**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure hazardous chemicals were secured on three of six units including the secured Dementia Unit (South). These failures placed cognitively impaired resident's unsecured access to hazardous chemicals. The failure to safely secure hazardous chemicals caused an unsafe environment and placed residents at risk for serious injury, impairment, or death from ingestion of inappropriate substances. An Immediate Jeopardy (IJ) was called on 05/17/2022 at 4:49 PM. The IJ was removed on 05/23/2022 at 2:47 PM, after chemicals were secured and staff was educated on the dangers of unsecured chemicals. Findings included . According to the Safety Data Sheet (SDS), revised 07/22/2020, identified the Q.T. Plus, a disinfectant/cleaner as a dangerous combustible liquid that causes respiratory and skin sensitization, severe skin burns and eye damage, and blindness could result. The hazards included that Q.T. Plus may cause an allergic skin reaction, allergy, asthma symptoms or breathing difficulties if inhaled. The SDS directed staff to store the Q.T. Plus in a well-ventilated place or wear a respirator, store locked up and do not eat or drink when using. The SDS included a warning to store the disinfectant/cleaner in the original container in areas inaccessible to children. <SOUTH UNIT> In an observation on 05/16/2022 at 9:30 AM, the PPE (Personal Protective Equipment) cart outside of room [ROOM NUMBER] had a container of Hydrogen Peroxide wipes on top of the cart. The wipes were at wheelchair height and accessible to wandering residents in the secured dementia unit. The label read Keep Out of Reach of Children (KOROC). In an observation on 05/16/2022 at 9:38 AM, there was a Sani hand sanitizer wipes container on top of PPE cart outside room [ROOM NUMBER], containing 70% alcohol. The label showed, if swallowed, get medical help, or contact the Poison Control Center Immediately, the label stated KOROC. At this time, there were two residents observed wandering the halls independently without assistive devices. In an observation on 05/16/2022 at 10:37 AM, 11:00 AM, 11:47 AM, 12:15 PM, 2:35 PM and 3:20 PM, the Sani hand sanitizer wipes remained on top of the PPE cart outside of room [ROOM NUMBER]. In an observation on 05/16/2022 at 10:37 AM, a container of Sani hand sanitizer wipes remained on top of the PPE cart outside of room [ROOM NUMBER]. In an observation on 05/16/2022 at 11:47 AM, a container of Sani hand sanitizer wipes remained on top of the PPE cart outside of room [ROOM NUMBER]. There was one unidentified resident observed nearby wandering in unit with staff accompanying them. In an observation on 05/16/2022 at 12:15 PM, a container of Sani hand sanitizer wipes remained on top of the PPE cart outside of room [ROOM NUMBER]. In an observation on 05/16/2022 at 2:35 PM, a container Sani hand sanitizer wipes remained on top of PPE cart outside of room [ROOM NUMBER]. In an observation on 05/16/2022 at 3:20 PM, Sani hand sanitizer wipes container remained on the top of PPE cart outside of room [ROOM NUMBER]. In an observation and interview on 05/17/2022 at 12:39 PM, Staff M, Housekeeper, left the housekeeping cart unattended to go into the South pantry without their cart. On top of the cart was a one-gallon bucket with a side label indicating it was Q.T. Plus by [NAME]. The lid over the chemicals showed Shoppers Value Strawberry Swirl Ice Cream. Resident 102 was observed to wander out of their room in front of the housekeeping cart. There were no staff present. Review of Resident 102's, 04/29/2022 Quarterly Minimum Data Set (MDS) assessment, showed the resident had severe cognitive impairment and wandering behaviors. The resident was ambulatory and required supervision and used no assistive devices. When Staff M returned to their housekeeping cart at 12:44 AM, they were asked about the unsecured chemicals. Staff M stated it contained Q.T., a cleaner and they always left it on their cart as it was used to clean high touch areas. Staff M stated they were unable to get a new container of Q.T. and needed a lid so they replaced it with the strawberry ice cream one. Staff M stated most of the residents stayed away from their housekeeping cart except (Resident 42). Staff M stated they had to keep Resident 42 away from their cart and mop bucket. Review of Resident 42's 03/28/2022 Quarterly MDS assessment, showed severe cognitive impairment and wandering behaviors that put the resident at risk for physical illness or injury. The resident was able to self-propel around the unit in their wheelchair. In an observation