**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes 1227387 and 1227390.Based on interview and record review the facility failed to implement fall prevention interventions for one (R101) of three residents reviewed for accidents, hazards, and adequate supervision, resulting in multiple falls with the potential for injuries. Findings include:This citation pertains to intakes 1227387 and 1227390.Based on interview and record review the facility failed to implement fall prevention interventions for one (R101) of three residents reviewed for accidents, hazards, and adequate supervision, resulting in multiple falls with and without injury.Findings include:On 8/4/25 at 10:30 a.m. R101 was contacted via telephone regarding the allegations reported to the state agency. R101 said they experienced several falls when trying to get something off the floor, when needing to go to the bathroom independently, and after putting on and waiting for the call light to be answered. R101 said the nurses put the resident at the nurse's station all day because of the multiple falls, I tried to get whatever fell off the floor and the nurses took too long to help me, so I did it myself and fell. I hurt my head, my shoulders, legs and back. Review of the clinical record documented R101 was admitted into the facility on 2/2/25 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinson's disease, and history of falling. R101 was discharged to another facility and no longer resides at the facility. According to the quarterly Minimum Data Set assessment dated [DATE], R101 was cognitively intact (BIMS-13), and required one person assistance with activities of daily living. Review of the Risk for Falls care plan, dated 2/2/25 documented:R101 is at risk for falls related to injury and falls related to: history of falls, hemiparesis, impaired cognition, decreased transfer and locomotion mobility.Goal: Will be free from injury and related to falls through the review date.Interventions: Keep the residents' environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position. 2/2/25Staff to ensure that all items are in reach and accessible (i.e. remote control, cell phone, water cup, books, ink pens, etc.). 2/20/25Put the call light within reach and encourage him/her to use it for assistance as needed. 2/2/25Staff to locate a different room, closer to the nurse's station. 5/30/25 Review of the following Incident and Accident reports documented in part for following falls:-2/3/25 16:00- Incident Description: .In room, observed resident lying on floor, on the right side, near the bed. I was reaching for my call light and the end table moved and I rolled out of bed.Immediate Action taken: . Resident complained of pain in right shoulder.-2/18/25 12:09- Incident Description: .Observed resident on floor in bathroom in room with back against the wall facing the toilet. Resident stated trying to grab onto the rail with the weak hand and slid onto the floor. No injury observed.-2/20/25 00:00- Incident Description: The resident was observed on the floor unwitnessed on the left side. No injuries observed.There was no statement from resident about the fall. -2/26/25 05:55- Incident Description: CNA observed resident on the floor in room. observed laying on back in front of the wheelchair. Resident stated trying to get call light off the floor. No injury observed.-3/13/25 00:00- Incident Description: The resident was observed in the bedroom on buttocks and pillow near the bedroom door trying to get remote control. No injury observed.-3/26/25 00:00- Incident Description: Observed resident on buttocks on the floor in front of the wheelchair. The Resident was trying to get remote off floor. No injury observed.-5/17/25 14:00- Incident Description: Called in the room due to the patient's fall and bruising around the eye. Resident was trying to get the bed remote on the side of the bed.-5/29/25 15:45- Incident Description: Resident was observed sitting on buttocks. Resident said was trying to go to the bathroom. No injury observed.-6/10/25 11:15- Incident Description: The resident was observed on the floor on side of the bed on buttocks trying to obtain eyeglasses. No injury observed. 0n 8/4/25 at 4:25 p.m. CENA A was interviewed and queried about implementing interventions to residents that are at risk for falls. CENA A said the aides are supposed to ask the resident or look in the resident's chart to know their status. Any changes to the resident are reported to the nurse so the care guide can be updated. The aides are supposed to read the care guide to know if the resident has fall precautions. A lot of the time, residents drop their call lights and remotes on the floor. But if the rounds are done regularly or call lights answered, then residents would probably not fall. On 8/4/25 at 4:40 p.m. the Director of Nursing (DON) was interviewed. The DON said the resident was reviewed in Fall Risk meetings and recalled the number of times the resident (R101) fell and would be better to be close to the nurse's station. The reason for the residents' falls were identified. We tried to put frequently used items within reach. Nursing staff are supposed to check on residents at least every two hours. The resident fell a lot while in the room due to the resident not wanting to come out of the room so the staff should have done visual checks. According to the DON,visual checks are not documented, and therefore no review could be completed. Review of the facility's policy titled Fall Management dated 7/8/25 documented in part the following: The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain the cleanliness of a geriatric recliner for one (R78) of two residents reviewed for clean, comfortable and homelike environment. Findings include: On 11/20/24 at 6:17 a.m. R78 was observed in the common area of the unit sitting in a geriatric recliner. R78 appeared very anxious, restless, and confused. R78 legs were bent, and the lower part of the recliner was observed with dried food, dust, and candy wrappers. The left side of the recliner had dried brownish colored drip stains and the top of the recliner had a dried white substance. On 11/22/24 at 12:37 p.m. R78 was again observed in the common area of the unit sitting in the geriatric recliner. The recliner was observed with dried food, dust, stains, and trash as observed on 11/20/24. On 11/22/24 at 1:09 p.m. the Assistant Director of Nursing (ADON G) was asked to observe R78's recliner. ADON (G) was then interviewed about the cleaning of wheelchairs and recliners. ADON (G) said the chairs are cleaned on the midnight shift by the aides on shower days and as needed. Chair cleaning is assigned on the assignment sheet at the nurse's station. The assignment sheets were reviewed (last 7 days). The cleaning of chairs was not noted on the assignment sheets. Review of the clinical record document R78 was admitted into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, glaucoma, and hallucinations. According to the admission Minimum Data Set assessment dated [DATE], R78 required dependent one person assistance with activities of daily living. Review of the facility's policy titled Cleaning and Disinfecting Multi-Use Resident Equipment