Based on observation, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy and procedure when Nurse Aide (NA) #1 did not doff her gloves, perform hand hygiene and don clean gloves after removing a dressing and before cleaning the wound during wound care to Resident #26. The deficient practice occurred for 1 of 8 staff members observed for infection control practices (NA #1). The findings included: Review of the facility's policy entitled Hand Hygiene last updated May 2025 read in part: Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub with 60% to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Hand Hygiene Table Use either soap and water or alcohol-based hand rub for the following conditions: - Before performing invasive procedures. - Before applying and after removing personal protective equipment (PPE) including gloves. - Before and after handling clean or soiled dressings, linens, etc. - After handling items potentially contaminated with blood, body fluids, secretions or excretions. An observation of NA #1 and Nurse #1 providing wound care to Resident #26's coccyx wound was made on 07/08/25 at 10:25 AM. Nurse #1 had gathered all her dressing supplies and placed them on a barrier on the overbed table. The dressing on the coccyx wound was removed by NA #1 who was assisting with wound care. NA #1 removed the dressing and without doffing her gloves, sanitizing her hands and donning clean gloves, proceeded to clean the wound with normal saline-soaked gauze and then dried the wound with a dry gauze pad. NA #1 doffed her gloves after cleaning and drying the wound, washed her hands with soap and water, donned clean gloves and assisted Nurse #1 in completing the wound care and application of wound vac to Resident #26's coccyx wound. After the wound care was completed, Nurse #1 and NA #1 gathered the supplies and trash, doffed their gowns and gloves, washed their hands with soap and water and left the room. An interview on 07/08/25 at 2:29 PM with Nurse #1 and NA #1 revealed they both thought the wound care had gone well. NA #1 stated she should have doffed her gloves, sanitized her hands, and donned clean gloves after removing the dressing and before cleaning and drying the wound in preparation for application of the wound vac. NA #1 stated it was an oversight and she knew that she should have doffed her gloves, sanitized her hands and donned clean gloves prior to cleansing Resident #26's wound. An interview on 07/08/25 at 4:09 PM with the Infection Preventionist (IP) revealed NA #1 should have doffed her gloves, sanitized her hands, and donned clean gloves after removing Resident #26's dressing and before cleaning the wound with normal saline. The IP stated they were constantly doing education on infection prevention practices and they would provide NA #1 with one-to-one education. An interview on 07/08/25 at 6:39 PM with the Administrator revealed it was her expectation for all staff to follow infection prevention procedures when providing resident care. The Administrator stated NA #1 should have removed her gloves, sanitized her hands and applied clean gloves prior to cleaning Resident #26's wound.

Based on observations, record review and staff interviews, the facility failed to: 1) ensure items stored ready for use were labeled and dated in the walk-in freezer; 2) remove expired food items in 1 of 2 coolers. These practices had the potential to affect food served to residents. Findings included: a An observation and interview conducted with the Dietary Manager (DM) on 05/06/24 at 10:00 AM revealed there were two bags of hash browns (20 each) that were not labeled or dated in the walk-in freezer. The DM could not recall when they had been placed in the freezer and indicated the bags should labeled and dated. b. An observation conducted on 05/06/24 at 10:05 AM revealed two packages of ten pounds of ground beef on a tray with thaw date 05/03/24. The observation further revealed the ground beef to be turning a gray like color. An observation and interview conducted with the DM on 05/06/24 at 11:05 AM revealed the ground beef to be a gray color and thaw date labeled 05/03/024. The DM stated the ground beef was planned for use on 05/07/24 for sloppy joes and 05/08/24 for meat loaf for resident meals. The DM indicated she had been educated from the prior DM ground beef could be thawed and used after 3 to 5 days. An interview with the DM on 05/08/24 at 1:25 PM revealed she had newer staff and felt like there was a need for education and training for labeling and guidelines for different type of meats. An interview conducted with the Administrator on 05/08/24 at 2:25 PM revealed he understood the concerns and