**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12.006.09D3 Based on record review, observations, and interviews, the facility failed to ensure the indwelling foley catheter was discontinued for 1 resident (Resident 33) of 1 sampled resident to prevent the potential for urinary problems including infection. The facility census was 33. Findings are: Record review of the admission record dated 1/18/2024 for Resident 33 revealed the resident was admitted to the facility 01/18/2024 with an indwelling foley catheter (tube inserted directly into the bladder for urine drainage) after the resident obtained a left fracture of the acetabulum (left pelvis). Resident 33 did not have surgery for the fracture. Record review of the nursing progress notes for Resident 33 dated 1/24/2024 revealed Resident 33 was seen on 01/24/2024 by the Primary Care Provider (PCP). On that date, the orders were that facility nursing staff were to leave the indwelling foley catheter (catheter) in place until able to ambulate and toilet with 1 assist. Record review of the Physical Therapy (PT) progress note dated 2/13/2024 revealed PT documented patient is ambulatory with 1 assist with therapy. Record review of Resident 33's Progress Note dated 2/21/2024 revealed Resident 33 was able to ambulate to the dining room with one assist from Physical Therapy (PT). Resident 33 is now ambulatory with 1 assist. Record review of nursing communication with the PCP on 2/29/2024. Assistant Director of Nursing (ADON) faxed Resident 33 has an indwelling catheter, but we do not have a DX (diagnosis) for a catheter. Please select an appropriate DX. There was a selection for Neurogenic Bladder or Obstructive Uropathy. The PCP's answer was returned by fax and stated: Patient has catheter due to post op status and decreased mobility. Neither DX is appropriate. Review of the nursing progress note dated 3/5/2024 at 4:00 PM the catheter was removed based on the order from 1/24/24. (This was 21 days after Resident 33 was able to ambulate with 1 assist). Review of the nursing progress note dated 3/06/2024 at 9:15 AM the catheter was replaced due to inability to void. A new order was received from Physician. Occupational Therapy began a 5-day bladder training program. Observation in Resident 33 room [ROOM NUMBER]/06/2024 at 9:10 AM revealed Resident 33 was assisted to bed by the Medication Aide-H (MA-H). MA-H assisted Resident 33 to a lying position and the catheter bag was lifted above Resident 33 before placing it on the edge of the bed where it was then touching the floor. Observation on 03/11/2024 at 6:47 AM, revealed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) removed Resident 33's catheter. Observation in the Dining Room on 03/11/2024 at 12:05 PM revealed Resident 33 was sitting at their assigned table area for meal calling out for help and voiced a need for help. When approached, Resident 33 voiced they needed to use the bathroom. MA-H was informed Resident 33 needed to use the bathroom. Observation in the Dining room on 03/11/2024 at 12:14 PM revealed Resident 33 remained at their table sitting in the chair and did have an feeding assistant next to them. Resident 33 had not been taken to the bathroom. Interview with the DON on 3/12/2024 at 10:00 AM revealed the facility nursing staff had requested a diagnosis for the catheter and was told only that Resident 33 had the catheter in place until the resident was able to ambulate with the assistance of one person. Resident 33 did not have a diagnosis for the Urinary Catheter upon admission. We did try to get a diagnosis for urinary retention, but the physician said 'no'. The DON revealed the facility did have Provider orders to remove the catheter once the resident was ambulatory with one assist and could sit to toilet. The DON, ADON, and Registered Nurse-B (RN-B) had tried multiple times to pull the catheter but the facility Occupational Therapist and Physical Therapist declined. Interview on 03/12/2024 at 10:12 AM with the ADON via a phone call revealed [gender] was aware of the order to remove Resident 33's catheter when the resident was able to ambulate and toilet with one assist. The ADON revealed therapy had informed nursing staff to not pull the catheter.

