Based on observations and interviews, the facility did not ensure personal protection of resident medical records for 1 of 1 resident (R2). Licensed Practical Nurse (LPN) F did not ensure personal protection of R2's medical records when leaving the medication cart in the hallway unattended and the computer screen open. Findings include: The facility's policy entitled, Medication Administration, reads in part Any personal information must be hidden when not in use (cover report sheets, minimize or close computer screen). On 10/31/23 at 7:21 AM, Surveyor observed a medication cart in the 200-hallway unattended. When Surveyor walked past the medication cart the computer screen was opened. R2's information was up on the computer screen so anyone walking by could see the information. Approximately 3 - 5 minutes later, LPN F returned to the medication cart. On 11/01/23 at 8:03 AM, Surveyor interviewed Certified Nursing Assistant (CNA) and Medical Assistant (MA) G and asked what their process was when leaving medication cart. CNA/MA G indicated they lock the cart, cover up any papers with identifiable names on them, pull the screen down on their computer for privacy and make sure there are no medications left on the cart. On 11/01/23 at 8:06 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the practice is before a nurse leaves their medication cart. DON B indicated locking cart, computer screen down or locked, and covering papers with any names on them.

Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's background information disclosure (BID) was last obtained on 09/17/18. Findings include: The facility policy, entitled Allegations of mistreatment/neglect/abuse/injuries of unknown source, misappropriation of resident property, exploitation, and resident to resident altercations, revised, November 2018 states in part The BID, IBIS, OIG and DOJ checks are completed every four years by the Human Resources Department. On 10/31/23, Surveyor reviewed 8 random staff Background Information Disclosures (BID) as part of the caregiver program compliance check. Surveyor was reviewing a BID for Certified Nursing Assistant (CNA) H; the form was dated 09/17/18. Surveyor reviewed the Department of Justice report that was attached, and it had the date of 09/17/18 indicating that is the date the BID was completed. On 10/31/23 at about 1:30 PM, Surveyor interviewed Business Administration Assistant (BAA) E and asked if they had an updated BID for CNA H. BAA E looked through CNA H's personnel file and said, I guess not. On 10/31/23 at 3:06 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and told her the BID for CNA H was last done on 09/17/18 asked if they thought the BID was up to date. NHA A indicated with what Surveyor was telling NHA A, if BAA E cannot find another one then it is not up to date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide appropriate care and treatment for 1 of 2 sampled residents (R) (R13) who were at risk for pressure injuries. R13 was observed in bed in a supine position without being repositioned and without heels being elevated for 4 hours. Findings include: The facility policy entitled, Repositioning, dated 6/2022, states in part: Staff will ensure resident is repositioned per the resident plan of care or [NAME], residents will be given pressure relieving devices for impaired or risk of impaired skin integrity. Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 02, November 2023, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Turn and reposition all individuals at risk for pressure injury, turn the individual into a 30-degree side lying position and use your hand to determine if the sacrum is off the bed, ensure that the heels are free from the bed, use heel offloading devices for high risk pressure injuries. R13 was admitted on [DATE] and current diagnoses, in part: non-Alzheimer's dementia, Huntington's disease, and arthritis. Surveyor completed record review of the Minimum Data Set assessment (MDS), dated [DATE], which indicates the resident's most recent Brief Interview for Mental Status (BIMS) score was an 11 out of 15 total points. According to the BIMS assessment, a score of 11 indicates the