working. Things were getting better until this outbreak happened. 6. Per observation on 10/10/22 at 12:15 PM, a LNA was seen in a resident's room (#317) delivering a lunch tray to a COVID-19 positive resident without wearing the required gown and gloves. Upon leaving the room, s/he did not perform any hand sanitization. Signage was posted on the wall outside the room indicating that Transmission-Based Precautions (TBP) were to be followed and that required Personal Protective Equipment (PPE) was to be worn prior to entering the room. When asked why s/he failed to wear the required PPE or wash hands or perform any hand sanitizing, s/he stated, I just didn't think about it, I'm agency. 7. The sanitizer mechanism located on the wall unit outside of room [ROOM NUMBER], on the left side of the North Hall, was empty and did not contain any hand cleaning product. room [ROOM NUMBER], a room which required the use of PPE for transition-based precautions, did not contain any hand sanitizer, and there was no receptacle available to place soiled PPE in prior to exiting the room, thus causing staff to exit the room and remove their gown in the receptacle in the hall, increasing the risk of spread. The missing sanitizer and receptacles were confirmed by housekeeping at the time they were found to need replacing. 8. Observation on 10/10/22 at 12:30 PM revealed an LNA in the resident hallway outside of room [ROOM NUMBER], wearing an N95 mask with the top elastic strap laying across the top of mask on her/his nose. At the time of this observation, the LNA was observed walking by the ICP, who acknowledged the LNA and failed to correct her/his inappropriate use of PPE. Interview on 10/10/22 at 12:55 PM with the ICP regarding the observation noted above. The ICP confirmed that the LNA was not wearing her/his PPE correctly, as the top elastic strap should be placed around her/his head as per the manufacturer's recommendations for use. 9. During observation on Unit 3 South on 10/11/2022 at 9:20AM an agency LNA was observed entering a Covid positive resident's room (#317) without the required person protective equipment (PPE) on, other than a face shield. When s/he exited the room s/he was asked if the resident in that room was positive for COVID-19 and if the resident was on precautions s/he stated yes, I should have put on a gown before I went in there. 10. During observation on Unit 3 South on 10/11/22 at 11:00 AM a LNA was seen entering a room (#324) of two COVID-19 positive residents without a protective gown and gloves and set up a meal tray for the resident. Upon exit of the room this surveyor asked the LNA if the residents in the room were positive for COVID or if they no longer required use of PPE, the LNA confirmed that they were COVID-19 positive, and s/he should have had it on. 11. Per observation on 10/12/22 at 12:00 PM an LNA entered a resident room on a COVID-19 positive unit on the third floor to respond to a call light. The facility was amid a Covid 19 outbreak and following transmission-based precautions to include all staff wearing N-95 masks and eye covering. When entering a resident room designated as having residents with Covid-19 by a sign at the door the additional infection control measure included donning a disposable plastic gown to protect clothing and protect residents from cross contamination. The LNA approached the room already dressed in PPE to include plastic clothes covering gown, gloves, an N-95 mask and a face shield, upon entering the room the LNA handled the call bell to turn it off, put his/her hand on the resident's arm and exited the room without removing the PPE or sanitizing his/her hands. The LNA confirmed he/she was unsure of when to Donn or doff his/her PPE. 12. Per observation on 10/12/2022 at 12:10 PM a trash receptacle inside room [ROOM NUMBER] designated as having Covid-19 positive residents was observed to be overflowing with disposable PPE with soiled linens on the floor next to it. This practice increases non-infected residents' risk of exposure to COVID-19. The unit LPN confirmed used PPE and linens did not belong on the floor. 13. Per observation at 10/12/2022 12:15 PM on the third floor in the empty resident dining area 2 LNA's were observed standing near the food service area having a conversation without wearing masks or eye protection, when questioned both LNA's confirmed they should be wearing N-95's and eye protection. On 10/12/2022 at approximately 12:50 PM the Regional Nurse Consultant confirmed that the staff should be wearing masks and eye protection when on the Unit. 14. Observation on 10/12/22 at 1:34 PM an LNA was observed coming out of resident room [ROOM NUMBER] which housed a resident who was COVID-19 positive. The LNA leaned out over the door threshold with a tray of dishes and attempted to flag down a staff member to come take the tray. Another LNA came and took the tray without gloves on and placed the tray inside the tray cart. She/he did not perform hand hygiene and immediately proceeded to room [ROOM NUMBER], where she/he was observed going into this room and no hand hygiene was performed before entering. room [ROOM NUMBER] does not house a COVID-19 positive resident at the time of this