**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview the facility failed to provide follow infection prevention practices when providing personal care, catheter care, and wound care 2 of 2 residents reviewed (Resident #3 and #111). While completing wound management and incontinence care, the facility failed to complete hand hygiene between gloves and failed to keep clean items clean. While providing care, the staff failed to use clean hands to get clean wash cloths for incontinence. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS listed 1 unstageable pressure ulcer and 1 stage one pressure ulcer present upon admission. Resident #3's Orders printed 1/18/24 listed the following orders: a. Dressing change dated 12/28/23 to apply white foam to the right dorsal (top side) foot for protection and change 3 times a week. b. Wound care dated 12/20/23 cleanse left heel with ¼ percent peroxide with ¾ saline solution, rinse with saline, apply thin layer of santyl (ointment use to treat wounds) to wound bed only, apply Aquacel AG advantage (dressing), apply white foam, 4x4 gauze, and Kerlix. On 1/17/24 at 9:38 AM observed Staff A, Registered Nurse, conduct wound care on Resident #3's left and right heels. Staff A removed her gloves and replaced them without completing hand hygiene in between for 7 out 7 times. The Handwashing / Hand Hygiene policy dated January 2022 directed hands may be cleansed with alcohol-based hand rub or wash with soap and water before and after each patient contact and after removing / changing gloves. On 1/18/24 at 8:38 AM the Administrator explained he spoke with the medical staff that work both the morning and evening on 1/17/24 at 7 PM. The Administrator reported the medical staff realized after looking at procedures and policies, they didn't complete hand hygiene when they changed their gloves from contaminated to clean procedures. The Administrator stated they expected staff when moving from a contaminated procedure to a clean procedure, they would complete hand hygiene and then apply new gloves. The Administrator said they also would complete hand hygiene with all glove changes. On 1/17/24 at 3:49 p.m. observed Staff D, Certified Nursing Assistant (CNA), and Staff C, Certified Medication Aide (CMA), assist Resident #3 with incontinence care. They removed her pants and opened her incontinent pad. They had a basin of soapy water and a basin of clear water with wash cloths on a bedside table on a barrier. Staff C wrung out a washcloth and folded it over 2 times. She wiped across the lower abdomen, pulled that layer back, wiped down the right groin, then the left turning the cloth between wipes. She retrieved a washcloth from the clear water and wiped over the areas in the same manner. Without completing hand hygiene, Staff C changed gloves and retrieved another washcloth from the soapy water basin, and squeezed out the excess water. She wiped down the mid genital area and then each side turned the cloth after each wipe. She then changed gloves with no hand hygiene and cleansed down the catheter tubing about 6 inches with a soapy washcloth prepared as previous, turned the cloth and wiped down the tubing again. She then retrieved a washcloth from the clear water basin and wiped down the catheter tubing as before. She then used an alcohol wipe times 2 on the catheter tubing. Staff B, Registered Nurse (RN), (entered) and prepared to do the resident's coccyx treatment. The resident had been incontinent of stool. Staff B washed her hands and gloved. She cleaned the area first with disposable wipes and removed the dressing. She then cleansed the area with soapy washcloths, avoiding the pressure area, then changed gloves with no hand hygiene. She wiped the area with a washcloth from the water basin, then patted dry. She changed her gloves with no hand hygiene and prepared to do the treatment. She cleansed the pressure area, rinsed, then irrigated with Dakin's solution. 2. Resident #111 ' s Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. The MDS included diagnoses of acute osteomyelitis (infection of the bone) of the left foot and ankle, and gas gangrene (infection of soft tissue). The Baseline Care Plan dated 1/5/24 identified Resident #111 had skin care needs related to his left foot and received intravenous (IV) antibiotic therapy. On 1/17/24 at 10:40 a.m. Staff A, Registered Nurse (RN), and Staff B washed their hands and applied gloves. Staff A removed the soiled dressings from Resident #111 ' s foot. The dressing appeared moderately saturated with serosanguinous drainage. Staff A changed her gloves, and without completing hand hygiene, used peroxide and normal saline to clean the wounds. She then used 4 by 4 gauze sponges to dry Resident #111 ' s foot. Staff A again, changed gloves without hand hygiene. Staff A used Dakin's solution on the wounds and dried the foot with sponges. Staff A changed gloves with no hand hygiene. Staff A dressed the foot and wrapped with kling and ace. The Center for Disease Control's (CDC's), Hand Hygiene in Healthcare Settings last reviewed 11/21/23, directed to use an alcohol-based hand sanitizer as the preferred method for cleaning your hands when they are not visibly dirty because it was more effective at killing potentially deadly germs on hands than soap, and was easier to use during the course of care, especially when moving from soiled to clean activities with the same resident. Always clean your hands after removing gloves. Dirty gloves can soil hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, the facility failed to ensure a binding arbitration agreement consisted of key factors necessary for compliance for 8 of 8 residents in the facility (Resident #1, #2. #3, #4, #107, #108, #109, and #111). Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #2 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's record contained a signed admission Agreement which included an Arbitration Agreement on page 11 and the resident's signature on page 17. On 1/17/24 at 3:31 p.m. Resident # 2 stated she signed so much she doesn't remember what she signed. She did not know what an arbitration agreement was. The facility Binding Arbitration agreement included: By signing this Agreement, you agree with the Facility that any dispute between you and the Facility, including any dispute over services rendered prior to the date this Agreement was signed and any dispute arising out of your care, including the scope of this arbitration clause and the arbitrability of any claim or dispute, against whomever made (including, to the full extent permitted by applicable law third parties who are not signatories to this Agreement) shall be resolved by binding arbitration with one arbitrator by the American Arbitration Association in accordance with the applicable procedures for the type of dispute which will be either the commercial or consumer procedures of the American Arbitration Association. Notwithstanding the preceding sentence, this binding arbitration provision shall not apply to any actions taken by the Facility to collect on charges owed by you or to any actions taken by the Facility relating to your transfer or discharge as discussed above. Any award of the arbitrator may be entered as a judgment in any court having jurisdiction. This Agreement shall be governed by and interpreted under the Federal Arbitration Act, 9 U.S.C. §§ 1-16. This provision for arbitration may be revoked by written notice delivered to the Facility's Administrative Office within ten days of your signature on this Agreement. All claims arising prior to the effective date of the revocation shall continue to be governed by this provision. You understand that the result of executing this Agreement is that claims, including malpractice claims that you may have against the Facility and its employees and agents, cannot be brought as a lawsuit in a court before a judge or jury and you agree that all such claims will be resolved as described in this section. Nothing in this Agreement prevents you from contacting regulatory or administrative agencies in relation to services provided by the Facility. The facility failed to ensure the resident or his/her representative acknowledged the he/she understood the agreement, failed to give the resident/representative the option to rescind the agreement within 30 days, explicitly state the resident/representative was not required to sign a binding arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. On 1/18/24 at 8:32 a.m. the Business Office Manager explained she did the admission paperwork with residents when they came in. She summarized things and told the new resident that a binding arbitration agreement meant an arbitrator would settle disputes between the resident and the facility. When the resident signed the admission agreement it included the arbitration agreement. On 1/17/24 at 2 p.m. the Administrator explained the admission packet contained their arbitration agreement. He stated all of the residents signed an admission agreement that included the arbitration agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, the facility failed to ensure a binding arbitration agreement consisted of key factors necessary for compliance for 8 of 8 residents in the facility (Resident #1, #2. #3, #4, #107, #108, #109, and #111). Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #2 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's record contained a signed admission Agreement which included an Arbitration Agreement on page 11 and the resident's signature on page 17. On 1/17/24 at 3:31 p.m. Resident # 2 stated she signed so much she doesn't remember what she signed. She did not know what an arbitration agreement was. The facility Binding Arbitration agreement included: By signing this Agreement, you agree with the Facility that any dispute between you and the Facility, including any dispute over services rendered prior to the date this Agreement was signed and any dispute arising out of your care, including the scope of this arbitration clause and the arbitrability of any claim or dispute, against whomever made (including, to the full extent permitted by applicable law third parties who are not signatories to this Agreement) shall be resolved by binding arbitration with one arbitrator by the American Arbitration Association in accordance with the applicable procedures for the type of dispute which will be either the commercial or consumer procedures of the American Arbitration Association. Notwithstanding the preceding sentence, this binding arbitration provision shall not apply to any actions taken by the Facility to collect on charges owed by you or to any actions taken by the Facility relating to your transfer or discharge as discussed above. The facility failed to ensure the arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that was convenient to to both parties. On 1/18/24 at 8:32 a.m. the Business Office Manager explained she did the admission paperwork with residents when they came in. She summarized things and told the new resident that a binding arbitration agreement meant an arbitrator would settle disputes between the resident and the facility. When the resident signed the admission agreement it included the arbitration agreement. On 1/17/24 at 2 p.m. the Administrator explained the admission packet contained their arbitration agreement. He stated all of the residents signed an admission agreement that included the arbitration agreement.