Based on observations, interviews, and record reviews the facility failed to ensure residents did not have cigarette lighters in their possession and/or rooms for 2 (Resident #32 and Resident #79) of 2 (Resident #32 and Resident #79) sampled residents reviewed for accidents and hazards while smoking. Findings: Review of the facility's Smoking Policies and Regulations dated October 2022 revealed, in part, this policy and procedure was developed to ensure the safety of the residents. Further review revealed cigarette lighters were not permitted in a resident's room and would be kept at the nurses stations. Further review revealed adherence to this policy and procedure would be strictly enforced. Resident #32 Review of the facility's Smoking Task Listing Report dated 09/23/2024 revealed, in part, Resident #32 was identified as an independent smoker. Review of Resident #32's care plan revealed, in part, Resident #32 had a potential for injury related to smoking. Resident #79 Review of the facility's Smoking Task Listing Report dated 09/23/2024 revealed, in part, Resident #79 was identified as an independent smoker. Review of Resident #79's care plan revealed, in part, Resident #79 had a potential for injury related to smoking. In an interview on 09/25/2024 9:45 a.m., S5Licensed Practical Nurse (LPN) indicated she was unsure if residents were allowed to keep cigarette lighters in their possession. In an interview on 09/25/2024 at 9:54 a.m., S6Certified Nursing Assistant (CNA) indicated Resident #32 was allowed to keep her cigarette lighter in her possession. Observation on 09/25/2024 at 10:02 a.m. revealed, in part, Resident #32 was in her room and had a cigarette lighter in the basket of her rolling walker. In an interview on 09/25/2024 at 10:02 a.m., Resident #32 indicated she was allowed to keep her cigarette lighter in her possession and/or room. In an interview on 09/25/2024 at 10:02 a.m., S6CNA confirmed Resident #32 had a cigarette lighter in the basket of her rolling walker and the cigarette lighter was functional. In an interview on 09/25/2024 at 10:10 a.m., S7CNA indicated smokers who were identified as independent smokers were allowed to keep cigarette lighters in their possession. In an interview on 09/25/2024 at 10:22 a.m., S8LPN indicated smokers who were identified as independent smokers were allowed to keep cigarette lighters in their possession. Observation on 09/25/2024 at 10:32 a.m. revealed Resident #79 had a cigarette lighter in his room on top of a small dresser. Further observation revealed Resident #79's cigarette lighter was functional. In an interview on 09/25/2024 at 10:32 a.m., Resident #79 indicated he was an active smoker and he was allowed to keep his cigarette lighter in his possession. In an interview on 09/25/2024 at 10:37 a.m., S2Director of Nursing (DON) indicated he was not aware the facility's smoking policy specified residents were not allowed to keep cigarette lighters in their possession. S2DON further indicated he was not aware cigarette lighters should have been kept at the nurse's station(s). In an interview on 09/25/2024 at 11:05 a.m., S1Administrator confirmed the facility's smoking policy prohibited smokers from keeping cigarette lighters in their possession and the lighters should been kept at the nurse's station(s).

Based on observations and interview the facility failed to ensure clean items in the facility's laundry room were not kept in the contaminated laundry area. Findings: Observation on 09/23/2024 at 4:00 p.m. of the contaminated area in the laundry room, revealed clean mop heads and clean microfiber cleaning cloths were hanging from rods attached to the wall. Observation on 09/24/2024 at 9:10 a.m. of the contaminated area in the laundry room, revealed clean mop heads and clean microfiber cleaning cloths were hanging from rods attached to the wall. In an interview 09/24/2024 at 11:00 a.m., S4Assistant Director of Nursing/Infection Prevention Control Program indicated clean mop heads and clean microfiber cleaning cloths should not be hung to dry in the contaminated area of laundry room.