observation. The same LNA was observed coming out of room [ROOM NUMBER] with a tray that contained dishes, paper towels were observed as a barrier between the tray and her/his hands. She/he took the tray to the tray cart, placed the tray inside the cart and proceeded to the kitchenette entrance door where she/he entered the lock code on the code pad, opened the door to the kitchenette and entered. She/he did not perform hand hygiene between putting the tray from room [ROOM NUMBER] into the tray cart and entering the lock code on the kitchenette door. Interview on 10/12/22 at 1:38 PM with this above noted LNA, regarding the differences in her/his practice of picking up trays from a COVID-19 positive room vs. the non-COVID-19 positive room. She/he said it was not clear what she/he was supposed to be doing at that point. She/he stated that she/he had received some additional training regarding infection control practices, but it was quick and not entirely clear what the process is supposed to be for tray pick up. 15. On 10/13/22 at 9:40 AM a laundry person was noted putting a gown on and going into room [ROOM NUMBER] (not designated a covid positive room). She/he was interviewed on 10/13/22 at 9:42 AM regarding her/his practice of wearing a disposable gown into a non-covid room and she/he stated that the gowns and gloves are required in rooms that have signs on the doors. When asked if room [ROOM NUMBER] had a sign on the door and she/he didn't know. room [ROOM NUMBER] did not have a sign indicating the room was a precaution room. At 9:52 AM on 10/13/22 this same laundry staff was observed going into a COVID-19 positive resident's room (#213) with a few hangers of laundry and entered the room without a disposable gown or gloves. There was a sign outside room [ROOM NUMBER] indicating the requirement for the use of PPE. Interview with the laundry staff who confirmed that she/he should be wearing a disposable gown and gloves to enter any room that is indicated by a sign that the room is a precaution room. The laundry staff member did not see any sign - the sign was pointed out to the laundry staff, as well as the orange sign that was inside the door on the left side of the wall indicating the need to wear PPE, she/he stated that she/he was used to the sign being a little higher and that she/he did not see it. 16. Interview on 10/13/22 at 1:20 PM with the ICP regarding the training and competency of staff related to infection control and COVID-19 prevention, revealed that Genesis employees must do their annual mandatory educational training on the Vital Learn Electronic System. The ICP can run reports for tracking and states I do spot checks for extra training when we have unit managers. The ICP keeps records of education but not always. If agency staff are hired, when they come through the door, the ICP reviews their agency packet to see what's needed. Per the ICP We lag on this. Audits are conducted in the housekeeping/laundry department on a weekly basis. Observations of meal service are conducted weekly to observe hand hygiene, gloving, and wearing proper personal protective equipment (PPE) during delivery of meal trays to COVID positive rooms and dietary staff serving behind the line. Observations are done in the kitchen monthly to observe preparation of food, and cleanliness of kitchen. The ICP states audits have not been done in a while since we came back to Genesis [this occurred in July] and no evidence related to the above was provided. On 10/14/22 at 09:21 AM a list of examples of training/audits (minus the mandatory annual education which another nurse educator works on) was given to the ICP. This list included items such as cleansing of equipment (glucometer, mechanical lift, wheelchairs, et.), hand hygiene, COVID education, reporting breaches of the integrity of equipment. There is no documented evidence of audits related to infection control. The ICPs response at 11:52 AM when asked for the above information regarding any audits/education was No, I don't have any of this. Additional findings of non-compliance related to infection control that were identified during the survey include: 1. Observation in room [ROOM NUMBER], on 10/13/22 at 10:45 AM of Resident #52's midline IV was place in her/his left upper arm. A dressing was observed over the midline IV that was grayish in color and appeared dirty - the dressing was dated 9/29/22. Interview on 10/13/22 at 10:45 AM with the resident, who is A&Ox3 and stated that this dressing is the dressing that was put on at the hospital prior to her/his admission to this facility. This was reviewed with the nurse, who confirmed she/he was part of the emergency response team and was an LVN (Licensed Vocational Nurse). She/he confirmed that Resident #52's dressing appeared dirty, and she/he also confirmed the date on the dressing as being 9/29/22 and that this resident was admitted to this facility on 9/30/2022. 