**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure MDS data was transmitted within 14 days of completion for 1 of 10 residents (CR #4), in that: - CR #4's discharge assessment was never completed and submitted following discharge on [DATE]. This failure could place residents at risk for receiving unnecessary services or inadequate care. Finding included: Record review of CR #4's face sheet, printed 6/8/2023 revealed an [AGE] year-old female who was admitted on [DATE] and discharged [DATE]. Record review of CR #4's MDS section I, dated revealed the resident had diagnoses including osteoporosis and hypertension. Record review of CR #4's MDS, dated [DATE], revealed the resident MDS OBRA assessment completed but not a discharge assessment. In an interview with the MDS Coordinator on 06/09/2023 at 7:11AM, the MDS Coordinator stated CR #4 was only in the facility for 5 days and on the 5th day, she completed the OBRA and admission assessment but forgot to check off that she discharged . She also stated per policy of the RAI manual, the rule was to transmit completed assessments within 14 days. The MDS Coordinator stated she did not know what the implications were because this was the first this had happened to her. In an interview with the Program Director on 06/09/23 at 09:57AM, she stated she monitors information she receives from feedback reports, and provider reports and 5-star reports provided by CMS. She stated there was not necessarily a report to see missed MDS assessments. She also said she was not too familiar with all the types of MDS assessments, but in this case believes the MDS Coordinator made an honest mistake but had corrected the issue today. Record review of the RAI Manual, revised October 2019, stated, . Short-term or respite residents: An RAI must be completed for any individual residing more than 14 days on a unit of a facility that is certified as a long-term care facility for participation in the Medicare or Medicaid programs. If the respite resident is in a certified bed, the OBRA assessment schedule and tracking document requirements must be followed. If the respite resident is in the facility for fewer than 14 days, an OBRA admission assessment is not required; however, an OBRA Discharge assessment is required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 30 opportunities, which involved 1 of 4 residents (Resident #7) and 1 of 3 staff (RN A) reviewed for medication errors in that: -RN A failed to administer Resident #7's medications via G-Tube ( A tube inserted into the abdomen directly into the stomach to provide nutrition, liquid and medications) individually and failed to administer a water flush between each medication. These failures could place residents who receive medications via gastrostomy tube by placing them at risk of inadequate therapeutic outcomes and a decline in health. Findings included: Record review of Resident #7's admission face sheet dated 05/15/2023 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: malignant neoplasms (cancer) of the tongue, head, neck and face, respiratory failure (lungs cannot get enough oxygen into the blood), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), chronic heart failure, and G-Tube. Record review of Resident #7's admission MDS dated [DATE] revealed in part: Resident #7's speech clarity the resident was absent of spoken words. The resident's BIMS was 14 to indicate he was cognitively intact. Resident # 7 was totally dependent by one staff for eating. The resident's active diagnoses were medically complex to include cancer, heart failure, tracheostomy. Record review of Resident #7's care plan dated 05/27/2023 revealed in part: Focus: Nutrition; Goal: To achieve/improve and maintain an adequate nutritional status; to administer tube feeding safely; to administer medications without complications; Interventions: If more than one medication was being administered, flush with 10ml of water between each medication. Record review of Resident #7's physician's order report dated June 2023 revealed the following orders: Multiple vitamin one tablet by feeding tube daily, order start date 05/16/2023; Entresto 24-26Mg (medication to treat chronic heart failure) one tablet by feeding tube two times daily, order start date 05/17/2023; Plavix 75 Mg (medication to prevent blood platelets from clumping together to form clots) one tablet by feeding tubes daily, order start date 05/24/2023. Record review of the unit training titled Feeding Tubes: Nasoenteral (Tube inserted through the nose to the stomach to administer medications, nutrition) , Gastrostomy and Small Bowel, dated 02/06/2023 read in part: Administer each medication separately, flush the tube after each medication administered with 30ml of water. In an observation on 06/07/2023 at 11:51 AM, Resident # 7 was sitting up in bed awake, alert and nonverbal. RN A checked Resident # 7's blood pressure which was 115/54. RN A returned to the medication cart. RN A placed the resident's multiple vitamin, entrestro and Plavix in the pill crusher. RN