dated 10/11/23 documented in part: Cleaning and disinfection are essential for ensuring that multi-use medical equipment does not transmit infectious pathogens to residents . Noncritical items are resident care items that come in contact with intact skin but not mucous membranes and include, but are not limited to: .wheelchairs . Noncritical resident care items carry very little risk of transmitting infectious agents to residents even when they come in contact with non-intact skin or mucous membranes. However, these items may contribute to secondary transmission by contaminating the hands of health care workers . Thus, reusable noncritical resident care items should undergo cleaning and disinfection when they're visibly soiled and on a regular schedule (for instance, after each use, daily or weekly), as determined by the health care facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was completed and transmitted to CMS (Center for Medicare and Medicaid) within 14 days after completion for one (R54) reviewed during the Resident Assessment review, resulting in inaccurate tracking of resident assessments (admission, quarterly, and discharge). Findings include: On 11/22/24 at 12:01 p.m., review of the clinical record revealed R54 had an admission MDS assessment with an assessment reference date (ARD) of 7/1/24. This MDS documented that it had been Completed (7/10/24); locked and accepted on 7/23/24. R54 discharged from the facility on 7/19/24. Review of the discharge MDS assessment revealed the assessment was not completed or submitted which was indicated on the resident assessment as MDS Record over 120 days. Review of the MDS tracking located in the MDS tab in the electronic medical record read, Next Tracking/discharge: Discharge- ARD: 7/19/24, 112 days overdue. On 11/22/24 at 1:17 p.m., the MDS Coordinator (Nurse D) was interviewed. MDS Nurse D acknowledged the discharge assessment was not completed and said they were uncertain why the assessment was missed. Review of the RAI (Resident Assessment Instrument 3.0) [NAME] dated October 2024 documented in part: Responsibilities of Nursing Homes for Completing Assessments- The requirements for the RAI are found at 42 CFR 483.20 and are applicable to all residents in Medicare and/or Medicaid certified long-term care facilities. The requirements are applicable regardless of age, diagnosis, length of stay, payment source or payer source . An RAI (MDS) must be completed for any resident residing in the facility .An RAI must be completed for any individual residing more than 14 days on a unit of a facility that is certified as a long-term care facility for participation in the Medicare or Medicaid programs. If the respite resident is in a certified bed, the OBRA assessment schedule and tracking document requirements must be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide timely ADL (Activities of daily living) care to include nail care and beard care for one resident (R28) of three residents reviewed for ADL care resulting in dissatisfaction with care. Findings include: On 11/20/24 at 9:07 AM R28 was observed in bed with long fingernails with debris and an unkempt beard. R28 stated I could use a shave and get my nails cut. On 11/21/24 at 8:41 AM R28 was observed with long fingernails with debris and an unkempt beard. Record review of R28's Electronic Health Record (EHR) revealed admitted to facility on 1/28/22 with pertinent diagnosis of hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following cerebral infarction (stroke) affecting right dominant side. Review of the Minimum Data Set (MDS) dated [DATE] for R28 revealed a Brief interview for Mental Status (BIMS) of 13/15 intact cognition and substantial/maximum assistance for personal hygiene. On 11/21/24 at 2:08 PM R28 was observed with Licensed Practical Nurse (LPN) B. LPN B agreed R28's fingernails were long with debris and his beard was unkempt. R28 agreed to have his nails cut and beard trimmed when offered by LPN B. LPN B said usually nails are cut and beards are trimmed when residents are given bed baths/showers. Record review of R28's care plan dated 11/5/24 revealed Resident requires limited assistance with one staff assistance with personal hygiene and oral care. Record Review revealed no resident refusals of ADL care in the EHR and R28 received a bed bath/shower on 11/20/24 at 19:43 (7:43 pm.) On 11/22/24 at 9:35 AM the Director of Nursing (DON) was interviewed and said ADLs are expected to be performed as needed for residents. Review of the facility policy titled Routine Resident Care revised 3/7/23 revealed in part .Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Daily personal hygiene minimally includes assisting residents with washing their face and hands, shaving, nail care, combing their hair each morning. Any concerns will be reported to the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to include one resident (R93) out of four residents reviewed for limited ROM in the restorative program. Findings include: On 11/20/24 at 12:38 PM, R93 was interviewed while in bed and stated, I'm not getting therapy or any exercises. I was supposed to get exercises after therapy finished. Record review of Electronic Health Record (EHR) revealed R93 admitted to the facility on [DATE] with diagnoses that included acquired absence of right leg below knee, absence of left leg below knee. Review of the Minimum Data Set (MDS) dated [DATE] for R93 revealed a Brief interview for Mental Status (BIMS) 15/15 intact cognition and substantial/maximal assistance for transfers. Record review of the physical therapy discharge summary note dated 11/1/24 revealed RNP/FMP (restorative nursing program/functional maintenance program): to facilitate maintaining current level of performance and in order to prevent decline, development of an instruction in the following RNP has been completed with the idt (interdisciplinary team): bed mobility and transfers. Record review of the occupational therapy Discharge summary dated [DATE] revealed RNP/FMP to facilitate maintaining current level of performance and in order to prevent decline development of and instruction in the following RNPs has been completed with the IDT:ROM (range of motion) (active). Record review of the EHR did not reveal a therapy to restorative form completed for the physical therapy discharge on [DATE]. Record review of the occupational therapy to restorative form completed on 11/10/24 revealed teaching received by nursing signed by Licensed Practical Nurse C. Record review of the restorative assessment was made on 11/13/24. Further review of the EHR for R93 revealed no orders, care plan and/or [NAME] for a restorative ROM program. On 11/21/24 at 12:40 PM Licensed Practical Nurse/Restorative Nurse (LPN) C was interviewed and said R93 was not on restorative nursing services but based on the documentation in the EHR (R93) should be. LPN C said physical therapy did not send over a referral for restorative services. LPN C said she receives a therapy to restorative form then does an assessment and based on the restorative assessment restorative services would begin within three business days. On 11/22/24 at 9:35 AM the Director of Nursing (DON) was interviewed