**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the Renal Therapeutic Diet for 1 of 2 residents (R32) reviewed for therapeutic diets in the sample of 35. Findings Include: R32's Minimum Data Set (MDS) dated [DATE] documents R32 is cognitively intact. R32's Physician Order Sheet dated 7/1/24 documents diet order Renal, CCD (Consistent Carbohydrate) regular texture, Regular liquid, and no added salt. R32'S Face Sheet dated 4/9/23 documents R32's has the diagnoses End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus without complications. R32's End Stage Renal Failure Care Plan dated 11/5/23 documents compliance with treatment plan, fluid restrictions, and dietary restrictions. R32's Meal Card does not reflect a Renal, CCD (Consistent Carbohydrate) no salt added diet. For breakfast her meal card documents 4 ounces of ham and potato casserole, sausage links, oatmeal, fresh cantaloupe, rye toast. For lunch the meal card documents garden salad, Italian wedding soup, salami sandwich, potato chips, and frosted vanilla cupcake. On 8/29/24 at 3:30 PM, two CNA's (Certified Nursing Assistants) were on the 200 hall with meal cards asking the residents what they want to eat for dinner. V11, CNA stated I'm sorry I don't know what a renal diet is. I couldn't tell you. I know she is diabetic. V12, CNA stated a renal diet means you should watch their salt and fluids. On 08/30/24 at 9:25 AM, V13, Assistant Manager/Day Shift [NAME] stated you limit potatoes, tomatoes, and bananas. I give them what they order on their ticket, which usually shows different choices for the renal diet. (the diet card does not show different choices for the renal diet.) On 08/30/24 at 9:35 AM, R32 stated a renal diet is when you eat less salt. I can have tomatoes; potatoes and I only eat one banana. R32 had a bag of potato puffs lying on her bed. R32 stated that's my snack for dialysis. My kids give me that. The Facility policy titled Therapeutic Diets dated 1/2017 documents: A therapeutic diet must be prescribed by the resident's attending physician. The Physician's diet order should match the terminology used by food services.

Based on observation, interview, and record review, the Facility failed to ensure the dish machine had the chemical level required for effective sanitation and failed to store food in accordance with professional standards for food service safety. This has the potential to affect all 70 residents residing in the Facility. Findings include: 1. On 8/27/24 at 12:02 PM, V5, Dietary Aid, removed a tray of dishes from the dish machine after the cleaning cycle was completed and placed the tray next to the machine on the clean side of the machine. V5 then placed a tray of dirty dishes in the machine and began another cleaning cycle. When the wash cycle began, V5 placed a sanitizer test strip in the dish water reservoir on the front of the machine. V4, Dietary Manager, was in the room and stated, Not yet prompting V4 to wait before attempting the test. V5 waited until the final rinse cycle began, then placed the strip in the reservoir. The test strip did not change color and remained white. V4 stated the dish machine was tested earlier that morning. On 8/27/24 at 12:15 PM, V4, Dietary Manager, brought a different test strip package into the dish room. She stated they were the sanitizer test strips, because the other strips were not working. V4 placed a test strip in the reservoir during the final rinse cycle. The strip turned light orange which correlated to 100 ppm (parts per million) on the test strip package. V5 stated it was supposed to be 200 ppm. On 8/27/24 at 12:21 PM, V4, Dietary Manager, stated she located a different kind of test strip, because they should be turning purple. V4 placed the strip in the water reservoir during the final rinse, and the strip remained white. V4 stated she would call the maintenance technician who comes monthly, because there is not much sanitizer coming out of the tubing during the rinse. 2. On 8/27/24 at 12:12 PM, There was a box of uncooked pork loin fritters on a shelf directly above a box of cookie dough. There was a box of uncooked beef loin fritters on a shelf directly above another box of cookie dough. There was a box of uncooked beef Philly steak that was placed on top of a box of pizza dough. There was a box of frozen uncooked shrimp on a shelf directly above a box of nutritional shakes. On 8/27/24 at 12:40 PM, V4, Dietary Manager, stated I was thinking it would be ok (to store uncooked animal protein on higher shelves) since they're frozen. On 8/28/24 at 2:30 PM, V1, Administrator, stated she was unable to find the dish machine specifications and may have to order a new user manual. On 8/30/24 at 9:45 AM, V2, Director of Nursing (DON), stated she expects dietary staff to follow all dietary policies. The Facility's Undated Dish Machine Operation Policy documents, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. Check the dishwashing machine each morning before first set of dishes are to be washed. