**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, family interview, clinical record review, and facility document review, the facility staff failed to ensure implementation of infection control practices and precautions to prevent the spread of infection and communicable disease during an identified occurence of a respiratory illness. A facility staff member entered a resident room that was positive for the flu with no PPE (personal protective equipment) in place; failed to perform any hand hygiene prior to leaving this room; failed to implement the requirment for droplet precautions; failed to ensure the staff and surveyor were aware of who had the flu; and failed to ensure a visitor was given education in regards to wearing PPE when visiting a resident on contact isolation for 6 of 25 residents (Residents #15, #19, #32, #44, #45, and #59). The scope and severity was originally cited at Immediate Jeopardy, Level IV isolated and was reduced to a Level II isolated after the facility was cleared of Immediate Jeopardy. The interim Administrator, interim DON (director of nursing), RVPO (regional vice president of operations), and RDCS (regional director of clinical services) were notified on 03/01/2020 that the extended survey process had begun at 10:20 a.m., as the survey team had identified Immediate Jeopardy in the area of Infection Control. The findings included: A facility staff entered a room of a resident who was positive for type A flu with no PPE in place and after speaking with this resident walked to the roommate and spoke with them, exited the room without performing any hand hygiene, failed to identify a resident who had the flu to the surveyor which resulted in the surveyor entering the room and speaking with both residents in this room with no PPE in place, failed to ensure all direct care staff were aware of residents who were positive for the flu, and failed to ensure a visitor was given education in regards to visiting a resident on contact isolation for ESBL (extended spectrum beta-lactamases) a type of UTI (urinary tract infection). Per the CDC (Centers for Disease Control and Prevention) website. Key Facts About Influenza (Flu) .Flu is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs. It can cause mild to severe illness, and at times can lead to death. The best way to prevent flu is by getting a flu vaccine each year .Flu usually comes on suddenly. People who have the flu often feel some or all of these symptoms fever or feeling feverish/chills (It's important to note that not everyone with flu will have a fever) .Period of contagiousness: You may be able to spread flu to someone else before you know you are sick, as well as while you are sick. People with flu are most contagious in the first 3-4 days after their illness begins. Some otherwise healthy adults may be able to infect others beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick. Some people especially young children and people with weakened immune systems, might be able to infect others for an even longer time. Complications of the flu can include bacterial pneumonia .worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes . Tamiflu insert: Indications and usage treatment of acute, uncomplicated influenza A and B in patients 2 weeks of age and older who have been symptomatic for no more than 48 hours. Prophylaxis (action taken to prevent disease) of influenza A and B. Information regarding residents included in this citation: 1. Resident #15's face sheet included the diagnoses, Alzheimer's disease, age related cognitive decline, hypertension, and dysphagia. Section C (cognitive patterns) of the residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/20/2019 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. Section G (functional status) was coded 0/0 in the areas of transfer, bed mobility, walk in room/corridor and toileting, indicating the resident was independent. The residents clinical record included a physicians order for tamiflu 30 mg two times a day for 10 administrations. This medication was started on 02/28/2020 at 10:00 a.m. The resident did not receive a flu shot Consent Refused. The surveyor did not find any progress notes to indicate this resident was symptomatic for the flu. During the observations of this resident, no problems were observed. 2. Resident #19's face sheet included the diagnoses essential hypertension, chronic diastolic congestive heart failure, anemia, unspecified convulsions, and chronic obstructive pulmonary disease. Section C of the residents quarterly MDS assessment with an ARD of 12/28/2019 included a BIMS score of 12 out of a possible 15 points. Section G (functional status) was coded 0/0 in the areas of bed mobility, transfers, walk in room/corridor to indicate the resident was independent in these areas. Toilet use was coded 1/1 limited assistance with setup help only. The residents clinical record included a Discharge summary dated [DATE] that indicated this resident was admitted to the hospital on [DATE] with influenza type A. The resident was readmitted to the facility on [DATE]. The discharge summary included information to indicate the resident received oseltamivir (taniflu) at