and said the expectation is that restorative services should be assessed per therapy recommendations. Review of the facility policy titled Restorative Nursing revised 4/26/24 revealed in part: The facility strives to enable the resident to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being. A licensed nurse will manage the restorative nursing process with assistance of nursing assistants trained in restorative care. Nursing restorative is available up to 6-7 times per week. Components of the restorative nursing program include interdisciplinary process: a referral from skilled therapy services via the Therapy to Restorative Program Plan, and/or during weekly interdisciplinary Team Meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure respiratory care equipment was stored in a sanitary manner for one resident (R276) out of two residents reviewed for respiratory care resulting in the potential for respiratory infections. Findings include: On 11/20/24 at 10:23 a.m. R276 was observed sitting in a wheelchair, in the room. R276 was alert, oriented to person, place, situation, and able to make all needs known. On the nightstand, a CPAP machine (A continuous positive airway pressure device used for treating sleep apnea disorders.) mouthpiece and tubing was observed loosely wrapped around machine with the mouthpiece resting on the nightstand's surface uncovered. R276 was queried about the uncovered mouthpiece and stated, The other places have always given something to put over it to keep from getting dirty but not here. It has fallen on the floor. I just pick it up and put back on the table. Sometimes they clean it in the morning but not before I put it on at night. On 11/20/24 at 12:51 p.m. R276 was observed attempting to move the wheelchair and bumped the nightstand in which the uncovered mouthpiece fell and landed on the floor. R276 picked the mouthpiece off the floor by grabbing the tubing and placed it back on the nightstand. Review of the clinical record documented R276 was readmitted into the facility on [DATE] with diagnoses that included obstructive sleep apnea. R276 required extensive one person assistance with activities of daily living and had intact cognition. Review of the physician's orders documented: Clean tubing and mask with soap and water, rinse with water, and let air dry. One time a day every 7 day(s). Start date: 10/3/2024. Review of care plans documented the following: Resident has a potential for difficulty breathing and risk for respiratory complications R/T: Obstructive Sleep Apnea. 10/4/2024 Interventions: -Administer medication & treatments per physician orders. - Observe for s/sx (signs and symptoms) of respiratory infection. Review of the November 2024 medication treatment record (MAR) documented the cleaning of the CPAP tubing and mask was on 11/14/24. There was no other documentation of additional cleanings. On 11/22/24 at 1:13 p.m. Unit Manager G was interviewed and queried how are CPAP machine mask stored when not in use. Unit Manager G said the mask are placed in a plastic bag when not in use however a company provides them. The nurses are responsible for proper storage of the mask when not in use. Unit Manager G was unaware R276 did not have the proper covering for the CPAP mask. Review of the facility's policy titled Use of Oxygen (also used for CPAP and BIPAP) dated 8/17/21 documented in part the following: The mask should be changed weekly and dated. It should be changed when soiled or dirty . The mask, when not in use, should be stored in a clean bag .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure routine dental services were provided to one resident (R63) of three residents reviewed for routine dental services, resulting in unmet oral health needs, discomfort, and loss of dignity. Findings include: On 11/20/24 at 9:45 a.m. was observed in bed resting. R63 presented as alert, oriented to person, place, and situation. R63 stated, I don't like the food here. I get soft food because I have trouble chewing. I asked to see a dentist, but no one has said anything about an appointment to see one. R63 pulled the bottom lip down and exposed two teeth (no other teeth except the two shown). R63 stated, I want these last two teeth pulled so I can get dentures and go back to a regular diet. I'm not eating like I want to. I eat more outside food. I want to gain more weight, but I can't if I'm not eating. If I can get them pulled, I will grin from ear to ear like a [NAME] cat. R63 confirmed being in the facility for about two months. Review of the electronic medical record documented R63 was admitted into the facility on 9/7/24 with diagnoses that included prediabetes, severe protein-calorie malnutrition, peripheral vascular disease, and chronic obstructive pulmonary disease. According to the admission Minimum Data Set (MDS) assessment dated [DATE], R63 was cognitively intact with a BIMs score of 15 and required one- person assistance with activities of daily living. The MDS assessment also documented in the Oral Health and Swallowing section as No natural teeth or tooth fragment(s) (edentulous). Review of the Oral/Dental care plan dated 9/16/24 documented: The resident is at risk for infection, pain or bleeding in the oral cavity, has oral/dental health problems r/t: missing teeth. Interventions: Coordinate arrangements for dental care, transportation as needed/as ordered. Observe/document/report to physician PRN s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. Review of the Physician Orders dated 9/7/24 documented: Dental evaluation and treatment as indicated. On 11/21/24 at 4:18 p.m. the Director of Nursing (DON) and Social Service Director (SSD H) were interviewed about the delay with R63 receiving dental care. The DON said any department can refer for dental. Social Service ensures they are seen by the dentist. The DON and SSD H said they were unaware the resident needed dental care because the resident did not verbalize needing dental care. The DON acknowledged there was a physician order for a dental evaluation, however said the order was a standard order (an order written IF needed). The DON also acknowledged a dental care plan was developed identifying dental concerns, however said the care plan did not necessarily mean there was dental concerns that needed to be addressed. SSD H said dental services were not offered to the resident while conducting the initial assessment upon admission. SSD H also said the resident did not want to see the dentist, however there was no documented evidence the resident declined dental services. On 11/21/24 at 4:35 p.m. Registered Dietician (RD) E was interviewed and said R63 dental status was documented in the admission nutrition evaluation (dated 9/10/24) c/o difficulty chewing. R63 was changed to a mechanical soft diet due to indentation. The resident was edentulous (except two teeth) but did not express wanting dental care to get dentures. Review of the facility's policy titled Dental Services effective 11/4/24 documented in part: The facility will provide, or obtain from an outside resource, routine and twenty-four (24) hour emergency dental services to meet the needs of the resident and when requested by the resident.