Based on observations, interviews and record review the facility failed to ensure an adaptive call bell was available for a resident with limited range of motion in her hands for 1 (Resident #44) of 30 initial pool residents reviewed for call bell use. Findings: Review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/2023 revealed, in part, Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #44 was cognitively intact, and Resident #44 was totally dependent and required two person physical assistance for bed mobility, transfer, and toilet use. Review of Resident #44's care plan revealed, in part, Resident #44 had functional limited range in her hands related to bilateral hand contractures. Further review revealed, a goal of Resident #44 will be free of injury and complications with interventions that included placing a call light within reach, assisting with ADLs as needed, and providing assistive/supportive devices. Observation on 09/25/23 at 11:14 a.m. revealed Resident #44's had limited range of motion in both hands. In an interview on 09/25/2023 at 11:14 a.m., Resident #44 stated she is unable to use the call bell in her room, and she has to holler for assistance when needed. Resident #44 further stated she did not like having to holler for assistance, and wished she had another way to call for assistance. In an interview on 09/28/2023 at 9:09 a.m., S11Certified Nursing Assistant (CNA) stated Resident #44's hands were contracted and she could not use the call bell. S11CNA further stated that Resident #44 had to scream out for assistance when she needed it by yelling help or calling the CNA's names. S11CNA further stated Resident #44 should not have to holler out for assistance, and Resident #44 should have an adaptive call bell that allowed her to use the call bell system independently. In an interview on 09/28/2023 at 9:10 a.m. S16CNA stated she thinks the resident should be given one of the flat pad-like call bells, because she could use that to call for assistance instead of having to holler for help. In an interview on 09/28/2023 at 9:13 a.m. S18Registerd Nurse (RN) stated Resident #44 had dexterity issues in her hands and had to holler for assistance. Observation on 09/28/2023 at 9:28 a.m. revealed S18RN tested to see if Resident #44 could use the call bell in her room. Further observation revealed that Resident #44 was unable to press the call bell button. In an interview on 09/28/2023 at 9:28 a.m., S18RN confirmed Resident #44 was unable to use her call bell in her room. In an interview on 09/28/2023 at 11:00 a.m., S2Director of Nursing (DON) stated that facility should have accommodated Resident #44's need for an adaptive call bell, and Resident #44 should not have to holler for assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident with a new diagnosis of unspecified psychosis was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #47) of 2 (Resident #47 and Resident #18) sampled residents reviewed for PASARR. Findings: Resident #47 Review of Resident #47's medical record revealed, in part, Resident #47 was admitted to the facility on [DATE]. Review of Resident #47's Level 1 Pre-admission Screening and Resident Review dated 10/16/2021 revealed, in part, Resident #47 was not diagnosed with a mental illness. Review of Resident #47's medical records revealed, in part, Resident #47 received a new mental illness diagnoses of unspecified psychosis and depression on 03/21/2023. Review of Resident #47's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/2023 revealed, in part, Resident #47 had an active diagnoses of psychotic disorder and depression. Review of Resident #47's medical record revealed, in part, Resident #47 was not evaluated for a Level II PASARR after receiving a new mental illness diagnosis of unspecified psychosis on 03/21/2023. In an interview on 09/27/2023 at 9:30 a.m., S19MDS verified Resident #47 was diagnosed with a mental illness of unspecified psychosis on 03/21/2023. In an interview on 09/27/2023 at 9:35 a.m., S20Social Worker (SW) stated she was not made aware when Resident #47 received a mental illness diagnosis and did not know it was required to have residents with a new mental illness diagnosis evaluated for a Level II PASARR until 09/19/2023. S20SW further stated Resident #47 should have been referred to the appropriate state-designated agency for a Level II PASARR after receiving a mental illness diagnosis on 03/21/2023. In an interview on 09/27/2023 at 9:40 a.m., S2Director of Nursing stated the facility did not have a system in place for submitting residents with a new mental health diagnosis for evaluation to the appropriate state-designated agency for Level II PASARR evaluation.