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. If a chemical sanitizer is used, check the concentration using the correct test tape for type of sanitizer in use. The Facility's Undated Food Storage (Dry, Refrigerated, and Frozen) Policy documents, Guideline: Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/27/24 documents there are 70 residents living in the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure residents were free from verbal abuse for 1 of 3 residents (R45) reviewed for abuse in the sample of 44. Findings include: R45's Minimum Data Set (MDS), dated [DATE], documents R45 is cognitively intact and requires extensive to total assistance with most Activities of Daily Living. R45's Progress Note by V1, Administrator, on 5/14/23 at 11:22 AM documents, Resident reported an agency CNA had been rude with her and threw a grabber on her bed and it landed on the resident's legs. This writer assessed bilateral lower legs and saw (no) injuries or discolored areas. The Facility's Initial Report sent to the Illinois Department of Public Health by V1 on 5/14/23 documents, At 10:30 AM on 5/14/2023, I was notified by (V12, CNA, Certified Nurse Aide), and (V13, CNA) that resident (R45) had told them a night shift CNA had thrown a grabber at her. Administrator went and immediately spoke with (R45) about allegation. (R45) states she was in bed and (V14, CNA) responded to call light and when asked to apply lotion to residents back she stated she couldn't reach the lotion and needed a grabber, (R45) handed (V14) her grabber at which point (V14) left room for 20 minutes. When (V14), CNA, returned to room she threw the grabber on the bed, and it landed on (R45)'s lower legs. (R45) states (V14) CNA was rude with her both times she came in room telling her she could do things herself. Roommate (R57) interviewed, and states (V14) was rude to (R45) but not her. (R45) states (V14) did not return to room after that. This writer examined legs and found no injuries or discoloration, (R45) states legs did not hurt when it (hit) by grabber. The Facility's Final Report sent to Illinois Department of Public Health by V1on 5/19/23 documents, At 10:30am on 5/14/23 I was notified by (V12), CNA and (V13), CNA that resident (R45) had told them a night shift CNA had thrown a grabber at her. Administrator went immediately to speak to (R45) about allegation. Resident states she was in bed at approximately 1830 (6:30 PM) on 5/13/23and (V14), CNA, responded to call light and when (R45) asked her to apply lotion to her back (V14) stated she couldn't reach the lotion and needed a grabber, (R45) handed (V14) her grabber to use and (V14) then left room returning 20 minutes later. Upon re-entering resident's room (V14) threw the grabber on the bed and it landed on (R45)'s lower legs and told (R45) to apply the lotion herself. (R45) states she only had those 2 encounters with the CNA (V14) then another (another) CNA took over her care. (R45) denies telling any staff about the episode until the next morning when she spoke to CNAs (V12) and (V13). Roommate (R57) was interviewed and states that she heard (V14) being rude to (R45) but she wasn't rude to her. (V14) is an agency and did not return calls for interview about episode. (V14) has been marked as a do not return on the agency portal. (R45) during interview stated she found the way care was refused and the way she was spoken to by (V14) was abusive. On 7/20/23 at 9:50 AM, V13 stated, (R45) told me that (V14) came in and was rude and nasty to her and got upset with her because she wanted things, then (V14) took the grabber and threw it at (R45). (R45) was upset, but said her leg wasn't hurt. On 7/20/23 at 11:28 AM, R57, R45's roommate, stated, (V14) was not very nice to (R45). She was very ugly to her. (R45) told (V14) she was going to turn her in, then (V14) made a remark that was not very nice. Then (V14) threw her hands up and broke my little flower (decoration). It was a gift from my old roommate who passed away. (V14) is in the wrong profession. R57's MDS, dated [DATE], documented R57 was cognitively intact. On 7/20/23 at 1:47 PM, V1 stated she would not expect staff to throw items on resident beds. The Facility's Abuse, Prevention and Prohibition Policy revised 10/2022 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Policy documents This facility prohibits mistreatment, neglect or abuse of residents. The Policy documents The residents must not be subjected to abuse by anyone.

