Based on observation, interview, and record review, facility staff failed to prevent the spread of bacteria and other infection causing contaminants during the provision of care for two residents (Residents #37 and #36) when staff failed to remove soiled gloves and/or properly wash hands. The facility census was 50. 1. Review of the facility's policy titled, Perineal Care, dated February 2018, showed staff were directed to do the following: -Place the equipment on the beside stand; -Wash and dry hands; -Provide perineal care; -Remove gloves and discard into designated container; -Wash and dry hands thoroughly; -Reposition bed covers. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2019, showed staff were directed to do the following: -This facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of health-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or bodily fluids, and after removing gloves; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 2. Observation on 10/16/23 at 3:02 P.M., showed Nurse Aide (NA) K and Restorative Nurse Aide (RNA) Therapist entered Resident #37's room to provide perineal care. The NA and RN A provided perineal care, did not wash hands or change gloves, and pulled the resident's brief up. The NA touched the resident, the wheelchair, and the remote with the same soiled gloves. The RNA placed a nasal cannula on the resident and repositioned the resident with the same soiled gloves on. The NA removed his/her gloves and without performing hand hygiene, touched the gait belt and the wheelchair. 3. Observation on 10/17/23 at 9:36 A.M., showed NA H, NA I, Certified Nurse Aide (CNA) J and Licensed Practical Nurse (LPN) L entered Resident #26's room to provide perineal care. CNA J closed the drapes and put on gloves without performing hand hygiene. CNA J pulled down the brief and assisted the resident onto the commode, removed the gait belt and adjusted the resident's clothing without performing hand hygiene or changing gloves. LPN L wiped the resident's buttocks and with the same soiled gloves on, placed his/her hand in a container of A and D ointment (barrier cream), and applied cream to resident. CNA J removed the resident's soiled brief, removed gloves, did not perform hand hygiene, and put a clean brief on resident. During an interview on 10/19/23 at 8:27 A.M., CNA N said staff should perform hand hygiene when entering a resident room and before putting gloves on. The CNA said staff should perform hand hygiene and change gloves after providing care and before putting a clean brief on the resident. If staff does not perform hand hygiene or change gloves after providing care and before moving on to a clean task, it could spread germs. During an interview on 10/19/23 at 8:41 A.M., LPN M said staff should gather supplies, wash hands and apply gloves prior to providing care. The LPN said staff have been educated to change gloves and perform hand hygiene when moving from dirty to clean tasks. The LPN said staff should always perform hand hygiene after removing gloves, since gloves are porous and do not replace hand washing and could potentially contaminate surfaces. If staff provided care, then placed the same soiled gloves into the container of A and D ointment, it would contaminate the entire container of ointment. During an interview on 10/19/23 at 9:54 A.M., the Administrator said staff were educated to change gloves and perform hand hygiene when going from a dirty to a clean task. He/She said there is a risk of contamination and infection if staff did not perform hand hygiene and change gloves between task. During an interview on 10/19/23 at 10:22 A.M., the Director of Nursing (DON) said staff should assume everything they touch is dirty and hands should be washed before, during and after cares. The DON said staff should perform hand hygiene in between glove changes, especially if visibly soiled, and work from dirty to clean. The DON said gloves do not replace the need for hand hygiene and he/she expects staff to use soap and water or an Alcohol Based Hand Rub (ABHR), especially between glove changes. He/she said the facility does pericare audits that has a check list for hand hygiene and they are due by the end of the month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure the residents' environment remained free of accident hazards when the facility staff failed to ensure sharps, chemicals and medications were stored in a manner not accessible to residents. The facility census was 50. 1. Review of the facility's Hazardous Areas, Devices and Equipment policy, dated July 2017, showed: -All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety mitigate accident hazards to the extent possible; -As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee; -A hazard is defined as anything in the environment that has the potential to cause injury or illness; -Examples of environmental hazards included, but are not limited to the following: a. Equipment and devices that are left unattended or are malfunctioning; b. Devices and equipment that are improperly used or poorly maintained; c. Sharp objects that are accessible to vulnerable residents; d. Open areas or items that should be locked when not in use; g. Access to toxic chemicals; -The safety committee will recommend measures to ensure that the vulnerable residents ca not access hazardous areas in the facility (locks, alarms, supervision, etc.); -The safety committee will periodically check for the implementation and integrity of measures intended to prevent residents from accessing hazardous areas; -Interim safety measures for temporary hazards such as painting or construction work, may be necessary. These may included posting warning signs, redirecting foot traffic, increasing supervision and if necessary, limiting access to anyone but authorized personnel. 