Based on observation, interview, and record review, the facility failed to ensure the hot water sanitation rinse cycle was maintained and failed to run test strips to test the surface temperature of the dishwasher. This has the potential to affect all 74 residents residing in the facility. Findings include: The facility's Dishwashing Machine policy, dated 2011, documents the following: The dining services staff shall maintain the operations 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. This form documents to 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 the dishwashing machine to heat up. The facility's Dishwasher Instructions,, revised 12/96, documents, The minimum water temperatures for the hot water wash is 150 degrees Fahrenheit, and the rinse is 180 degrees Fahrenheit. On 3/24/25 at 09:32 AM, a kitchen tour was conducted with V4, Dietary Manager/DM. The dishwashing machine hot water wash cycle temperature gauge documented 159 degrees Fahrenheit, and the rinse cycle temperature gauge documented 178 degrees Fahrenheit. V4 stated the temperature gauge on the dishwashing machine is used to determine the accuracy of the high temperature rinse cycle. At that same time, V4 stated no other testing is done, and V4 has never used test strips to check the temperature of the water. V4 verified the rinse temperature should reach at least 180 degrees Fahrenheit. On 3/24/25 at 12:45 PM, V1, Administrator, stated a test strip has never been done to check the internal hot water wash and rinse cycle temperatures of the dishwashing machine. The facility's Resident Bed List Report, dated 3/25/25, documents 74 residents reside in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 3/25/25 at 10:15 AM, V4, CNA/Certified Nursing Assistant, provided incontinence care for R45, who was incontinent of stool. V4 did not change gloves after providing incontinence care for R45's bowel movement. At that same time with the same soiled gloves, V4 rolled R45 side to side in bed and placed a clean incontinence brief under R45. With the same soiled gloves, V4 then assisted V6, CNA, with placement of a full mechanical sling under R45 and transferred R45 from his bed into a wheelchair. During R45's transfer, V4 supported R45 and positioned him over the wheelchair while in the sling, and V6 lowered R45 into the wheelchair using the mechanical lift's controls. On 3/25/25 at 10:30 AM, V4, CNA, verified she did not change her gloves or perform hand hygiene throughout R45's incontinence cares and transfer. On 3/26/25 at 1:45 PM, V2, DON/Director of Nursing, stated gloves should be removed, hand hygiene performed, and clean gloves donned after performing incontinence cares and before placing a clean incontinence brief for a resident. The facility was unable to provide a policy identifying appropriate infection control procedures for the donning and doffing of gloves during incontinence care. The facility was also unable to provide a policy and procedure for incontinence care. The facility's Resident Bed List Report, dated 3/25/25, documents 74 residents reside in the facility. Based on observation, interview, and record review, the facility failed to ensure infection control and prevention practices were utilized per policy for three (R13, R45, R55) of 24 residents reviewed in a sample of 24. This failure has the potential to affect all 74 residents who reside in the facility. Findings include: The Transmission-Based (Isolation) Precautions policy, dated 10/24/22, documents, Contact precautions refer to measures that are intended to prevent transmission of infectious agent which are spread by direct or indirect contact with the resident or the resident's environment. High touch objects and environmental surfaces should be cleaned and disinfected with an EPA/Environmental Protection Agency-registered disinfectant for healthcare use at least daily and when visibly soiled. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicate in transmission through environmental contamination (Clostridium-difficile). Residents experiencing fecal incontinence or diarrhea that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, should be placed on contact precautions. The Enhanced barrier Precaution (EBP) policy, dated 3/20/24, documents, EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves during high contact resident care activities. EBP will be initiated for residents with wounds and a physician's order is not required. EBP will be identified by a small sign reading EBP placed on the door frame. PPE for EBP is only necessary when performing high-contact care activities. High-contact resident care activities include wound care. The Hand Hygiene policy, dated 1/30/24, documents, The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning and doffing gloves and immediately after removing gloves. The Center for Disease Control (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, documents, To conduct hand hygiene before moving from work on a soiled body site to a clean body site on the same patient and immediately after glove removal. When to change gloves and clean hands: if gloves become soiled with blood or body fluids after a task, if moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. C-difficile is a spore-forming bacterium that can lead to a common healthcare-associated infection causing severe diarrhea. Spores are inactive form of the germ and have a protective coating allowing them to live on surfaces for months. The CDC's Infection Control Appendix A: Figure. Example of Safe Donning and Removal of Personal Protective Equipment (PPE) documents A gown should gown fully cover torso from neck to knees, arms to end of wrist, and wrap around the back and fasten in back at neck and waist. The facility's Standard Precautions Policy, undated, documents the following: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing care services. 