**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled Hand Hygiene, the facility failed to ensure that staff followed hand hygiene practices during the delivery of resident clothes on one of three units (Hall B) and during wound care for one of five residents (R) (R7) with wounds. These deficient practices had the potential to place the residents residing on Hall B and R7 at risk of infection due to cross-contamination. Findings Include:Review of the facility's policy titled Hand Hygiene, revised 12/27/2024, revealed the Guideline section included, Associates should use alcohol based hand rub or wash hands with soap and water for the following indications: Immediately before touching a patient. Before performing aseptic tasks. Before moving from a soiled body site to a clean body site. After touching a patient or the patient's immediate environment. After contact with blood or contaminated surfaces. Immediately after glove removal. Gloves should not substitute for hand hygiene, and hand hygiene must be performed before donning gloves and immediately after removing gloves.1. Observation on 9/16/2025 at 12:14 pm revealed that Laundry Aide EE delivered clean clothing to three residents' rooms on Hall B without performing hand hygiene upon entering or exiting any room.In an interview on 9/16/2025 at 12:18 pm, Laundry Aide EE acknowledged that she did not perform hand hygiene when delivering resident clothing on Hall B. She stated she just forgot. She further stated that there were signs posted throughout the facility reminding staff to perform hand hygiene.2. Review of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE], and diagnoses included, but were not limited to, pressure ulcer of other site stage 3.Review of the Physician's Orders for R7 revealed orders dated 7/15/2025 and 8/28/2025 to apply collagen dressing on Tuesday, Thursday, and Saturday once per day. The procedure included cleaning the right lower leg with normal saline, patting it dry, applying collagen to the open area, applying [treatment] on top, and covering it with a border dressing, related to a stage 3 pressure ulcer.Observation on 9/17/2025 at 10:04 am revealed the Director of Nursing (DON) performed wound care for R7. During the wound care observation, the DON removed her gloves and put on a new pair without performing hand hygiene between dirty and clean dressing changes. In an interview on 9/17/2025 at 10:25 am, the DON confirmed she didn't perform hand hygiene between glove changes during wound care for R7.In an interview on 9/17/2025 at 6:19 pm, the Wound Care Consultant stated that hand hygiene was required between glove changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled A Comprehensive Patients' Rights Program, the facility failed to ensure staff interacted with a resident in a courteous manner and allowed them access to their room for one of four residents (R) (R33) reviewed for choices out of a sample of 19 residents. This failure placed R33 at risk of their rights being violated and not upheld. Findings include: Review of the facility's policy titled A Comprehensive Patients' Rights Program, reviewed 12/29/2023 reads in part, .We believe that all staff should understand the importance of treating patients with care and respect, and honoring patients' rights to make personals choices . Review of R33's undated admission Record, located in the resident's Electronic Medical Record (EMR) under the Resident Summary tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, type 2 diabetes, and major depressive disorder. Review of R33's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/5/2024 located in the resident's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired. Observation on 5/7/2024 at 11:03 am revealed that R33 knocked on his room's door and asked to go inside the room. Nurse Aide Trainee (NAT) 1 opened the door and stated to R33, Go to activities, you need to go to activities and closed the door. R33's facial expression revealed he was visibly upset. Continued observation revealed that R33 waited in front of his room's door until it was opened at 11:08 am. NAT1 then stated to R33, Hurry up and get in here and get what you need. R33 then proceeded into his room. During an interview on 5/7/2024 at 11:09 am, Certified Nursing Assistant (CNA) 1 stated that she, NAT1, and CNA2 were providing care to R33's roommate when R33 knocked on the door. CNA1 stated they had been trained to tell residents they were providing patient care and to ask them to wait. CNA1 stated residents were more than welcome to come in but NAT1 just hollered for R33 to go to activities instead. During an interview on 5/7/2024 at 11:11 am, CNA2 stated she, CNA1, and NAT1 were providing care to R33's roommate when R33 knocked on the door. CNA2 stated when R33 knocked on the door NAT1 instructed R33 to go to activities. CNA2 stated after they finished providing care, NAT1 also was the one that instructed R33 to come into the room and get what he needed. CNA2 stated she did not feel NAT1's statements and tone were appropriate. CNA2 stated they had been trained to open the door and explain they were providing care. CNA2 stated if