resident has moderately impaired cognition. The MDS documents R13 being at risk of pressure injury, always incontinent of bladder and frequently incontinent of bowels. R13 is dependent on staff for activities of daily living and maximum assist of staff to roll in bed. Nurse notes indicated through assessments that Braden scale was conducted for R13 with a score of 10. Braden scale is utilized to measure pressure sore at risk and 10-12 is considered high risk. Care plan from 10/05/23 indicates that R13 needs assistance with cares and repositioning. A pressure redistribution mattress, use pillows to position comfortably, float heels for offloading and apply Roho wheelchair cushion. R13 needs help to move. Physician orders from 08/18/21 indicate ensure that Dycem cushion is under resident when in wheelchair. On 10/30/23 at 10:04 AM, Surveyor observed R13 lying in bed on back in the dark. On 10/31/23 at 7:10 AM, Surveyor observed R13 sleeping while lying in bed on back, heels on bed and not elevated. On 10/31/23 at 8:41 AM, Surveyor observed R13 sleeping while lying in bed on back and covers on. On 10/31/23 at 9:15 AM, Surveyor observed R13 sleeping while lying in bed on back. R13 continues to be sleeping in same position. On 10/31/23 at 10:00 AM, Surveyor observed R13 sleeping while lying in bed on back. On 10/31/23 at 10:03 AM, Surveyor observed Certified Nursing Assistant (CNA) C provide personal cares. Surveyor observed R13's both heels directly resting on the bed with no offloading device. Surveyor asked CNA C if anything is used to off-load heels. CNA C indicated the foot of the bed is angled down. Surveyor observed a foam cushion with Dycem in Broda chair. The foam cushion is not a Roho cushion. The care plan directed a wheelchair Roho cushion be applied. On 10/31/23 at 1:03 PM, Surveyor interviewed R13 and asked about repositioning and how often R13 gets repositioned. Surveyor also asked R13 about floating heels to prevent skin breakdown and how R13 feels about having her feet elevated. R13 indicated that R13 is ok with her cares and that R13 doesn't like to be repositioned with legs elevated. On 11/01/23 at 6:57 AM, Surveyor observed R13 sleeping while lying in bed on back. On 11/01/23 at 7:51 AM, Surveyor observed R13 sleeping while lying in bed on back. On 11/01/23 at 7:54 AM, Surveyor interviewed CNA K and asked process for repositioning R13 and when the last time R13 was repositioned this morning. CNA K stated that usually we go in and try to reposition often but there are times where R13 doesn't want to be repositioned. CNA K indicated that night shift gave report that rounds were completed around 4:00 AM on 11/01/23, but that CNA K was unsure if that is when R13 was repositioned. Surveyor asked CNA K if CNA K had repositioned R13 or when will CNA K will be going in R13's room to reposition. CNA K stated CNA K has not yet gone in this morning, but usually will go in before breakfast to reposition. CNA K indicated R13's comprehensive care plan does state offload on heels so with any residents we use pillows to prop feet up. CNA K indicated to have never seen R13 to have a pillow in room to float heels. R13 may not want to have feet up. CNA K indicated we follow care plan in R13's room for what interventions to perform per care daily. On 11/01/23 at 8:05 AM, Surveyor reviewed CNA care plan for R13 with CNA K, and it states in part, for repositioning that R13 needs assistance with repositioning. CNA K indicated the care plan was very vague. On 11/01/23 at 8:09 AM, Surveyor observed CNA K enter R13's room, and then exit with trash. Surveyor interviewed CNA K who indicated that R13 had an incontinent episode and CNA K changed her. Surveyor observed R13 in supine position and sleeping again. On 11/01/23 at 12:10 PM, Surveyor interviewed DON B asked expectations of CNAs and repositioning residents who are totally dependent on staff to reposition. DON B indicated that facility knows on R13's reposition and care plan interventions are not adequate. DON B indicated due to the at risk for skin issues it is expected that CNAs reposition residents often and that waiting over a couple hours is too long before needing repositioning.