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's careplan was updated following the residents attempt to exit the facility for 1 (Resident #102) of 3 (Resident #88, Resident #94, and Resident #102) residents investigated for dementia care. Review of Resident #102's medical record revealed, in part, an admission date of 08/22/2022 with a readmission date of 01/03/2023 with a diagnosis of Vascular Dementia with Mood Disturbance. Review of Resident #102's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/2023 revealed, in part, Resident #102's Brief Interview for Mental Status Score was 3 which indicated Resident #102 had severe cognitive impairment. Review of Resident #102's Comprehensive Care Plan, with a start date of 08/29/2022, revealed, in part, Resident #102 had a history of wandering and moved around a lot in her wheelchair. Review of Resident #102's nurse's notes revealed, in part, a nurse's note with a date of 09/11/2023 and time of 9:56 a.m. that read is was a late entry for 09/10/2023. Review revealed, Resident #102 rolled herself to the front door of the facility and was trying to get out. Further review revealed, Resident #102 was able to hold the door on her own and had to be continuously redirected all day. In an interview on 09/28/2023 at 1:47 p.m., S4Careplan stated she is responsible for Resident #102's careplan. S4Careplan stated she was not informed Resident #102 had attempted to exit out of the front door of the facility. S4Careplan further stated when Resident #102 attempted to exit out of the front door of the facility on 09/10/2023, an elopement risk assessment should have been performed and her careplan should have been updated to reflect new interventions. In an interview on 09/28/20023 at 3:45 p.m. S2DON confirmed Resident #102 should have been reassessed and had her careplan updated to reflect new interventions put in to place for Resident #102's wandering. There was no documented evidence and the facility failed to present any documented evidence that Resident #102's careplan was revised and updated after Resident #102 attempted to exit out of the front door of the facility on 09/10/2023.

Based on observations, interviews, and record review the facility failed to ensure proper infection control techniques were practiced to prevent urinary tract infection for 2 (Resident #44 and Resident #87) of 2 residents observed for perineal care (washing the genital and rectal areas of the body). Findings: Review of the facility's Perineal Care policy revealed, in part, when providing perineal care to a female resident the genital area should be washed moving from front to back, while using a clean portion of a wash-cloth or pre-moistened wash wipe for each stroke. Resident #44 Observation on 09/26/2023 at 3:17 p.m., revealed, S16Certified Nursing Assistant (CNA) performed incontinence care by wiping Resident #44's rectal area forward into Resident #44's vaginal and urethral area (wiping back to front) three times. Further observation revealed a visible streak of brown was noted on the towel after S16CNA wiped from Resident #44 from back to front. In an interview on 09/27/2023 at 12:11 a.m., S16CNA stated that she should not have wiped Resident #44 from back to front when she performed perineal care. In an interview on 09/27/2023 at 1:25 p.m., S5Assistant Director of Nursing (ADON) stated S16CNA should have wiped Resident #44 from her vaginal and urethral area back to her rectal area (wiping front to back). In an interview on 09/27/2023 at 3:11 p.m., S6CNA Supervisor stated that S16CNA should not have wiped Resident #44 from back to front. In an interview on 09/27/2023 at 4:52 p.m., S2Director of Nursing (DON) stated that S16CNA should not have wiped Resident #44 from back to front. Resident #87 Observation on 09/26/2023 at 3:50 p.m., revealed S21CNA performed Resident #87's perineal care by wiping Resident #87's right and left labia in a down and up (wiping back to front and front to back) motion with the same corner of a wet towel repeatedly. Further observation revealed, S21CNA drained Resident #87's catheter, and allowed the catheter drainage valve to touch the floor while she went to dispose of urine. Further observation revealed upon S21CNA's return, she placed the drainage valve back into its holder on the catheter bag without cleaning the drainage valve. In an interview on 09/27/2023 at 1:25 p.m., S5ADON stated CNAs should not be wiping resident's in a back to front motion when performing perineal care. In an interview on 09/28/2023 at 2:28 p.m., S21CNA stated that she should not have used the same corner of the towel or wiped in a back to front motion when performing Resident #87's perineal care. S21CNA further stated that she should not have let the drainage valve of Resident #87's catheter bag touch the floor and confirmed that she did let the drainage valve of Resident #87's catheter