2. Observation on 10/9/22 at 8:40 PM of the second floor (Unit 2) revealed a long hallway with an open nurses station in the middle. The portion of hall to the left of the nurses station housed 12 residents, 7 of these residents were Covid-19 positive. One additional COVID-19 positive resident was currently admitted to the hospital. The portion of the hallway to the right of the nurses station was empty of residents. The hallway that was housing residents was observed to have a lot of debris on the floor, consisting of gloves, clear plastic wrappers, small pieces of paper, and long pieces of thin blue plastic, as well as dirt/sand. To the right side of the resident's hallway were 2 uncovered bins, 1 contained what appeared to be dirty gloves, and the other appeared to be empty. Interview on 10/9/22 at 8:35 PM with an LNA, who stated one bin is for trash and the other bin she/he believed was for linens. She/he stated, I do not know if they should be covered, this is only my third shift here and I don't know the policy for having the bins covered or uncovered. Interview on 10/9/22 at 8:50 PM with the nurse on duty who identified her/himself as an emergency response nurse, confirmed the hallway where resident rooms are located was littered with debris that consisted of gloves, pieces of blue plastic that she/he identified as pieces of the disposable gowns that are used to go into the rooms of residents who are on precautions due to a covid positive status, clear plastic wrappers, she/he identified as the packaging to protective eyewear, small pieces of paper and dirt. She/he stated that staff have not had time to clean on the unit and to her/his knowledge there are no housekeeping staff available. When asked about the uncovered bins in the resident's hallway, she/he stated they were for dirty linens and disposable items and thought they probably should be covered and labeled, she/he did not know the facility policy regarding bins in the hallway. 3. Observation on 10/9/22 at 9:08 PM of the tub/shower/whirlpool room revealed a shower area that was separated from a second shower area and a whirlpool tub area. Upon entering the tub/shower/whirlpool room to the left is a shower area that was noted to be dirty, the floor had many broken tiles, some missing pieces of tile, most of the grout that was between the remaining tiles was gray, black, or yellow in color, there was a washcloth that was draped over the shower bar at the right side of the shower wall. The washcloth appeared dirty, it was gray in color, it was hard/crusty and formed to the shower bar. To the right of the entrance door, across from the first shower area (referenced above) was a bariatric sized tub chair and upon it was an unfolded towel hanging off the left side of the shower chair. To the left of the tub/shower/whirlpool room, to the right of the first shower area was a second shower area that revealed a PVC (polyvinyl chloride) pipe shower bed with thick plastic foam covered mattress that was in disrepair. The headrest of the plastic foam covered mattress revealed 3 slits and a piece of clear plastic tape that exposed the foam mattress. Upon touch of the foam mattress, it was noted to be moist and with a little applied pressure a clear liquid oozed out of the foam mattress. On the floor of this second shower area was a gray plastic strap that is used to secure residents in the tub chair for transport and use of the whirlpool tub. To the right of this second shower area was a covered plastic bin and atop of the cover was a neatly folded [NAME] that had some pieces of white plastic type material that resembled drier sheets, and 2 face masks around and on top of the [NAME]. Interview on 10/9/22 at 9:30 PM with the emergency response nurse, who confirmed that the shower room was a mess, had several infection control issues as noted above, and that s/he would leave a note for the oncoming shift nurse to address these identified concerns. Interview on 10/9/22 at 1:00 AM with a facility staff nurse who had relieved the emergency response nurse, who stated she/he was not aware the equipment was in disrepair but confirmed the slits in the plastic covering of the mattress which exposed the foam mattress. She/he also confirmed that the tub/shower/whirlpool room was dirty, tiles were broken or missing. 4. Observation on 10/9/22 at 9:15 PM of the Clean Utility room revealed a small room that was dirty, the floor had empty syringe wrappers, a covered blood draw needle, trash can with what appeared to be a dried bouquet of flowers that was holding the cover of the trash can open, a box of N95 masks open to and laying on its side on a dusty metal shelf, 4 glass jars, 1 labeled BANDAGES and contained cotton balls and was covered with a metal cover, 1 labeled GAUZE that was empty and was covered with a metal cover, a second glass jar that was labeled GAUZE that was full of 2x2 gauze squares and was not covered , and 1 labeled APPLICATORS that was full of tongue depressor sticks, that was not covered. 5. Observation on 10/9/22 at 9:30 of the 2nd floor kitchenette and dining area revealed a full trash can, dishes with food on trays, a refrigerator with dirty shelves and inside doors, a large mouse trap under a commercial utility shelving unit, a rat trap between the kitchenette wall and the refrigerator of the serving area, dried food on counters, doors, and the microwave. The bottom part of the doorway and floor into the kitchenette had a thick black substance that was also present in the spaces between the wood floor at the doorway. The 3 compartments in the steam table each had dirty water in them with what appeared to be food particles and debris. 