on 05/17/2022 at 12:48 PM, Staff M left their housekeeping cart once again to go out of the secure unit, leaving the Q.T. Plus chemicals unattended. Resident 102 had wandered back into their room and then wandered out of their room again in front of the unsecured chemicals. In a continuous observation on 05/17/2022 at 12:55 PM, seven minutes later, Staff M returned to the unit with a new QT Plus label to put on the top of the chemicals. Staff M stated Staff X, Environmental Services, was going to get the housekeeping staff new Q.T. Plus containers. In a similar observation on 05/17/2022 at 1:03 PM and 1:10 PM, Staff M, left their housekeeping cart with unsecured unattended chemicals on top of the cart while two residents wandered on the unit near the cart without direct supervision. Review of a requested dementia unit audit of cognitive status, and ambulatory status was received on 05/17/2022 at 3:28 PM, revealed there were twenty-five residents with significant cognitive impairment on the South unit. Thirteen of the twenty-five residents were able to ambulate, and nine residents could self-propel in their wheelchair and would have access to unsecured chemicals. An Immediate Jeopardy (IJ) was called on 05/17/2022 at 4:49 PM. In an observation on 05/20/2022 at 11:51 AM, Resident 87 was up in their wheelchair in their room. A container of Sani hand sanitizer wipes was located at the sink. Staff K, Licensed Practical Nurse (LPN), was informed there were unsecured chemicals at the resident's sink. Staff K stated they would let the aide know. <NORTH> In an observation on 05/16/2022 at 10:01 AM, there were two medication cups containing an unknown white substance on the nightstand of Resident 74. In an observation on 05/16/2022 at 11:50 AM, the treatment cart on the North B hallway had Clorox Hydrogen Peroxide Wipes and Sani Cloths containers unsecured and accessible to residents. In an observation on 05/16/2022 at 12:03 PM, there was a jar of Tri-Derma pain reliever cream and a bottle of antifungal powder unsecured on Resident 7's bedside table. The bottles contained the warning of KOROC. <CENTRAL> In an observation on 05/16/2022 at 9:34 AM, the PPE cart outside room [ROOM NUMBER] had Hydrogen Peroxide wipes on top of the cart. In an observation on 05/17/2022 at 1:41 PM, there was a container labeled Germicidal on the unattended housekeeping cart in the hall between rooms [ROOM NUMBERS]. In an observation on 05/17/2022 at 2:44 PM, Clorox Wipes were on top of the isolation cart outside room [ROOM NUMBER]. On 05/18/2022 at 9:10 AM, there was an in-service posted at the South nurse's station dated 05/17/2022 that showed, Do not leave chemicals unattended. All chemicals must be secured inside the housekeeping cart and or inside the PPE drawers, including disinfectant wipes, hand sanitizers, and chemicals with a label keep out of children. Carts must be locked at all times when unattended including housekeeping carts. PPE bin drawers must be closed after removing an item. In an observation on 05/20/2022 at 9:31 AM, Clorox Hydrogen Peroxide wipes were left unattended on top of housekeeping cart outside room [ROOM NUMBER]. The housekeeper was in the room mopping. There were six residents with cognitive impairment seated nearby. In an observation on 05/20/2022 at 9:33 AM, Staff L, Nursing Assistant Certified (NAC), walked past the housekeeping cart with the unsecured Clorox Wipes on top of the cart. At 9:34 AM, Staff K and Staff L walked past the wipes. At 9:37 AM, Staff K threw a medication cup into the housekeeping cart garbage bin and walked past without securing the chemicals. In an observation on 05/20/2022 at 9:40 AM, Staff N, Housekeeper, was asked about the unsecured and unattended Clorox Wipes located on top of their cart while they were in a room mopping. They stated chemicals should have been locked up. In an interview on 05/23/2022 at 1:52 PM, Staff M, Housekeeper stated they had been in serviced on chemical security and they were not to use ice cream containers for chemical storage. In an interview on 05/25/2022 at 3:15 PM, the Director of Nursing Services (DNS) stated the facility did not have a chemical security or storage policy In an interview on 05/26/2022 at 10:45 AM, Staff B, Nurse Manager, stated the expectation was to secure chemicals and to be alert to residents on the unit and, look out for staff to ensure chemicals were locked up. In a joint interview on 05/17/2022 at 4:49 PM, the Administrator, DNS, and Staff A, Assistant Director of Nursing Services (ADNS), were notified of the identified failure to secure hazardous