bag touch the floor. In an interview on 09/27/2023 at 3:11p.m., S6CNA Supervisor stated 21CNA should have used different corners of the towel when performing Resident #87's perineal care and S21CNA should not have wiped Resident #87 in a down and up motion when performing perineal care. S6CNA supervisor further stated S21CNA should not have let the drainage valve to Resident #87's catheter bag touch the floor. In an interview on 09/27/2023 at 4:52 p.m., S2DON stated that S21CNA should not have wiped Resident #87 in a down and up motion and should not have let the drainage valve of Resident #87's catheter bag touch the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews the facility: 1. Failed to notify a resident's physician of a change in a resident's condition for 3 (Resident #44, Resident #67, and Resident #87) of 25 residents included in the final resident sample; 2. Failed to notify a resident's responsible party of a change in condition for 2 (Resident #44 and Resident #87) of 25 residents included in the final resident sample; and, 3. Failed to notify a resident's hospice agency of a change in condition for 1 (Resident #87) of 25 residents included in the final resident sample. Findings: Review of the facility's Change in Resident Medical Status policy revealed, in part, a facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a need to alter treatment significantly or to commence a new form of treatment. Resident #44 Observation on 09/25/23 at 11:14 a.m. revealed Resident #44's had a border gauze dressing to the top of her right hand with no date or initials on it indicating the last time it was changed. In an interview on 09/26/2023 at 3:16 p.m., Resident #44 stated that the wound to the top of her right hand was new and appeared yesterday, and a treatment nurse had performed wound care on the wound to the top of her right hand yesterday. Observation on 09/26/2023 at 3:16 p.m. revealed Resident #44 had a border gauze dressing to the top of her right hand and it was not dated or not initialed indicating the last time it was changed. Review of Resident #44's Wound assessment dated [DATE] revealed, in part, Resident #44's had a new wound to the top of her right hand that was first assessed on 09/26/2023, and Resident #44's physician and responsible party were notified on 09/26/2023. In a phone interview on 09/27/2023 at 2:40 p.m., Resident #44's responsible party stated that no one had contacted him regarding residents new wound to the top of her right hand. In a phone interview on 09/27/2023 at 2:45 p.m., Resident #44's nurse practitioner stated she was not informed that Resident #44 had a new wound to the top of her right hand. In a phone interview on 09/27/2023 at 2:47 p.m., Resident #44's physician stated he was not informed that Resident #44 had a new wound to the top of her right hand. In an interview on 09/27/2023 at 3:24 p.m., S8Treatment Nurse (TN) stated the staff member who initially found the wound to the top of Resident #44's right hand, should have notified Resident #44's physician and Resident #44's responsible party. S8TN further stated that she should not have documented that she notified Resident #44's responsible party or Resident #44's physician of the new wound to the top of Resident #44's right hand when she had not notified them. In an interview on 09/27/2023 at 3:34 p.m., S7LPN stated the staff member who first found the new wound to the top of Resident #44's right hand was responsible for notifying Resident #44's physician. S7LPN further stated that she did not notify Resident #44's physician until today about the new wound to the top of Resident #44's right hand. In an interview on 09/27/2023 at 4:52 p.m., S2Director of Nursing (DON) stated that whoever found the wound on the top of Resident #44's right hand, should have notified Resident #44's physician and Resident #44's responsible party. S2DON further stated that if S8TN did not notify Resident #44's physician and responsible party of the new wound to the top of Resident #44's right hand, S8TN should not have documented that she did. In an interview on 09/28/2023 at 11:00 a.m., S2DON stated the facility could not provide any documentation that Resident #44's physician or responsible party was notified on 09/25/2023 or 09/26/2023 of the new wound to the top of Resident #44's right hand. Resident #67 Review of Resident #67's care plan revealed, in part, the problems of a potential for injury related to Resident #67 taking Aspirin (a medication that can be used as a blood thinner) and Plavix (a medication that can be used as a blood thinner) with an intervention of observe for presence of active bleeding, hematuria, petechia, bruising, bloody stool, nose bleeds and contact the medical doctor as needed. Review of Resident #67's record