Based on observation, interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 2 residents (R) observed receiving insulin. (R4) Staff did not follow current standard of practice of priming the insulin pen prior to setting the dose to be administered to ensure the insulin pen and needle are working and the air was removed to ensure the correct amount of insulin would be administered. Findings include: Facility policy entitled, Insulin Administration stated in part, .If using an insulin pen, cleanse hub then, prime pen with 2 units .: On 10/31/23 at 7:55 AM, Surveyor observed Licensed Practical Nurse (LPN) F prepare two insulin pens (Lispro and Humulin) for administration to R4. LPN F took two insulin pens out of medication drawer and verified medication labels with medication orders on the Medication Administration Record. LPN F removed the cap from the Humulin insulin pen and wiped tip of the pen with alcohol pad. LPN F attached a needle to the pen and dialed the pen to the ordered dose of 11 units. LPN F did not prime the needle with 2 units prior to dialing pen to the ordered dose. LPN F removed cap from the Lispro pen and wiped the tip with an alcohol pad. LPN F attached a needle and dialed the pen to the ordered dose of 5 units. LPN F did not prime the needle with 2 units prior to dialing the pen to the ordered dose. LPN F administered both insulin doses to R4. Immediately after the procedure, Surveyor asked LPN F if they primed the needles on the insulin pens prior to dialing the pens to the ordered dose to ensure the pen was in working order and the air was removed to ensure the correct amount of insulin would be administered. LPN F stated they were never taught to do that, and they did not usually prime insulin pens with 2 units prior to dialing pen to the ordered dose. On 10/31/23 at 12:19 PM, Surveyor interviewed Director of Nursing (DON) B about the observation of LPN F drawing up 2 insulin pens to the ordered dose without priming the needle first for R4. DON B stated staff were supposed to prime the needle on insulin pens prior to dialing the pen to the ordered dose of insulin to ensure the resident received the correct dose of insulin.

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 33 residents residing in the facility. The facility does not have a director of food and nutrition services with the minimum requirements or a full time registered dietitian on site. Findings include: On 10/30/23 at 9:30 AM, Surveyor performed the initial walkthrough of the kitchen with Dietary Supervisor (DS) M. Surveyor asked DS M what qualifications they held that allowed them to assume the role of Dietary Supervisor. DS M said they had ServSafe certification, and they were working on completing a course that would qualify them as a Certified Dietary Manager. On 10/31/23 at 1:59 PM, Surveyor interviewed DS M regarding the oversight of a registered dietitian. DS M said they have a registered dietitian they work with, and they come only on Monday to complete the tasks required of a registered dietitian. The registered dietitian is also available by phone every day of the week. The facility did not provide evidence that the registered dietitian was monitoring the kitchen for oversight of all kitchen operations. On 10/31/23 at 2:17 PM, Surveyor interviewed DS M regarding their current qualifications to perform director of food and nutrition services for the facility. DS M said they do have the ServSafe qualification but have not yet finished their courses to become a certified dietary manager. DS M has no other certification besides ServSafe related to food and nutrition services. DS M is working on a four-year degree from the University of North Dakota, which is not yet completed. Record review revealed that DS M was hired on 10/08/23. On 11/01/23 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the lack of certification for DS M and the oversight of the registered dietitian. NHA A said they were still hiring for a Dietary Manager, and that DS M was the dietary supervisor. They required the dietary manager to have the necessary qualifications but have not been able to hire someone; they still have a job position posted. At this time, NHA A and DS M worked together with the registered dietitian to make sure everything was covered. Surveyor asked what qualifications NHA A had related to dietary services, and NHA A replied none; NHA A did say they have a four-year degree in business administration. The facility hopes to move DS M into the dietary manager position once they receive the qualifications. Surveyor then asked about the expectations that NHA A has regarding the qualifications of the director of food services, and they replied they would expect them to have the proper certifications. They are still hiring to try and find someone as soon as possible.

Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 33 of 33 residents residing in the facility. Dietary Supervisor (DS) M and Dietary Aide (DA) N did not use a hair restraint over their beards while preparing, serving, and operating in the kitchen. Findings include: The facility policy, entitled Infection Control - Dress Code 2.4, not dated, states in part: A. All staff must have their hair restrained in a hairnet Men should be clean shaven or they will be required to wear a beard net. On 10/30/23 at 9:30 AM, Surveyor performed the initial walkthrough of the kitchen with DS M. The Surveyor observed that DS M had a noticeable beard approximately ½ in long protruding from behind the mask they wore. The mask did not cover all the beard, only around the mouth area. The surveyor also observed that DA N had a noticeable beard that protruded from behind the surgical mask that they wore. Both individuals had full beards that traveled from ear to ear. On 10/30/23 at 11:38 AM, Surveyor observed lunch being prepared for the facility. DA N was cooking and taking temperatures for all foods, including pureed foods. DA N did not have a beard net at this time and did have a full beard, as described in the previous observation. DS M entered the kitchen at this time to supervise as the food was being prepared and served. DS M also did not have a beard net and still had a full beard, as described previously. On 11/01/23 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the lack of hair restraints used. NHA A would expect they follow the policy and be clean shaven or use a beard net.