the hospital. Upon readmit to the facility LPN #1 documented an admission date and time of 02/28/2020 at 7:15 a.m. with a diagnosis of Flu B and cough (discharge summary from the hospital reads influenza type A). The resident's current physicians orders included an order for Tamiflu .30 mg by mouth two times a day for Flu B (+) until 03/02/2020. The order date was documented as 02/28/2020 with a start date of 02/29/2020. The tamiflu was started on 02/29/2020 at 10:00 a.m. Flu shot administered on 10/01/2019. This resident was not on isolation. Resident #19's care plan included the focus area resident positive for flu with hypoxia sent to emergency department. Order transcribed on 03/01/2020 at 7:25 p.m. for Droplet isolation for influenza + A. Until completes tamiflu on 3/2/2020. D/C (discontinue) isolation on 3/3/2020. The isolation was started after the surveyors entered the building and identified that this resident was not on precautions. Resident #19 was observed by the surveyor to have a non-productive cough. Resident #19 verbalized to the surveyor that they were feeling better. Resident #15 and #19 were roommates. Numerous observations were made of these residents and the surveyor never observed the privacy curtain between these 2 residents to be shut. The residents also shared a bathroom. The bathroom door was located on Resident #19's side of the room. 3. Resident #32's clinical record included the diagnoses, chronic obstructive pulmonary disease, essential hypertension, and chronic pain syndrome. Section C of the Residents quarterly MDS assessment with an ARD of 01/16/2020 included a BIMS score of 15 out of a possible 15 points. A progress note documented on 02/27/2020 revealed that the resident had a temperature of 99.5 continued to feel bad, has croupy cough, wheezing throughout lung fields, productive cough with greenish sputum. Flu swab completed. The clinical record included a negative test screen for the flu type A and B dated 02/27/2020. The facility documented they notified the residents daughter of confirmed flu cases in the facility and that all residents were to be treated with tamiflu. Flu shot administered on 10/01/2019. The facility provided the surveyor with order summary report for all the residents in the facility that were on tamiflu. Resident #32 had an order for tamiflu 75 mg two times a day. Order date 02/27/2020 start date 02/28/2020. This resident denied feeling sick when observed by the surveyor. 4. Resident #44's face sheet included the diagnoses sepsis due to escherichia coli, chronic obstructive pulmonary disease, type 2 diabetes, and chronic diastolic heart failure. Section C of the resident's admission MDS assessment with an ARD of 01/31/2020 included a BIMS summary score of 11 out of a possible 15 points. Resident #44's care plan included the focus area admitted after acute care stay for sepsis related to ecoli infection UTI (urinary tract infection) ESBL in urine. Interventions included contact isolation as ordered. The facility provided the surveyor with a copy of a lab report indicating the resident tested positive for ESBL on 02/25/2020. The clinical record included an order for Tamiflu .30 mg by mouth one time a day for flu prophylaxis for 5 administrations. The order date was documented as 02/27/2020 with a start date of 02/28/2020. The tamiflu was started on 02/28/2020 at 10:00 a.m.; the resident was also receiving the antibiotic doxycycline (02/28/2020) 100 mg two times a day. Flu shot administered on 10/22/2019. Order for contact isolation (02/27/2020) for ESBL in urine. 5. Resident #45's face sheet included the diagnoses paroxysmal atrial fibrillation, diastolic congestive heart failure, and anemia. Section C of the resident's annual MDS assessment with an ARD of 02/05/2020 included a BIMS score of 12 out of a possible 15 points. This resident had an order for tamiflu 75 mg two times day. Order date 02/27/2020 and a start date of 02/28/2020. This medication was started on 02/28/2020. Flu shot administered on 10/01/2019. This resident was in the same room as Resident #59 who tested positive for the flu. This resident voiced no concerns to the surveyor to indicate they felt sick. 6. Resident #59's face sheet included the diagnoses age related osteoporosis, hypothyroidism, Alzheimer's disease, and unspecified dementia. Section C of the residents quarterly MDS assessment with an ARD of 02/21/2020 included a BIMS score of 3 out of a possible 15 points. Resident #59's care plan included the focus area positive for type A flu. Interventions included droplet isolation as ordered. The residents clinical record included a lab test dated (02/27/2020) stating the resident was positive for type A flu. Flu shot administered on 10/01/2019. The facility provided the surveyor with an order summary report for active orders as of 03/01/2020. This order summary did not include a physicians order for droplet isolation. It did include an order for Tamiflu .Give 75 mg by mouth two times a day for Flu (+) A for 5 days. This order was dated 02/27/2020 with a start date of 02/28/2020. A review of the eMARs indicated this medication was started on 02/28/2020 at 9:00 a.m. The clinical record included a