Based on observation, interview and record review the facility failed to ensure resident equipment was cleaned and sanitized sanitary equipment for 14 of 14 residents that resided on the third floor. Findings Include: On 11/22/24 at 9:00AM, a shower chair was observed in the hallway with visible dried feces. In addition, the sit to stand machine (device used for positioning residents) was noted to be soiled with dirt and food particles. On 11/22/24 at 9:10 AM, LPN A was queried concerning who was responsible for cleaning the resident's equipment. LPN A indicated the equipment should have been cleaned by the midnight shift. LPN A further indicated the equipment should have been cleaned after each use to prevent cross contamination. On 11/22/24 at 9:20 AM, the Nursing Home Administrator, (NHA) was shown the shower chair while she was rounding on the unit. The Administrator reiterated after observing the shower chair the facility was responsible for cleaning the equipment and the equipment should be cleaned after each use and on the midnight shift. A request for the facility's policy on cleaning equipment was made at this time. On 11/22/24, record review of the facility's policy entitled Cleaning and Disinfecting Multi-Use Resident Equipment dated 10/11/23 documented in part: Cleaning and disinfection are essential for ensuring that multi-use medical equipment does not transmit infectious pathogens to residents . Noncritical items are resident care items that come in contact with intact skin but not mucous membranes and include, but are not limited to: .wheelchairs . Noncritical resident care items carry very little risk of transmitting infectious agents to residents even when they come in contact with non-intact skin or mucous membranes. However, these items may contribute to secondary transmission by contaminating the hands of health care workers . Thus, reusable noncritical resident care items should undergo cleaning and disinfection when they're visibly soiled and on a regular schedule (for instance, after each use, daily or weekly), as determined by the health care facility

This citation pertains to intake MI00143137. Based on interview and record review the facility failed to ensure an x-ray for one resident (R906) was completed in a timely manner. Findings include: During an interview on 3/7/24 at 11:00 AM with R906, it was reported that a fall occurred when entering the facility on 3/5/24 at approximately 5:45 PM. R906 further reported that an x ray was done, This morning. Record review of electronic medical records (EMR) revealed admission into facility on 3/5/24. According to the Brief Interview for Mental Status (BIMS) dated 3/6/24, R906 was Cognitively Intact. During an interview on 3/7/24 at 9:45AM with Attending Physician (AP) A, it was reported that an x ray was ordered on the evening of 3/5/24. Record review of Physician Orders documented: X ray of left leg, left knee, and left hip dated 3/5/24 at 9:19 PM. On 03/07/2024 at 10:02 AM, Licensed Practical Nurse (LPN) B, reported that an order was received from AP A on 3/5/24 and was entered into the resident's electronic medical record (EMR). It was further reported that it was a stat (immediately) order, but the company that does x- ray does not do stat orders. These orders should be completed the next day. LPN B then said, Orders for x- rays must be called or entered in the x-ray provider's system. When asked if this step was completed. LPN B responded, No. I endorsed it over to the oncoming nurse to finish. Interview on 03/07/2024 at 11:13 AM with Unit Manager C, it was reported that the Physician's order was not completed and sent to x ray provider until 3/6/24 at 6:14 PM. It was further reported that the Physician's order should have been completed on the night of 3/5/24, so it could have been done by the next day. Record review of x- ray provider's Order Confirmation documented: .Order Date: 3/6/2024- Order Time: 6:14 PM. Record review of Radiology Report dated 3/7/24 documented: Date of Service 3/7/2024. During an interview on 3/7/24 at 2:20 PM with Director of Nursing (DON), it was reported that the order for the x- ray should have been completed on 3/5/24 when it was received.

This citation pertains to intake MI00142795. Based on interview and record review the facility failed to provide adequate supervision during care for one resident (R905) out of three residents reviewed for ADL (Activities of Daily Living) resulting in a fall with injury. Findings include: During an interview on 3/7/24 at 10:15 AM with a Concerned Family Member (CFM) D, it was reported that R905 had fallen out of bed while care was provided by staff. Record review R905's Nurses Notes dated 2/16/24 at 7:12 AM it was documented, during patient care resident fell from bed. During an interview on 3/7/24 at 1:09 PM with Unit Manager (UM) E, it was reported that when Certified Nursing Assistant (CNA) F was providing care, R905 was moved away from CNA F while in bed resulting in the resident falling out of bed. When asked if this fall could have been prevented, UM E responded, If the resident had been pulled toward the staff member or positioned in the middle of bed it could have prevented the fall. When asked if the resident received an injury from the fall, UM E reported that R905 had a small laceration (cut) on the back of head. Record review of Skin/Wound Progress Note dated 2/16/24 at 3:10 PM documented . the size of the laceration was 1.0 x 0.5 cm (centimeters) with a depth of less than 0.01 cm . Record review of electronic medical records (EMR) revealed admission into facility on 3/27/19 with a pertinent diagnosis of muscle wasting and atrophy. According to the Brief Interview for Mental Status (BIMS) dated 1/29/24, R905's cognition was rated at Severe Impairment. Record review of Functional Abilities and Goals, dated 1/24/24 documented, Mobility-Roll Left and Right- Substantial/Maximal assistance. Further review of Functional Ability Deficit care plan documented, Bed Mobility: Resident requires total assistance with one staff assistance to reposition and turn in bed (dated 10/26/23). During an interview on 3/7/24 at 2:20 PM with Director of Nursing (DON), it was reported that the staff member should not have repostioned the resident away from self while providing care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practice statements. Deficient Practice Statement #1. This citation pertains to Intake MI00139389. Based on observation, interview, and record review, the facility failed to ensure prescribed medications octreotide acetate injection (used to treat severe diarrhea) and triamcinolone acetonide ointment (used to treat various skin conditions) were provided in a timely manner for two residents (R102 and R121) reviewed for quality of care, resulting in resident frustration, and the potential for unmet care needs. Findings include: It was reported to the State Agency that the facility failed to administer medications as ordered. Resident #102 - A review of the admission record for Resident #102 (R102) documented an admission date of 8/21/2023 with diagnoses that included bladder cancer. A Minimum Data Set assessment dated [DATE] documented intact cognition and the presence of an ostomy. Physician orders for R102 included: Octreotide acetate injection solution 500 mcg/ml. Inject 0.6 ml subcutaneously three times a day for diarrhea. Start date 8/24/23. End date 9/1/23. On 9/21/2023 at 12:54 PM, a review of the clinical record for R102 was conducted with the Director of Nursing (DON). Nursing documentation related to the administration of octreotide acetate injection solution documented in part the following: 8/21/23 at 9:00 PM - not available 8/22/23 at 9:00 AM - writer followed up with pharmacy, to be delivered today. 