Based on interview, and record review the facility failed to ensure that residents who require antibiotics are prescribed the appropriate antibiotics to treat infections for 4 of 4 residents (R11, R41, R47, R58) reviewed for antibiotic stewardship in a sample of 44. Finding include: The Facility's Infection Prevention and Control Manual Antibiotic Stewardship and MDROs dated 2019 documents It is the policy of this facility to provide systematic efforts to optimize the use of antibiotics in order to maximize their benefits to residents, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. Antibiotic Stewardship will include an assessment process, use of evidence-based criteria, efforts to identify the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed. 1. R11's Urinalysis report, dated 5/29/23, documents R11 had 2+ blood, 1+ protein, 3+ leukocytes and greater than 50 white blood cells. There was no culture and sensitivity attached to these results. R11's Health Status Note dated 05/29/23 at 3:40 PM documents Partial UA (urinalysis) rec'd (received) and reported to (V22, Physician), on call for (V21, Physician). (V22) would like to order Bactrim DS but this nurse informed him that resident's POA refuses Bactrim as it upsets her stomach. New order rec'd for Macrobid 100 mg (milligrams) PO (by mouth) BID (twice daily) for 5 days. POA (Power of Attorney) notified. At this time, there was no Culture and Sensitivity (C&S) results to ensure that Macrobid was sensitive to the organism causing R11's UTI. R11's Physician Order dated 05/31/23 documents Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohydrate Macro); Give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 11 Administrations 7 days total. R11's C&S report, dated 6/2/23, documented Bactrim had intermediate sensitivity to the urinary bacteria. R11's Health Status Note dated 06/05/23 at 9:59 AM documents Final urine culture rec'd with intermediate sensitivity noted to Macrobid, (V21) notified, awaiting any new orders. R11's Physician Order dated 06/05/23 documents Cefuroxime Axetil Oral Tablet 500 MG (Cefuroxime Axetil); Give 1 tablet by mouth two times a day for UTI for 5 Days. 2. R41's Health Status Note dated 03/04/23 at 11:04 AM documents UA (urinalysis) from 03/01/23 rec'd, cx (culture) pending, (V16) notified, awaiting any new orders. R41's Health Status Note dated 03/04/23 at 2:10 PM documents (V23), NP (Nurse Practitioner) here, new order rec'd for Keflex 500 mg PO TID (three times daily) x 5 days. Resident aware and agrees with plan. This was ordered prior to identifying if the organism causing R41's UTI was sensitive to Keflex. R41's Physician Order dated 04/12/23 documents Amoxicillin-Pot Clavulanate Tablet 875-125 MG; Give 1 tablet by mouth two times a day for UTI for 7 Days to start 04/12/23 after UA collection. This antibiotic was started prior to getting a UA or C&S. R41's Health Status Order dated 05/29/23 at 11:43 AM documents Partial UA result rec'd and reported to (V16), cx (culture) pending, awaiting any new orders. R41's Health Status Note dated 05/29/23 at 1:18 PM documents New order rec'd per (V16) for Keflex 500mg PO TID for 7 days. Resident aware and agrees with plan. R41's Physician Order dated 05/29/23 documents Cephalexin Capsule 500 MG; Give 1 capsule by mouth three times a day for UTI for 7 Day. This antibiotic was started prior to getting C&S results to determine if the antibiotic used was sensitive to the organism causing R41's UTI. 3. R47's Nursing Note dated 05/03/23 at 9:50 AM documents UA WAS OBTAINED LAST NIGHT AND SENT TO LAB. AWAITING RESULTS. R47's Physician Order dated 05/06/23 documents Cephalexin Capsule 500 MG; Give 1 capsule by mouth three times a day for infection for 7 Days. R47's Nursing Note dated 05/06/23 at 2:49 PM documents UA results. E. Coli detected. New order for Keflex 500mg 1 po BID x7 days. Resident and POA aware and voices understanding. R47's Urine Culture dated 05/06/23 documents Escherichia Coli. No sensitivity report noted. Unknown if E. Coli is susceptible to Keflex antibiotic. 4. R58's Health Status Note dated 07/10/23 at 6:07 PM documents R58's UA results were received and a new order from Bactrim DS 800/160, 1 tablet po twice daily for 7 days for UTI. R58's Urinalysis dated 07/10/23 documents Culture, urine microbiology tests to follow on separate report. R58 was started on Bactrim prior to receiving the C&S report to determine if the antibiotic given was sensitive to the organism causing R58's UTI. R58's Physician Order dated 07/15/23 documents Ciprofloxacin HCl Oral Tablet 500 MG (Ciprofloxacin HCl); Give 1 tablet by mouth two times a day for UTI for 10 Days. On 07/21/23 at 10:47 AM, V2, Director of Nursing, DON, stated that the facility's medical director, V16, is old school. V2 stated that V16 does not wait for the culture and sensitivity prior to ordering antibiotics. V2 