A crushed the three tablets together. RN A added the crushed medications to a cup with 280 ml of water. The three mediations were dissolved in the cup of water. RN A returned to the resident. RN A checked Resident #7's stomach residual (purpose of checking stomach residual was to check the amount of liquid in the stomach prior to medications and feedings). RN A flushed Resident #7's G-Tube with 15ml water. RN A added the three dissolved mediations in to a 60 ml syringe. The mediations were administered by gravity flow into the G-Tube. RN A administered all three medications at one time. In an interview on 06/07/2023 at 12:05 PM immediately after the medication administration RN A stated she did mix Resident #7s multiple vitamin, Plavix and entrestro together. RN A stated this was how she gave the resident his medications. RN A stated she administered the medications this way to prevent the G-Tube form clogging. In a follow up interview on 06/07/2023 at 1:15 PM RN A stated she did crush resident #7's Multiple vitamin, Plavix and entrestro together. RN A stated she put them together in one cup of water to dissolve the medications. The RN stated she wanted to prevent the resident's G-Tube from clogging. RN A stated each medication should have been crushed separate. She continued and stated she should have flushed after each medication with water. RN A stated the risk of not separating the medication was the possibility of an interaction between the medications. In an interview on 06/08/2023 at 12:22 PM, the Unit Manager stated her expectations were G-Tube medications were crushed and administered separately. The Unit Manager stated each medication was to be separated with a water flush. The Unit Manager stated each mediation was to be crushed separate then dissolved in water. She continued and stated G-Tube crushed medications were not to be administered together. The Unit Manager stated one risk of the medications administered together was a possible interaction between medications. The Unit Manager stated another risk was if the tube clogged during administration the nurse would not be able to determine which mediation had been administered. The Unit Manager stated to prevent this from occurring again all staff would be in serviced on G-Tube medication administration. The Unit Manager stated the nurse who administered the medication would be in serviced one on one. In an interview on 06/08/223 at 2:12 PM, the Director stated her expectations for G-Tube medications were crushed and administered separately. The Director stated each medication was dissolved in water. She continued and stated a water flush was to be given between each medication. The Director stated a risk of combining the mediations were compatibility. The Director stated another risk of combining the medication was not knowing what or how much of a medication was administered if the tube became clogged. The Director stated the plan to prevent this from occurring again was staff education. The Director stated the monitoring of medication administration was done by the Hospital Pharmacy Technician. The Director stated the Hospital Pharmacy Technician monitors medication administration. The Directory stated the Hospital Pharmacy Technician audited the staff by observing mediation administration monthly. In an interview on 06/09/2023 at 8:17 AM, the Hospital Pharmacy Technician stated she did monthly observations of medication administration to audit the staff's medication administration. The Pharmacy Technician stated she had not had any issues with her observation. The Pharmacy Technician stated she had not done any recent G-Tube administration observation. The Pharmacy Technician stated she followed the nurse and what medication that was scheduled. The Pharmacy Technician stated the correct way to administer the G-tube mediations was separately with a water flush between each medication to prevent them from mixing together. The Pharmacy technician stated if she observed a problem during her audits, she notified the Unit Manager for additional education. Record review of the policy titled Feeding Tube: Medication Administration dated February 2023 read in part .22. Administer liquid or dissolved medications by pouring it into the syringe and flush. A. After the administration of medications or formula, clear the tube by flushing it with a minimum of 15 ml of purified water .