D. Record review of the Basic Care Plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) for Resident 33 dated 1-18-2024 revealed an indwelling foley catheter (a flexible plastic hollow tube inserted into the bladder to continuously drain urine) present at admission. Record review of the Comprehensive Care Plan (CCP) dated 2/19/2024 for Resident 33 revealed the following: Category: Skin. Resident 33 is at risk for skin breakdown. Braden score and use of foley catheter. Resident 33 likes to lay in bed throughout the day and needs staff assistance for sufficient movement throughout the day and at night. Resident 33 also has a foley catheter that could cause skin irritation. She wears underwear only during the day and night. Skin is assessed weekly. If staff notice skin breakdown, notify charge nurse. For all treatments see TAR. The CCP contained no interventions to direct staff on the care required for the foley catheter. Observation on 03/11/2024 at 06:47 AM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) are in the room of Resident 33 preparing to remove the catheter. Explanation given to Resident 33 about the procedure as resident was told resident would now need to use the bathroom for toileting as there would no longer be a tube draining the bladder. The staff removed and discarded the catheter. Record Review on 3/12/2024 of the CCP for Resident 33 dated 2/19/2024 shows no further updates to the area of skin after removing the foley catheter on 3/11/2024. Interview on 3/12/2024 at 10:00 AM with the DON confirmed that the DON is unable to identify an area on the CCP which discusses only the catheter or interventions for catheter care. When asked about when and how facility focus on areas on the CCP are created, the DON revealed the ADON does all of the care planning. The DON called the ADON and remained in the room. The DON put the phone on speaker. Interview on 3/12/2024 at 10:12 AM with the ADON via phone. This surveyor asked the ADON about the CCP and why the urinary catheter, diagnosis, and interventions are not included on the CCP. We had a care plan meeting and were told to combine areas when we could. The ADON confirmed that there is no individual care plan or interventions for the specifically for the foley catheter. The ADON confirmed I have not changed the care plan since the catheter was pulled yesterday and I am not in the office today. That will be updated when I return to the facility. C. A review of Resident 6's Care Plan dated 07/30/2020 with a problem start date of 1/30/2020 the category for medications revealed Risperidone for Schizophrenia (a serious mental illness in which people interpret reality abnormally). A review of Resident 6's Continuity of Care Document dated 03/12/2024 showed a listing of current medications including frequency, instructions, diagnosis associated, start date, end date, and last administered. The medication Risperidone 0.5 mg (milligram), oral one tablet by mouth twice a day. The diagnosis used for the medication revealed adjustment disorder with mixed anxiety and depressed mood. The Continuity of Care Document dated 03/12/2024 reveals last administered dose for Risperidone on 03/12/2024 at 7:27:34 AM. A review of Resident 6's active diagnoses list signed by the physician dated 02/26/2024 did not reveal a diagnosis of Schizophrenia. A review of Resident 6's Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 02/23/2024 pages 25, 26, and 27 Section I lists active diagnoses. The record reveals under psychiatric/mood disorder, anxiety and depression are listed, none other. During an interview on 03/12/2024 at 09:10 AM, the Director of Nursing (DON) stated Resident 6's Care Plan has indicated Risperidone use for Schizophrenia and should not. The DON confirmed that Resident 6 does not have an active diagnosis of Schizophrenia. Licensure Reference Number 175 NAC 12-006.09C Based on observation, record review, and interview the facility failed to develop a Comprehensive Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) to include resident care needs for Resident 30 and Resident 28; to include interventions to prevent skin alterations for 2 residents (Resident 3 and 12); to address specific targeted mood and behaviors for psychotropic medications for Resident 3; to include accurate diagnosis for Resident 6; and for indwelling foley catheter for Resident 33. This had the potential to for 6 of 12 sampled residents. The facility census was 33. Findings are: A. Record review of the facility admission Agreement dated 12/20/21 revealed that Plan of Care means a care plan for nursing care, activities, restorative and rehabilitative services and psychosocial care offered by the facility as identified in the resident's plan of care established by the facility in collaboration with the resident/resident