Number of residents sampled:Number of residents cited:Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (30) observed self-administering a nebulizer (device that converts liquid medication into an inhaled mist) treatment in his room, was assessed for the ability to safely self-administer medications according to the provider's policy.Findings include: 1. Observation and interview on 7/23/25 at 8:52 a.m. of a medication pass with licensed practical nurse (LPN) I revealed:*LPN I assembled resident 30's medications taken by mouth, his inhaler, and nebulizer solutions from the Elm/Oak medication cart in the Oak common area.*She brought the medications and supplies to resident 30's room.*Resident 30 was administered his pills and his inhaler.*LPN I put two nebulizer solutions, ipratropium bromide (a medication used to open the airway of people with lung disease), and levalbuterol (a medication for wheezing and shortness of breath) into resident 30's nebulizer administration device, placed the mask on resident 30's face and turned on the nebulizer.*LPN I told resident 30 she would set a timer to remind her to return and take off his nebulizer mask and left the resident's room.*LPN I stated there were not any residents in the facility who self-administered medications.*She confirmed by leaving resident 30 after setting his nebulizer treatment up for administration he was self-administering the medication.*She would not be able to verify resident 30 was administered all of the medication in the nebulizer device because she had not remained in the room while he was taking the nebulizer.*She did not know if resident 30 had a completed assessment for the ability to safely self-administer his nebulizer medications. 2. Review of resident 30's electronic medical record (EMR) revealed:*His 6/5/25 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated he was cognitively intact.*He had a diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and can make it difficult to breathe).*A 7/1/25 physician's order for Ipratropium bromide 0.02% solution for inhalation [generic]; [physician's name]: Inhale 2.5 ml [milliliters] (0.5 mg [milligrams] total) by nebulization Three Times a Day, and Levalbuterol 1.25mg / 3ml solution for nebulization [generic]; (physician's name): 3 ml (1.25 mg total) by nebulization Three Times a Day.*There was no physician's order for him to self-administer the nebulizer medications.*There was no self-administration of medications assessment completed.*Self-administration of medications was not included in resident 30's 7/23/25 care plan. 3. Interview on 7/23/25 at 3:25 p.m. with resident 30 revealed:*Nursing staff would usually set up his nebulizer medications for administration, leave his room while the nebulizer was being administered, and then return after the nebulizer was complete to clean the nebulizer mask.*He was comfortable self-administering his nebulizer medications. 4. Interview on 7/23/25 at 3:27 p.m. with director of nursing (DON) B revealed resident 30 had not had a self-administration of medications assessment completed. 5. Interview on 7/24/25 at 12:45 p.m. with administrator A and DON B revealed:*No residents in the facility had been assessed to safely self-administer medications.*DON B expected LPN I would have remained in resident 30's room to monitor the administration of the nebulizer medication, if he was not assessed to safely administer them.*She confirmed by LPN I not remaining in resident 30's room during the administration of the nebulizer, resident 30 was self-administering his nebulizer medication. Review of the provider's 10/8/12 Medication Self-Administration policy revealed:* An individual Resident may self-administer drugs if the interdisciplinary team (IDT) has determined that this is a safe practice.* If a resident requests to self-administer drugs, the IDT is responsible for determining if it is safe for the Resident to do so before the Resident may do so.* Documentation of the self-administration plan should be done in the Resident's care plan.* The facility may require that drugs be administered by the nurse of medication aide until the IDT has had an opportunity to obtain information necessary to assess the Resident's ability to self-administer drugs. ,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:Number of residents cited:Based on observation, interview, record review, and policy review, the provider failed to ensure: *Medication labels matched the current physician orders for one of one randomly observed resident (28) according to the provider's policy. Findings include: *Medications with shortened expiration dates [medications that, after opening, expire prior to the manufacturer's expiration date] were labeled properly and disposed of after having outdated for one random resident (18) in one of two medication carts, (Maple/Aspen cart) and a provider stock medication in one of one medication room. 1. Observation and interview on [DATE] at 8:21 a.m. with certified medication aide (CMA) N during medication pass revealed:*Resident 28's artificial tears eye drops (medication for dry eyes) medication administration order (MAR) read, Artificial Tears (dextran 70- hypromellose) eye drops (Dextran 70-hypromellose) - 1 drop Opthalmic [related to the eye] Four Times a Day, and the pharmacy medication label read one drop to both eyes four times per day as needed.