2. Observation on 10/18/23 at 1:45 P.M., showed the doors to the closet located between resident occupied rooms [ROOM NUMBERS] unlocked and the area unattended by staff. Observation showed two mechanical saws with blades and other maintenance tools stored unsecured in the closet. During an interview on 10/18/23 at 1:45 P.M., the maintenance director said the maintenance tools were placed in the closet for storage. The maintenance director said there were confused residents on the unit that would be able to access the closet and maintenance tools and sharp objects like saw blades should not be stored accessible to residents. Observation on 10/18/23 at 1:50 P.M., showed a 32 ounce spray bottle of disinfectant spray and one gallon of bleach stored unsecured in the shared bathroom to resident rooms [ROOM NUMBERS] and the area unattended by staff. During an interview on 10/18/23 at 1:50 P.M., the maintenance director said he/she believed the chemicals were left in the bathroom because the resident in room [ROOM NUMBER] was on transmission based precautions, but chemicals should be locked up when not in use and not be left accessible to residents no matter what. Observation on 10/18/23 at 2:25 P.M., showed the doors to the closet at the end of the 200 hall unlocked and the area unattended by staff. Observation showed nine five gallon buckets of vinyl floor adhesive stored unsecured in the closet. Further observation showed human health and hazard warnings printed on the product labels. During an interview on 10/18/23 at 2:25 P.M., the maintenance director said toxic materials should not be stored accessible to residents and he/she did not know why the buckets of floor adhesive were stored in the closet. The maintenance director said the facility had residents that would be able to access the closet. During an interview on 10/19/23 at 9:45 A.M., the Director of Nursing (DON) said, while it is a global effort among all staff, environmental staff are responsible to maintain the environment free of hazards. The DON said sharp objects like saw blades and chemicals should not be stored in a manner accessible residents and if anyone sees them improperly stored, they should remove them and secure them elsewhere. The DON said storing toxic materials and sharp objects in a manner accessible to residents had the potential for injury and illness. During an interview on 10/19/23 at 10:10 A.M., the administrator said maintenance staff is responsible for the storage of maintenance tools and supplies and environmental services staff are responsible for the storage of chemicals and other toxic materials. The administrator said neither should be stored accessible to residents and should be locked up when not in use. The administrator said whomever last the item should ensure that it is stored properly and the storage of such materials accessible to residents had the potential of injury and illness. 3. Review of Resident #48's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/18/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Wanders daily; -Independent with going from sitting position to standing position, transferring from bed to chair and chair to bed, toilet transfers and walking up to 150 feet; -Received Antipsychotics on a routine basis; -Diagnoses of Non-Traumatic Brain Dysfunction (injuries to the brain that are not caused by an external physical force to the head), Alzheimer's Disease (progressive mental deterioration, due to generalized degeneration of the brain and causes premature senility), Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, resulting from organic disease of the brain) and Parkinson's Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). Review of the resident's care plan, dated 10/02/2023, showed staff documented the resident has Dementia with behavioral disturbances and Parkinson's disease, is very confused and wanders about most of the day, is severely impaired with decision making, wanders about the facility and is not aware of own safety, could potentially be found in a dangerous place, will wander into other residents rooms, and receives antipsychotics medications due to hallucinations. Observation on 10/17/23 at 9:21 A.M., showed the resident sat in his/her recliner. The resident then got up, wandered out to the hall, and walked own the hall independently with a walker. Observation on 10/17/23 at 10:16 A.M., showed the resident appeared confused and unable to communicate. A sharps container with used sharps in it, sat on the resident's window sill along with an insulin pen and unused needles. Observation on 10/17/23 at 3:56 P.M., showed the sharps container with used sharps and a Glargine Insulin pen with 40 units of insulin still in the pen, sat on the resident's window sill. Further observation showed