it is a resident wanting to come into their room then they just pull the curtain and allow the resident to come in. During an interview on 5/7/2024 at 11:43 am, NAT1 stated this was the first time she had experienced a resident knocking and wanting to come into their room while care was being provided to another resident. NAT1 stated when R33 knocked on their door, she opened the door and asked R33 what he needed, then instructed R33 to go to activities, and closed the door back. NAT1 stated after she was finished providing care, she opened the door and told R33 to come in. NAT1 stated she did not recall stating, Hurry up and get in here and get what you need. NAT1 also stated that CNA2 spoke to her after the interaction and told her that R33 had the right to come into the room. During an interview on 5/7/2024 at 2:01 pm, R33 stated he was trying to get into his room to get some money for the soda machine. R33 stated that was the first time he had been denied access to his room. R33 confirmed he had become frustrated at having to wait outside the door. During an interview on 5/8/2024 at 12:57 pm, the Director of Nursing (DON) stated it was her expectation the staff would have allowed R33 in his room when he wanted to go in. The DON stated there was a privacy curtain in the room that could have been pulled to allow privacy if needed. The DON also stated it was the resident's right to go in and out of their room as they please.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record reviews, the facility failed to ensure residents were as free from accidents and hazards as possible for one of 19 sampled residents (R) (R35). R35 sustained an injury when his scrotum was caught in between the toilet seat and the toilet. However, the facility did not address the resident's toilet to ensure another injury would not occur. This failure placed the resident at risk of sustaining another injury. Finding include: Review of R35's undated admission Record, located in the resident's Electronic Medical Record (EMR) under the Resident Summary tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included absence of right leg above knee. Review of R35's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/2024, located in the resident's EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. Review of R35's Event-Initial Note v3.0 dated 4/25/2024 and located in the resident's EMR under the Data Collection tab documented, [R35's Name] was transferring from the wheelchair to the toilet and got their scrotum caught on a rusty screw and squashed from the toilet lid causing a skin tear to bottom of scrotum. Review of R35's Nurses Note dated 4/25/2024 and located in the resident's EMR under the Progress Notes tab documented at 10:20 pm [R35's Name] came to the nursing station and stated he went to the restroom and when transferring from the wheelchair to the toilet he got his scrotum caught on a rusty screw and the toilet lid squashed his scrotum. [R35's Name] has an abrasion noted to bottom of scrotum area cleaned with normal saline. Nurse Practitioner notified and R35 is his own responsible party. Review of R35's Nurses Note dated 5/8/2024 documented that R35 reported, Got my scrotum pinched between the toilet lid and the toilet seat.Open area noted to scrotum. Treatment Nurse and Physician made aware. The area was cleaned and dressed by a treatment nurse. The toilet was looked at by maintenance and the Director of Nursing (DON). There was no rust noted. No visible screws or nails protruding. The raised seat was removed and replaced by maintenance. During an interview on 5/7/2024 at 10:40 am, R35 stated his testicles had gotten caught and scraped by the toilet seat a couple of weeks ago, and the facility had not done anything about it. R35 stated he had a skin tear on his testicles from the incident. During an interview on 5/10/2024 at 1:13 pm, the DON stated R35 reported to nursing that he cut or scratched himself on something when he independently transferred from his wheelchair to the toilet. The DON stated nursing examined the toilet and did not see anything that could have injured R35. However, they did replace the raised toilet seat (after the surveyor had brought it to the facility's attention). The DON also stated the toilet seat should have been examined and replaced following the initial incident on 4/25/2024. The DON stated it was her expectation the nurse who completed the nursing note dated 4/25/2024 would have investigated the cause of the injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain a clean environment for 1 of 13 resident rooms (room [ROOM NUMBER]) on Hall A. Observations revealed that room [ROOM NUMBER] was not clean and had dried food and a sticky substance on the bedside table during the survey. This failure had the potential to place residents in an environment for use of unsanitary and unsafe equipment. Findings included: Observation on 02/07/2023 at 9:58 a.m. in room [ROOM NUMBER], the bedside table was observed to have dried, white liquid matter on the base of the bedside table and the wall next to the bed had dried matter, medium brown in color, approximately two inches in