representative. Record review of the facility Resident's Rights dated 2016 revealed that the nursing facility must include an assessment of the resident's strengths and needs in the planning process. Record review of the facility Care Plan Meeting Notice dated 6/22/23 revealed that care plan goals are developed from the resident's needs. Record review of the facility policy titled Baseline Care Plan dated 10/12/20 revealed that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Initial goals shall be established that reflect the resident's stated goals and objectives. Interventions shall be initiated that address the resident's current needs including: any health and safety concerns to prevent decline or injury such as elopement, fall, or pressure injury risk; any identified needs for supervision, behavioral interventions, and assistance with activities of daily living; any special needs such as for intravenous (IV) therapy, dialysis, or wound care. Once established, goals and interventions shall be documented in the designated format. Record review of the Face Sheet (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) dated 3/7/24 for Resident 28 revealed that Resident 28 admitted into the facility on 7/10/23. Diagnoses included malignant neoplasm of the prostate (prostate cancer), malignant pleural effusion (A condition in which cancer causes an abnormal amount of fluid to collect between the thin layers of tissue lining the outside of the lung and the wall of the chest cavity), and pain. Record review of the Physician Order Report for Resident 28 dated 3/12/24 revealed an order to monitor dressing to PleurX drain (a thin, flexible tube that's placed in your chest to drain fluid from your lungs) dated 10/10/23. An order to drain PluerX drain as needed with symptoms of cough or chest discomfort dated 12/6/23. Observation on 3/12/24 at 1:39 PM in the room of Resident 28 revealed a gauze dressing covered with a tegaderm dressing (a transparent medical dressing) over the pleurX drain on the right mid abdomen. Interview on 3/11/24 at 3:10 PM with Registered Nurse-B (RN-B) confirmed that Resident 28 has a pleureX drain that drained as needed. RN-B revealed you can tell when it needs drained as Resident 28 begins coughing a lot. Record review of the current Care Plan for Resident 28 dated 3/7/24 revealed that it did not contain any goals or interventions for care of Resident 28's pleurX drain for the excess fluid caused by the malignant pleural effusion. Interview on 3/12/24 at 8:47 AM with Medication Aide-M (MA-M) revealed that MA-M reviews the resident care plan for resident specific care and interventions. Interview on 3/12/24 at 9:40 AM with Nurse Aide-N (NA-N) revealed that NA-N provides care for Resident 28. NA-N was unsure about the pleurX drain or any care interventions for the drain or dressing. NA-N revealed that NA-N refers to the resident care plan to know what cares are required by the resident. Interview on 3/12/24 at 1:08 PM with the facility Director of Nursing (DON) confirmed that Resident 28 has cancer and a pleurX drain for the resident's pleural effusion. The DON confirmed that the expectation was that the care plan for Resident 28 should include the pleurX drain and interventions for staff to follow in caring for the drain. The DON confirmed that the care plan for Resident 28 did not have a goal or interventions for the resident's pleurX drain. B. Record review of the Face Sheet dated 3/7/24 for Resident 30 revealed that Resident 30 admitted into the facility on 8/30/22. Diagnoses included dysuria (discomfort, pain, or burning when urinating), heart failure, and abnormal weight loss. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 30 dated 8/4/23 revealed that Resident 30 received an antibiotic on all 7 days of the 7-day lookback period. Interview on 3/11/24 at 12:26 PM with the facility Assistant Director of Nursing (ADON) confirmed that Resident 30 started a prophylactic antibiotic (an antibiotic taken to prevent an infection) due to chronic urinary tract infections. Record review of the Care Plan for Resident 30 dated 3/7/24 revealed that it did not contain any goals or interventions for Resident 30's history of urinary tract infections. Interview on 3/12/24 at 1:08 PM with the DON confirmed that goals and interventions for monitoring for urinary tract infection and preventive interventions are expected to be on the resident care plan. The DON confirmed that a goal and interventions for urinary tract infection was not found on the care plan