chemicals, labeled with the warning, Keep out of the reach of children in the South, secured dementia unit and on the North and Central resident hallways. They were informed one resident was observed wandering by the unsecured chemicals covered with a strawberry ice cream lid and staff confirmed another resident (42) had tried to get into their housekeeping cart and mop bucket. Of immediate concern, was the South unit was comprised of twenty-five residents with significant cognitive impairment, thirteen of which could walk around the unit while nine were able to self-propel in their wheelchair. The DNS stated that the health department had advised them to have the wipes accessible for use. In an interview on 05/25/2022 at 3:15 PM, the DNS stated the facility had no policy for securing chemicals. Reference: (WAC) 387-97-1060(3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for four of six Units. The facility failed to ensure oversight and implementation of their Infection Prevention and Control Program during a Coronavirus Disease 2019 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak. The facility failed to ensure the staff appropriately used personal protective equipment (PPE), failed to ensure the staff cleaned and disinfected reusable medical equipment, failed to ensure appropriate hand hygiene practices were followed, failed to ensure Transmission Based Precautions (TBP) were implemented with Coronavirus Disease 2019 (COVID-19) positive residents, and failed to ensure appropriate handling of a urinary catheter bag in accordance with infection control standards of practice. The COVID-19 outbreak at the facility, had a result of 35 residents test positive, 35 staff members test positives, and the death of three residents (110, 113, 114). These failures placed all residents, visitors, and staff at risk for potential exposure to COVID-19, other infections and increased the likelihood of serious harm or death, which constituted an Immediate Jeopardy (IJ). On [DATE] at 3:01 PM, the facility was notified of an IJ at CFR 483.80 (a)(2)(iii) F880 related to the facility's failure to implement proper use of PPE for COVID-19 positive residents, and incomplete education to facility staff on PPE use during a COVID-19 facility outbreak. The facility removed the immediacy and was validated on [DATE] at 11:30 AM by implementing a removal plan with staff education on proper use of PPE, disinfection protocol for face shields, proper use of N95 (form of breathing respirator), appropriate hand hygiene protocol, and appropriate TBP procedures for COVID-19 positive residents. Written education and return demonstration training was provided to all staff. Findings include . RESIDENT 110 Resident 110 admitted to the facility on [DATE], with diagnosis to include heart failure. Review of the facility admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had not received Hospice Services, did not require supplemental oxygen, and had received physical and occupational therapy. Review of the Documentation Survey Report v2 (Report of the residents' functional abilities) for [DATE] showed the resident was consuming 51% - 75% of their meals independently, participated in activities daily, had a stable blood pressure, body temperature, and oxygen saturation level and did not require supplemental oxygen. Review of the facility progress note dated [DATE] at 9:14 AM, showed the resident had tested positive for the COVID-19 virus. Review of the facility progress note dated [DATE] at 3:23 PM, showed the resident was in respiratory distress with oxygen saturation (level of oxygen in the blood) levels below baseline, and required supplemental oxygen via nasal tubing (tubing delivering oxygen into the nose). Review of the facility progress note dated [DATE] at 3:39 PM, showed the resident was unresponsive, with labored breathing, the resident's oxygen saturation levels were below baseline, and they required supplemental oxygen via a facial mask (breathing mask that delivers oxygen to the nose and mouth at the same time). The resident had a heart rate that was elevated above baseline and provider (doctor) was notified. Review of the facility progress note dated [DATE] at 5:25 PM, showed the residents wife wanted the resident to be sent to the hospital, the Emergency Medical Technicians (EMT) were contacted via 911 and the resident was sent to the hospital. Review of an email communication dated [DATE] at 12:03 PM, from the Director of Nursing Services (DNS) stated Resident 110 passed away on [DATE] at the hospital. RESIDENT 113 Resident 113 admitted to the