-The MAR did not indicate which eye the artificial tears eye drops were to be administered into.-The MAR order indicated the artificial tears were scheduled to be administered four times per day while the pharmacy label indicated the artificial tears were to be administered four times a day as needed.*CMA N indicated she gave the artificial tears in both of resident 28's eyes because resident 28 had always told her to put it in both of her eyes.*CMA N verified there was no direction on the MAR to indicate which eye the artificial tears were to be administered into, and the directions on the pharmacy label and in the MAR did not match.*RN clinical care coordinator F asked resident 28 which eye she was to receive the artificial tears into and resident 28 stated she received in both of her eyes. Interview and record review on [DATE] at 8:30 a.m. with registered nurse (RN) clinical care coordinator F revealed:*She verified the artificial tears order on resident 28's MAR did not indicate which eye the drops were to be administered into and the MAR instructions for administration did not match the pharmacy label instructions.*She verified the pharmacy label should have reflected the accurate administration instructions in order to complete the medication administration checks prior to administration of a resident's medication.*RN clinical care coordinator F retrieved the original physician's order for the administration of the resident's artificial tears, which indicated the artificial tears were to be administered into both eyes four times daily. Interview on [DATE] at 9:23 a.m. with CMA N revealed:*She had been a CMA at this facility for about one month.*She was a CMA prior to beginning her CMA position at this facility.*She had not noticed resident 28's MAR did not include which eye the artificial tears were to be administered into because she trusted the training she was provided by the nurses, and that was to administer resident 28's artificial tears into both eyes.-Additionally resident 28 had always told her that she received the artificial tears in both eyes.*If she would have noticed resident 28's MAR for artificial tears did not contain which eye the medication was to be administered into she would have asked the nurse to clarify the order. 2. Observation and interview on [DATE] at 10:40 a.m. of the medication room with RN clinical care coordinator F revealed:*Inside the refrigerator in the medication room was an opened vial of tuberculin solution (an injectable medication used to test for tuberculosis).*There was no date documented on the vial or the box the tuberculin solution was stored in to indicate when the vial was opened or when it use-by date after opening.*RN clinical care coordinator verified the tuberculin solution was open, and did not contain a date to indicate when it was opened or when it expired.*She stated the tuberculin solution was to be destroyed 30 days after the vial was opened, but she was unable to determine when the 30 days would have been because there was no date to indicate when the vial was opened.*She stated the tuberculin solution was used last week to test one staff member that was unable to have his blood drawn for the Gold test (a laboratory test for tuberculosis) that the facility routinely used. 3. Observation and interview on [DATE] at 11:40 a.m. of the Maple/Aspen medication cart with licensed practical nurse (LPN) K revealed:*Resident 18's latanoprost (medication used to treat increased pressure in the eye) eye drops were documented as opened on [DATE] and did not have an used-by date after opening identified on the bottle or box the eye drops were stored in.*LPN K confirmed that resident 18's latanoprost contained an opened date of [DATE], and that there was not an used-by date after opening indicated on the bottle or box that contained the bottle of latanoprost.*She was not sure how long latanoprost was able to be used for after opening before it needed to be destroyed.*She indicated there was a reference related to medications with shortened expiration dates in the narcotic binder on each medication cart.