**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E: Observation on 11/14/2023 at 12:14 PM revealed Medication Aide C (MA C) obtained Resident #26 blood sugar then removed their gloves and exited the room. MA C did not perform hand hygiene. MA C placed the blood sugar equiptment within the medication cart. Observation on 11/15/2023 during medication administration from 7:21 AM to 8:35 AM by LPN G the following was observed: - LPN G administered an inhaled medication to Resident #8 by placing tip of the inhaler into the resident's nostril. LPN G did not perform hand sanitization then applied gloves to both hands. LPN G then applied a topical medication using gloved hands, removed their gloves and did not complete hand sanitization prior to applying another set of gloves to both hands. LPN G then applied another topical medication to resident and removed their gloves. LPN G did not perform hand sanitization and proceeded to return all items to the medication cart. - LPN G performed the task of obtaining Resident #26 blood sugar with gloves on their hands. LPN G then removed gloves and did not perform hand hygiene. LPN G then administered Resident #26 oral medications and fluids. LPN G returned to the medication cart and returned items used during task in medication cart then charted the medication pass. LPN G did not perform hand hygiene. Interview on 11/15/2023 at 8:35 AM with LPN G revealed hand hygiene should be performed between glove changes. F. Observation on 11/15/2023 from 8:30 AM to 8:55 AM revealed Resident #25 recieved care by Nurse Aide (NA H) and Nurse Aide I (NA I). The observation revealed: - NA H removed gloves and utilized a handheld radio within Resident #25's room then exited the resident room without performing hand sanitization. - NA H returned to Resident #25's room and applied gloves to both hands without performing hand sanitization. - NA I removed gloves from both of their hands and applied new gloves without performing hand sanitization. - NA I again removed gloves and placed a clean incontinence product on Resident #25 without performing hand sanitization. - NA I and NA H exited Resident #25 room after providing cared without performing hand sanitization. G. Observation on 11/15/2023 from 9:00 AM to 9:20 AM revealed Resident #24 recieved care by NA H and NA I. The observation revealed: - NA I removed gloves and assisted to pull up Resident #24 pants without performing hand sanitization. -NA H removed gloves and assisted to pull up Resident #24 incontinence product without performing hand sanitization. -NA H exited Resident #24's room after providing care without performing hand sanitization. Interview on 11/14/2023 at 10:10 AM NA H revealed [gender] should have used alcohol-based hand hygiene between glove changes. Interview on 11/16/2023 at 9:20 the facility Infection Preventionist (IP), revealed alcohol-based hand gel should be used between glove changes. Review of facility supplied policy labeled Hand Hygiene dated 01/23 Section 6 letter B stated, the use of gloves does not replace hand washing. Wash hands after removing gloves. Further review of the Hand Hygiene table located within the policy revealed hand hygiene with soap, water, and antimicrobial soap or alcohol-based hand gel should be performed before applying and after removing personal protective equipment, including gloves. Review of facility supplied policy labeled peri care dated 1/2023 Section 1 letter B perform the beginning four steps, wash your hands, Section 16, after providing cares, remove gloves complete hand hygiene, Section 20 after removing soiled items and trash from room, complete hand hygiene, Section 21 perform ending four steps, letter C hand hygiene.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed resident is cognitively intact and dependent on staff for transfers, toileting, and personal hygiene. Licensure Reference Number 175NAC 12-006.17D Licensure Reference Number 175NAC 12-006.18C1 Based on observations, record reviews, and interviews the facility failed to ensure that staff performed hand sanitization (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) to prevent the potential for cross contamination during laundry delivery for 13 residents (Residents 39, 40, 54, 47, 51, 14, 32, 11, 7, 22, 29, 50, and 2) of 13 residents observed; failed to ensure that staff performed hand sanitization to prevent the potential for cross contamination during delivery of room meals for 4 residents (Residents 29, 15, 26, and 31) of 4 residents observed; failed to ensure that laundry was handled in a manner to prevent the potential for cross contamination for 3 residents (Residents 39, 14, and 11) of 13 residents observed; failed to ensure that staff removed soiled gloves between resident rooms to prevent the potential for cross contamination for 2 residents (Residents 34 and 311); failed to ensure that staff performed hand sanitization during medication administration to prevent the potential for cross contamination for 3 residents (Residents 8, 43, 26) of 4 residents observed; and failed to perform hand sanitization as required during resident perineal care (cleaning of the private parts of the body) for 2 residents (Residents 24 and 25) of 2 residents observed. The facility census was 59. Findings are: A. Record review of the facility policy titled Infection Prevention and Control Program dated 1/2023 revealed that the facility will implement Hand Hygiene Policies consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. The section titled Linens revealed that laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection. Record review of the facility policy titled Hand Hygiene dated 1/2023 revealed that staff involved in direct resident contact will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The Hand Hygiene Table revealed that