1. R13's Facesheet documents R13 was admitted on [DATE], with diagnoses of Hypertensive Chronic Kidney Disease, Venous Insufficiency, Major Depressive Disorder and Generalized Weakness. On 2/19/25, R13 returned from a hospital stay with diagnoses of Clostridium Difficile (C-diff/Infection of the large intestine), Sepsis (Infection in the blood stream), Pneumonia, Acute Respiratory Failure, and Gastro-Esophageal Reflux Disease with Esophagitis. R13's Stool Culture results, dated 3/21/25, documents R13 tested positive for C-difficile, and antibiotics were ordered. R13's Physician Order, dated 3/13/25, documents to initiate Contact Precautions/Isolation for C-difficile infection. On 3/25/25 at 10:05 AM, R13's door frame had a Contact Precaution sign posted and a sign with instructions to wash hands with soap and water. R13's bathroom had brown substance (stool) on toilet seat, toilet base, and on floor from the doorway to the toilet. The bathroom sink was the only sink available for hand hygiene, and staff would have to walk through the door and past the toilet to get to the sink. On 3/25/25 at 11:00 AM, V5 (Registered Nurse) went into R13's Contact Isolation room and administered medications and cleaned the bathroom. V5's gown was not tied in the back. On 3/25/25 at 10:05 AM, R13 stated she is still having diarrhea stools and had a mess in the bathroom. 2. R55's Face sheet documents R55 was admitted on [DATE], with diagnoses of Closed Fracture Right Femur, Muscle Wasting and Atrophy, Diabetes Mellitus Type 2, Glaucoma, Sacral Wound and Anemia. R55's Physician Order, dated 3/6/25, documents to apply collagen sheet into the coccyx wound and cover with calcium alginate and bordered gauze daily. On 3/25/25 at 1:55 PM, V5 (Registered Nurse) was observed to open the treatment cart, remove dressing change supplies and scissors. V5 proceeded to open the collagen package, cut the collagen sheet with scissors from the drawer without cleaning them, then opened the calcium alginate package and walked down the hall to R55's room to conduct wound care on R55. On 3/25/25 at 2:01 PM, R55's doorframe had an EBP sign posted. On 3/25/25 at 2:01 PM, V5, RN, donned a PPE gown and did not button the front of the gown up. At that same time, R55's sacral wound dressing change was conducted. V5 removed R55's dirty dressing and V5 removed gloves and donned new gloves without conducting hand hygiene. On 3/25/25 at 10:50 AM, V2, DON/Director of Nursing, agreed a staff member would have to walk through the brown substance (stool) to get to the sink to wash hands, and could potentially contaminate the environment outside of R13's room. V2 stated, I will get that cleaned up immediately. On 3/27/25 at 11:30 AM, V2, DON, stated, All gowns should have been secured in the back; hand hygiene should have been conducted after gloves were removed; (R13's) bathroom should have been cleaned as soon as possible after being soiled; the wound dressing should have been opened at (R55's) bedside; and scissors should have been disinfected prior to use and prior to placing them back in the treatment cart. On 3/27/25 at 2:20 PM, V1 (Administrator) stated, We like to keep nurses on the same unit because they get to know their residents. It's stable staffing but of course, if someone needs assistance or whatever, the nurses can go anywhere in the facility to care for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide a homelike environment when an alarm was placed on a restroom door affecting two (R29, R69) of 18 residents reviewed for homelike environment in a sample of 31. Findings include: Facility policy, dated 01/30/24, and titled Safe and homelike environment documents, The facility will provide a safe, Clean, comfortable and homelike environment. Definition for comfortable sound levels means levels that do not interfere with the resident's hearing, levels that enhance privacy when privacy is desired, and levels that encourage interaction when social participation is desired. On 04/22/24 at 9:48 AM, the bathroom door of R29 and R69's was noted to have a tab alarm active. R69 had a chair alarm and an alarmed mat on the floor next to her bed. R69's Minimum Data Sheet (MDS), dated [DATE], documents R69 has a Brief Interview for Mental Status score of 7 indicating severe cognitive impairment. R29's 03/15/24 MDS R29 has severe cognitive impairment. On 04/22/24 at 9:48 AM, a tabbed alarm was noted to be attached to the frame of R29's and R69's bathroom door with the tab mounted to the door. On 04/23/24 at 12:59 PM, V5, Care Plan Coordinator, stated the tabbed alarm on the bathroom door was intended to keep R69 from attempting to go into the bathroom independently and potentially falling.