for Resident 30 and should be on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.18E3a Based on observation, record review, and interview the facility failed to monitor and record facility hot water temperatures to protect residents from the potential for burns/scalding for 4 of 16 sampled residents (Residents 21, 11, 26, and 29). The facility census was 33. Findings are: A. Record review of the facility Resident Rights dated 2016 revealed that the resident has the right to a safe, clean, comfortable, and homelike environment. The nursing facility must provide a safe, clean, comfortable, and homelike environment ensuring the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Provide comfortable and safe temperatures. Observation on 3/6/24 at 12:18 PM in the room of Residents 21 and 11 (roommates) revealed that the hot water at the bathroom sink measured with a thermometer read a temperature of 127.2 degrees Fahrenheit. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 21 dated 1/12/24 revealed that Resident 21 is able to stand from a sitting position independently. Resident 21 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 7. (A score of 0-7 indicates the resident has severe cognitive impairment). Record review of the current Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 3/7/24 for Resident 21 revealed that Resident 21 may not always call for assistance. Resident 21 doesn't need physical assistance for transfers unless Resident 21 is not feeling well. Interview on 3/6/24 at 12:31 PM with Nurse Aide-A (NA-A) revealed that Resident 21 uses the bathroom on their own. Observation on 3/11/24 at 11:02 AM in the room of Resident 21 revealed that Resident 21 ambulated into the bathroom unassisted. Interview on 3/6/24 at 12:45 PM with the Maintenance Supervisor (MS) revealed the facility process for monitoring the hot water temperatures is to go to the boiler room each morning. MS revealed that MS observes the thermometer for water coming out of the hot water heater and also the thermometer for the hot water temperature as it leaves the mixing valve. MS revealed if the hot water temperature exiting the mixing valve is 120 degrees Fahrenheit or above, MS increases the cold water. MS confirmed that the maximum temperature allowed for hot water is 120 degrees Fahrenheit. MS confirmed that the morning check is a visual check and the temperatures are not documented. MS revealed that the facility had legionella (a water borne bacteria that can cause pneumonia type illness) in the water system months ago and turned the hot water as high as it would go at around 180 degrees Fahrenheit to try to treat the legionella. MS revealed that the plumber told them the mixing valve would likely not be right after running the high temperatures. MS revealed that the facility did random checks of hot water temperatures previously but stopped doing that about 6 months ago when they started doing the daily visual check of the hot water heater and mixing valve. This surveyor requested the documentation of the last 3 random checks performed. Record review of the facility Tracking Tool (Water Temp, Ventilation) dated 5/31/23 revealed hot water temperatures from resident rooms and the public restrooms all in required range. The Tap Water Temperature Checks dated 4/24/23 and 3/2/23 revealed random room hot water temperatures documented. All in required range. Interview on 3/6/24 at 2:20 PM with the MS confirmed no documented temperature checks of hot water had been performed after 5/31/23. B. Record review of the Face Sheet (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) for Resident 11 revealed that Resident 11 admitted into the facility on [DATE]. Diagnoses included dementia. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/19/24 for Resident 11 revealed that Resident 11 had a BIMS score of 10. (A score of 8-12 indicates moderate cognitive impairment). Record review of the Care Plan for Resident 11 dated 3/7/24 revealed that Resident 11 uses a wheelchair for mobility. Observation on 3/6/24 at 12:18 PM in the room of Residents 21 and 11 (roommates) revealed that the hot water at the bathroom sink measured with a thermometer read a temperature of 127.2 degrees Fahrenheit. Interview on 3/7/24 at 12:18 PM with Nurse Aide-A (NA-A) revealed that Resident 11 is assisted to the bathroom and is able to wash their hands. C. Record review of the Face Sheet for Resident 26 dated 3/12/24 revealed that Resident 26 admitted into the facility on 2/13/23. Diagnoses included dementia and Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/19/24 for Resident 26 revealed that Resident 26 had a BIMS score of 10. (A score of 8-12 indicates moderate cognitive impairment). Record review of the Care Plan dated 3/12/24 for Resident 26 revealed that Resident 26 will use the walker to walk short distances. Observation on 3/06/24 at 12:15 PM in the room of Resident 26 revealed that the hot water at the bathroom sink measured with a thermometer read a temperature of 123.9 degrees Fahrenheit. Interview on 3/06/24 at 12:30 PM with Resident 26 revealed that the resident does use the bathroom sink to wash hands. Resident 26 revealed that staff assist the resident into the bathroom. D. Record review of the Face Sheet for Resident 29 dated 3/12/24 revealed that Resident 29 admitted into the facility on 8/11/23. Diagnoses included constipation and enlarged prostate. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 2/2/24 for Resident 29 revealed that Resident 29 had a BIMS score of 99. (A score of 99 indicates the resident was unable to cognitively complete the assessment). Record review of the Care Plan dated 3/12/24 for Resident 29 revealed that Resident 29 is incontinent of urine and does not allow staff to assist the resident with toileting. Observation on 3/06/24 at 12:12 PM in the room of Resident 29 revealed that the hot water at the bathroom sink measured with a thermometer read a temperature of 120.3 degrees Fahrenheit. Interview on 3/6/24 at 12:31 PM with NA-A revealed that Resident 29 goes to the bathroom on their own and is independent in the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record Review of the policy entitled Catheter: Insertion, Removal, Care, Irrigation, Instillation dated 3/2014 states to Position the bag to avoid urine reflux into the bladder, kinking, or gross contamination of the bag. Keep the bag below the level of the bladder at all times to prevent the backflow of urine and decrease the risk for infection. Do not leave the bag laying on the floor. Record Review of the Policy and Procedure titled Perineal Care revised 6/1/2005 and signed and dated 7/11/2005 by the then acting Director of Nurses is the current policy and procedure used for perineal care. There have been no further updates or revisions to this policy. Record Review of Annual Competencies dated 1/23/2024 Identified what each newly hired nursing staff is trained on for direct resident care and what all direct care employees review annually. Competencies included Incontinence Care Female, Urinary Catheter Care, Oral Care, and Denture Care. Observation on 3/11/2024 at 07:02 AM in Resident 33 room. Nursing Assistant-D (NA-D) came in as soon as the nursing staff had left after removing the patient indwelling foley catheter. NA-D came in to dress the resident for breakfast, but the resident wanted to sleep longer. NA-D used Alcohol Based Hand Sanitizer (ABHS) to perform hand hygiene and left the room. Observation on 03/11/24 at 07:16 AM in Resident 33 room. NA-D used ABHS to perform hand hygiene and donned gloves. NA-D encouraged the resident to get dressed as it is time for breakfast. No peri care was done. NA-D began the process of dressing Resident 33 putting on clean underwear, pants, socks, and shoes while Resident 33 was still lying in bed. NA-D then assisted Resident 33 to a sitting position and removed pajama top, applied deodorant, and then dressed resident in a clean shirt. NA-D then helped Resident 33 put on glasses and donned the gait belt. NA-D removed gloves. No hand hygiene was done. Resident 33 was assisted to a standing position and NA-D pulled up underwear and pants the rest of the way while resident was standing at bedside. Resident 33 ambulated to the bathroom with standby assist of NA-D. In the bathroom, Resident 33 is coached to use the grab bars to sit on the toilet. NA-D performed hand washing for 20 seconds with soap and water, dried the hands thoroughly, and donned new gloves. NA-D then assisted the resident with warm wash cloth to clean face with soap and water. NA-D made bed and placed dirty linen bag beside the bathroom door then helped resident blow the resident nose. NA-D obtained clean peri pad from the closet, placed new peri pad, in underwear, rinsed dentures, gave them to the resident, and assisted the resident to place the dentures. NA-D used 4 disposable cleansing cloths for peri care. From the back, NA-D wiped front to back, only between the labia, and towards the back, folded the disposable cloth, wiped front to back