*The narcotic binder for the Maple/Aspen cart was not on the medication cart at that time for her to reference. 4. Review of the provider's undated Expiration Dates of Medications resource revealed:*Tuberculin solution was to be destroyed 30 days after opening.*Latanoprost eye drops were to be destroyed 6-weeks after [the] bottle has been opened or expiration date on the box; whichever comes sooner. 5. Review of resident 18's [DATE] MAR revealed he was administered latanoprost eye drops nightly from [DATE] through [DATE]. Those administrations occurred after the bottle should have been discarded since they were after six weeks from the date the bottle was opened on [DATE]. 6. Interview on [DATE] at 12:45 p.m. with administrator A and director of nursing (DON) B revealed:*It was DON B's expectation that the pharmacy labels on the resident's medication match the physician's order in the resident's MAR.*Resident 28's MAR should have indicated which eye an eye drop should be administered into to ensure the physician's order was followed.*The tuberculin solution should have been dated when it was opened to determine when it would have needed to be destroyed.*The latanoprost should have been destroyed six weeks after it was opened.-She verified resident 18's latanoprost should have been destroyed on [DATE]. Review of the provider's [DATE] Medication Procurement/Labeling policy revealed:* To ensure all medications (prescriptions, over-the-counter, and homeopathic) are obtained and administered in accordance with State and Federal regulations.* All medication coming into the facility must have:-1. Physician's order containing:--a. Resident name--b. Name of medication--c. Dosage--d. Route (i.e. oral). For topical medications, site must also be specified.--e. Frequency (i.e. one hour before meals)-2. Proper labeling (must match all elements of [the] physician [physician's] order with no variances) Any exceptions to the above requirements must be addressed with nursing services prior to [the] administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:Number of residents cited:Based on observation, interview, and manufacturer's manual review, the provider failed to assess the safety for one of one sampled resident's (10) side rail to be sure it was fastened securely to the bed and for possible risk of entrapment. Findings include: 1. Observation and interview on 7/22/24 at 2:47 p.m. with resident 10 in his room revealed:*He had a black upside-down U-shaped side rail on the left side of his bed.*It was located about halfway between the foot and the head of his bed.*The D shaped opening at the top of the side rail measured eight inches wide by four and a quarter inch high.*He stated he used the side rail to reposition himself while he was in bed.*He had been educated on how to use the side rail by staff.*He had an electronically adjustable bed. 2. Review of resident 10's electronic medical record revealed:*He was admitted on [DATE].*His 5/8/25 Brief Interview for Mental Score (BIMS) assessment score was 14, which indicated he was cognitively intact.*His 7/23/25 care plan indicated:- I require assistance with my ADL's [activities of daily living] related to a history of falls, physical limitations, depression, incontinence, and antidepressant use.- I use a bed cane [side rail] to reposition in bed.*The 4/22/25 Negotiated Risk-Side Rail assessment reflected, Update maintenance to install the side rail device. Maintenance installs side rails per manufacturer guideline and compatible with bed/mattress. Maintenance will complete quarterly checks of the side rail for ongoing appropriate installation and secure fit. Maintenance will be advised if side rails need to be removed, if the become loose, or if there are any other apparent concerns with physical installation of the device. 3. Interview on 7/23/25 at 12:03 p.m. with director of nursing (DON) B revealed:*The provider did not have a policy related to side rails.*She referred to the provider's 8/13/12 Restraint policy when the provider's side rail policy was requested. 4. Continued observation and interview on 7/23/25 at 12:20 p.m. with resident 10 in his room.*He had chosen and purchased the side rail, that his son-in-law installed on the.*The side rail had been on his bed for about four to five months.*To get out of bed he would use the side rail to lean his back against, then he pulled himself forward to the other side of the bed.*At times he would push against the side rail while he was seated on the bed to get out of bed.*The side rail could be moved towards the foot and the head of the bed.