Based on interview, record review, and observation, the facility failed to implement Contact Isolation Precautions and Enhanced Barrier Precautions to contain the potential spread of Multi Drug-Resistant Organisms. This failure has the potential to affect all 76 residents residing in the facility. Findings Include: Current facility map documents their are four hallways in the nursing home. The facility policy named, Enhanced Barrier Precautions/EBP, dated 3/20/24, documents, It is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of Multidrug-Resistant Organisms. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of Multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident activities, such as dressing, bathing, providing hygiene, wound care: any skin opening requiring a dressing. The facility policy named, Transmission-Based (isolation) Precautions, dated 1/30/2024, documents, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens mode of transmission. 1. R334 did not have any signage on the door to show R334 was in isolation or EBP precautions. R334's Wound Round-description, dated 4/23/2024, documents, Site one: Infection, back 2.7 x 6 x 0.4CM (Centimeters). Negative Pressure Wound Therapy twice a week. R334's wound culture results of R334's back, from a local hospital, dated 3/26/2024, documents, Heavy Methicillin Resistant Staph Aureus. R334's Care plan, dated 4/10/2024, documents, (R334) requires intravenous antibiotic therapy due to MRSA (Methicillin- resistant Staphylococcus aureus) resulting from an infection in the wound on his back. R334's Wound Evaluation and Management Summary, dated 4/23/2024, documents, Wound Back Full Thickness, etiology: infection, duration over 21 days. Primary Dressing: Negative pressure wound therapy. Apply twice a week and as needed for 16 days. Site one: Surgical Excisional Debridement Procedure: Remove Necrotic Tissue and Establish the Margin of Viable Tissue. On 4/21/2024 at 10AM, R334 was laying in his bed resting, watching television. R334's wound vacuum to his back and tubing is laying in the bed. R334 stated, This is used for the infection I have in my back. R334 did not have any signage on the door to show R334 was on isolation precautions. On 4/23/2024 at 12:30PM, V2/DON (Director of Nurses) stated, (R334) is not on any isolation right now. (R334) has a wound vac that is in place all the time. The infection that (R334) has is always contained. We did not place him on Enhanced Barrier Precautions or Contact Isolation. On 4/23/2024 at 12:45PM, V3/Infection Preventionist stated, No, we did not put (R334) on Contact isolation or Enhanced Barrier Precautions. (R334) has a wound vac in place so, he does not need to be isolated. On 4/23/2024 at 1:10PM, V12/LPN(Licensed Practical Nurse) stated, R334 is not in isolation. When his wound vac is changed, we only use gloves, and no gowns are needed. On 4/24/2024 at 10:30AM, V16/Bath Aide stated, I give every resident in the facility a bath or shower, except for 200 halls. I go to all halls. (R334) gets a bath from me. He can come down to the shower room and gets into the bath carefully. The nurse who is on duty will take his wound vac off and leave it off while he gets his bath. I only use gloves when bathing (R334). The gloves get a lot of water in them when bathing him, but I still have to use them because his wound is infected. On 4/23/2024 at 1:20PM, V13/CNA(Certified Nursing Assistant) stated, When I take care of (R334) I only use gloves. I do not use a gown when taking care of (R334). At that same time, V13 verified she helps out on any hallway that needs help to make sure the residents are taken care of. On 4/23/2024 at 1:30PM, V14/CNA (Certified Nursing Assistant) stated, The only thing I use is gloves during (R334) cares. He is not on any isolation that I know of. At that same time ,V14 verified she helps out on any hallway that needs help to make sure the residents are taken care of. 2. On 04/22/24 at 10:02 AM, V5, Infection Preventionist, was observed changing R45's sacral area wound. V5 was assisted by V4 who was wearing gloves. V5 washed her hands, donned gloves and cleaned R45's wound with cleanser. V5 then removed her gloves and washed her hands again before donning new gloves, packing R45's wound with calcium alginate and applying a border gauze. V4 and V17, both CNAs, then utilized a mechanical lift to transfer R45 to the recliner. During the transfer, V4 and V17 wore only gloves. Both CNAs verified they only wear gloves for R45, and did not know they needed to wear anything else. V4 and V17 both verified they help out on any hallway that needs help to make sure the residents are taken care of. No gowns or signage indicating R45 required enhanced barrier precautions due to wounds was seen in R45's room. On 04/22/24 at 10:12 AM, V4, Assistant Director of Nursing/Infection Preventionist, was observed administrating R17's Vancomycin through a peripherally inserted central catheter (PICC) line in R71's left arm. V4 donned gloves, identified R71, then cleaned and flushed the PICC line with Normal Saline prior to connecting the Vancomycin. At that same time, V4 verified she only wears gloves with R17's IV. V4 did not wear a gown and there was no signage for Enhanced Barrier Precautions in R71's room. The Centers for Medicare and Medicaid Services form 671 entitled Long Term Care Facility for Medicare and Medicaid, dated 4/21/2024, and signed by V1/Administrator documents 76 residents currently residents in the facility.

