Based on observations, interviews, resident record review, and review of a facility policy titled Hand Hygiene the facility failed to ensure Employee Identifier (EI) #3, Certified Nursing Assistant (CNA), did not create the potential for cross-contamination during meal delivery on 9/25/2023 when she was observed not washing or sanitizing her hands between residents. after touching a dirty bedside table, dirty window blinds, and a resident chair before touching the clean tray cart, donning gloves and setting up a resident tray. This had the potential to affect 21 residents who received meal trays on unit two. Findings include: A facility policy titled Hand Hygiene with an implemented date of 6/1/2022 documented the following: . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table . Between resident contacts . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . On 9/25/2023 at 5:14 PM, EI #2 CNA was observed delivering meal trays to residents in their rooms. EI #2 delivered a tray with bare hands, for RI #5, placing the tray on RI #5's bedside table. EI #2 then pulled the window blinds down and left the room without washing or sanitizing her hands. EI #2 then delivered a meal tray for RI #1, placing the tray on the bedside table, moving the bedside table in front of RI #1, and exiting the room without washing or sanitizing her hands. RI #4 was in the hallway in a chair. EI #2 pushed RI #4 in the chair, holding the handles of the chair, to a common area without washing or sanitizing her hands. EI #2 continued to pass out meal trays without washing or sanitizing her hands, touching the food cart down the hall, and delivering a meal tray for RI #3. EI #2 set the tray down and moved the bedside table in front of the resident. EI #2 continued out of the room without washing or sanitizing her hands, and delivered a tray for RI #2. EI #2 placed the tray on the bedside table, turned the resident around in the wheelchair by the handles of the wheelchair, and then pushed the bedside table up to the resident. EI #2 then, without washing or sanitizing her hands, donned gloves and began setting up the meal tray for RI #2, opening containers of food, drinks, silverware, and condiments. EI #2 then removed her gloves and went to the common area down the hall and pushed RI #4 in a chair from the common area to RI #4's room. EI #2 then delivered RI #4's meal tray, all without washing her hands. On 9/25/2023 at 5:30 PM EI #2 CNA was asked, when was she supposed to wash or sanitize her hands. EI #2 responded, before entering and after leaving every room. EI #2 stated, that the facility policy was to wash or sanitize hands before entering and after leaving every room. EI #2 stated, she did not sanitize or wash her hands before touching the clean trays after handling the dirty bedside tables, window shades, resident's chairs, donning or doffing gloves. EI #2 stated, the risk of not washing or sanitizing her hands after touching a dirty tray was the spread of germs, infections. EI #2 stated, she should have washed or sanitized her hands after leaving each room before picking up each clean tray. On 9/26/2023 at 11:00 AM EI #1 Infection Preventionist was asked, according to policy when should staff wash or sanitize their hands. EI #1 responded, before entering a room, when visibly dirty, when in contact with a resident, when leaving the room, and when delivering or picking up the trays. EI #1 stated, the risk for what EI #2 had done, was contamination of everything she touched. EI #1 stated, she should have washed or sanitized her hands before entering every room and leaving every room.

Based on interview, record review and a facility policy tilted Abuse, Neglect and Exploitation the facility failed to report two allegation of physical abuse involving Resident Identifier (RI) # 50 and RI # 44 within two hours of staff being made aware of the incident. This affected 2 of 3 abuse files reviewed during the survey. Findings Include: A review of a policy titled Abuse, Neglect and Exploitation dated March 2019 documented the following: . VII Reporting/Response . Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . On 6/1/2019 at 11:49 AM, the State Agency received a report by the facility regarding physical abuse by RI #50 toward another resident. The report indicated the incident occurred on 5/31/19 at 5:06 PM. On 6/17/19 at 1:12 PM, the State Agency received a report by the facility regarding physical abuse by a staff toward RI #44. The report indicated the incident occurred on 6/17/19 at 7:00 AM. On 07/09/19 2:36 PM, Employee Identifier (EI) #1, Administrator was interviewed. He was asked when did the allegation of physical abuse occur concerning RI #50. EI #1 replied on 5/31/19. He was asked when was it reported to the State Agency. EI #1 replied on 6/1/19, after he became aware, that was a Saturday morning. EI #1 was asked when should it have been reported to the State Agency. He replied it should have been reported by 7:06 PM on 5/31/19. EI #1 was asked when did the incident of physical abuse involving RI #44 occur. He replied on 6/17/18 at 7:00 AM. EI #1 was asked when was it reported to the State Agency. He replied at 12:02 PM on 6/17/18. When asked when should it have been reported to the State Agency, EI #1 replied by 9:00 AM on 6/17/18. EI #1 was asked why should allegations of abuse be reported to the State Agency within 2 hours. He replied to protect the resident or others involved.