four needle caps four millimeters (mm) in size for the Glargine insulin pen, still in the package, on the window sill. A blue twin blade razor sat on a table beside the toilet in the resident's room. Observation on 10/17/23 at 4:05 P.M., showed the resident got up from the table and walked with his walker to his/her bathroom independently. Certified Nurse Aide (CNA) A encouraged the resident to use the bathroom and then left the resident in the bathroom. Observation on 10/18/23 at 12:01 P.M., showed the sharps container, four mm needles and insulin pen still on window sill of the resident's room. Further observation showed the razor blade still sat on the table by the resident's toilet. During an interview on 10/18/23 at 3:21 P.M., CNA A said he/she thinks the nurse is supposed to have the sharps and insulin pen. The CNA said the resident can stand and ambulate independent, but is very confused, so there is potential for an accident with the insulin being left out. The CNA said the razor should be secured in the shower room. The CNA said he/she did not know why it was still in there. During an interview on 10/18/23 at 3:34 P.M., Licensed Practical Nurse (LPN) G said the resident had sharps in his/her room because his/her roommate is a diabetic. The LPN said the sharps and insulin started getting left in the room when the resident's roommate had COVID and the resident had been moved to another room, but the resident had been moved back into the room. The LPN said it was something staff should probably take out of there. The LPN said the razor should be out of reach of the resident and kept in a sharps container in the shower room. The LPN said the insulin, needles and razor were overlooked. During an interview on 10/19/23 at 9:38 A.M., the DON said the resident's cognition is probably poor. The resident wanders some. The DON said the resident can transfer and ambulate independently. The DON said insulin should not be in the resident's room, and staff should have placed the insulin in the medication room. The DON said impaired residents should not have access to razors. The DON said staff are instructed to keep razors in a locked cabinet in the shower room, so impaired residents do not have access. During an interview on 10/19/23 at 10:54 A.M., the Administrator said staff should store insulin and sharps in the medication room. The administrator said impaired residents could get into the medication and have an adverse reaction to it. The administrator said staff should store razors in locked shower rooms when not in use. The administrator said there is a risk of injury for cognitively impaired residents.

Based on observation, interview and record review, facility staff failed to maintain kitchen equipment, lighting devices and air movement systems in a clean sanitary manner to prevent the potential for cross-contamination. The facility census was 50. 1. Review of the facility's policy titled, Cleaning and Sanitation, revised 10/18/23, showed staff were directed to wipe down the oven range after every meal. Wipe down all surfaces of the oven after every meal and deep clean as needed (PRN). Sprinkler pipes should be cleaned with degreaser and wiped down once a month. Make sure no food is out when wiping down the pipes. Review of the facility's kitchen cleaning schedule, undated, showed staff were directed to clean every night before closing up the kitchen. The schedule did not direct staff to clean the oven, hood, fans, or vents. Review of the facility's policy titled, Dishwasher Instruction, revised 10/19/23, showed staff were directed to watch the temperature of the dishwasher, and check it if it gets above 120 degrees Fahrenheit. Log the dishwasher temperature and sanitizer level on the daily log sheet. 2. Observation of the kitchen on 10/16/23 at 10:34 A.M., showed: -A [NAME] ceiling fan on in the kitchen, the fan hung above the food preparation area and had one of four blades missing. The other three blades bowed down and had white dirt and debris covering the surface; -Front and bottom of stainless steel oven doors had a black grease like substances running down them; -Exhaust hood had a build up of black and brown, grease like substances; -Broken light cover for florescent light fixture above stored foods in dry storage; -Sprinkler system line ran above stove and food preparation areas, had debris and grease like substance built up on it; -Window Air Conditioner (AC) blew air across food preparation areas and had black, circular spots and debris on the vents. 