8/22/23 at 9:00 PM - medication not available. 8/23/23 at 9:00 PM - on order. 8/24/23 at 9:00 AM - on order. 8/24/23 at 1:00 PM - on order. 8/24/23 at 9:00 PM - on order. 8/26/23 at 9:00 AM - medication ordered. 8/26/23 at 1:00 PM - awaiting med delivery. 8/31/23 at 9:00 AM - on order will f/u with pharmacy. 8/31/23 at 1:00 PM - awaiting from pharmacy. On 9/21/23 at 4:05 PM, the DON reported there was no documentation to hold octreotide acetate injection solution for constipation and/or diarrhea. Resident #121 - On 9/19/23 at 8:31 AM, Resident #121 (R121) stated, I have psoriasis over 80% of my body and I'm not receiving treatment. Patches of discolored and somewhat scaly skin was observed on R121's hands and wrists. On 9/20/23 at 11:12 AM, Licensed Practical Nurse (LPN) E said R121's psoriasis ointment was in the treatment care. There was no psoriasis ointment available for R121 when an examination of the contents of the treatment cart was conducted with LPN E. LPN E said she did not give R121 his psoriasis treatment today. LPN E stated, I just found out he didn't have any. I have to order him some more. On 9/20/23 at 11:23 AM, R121 said he didn't receive his psoriasis ointment today or yesterday (9/19/23). A review of the admission Record for R121 documented an admission date of 8/29/23 with diagnoses that included sarcoidosis, type 2 diabetes mellitus, and peripheral vascular disease. A MDS assessment dated [DATE] documented intact cognition. R121 has a physician order for Triamcinolone Acetonide Ointment 0.1 % Apply to psoriasis plaques topically two times a day for psoriasis condition is generalized - apply to all affected areas -Start Date- 09/06/2023 0900. A review of the September 2023 Medication Administration Record revealed that Triamcinolone Acetonide Ointment was not applied on 9/9/23, 9/13/23, 9/14/23, or 9/15/23. On 9/21/23 at 11:08 AM, the DON said medications should be documented when it is given and if it is not given there should be an explanation. A review of the facility policy titled, Medication Administration, dated 9/9/22, documented in part the following: Guest/resident medications are administered in an accurate, safe, timely, and sanitary manner. On 9/13/2023 at 5:35 PM, during the exit conference, the NHA and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not. Deficient Practice Statement #2. This citation pertains to Intakes MI00136145 and MI00138771. Based on interview and record review, the facility failed to ensure wound treatments were consistently documented per physician orders and nursing standards of practice for treatment administration for three residents (R22 and R168) of seven residents reviewed for wound care, resulting in the potential for unmet care needs. Findings include: It was reported to the State Agency that the facility failed to provide adequate and appropriate care to prevent pressure sores. Resident #22 - A review of the admission Record for Resident #22 (R22) documented an admission date of 7/19/2023 with diagnoses that included Stage 3 sacral pressure ulcer, functional quadriplegia, and Type 2 diabetes mellitus. R22 discharged from the facility on 9/11/2023. A Minimum Data Set (MDS) assessment of 7/26/2023 documented intact cognition, the presence of two stage 3 pressure ulcers, two unstageable deep tissue injuries, and one venous ulcer. A review of R22's admission assessment dated [DATE] documented in part: right buttock: open area; left buttock: open area; right heel: open area; right toe: missing pinky toe. A review of R22's admission summary dated [DATE] documented in part the following: (R22) is an [AGE] year-old female with a history of hypertension, Type 2 diabetes, and weakness in both lower extremities. (R22) has a stage 2 pressure wound on both right and left buttocks, and excoriation in vagina area, right pinky toe is missing, and right ankle has an open area. Review of R22's care plans documented the following: 1. (R22) is at risk for impaired skin integrity/pressure injury related to: bowel incontinence, history breast cancer, diabetes mellitus, impaired bed, transfer, and repositioning mobility. admitted with two stage 3 pressure wounds, one diabetic ulcer, two deep tissue wounds. Date created and initiated: 7/19/2023. 2. (R22) has an actual impaired skin integrity related to pressure, right heel, stage 3 ulcer. Date initiated: 7/20/2023. Date created: 8/28/2023. Interventions: - Refer to potential for skin impairment care plan for interventions. Date initiated and created: 8/28/2023. - Treatment as ordered. Date initiated and created 8/28/2023. 3. (R22) has actual impairment to skin integrity of right and left buttock related to pressure, decreased in mobility. Date initiated and created 7/19/2023. Interventions: Follow facility protocols for treatment of injury. Date initiated and created: 8/28/2023. 4. (R22) has diabetic ulcer dorsal right foot related diabetes. Date initiated: 7/20/2023. Date created 8/28/2023. Intervention: Administer treatment to the wound as per order. Date initiated and created 8/28/2023. On 9/21/2023 at 11:34 AM, a review of the Treatment Administration Records (TAR) for R22 with the Director of Nursing (DON) revealed that wound care was not documented on the TARs as follows: 1. Coccyx: clean with normal saline, pat dry. Apply Silvadene and cover with dry dressing. Start date 8/18/23. End date: 9/12/23. Wound care not documented on 8/19/23, 8/20/23, 8/26/23, 8/27/23, and 9/10/23. 2. Left buttock. Clean with normal saline, pat dry. Apply Silvadene (thin layer) and cover with dry dressing. Start date 8/18/23. End date: 9/12/23. Wound care not documented on 8/19/23, 8/20/23, 8/26/23, 8/27/23, and 9/10/23. 3. Right buttock. Clean normal saline, pat dry. Apply Silvadene (thin layer) and cover with dry dressing. Start date 8/18/23. End date: 9/12/23. Wound care not documented 8/19/23, 8/20/23, 8/26/23, 8/27/23, and 9/10/23. 