*Resident 10 stated that at times the strap that secured the side rail to the bed would loosen, as it was at that time, which made it possible to move the side rail around on the bed. 5. Interview on 7/23/25 at 3:27 p.m. with physical therapist H revealed:*Resident 10 was currently working with physical therapy due to an increased number of falls.*Resident 10 was independent with getting in and out of bed.*She had not witnessed how resident 10 used the side rail to get in and out of bed.*She was not aware of where the side rail was attached to the bed, that it was loose, or how resident used the side rail.*He had been educated by therapy to use the head of the bed adjustments to assist himself into a seated position in the bed to make the transfers out of bed easier for him.*The therapy department had not completed an assessment on resident 10 for entrapment risks or his side rail. 6. Interview on 7/23/25 at 4:20 p.m. with certified medication aide (CMA) O revealed:*Resident 10 used the side rail to get in and out of bed by pulling on the side rail to sit himself up.*He was independent with getting in and out of bed.*She had not noticed resident 10's side rail being loose.*If she had noticed it was loose she would notify maintenance to have it secured.*She was aware of the risks of entrapment related to side rail use but did not feel resident 10 was at risk related to his side rail.*She indicated it was the provider's protocol to have a resident or resident's representative sign a release of liability if they requested the use of a side rail. 7. Interview on 7/23/25 at 3:27 p.m. with plant manager E revealed:*He oversaw maintenance for the facility.*The therapy department was responsible for the installation of bed rails.*Resident 10 had purchased his own bed rail on his bed, but plant manager E was not sure who completed the installation of the bed rail on resident's bed.*He completed bed rail checks when he did the routine room checks.-He checked the tightness of the bed rail, and clearance of the bedrails on the adjustable beds.*He had not taken measurements in the zones of entrapment or completed an entrapment assessment for resident 10's side rails. 8. Interview on 7/24/25 at 12:45 p.m. and continued interview at 1:40 p.m. with administrator A and DON B revealed:*Facility staff had not installed resident 10's side rail onto his bed. The DON entered his room to find it already installed on 4/22/25.*An entrapment assessment had not been completed for resident 10 related to the side rail.*She did not consider that side rail a risk of entrapment because of resident 10's cognition.*No measurements had been taken to assess for entrapment risk related to his side rail.*The provider did not have a formal process or policy to assess for entrapment risk.*When asked about the opening dimensions at the top of resident 10's side rail, related to the entrapment prevention guidelines, DON B stated those measurements were recommendations not requirements.*DON B did not consider resident 10's side rail to be a restraint but had referred to the restraint policy when a bed rail policy was requested.*DON B indicated there was not a side rail policy.*It was the DON's expectation that if staff noticed a side rail was loose, they were to notify maintenance to have it tightened to ensure resident safety.*If a resident requested a side rail then an assessment would be completed and the side rail would be reevaluated with the resident's quarterly assessments.*As a facility side rails were discouraged because of recurring assessments that should have been completed for them. Review of the provider's 8/13/12 Restraints policy revealed, It is the policy of this facility not to use physical or chemical restraints for the purpose of disciple or convenience. Review of the undated manufacturer's instructions for the Panacea 3500 Bed revealed:* The Hospital Bed Safety Workgroup (HBSW), in partnership with the FDA, has recognized potential entrapment zones in hospital bed systems and has developed dimensional guidance to reduce the risk of entrapment. The FDA [Food and Drug Administration] considers the term ‘hospital bed system' to encompass the bed frame and its components, including mattress, bed assist rails, headboards and footboards, and any accessories to the bed.* The entrapment zones involve the relationship of components controlled by the healthcare facility or individual user. Compliance to the dimensional guidelines for reducing the risk of entrapment is primarily the responsibility of the healthcare facility or the individual user. Anyone having any involvement with hospital bed systems should review and understand the FDA guidelines. Review of 2/16/24 manufacturer's instructions for the Stander side rail that was the side rail on resident 10's bed revealed:* BEFORE INSTALLING THIS PRODUCT, YOU MUST ENSURE THAT IT IS SAFE TO USE ON YOUR BED AND MATTRESS. This product can only be used on beds and mattresses that comply with the specifications set forth in the enclosed MATRESS CONDITIONS & SAFETY COMPONENETS and ASSEMBLY INSTRUCTIONS.