stated V16 orders antibiotics for symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide residents and/or resident's representatives education on the risks and benefits of influenza and pneumococcal immunizations, and document education and refusals in the residents' medical records for 4 of 5 residents (R31, R35, R61 and R70) reviewed for influenza and pneumococcal immunization in the sample of 44. Findings include: 1. R31's Face Sheet documents R31 was admitted to the facility on [DATE] with diagnosis of Pneumonia, unspecified organism, abnormal sputum, Shortness of Breath, Cardiomyopathy and Chronic Kidney Disease. R31's Minimum Data Set, MDS, dated [DATE] documents R31 has severe cognitive impairment. The MDS documents R31 received the Influenza immunization 10/24/22. R31's MDS documented the pneumococcal vaccine was offered and declined. R31's medical records do not document R31 received education of the risks or benefits of the pneumococcal vaccination and there was no documentation R31 and/or R31's representative signed a refusal or declination form. 2. R35's Face Sheet undated documents was admitted to the facility on [DATE] with a diagnosis of Hemiplegia, Cerebral Infarction, Mild Cognitive Impairment of Uncertain or Unknown etiology and COVID-19. R35's MDS, dated [DATE], documents R35 has severe cognitive impairment. R35's MDS documents R35 received the Influenza vaccine on 10/24/22 and that R35 received the Pneumococcal immunization. R35's medical records do not document that R35 received education of the risks or benefits of the pneumococcal vaccination. 3. R61 Face Sheet undated documents R61's was admitted to the facility 5/2/22 with medical diagnosis of Atrioventricular Block, First degree, Type 2 Diabetes, Nondisplaced comminuted fracture of right patella, Initial encounter for closed fracture and Unilateral Primary Osteoarthritis left knee. R61's MDS, dated [DATE], documents R61 is cognitively intact. The MDS documents R61 received the Influenza immunization 10/25/22 the pneumococcal immunization was offered and declined. There was no documentation in R61's medical records that R61 and/or R61's responsible party received education of the risks or benefits of the pneumococcal vaccination and did not sign a refusal or declination form. On 7/20/23 3:00 PM R61 stated she R61 did not know anything about a pneumonia shot. 4. R70's Face Sheet documents R70 was admitted to the facility on [DATE] and discharged [DATE]. R70's diagnosis was documented as Chronic Kidney Disease, Unspecified B-Cell Lymphoma, and fracture of Unspecified part of neck of right Femur, Subsequent encounter for closed Fracture. R70's MDS dated [DATE] documents R70 is cognitively intact. The MDS documents R70 received the Influenza immunization 10/25/22, the pneumococcal immunization was offered and declined. R70 medical records did not document he received any immunizations during his stay in the facility. R70's medical record did not document that R70 received education of the risks or benefits of the pneumococcal vaccination and did not sign a refusal or declination form. On 7/19/23 at 3:05 PM V2 Director of Nursing (DON) stated she had only been in the job a couple of months and was uncertain what procedure the previous DON had in place. But she (V2) did not have any refusal forms signed. On 7/20/23 at 1:35 PM V1, Administrator, stated, We have something we need to get straighten out and hence forth we will have documentation of refusals. The facility Policy Pneumococcal Vaccine revised August 2008 documents Residents/representatives have the right to refuse vaccination. Refusal will be documented on the Pneumococcal Immunization Informed Consent form and will include the date, reason for refusal and signature.

Based on interview and record review the facility failed to have a Registered Nurse (RN) in the facility for 8 hours daily. This has the potential to affect all 70 residents living in the facility. Findings include: The Facility Nursing Schedule dated July 4th through July 18 was reviewed, and on July 14, 2023, the facility did not have a Registered Nurse (RN) for eight consecutive hours. On 7/20/23 at 3:30 PM, V2, Director of Nursing stated, that was an oversight, and it has been corrected. On 7/21/23 at 10:25 AM V1 Administrator stated, we use the state regulations for our policy for staffing. The facility's Resident Census and Conditions of Residents Form, CMS 672, dated 7/18/23 documents the facility has a census of 70 residents. The CMS 672 documents 5 residents have indwelling or external catheters, 1 resident is restrained, 5 residents have pressure ulcers, 33 residents have dementia, 7 residents are receiving Hospice, 2 residents are receiving dialysis, 2 residents are receiving intravenous therapy/IV nutrition, and or/ blood transfusions, and 10 are residents are receiving antibiotics.