4. Right gluteal: clean normal saline, pat dry. Apply Silvadene (thin layer) and cover with dry dressing. Start date 8/18/23. End date: 9/12/23. Wound care not documented on 8/19/23, 8/20/23, 8/26/23, 8/27/23, and 9/10/23. 5. Right heel. Clean normal saline, pat dry, apply Santyl (a nickel thick layer) and Calcium Alginate and cover with dry dressing. Start date 8/18/23. End date: 9/12/23. Wound care not documented on 8/19/23, 8/20/23, 8/26/23, 8/27/23, and 9/10/23. 6. Santyl ointment to right 5th toe, clean with normal saline, apply dry dressing. Start date 7/28/23. End date 8/18/23. Wound care not documented on 8/12/23 and 8/13/23. 7. Santyl ointment to right 5th toe, clean with normal saline, pat dry, apply Santyl (nickel thick layer) and calcium alginate, cover with dry dressing. Start date 8/18/23. End date 8/18/23. Wound care not documented on 8/19/23, 8/20/23, 8/26/23, 8/27/23, and 9/10/23. 8. Santyl ointment to right/left buttock. Start date 7/28/23. End date 8/18/23. Wound care not documented on 8/12/23 and 8/13/23. Resident #168 - A review of the admission Record for Resident #168 (R168) documented an initial admission date of 1/13/2023, discharged date of 2/12/2023, readmission date of 2/28/2023, discharge date of 3/10/2023, readmission date of 3/23/2023, and discharge date of 4/8/2023. R168's diagnoses listed when admitted on [DATE] included non-pressure chronic ulcer of right heel and midfoot, peripheral vascular disease, and Type 2 diabetes mellitus. A MDS assessment dated [DATE] documented intact cognition. A review of R168's care plans documented in part the following: Focus: (R168) is at risk for impaired skin integrity/pressure injury related to diabetes mellitus, peripheral vascular disease, coronary artery disease, weakness, impaired bed, transfer, and transfer mobility. Right foot ulcer. Created on: 01/14/2023. Interventions included: - Follow facility policies/protocols for the prevention/treatment of impaired skin integrity. Date initiated: 1/14/2023. - Observe dressing frequently to ensure it is intact and adhering. Report loose dressing to nurse. Date initiated: 1/21/2023. On 9/21/2023 at 10:41 AM, a review of the TAR records for R168 with the DON revealed that wound care was not documented on the TARs as follows: 1. Apply Hydrogel every day and as needed on Sacrococcyx/ Bilateral Buttocks, Right Hip, Left Hip until treatment nurse evaluation one time a day for wound care. Start date: 3/24/2023. End date: 4/06/2023 Wound care not documented on 3/29/23, 3/30/23, 3/31/23, and 4/2/23. 2. Dakins (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to Sacral region topically one time a day for Wound. Start date 3/24/23. End date 4/10/23. Wound care not documented on 3/29/23, 3/30/23, 3/31/23, and 4/2/23. 3. Santyl External Ointment 250 unit/gm (Collagenase) Apply to Sacral Wound topically one time a day for wound. Start date 3/24/23. End date 4/10/23. Wound care not documented on 3/25/23, 3/29/23, 3/30/23, and 3/31/23, and 4/2/23. On 9/21/2023 at 11:40 AM the DON said wound care was not consistently provided according to physician's orders. The DON stated, I believe the residents' wounds were being treated, but there is no way to show that the care was provided. On 9/21/2023 at 5:35 PM, during the exit conference, the NHA and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #163 A review of R163's Electronic Medical Record revealed R163 was admitted to the facility on [DATE] and discharged from the facility on 7/12/23. R163 had medical diagnoses that included Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Hemiplegia and Hemiparesis of the right dominant side, and Weakness. A review of R163's MDS dated [DATE] revealed R163 had a Brief Interview of Mental Status score of 15/15 (cognitively intact). Per MDS, R163 was frequently urinary incontinent, had a risk for pressure ulcers, and required extensive two-person assistance bed mobility, transfers, and toileting. A review of R163's care plan revealed the following: Focus: (R163) is at risk for impaired skin integrity/pressure injury R/T: weakness, SOB (shortness of Breath)/COPD (Chronic Obstructive Pulmonary Disease), incontinence, history COVID (Corona Virus), CKD (Chronic Kidney Diseas), CAD (Coronary Artery Disease), DVT (Deep Vein Thrombosis) BLE (Bilateral Lower Extremities), DM (Diabetes Mellitus), Stroke, CHF (Congestive Heart Failure), impaired bed, transfer, and repositioning .Goal: Minimize risk in an effort to reduce likelihood of pressure injury development through next review date .Interventions: Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; Observe dressing frequently to ensure it is intact and adhering. Report loose dressing to nurse. A review of a nursing progress note dated 12/20/22 at 3:18 AM revealed, Resident arrived via ambulance accompanied by EMT Emergency Medical Transportation) on stretcher .Resident has discoloration to BLE and both feet, also open area on buttocks. A review of R163's PCC Skin and Wound- Total Body Skin Assessments revealed R163 did not receive a skin assessment until 1/13/23. A skin assessment dated [DATE], revealed R163 had an open wound to her coccyx. A nursing progress note dated 2/15/23 revealed the following: Resident complained about discomfort to her backside. Writer assessed resident; resident has an open area to coccyx. Resident stated it happened during her transfer during dialysis. Writer cleaned wound and patched it with gauze. Wound consult and treatment placed. Unit manager notified. A review of R163's orders revealed the following: - Wound Consult; Open Area to Coccyx with a start date of 2/15/23. - Clean coccyx, pat dry, apply gauze with a start date of 2/15/23. - Clean coccyx, pat dry, medihoney, apply gauze with a start date of 2/15/23. No orders were placed for wound treatment prior to 2/15/23. On 9/21/23 at 4:04 PM the DON (Director of Nursing) was interviewed regarding the lack of treatment of R163's wound. The DON said that it is her expectation that the nursing staff place a wound care consult as soon as a wound is observed, once the consult is ordered an initial wound care intervention should be implemented. A review of the facility policy titled, Skin Management, dated 12/15/22, revealed in part the following: Guest/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. This citation pertains to Intakes MI00136145 and MI00138771 Based on interview and record review, the facility failed to provide timely treatment and interventions to promote the healing of pressure ulcers for three residents (R151, R168, and R163) out of seven residents reviewed for wound care, resulting in the potential for worsening of the pressure injury. Findings include: It was reported to the State Agency that facility staff did not provide adequate care for pressure wounds. Resident #151 - A review of the admission Record for Resident #151 (R151) documented an initial admission date of 7/14/2023 and readmission date of 8/10/2023. R151's diagnoses included cancer of the larynx, adult failure to thrive, chronic respiratory failure with hypoxia, peripheral vascular disease, atrial fibrillation, and type 2 diabetes mellitus. A Minimum Data Set (MDS)assessment dated [DATE] documented intact cognition and no pressure or venous ulcers. Physician orders documented: 1. Apply Santyl ointment nickel thick to sacrococcyx every day shift for wound care. Clean with normal saline. Apply treatment with secondary dry dressing. Start date 8/14/23. End date 8/18/23. 