2. R25's current medical record documents R25's diagnoses to include: Dementia, Cognitive Communication Deficit, and Other Symptoms and Signs Involving Cognitive Functions and Awareness. R25's most recent Fall Risk Assessment Tool (dated 02/06/23) documents a score of 21, indicating R25 is at high risk for falls. R25's current medical record documents R25 fell at the facility on the following dates: 12/12/22, 12/19/22, 01/20/23, 02/02/23, and 02/06/23. On 02/07/23 at 08:00 AM, R25 was sitting in a wheelchair with a fall prevention alarm in place at a table in the dining room. R25 was eating breakfast, and V6 (R25's daughter) was sitting next to R25. A large hematoma was present on the left side of R25's forehead and an extensive amount of dark purple facial bruising was present on R25's forehead extending down into R25's orbit areas. R25's daughter stated she sustained the injuries after a recent fall. R25's Event Report (dated 01/20/23) documents the following: (R25) was left in the bathroom without supervision. She attempted to stand and pull pants up independently and fell to the ground. The following fall prevention intervention was implemented after R25's 01/20/23 fall and was documented on her current care plan: (R25) will not be left alone in the bathroom. On 02/08/23 at 3:15 PM, V2 (Director of Nursing) stated, (R25) should not have been left alone in the bathroom. She is a high risk for falls, has a history of multiple falls, and has poor safety awareness due to her Dementia. R25's Event Report (dated 02/02/23) documents the following: (R25) was found on the floor lying on her left side at 03:00 PM. R25's current care plan documents the following fall prevention intervention was implemented on 02/02/23 after R25's fall: Staff to ensure that chair alarm is on and functioning properly. On 02/08/23 at 3:30 PM, V2 (Director of Nursing) stated R25's fall prevention alarm was not functioning at the time of R25's fall on 02/02/23. Based on observation, interview, and record review, the facility failed to provide supervision during toileting for a resident with a diagnosis of Dementia and failed to ensure fall prevention alarms were functioning for two of two residents (R25, R84) reviewed for falls in the sample of 31. Findings include: The facility's Fall Prevention Program, dated 10/24/22, states Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 6. High risk protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. 8. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 1. R84's Fall Risk Assessment, dated 1/11/23, documents R84 is at moderate risk for falls. R84's Pre-admission History and Physical, dated 11/27/22, documents R84 had a couple falls at home. R84's Minimum Data Set assessment, dated 1/17/23, documents R84 requires extensive assistance with transfers, ambulation, and toileting. R84's Care Plan, dated 1/2/23, documents the following: R84 had a fall at home, prior to facility admission, that resulted in a sacral fracture; R84's post fall intervention, dated 1/06/2023, to implement a pressure pad alerting device in bed and chair at all times to notify staff if R84 is attempting to self-transfer/ambulate as she does not always remember to ask for assistance. R84's Event Report, dated 1/6/23, documents R84 fell in her room while trying to move a bedside table and lost her balance. The Event Report ,dated 1/6/23, documents the Root Cause Analysis for R84's fall was (R84) attempting to self-transfer without assistance. R84's Hospital Record, dated 1/6/23, documents R84 fell at the facility and sustained a Lumbar Compression Fracture with Sacral Pain and a Scalp contusion. R84's Event Report, dated 2/8/23 at 2:37 AM, documents R84 was found on the floor next to her bed on her hands and knees. On 2/8/23 at 11:20 AM, V2 (Director of Nursing) stated investigation of R84's fall on 2/8/23, determined R84's pressure pad alerting device was not sounding when staff found R84 on the floor. V2 stated the pressure pad alerting device should be functioning at all times.