* Stop using immediately if product shifts out of its original position.* If this product is used in a nursing home, assisted living center, or similar facility, follow these instructions and all of the institution's Bed Rail/Handle installation policies.* Always make sure this product is properly secured to bed.* ENTRAPMENT ZONES-Zone 1: Within the Rail- Any open space between the perimeters of the rail can present a risk of head entrapment. The FDA recommended space is less that 4.75 in [inches] (12 cm [centimeters]).* Compatibility: DO NOT use on adjustable beds.

Based on observation, interview and policy review the provider failed to ensure food items were appropriately packaged and safely stored away from cleaning chemicals in [one of one kitchen]. Findings include: 1. Observation on 1/30/24 at 8:00 a.m. in the kitchen revealed: a. In the dry food storage room, the following chemicals were stored on a metal rack alongside metal racks of food: *Prominence Heavy Duty Floor Cleaner *Suma Pan-Clean Detergent *Suma Break Up SC, Heavy Duty Foaming Grease Release Cleaner *Medallion Stainless Steel Cleaner *Suma-Diverpak Dish Detergent *Lime-A-Way Lime Scale Remover *Suma Gloss Concentrated Pre-Soak for silver and stainless steel *Suma Cal X Descaler *Dawn Dish Soap *Monogram Glass Cleaner b. Inside the stand-up freezer there was a bag of frozen donuts that was opened and exposed to the air. c. Inside the upright refrigerator/freezer there were unlabeled and undated frozen bags of pizza, hamburger patties, and chicken nuggets that were opened and exposed to the air. Interview on 1/30/23 at 10:00 a.m. with dietary manager (DM) C regarding the above observation revealed: *The chemicals had been stored since before she had begun her employment. *She thought about moving the chemicals. *She was unsure if there was another location to store those chemicals. *She confirmed the food items observed in the upright freezer and the upright refrigerator/freezer were not dated, labeled, and sealed when they were opened. *It was her expectation that staff would store opened food items in sealed bags that were labeled and dated. Interview on 2/1/24 at 8:10 a.m. with administrator A revealed: *The food storage policy stated that chemicals were to have been stored on a different rack than the food items but did not need to be stored in a different location. *It was her expectation that opened food items be sealed and dated. *The dietary policies were in the process of being reviewed and updated. Review of the provider's undated Food Storage Policy and Procedure Manual revealed: *4. Chemicals must be clearly labeled, kept in original containers when possible, kept in a locked area and stored away from food. *14. c. Frozen Foods: All foods should be covered, labeled, and dated.

3. Continuous observation on 12/20/22 from 8:17 a.m. through 9:00 a.m. of CNA G with residents 16 and 34 revealed she: *Entered resident 16's room and without sanitizing her hands or wearing gloves reconnected his oxygen tubing to his continuous positive airway pressure (CPAP) breathing device. -Left his room without sanitizing her hands to assist another CNA with a different resident's care. Further observation on 12/20/22 at 8:28 a.m. with CNA G upon her return to resident 16's room revealed: *Without sanitizing her hands she entered his room, put on a pair of gloves, and emptied his urinal into the toilet. -After wiping the rim of the urinal with a personal care wipe, she removed her gloves. *Without sanitizing her hands she applied a new pair of gloves and put on his support stockings, socks, pants, and shoes. -She moved his wheelchair next to his bed and removed her gloves. *Without sanitizing her hands she: -Repositioned his wheelchair, replaced his oxygen tank with a full tank, handed the resident his oxygen tubing, and placed the empty tank onto the oxygen concentrator. -Placed his CPAP tubing on the bedside table, gave him his hearing aids, placed a clean brief into his walker storage seat, made his bed, adjusted his pillows, adjusted his window blinds, and placed his oxygen concentrator tubing across his bed. *She left his room without sanitizing her hands. Further observation on 12/20/22 at 8:48 a.m. of CNA G in resident 34's room revealed: *After leaving resident 16's room, she entered resident 34's room without sanitizing her hands. *She: -Removed resident 34's clothes from his closet and applied clean gloves. -Flushed his