3. Observation of kitchen on 10/18/23 at 8:45 A.M., showed the centralized AC ceiling vents had a build up of dirt and debris on them, and blew air directly down on the fryer and stove during food preparation. During an interview on 10/18/23 at 2:04 P.M., Dietary Aide (DA) T said he/she was not sure who was responsible for cleaning the vents, but thought it was the maintenance staff. The DA said he/she hasn't seen a cleaning schedule, and the Dietary Manager (DM) just tells him/her when something needs cleaned. The DA said the staff doesn't have scheduled times to clean the stove hood. The DA said the cook is supposed to clean the oven and stove. The DA said he/she is supposed to tell the DM is he/she sees something that needs fixed, or cleaned by maintenance. The DA said he/she goes into the dry storage every day and has not seen a broken light cover. The DA said he/she usually checks the temperature of the dishwasher and it has not been reaching the required temperature, he/she told the DM when the facility first got it, about a couple months ago. During and interview on 10/18/23 at 2:12 P.M., [NAME] V said staff have a cleaning schedule on the fridge and they use it every night. The cook said maintenance cleans sprinklers, fans and vents. The cook said the hood company comes and cleans the hood, and they were at the facility about a month ago. The cook said he/she notifies the DM and he/she lets maintenance know when something needs to be done. The cook said he/she had not noticed the broken light cover. The cook said the ceiling fan needs to be cleaned, but he/he has not notified the DM. The cook said the hood, vents and AC unit are dirty and need cleaned. The cook said he/she had not notified the DM. During an interview on 10/18/23 at 2:21 P.M., the DM said maintenance cleans the AC units, but he/she is not sure if it's scheduled. Maintenance cleans sprinklers, and the stuff that is up high should be reported to him/her and he/she reports it to maintenance, or in the maintenance log. The DM said he/she asked maintenance to take down the ceiling fan, because it does not work right, and just collects dust. The DM said the facility has a company that comes in and cleans the hood quarterly and the kitchen staff will wipe down the outside. He/She said the company just cleaned the hood. If staff find something that needs repaired they are supposed to fill out a repair sheet on the clip board kept by the housekeeping department. The DM said he/she did not know a light cover in dry storage was broken. The DM said the evening kitchen staff are supposed to clean the stove, but anyone who sees it dirty, can clean it. The DM said he/she had a staff member who completed the deep cleans, but lost him/her two weeks ago, but honestly if staff in the kitchen sees something is dirty, staff should be cleaning it. During an interview on 10/19/23 at 9:59 A.M., the Maintenance Director (MD) said maintenance staff should clean the AC unit in the kitchen. The MD said he/she expects staff to fill out maintenance request forms if something needs cleaned. The MD said maintenance staff should have seen how dirty the AC is, when washing and cleaning the AC filters. The MD said ceiling vents are cleaned on a quarterly basis, the staff use dusters, but the ones in the kitchen should had been taken down and washed. The MD said he/she didn't know that there was anyone designated to clean ceiling fan, he/she would hope anyone who found it dirty would clean it. The MD said he/she did not double check on their accuracy of work, by the contracted company who cleaned the hood, he/she just checked to see the hood had a clean sticker, he/she should have looked deeper at the hood to make sure they cleaned it. The MD said dietary cleans the stove and equipment. The DM said maintenance cleans the sprinkler heads to make sure they are grease free. The MD said no staff from maintenance had been assigned to clean sprinkler lines in the past. 4. Review of Dishwasher directions label, showed wash and rinse cycle should reach a minimum of 120 degrees. Observation on 10/18/23 at 9:11 A.M., showed DA U complete a wash cycle of breakfast dishes. The wash cycle heated to 85 degrees Fahrenheit and the rinse cycle heated to 95 degrees Fahrenheit. Further observation showed the DA continued to wash and rinse four loads of resident dishes and place the dishes on a drying rack. Observation on 10/18/23 at 9:21 A.M., showed the DA U washed a load of resident water pitchers. The wash cycle heated to 82 degrees Fahrenheit and the rinse cycle heated to 87 degrees Fahrenheit. Further observation showed the DA took dishes off the drying rack and stacked on other dishes ready for use. During an interview on 10/18/23 at 9:18 A.M., DA U said he/she normally runs the dishwasher. The DA said the dishwasher is a low temperature dishwasher. The DA said he/she doesn't know the temperatures the wash cycle and rinse cycle is supposed to get to. The DA said staff are supposed to check dishwasher temperatures daily. The DA said he/she checks the temperatures daily, but later in the day, because the dishwasher starts to heat up. During an interview on 10/18/23 at 10:42 A.M., maintenance worker (MW) S said the company the facility got the dishwasher from, said 90 degrees Fahrenheit to 130 degrees Fahrenheit is the effective range for the chlorine to work. During an interview on 10/18/23 at 9:25 A.M., the DM said he/she does not know the temperatures the dishwasher has to reach for the wash and rinse cycle. The DM said the dishwasher doesn't have a thermometer. The DM said maintenance checks the dishwasher temperatures once a month. The DM said kitchen staff does not check dishwasher temperatures daily. The temperature of the water in the dishwasher is whatever the temperature of the water in the building is. The DM said maintenance is who talks to the dishwasher company. During an interview on 10/19/23 at 9:59 A.M., the MD said he/she didn't know the low temperature dishwasher temperatures needed to be checked. The MD said no one has checked the dishwasher and that was his/her fault.