facility on [DATE], with diagnosis to include diabetes and kidney disease. Review of the facility Quarterly MDS assessment dated [DATE], showed the resident had intact cognition, had not received supplemental oxygen, and did not require hospice services. The resident was able to transfer with the supervision of one person, ambulated (walked) with no assisted device, and needed supervision for eating and toilet use. Review of the facility progress note dated [DATE] at 9:16 AM, showed the resident had tested positive for the COVID-19 virus. Review of the facility progress note dated [DATE] at 2:00 PM, showed the resident had a poor appetite. Review of the facility progress note dated [DATE] at 7:52 AM, showed the resident had been found in sitting in a chair in the bathroom not feeling well, appeared to have labored breathing and sweating. Review of the facility progress note dated [DATE] at 10:00 PM, showed the resident had difficulty walking, appeared weak to the nurse, and had labored breathing. Review of the facility progress note dated [DATE] at 7:24 AM, showed that at 11:40 PM the night before, the resident had a blueish color to their nail beds, labored breathing above their normal baseline. The resident continued to have labored breathing throughout the shift per the nurse. At 4:00 AM on [DATE], the resident was found to have no vital signs and was pronounced dead. RESIDENT 114 Resident 114 admitted to the facility on [DATE], with diagnosis to include fracture to the back with surgical repair. Review of the facility admission MDS assessment dated [DATE], showed the resident had intact cognition, had not received supplemental oxygen, and did not require hospice services. The resident was able to ambulate with the assist of one person using a walker and ate meals with set up assist. Review of the facility progress note dated [DATE] at 8:46 PM, showed the resident had tested positive for COVID-19 virus. Review of the facility progress note dated [DATE] at 11:25 PM, the resident had complained of a cough and was producing thick yellow sputum and reported a sore throat. Review of the facility progress note dated [DATE] at 1:37 PM, the resident reported a cough, with greenish colored sputum. Review of the facility progress note dated [DATE] at 10:23 AM, the resident had an elevated body temperature above base line, blood pressure was below their normal baseline, had an increased heart rate, increased respirations, and required supplemental oxygen. Review of the facility progress note dated [DATE] at 1:48 PM, resident was declared deceased at 10:42 AM. <Personal Protection Equipment> Review of Center for Disease Control (CDC) policy titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 2, 2022, stated: - Residents with confirmed or suspected COVID-19 requires a National Institute of Occupational Safety and Health (NIOSH) approved respirator as PPE and should be removed and discarded after the patient care encounter and a new one should be placed on; and - Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting including residents. Review of CDC policy titled, How to use your N95 Respirator, updated [DATE]th, 2022, showed the N95 respirator must fit snug against the face, with no gaps or items in the way. Do not crisscross the straps ensure the straps lay flat and are not twisted. In the event there are gaps or improper use of straps the N95 respirator was not worn correctly and was not an effective respirator for use with COVID-19 positive residents. Review of the CDC policy titled, Strategies for Optimizing the Supply of Eye Protection, updated [DATE], ensured appropriate cleaning and disinfection after each use if reusable face shields or goggles are used. Review of the facility policy titled, Novel Coronavirus Prevention and Response, dated [DATE], stated staff are educated on proper use of personal protective equipment for standard, contact, droplet, and airborne precautions, including eye protection. In a continuous observation on [DATE] at 2:29 PM, Staff G, Licensed Practical Nurse (LPN), was observed to enter room [ROOM NUMBER], a known COVID-19 positive resident room wearing a surgical mask underneath a N95, eye protection, gown, and gloves. Staff G then exited the room removing gloves, and gown and discarded into the waste basket. Staff G performed hand hygiene with alcohol-based hand gel (ABHG) and proceeded back to their medication cart down the hall. Staff G did not change their N95 after a resident encounter with a COVID-19 positive resident and did not disinfect their eye protection. In an interview on [DATE] at 