revealed, in part, weekly body audits performed on 09/07/2023, 09/14/2023, and 09/21/2023 with documentation of no new skin issues. Review of Resident #67's progress notes for September 2023 revealed, in part, no documentation of bruising to Resident's left upper forearm, or right and left hands. An observation 09/25/2023 at 11:30 a.m. of Resident #67 revealed a hard ball size light purple bruise to the left upper forearm below the elbow. Further observation revealed a dark purple bruising noted across the top of Resident #67's right and left hands. In an interview on 09/27/2023 at 10:30 a.m., S17License Practical Nurse (LPN) stated if any unusual skin issues are noted they should be reported and documented. S17LPN further stated no one informed her of bruising to Resident #67. In an interview on 09/27/2023 at 11:10 a.m., S13Certified Nursing Assistance (CNA) stated she transfers Resident #67. S13CNA further stated she noticed bruising to Resident #67's left upper forearm and hands, but did not report the bruising to anyone. In an interview on 09/28/2023 at 8:30 a.m., S15CNA stated she had noticed the bruising to Resident #67's right and left hand and also, Resident #67's left upper forearm. She stated she did not report the bruising to the nurse. In an interview on 09/28/2023 at 12:30 p.m., S10CNA stated she noticed the large bruise to Resident #67's left forearm and on the top of Resident #67's right and left hands. She stated she had not reported the bruising to the nurse. In an interview on 09/28/2023 at 3:08 p.m., S2Director of Nursing (DON) stated the bruising to Resident #67's left forearm and Resident #67's right and left hands should have been reported. Resident #87 Observation on 09/25/2023 at 10:52 a.m. revealed that Resident #87's urine in her urinary catheter tubing and bag was dark yellow and cloudy. Observation on 09/26/2023 at 9:13 a.m. revealed sediment in Resident #87's urinary catheter bag tubing. Observation on 09/26/2023 at 3:50 p.m. during catheter care, revealed a new pressure injury to Resident #87's left labia. Further observation revealed that when emptying the urine from Resident #87's catheter bag, S22Certified Nursing Assistant (CNA) stated that Resident #87's urine had an odor. Review of Resident #87's Wound assessment dated [DATE] revealed, in part, Resident #87's had a new pressure injury to her left labia. Further review revealed, Resident #87's primary physician and Resident #87's responsible party were notified of the new wound to Resident #87's left labia. In an interview on 09/27/2023 at 11:33 a.m., Resident #87's nurse practitioner stated that Resident #87's primary physician was out of the country, and that she was not notified of Resident #87's new pressure injury to her left labia, the sediment in Resident #87's urine, or of the odor to Resident #87's urine and could not find any documentation that the primary physician's office was notified. In an interview on 09/27/2023 at 2:26 p.m., Resident #87's responsible party stated no one had contacted her regarding the residents new pressure injury to her left labia. In an interview on 09/28/2023 at 2:28 p.m. S21CNA stated she did not notify any nurse of the odor to Resident #87's urine. In an interview on 09/27/2023 at 3:05 p.m., S18RN stated that she had not noted any sediment in Resident #87's urine nor had any CNA informed her that Resident #87 had an odor to her urine. S18RN further stated Resident #87's physician and hospice agency should have been notified of the color and sediment in Resident #87's urine. In an interview on 09/27/2023 at 3:06 p.m., Resident #87's Hospice Nurse stated no one from the facility had contacted Resident #87's hospice agency regarding Resident #87's new pressure injury to her left labia or sediment and odor to Resident #87's urine. In an interview on 09/27/2023 at 3:24 p.m., S8TN stated she did not notify Resident #87's responsible party or hospice agency of the new pressure injury to Resident #87's left labia, and that S7LPN was responsible for notifying Resident #87's physician of the new pressure injury. S8TN further stated she should not have documented that she contacted Resident #87's primary physician and responsible party if she did not. In an interview on 09/27/2023 at 3:34 p.m., S7LPN stated the staff member that first noted a wound was responsible for notifying the resident's physician and responsible party. S7LPN further stated that she thought she had notified Resident #87's physician yesterday, but did not. In an interview on 09/27/2023 at 4:52 p.m., S2DON stated that S8TN should not have documented that she notified Resident #87's physician and responsible party of Resident #87's new left labia pressure injury if S8TN did not notify Resident #87's physician and responsible party of the above wound.