6. Observation on 10/9/22 at 11:53 PM the survey team did a walkthrough of the facility's main kitchen with the ICP, the following issues were observed: a.) Ice scoop was inside the ice machine with the handle of the scoop exposed to the ice. b.) A box of Instant Food Thickener was observed in an open plastic bag and set inside a box that was labeled by the manufacturer as the contained food product. c.) The commercial blender was dirty with crumbs and debris around the blender motor and on the table the equipment was sitting on d.) The food puree machine pitcher was cracked all the way around the bottom of the container just above where the blades are located inside the pitcher e.) An air conditioner was observed in one of the windows across from the table where the mixer, puree machine and various other equipment for food prep were stored. The air conditioner was noted to have a thick and sticky substance on the front grill where the cool air comes out of the conditioner and into the environment. Within this thick and sticky substance was noted some hair, dust, and insects. In front of the air conditioner was a spray can of non-stick spray that was without the cover, and beside that spray can of non-stick spray was a second can of the same product, also without a cap. f.) An opened box of cornstarch was noted on the counter next to the air conditioner, in front of three, 4-inch binders - 1 labeled Breakfast, 1 labeled Lunch, and 1 labeled Dinner g.) On a 3-tiered utility rack, it was noted the top and middle rack housed 18 plastic containers of spices on the top rack of which 6 were open to the environment h.) A commercial sized mixer was noted on a table and was covered with a black trash bag. Upon removing the black trash bag to view the mixer, it was noted to be dirty - the wire guard, the mixing bowl, and underneath the mixer above where the mixing bowl would sit were all spattered with dried material, as was the table the mixer sat on. i.) A commercial can opener was attached to a table and was noted to have a thick sticky red substance on the blade of the can opener and the bracket that holds the removable can opener had a thick black and yellow sticky substance with what appeared to be hair. j.) A large refrigerator was observed and upon opening the doors, a full container/pitcher with a light-yellow liquid inside, revealed a tag and upon the tag was written Orange - Use by 9/16. A full second container/pitcher was noted with a tangerine-colored liquid inside and there was no tag on the container. k.) A steam table with 3 separate sections were noted to be full of hot dirty water l.) A sideboard attached to the steam table was visibly dirty with a white greasy substance m.) In the corner of the kitchen, behind the 2nd entrance/exit door was a sticky mouse trap that was covered with various sizes of black spots. Upon closer inspection these black spots were ants, spiders, flies (large and small), and various other insects and dirt. To the left of the sticky trap was a large mousetrap. n.) In front of the above-mentioned sticky trap was a substance that was dark brown with variations of brown, yellow, black, and red. This substance appeared wet and was noted to be sitting in an area that was wet with a clear grayish color that extended from the sticky trap and mouse trap and encompassed this unidentified brown object. The object could not be identified. This was shown to the ICP person who stated that she/he did not know what this brown object was as I'm not a biologist but I can tell you that's not mouse shit or rat shit. o.) The grout in the kitchen was noted to be black and crusty over most parts of the floor. p.) A large commercial utility rack revealed stacked square and round plastic containers and there were moisture/water droplets between the layers of stacked containers. q.) A second large commercial utility rack revealed stacked square metal containers and there were moisture/water droplets between the layers of stacked containers. r.) A steam machine was noted to be wet inside on the sides and top of the machine. s.) Under the oven/stove was a thick sticky and greasy substance black in color, that extended under a utility rack and a light-yellow substance was noted dripping down the front of the stove on the oven door and was pooling on the lip at the bottom of the stove/oven. t.) The inside of the oven was noted to have a large thick pool of black and red gel like substance on the inside base of the oven. At the time of the kitchen walk-through, the ICP was present for the entire walk-through, and as issues presented, they were shown and confirmed by the ICP person. The ICP confirmed that it is the expectation that the dietary staff clean the kitchen prior to leaving for the night, especially when managing an identified issue with rodents. 