with the same cloth, and disposed of the cloth. NA-D then used one cleansing wipe and wiped the patient front to back only once, discarded the wipe, took the final disposable cleansing cloth, wiped front to back once, and discarded the wipe. NA-D didn't clean thighs, didn't clean the area between the perineum and the thighs, didn't clean the buttocks, and therefore, did not clean the entire peri area. Resident 33 was assisted off the toilet, ambulated to room door, and care was transferred to the Physical therapist who had interrupted NA-D three different times. NA-D then gathered the bags of trash and laundry. NA-D removed gloves, used ABHS, and left the room with the bags of laundry and trash. Interview on 3/11/2024 at 2:45 PM with DON. This surveyor questioned the DON about expectations of peri care. First, nursing staff should encourage the residents to do as much as possible by themselves. Otherwise, if the resident is not able to perform peri care, we will help them. When asked how they teach them to clean the resident if they are standing up, the DON confirmed that the staff should clean front to back. The DON also revealed that the entire perineum should be cleansed including the front and the groin area. The DON confirmed that there should be a change of gloves when going from dirty to clean with hand sanitized with an ABHS if hands appear clean and washed with soap and water if hands are visibly soiled. Education of nursing staff and new hires are done upon hire and then annually. These records are kept for future reference. Audits for hand hygiene are done annually with competencies. C: Observation on 03/11/24 at 07:50 AM in Room of Resident 16. NA-D uses ABHS to perform hand hygiene, dons gloves, gown, N95, and goggles prior to entering the double occupancy room with COVID precautions. NA-D states it is difficult to see through the goggles, and notes that another staff member is using the good safety glasses. At resident bedside, it is noted that the Resident 16's brief has stool leaking out both sides on the front side. Resident lying on their back with head of bed (HOB) elevated. Resident has a G-Tube (a flexible hollow tube inserted through the belly that brings nutrition directly to the stomach so that the individual can obtain the needed fluids and caloric intake needed daily) and is visibly clean and dry. NA-D pulled down the brief at the front, rolled and tucked the brief between the resident legs. NA-D then removed the resident's leg braces, positioned resident for cleaning, gathered several clean wipes and started wiping what NA-D could from front to back. NA-D was not able to spread the resident legs for cleaning. NA-D stated again that NA-D can barely see out of the goggles. NA-D did not call for assistance on the radio each staff member carried to request help when needed. NA-D then rolled Resident 16's brief under the left side as far as possible, and then assisted the resident to their left side. NA-D used one cleaning cloth and wiped both buttocks, then placed it on the dirty brief. NA-D then touched the resident's right thigh with a dirty, soiled glove. NA-D used several disposable cleansing cloths and wiped front to back multiple times each time disposing of the dirty cleansing cloth on the dirty brief that remained under the resident. NA-D about it being difficult to see through the goggles. NA-D rolled up the dirty brief and continued to wipe off the resident. NA-D reached into the bag of disposable cleaning cloths numerous times with the dirty gloves to obtain a clean cloth. When there were no more clothes, NA-D reached for a new pack of wipes, continued to use more disposable cleansing cloths, reaching into clean cloth package with dirty gloves, until NA-D felt the resident was cleaned of all stool. NA-D still did not request assistance with Resident 16. NA-D placed a new chux (a kind of ultra-absorbent incontinence products that are designed to be placed on the top of a bed, wheelchair, or any surface you want to protect) under the resident, tucked it under Resident 16 right side, rolled the Resident 16 to the right side, pulled the clean chux and brief under the patient, and then rolled resident back to a supine (lying on one's back) position. NA-D cleaned the thighs and stated there is a spot of stool that was missed on the right thigh and again complained of the goggles being difficult to see through. Before NA-D fastened the brief NA-D identified more BM that had been missed on the front peri area. NA-D obtained more cleansing