Example 2 On 10/31/23 at 8:19 AM, Surveyor observed Laundry Aide (LA) J collect garbage from hall 200. LA J gathered garbage from small trash can on hall 200. LA J picked the trash bag up, resting on scrubs across abdomen, and brought it out to the back dumpster. Surveyor observed the dumpster lid open, and LA J threw garbage into dumpster and left the lid open. On 10/31/23 at 8:25 AM, Surveyor interviewed LA J and asked about the garbage dumpster being left open. LA J stated that the dumpster lid is always open. Based on observation, interview, and policy review, the facility failed to dispose of garbage and refuse properly. This has the potential to affect all 33 of 33 residents residing in the facility. The facility did not ensure the garbage dumpster lids were closed; this was observed multiple times during the survey. This is evidenced by: The facility policy, entitled Pest Control, not dated, states: Ongoing measures are taken to prevent, contain, and eradicate household pests such as roaches, ants, mosquitoes, flies, mice and rats All state and local regulations are followed. On 10/30/23 at 9:30 AM, Surveyor performed the initial walkthrough of the kitchen with Dietary Supervisor (DS) M. When looking at the garbage dumpsters, Surveyor observed them to be open. On 10/31/23 at 8:52 AM, Surveyor observed the large blue dumpster located outside, near the dietary employee entrance and the outdoor freezer, was open and not covered. On 10/31/23 at 1:59 PM, Surveyor observed that the large blue garbage dumpster was not covered and was open. On 11/01/23 at approximately 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the open dumpsters. NHA A said they would expect them to be closed to prevent attracting pests that may get into the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has potential to effect 33 of 33 residents reviewed. Observations were made of laundry and nursing staff not performing hand hygiene with delivery of linens to residents. Registered Nurse (RN) D did not wear appropriate PPE during wound care for R4; staff did not use the proper technique by putting a barrier under R4's foot during wound care to ensure that R4 would be free from the spread of infection. Certified Nursing Assistant (CNA) C did not complete proper hand hygiene when providing personal cares to R13. Proper signage was not used for R4 who is on precautions due to Methicillin-resistant Staphylococcus aureus (MRSA) in the urine. Findings include: Example 1 The facility policy entitled, Water Management Program, states in part: Identify building water systems that need Legionella control measures, review diagrams, determine proper control measures to avoid infections. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system using a flow diagram of the system to include an assessment of the facility's water system to identify all locations where Legionella could grow and spread. - Identify where control measures should be applied. - Include a process to confirm the WMP was being implemented and was effective. - Document and communicate all the activities. - Include a water management team that reviews processes. The section of the policy entitled, Identify building water systems that need Legionella control measures, contained: see water flow diagrams, review water systems when changes or remodeling occurs, and infection control nurse will review annual water quality reports from the city of Galesville. Surveyor noted the flow diagram was generic and does not specify any distinguished locations or areas where Legionella could grow, spread, or any measures to control the possible spread. The section of the policy entitled, Determine proper control measures to avoid Legionella infections contained: Night shift staff will run sinks in empty rooms for two minutes weekly, ensure water heaters are maintained at appropriate temperatures, surfaces that may contain biofilm are cleansed, document any changes in interventions as needed. Surveyor noted the above four control measures-weekly night shift checks, water heaters maintained, surfaces with biofilm cleansed, and documenting any changes in interventions-were the only risk hazards/control measures documented in the facility's WMP. Surveyor noted the facility's WMP did not document specific names, contact information or assignments of the individuals on the team, and the plan did not contain all the control points or measures taken to reduce Legionella. The above policy/WMP did not address dead legs throughout the facility. On 10/31/23 at 2:00 PM, Surveyor interviewed Director of Nursing (DON)/Infection Preventionist (IP) B about water management plan. DON B indicated that the facility policy is not really detailed, and they do not have a formal diagram pertaining to exactly where they are preventing the risk of Legionella in the water systems. DON B indicated that they do not have the best system in place. Example 2 The facility policy entitled, Hand Hygiene, states in part: Handwashing required after removing gloves, between residents, and before leaving a resident's room. On 10/30/23 at 11:33 AM, Surveyor observed Laundry Aide (LA) J go into R6's room and deliver clean linen into the linen drawer behind the door. LA J exited room, went to linen cart, pulled out all clean linens and entered R11's room without performing hand hygiene. LA J entered R10's room without performing hand hygiene and delivered clean linen into drawer. LA J touched drawer surfaces, exited back out of room and went to clean linen cart without performing hand hygiene. LA J was observed entering and exiting R29, R13, and R23's room without hand hygiene. On 10/30/23 at 11:36 AM, Surveyor observed LA J exit R23's room and go to clean linen cart to grab clean bath towels and deliver to bathroom without performing hand hygiene. On 10/30/23 at 11:39 AM, LA J stocked clean linen cart on hall 100 with clean linens. No hand hygiene was performed. LA J went to Hall 200 and delivered clean linens down the hall. On 10/30/23 at 11:43 AM, Surveyor interviewed LA J and asked process for preventing infection when delivering clean linens to residents' rooms. LA J indicated that LA J was unsure how to answer the question, but the facility makes sure that we have clean hands before delivering linens. Surveyor asked how to prevent infection when going in and out of resident's rooms and touching their drawers when delivering linens. LA J indicated that there isn't anything else we do, and there isn't much else we can do. On 10/31/23 at 7:55 AM, Surveyor completed tour of laundry services with LA J. LA J indicated that laundry gathers dirty linen from the hall 100 and hall 200 and separates into personal linens in one sink and regular linens such as towels, bedspreads, and wash cloths in the other sink. Surveyor asked how isolation linens are handled. LA J stated that they are handled the same as regular dirty linen because the chemicals sanitize clothes in the washer. LA J indicated she uses gloves for all linens, but she does not need to use PPE in the handling process of isolation linens. On 10/31/23 at 8:15 AM, Surveyor observed LA J collect dirty linens from hall 100. LA J reached into cart and pulled out dirty linens and dirty linen brushed across LA J's scrubs in the front. On 10/31/23 at 8:19 AM, Surveyor observed LA J collect dirty linens from hall 200. LA J reached into cart and pulled out dirty linens and dirty linens brushed against LA J's scrubs in the front. LA J emptied garbage out and picked the bag up and rested the trash across LA J's abdomen on scrubs and brought out to the back dumpster. LA J entered facility with same gloves on and started sorting dirty linens into the two sinks in the laundry area. Once completed, LA J took gloves off and walked into the clean linen side and began pulling the clean linen cart over to sort clean linens. LA J did not perform hand hygiene. On 10/31/23 at 8:30 AM, Surveyor interviewed LA J and asked process for after handling dirty linens when sorting them into sink and taking gloves off. Surveyor asked if LA J completed hand hygiene and LA J indicated no, I just reapply a new pair of gloves before handling clean linens. Surveyor asked if LA J uses a gown to protect scrubs while handing isolated dirty linens and LA J indicated no. On 10/31/23 at 8:40 AM, Surveyor observed LA J apply new pair of gloves while handling clean linens out of dryer. LA J dropped a clean sock on ground, picked it up and placed it back into clean linen pile in bin. LA J proceeded to washer and took handfuls of clean linens, held it against body onto scrubs and placed into dryer. LA J then went to dirty linens, grabbed dirty linens and placed into washer. LA J took off gloves and went straight into the clean linen area. LA J did not perform hand hygiene between dirty linens and clean linens. On 10/31/23 at 8:45 AM, Surveyor interviewed DON B and asked the process and expectations for handling linens and isolation linens from staff. DON B indicated that staff is supposed to utilize gloves when handling dirty linens and keep dirty linens away from scrubs or clothes when handling. DON B indicated staff should sanitize after completing handling of dirty linens. DON B indicated when handling clean linens, washing or sanitizing hands is expected. DON B stated laundry staff should be using gloves and a gown when handling dirty isolation linens to make sure that clothes are not touching scrubs and laundry staff is expected to sanitize or wash hands if soiled after handling dirty linens and before handling clean linens. DON B also indicated that if any clean linen falls on the ground it is considered automatically dirty and needs to be rewashed in the chemical sanitizing process in washer. DON B indicated she is unaware that laundry staff does not have personal protective equipment (PPE) stored in the laundry area. On 10/30/23 at 2:05 PM, Surveyor observed Certified Nursing Assistant (CNA) L deliver clean linens to R30's