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and/or implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 8 Residents (Resident #165) reviewed for comprehensive care plans, in that: Resident #165 use of feeding tube was not included in his care plan. This failure affected 1 resident and placed him at risk of not having his needs met. Findings include: Resident #165 Record review of Resident #165's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: malignant neoplasm of bladder, metabolic encephalopathy, malignant neoplasm of right ureter, acute kidney failure, acidosis, acute post hemorrhagic anemia, gross hematuria, chronic atrial fibrillation, malaise, weakness, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, chronic kidney disease, stage 3, and non-pressure chronic ulcer of other part of right foot with unspecified severity. Record review of Resident #165's Admission's MDS dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Further review of the MDS revealed he did not have a feeding tube and had a that therapeutic diet. Record review of Resident #165's care plan dated 9/21/19 revealed a problem area of nutrition that revealed he was on a heart healthy diet and has episodes of nausea. The nutrition care plan further stated he needs limited assistance to eat. His interventions included: 1. Assess patients' nutritional status and monitor for associated complications. 2. Monitor glucose, serum albumin levels and report abnormalities. 3. Medicate as prescribed for nausea and vomiting. 4. Refer to Dietary/Nutritional Consult for thorough nutritional assessment and planning. 5. Assess awareness and understanding of patients and/or caregiver regarding the importance of adequate nutritional intake and with their disease process. Further review of the care plan revealed no mention of care for Resident #165's feeding tube. Record review of Resident #165's Interventional radiology (IR) Feeding Tube results dated 10/14/19 revealed study results, Examination: IR Gastrostomy Catheter Initial Placement, Clinical History: Dysphagia Malnutrition needing PEG, Procedure: Gastrostomy tube placement, Complication: No immediate Complications, Impression: Percutaneous placement of 16 French push-type gastrostomy tube, Plan: Okay to use gastrostomy tube in 6 hours. Record review of Resident #165's nursing note date 10/14/19 at 10:32AM revealed the resident was received status post gastrostomy tube insertion. Record review of Resident #165's nutritional evaluation dated 10/14/19 at 1:57PM revealed recommendations, in part, .1. When PEG cleared for use. EN regimen as followed: - Isosource 1.5 with goal rate at 50ml/hr. Initiate at 30ml/hour and advance 10 every 4 hours to goal rate . - Regular fluid flushed per MD to maintain tube patency and adequate hydration. Suggest 75 ml every 4 hours to provide additional 450Mls fluid daily. - When tolerating continuous regimen for > 24 hours, can advance to bolus regimen: 1 carton Isosource 1.5 at 5 times daily . Further review of the evaluation revealed an assessment with details, in part, .Patient with confusion and difficulty swallowing, MBS (modified Barium Swallow)10/2 and 10/7. Per Speech Language Pathologist (SLP), patient not safe for PO (by mouth) diet at this time. Per MD, to continue pleasure feeds with nectar thick liquids. Patient started on TPN (Total parenteral nutrition) due to family not being ready for PEG 10/10. PEG placed on 10/14 . The evaluation also reviewed diet orders that were ordered on 10/11/19 and started on 10/14/19 of, NPO effective Midnight Diet effective midnight, Comments: PEG insertions 10/14/19 Question: NPO Answer: Except Meds. Record review of Resident #165's physician progress notes dated 10/14/19 at 3:30PM revealed a plan for Malnutrition/dysphagia that the resident was status post IR PEG placement today - will initiate tube feeding nutritional recommendations - continue aspiration precautions. Record review of Resident #165's nursing notes dated 10/15/19 at 8:10AM revealed, Hand off received from Night RN, Patient supposed to get PEG tube feeding from midnight, but per Night RN, waiting for kangaroo pump to start feeding. Tried to start feeding now but PEG tube is clogged, found granules in the PEG tube. Record review of Resident #165's TPN Progress note dated 10/15/19 at 3:25PM revealed in part, .-Changes today: clogged PEG tube - unable to start tube feed today, continue TPN at current rate . Record review of Resident #165's Nursing note dated 10/15/19 at 4:27PM revealed in part, .Tried to start feeding via PEG, but its clogged . Record review of Resident #165's Nursing note dated 10/15/19 at 7:32PM revealed in part, Spoke to Doctor regarding PEG tube clogged, MD will put the order to reinsert the PEG. Record review of Resident #165's imaging for IR G-tube Exchange/Replace dated 10/16/19 at 6:31PM revealed an impression of, Uncomplicated gastrostomy tube exchange. The new Gastrostomy tube is ready for use. Record review of Resident #165's nursing note dated 10/16/19 at 6:18PM revealed in part, .Currently patient OFF unit. At 6:30PM received report from RN that patient has new PEG tube because de-clogging was not successful . Record review of Resident #165's nursing note dated 10/16/19 at 6:18PM revealed in part, .Procedure completed . Patient to be transferred back to SNF . Record review of Resident #165's Plan of Care note dated 10/17/19 at 1:58AM revealed in part, .patient tolerating PGT feedings . Observation and interview on 10/17/19 at 12:39PM, Resident #165 said he was doing okay and said he'd been at the facility for a few weeks, the resident was pleasantly confused. Resident #165 was attached to g-tube feeding machine