Based on observation, interview, and record review, the Facility failed to store, prepare, and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 70 residents living in the Facility. Findings include: On 7/18/23 at 12:18 PM, V6, Cook, removed a bowl of tomato soup from the microwave and placed it on R65's tray. V6 did not test the temperature of the soup before tray was passed to R65. On 7/18/23 at 12:37 PM, V6, Cook, removed a bowl of tomato soup from the microwave and placed it on R30's tray. V6 did not test the temperature of the soup before the tray was passed to R30. On 7/18/23 at 12:47 PM, V6, Cook, removed a pan of hash brown casserole from the oven and placed it on the steamtable. V6 did not test the temperature of the casserole and plated the casserole on both R45's and R57's trays. The trays were then passed to R45 and R57. On 7/19/23 at 9:54 AM, the Nourishment room freezer had a half empty container of ice cream from a fast-food restaurant that was not labeled or dated. In the Nourishment refrigerator, there was a sealed plastic bag of watermelon cubes that was not labeled or dated. There was a half empty jar of pickled jalapenos with no date and a half empty jug of lemonade with no date. On 7/18/23 at 1:00 PM, V5, Food Service Director, stated she expects her staff to check temperatures before serving. On 7/20/23 at 8:37 AM in the dining room refrigerator there was a container labeled Italian chicken that was not dated. There was a plastic bag with four pieces of an unknown breaded meat that was not labeled or dated. There was an opened jar of cherries and an opened jar of jelly that were not dated. There were two opened containers of snow cone syrup that were not dated. On 7/20/23 at 1:47 PM, V1, Administrator, stated she expects staff to follow the Facility's food service policies. The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy, undated, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. The Policy documents General storage guidelines to be followed: All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. The Policy documents Keep potentially hazardous foods out of the temperature danger zone (41 °F - 135°F, or per state specific regulations). The Facility's Monitoring Food Temperatures for Meal Service Policy, undated, documents, Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. Procedure: Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. The Policy documents If the serving/holding temperature of a hot food item is not at 135° F (Fahrenheit) or higher (check your state specific regulations: some states require 140°F minimum hot holding temperature) when checked prior to meal service, the item will be reheated to at least 165° F for a minimum of 15 seconds. The Resident Census and Condition of Residents Form, CMS 672 dated 7/18/23 documents there are 70 residents living in the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on interview and record review, the facility failed to identify causative organisms to assist with identification of patterns to prevent infections. This has the potential to affect all 70 residents living in the facility. Findings include: 1. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated February 2023 documents Sections for infection site, symptoms, date of culture/x-ray and organism/results. The Line Listing documented on 02/27/23: R55 had symptoms of dysuria and was started on Keflex with no causative organism/results listed. 2. The facility Infection Control Log for March 2023 documents 5 cultures with no organisms listed on the log. There was a total of 24 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated March 2023 documents on 03/20/23 R19 had symptoms dysuria. The Line Listing documented R19 was started on Bactrim DS with no organism/results listed. The Line Listing documented 03/05/23 R59 had symptoms of lethargy and was started on Keflex with no causative organism/results listed. The Line Listing documented on 3/6/23, R49 had symptoms of urinary symptoms and was started on Levaquin with no causative organism/results listed. 3. The facility Infection Control Log for April 2023 documents one culture with no organism listed on the log. There was a total of 11 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated 04/17/23 documents R4 had symptoms of dysuria. The Line Listing documented she had no growth but was started on Keflex for UTI. 4. The facility Infection Control Log for May 2023 documents 4 cultures with no organisms listed on the log. There was a total of 22 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated May 2023 documents on 05/03/23 R13 had symptoms of abnormal UA results. The Line Listing documents R13 was started on Macrobid with no causative organism/results listed. The Line Listing documents on 05/08/23 R13 had symptoms of lethargy and was started on Macrobid with no causative organism/results listed. The Line listing documents on 05/05/23 R32 had symptoms of lethargy and was started on Bactrim with no causative organism/results listed. 5. The facility Infection Control Log for June 2023 documents 3 cultures with no organisms listed on the log. There was a total of 9 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated June 23 documents on 06/08/23 R30 had dysuria and was started Bactrim DS with no causative organism/results listed. 