diameter. Observation on 02/07/2023 at 11:25 a.m., the wall next to the bed in room [ROOM NUMBER] had dried matter, medium brown in color, approximately two inches in diameter. The bedside table base had a sticky substance that covered the base of the legs. Observation on 02/07/2023 at 4:45 p.m., the wall next to the bed in room [ROOM NUMBER] had been cleaned; however, the bedside table still had a sticky substance on the base of the bedside table. Observation in room [ROOM NUMBER] on 02/08/2023 at 9:54 a.m., the bedside table had a sticky substance that covered the base of the table, the wall under the window had dried, brown matter splattered on it, and the fall mat next to the bed was observed to have dried, brownish/orange matter on it. Interview on 02/08/2023 at 9:58 a.m. with Laundry Aide 9 in room [ROOM NUMBER], stated she had worked in the facility for 32 years. She stated the rooms were cleaned daily, including sweeping, mopping, dusting, emptying trash, and cleaning the bathrooms and, then after lunch, housekeeping staff checked the rooms to make sure the trash was emptied, and the bathrooms were clean. The Laundry Aide 9 further revealed that she had not yet cleaned room [ROOM NUMBER]. Observation on 02/08/2023 at 12:53 p.m., the bedside table in room [ROOM NUMBER] still had a sticky substance on the base, and there was a dried, brown substance splattered on the wall. The fall mat had been turned upside down lying next to the bed. Observation and interview on 02/08/2023 at 2:28 p.m. with the Housekeeping/Laundry Supervisor in room [ROOM NUMBER], the fall mat was flipped over, revealing food underneath, and stuck to the fall mat. The Housekeeping/Laundry Supervisor observed the food on the floor, and under the mat, and stated that the substance on the floor and on the wall under the window appeared to be food. The Housekeeping/Laundry Supervisor revealed there was something sticky on the base of the bedside table. He stated his expectation would be for the area to be cleaned daily. He stated he was not aware of a policy regarding daily cleaning of rooms, only a list of what to deep clean when a resident left the building. Interview on 02/08/2023 at 3:55 p.m. with the Administrator, she stated it was her expectation that rooms should be cleaned daily, and walls and bedside tables should not have food, liquids, or debris on them. She stated she was unaware of a policy related to cleaning the resident rooms.

Based on observations, staff and resident interviews, record review, and a review of the facility policy titled, Care of Fingernails/Toenails the facility failed to ensure grooming assistance was provided for 1 of 3 sampled residents (R) (#54) reviewed for activities of daily living (ADLs). Observations and interviews revealed that #54 was not provided toenail care. This failure had the potential to negatively impact the resident's quality of life. Findings included: A review of the facility policy titled, Care of Fingernails/Toenails dated 12/04/2021, specified, It is the intent of this center to provide appropriate nail care to all patients. The most recent quarterly Minimum Data Set (MDS), for R#54 dated 01/02/2023, revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The resident required supervision with personal hygiene. Review of the care plan for R#54 dated 03/14/2020, revealed the resident had a self-care deficit, and interventions included to assist with ADLs as needed, provide assistance with self-care as needed, and provide cues as needed. Observation and interview on 02/06/2023 at 10:04 a.m. revealed that R#54's toenails on both feet were long and sharp. R#54 indicated staff had not cut their toenails. R#54 indicated they would like their toenails to be trimmed. Observation on 02/07/2023 at 9:44 a.m. revealed that R#54's toenails remained long and sharp. Observation on 02/08/2023 at 10:34 a.m. revealed that R#54's toenails remained long and sharp. Interview on 02/08/2023 at 10:45 a.m. with a Certified Nursing Assistant (CNA) 6, revealed that the nurses and the treatment nurse were responsible for toenail care. CNA 6 stated she thought CNAs could cut resident's toenails if the resident was not diabetic. Interview on 02/08/2023 at 11:14 a.m. with a Certified Medication Aide (CMA) 3, revealed that CNAs could perform toenail care if the resident was not a diabetic; otherwise, the treatment nurse completed nail care. CMA 3 indicated toenail care was done with showers. Observation and interview on 02/08/2023 at 12:22 p.m. with the Wound Care Nurse revealed CNAs provided toenail care if the resident was not diabetic. The Wound Nurse stated that the CNAs could provide toenail care for R#54. The Wound Nurse observed R#54's feet and stated that the resident's toenails needed to be trimmed. Interview on 02/08/2023 at 2:16 p.m. with the Director of Nursing (DON), revealed she expected nail care to be provided when needed and that residents' toenails should be checked daily. Interview on 02/09/2023 at 9:26 a.m. with the Administrator, she revealed that the expectation was that all staff would be aware of care for the residents and know for whom they could and could not perform nail care.