hand hygiene is indicated between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves, before and after handling clean or soiled dressings and linens, and after handling items potentially contaminated. Observation on 11/14/23 at 11:33 AM on the facility 100 and 200 halls revealed that Environmental Services Aide-A (ESS-A) removed clothing on hangers from inside the laundry cart. ESS-A carried the clothes into the room of Resident 39. ESS-A exited the room of Resident 39 and returned to the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 40. ESS-A exited the room of Resident 40 carrying used empty clothes hangers and returned to the laundry cart. ESS-A hung the empty hangers on the rack inside the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 54. ESS-A exited the room of Resident 54 carrying used empty clothes hangers and returned to the laundry cart. ESS-A hung the empty hangers on the rack inside the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed folded linens from inside the laundry cart. ESS-A carried the linens against the front of their uniform into the room of Resident 39. ESS-A exited the room of Resident 39 and returned to the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 47. ESS-A exited the room of Resident 47 and returned to the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 51. ESS-A exited the room of Resident 51 carrying used empty clothes hangers. ESS-A hung the empty hangers on the rack inside the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed folded clothing from inside the laundry cart outside the room of Resident 14 and held them against the front of their uniform. ESS-A continued to hold the clothing against the front of their uniform with their right hand and arm cradling the clothing. ESS-A removed a hanger with a shirt from inside the laundry cart with the left hand. ESS-A carried the clothing into the room of Resident 14. The folded clothing was held against the front of the uniform as it was carried into the room of Resident 14. ESS-A exited the room of Resident 14 carrying used empty clothes hangers and placed them on the rack inside the laundry cart. ESS-A did not perform hand sanitization. Observation on 11/14/23 at 11:33 AM on the facility 100 and 200 halls revealed that Environmental Services Aide-B (ESS-B) removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 32. ESS-B exited the room of Resident 32 carrying used empty clothes hangers. ESS-B returned to the laundry cart and hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. ESS-B removed clothing on hangers from inside the laundry cart. The clothing rubbed against the right arm and uniform sleeve of ESS-B as ESS-B carried them into the room of Resident 11. ESS-B exited the room of Resident 11 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. ESS-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 7. ESS-B exited the room of Resident 7 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. ESS-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 22. ESS-B exited the room of Resident 22 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. ESS-B pushed the laundry cart further towards the nurse's station. ESS-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 29. ESS-B exited the room of Resident 29 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. ESS-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 50. ESS-B opened the closet door and hung the clothing on the rack inside the closet. ESS-B removed used empty clothes hangers from the rack in the closet. ESS-B exited the room of Resident 50 and placed the empty hangers on the rack inside of the laundry cart. ESS-B did not perform hand sanitization. ESS-B pushed the laundry cart around the corner and stopped near the entry to the room of Resident 2. ESS-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 2. ESS-B exited the room of Resident 2 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. Interview on 11/14/23 at 1:36 PM with ESS-B confirmed that ESS-B received training on hand washing and hand sanitizer use from the facility. ESS-B confirmed that hand hygiene (hand sanitization) is to be performed after putting stuff in resident rooms and closets. Interview on 11/14/23 at 1:41 PM with ESS-A confirmed that the facility provides yearly training on hand hygiene. ESS-A revealed that hand sanitizer is located in the halls for staff to use. ESS-A confirmed that hand hygiene is to be performed after leaving a resident room before going to deliver laundry to the next resident room. Interview on 11/15/23 at 5:00 PM with the facility Director of Nursing (DON) confirmed that staff are expected to perform hand sanitization when exiting resident rooms. The DON confirmed that staff are expected to perform hand sanitization when going between resident rooms including during laundry delivery. B. Record review of the facility policy titled Hand Hygiene dated 1/2023 revealed that staff involved in direct resident contact will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The Hand Hygiene Table revealed that hand hygiene is indicated between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves, before and after handling clean or soiled dressings and linens, and after handling items potentially contaminated. Observation on 11/15/23 at 8:55 AM outside the room of Resident 29 revealed that Dietary Aide-F (DA-F) lifted the blue side cover of the room meal cart over the top of the cart. DA-F picked up a covered plate and carried it into the room of Resident 29. DA-F was in the room for approximately 50 seconds. DA-F exited the room and pulled the blue side cover down. DA-F pushed the cart down the hall and stopped near the room of Resident 15. DA-F did not perform hand sanitization. DA-F lifted the blue side cover of the cart and removed a covered