room. CNA L touched bathroom doorknob to put into bathroom and exited R30's room. CNA L walked over to clean linen cart and pulled more linens out. CNA L did not perform hand hygiene before or after delivering clean linens. On 10/30/23 at 2:07 PM, Surveyor observed CNA L enter R32's room and deliver clean linens to drawer. CNA L then walked into bathroom and placed clean linens on bathroom bar. CNA L exited R32's room and did not perform hand hygiene. On 10/30/23 at 2:11 PM, Surveyor observed CNA L enter R24's room holding clean linens against body on scrubs then delivered into bathroom. CNA L opened bathroom door and placed towels on the bathroom bar. CNA L exited R24's room and proceeded to clean linen cart without hand hygiene performed. On 10/30/23 at 2:15 PM, Surveyor observed CNA L enter R31's room to deliver clean linens. CNA L had clean linens held against body of scrubs while walking down the hallway and into R31's room. CNA L delivered socks to R31's drawer and hand towels delivered to bathroom. Surveyor did not observe hand hygiene performed before or after. On 10/30/23 at 2:27 PM, Surveyor interviewed CNA L and asked what process for minimizing infection spread between residents when delivering clean linens? CNA L indicated that we usually sanitize hands before entering rooms and after exiting rooms. Surveyor asked if CNA L completed hand hygiene before and after entering and exiting residents' room, and CNA L indicated she did not perform hand hygiene. Example 5 The facility policy, entitled Infection Control - MRSA or other MDROs, date revised June, 2023, states in part: When MRSA or other MDROs are identified, contact precautions should be considered and implemented . b. Contact Precautions . ii. Wear gloves when entering the room. During the course of providing care for a resident changes gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal matter and wound drainage). Remove gloves before leaving the resident's room and wash hands immediately with an antimicrobial agent After glove removal and hand washing, ensure that hands do not touch potentially contaminated environment surfaces or items in the resident's room to avoid the transfer of microorganisms to other residents and environments iii. Wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room, or if the resident is incontinent or has diarrhea, an ostomy or wound drainage not contained by a dressing. The Center for Disease Control and Prevention (CDC) standard of practice, entitled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 07/12/22, states, Contact Precautions are one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions alone. Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room . Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, . Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions On 10/30/23 at 1:41 PM, Surveyor observed that R4 had a sign next to their door that said, Stop contact precautions and indicated that any providers entering the room must: Put on gloves before room entry. Discard gloves before room exit. Put on a gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 10/31/23 at 7:59 AM, Surveyor interviewed Director of Nursing (DON) B regarding their expectations regarding PPE during cares for R4. DON B said that R4 is under contact precautions due to the MRSA in their urine. DON B's expectation is that anyone who is doing direct care with R4's catheter, anything with R4's urine, and cleaning their restroom would wear gown, mask, and gloves and use hand hygiene before and after. If staff were to only be in the room working with low-risk items, then they would only need to use hand hygiene before and after leaving. On 10/31/23 at 9:28 AM, Surveyor interviewed Certified Nursing Assistant (CNA) O about the contact precautions. CNA O said they only needed to wear the full PPE listed on the sign when working with R4's urine or anything the urine would touch. CNA O did wear full PPE in R4's room due to entering to empty R4's catheter. CNA O said they get told what to do for any resident on precautions in the morning meetings, which is how they knew what to do for R4. On 10/31/23 at 9:36 AM, Surveyor observed RN D setting up in R4's room to perform wound care. RN D was only wearing gloves at the time of observation; they did not have plans to have contact with R4 at the time per the interview with RN D. On 10/31/23 at 9:48 AM, RN D performed wound care for R4 for a pressure ulcer on their feet. RN D only wore gloves during the process. Surveyor interviewed RN D regarding the lack of other PPE, and they said that due to not working with his urine, they did not believe they needed to have the full PPE on. When asked how they get their information, RN D said they get it during the morning meeting or from the memos that the facility sends out. RN D also said that if they have any changes, they usually go to an Inter-Disciplinary Team (IDT) meeting, which then sends out a memo to all staff highlighting any changes