2:35 PM, Staff G confirmed that the resident in room [ROOM NUMBER] was positive with COVID-19. Staff G stated they had not had any education regarding disposing of their N95 after resident encounters with COVID-19 and replacing with a new N95. Staff G stated they had not had any education on proper use of the eye protection and were unaware they were to disinfect they eye protection after they provided care to a COVID-19 positive resident. Staff G stated they thought they were providing themselves extra precaution by applying a surgical mask under their N95. Staff G confirmed they were providing care with COVID-19 positive and negative residents. In an observation on [DATE] at 3:06 PM, Staff Z, Registered Nurse (RN), was observed to exit a resident room wearing their eye wear on top of their head. Staff Z continued to wear eye protection on top of their head while they assisted a resident in the hallway apply their surgical mask to their face, adjust the resident's jacket and push the resident in the wheelchair down to the nurse's station. In an interview on [DATE] at 3:17 PM, Staff Z continued to wear the eye wear on top of their head during the interview. Staff Z stated they were to always wear eye protection with all resident encounters. Staff Z never acknowledged they had their eye wear on ineffectively. In an observation on [DATE] at 1:39 PM, Staff O, LPN, was observed to provide closed contact care to a resident in room [ROOM NUMBER]. The signage outside of the room indicated aerosol contact precautions. Staff O was observed to exit the room and remove their gloves and gown, performed hand hygiene with ABHG and walk down the hallway and place a lunch lid at the nurse's station. Staff O did not remove their N95 and replace with a clean one. Staff O did not disinfect their eye protection. In an interview on [DATE] at 1:41 PM, Staff O confirmed the resident in room [ROOM NUMBER] was COVID-19 positive. Staff O stated they were the nurse for both COVID-19 positive residents and negative residents. Staff O stated they were supposed to discard their N95 anytime they were in close contact with a COVID-19 positive resident and replace with a new one. Staff O stated they were supposed to disinfect their eye protection anytime they were in close contact with a COVID-19 positive resident. Staff O stated I guess I forgot when asked why they did not replace their N95 or why they did not disinfect their eyewear after caring for the COVID-19 positive resident in room [ROOM NUMBER]. In an observation on [DATE] at 9:11 AM, Staff AA, Physical Therapy Assistant (PTA), was observed in a COVID-19 positive residents' room with the door open. Staff AA was observed to be less than 6 feet from the resident while assisting with therapy exercises with the resident and was wearing a gown, gloves, eye wear and a surgical mask. In an interview on [DATE] at 9:19 AM, Staff AA stated they were instructed to wear a N95 respirator for all COVID-19 positive residents. Staff AA stated the reason for only having a surgical mask on was I forgot this time, I thought I was already wearing one. In an observation on [DATE] at 12:57 PM, Staff L, Nursing Assistant Certified (NAC), was observed exiting the room of a COVID-19 positive resident. Staff L was observed to not remove their N95 when they removed their PPE, Staff L did not replace their N95 after providing care to a COVID-19 positive resident. In an observation and interview on [DATE]at 9:06 AM, Staff DD, NAC, was observed to enter a COVID-19 positive room to provide care not wearing a N95 respirator. Staff DD, then exited the room, removed the mask, and placed another one on their face. Staff DD stated they were unaware they were not wearing a N95 as the PPE bin outside of the COVID-19 positive room was stocked with those type of masks. In an observation on [DATE] at 11:40 AM in the South Unit common room there were seventeen residents sitting and only one resident was wearing a surgical mask. Eight of the residents were seated closely together within one to two feet apart. Staff were observed to walk past the residents and did not make efforts to have residents wear a mask. In an observation on [DATE] at 9:11 AM, Resident 50 was observed to not be wearing any source control (face mask) and was observed to be coughing repeatedly and wiping their runny nose with bare hand. Resident 89 was seated less than six feet away. In an observation on [DATE] at 11:01 AM, Staff B, Nurse Manager (NM), was observed to enter a COVID-19 positive resident room with their N95 straps were crisscrossed which is incorrect placement. Staff