progress note to indicate the family was notified on 02/27/2020 that the resident had a confirmed case of the flu and would be treated with tamiflu. Three surveyors arrived at the facility on 03/01/2020 (Sunday) at approximately 8:25 a.m. Upon arrival, the surveyors observed a sign posted on the outside of the door reflecting the presence of the flu and requesting visitors to please refrain from visiting. This surveyor entered the front of the building and motioned for a staff person to come outside. This staff person was LPN (licensed practical nurse) #1. Upon exiting the building this staff person stated, they had 3 residents in the facility who had the flu. The survey team leader placed a call to the long-term care supervisor and permission was given to enter the building. The surveyors entered the building at 8:30 a.m. The census in this 60-bed facility was 58 indicating the facility had 2 empty beds. 03/01/20 at 8:39 a.m., the surveyor entered the facility kitchen. The surveyor observed 2 dietary staff in the kitchen dietary person #1 and #2. These staff stated they were not currently using the dining room due to the flu. When asked the procedure for residents in regards to dishes, dietary person #1 stated we do not know who has the flu and no one had advised us on what to do. The surveyor exited the kitchen and began initial tour on the 200 hall. This surveyor observed 3 carts outside resident rooms on 200 hall and proceeded down this hallway. The surveyor observed a cart with PPE located outside of a private room which was not assigned to this surveyor. This resident was identified to surveyor #2 as being on contact isolation for ESBL. 1. Residents #59 and #45: Upon approaching Resident #s 59 and 45's room , the surveyor observed a plastic cart that contained PPE and a sign indicating this resident was on droplet precautions. This sign read, STOP DROPLET PRECAUTIONS Visitors must report to Nursing Station before entering. There was a check mark beside these 3 statements Perform hand hygiene before entering and before leaving room, Wear mask when entering room Visitors and health care workers, and Dietary may not enter. The surveyor observed a staff person in this room with no PPE in place. The surveyor observed this staff person to speak to the resident (Resident #59) in the bed by the window (bed B), walk from this bed to the bed by the door (bed A) and speak with this resident (Resident #45). This staff person exited the room without performing any hand hygiene. Upon exiting the room, the staff person identified themselves as being the environmental service director. This staff person acknowledged they did not have any PPE in place and stated I probably should have put on a gown and mask. This staff person stated the resident in the bed A did not have the flu but the resident in the bed B did have the flu. When asked who they had spoken to in the room. This staff person stated they had spoken with the resident in bed B and the went up to the bedside of the roommate and spoke with them (bed A). This staff person was later identified to the surveyor as being the manager on duty. The surveyor did not enter the room at this time. 2. The surveyor continued initial tour and upon approaching Resident #s 32 and 44's room, the surveyor observed a red stop sign on the door frame that stated check with nurse before entering. Outside of this room, the surveyor observed a cart containing PPE. The surveyor did not enter the room at this time. CNA #1 was observed exiting the residents' room and when asked about PPE stated, they were unsure if you had to have PPE on when picking up food trays. 3, Residents #15 and #19. The surveyor continued with initial tour and entered Resident #s 15 and 19's room. CNA (certified nursing assistant) #1 entered the room also and stated I think I am following you. This CNA did not have any PPE in place and there was no signage or PPE outside the room to indicate anyone in this room was on precautions. The surveyor spoke with both residents in this room and exited the room. 03/01/2020 9:27 a.m., LPN #2 verbalized to the surveyor that Resident #19 had been readmitted from the hospital and they were unsure if they had the flu. The surveyor requested LPN #2 to check the EHR (electronic health record) for the current diagnosis. LPN #2 was unsure of where to find this information was told by the surveyor to check the discharge summary. The discharge summary located in the EHR revealed that Resident #19 had been readmitted to the facility on [DATE]. This discharge summary revealed that Resident #19 had been admitted to the hospital on [DATE] with type A influenza and was placed on respiratory precautions. The resident was discharged back to the facility on [DATE] the discharge diagnosis were documented as influenza, AKI (acute kidney injury), and acute hypoxic respiratory failure resolved. The surveyor approached LPN #2 and asked for clarification regarding the residents on the hall. LPN #2 stated 2 Residents had the flu and identified these as being the resident in Resident #59's bed and Resident #32's bed. The surveyor was unsure who had exactly had the flu on this hallway after these observations and interviews. 