that was on and set to feed 50ml every hour and to flush 75ml every 4hrs. the machine read that 541Ml had been fed and 806ml had been flushed. The formula bag that was being administered was dated 10/16/19 and had 50ml/hr written on the bag. Observation on 10/18/19 at 10:19AM, Resident #165 was sleeping, his g-tube was attached and running to the settings of feed 50ml every hour and to flush 75ml every 4hrs. The formula bag being administered was dated 10/17/19 at 9:00PM. Record review of Resident #165's Plan of Care note dated 10/18/19 at 2:19AM revealed in part, .patient tolerating tube feedings . Interview on 10/18/19 at 3:00PM, the MDS Coordinator reviewed the care plan on her computer and could not find where in the care plan it addressed Resident #165's feeding tube. She searched Resident #165's clinical record and said the resident did not come to the unit with g-tube and said it was placed after he admitted . She said he had the g-tube placed on 10/16/19 and started feedings yesterday (10/17/19). Interview on 10/18/19 at 5:30PM, Nurse Manager said she expects the care plans to be updated immediately after a change or if a new problem presents. The Nurse Manager said the care plans should be every shift. Interview on 10/18/19 at 5:52PM, MDS Coordinator said the care plan should be updated immediately when a new care area develops. The MDS Coordinator said herself and nurses are able to update the care plans. Record review of the facility's Assessment and Reassessment and Planning of Care policy (Revised 1/31/19) revealed in part, .The plan of care should be based upon needs identified during the admission assessment. The plan of care should be revised every shift and as necessary to reflect the changing needs of the patient and the patient's condition. Initiate planning for each active problem/condition/ comorbidity/ or care need which may affect or be affected by the course of hospitalization .The frequency of reassessment will be based on the patients diagnosis, condition and needs but a complete reassessment should occur at least every eight hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to provide services as outlined by the comprehensive care plan to meet professional standards of quality for 1 of 9 residents (Resident #165) during medication administration, in that: 1. RN #1 failed to completely administer thru the gastrostomy tube, Cholecalciferol (Vitamin D3) 2,000 units as ordered by physician for Resident #165. This deficient practice affected 1 resident and placed him at risk of not receiving the intended therapeutic benefit of his medication. The findings were: Resident #165 Record review of Resident #165's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: malignant neoplasm of bladder, metabolic encephalopathy, malignant neoplasm of right ureter, acute kidney failure, acidosis, acute post hemorrhagic anemia, gross hematuria, chronic atrial fibrillation, malaise, weakness, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, chronic kidney disease, stage 3, and non-pressure chronic ulcer of other part of right foot with unspecified severity. Record review of Resident #165's Admission's MDS dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Further review of the MDS revealed he did not have a feeding tube and had a that therapeutic diet. Record review of Resident #165's Interventional radiology (IR) Feeding Tube results dated 10/14/19 revealed study results, Examination: IR Gastrostomy Catheter Initial Placement, Clinical History: Dysphagia Malnutrition needing PEG, Procedure: Gastrostomy tube placement, Complication: No immediate Complications, Impression: Percutaneous placement of 16 French push-type gastrostomy tube, Plan: Okay to use gastrostomy tube in 6 hours. Record review of Resident #165's care plan dated 9/21/19 revealed a problem area of nutrition that revealed he was on a heart healthy diet and has episodes of nausea. The nutrition care plan further stated he needs limited assistance to eat. His interventions included: 1. Assess patients' nutritional status and monitor for associated complications. 2. Monitor glucose, serum albumin levels and report abnormalities. 3. Medicate as prescribed for nausea and vomiting. 4. Refer to Dietary/Nutritional Consult for thorough nutritional assessment and planning. 