B then exited the COVID-19 positive room and placed a new N95 on with the straps worn incorrectly. In an observation on [DATE] at 11:41 AM, Resident 50 was observed to not be wearing any source control (face mask) and was observed to be coughing repeatedly and wiping their runny nose with bare hand. Resident 89 was seated less than six feet away. In an observation on [DATE] at 1:20 PM, there were sixteen residents sitting in the common area on the South unit with no source control. There were six residents seated closely together with in one to two feet apart. Staff were observed to walk past the residents and did not make efforts to have residents wear mask. In an observation on [DATE] at 2:14 PM, Resident 50 was observed in the common area of South Unit coughing and wiped their runny nose with a bare hand. In an interview on [DATE] at 8:50 AM, the DNS entered the South Unit and reported that Resident 50 was now positive for COVID-19 virus. <Hand Hygiene> In a review of facility document titled, Glove Use, dated [DATE] stated: - Perform hand hygiene prior to placing gloves on; - Hand hygiene is to be performed immediately after removing gloves; - Gloves are to be changed if they are damaged, soiled following a task, moving from a soiled body site to clean; and - Reference procedures from the CDC. In a review of facility policy titled, Infection Control and Prevention, updated [DATE], stated hand hygiene shall be performed in accordance with the facility established hand hygiene procedures. In a review of the CDC policy titled, Hand Hygiene Guidance, reviewed [DATE], stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove removal. In an observation on [DATE] at 2:38 PM, Staff G was observed to exit a COVID-19 positive resident room, at 2:39 PM they touched the front of their N95 and lifted it away from their face and pulled out the surgical mask underneath the N95. Staff G discarded the surgical mask into the garbage, adjusted their N95 by touching the front of the mask. Staff G did not perform hand hygiene, reached into their shirt pocket, retrieved keys, and unlocked the medication cart. In an observation on [DATE] at 2:54 PM, Staff FF, NAC, was observed to perform incontinent care on a resident. Staff FF performed hand hygiene and placed gloves on their hands and prepared wash clothes to clean resident. Staff FF then approached the resident removed blankets, pants, and opened the resident's adult incontinent brief. Staff FF then stated they needed more items and placed the soiled front of adult incontinent brief over the resident's private area, walked away from the bed, touched the privacy curtain, and went to sink to grab trash bags and more wash clothes. Staff FF did not remove their gloves and did not perform any hand hygiene. Staff FF then reapproached the resident and began to clean the front private area, then tucked the soiled adult incontinent brief under resident and rolled resident on to their side. Staff FF cleaned the backside of the resident where stool was present on the incontinent brief. Staff FF then stated they needed more washcloths, left resident exposed, removed gloves, and grabbed more wash clothes and clean clothes out of the closet. Staff FF did not perform hand hygiene and placed new gloves on. Staff FF returned to finish cleaning the resident, applied a new clean brief and clean pants. Staff F then covered the resident, performed hand hygiene, and went to obtain clean linens to change the bedding. In an interview on [DATE] at 3:38 PM, Staff FF stated they did not perform hand hygiene properly and stated they knew better. Staff FF did not offer a reason as to why they did not perform hand hygiene effectively. <Transmission Based Precautions> Review of the facility isolation sign for Transmission Based Precautions (TBP), titled Aerosol Contact Precautions, undated, stated directions for TBP for COVID-19 positive residents. The sign instructed healthcare workers to keep the door closed. In an observation on [DATE] at 9:40 AM, room [ROOM NUMBER] had visible aerosol contact isolation instructions posted on the door. Resident 99 was visible in room, the door to the room was open. In an observation on [DATE] at 9:52 AM, staff were observed to walk past the room [ROOM NUMBER], and the door was open. In an observation on [DATE] at 11:30 AM, room [ROOM NUMBER] had visible aerosol contact isolation instructions posted on the door. Resident 99 was visible in room, and the door to the room was open. In an observation on [DATE] at 10:32 AM, the room [ROOM NUMBER] had visible aerosol contact isolation instructions