6. The facility Infection Control Log for July 2023 documents 2 cultures with no organisms listed on the log. There was a total of 5 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated July 23 documents on 07/12/23 R32 had symptoms of malodorous dysuria and was started Keflex with no organism/results listed. On 07/21/23 at 10:47 AM, V2, Director of Nursing (DON), stated that the infection control log is missing organisms because sometime hospice will not order antibiotic but will not do a culture and sometimes the doctor will order antibiotics before the culture comes back. Facility's Infection Prevention and Control Program Manual Surveillance dated 2019 documents Infection prevention begins with routine and ongoing surveillance to identify possible communicable diseases or infections before they can spread to other persons in the facility or have the potential to cause, an outbreak. The facility closely monitors all residents who exhibit signs/symptoms of infection through ongoing surveillance and has a systematic method for collecting, consolidating, analyzing, and interpretation of data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes. The intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, surveillance is crucial in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, direct in-service education, and identify individual resident problems in need of intervention. The Resident Census and Condition of Residents Form, CMS 672 dated 7/18/23 documents there are 70 residents living in the Facility. B. Based on observation and record review, the facility failed to perform hand hygiene to prevent the spread of infection for 3 of 11 residents (R11, R47, R58) reviewed for infection control in the sample of 44. Findings include: 1.R11's Minimum Data Set, dated [DATE] documents R11 requires extensive assistance of two plus persons for toilet use and is always incontinent of urine. R11's Physician Order, dated 6/5/23, documented R11 was receiving Cefuroxime Axetil for a Urinary Tract Infection (UTI) On 07/20/23 at 1:58 PM, V20, CNA, assisted R11 with incontinent care. V20 washed hands with soap and water in bathroom. V20 donned gloves and removed blanket from R11. V20 washed R11's peri-area and vagina with wet wash cloth. V20 dried R11's peri-area and vagina with a towel. V20 rolled R11 toward wall and washed R11's buttocks and gluteal cleft with a new wet washcloth and dried with a towel. V20 placed a new bed pad under R11. R11 was rolled toward V20. Bed pad was straightened out and R11 was rolled onto back. V20 doffed gloves and covered resident with blanket. V20 donned new gloves without hand hygiene and cleaned up supplies. 2. R47's Nursing Note dated 05/03/23 at 9:50 AM documents UA WAS OBTAINED LAST NIGHT AND SENT TO LAB. AWAITING RESULTS. R47's Physician Order dated 05/06/23 documents Cephalexin Capsule 500 MG; Give 1 capsule by mouth three times a day for infection for 7 Days. R47's Nursing Note dated 05/06/23 at 2:49 PM documents UA results. E. Coli detected. New order for Keflex 500mg 1 po BID x7 days. Resident and POA aware and voices understanding. On 07/20/23 at 1:43 PM, V20, CNA assisted R47 with incontinent care. V20 washed hands with soap and water in bathroom. V20 donned gloves, pulled down covers, and open trash bags. V20 doffed gloves and donned new gloves without hand hygiene. V20 washed R47's peri-area and vagina with wet wash cloth. V20 then dried R47's peri-area and vagina with a towel. V20 doffed and donned new gloves without hand hygiene. V20 washed R47's buttocks and gluteal cleft with wet wash cloth, dried R47's buttocks with a towel and rolled a bed pad under R47. V20 doffed and donned new gloves without hand hygiene. Bed pad was straightened out and R47 was covered up. V20 doffed gloves and lowered bed. V20 donned new gloves without hand hygiene and clean up trash bags and supplies. 3.R58's MDS dated [DATE] documents a BIMS score of 4 out of 15. Resident is total dependence of two plus persons for toilet use. Resident is always incontinent of urine. R58's Physician's Order, dated 7/15/23, documented he was receiving Ciprofloxacin HCL for a UTI. On 07/20/23 1:12 PM, V4, CNA and V13, CNA assisted R58's with incontinent care. Both CNAs washed their hands with soap and water in the bathroom prior to starting. V4 washed R58's buttocks and gluteal cleft with wash cloth. V4 doffed gloves and donned new gloves without any hand hygiene. V4 then washed R58's peri-area and penis with a washcloth. V4 doffed gloves and donned new gloves without any hand hygiene. V4 dried R58's peri-area with a towel. V4 doffed gloves and donned new gloves without hand hygiene. V13 rolled R58's toward her. V4 placed incontinent brief under R58. R58 was then rolled toward V4. R58 was rolled on his back and incontinent was pulled up in front and secured. R58 covered up. V4 doffed gloves and donned new gloves without hand hygiene. The Facility's Infection Prevention and Control Program, dated 2019, documents that written standards, policies and procedures for the program will include f. The hand hygiene procedures to be followed by staff involved in direct resident contact. The Program documents that the facility will develop and implement written policies and procedures for infection control that, at a minimum Require staff to follow hand hygiene practices consistent with accepted standards of practice.