03/01/2020 9:25 a.m., CNA #2 verbalized to the surveyor that no one on 100 hall had the flu. Then stated Resident #19 and Resident #59 had the flu and they thought Resident #32 was showing symptoms. 03/01/2020 9:32 a.m., RN (registered nurse) #1 was asked who had the flu and stated she was told one person had the flu but was not given the name of who this person was. RN #1 was from a sister facility. 03/01/2020 9:34 a.m., housekeeper #5 was asked how you would determine if someone was on isolation. Housekeeper #5 stated the way they knew is they would look at the door signs and the cart outside the room that contained PPE. 03/01/2020 9:35 a.m., LPN #1 stated identified Resident #19 and Resident #59 as having the flu. 03/01/2020 9:37 a.m., the interim DON (director of nursing) verbalized to the survey team that Resident #19 and #59 had the flu. The interim DON was notified that the environmental service director was in Resident #59's room with no PPE in place, that resident #19 did not have any signage or PPE outside their room, that the dietary department had no knowledge of who had the flu, and that the surveyor had entered Resident #s 15 and 19's room with no knowledge that a resident in this room had the flu. 03/01/2020 10:07 a.m., the surveyor and the interim DON walked to room Resident #19's room. No signage observed on door. No PPE in hallway outside this room. 03/02/2020 9:47 a.m., CNA #3, stated I know Resident #19 did have the flu, Resident #59 has the flu, and Resident #32 was showing signs of the flu. CNA #3 stated she knew to dress out when she saw precautions outside the room. CNA #3 stated she had not worked this hall (200) since Resident #19 had been re-admitted . 03/02/2020 9:47 a.m., LPN #2 now stated Resident #59 and Resident #19 had the flu and that was all they were aware of. When asked why Resident #19 did not have any precautions outside their room LPN #2 stated she did not know. 03/01/2020 9:53 a.m., interview with laundry person #1 stated they did not know who in particular had the flu. However, knew the hall was 200 hall. An observation of the laundry room was completed with no problems identified. 03/01/2020 10:12 a.m., CNA #9 stated she had been called in to work and stated she had worked on Friday 02/28/2020. When asked who had the flu she named Resident #19 and no one else that they were aware of. CNA #9 added they might have told them and it might have slipped their mind. 03/01/2020 10:20 a.m., supervisor made aware and IJ (Intermediate Jeopardy) was called. The interim DON, DON from sister facility, RN #1, and LPN #3 were notified of same. During this meeting the interim DON verbalized to the survey team that Resident #32 did not have the flu. The interim DON was asked their expectation of staff being aware of who had the flu. The interim DON stated of course the staff should know who has the flu and it should be communicated during report from the CNA and the nurse. The interim DON added dietary should be aware and it was discussed in the morning meeting (stand up meeting) on Friday. LPN #3 added that they were aware Resident #19 was positive for the flu in the meeting on Friday. Policies regarding infection control. Isolation Precautions/Isolation Meals. Date reviewed 06/03/2019 DON/Infection control nurse or designee will determine if isolation precautions are necessary .The combination of hot water and/or detergent used in dishwashers is sufficient to decontaminate dishware and eating utensils. No special precautions are needed for dishware such as use of disposable items. Infection Control-General. Date reviewed 07/19/2019 PURPOSE: To protect residents and staff by preventing the spread of infection .Staff shall by knowledgeable and adhere to all department and facility infection control policies. Staff shall by knowledgeable of Standard and Transmission-Based Precautions . Infection Prevention and Control Program for Employees, Contract Staff and volunteers. Date reviewed 07/19/2019. It is the policy of ______ Healthcare facilities to maintain an organized, effective facility-wide program designed to systematically prevent, identify, and control and reduce the risk of acquiring and transmitting infections among employees, volunteers, and contract healthcare workers; to conduct surveillance of communicable disease and infectious outbreaks, and employee health. This program involves the collaboration of many programs and services within the facility and is designed to meet the intent of regulatory guidance .In collaboration with the Director of Nursing and the facility Medical Director, the infection Preventionist has the authority to institute emergency medical and or administrative action when there is danger or threat to residents and/or personnel regarding infection prevention/control matters. This includes but may not be limited to: Isolate or cohort residents with known or suspected infectious diseases in an effort to reduce the risk of disease transmission .Infection Preventionist, in collaboration with other direct resident care providers, provides education to residents, families and volunteers as appropriate . Hand Washing Date revised August 2015. POLICY: Hand washing