plate and a napkin with silverware. DA-F carried the plate into the room of Resident 15 and moved items to set the plate and silverware on the overbed table in front of the resident. DA-F exited the room and picked up a coffee cup by the handle and poured coffee from the white carafe into the cup. DA-F carried the cup into the room of Resident 15. DA-F exited the room. DA-F did not perform hand sanitization. DA-F removed a plate of food from the cart and carried it into the room of Resident 26. DA-F sat the plate on the overbed table at the resident bedside. DA-F exited the room and picked up 2 coffee cups by their handles. DA-F poured coffee into the 2 cups from the white carafe. DA-F carried the 2 cups of coffee into the room of Resident 26 and sat them on the overbed table. DA-F exited the room. DA-F did not perform hand sanitization. DA-F pulled the blue side cover on the cart down. DA-F pushed the cart to just outside the room of Resident 31. DA-F lifted the blue side cover and removed a covered plate and carried it into the room of Resident 31. DA-F sat the plate on top of items on the overbed tray, touching the items with their hands. DA-F exited the room and pulled the blue side cover back down. DA-F pushed the cart to the facility 300 hall. DA-F did not perform hand sanitization. Interview on 11/15/23 at 1:59 PM with Dietary Aide-F (DA-F) confirmed that the dietary aide was trained on proper hand washing and use of hand sanitizer. DA-F confirmed that hand hygiene is to be performed between resident rooms when going from room to room. Interview on 11/15/23 at 5:00 PM with the facility Director of Nursing (DON) confirmed that staff are expected to perform hand sanitization when exiting resident rooms. The DON confirmed that staff are expected to perform hand sanitization when going between resident rooms including during room meal delivery. C. Record review of the facility policy titled Infection Prevention and Control Program dated 1/2023 section titled Linens revealed that laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection. Observation on 11/14/23 at 11:33 AM on the facility 100 and 200 halls revealed that Environmental Services Aide-A (ESS-A) removed folded linens from inside the laundry cart. ESS-A carried the linens against the front of their uniform into the room of Resident 39. ESS-A exited the room of Resident 39 and returned to the laundry cart. ESS-A did not perform hand sanitization. ESS-A removed folded clothing from inside the laundry cart outside the room of Resident 14 and held them against the front of their uniform. ESS-A continued to hold the clothing against the front of their uniform with their right hand and arm cradling the clothing. ESS-A removed a hanger with a shirt from inside the laundry cart with the left hand. ESS-A carried the clothing into the room of Resident 14. The folded clothing was held against the front of the uniform as it was carried into the room of Resident 14. ESS-A exited the room of Resident 14 carrying used empty clothes hangers and placed them on the rack inside the laundry cart. ESS-A did not perform hand sanitization. Observation on 11/14/23 at 11:33 AM on the facility 100 and 200 halls revealed that Environmental Services Aide-B (ESS-B) removed clothing on hangers from inside the laundry cart. The clothing rubbed against the right arm and uniform sleeve of ESS-B as ESS-B carried them into the room of Resident 11. ESS-B exited the room of Resident 11 carrying used empty clothes hangers. ESS-B hung the empty hangers on the rack inside the laundry cart. ESS-B did not perform hand sanitization. Interview on 11/14/23 at 1:36 PM with ESS-B confirmed resident clothing is to be carried so it does not touch their uniform. Interview on 11/14/23 at 1:41 PM with ESS-A confirmed that resident clothing and linens are to be carried so that they do not touch their skin or uniform. Interview on 11/15/23 at 5:03 PM with the Facility Administrator (FA) confirmed that staff are expected to carry clothing and linens in a manner to prevent them from touching the staff uniform. D. Record review of the facility policy titled Hand Hygiene dated 1/2023 revealed that staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The Hand Hygiene Table revealed that hand hygiene is indicated between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves, before and after handling clean or soiled dressings and linens, and after handling items potentially contaminated. Observation on 11/15/23 at 9:44 AM revealed that Dietary Aide-F (DA-F) pushed a cart from near the room of Resident 31 towards the nurse's station. DA-F wore blue disposable gloves. DA-F stopped outside the room of Resident 34. DA-F entered the room and then exited carrying a used plate and utensils. DA-F scraped remaining food debris from the plate into the trash on the end of the cart. DA-F sat the items in the bins on the cart that contained other soiled plates and utensils. DA-F did not remove the gloves or perform hand sanitization. DA-F pushed the cart using the gloved hands to outside the room of Resident 311. DA-F entered the room and then exited carrying a used plate and utensils. DA-F scraped food debris from the plate into the trash. DA-F placed the plate and silverware in a bin on the cart. DA-F did not remove the gloves or perform hand sanitization. Interview on 11/15/23 at 1:59 PM with Dietary Aide-F (DA-F) confirmed that the dietary aide was trained on proper hand washing and use of hand sanitizer. DA-F confirmed that gloves should not be worn in multiple resident rooms when going from room to room. Interview on 11/15/23 at 5:00 PM with the facility Director of Nursing (DON) confirmed that staff are expected to perform hand sanitization when exiting resident rooms. The DON confirmed that staff are not to reuse gloves between resident rooms.