Based on observations, interviews, and record review the facility failed to ensure: 1. Staff performed hand hygiene per facility policy during catheter care for 1 (Resident #87) of 2 residents (Resident #30 and Resident #87) investigated for catheters; 2. Staff performed hand hygiene per facility policy while serving meal trays to residents in their rooms; and 3. Staff handled soiled linen in a manner to prevent cross contamination of surfaces when 2 Certified Nursing Assistants (CNAs) (S16CNA and S21CNA) placed soiled linen on the floor for 2 (Resident #44 and Resident #87) of 2 residents observed during perineal care (washing the genital and rectal areas of the body) and 1 CNA(S21CNA) placed items used in a resident's room onto the clean linen cart. Findings: Review of the facility's Hand Hygiene policy revealed, in part, hand hygiene is indicated when entering and exiting a resident's room, before and after procedures, and before and after applying gloves. 1. Observation on 09/26/2023 at 3:50 p.m., revealed S21CNA did not perform hand hygiene before putting on gloves to perform Resident #87's catheter care. Further observation revealed, after performing Resident #87's catheter care and perineal care, S21CNA removed gloves, did not perform hand hygiene, and placed on new gloves before emptying Resident #87's catheter bag. In an interview on 09/27/2023 at 1:25 p.m., S5ADON stated 21CNA should have performed hand hygiene before performing Resident #87's catheter care and before putting on gloves to empty Resident #87's urine from her catheter bag. In an interview on 09/28/2023 at 2:28 p.m., S21CNA stated she should have performed hand hygiene before starting Resident #87's catheter care and before putting on gloves to empty Resident #87 urine from her catheter bag. In an interview on 09/27/2023 at 3:11p.m., S6CNA Supervisor stated 21CNA should have performed hand hygiene before performing Resident #87's catheter care and before putting on gloves to empty Resident #87 urine from her catheter bag. In an interview on 09/27/2023 at 4:52 p.m., S2DON stated that S21CNA should have performed hand hygiene before performing Resident #87's catheter care and should have performed hand hygiene after finishing perineal care, before putting on new gloves and emptying urine from Resident #87's catheter bag. 2. Observation on 09/26/2023 at 12:25 p.m. revealed S12CNA delivered a lunch tray to Resident #37, set up Resident #37's lunch tray, and then exit Resident #37's room and grab Resident #47's lunch tray off of cart without performing hand hygiene. Further observation revealed S12CNA then delivered Resident #47's lunch tray to his room, set up Resident #47's lunch tray, adjusted Resident #47's privacy curtain, exited Resident #47's room, and grabbed Resident #26's lunch tray and place it on top of her cart without performing hand hygiene. Further observation revealed S12CNA delivered Resident #26's lunch tray, exited Resident #26's room, grabbed Resident #6's lunch tray, delivered Resident #6's lunch tray to his room, set up Resident #6's lunch tray, exited Resident #6's room, and grabbed Resident #24's disposable lunch tray without performing hand hygiene, placed Resident #24's lunch tray back down on cart, put on personal protective equipment, and entered