2. Sacral: Cleanse with normal saline, pat dry. Apply Medihoney gel and cover with dry dressing everyday shift for wound care. Start date 8/18/23. End date 9/20/23. Review of nursing progress notes documented in part the following: - 8/11/2023 at 1:22 AM: Resident was admitted today (from local hospital). Resident is a [AGE] year-old with a history of hypertension, cancer of the larynx, Type 2 diabetes. Resident is blind in right eye. No skin issues noted. - 8/11/2023 at 4:04 PM (Note created on 8/16/2023 at 4:10 PM): (R151) assessed at his bedside for skin integrity impairment due to readmitted from hospital. Resident with a stage III pressure ulcer to sacrococcyx 90% pink base granulation tissue, 10% pale white slough, moderate amount serosanguineous drainage, no odor or signs of infection. Wound margin is well defined. Periwound skin moisture and color is normal. Measurement is positional 2.2x1.8x1.6x0.1cm. Periwound skin is fragile. Resident with cognitive deficit, educate to keep resident dry and frequent positional, avoid position directly on wound. - 8/15/2023 at 2:56 PM: (R151) assessed today for fragile skin integrity to sacrum wound bed, 100% pink base epithelial tissue, moist no drainage, continue with treatment, will evaluate with (wound care nurse practitioner) Wednesday with wound rounds. Review of Skin & Wound Evaluations documented in part the following: - 8/11/2023 at 2:45 PM: Stage 3 pressure wound, present on admission. Treatment: normal saline, medihoney and calcium alginate every day and as needed. (R151) assessed at his bedside for skin integrity impairment due to readmitted from hospital. Resident with a stage III pressure ulcer to sacrococcyx, 90% pink base granulation tissue, 10% pale white slough, moderate amount serosanguineous drainage, no odor or signs of infection. wound margin is well defined. Periwound skin moisture and color is normal. Measurement is positional 2.2x1.8x1.6x0.1cm. Periwound skin is fragile. Practitioner notified. - 8/11/2023 at 1:46 PM: Stage 3 sacrum pressure wound, present on admission. Treatment: normal saline and santyl ointment daily. Practitioner notified. On 9/21/23 at 11:22 AM, the Director of Nursing (DON) acknowledged that R151 returned to the facility on 8/10/23 with wounds, but R151's wound care order was not initiated until 8/14/23. Resident #168 - A review of the admission Record for Resident #168 (R168) documented an initial admission date of 1/13/2023, discharged date of 2/12/2023, and readmission date of 3/23/2023. R168's diagnoses listed when admitted on [DATE] included non-pressure chronic ulcer of right heel and midfoot, peripheral vascular disease, and type 2 diabetes mellitus. A MDS assessment dated [DATE] documented intact cognition and no pressure or venous ulcers. A review of R168's care plan documented in part the following: Focus: (R168) is at risk for impaired skin integrity/pressure injury related to diabetes mellitus, peripheral vascular disease, coronary artery disease, weakness, impaired bed, transfer, and transfer mobility. Right foot ulcer. Created on: 01/14/2023. Interventions included: Follow facility policies/protocols for the prevention/treatment of impaired skin integrity. Date initiated: 1/14/2023. Observe dressing frequently to ensure it is intact and adhering. Report loose dressing to nurse. Date initiated: 1/21/2023. A review of R168 physician's history and physical with an effective date of 1/18/2023 documented chronic ulcer of right heel and midfoot, right foot with unspecified severity. A review of the January 2023 TAR for R168 documented in part the following: - (R) Medial Heel: clean wound site with normal saline pat dry apply dry dressing every three days for wound care -Start Date: 1/25/2023. - (R) Lateral Heel: clean wound site with normal saline pat dry cover with dry dressing one time a day every three days/PRN for wound care -Start Date: 1/25/2023. - (R) Medial foot: clean wound site with normal saline pat dry apply dry dressing one time a day every three days/PRN for wound care -Start Date: 1/25/2023. On 9/21/2023 at 10:41 AM, the DON acknowledged that R168's physician note of 1/16/23 referenced lower extremity pressure injuries and no wound cared orders were written prior to 1/25/23. On 9/13/2023 at 5:35 PM, during the exit conference, the NHA was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation relates to intake MI00129792. Based on observation, interview, and record review the facility failed to provide a functional designated hand washing sink in resident room [ROOM NUMBER]'s restroom, and a safe and sanitary environment in the facility's Cardiac and C-unit's soiled utility rooms resulting in the increased potential for harm. Findings include: On 9/20/2023 between 10:35 AM and 11:10 AM, during an environmental tour of the facility, the Cardiac and C-unit's soiled utility rooms were observed with visible debris and dark colored liquid in their hoppers, along with a strong odor present in the room. On 9/20/2023 at 11:07 AM, while in the C-unit's soiled utility room with Housekeeper, staff C, the surveyor inquired on the current state of the hopper in the room to which they replied, I don't know why someone would leave it like this. There is a sign from maintenance telling staff not to use this sink right above it. During this time frame on the same environmental tour of the facility, lift batteries and their charging stations were observed installed and stored in the Cardiac and C-unit's soiled utility rooms. On 9/20/2023 at 10:45 AM, the surveyor inquired with staff C on the storage of items like these is a soiled utility storage room to which they replied, we don't store all of them in our soiled utility rooms throughout the building, so I'm sure we can move them to other areas. On 9/20/2023 at 11:01 AM, the surveyor tested the designated hand washing sink in resident room [ROOM NUMBER]'s restroom. At this time the surveyor turned the cold water valve to the, on position and no water came out. The surveyor then turned the hot water valve to the, on position and a slow drip resulted. On 9/20/2023 at 11:09 AM, at upon interview with LPN, staff A, on the current