for residents. On 11/01/23 at 7:35 AM, Surveyor interviewed CNA G regarding what the precautions sign outside R4's door said. After reading the sign posted outside R4's door, CNA G said that it did read that anytime a staff member would enter the room, they should put on a gown, mask, gloves, and use hand hygiene. On 11/01/23 at 7:53 AM, Surveyor interviewed DON B, asking who is responsible for putting up the signs for residents who are under precautions. DON B said they are the person responsible for placing the signs and setting up a resident under contact precautions. When asked about the difference between what the precautions sign read and what staff are saying the procedure is to work with R4, DON B said the sign does not reflect exactly what staff are being told to do. On 11/01/23 at 2:38 PM, Surveyor interviewed DON B about their expectations regarding using the proper precautions sign for someone with a Multi-Drug Resistant Organism (MDRO). DON B said that they should be using an enhanced barrier precautions sign as it reflects their policy better and that the enhanced barrier sign would give visitors or new providers the proper information they would need at the door to work with R4. Example 3 R4 was admitted to the facility on [DATE] and has a diagnosis that includes Methicillin-resistant Staphylococcus aureus (MRSA) in the urine, stage 2 pressure ulcer, and a catheter. On 10/31/23 at 9:36 AM, Surveyor observed Registered Nurse (RN) D performing wound care for R4's pressure ulcer on the right foot. RN D did perform hand hygiene before starting to work on R4's wound. During the observation, RN D cleaned the wound with presumably dirty gloves and reached into the clean bandage box before changing gloves. RN D grabbed a clean bandage and completed the dressing change. During the dressing change, RN D did not place a barrier under R4's foot initially while the old bandage was off, allowing R4's foot to rest on the dirty bed linens to perform the dressing change. On 10/31/23 at 2:30 PM, Surveyor observed a sign outside of R4's door which indicated contact precautions. Surveyor observed RN D provide wound care for R4. RN D entered R4's room to set up supplies and did not apply a gown. Surveyor observed RN D's clothing was touching R4's bed while providing wound treatment to R4's buttocks. Surveyor interviewed RN D asking about the location of MRSA infection. RN D indicated the MRSA is located in R4's bladder and has a suprapubic catheter that does not leak and is a closed system. On 11/01/23 at 10:40 AM, Surveyor interviewed Director of Nursing (DON) B asking about use of personal protection equipment during wound care for R4 and what precautions are implemented. DON B indicated contact precautions are used when providing cares to the infected area and staff are to wear gown, gloves, and mask. Surveyor asked what standards of practice are followed for contact precautions. DON B indicated the facility follows the Centers of Disease Control (CDC). Surveyor reviewed with DON B the observation of staff not wearing PPE during wound care and the facility policy does not follow CDC contact precaution guidance. DON B indicated the policies will be reviewed and updated and staff education will be provided. Example 4 On 10/31/23 at 10:03 AM, Surveyor observed CNA C provide R13 with personal cares. With gloved hands, CNA C cleansed buttocks of stool and removed gloves and washed hands. CNA C, after washing hands, used a paper towel to turn the faucet off and with the same paper towel dried hands. CNA C applied clean gloves and placed a clean brief on R13. CNA C emptied the wash basin into the toilet and dried the basin. CNA C removed gloves, washed hands, and turned the faucet off with clean hands and applied gloves. CNA C applied R13's shoes and combed R13's hair and removed gloves. CNA C gathered the garbage from the garbage can and without hand hygiene touched R13's water mug and held the straw for R13 to drink. On 10/31/23 at 1:24 p.m., Surveyor interviewed CNA C, asking the procedure for proper hand hygiene and when it should be completed. CNA C explained hand hygiene appropriately. Surveyor asked when observed turning the faucet off with paper towel should you use the same paper towel to continue to dry hands? CNA C stated she did use the same paper towel and should not have. CNA C stated she did turn the faucet off with her clean hand and should not have. CNA C stated she should have washed her hands after touching the garbage. Surveyor asked if the facility provides education on proper hand hygiene. CNA C indicated training is provided yearly and competencies are checked off. On 11/01/23 at 10:40 AM, Surveyor interviewed DON B asking about hand hygiene during resident cares. DON B indicated proper hand hygiene is to use clean paper towel to dry hands and not use the same paper towel that was used to turn off the faucet. A different dry towel is to be used to turn off the faucet. Education will be provided to staff.