Resident #24's room with his disposable lunch tray. In an interview on 09/27/2023 at 12:19 p.m., S12CNA stated she should have performed hand hygiene when she delivered and set up the above resident's lunch trays and did not. In an interview on 09/27/2023 at 12:21 p.m., S6CNA Supervisor stated S12CNA should have performed hand hygiene after exiting a resident's room but before grabbing another resident's tray. In an interview on 09/27/2023 at 4:52 p.m., S2DON stated that CNAs should perform hand hygiene between resident's when delivering and setting up lunch trays. 3. Observation on 09/26/2023 at 3:15 p.m., revealed S16CNA placed a towel and an incontinence pad, on the floor, in the corner of Resident #44's room by the door. In an interview on 09/26/2023 at 3:15 p.m., S16CNA stated that the towel and the incontinence pad on the floor were soiled linen because she had just cleaned Resident #44 from an incontinent bowel movement. Observation on 09/26/2023 at 3:17 p.m., revealed S16CNA performed Resident #44's perineal care. Further observation revealed, when finished with Resident #44's perineal care, S16CNA threw the towel used to perform Resident #44's perineal care on the floor. Observation on 09/26/2023 at 3:50 p.m. revealed S21CNA took a box of gloves and a package of wipes off of the clean linen cart and brought them into Resident #87's room. Further observation revealed S21CNA removed blankets and sheets from Resident #87's bed and threw them on the floor. Further observation revealed, S21CNA removed gloves from the glove box and wipes from the package brought into Resident #87's room without first performing hand hygiene while performing Resident #87's catheter care. Further observation revealed after S21CNA emptied urine from Resident #87's catheter bag, S21CNA removed her gloves, did not perform hand hygiene, grabbed the box of gloves and a pack of wipes from Resident #87's bedside table, left Resident #87's room with the box of gloves and the package of wipes, and placed the box of gloves and the package of wipes onto the clean linen cart in the facility's hallway. In an interview on 09/27/2023 at 12:11 a.m., S16CNA stated she should not have thrown soiled linen on the floor of Resident #44's room. In an interview on 09/27/2023 at 1:25 p.m., S5ADON stated CNAs should not place soiled linen on the floor of the resident's rooms. S5ADON further stated S21CNA should not have placed the box of gloves or the package of wipes used in Resident #87's room back onto the clean linen cart. In an interview on 09/28/2023 at 2:28 p.m., S21CNA stated she should not have thrown Resident #87's blankets onto the floor of her room. In an interview on 09/27/2023 at 3:11p.m., S6CNA Supervisor stated CNAs are not supposed to throw soiled linen on the floor of the resident's rooms. S6CNA Supervisor further stated S21CNA should not have placed the box of gloves or the package of wipes used in Resident #87's room back onto the clean linen cart. In an interview on 09/27/2023 at 4:52 p.m., S2DON stated the facility's CNAs should not have placed soiled linen on the floor of the resident's rooms. S2DON further stated that the box of gloves and the package of wipes should not have been placed back on the clean linen cart after being brought into Resident #87's room.