state of the sink in this room they stated, I was aware of it in the past. At this time the surveyor asked staff A on how they expected staff to clean their hands prior to providing care to the residents, and how the residents would clean their hands after using the toilet to which they replied, we can get some hand sanitizer or wipes in the room, but closest sink to wash in would be in the dining room down the hall. The surveyor then asked staff A if they thought the residents in this room could verbalize a complaint about the sink or be aware of the importance of using hand sanitizer or wipes if supplied to the room to which they responded, they have limitations, I would say probably not. On 9/20/2023 at 11:14 AM, upon interview with Maintenance Technician, staff B, on if they were made aware of this issue with the sink they stated, yes, we were told about it maybe three weeks ago. We had a plumber come out once, but we will probably have to break through the wall to fix it. On 9/20/2023 at 11:47 AM, record review with Housekeeping Supervisor, staff D, of the daily housekeeping cleaning logs from September 1st 2023 through the present date, revealed no comments made the housekeeping staff about the sink's functionality in this room. On 9/20/2023 at 2:25 PM, record review of facility work order # 8916 created on 9/6/2023 revealed the facility identified this issue with the sink and the ticket in open status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician's orders for oxygen therapy for one (Resident #22) out of two residents reviewed for oxygen therapy, resulting in the potential for undetected respiratory status changes and complications. Findings include: Resident #22 Review of an admission Record revealed, Resident #22 (R22) readmitted to the facility on [DATE] with pertinent diagnosis which included Dementia and Lobar Pneumonia. Review of a Minimum Data Set (MDS) assessment, with a reference date of 4/12/22 revealed R22 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 00, out of a total possible score of 15. In an observation on 6/30/22 at 1:05 p.m., R22 wore oxygen at 1.5L(liters)/min via nasal cannula. In an observation on 7/7/22 at 9:18 a.m., R22 wore oxygen at 2L/min via nasal cannula. Review of a Care Plan with focus (R22) is at risk for respiratory distress r/t (related to) SOB (shortness of breath) secondary to bronchospasm with a revised dated of 6/15/22. Interventions included .Give oxygen therapy as ordered by the physician . with a initiated dated of 8/1/18. Review of Physician Orders revealed, R22 did not have an order for oxygen administration. In an interview on 7/7/22 at 10:53 a.m., Director of Nursing (DON) B reported R22's oxygen order was not restarted after readmission [DATE]th. DON B then reported R22 needed oxygen. In an interview on 7/7/22 at 11:03 a.m., DON B confirmed R22 should have an order for oxygen administration. Review of a Physician's Order policy with a revised date of 6/24/21 revealed Purpose Physician orders are obtained to provide a clear direction in the care of the guest/resident . Treatment rendered to a guest/resident must be in accordance with the specific standing, written, verbal or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges .

Based on observation, interview, and record review the facility failed follow the standards of infection control (hand washing, glove use), during Activities of Daily Living (ADL) and cleaning of rooms for one resident (Resident #38) of total sample of 25 resident, reviewed for infection control, resulting in the potential for cross contamination and the spread of disease to a vulnerable population. Findings include: In an observation of 6/30/22 at 10:01 a.m., Housekeeper C stood in the hall at a cart and wore gloves. Housekeeper C put a trash bags in the cart. In an observation on 6/30/22 at 10:03 a.m., Housekeeper C entered a room and carried a trash can with gloved hands. Housekeeper C exited the room and did not remove gloves. Housekeeper C touched the trash can on cart, re-entered the resident room and wore the same gloves as previously observed. In an observation and interview on 6/30/22 at 10:04 a.m., Housekeeper C reported she should not wear gloves in the hall. Housekeeper C then reported she should put on new pair of gloves when entering a resident's room. Housekeeper C continued to clean the room and wipe the resident's bedside table without changing gloves and performing hand hygiene. In an observation on 6/30/22 at 10:06 a.m., Housekeeper C exited the room, removed gloves, and did not perform hand hygiene. Resident #38 Review of an admission Record revealed, Resident #38 (R38) readmitted to the facility with pertinent diagnosis which included Dementia. Review of a Minimum Data Set (MDS) assessment, with a reference date of 4/26/22 revealed R38 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 03, out of a total possible score of 15. In an observation on 7/1/22 at 12:39 p.m., Certified Nursing Assistants (CNA) D and E removed R38's clothes and cleaned her face. R38's had a large bowel movement (BM) indicated by coming out of the side of the brief. With CNA E present, CNA D cleaned R38's peri area and buttocks. CNA D put R38 on a clean brief and did not change gloves before application. CNA D then adjusted her mask with gloves used to clean R38's BM, then applied cream to R38's buttocks. In an observation on 7/1/22 at 12:59 p.m., CNA D continued to touch R38's personal items including call light, closet door, and Geri chair with the gloves used to clean BM off R38. In an interview on 7/1/22 at 1:03 p.m., CNA D reported gloves should be changed after BM is cleaned up. CNA D reported gloves should be removed and hand hygiene performed. In an interview on 7/1/22 at 3:11 p.m., CNA E reported gloves should be removed after cleaning a resident with a bowel movement and then hands should be washed. In an interview on 7/6/22 at 10:45 a.m., Director of Nursing (DON) B reported gloves should be changed after going from dirty to clean procedures. DON B reported hand hygiene should be performed after glove use. Review of a Hand Hygiene policy with a revised date of 2021 revealed, Policy: To decrease the risk of transmission of infection by appropriate hand hygiene. Hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections .When hands are visibly dirty or contaminated with proteinaceous material , are visibly soiled with blood or other body fluids, and in case of a guest/resident with a spore-forming organism use soap and water. Alcohol based hand sanitizer may be used before and after: touch a guest/resident, before performing an aseptic task or handling invasive medical devices, after glove removal, if moving from a contaminated body site to clean body site during guest/resident care, and after contact with contaminated surfaces .