toilet and assisted him with dressing while he sat on his bed side. -Applied his stand lift harness and moved him to the bathroom using the mechanical stand lift. --He had held onto the stand lift bars with his unwashed hands. -Removed his urine soaked undergarment and removed her gloves. *Without sanitizing her hands she touched the mechanical lift and lowered the resident to the toilet. *She: -Wet a washcloth and gave it to the resident to wash his face. -Dried her hands on a paper towel and went into his room to make his bed. -Applied a glove to one of her hands to carry his unbagged soiled laundry to a storage container in the middle of the hallway. -Opened his door and closed his door with her unsanitized hand. *She sanitized her hands while walking down the hallway prior to re-entering the closed door to his room. -This required touching the same door handle she opened with an unsanitized hand. *Without sanitizing her hands she: -Applied a clean pair of gloves and performed peri care to his groin and buttocks. -Removed her gloves and without sanitizing her hands put on a clean brief and pulled up his pants. -Transferred him back to his wheelchair using the mechanical stand lift. *She placed the stand lift in the hallway. *Without sanitizing her hands or the resident's hands she wheeled him down the hallway and into the dining room. -She moved a dining room chair out of the way and put his clothing protector around his neck. *She then returned to the hallway and moved the mechanical stand lift to the storage area in the middle of the hallway. -She did not sanitize the mechanical stand lift. *Without sanitizing her hands she touched a multi-use computer keyboard and a pencil to write on a piece of paper. Interview on 12/20/22 at 9:00 a.m. with CNA G regarding the above observations revealed she: *Had been a CNA since September 2022. *Had received her training at a sister facility by a level two CNA who would follow her around and give her advice. *Passed her skills training at the sister facility. *Received infection control continuing education on the facility computer and during monthly meetings. *Stated mechanical lifts were not cleaned between resident use. -The normal routine for mechanical lift sanitization occurred after breakfast, after lunch, at the end of each shift, and if a resident was sick. -She would be told by the nurse, or in shift report, if a resident was sick. *Felt wearing gloves and hand sanitization were part of a normal routine. -She stated that routine depended on if her hands were dirty, then she would wash or sanitize them. -If she had been wearing gloves then her hands would not necessarily be considered dirty when she removed them. *Fully washed her hands with soap and water after breakfast and at her break time. *Had been unable to identify any missed opportunities for hand sanitization during the above observations. Interview on 12/21/22 at 7:59 a.m. with DON B regarding the above observations revealed: *Hand hygiene was expected prior to, during, and following resident care. -Gloves and hand sanitizers were located in every bathroom. *If staff were unable to wash their hands going from a dirty to clean environment, she expected them to at least use hand sanitizer. *CNA G had passed a hand hygiene audit in July of 2022 while working as a housekeeper. *Agreed CNA G had missed opportunities for hand sanitization and glove use. *Felt there were opportunities for additional staff education regarding hand sanitization and glove usage. *The mechanical stand lifts were cleaned when visibly soiled and periodically through the day. Interview on 12/21/22 at 4:13 p.m. with DON B and ICN C regarding the observations above revealed: *ICN C stated proper hand hygiene and glove use had not occurred but should have unless there were extenuating circumstances. -She would prefer they (caregivers) take the opportunity (to ensure proper hand hygiene and glove use had occurred), but if unable, they do the best they can. *Shared resident equipment including pulse oximeters, blood pressure cuffs, and stand lifts were cleaned based on guidance revised in October 2022 from the State Operations Manual Appendix PP. -If residents were on isolation it (cleaning shared resident equipment) would have been different. *ICN C indicated Our policy is based on current regulations (from the SOM Appendix PP). Unless there was research to identify it (cleaning of shared equipment) had been changed, we are following the regulations as they stand. -Upon request and by end of survey she had not provided those specific infection control references from the SOM Appendix PP she continually referred to above. A Glove Use and/or Personal Protective Equipment (PPE) policy