7. Observation on 10/10/22 at 8:45 AM in the kitchen revealed a staff member in the dish room with her/his mask under her/his chin. Interview with this staff person regarding her/his role was in the kitchen, she/he pulled her/his mask up under her/his nose. The Food Service Director (FSD) and her/his supervisor were present at the time of this observation and interview with the staff, and when ask if the staff member was wearing her/his mask/PPE (Personal Protective Equipment) correctly, the Food Service Director Supervisor confirmed she/he was not and she/he spoke to the staff member telling her/him that she/he needed to wear her/his mask correctly. The staff member at that time pulled her/his mask up over her/his nose demonstrating appropriate PPE use at that time. A walk-through of the kitchen with the Food Service Director and her/his supervisor, the above findings from 10/9/22 were discussed and confirmed by the FSD's supervisor. 8. Observation on 10/10/22 at 12:33 PM it was noted that a tray with dishes, utensils, and napkins were placed on top of the infection control cart outside of room [ROOM NUMBER]. This was brought to the attention of the Infection Control Preventionist (ICP) on 10/10/22 at 1:32 PM. The ICP confirmed the tray atop the infection control cart and stated that nothing should be placed on top of the infection control carts as these carts are considered a clean surface. 9. On 10/11/22 at 08:45AM observation of the 3rd floor unit, revealed a door across from nurse station which is labeled clean utility with a key code pad. This same room is also labeled as such on the facility map. This surveyor asked a Licensed Nurse Assistant (LNA) what the door code was. This LNA knew the door code and stated, it's the same for all other utility rooms and proceeded to let two surveyors in. Upon entrance, the small room appeared to be a medication storage area rather than a Clean Utility room. It contained over the counter medications in a cabinet, a blue plastic tote full of medications on the floor, Lab supplies, syringes with needles (box of 26G x1/2 syringe) in a cabinet, and other supplies. The utility room was filthy with debris on the floor and a dark quarter sized area of sticky substance. The LNA confirmed that the floor was dirty, and that s/he did not ever really need anything in here. 10. Observation on 10/11/22 at 01:27 PM of the laundry department, contains laundry carts, for the transport of soiled linens. One cart was noted to be unclean with various items of built-up debris such as used gloves, food particles, paper products, a hair tie, a meal ticket, and other unrecognizable particles. There were layers of lint, dust and debris under a wooden pallet that contains large buckets of washing machine chemicals. Interview at the time of observation with a laundry attendant, confirmed the appearance of the dirty laundry cart and dirt/grime build up under the wooden pallet. Another observation of the laundry department and interview with the Infection Control Preventionist (ICP) was conducted the same afternoon on 10/11/22 at 4:15PM. The ICP confirmed that the laundry cart and under the wood pallet near the washing machines were filthy. The ICP confirmed that cleaning visible soiled areas and disinfecting linen carts had not been done. Observation and interview on 10/11/22 at 2:17PM with a housekeeper confirmed that the floor was dirty and s/he does usually wash the clean Utility floor but has been out for two weeks. This housekeeper revealed that all of 3rd floor is her/his cleaning responsibility. S/he stated that s/he had never had a nurse observe while [s/he] cleans the floor to this room and was not aware that [s/he] should not enter due to it containing medications but did know the code. 11. Observation of the 3rd floor Clean Utility room and Interview on 10/11/22 at 4:45PM with the ICP confirmed that the floor was dirty and that the room was clearly labeled Clean Utility outside the door and on the facility map but was being used as a medication room which did not contain such items as one would expect to have in a clean utility room. For example, Linens. The ICP confirmed that this room had not been cleaned in a while and that only nurses should have access. A day later, on the afternoon of 10/12/22 at 2:30PM, Observation and interview with a Genesis Nurse Consultant confirmed the room was not being used as a Clean Utility and indeed did not contain linens as one would expect, and the floor was still dirty. 12. Observation on 10/13/22 upon exiting room [ROOM NUMBER] at 10:58 AM, it was noted that the mattress on the bed next to the door in room [ROOM NUMBER] had been stripped of linens leaving just the mattress and at the foot of the mattress there was an area of approximately 2-foot diameter that showed significant wear to the fabric covering the mattress. This area was where the manufacturer had stamped on the mattress the name of the company, mattress type and various other unreadable information - most of this manufacturer stamp was gone. The integrity of the mattress is poor and unable to be cleaned adequately. The nurse, who was exiting the room at the same time confirmed the appearance of this mattress and she/he stated that the mattress was not usable and needed to be replaced. This was brought to the attention of the Clinical Quality Consultant and the Market President on 10/13/22 at approximately 11:15 AM.