Based on observation and interviews, the facility failed to ensure the upkeep of resident wheelchairs related to dirt, dust, and hair buildup. This affected seven residents (R) (#10, #32, #40, #64, #69, #77, and #89) of 57 residents that utilized wheelchairs. Findings include: 1.On 12/16/19 at 8:51 a.m. R#32 observed in hallway with dirt, dust, and hair buildup on undercarriage and spokes of the wheelchair. 2.On 12/16/19 at 9:37 a.m. R#77 was observed sitting in the wheelchair with dust and dirt buildup. 3.On 12/16/19 at 10:56 a.m. R#89 was observed sitting in a wheelchair with a white coating on the wheels and spokes of the wheelchair. 4.During observation of smoke break from 2:00 p.m. until 2:21 pm on 12/16/19, R#77, R#69, R#40, and R#10 were observed with dirt, dust, and hair buildup on undercarriage and spokes on wheelchairs. 5.During the smoke break observation on 12/17/19 at 9:15 a.m., R#77, R#69, R#64, R#40, and R#10 were observed with buildup on spokes and undercarriage of wheelchairs. During tour with the Housekeeping Supervisor on 12/18/19 from 10:03 a.m. until 10:20 a.m. he confirmed dust, dirt, and hair buildup on wheelchairs for R#10, R#32, R#40, R#69, R#77, and R#89. He confirmed that the floor techs are responsible for cleaning wheelchairs on the hallway. He explained that one hall is cleaned per week. He acknowledged that there is some difficulty is cleaning wheelchairs as residents do not want to get out of their chairs to be cleaned. He explained that it takes two or three hours to clean the wheelchairs and this is done during the day shift. The Housekeeping Supervisor did not have any documentation supporting which wheelchairs were cleaned and which residents refused to have their wheelchairs cleaned.

Based on observation and interviews the facility failed to assure the sanitary cleaning and storage of cigarette clips. This deficient practice affected five of nine residents that smoke. Findings include: On 12/16/19 at 2:00 p.m., there were nine residents present for the smoking break with five of the nine residents utilizing cigarette clips when smoking. One female resident was observed with the cigarette clip on lips and tongue. At the end of the smoke break all clips were placed in the smoking supply box without being cleaned and was then stored in the medication storage room. During the smoking observation on 12/17/19 at 9:15 a.m., there were nine residents present for the smoke break. There were five residents observed to be using smoking clips. One male and one female resident were observed with lips on cigarette clip while smoking. At the end of the smoking break the cigarette clips were placed in the smoking supply box without being cleaned and then stored in the medication room. During an interview on 12/18/19 at 10:57 a.m., Infection Control Specialist reported that she does not have a policy for staff to clean cigarette clips after resident's smoke and is not sure who is responsible for cleaning the cigarette clips. During an interview on 12/18/19 at 11:00 a.m. with Certified Nursing Assistant (CNA) AA it was reported that she does not clean the cigarette clips after resident's smoke, and she believes housekeeping staff is responsible for this. During an interview on 12/18/19 at 11:01 a.m. with the Housekeeping Supervisor it was reported that housekeeping does not clean the cigarette clips and has nothing to do with the smoking process. An interview was conducted with the Administrator on 12/18/19 at 11:07 a.m. and it was reported that there is no current policy or plan related to the cleaning of the cigarette clips after resident's smoke at this time. CNA BB reported on 12/18/19 at 12:12 p.m. that she does not clean the cigarette clips after resident's smoke and is not aware of who cleans the clips.