was requested of DON B on 12/21/22 at 2:50 p.m. She stated there were no such policies and PPE expectations were addressed within each specific resident care policy. Review of the provider's 10/23/2 Perineal Care policy revealed: *Equipment expected to be used during this care included gloves. *The procedure made no mention of when gloves were expected to be put on, changed, or removed. *On 12/21/22 at 2:50 p.m. DON B was asked for a specific date of the Perineal Care policy, but that was not provided prior to the end of the survey. Review of the provider's April 2020 Hand Hygiene policy revealed: *Indications: Hand hygiene should be done by staff: -Before and after physical contact with a Resident, whether or not gloves are worn, and between different site/care activities on the same Resident. -After contact with a Resident or Resident's body fluids, including specimen collection. -Before performing invasive procedures and handling devices such as IV's, catheters, urinary closed drainage systems and respiratory equipment. -Before eating, feeding a Resident, preparing food, liquids or snacks. Review of the provider's November 2018 Infection Control Disinfecting Personal Care Items policy revealed: *Purpose -To prevent the spread of infection when using multi resident use personal care items for residents who are on standard precautions. *Non-Critical Items include: vitals equipment, wheelchairs, therapy equipment, and facility owned electronic devices. -These items must be cleaned periodically and when visibly soiled using low-level disinfection techniques, i.e. Sani-cloth or similar product. Review of the CDC publication entitled CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings last reviewed on 11/29/22 revealed: *5f. Reprocessing of Reusable Medical Equipment references and resources: -1. Clean and reprocess (disinfect or sterilize) reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, blood pressure cuffs, oximeter probes, surgical instruments, endoscopes) prior to use on another patient or when soiled. Review of the 2021 APIC issued brief at : https://apic.org/noncritical-is-critical/ revealed: *Non-invasive portable clinical items shared among patients are part of the patient's immediate surroundings and may pose a threat of pathogen transmission. *The authors concluded that inappropriate disinfection practices increase the risk of HAIs [healthcare aquired infections] transmitted from such items. Based on observation, interview, review of a Centers for Disease Control (CDC) publication, review of an Association for Professionals in Infection Control (APIC) brief, and policy review, the provider failed to ensure infection prevention and control practices were appropriately followed for: *Glove use by one of one certified nurse aide (CNA) (D) during care provided for one of one sampled resident (21). *Cleaning by medication aide (MA) (F) of shared equipment used between two of two (1 and 14 ) observed residents. *Hand hygiene and glove use by one of one CNA G during care provided for two of two sampled residents (16 and 34). *Cleaning by CNA G of shared equipment used by one of one observed resident (34). Findings include: 1. Observation on 12/20/22 at 9:45 a.m. of CNA D and hospitality coordinator E in resident 21's room revealed: *They provided personal care for resident 21 after she had a bowel movement (BM). *CNA D removed the resident's soiled brief and used a wipe to clean the BM off her skin. *Without changing her soiled gloves she: -Placed a clean brief underneath the resident. -Applied Aloe Vesta protection cream on her skin. -Wiped the excess cream off her soiled glove onto the inside of the resident's brief. -Secured the brief and helped the resident to get dressed. *She removed her gloves and performed hand hygiene. Interview with CNA D on 12/20/22 at 10:50 a.m. revealed she: *Agreed she had not changed her gloves and knew she should have: -Removed her gloves after cleaning resident 21. -Put on new gloves before handling the clean brief and applying the skin cream. Interview on 12/21/22 at 4:13 p.m. with director of nursing (DON) B and infection control nurse (ICN) C regarding the observation above revealed they agreed CNA D should have changed her gloves after cleaning resident 21 and before applying her clean brief and the cream. 2. Observation and interview on 12/21/22 at 9:20 a.m. with MA F revealed she: *Took resident 1's vital signs with the same equipment she took resident 14's vital signs. -Had not cleaned that equipment between residents. *Had cleaned that equipment with a disinfectant wipe at the beginning of her work shift that day. *Stated it was not her usual practice to clean vital signs equipment between resident use.