is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing . Transmission Based Precautions revised date April 2016.Contact Precautions-intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment .Gloves-whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident. Gowns when anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the resident .Room placement-single room when available .Droplet Precautions-intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions .A single patient room is preferred for residents who require Droplet Precautions .A mask is worn for close contact with infectious resident. Gloves, gown, eye protection are worn adhering to Standard Precaution guidelines .Resident and/or responsible party will be notified of the reasons for and education on Transmission-Based Precautions. A sign will be placed on the doorframe of the resident's room indicating that visitors should stop a Nurses Station before entering. Staff should educate visitors regarding donning appropriate Personal Protection Equipment while adhering to the resident's right for privacy protection . 03/01/2020 10:37 a.m., the dietary manager verbalized to the surveyor that Resident #19 and #59 had the flu and that there was nothing special required when the food trays went to the hall. However, the food trays should be wrapped with a trash bag when it came back to dietary and the tray is held until the end of the run. The dietary manager stated they did not say who had the flu in dietary due to HIPAA (privacy laws) and they had not returned to the dietary department after the morning meeting on Friday. The surveyor did observe the food tray from Resident #s 45 and 59's room being handed from a staff in the room to a staff outside the room on 03/03/2020 at 8:37 a.m. This tray was wrapped in what appeared to be a plastic bag. 03/01/2020 10:47 a.m., interim Administrator notified that the environmental service director was observed in Resident #s 45 and 59's room and Resident #59 was positive for the flu with no PPE in place and no hand hygiene was completed prior to leaving the room. The staff gave conflicting information over who had the flu, no signage of PPE outside of Resident #s 15 and 19'room when a resident in this room had been re-admitted with the flu (Resident #19) and Intermediate Jeopardy had been called at 10:20 a.m. 03/01/2020 10:59 a.m., CNA #1, in regards to Resident #19, acknowledged she was in the room with no PPE in place and stated she honestly did not know the resident had the flu and she had just given them a bath on Friday. 03/01/2020 2:22 p.m., RVPO, RDCS, and the interim Administrator were notified of the issues regarding infection control. 03/01/2020 4:00 p.m., LPN #2 verbalized to the surveyor that she had administered Tylenol to Resident #59 for a tympanic (ear) temperature of 100.2 and aches and pain. Stating the resident stated she was aching/hurting all over. 03/01/2020 4:44 p.m., interim Administrator, RDCS, and the RVPO. Stated they had a kardex that was printed weekly from the care plan that staff could refer to. Resident #59's kardex had last been updated on 02/26/2020 and did not include any information regarding the resident being positive for the flu. 03/01/2020 Abatement plan provided to the survey team. 1. On 3/1/2020, at 1105 administrator was notified of IJ at 1020 for improper isolation signage for Flu, staff in room with isolation of Flu while not properly wearing PPE, and Staff not being aware of residents with the Flu. Resident had signage implemented immediately and all appropriate PPE placed outside of room. One on one education with Environmental Services Director on Isolation, Hand Hygiene, Proper Dawning and Doffing of PPE. 2. On 3/1/2020, the facility staff conducted assessment following Mcgeers guidelines on current resident to ensure no other signs and symptoms for new cases of the Flu. No additional signs and symptoms have been noticed for new cases of the Flu. No additional signs and symptoms have been noticed. Current residents have the potential to be affected by this noncompliance practice. 3. The facility Director of Nursing and designees immediately began to provide education for current staff regarding Isolation., Hand Hygiene, Proper Dawning and Doffing of PPE. Current staff will be educated prior to starting their next assignment on education. All remaining staff members not currently working, will not be permitted to work until education is received. On 3/1/2020, the Regional Director of Clinical Services provided education to the Director of Nursing and Nursing Home Administrator on Isolation, Hand Hygiene, Proper Dawning and Doffing of PPE. Education will be applied to New Hire Packets. 4. DON or designee will complete observation rounds daily to ensure Isolation signage and proper dawning and Doffing of PPE. Results of rounds will be brought to monthly Quality Assurance and Performance Improvement (QAPI) meetings for review and revision as necessary for the next 3 months. 