Based on observations, interviews, and record review the facility failed to ensure S3Treatment Nurse (TN) performed hand hygiene per facility policy when S3TN performed wound care. This deficient practice was identified for 2 (Resident #3 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5) residents reviewed for wound care. Findings: Review of the facility's Dressing Change Policy and Procedure revealed, in part, hand hygiene is to be performed before wound care procedures. Further review revealed, in part, gloves are to be removed and hand hygiene performed after removing old dressings, after cleansing and measuring wounds, and before applying any creams or new dressings. Resident #3 Observation on 03/14/2023 at 11:12 a.m., revealed S3TN cleaning an incontinence episode for Resident #3 and changing Resident #3's incontinence pad. S3TN then removed her gloves and put on new gloves without performing hand hygiene. S3TN proceeded to clean Resident #3's pressure injury with normal saline and gauze, but was unable to continue pressure injury wound care when Resident #3 began to have an incontinent bowel movement. S3TN exited Resident #3's room to get more supplies. Observation on 03/14/2023 at 11:23 a.m., revealed S3TN returned to Resident #3's room and applied gloves, cleaned Resident #3's from an incontinent bowel movement, removed her gloves, and then placed on new gloves without performing hand hygiene. S3TN then proceeded to clean Resident #3's pressure injury again with normal saline, applied barrier cream to Resident #3, and applied new dressing to Resident #3's pressure ulcer without changing her gloves or performing hand hygiene between each step. In an interview on 03/14/2023 at 2:04 p.m., S3TN stated she should have performed hand hygiene between providing incontinence care to Resident #3 and cleaning Resident #3's pressure injury. S3TN further stated she should have changed her gloves and performed hand hygiene between cleaning Resident #3's pressure injury, applying barrier cream to Resident #3, and applying dressing to Resident #3's pressure injury. In an interview on 03/16/2023 12:40 p.m., S2Assistant Director of Nursing (ADON) stated S3TN should have performed hand hygiene before performing Resident #3's pressure injury wound care, and S3TN should have performed hand hygiene and changed gloves between cleansing Resident #3's pressure injury, applying barrier cream to Resident #3, and applying new dressing to Resident #3's pressure injury. In an interview on 03/16/2023 at 12:48 p.m., S1Quality Improvement (QI) Nurse stated S3TN should have performed hand hygiene before starting Resident #3's wound care, and S3TN should have performed hand hygiene and changed gloves between cleaning Resident #3's pressure injury, applying barrier cream to Resident #3, and applying dressing to Resident #3's pressure injury. Resident #5 Observation on 03/14/2023 at 1:45 p.m., revealed S3TN applied gloves, removed dressing to Resident #5's left hand skin tear and Resident #5's left forearm skin tear, removed her gloves, and then applied new gloves without performing hand hygiene. S3TN then cleaned Resident #5's left hand skin tear and Resident #5's left forearm skin tear with normal saline and gauze, and then patted Resident #5's left hand skin tear and Resident #5's left forearm skin tear dry with gauze. Further observation revealed, S3TN did not perform hand hygiene or change gloves before she applied new dressings to Resident #5's left hand skin tear and Resident #5's left forearm skin tear. In an interview on 03/14/2023 at 2:04 p.m., S3TN stated she should have performed hand hygiene between removing old dressings from Resident #5's left hand skin tear and Resident #5's left forearm skin tear, and cleaning Resident #5's left hand skin tear and Resident #5's left forearm skin tear. S3TN further stated she should have performed hand hygiene and changed her gloves after cleaning Resident #5's left hand skin tear and Resident #5's left forearm skin tear before applying new dressings to Resident #5's left hand skin tear and Resident #5's left forearm skin tear. In an interview on 03/16/2023 12:40 p.m., S2Assistant Director of Nursing (ADON) stated S3TN should have performed hand hygiene between removing old dressing to Resident #5's left hand skin tear and Resident #5's left forearm skin tear and cleansing Resident #5's left hand skin tear and Resident #5's left forearm skin tear. S2ADON further stated S3TN should have performed hand hygiene and changed her gloves between cleansing Resident #5's left hand skin tear and Resident #5's left forearm skin tear, and applying new dressing to Resident #5's left hand skin tear and Resident #5's left forearm skin tear. In an interview on 03/16/2023 at 12:48 p.m., S1Quality Improvement (QI) Nurse stated S3TN should have performed hand hygiene after removing dressing to Resident #5's left hand skin tear and Resident #5's left forearm skin tear before she cleaned Resident #5's left hand skin tear and Resident #5's left forearm skin tear. S1QI Nurse further stated that S3TN should have changed her gloves between cleaning Resident #5's left hand skin tear and Resident #5's left forearm skin tear and applying new dressing to Resident #5's left hand skin tear and Resident #5's left forearm skin tear.