believed the staff were newer and needed more education and training and expected staff to follow rules and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interviews the facility failed to provide a safe transfer for 1 of 3 residents sampled for accidents (Resident #15). The findings included: Resident #15 was originally admitted on [DATE] with diagnoses that included hypertension and hyperlipidemia. Review of Resident #15's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was cognitively intact and required extensive assistance of two or more staff with transfers and toilet use. Review of Resident #15's care plan dated 10/31/22 revealed Resident #15 required assistance with activities of daily living (ADL) related to weakness and decreased mobility with admission to hospice services with diagnosis of cerebral atherosclerosis. Resident #15's goal was to be able to participate in ADL care through next review. Interventions included staff to assist with ADL care on a routine basis and as needed. Observation of the inside of Resident #15's closet door on 1/4/23 at 12:30 PM revealed a Transfer/ Mechanical Lift assessment dated [DATE] which indicated Resident #15 was a two person assist with no lift. Review of the facility incident report dated 12/4/22 at 6:43 PM revealed Nurse Aide (NA) #1 observed Resident #15 lose her balance and fell in the bathroom while trying to sit back into the wheelchair around 3:35 PM. The incident report further revealed NA #1 stated, I was trying to scoot the wheelchair behind her, and she fell and hit her head against the wall. The incident report indicated Resident #15 was assessed and no injuries were noted. An interview conducted with Resident #15 on 1/4/23 at 12:30 PM revealed NA #1 and NA #2 had assisted Resident #15 to the shower room to use the bathroom because Resident #15 preferred more room. Resident #15 further revealed NA #2 walked away while she was being transferred from her wheelchair to the toilet. Resident #15 indicated she became weak, and NA #1 was unable to hold her and assisted her to the floor. Resident #15 stated she usually had two person-assist for transfers and did not know why NA #2 had walked away. Resident #15 revealed she did not recall hitting her head or obtaining any injuries. Review of progress note dated 12/4/22 revealed Nurse Aide (NA) #1 observed Resident #15 lose her balance in the bathroom while trying to sit back in her wheelchair. The note further revealed vitals were taken and Resident #15 complained of a headache post fall and received Tylenol. An interview was unable to be conducted with Nurse Aide (NA) #1 during the investigation. An interview conducted with Nurse Aide (NA) #2 on 1/4/23 at 11:50 AM revealed he and NA #1 assisted Resident #15 to the restroom in the shower room to use the toilet. NA #2 further revealed NA #1 transferred Resident #15 from the wheelchair to the toilet while he had walked over to the linen cart an estimated 10 feet away from the toilet in the shower room. NA #2 stated he heard a thump and observed Resident #15 on the floor. NA #2 indicated he was aware and re-educated after the fall that Resident #15 was a two person assist for transfers. The interview further revealed residents in the facility had a [NAME] located on their closet doors that disclosed required assistance needed for transfers. An interview conducted with Nurse #1 on 1/4/23 at 11:17 AM revealed on 12/4/22 she had walked by the shower room and heard a thump. Nurse #1 further revealed she entered the room and observed Resident #15 and NA #1 on the floor and NA #2 away from the resident at the linen cart. Nurse #1 indicated Resident #15 had fallen forward on her knees and was a two person assist for transfers and both NAs should have been with the resident during the transfer. Nurse #1 revealed Resident #15 was assessed and did not have any injuries and she had educated both NAs about safely transferring residents with appropriate assist. An interview conducted with the facility Rehabilitation Manager on 1/4/23 at 2:40 PM revealed Resident #15 was not participating in therapy during the incident on 12/4/22. The Rehabilitation manager further revealed Resident #15 was a two person assist for transfers due to Resident #15 sometimes being weak and knees buckling. The Rehabilitation Manager indicated both NAs should have been with Resident #15 during the transfer to prevent the fall. An interview conducted with the Director of Nursing (DON) on 1/4/23 at 3:15 PM revealed Resident #15 required two-person extensive assistance for transfers. The DON further revealed both NAs should have assisted Resident #15 during the transfer to prevent the fall.