5. Person responsible: NHA, ________ (name omitted) Action Complete Date March 1, 2020 6. Date of Correction: March 1, 2020 03/01/2020 6:15 p.m., spoke with supervisor regarding the abating of IJ. The IJ was abated at 6:15 p.m. Interim Administrator, RDCS, and the RVPO were notified of same. 03/02/2020 8:48 a.m., new admission Resident #211 was identified by surveyor #2 as not currently being on tamiflu. Interim DON and Administrator notified of same. Upon returning to the conference room, the interim Administrator verbalized to the surveyors that this resident was not admitted with any signs and symptoms of the flu and they were put on the admissions rounds to be seen on Monday (today). 03/02/2020 9:23 a.m., the surveyor entered Resident #44's room. This resident was on contact isolation for ESBL in their urine. The surveyor dressed out in a gown, mask, and gloves provided in plastic cart directly outside the resident's room. The surveyor observed a female person sitting in a chair at the bottom of the bed with a mask in place. No other PPE was observed. This person identified themselves as Resident 44's family. The Surveyor introduced themselves and then pointed to the PPE and asked if anyone had explained all of this to them. This family member stated no one had explained to them the reason for the isolation/PPE and she had also vistied with the resident yesterday at the facility. Two staff noted to be exiting the room when the surveyor entered. Upon removal of the PPE the surveyor was unable to locate the container for the used PPE. The family member moved a curtain and showed the surveyor the container. The family member was sitting within inches of the container. Interim Administrator and the RVPO were made aware. The Interim Administrator left the conference to speak with the family member and when they returned stated he had spoken with the family member and the family member told him that they knew the resident was on isolation but she thought as long as she was not touching anything it was okay. The interim administrator stated they were educating the family member now and let them know as soon as they crossed the threshold it should be implemented. 3/02/2020 9:34 a.m., interim Administrator provided the survey team with 2 in-service forms dated 03/02/20 titled Isolation Procedures Donning/Doffing PPE-When to Use indicating that they had educated/in-service the family member in the room and the family member voiced understanding with no questions. The facility had also in-serviced 2 other family members of others that were visiting in the facility at that time. 03/02/2020 9:42 a.m., LPN #4, stated the family member asked if she had to wear a gown and she told them she didn't have to wear it if she wasn't doing patient care. I did not think she had to wear one. Interim Administrator and the RVPO made aware of same. 03/02/2020 9:47 a.m., Interim Administrator verbalized to the surveyor that they had spoken with LPN #4 and they would do one on one education with them and do a verbal write up. The interim Administrator stated the precautions are for everyone and the nurse thought it was just for direct care. 03/02/2020 10:10 a.m., Interim Administrator provided a copy of the disciplinary action form and stated they were going to re-educate all the families. 03/02/2020 10:13 a.m., call placed to supervisor. At 10:35 a.m., the interim Administrator and RVPO was notified that the facility was still in IJ. The facility provided the surveyor with a copy of a sign that read CONTACT PRECAUTIONS Visitors must report to Nursing Station before entering. At the top of this sign, the facility staff had transcribed the Resident #s 32 and 44's room. There was a check mark beside these four statements SPECIAL ENTERIC Perform hand hygiene before entering room AND wash hands with soap and water before leaving room, Wear gloves when entering room or cubicle, and whenever touching the patient's intact skin, surfaces, or articles in close proximity, Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces, and Use patient-dedicated or single-use disposable shared equipment or clean and disinfect shared equipment (BP [blood pressure] cuff, thermometers) between patients. The surveyor did not observe this sign to be outside of Resident #s 32 and 44's room on initial tour. However, there was a red sign attached to the doorframe that stated to check with nurse before entering and a plastic cart that contained PPE was positioned outside the door. 03/02/2020 10:43 a.m., LPN #4 was asked if they had received any information yesterday regarding isolation. LPN #4 stated they had. When asked if they had spoken with the family member in the room. LPN #4 stated they had and the family member wanted the resident sent out. LPN #4 stated the family member told her that lady said she had to wear a gown and they wanted to know if they had to wear one. LPN #4 stated she told the family member that if they were not providing patient care they did not have to. LPN #4 stated the infection was in the residents urine (ESBL) and they did not think they had wear one. LPN #4 then stated isolation applies to everyone and I knew that. 03/02/2020 11:00 a.m., CNA #10 stated isolations signs outside of the rooms are for nurses, visitors, everybody really. When asked if there was a family member present in Resident #44's room when they were in there CNA #10 stated yes. CNA #10[TRUNCATED]