5. Assess awareness and understanding of patients and/or caregiver regarding the importance of adequate nutritional intake and with their disease process. Further review of the care plan revealed no mention of care for Resident #165's feeding tube. Record review of Resident #165's Medication orders dated October 2019 indicated Resident #165's Order Cholecalciferol (vitamin D3) tablet 2,000 units oral daily start 10/18/19. During an observation of the medication pass on 10/18/19 at 11:45 a.m., RN #1 removed two Cholecalciferol 1,000 unit tablets from her Medication WOW(Workstation On Wheels). She scanned Resident #165's arm identification bracelet, the 2 Cholecalciferol packets, put the 2 white tablets into a silent night pill pouch, crushed the two white tablets with the silent night and poured the powdered white medication into a 30cc clear medication cup. RN #1 stopped Resident #165's feeding pump and disconnected the tubing, assessed the placement via aspiration with a 60cc irrigation syringe thru the [NAME] valve and then removed the syringe. RN #1 left the 60cc syringe attached to the tube, poured 20-25cc of water into the medication cup, stir the medication using the syringe tip(med was white powdered consistency that floated on top of water), connected the syringe to the [NAME] valve, poured the medication in the syringe which flowed thru via gravity and poured 20-30 cc of water thru the syringe via gravity. Surveyor noted there were 2-3 clumps of the white medication residue in the bottom of the syringe. RN #1 placed the residue syringe back in the syringe container and stated back in 1hour to turn pump on as she was walking out Resident #165 door. Surveyor intervened and asked to see the syringe in the container. Surveyor asked about the white clumps, RN #1 picked up the syringe agreed there were white clumps of mediation still in the syringe and that she did not see the medication that before disconnecting. RN #1 attached the syringe to the [NAME] valve and poured 20-30cc of water thru the syringe via gravity with twirling the syringe to facilitate the white medication going down the feeding tube, and disconnected the empty syringe from the tube placing it in the container. During an interview on 10/18/19 at 12:00 p.m., RN #1 confirmed there were white clumps of medication left in the medication syringe and that she didn't know how much of the Cholecalciferol the resident actually got, maybe half of it she said. RN #1 further stated Resident #165 was ordered cholecalciferol for his bones for debility and would finish clean the meds from the syringe to ensure the resident was given all of the ordered dosage. Interview on 10/18/19 with the facility Nurse Educator at 4:40 p.m. revealed the expectation for administering medications thru a feeding tube is to make sure no mediation is left in the syringe and to flush the syringe until the medication passes thru. She agree that resident #165 did not receive the complete dosage of Cholecalciferol the first time before surveyor intervention with RN #1. Interview on 10/18/19 with Nurse Manager at 5:20 p.m. revealed she agreed RN #1 did not administer the total dosage of cholecalciferol to Resident #165 as ordered by the physician and that was a medication error. Nurse Manager further stated RN #1 should have made sure the mediation had all passed thru the gastrostomy tube. Record review of facility's policy Skills; Feeding Tube: Medication Administration Quick Sheet revealed in part: Take steps to eliminate interruptions and distractions during medication preparation. 19. Prepare Medications for instillation into the feeding tube. b. Tablet: Crush the tablet using a pill-crushing device to grind it into a fine powder. Mix and dilute it in at least 30 ml of purified or sterile water. Fore more that one tablet, crush and dilute each individually. 27. Administer liquid or dissolved medication b pouring it into the syringe and flush. a. Following the administration of medications or formula, clear the tube by flushing with a minimum of 15ml of purified or sterile water. i. if water or medication does not flow freely, raise the height of the syringe to increase the rate of flow or have the patient change position slightly . ii. if these measures do not improve the flow, a gentle push with the bulb or plunger of the oral syringe may facilitate the flow. b. If administering more than one medication, give each separately and flush between medications with at least 15ml of purified or sterile water. c. Follow the last dose of medication with at least 15ml of purified or sterile water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infects for one 1 of 1 resident (Resident #63) reviewed for incontinence, in that; RN #21 handed the indwelling urinary catheter bag to PCA #9 above the bladder which resulted in back flow of urine. RN #21 did not perform hand hygiene during incontinent care for Resident #63 These failures affect 1 resident and placed him at risk of infection . Findings include: Resident #63 Record review of Resident #63's face sheet revealed admission date 10/16/19, 69yrs old with diagnosis to include: malignant neoplasm of head and neck, respiratory insufficiency, high blood pressure disorder, pain following surgery or procedure, coronary heart disease, type 2 diabetes, acquired stenosis of right external ear canal, brain cancer, abnormal brain function, acute kidney failure and debility. Record review of Resident #63's electronic record revealed he did not have a completed MDS or Care Plan for his Foley catheter. Resident #63 admitted [DATE]. Observation on 10/18/19 at 2:45 P.M. of Resident #63's incontinent and buttock wound care provided by RN #21 and PCA # 9 assisting revealed RN #21 had already set up her supplies on a white chux, on the