posted on the door. Resident 99 was visible in room, and the door to the room was open. <Universal Medical Equipment> Review of the facility policy titled, Novel Coronavirus Prevention and Response, dated [DATE] stated that all non-dedicated medical equipment used for a resident, needs to be cleaned and disinfected before use on another resident. In an observation and interview on [DATE] at 3:06 PM, Staff Z was observed to exit a resident room with a vitals machine cart (which included a blood pressure cuff, thermometer, oximeter, which tests the amount of oxygen in the blood), they walked to the nurse's station with the cart documented in a red binder, then plugged the vitals cart into the electrical outlet on the wall. Staff Z stated the process for reusable medical equipment was to wipe them down with the disinfectant wipes. Staff Z stated they only wiped the vitals cart down with a paper towel in the room and did not offer a reason why they did not follow policy. <Catheter Care> Review of the facility policy titled, Urinary Indwelling Catheters, dated [DATE], sated Indwelling urinary catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible. Maintain resident dignity by covering the urinary bag. In an observation on [DATE] at 9:42 AM, Resident 67's catheter bag was visible lying on the ground. The resident was unable to state when the last time the staff were in to care for their catheter bag. In observations on [DATE] at 2:12 PM and [DATE] at 10:30 AM, Resident 31's catheter was not covered under the wheelchair (w/c) and was dragging along the ground with dependent loops. The tubing was close to being caught in the wheels of the w/c. In an observation on [DATE] at 12:44 PM, Resident 79's catheter bag was three quarters full, and bag was attached to bed at head level with no privacy bag. In an observation on [DATE] at 8:54 AM, Resident 79's catheter bag was visible lying on the ground, part of the bag was under the wheels of the over the bed table. The resident was unable to state when the last time the staff were in to care for their catheter bag. In an observation on [DATE] at 9:14 AM, Resident 79's catheter bag was attached to the bed, no privacy bag visible. In an observation on [DATE] at 10:59 AM, Resident 79's catheter bag was attached to the bed, no privacy bag visible. In an interview on [DATE] at 1:30 PM, Staff A, Assistant Director of Nursing/Infection Prevention, stated that during an outbreak they try to encourage residents to wear surgical mask and stay in their rooms as it was an ongoing process all the time. The expectation was staff were disinfecting their eye wear after they care for a resident who has tested positive for COVID-19, and all universal equipment such as vitals carts should be wiped and disinfected after every use regardless of COVID-19 status. Staff A stated that they educate staff on infection control practices at general orientation, and then do competency checks, rounding and on the spot education. Staff A stated they attempt to educate on hand hygiene quarterly. Staff A did not offer a reason as to why staff were not disinfecting their eye wear, changing out their N95, not performing hand hygiene, and disinfection of equipment. In an interview on [DATE] at 2:10 PM, Staff GG, Staff Development Coordinator (SDC), stated they conduct general orientation once a month, but this month was cancelled due to the annual survey. They stated seven staff members were scheduled to attend, and they have already started working in their respected departments. Review of facility documentation packet for newly hired employees provided by the facility on [DATE] at 2:20 PM, had no documentation related to infection control prevention and procedures. The facility failed to ensure staff were wearing the appropriate PPE with working with COVID-19 positive residents, failure to properly disinfect eye protection after contact with a COVID-19 positive resident, there was failure by staff to perform proper hand hygiene during and after care of residents, failure to properly disinfect universal equipment after direct contact with a resident, and failure to ensure appropriate placement of a urinary catheter bag in accordance with infection control standards of practice. These breaches in infection prevention and control practices led to the spread of COVID-19 virus throughout the facility that subsequently led to the outbreak of 35 residents with COVID-19, which resulted in the hospitalization of Resident 110, and the death of Resident 110, Resident 113, and Resident 114. Reference WAC 388-97-1320 (1)(a)(c)(5)(c)(e)