The facility did not ensure they designated a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis. This had the potential to affect all 32 residents. The DON was named as the Nursing Home Administrator (NHA) on 7/23/22, leaving the DON position open since 7/23/22. This is evidenced by: On 09/26/22 at 9:26 AM, Surveyor conducted an entrance conference with DON B. When asked if there was an NHA, DON B told Surveyor that she was the acting NHA and had been working in that capacity. Surveyor asked her how long she has been the acting NHA. DON B indicated it has been since June. Surveyor asked DON B when she was informed of the change. DON B indicated she had an email and she would look for it. Surveyor asked if another staff member had been assigned to fill the DON role. DON B indicated there had not been anyone else assigned to the DON role. On 09/26/22 at 11:28 AM, Surveyor interviewed the previous NHA C and asked if there is anyone that helps with the vacant NHA position. NHA C indicated that a new NHA is starting on Monday. NHA C indicated that herself, along with another NHA from a sister facility, and the VP from corporate have been coming 1 time a week to assist with the NHA vacancy. Surveyor asked NHA C how long the NHA position has been vacant. NHA C indicated it has been vacant since 07/23/22. NHA C provided Surveyor with Nursing Home Notice of Change for Administrator or Director of Nursing Form: Type of change Administrator. The form listed the previous NHA of record and the new administrator of record to be DON B, date position began 07/23/22, work status Acting (Unlicensed). Surveyor also received the email to review that was received from the State of Wisconsin Licensing/Certification Program Coordinator which indicated they were in receipt of the form. The letter reads in part: .facility must have a licensed NHA no later than November 20, 2022. Surveyor asked NHA C if there was another staff that took over the DON position. NHA C indicated no. Surveyor asked NHA C if the facility had a waiver for not having a full time DON. NHA C indicated no.

Based on observation and interview, the facility failed to ensure food was handled and served in accordance with professional standards for food service safety. This has the potential to affect all 33 residents in the event of a foodborne illness outbreak. Staff observed touching ready to eat foods with contaminated gloves during observation of meal service. Findings include: Facility policy entitled Food Service Safety last revised on May 8, 2018, stated in part, .ii. Food handlers must wear single use gloves when handling ready to eat food. iii. Food can be handled with spatulas, tongs, deli sheets or other utensils . 09/27/22 12:18 PM Surveyor observed [NAME] E clean hands with alcohol based hand rub, apply single use glove to right hand. [NAME] E touched the plates, plate covers and was using that hand to lean on the counter that the food was served from. [NAME] E picked up biscuits with the same contaminated right gloved hand. 09/27/22 1:15 PM Surveyor interviewed [NAME] E and asked what is your policy regarding using your gloved hand touching ready to eat foods like a biscuit for instance, after that same gloved hand has touched everything else. [NAME] E responded we should be using tongs when we pick up ready to eat food. 09/27/22 1:25 PM Surveyor interviewed Dietary Manager (DM) D and asked what is your policy regarding using your gloved hand touching ready to eat foods like a biscuit for instance after that same gloved hand has touched everything else. DM D responded that you should use tongs to serve the biscuit. Surveyor requested a policy about gloved hands touching ready to eat foods and DM D was not sure that they had one and will check. 09/27/22 1:30 PM DM D presented Surveyor with a food service policy. 09/28/22 8:11 AM Surveyor observed [NAME] E using tongs to pick up ready to eat foods for breakfast.