wipes from container with the dirty gloves and cleaned the front peri area, fastened the brief and covered Resident 16. While the cleaning process had taken place, NA-D had also touched the G-Tube extension with dirty gloves. NA-D removed the soiled and dirty gloves, used ABHS only, and donned new gloves. At this point, NA-D used the radio to call for assistance. Nurse Aide-J (NA-J) entered the room, assisted NA-D to boost Resident 16 up in bed, and then dressed Resident in socks, leg braces, and clean pants. NA-J assisted Resident 16 to a sitting position, changed the resident's shirt, then assisted with the placement of the Hoyer Lift (a specialized lift for individuals who are not able to ambulate) sling. Another staff member brought the Hoyer lift to the resident door. NA-J and NA-D were then able to position the Hoyer lift (a mobility tool used to help seniors with mobility challenges get out of bed) and the resident wheel chair to get Resident 16 out of bed. Both NA-D and NA-J continued working without changing gloves or doing any hand hygiene (hand washing using soap and water or using ABHS to remove germs to reduce the risk of infection transmission among patients and health care personnel). NA-J rinsed Resident 16's dentures, obtained a warmed washcloth, cleansed the resident's face, and helped the resident put in their dentures. NA-J gathered the dirty linens and the trash from the room, removed the gown and gloves at the doorway per protocol, then asked where the dirty laundry and trash needed to be taken. NA-J walked down the hall and did not change NA-J's mask. No hand hygiene was done by NA-J. NA-J had on only her regular glasses without safety sides or goggles. (Protocol posted on Resident 16 door stated that the staff entering were to wear goggles.) NA-D removed their gown and gloves at the door per the protocol, used ABHS prior to leaving the room, then removed their N95 mask (a respiratory protective mask designed to protect the wearer from respiratory diseases), cleansed the hands with ABHS only, and donned a new mask. Interview on 3/11/2024 at 2:45 PM with DON. DON confirmed that in a situation such as a resident with a feeding tube and a large bowel movement such as had been encountered, the Staff member should call for additional assistance to care for the resident. LICENSURE REFERNCE NUMBER 175 NAC 12-006.17 Based on observation, record review, and interview the facility failed to use proper hand sanitization during the application and removal of personal protective equipment and use the recommended personal protective equipment when providing care for residents with a communicable disease to prevent the potential for cross contamination and Covid-19 which had the potential to affect all facility residents; and the facility failed to perform peri care in a manner to prevent the potential for cross contamination for 2 Residents (Resident 33 and 12) The facility census was 33. Findings are: A. Interview on 03/06/2024 at 8:35 AM with the Director of Nursing (DON) revealed the facility was currently in COVID-19 out break and had four residents that were currently positive for COVID-19 requiring isolation precautions. Observation on 03/06/2024 at 8:45 AM on the facility 200 hall revealed the following: -room [ROOM NUMBER] signage on the door stated Red Zone applying Personal Protective Equipment (PPE) must be done outside of the room. Step 1 put on your gown fasten ties at the top and the bottom. Step 2 remove your surgical mask. Sanitize your hands. Apply N95 mask, which is a respirator mask that is designed to achieve a very close fit and very efficient filtration of air borne particles. Make sure you tighten the nose piece to snuggly fit your face. Sanitize your hands. Step 3 apply goggles or face shield. Step 4 apply gloves. Removal of PPE. Step 1 remove gloves and gown inside the room. Sanitize your hands. Step 2 exit the room. Remove face shield or goggles and then remove your N95. Sanitize your hands. Step 3 apply surgical mask. Sanitize your hands. -room [ROOM NUMBER] signage on the door stated Red Zone applying Personal Protective Equipment (PPE) must be done outside of the room. Step 1 put on your gown fasten ties at the top and the bottom. Step 2 remove your surgical mask. Sanitize your hands. Apply N95 mask. Make sure you tighten the nose piece to snuggly fit your face. Sanitize your hands. Step 3 apply goggles or face shield. Step 4 apply gloves. Removal of PPE. Step 1 remove gloves and gown inside the room. Sanitize your hands. Step 2 exit the room. Remove face shield or goggles and then remove your N95. Sanitize your hands. Step 3 apply surgical mask. Sanitize your hands. In an interview on 03/07/2024 at 9:15 AM with the Assistant Director of Nursing (ADON) who acts also in the role of the facilities infection preventionist it was revealed that an additional resident had tested positive for COVID-19. In an observation on 03/07/2024 at 11:07 AM Nurse Aide (NA-A) was applying PPE in the hallway outside room [ROOM NUMBER]. NA-A removed their surgical mask and placed on an N95 mask. NA-A then applied a gown and tied the gown in the back then completed alcohol-based hand sanitization and applied gloves to both hands. NA-A did not put goggles on or follow the correct listed procedure for putting on PPE. In an interview on 03/07/2024 at 11:45 with the ADON it was revealed that staff should be wearing goggles and following the directions posted on the residents' doors for what PPE to wear. The ADON confirmed staff should not be wearing surgical masks either over or under their N95 masks. ADON stated the facility followed both Infection Control Assessment and Promotion Program (ICAP) and Centers for Disease Control (CDC) guidelines for infection prevention. In an interview on 03/07/2024 at 1:30PM with NA-A it was stated that staff know how to put on and take off their PPE and know what PPE to use by the signs posted on the outside of the door to the resident's room. In an observation on 03/11/2024 at 11:15 AM on the 200 hall it was observed that NA-J was walking in the hall with a yellow surgical mask over their N95 mask. In an observation on 03/11/2024 at 11:40 AM outside of room [ROOM NUMBER] it was observed that NA-J was exiting room [ROOM NUMBER] with a N95 mask over a yellow surgical mask and had no goggles on. In an observation on 03/11/2024 at 12:30 PM it was observed that Medication Aide-K (MA-K) was applying PPE in the hallway outside of room [ROOM NUMBER]. MA-K applied a N95 mask then applied a gown and tied it in the back. MA-K then placed their goggles on and then gloves on both hands. MA-K did not perform hand sanitization between any of the application of the PPE as listed on the door outside of the room before entering the room. In an observation on 03/11/2024 at 1:05 PM it was observed that MA-K was applying PPE outside of room [ROOM NUMBER] in the hallway. MA-K applied a gown, removed their surgical mask and applied a N95 mask and then applied gloves to both hands. MA-K did not perform hand sanitization between any of the application of the PPE as listed on the door outside of the room before entering the room. In an interview on 03/12/2024 at 8:32 AM Nurse Aide-D (NA-D) stated staff follow the directions for applying and removing PPE by reading the signs on the doors of the resident's room and completing the steps step by step. In a record review of facility supplied policy labeled Infection Prevention and Control Program dated 06/06/2023 revealed under isolation protocol that the facility will follow current CDC guidelines when caring for a resident with a communicable disease that is placed on transmission-based precautions. In a record review of CDC document labeled sequence for putting on PPE and not dated listed Step 1 put on gown, Step 2 put on mask or respirator, Step 3 apply goggles or face shield, and Step 4 apply gloves. In a record review of CDC document labeled sequence for removal of PPE and not dated listed Step 1 remove gloves wash your hands or use an alcohol based hand sanitizer, Step 2 remove goggles or face shield wash your hands or use an alcohol based hand sanitizer, Step 3 remove gown wash your hands or use an alcohol based hand sanitizer, Step 4 remove mask or respirator wash your hands or use an alcohol based hand sanitizer. In a record review of ICAP document labeled Zones, PPE and Testing dated 09/29/2022 under staff PPE listed full PPE, respirator, eye protection, isolation gown and gloves. In a record review of ICAP document labeled summary of recommendations for COVID-19 in a long term care facility dated 05/11/2023 under PPE required for care of residents with COVID-19 stated staff entering the room of a resident with COVID-19 should adhere to standard precautions and use respirator (N95), gown, gloves, and eye protection. In a record review of ICAP document not dated listed PPE removal perform hand sanitization, remove gown and gloves, perform hand sanitization, remove eye protection, perform hand sanitization, remove N95, perform hand sanitization.