resident's overbed table. RN #21 with assistance from PCA #9 turned Resident #63 to his left side facing the window, removed his indwelling foley catheter bag from the right side and passed it to PCA #9 who was positioned on the left of the bed. During this time surveyor noted yellow urine in the catheter tubing and 50cc in the outer collection measuring meter. Surveyor asked RN #21 if there was urine in the tubing that back flowed and RN #21 and PCA #9 responded simultaneously Yes. RN #21 unfastened the resident's brief and bowel movement approximately half dollar coin diameter with 1 inch depth was noted at the rectum. RN #21 opened a new package of wipes and removed 1wipe, cleaned the anus area one swipe and bowel movement got on her gloved index finger. RN #21 went back into wipe package with the bowel movement on her glove and removed another wipe and wiped his anus area again. RN #21 went back into the wipe package 5 times with the bowel movement on her glove and the last time used the same wipe for the left and right side of his buttocks wiping up and around the wound dressing to his right buttock, with same bowel movement soiled gloves on. RN #21 then washed her hands and double gloved them. RN #21 opened her wound care supplies that was on the table, removed his old dressing and removed her top/first layer of gloves (provided no hand hygiene), cleaned the stage 2 (dime size)wound to the right buttock and proceeded with the wound care treatment, never changing her gloves. RN #21 folded the old brief, that had scant bowel movement on it, inward toward Resident #63 and applied the new brief. RN #21 and PCA #9 then rolled him to the right side where PCA #9 further removed old brief and applied new brief then, removed his indwelling foley catheter bag from the left side and passed it to RN #21 who was positioned on the right of the bed during this time surveyor noted yellow urine in the catheter tubing again that back flowed. RN #21 and PCA #9 repositioned him, adjusted Resident #63's clothing and his bed linens, while wearing the same soiled gloves used to remove the old brief, then they washed their hands. Upon cleaning Resident #63's over bed table RN #21 picked up the unused wipes package, unused gauze, zinc tube and placed them in her left hand and used her right hand to remove the white chux and pushed it down X 2 in the same trash bag used to throw away the bowel movement wipes, old wound care dressing and old brief. RN #21 then without washing her hands used both her hands to place Resident #63's unused supplies, she had in her left hand, on his handwashing sink counter. RN #21 washed her hands and left the room. During an interview on 10/18/19 at 3:00 P.M., RN #21 stated she had been working for the facility for approximately one year and had not had an in-service on infection control but has had one on hand washing. She stated that she was taught to wash her hands before and after patient procedures and after changing gloves. RN #21 agreed that she should have done some type of hand hygiene after changing gloves. She further stated she double gloved to save time in changing gloves and that she should have changed her gloves when going into the wipe pack to prevent contamination of the other unused wipes in the packet. RN #21 stated she did not realize that she used the same gloves to remove the soiled brief and apply the new brief. RN #21 also said that if urine is in the tubing of the Foley catheter and goes back in the bladder it can cause infection, and that the tubing should be drained of urine then pass it over him. During an interview on 10/18/19 at 5:00 PM, the Nurse Educator stated she expected staff to do hand hygiene before donning and removing gloves, can use soap and water or alcohol based products. Nurse Educator said if gloves are soiled with poop, they change the gloves, if no bowel movement was on the gloves , they can continue with the same gloves and there was no need to change gloves with each new wipe until you get to a different Zone (body area). Nurse Educator further stated the expectation is to change gloves with a new brief because that is a clean item and should be clean. She continued to say before moving the foley catheter, urine in the tubing should be drained first to prevent re-entry of urine up-stream to the bladder. During an interview on 10/18/19 at 5:20 PM, with Director ED present , the DON stated she expected gloves to be changed with each wipe usage especially if soiled, staff should use clean to dirty technique. She stated that she probably would have done it differently, remove dirty then to clean and would have drained the urine out of the catheter tubing then move the bag. During an interview on 10/18/19 at 5:25 PM, the Director ED stated nurses can double glove, and taking off both gloves would be a glove change. Director ED said she expected staff to remove their gloves and either wash or sanitize their hands after touching a dirty area prior to moving to a clean area when performing incontinent care. Page #197, PROCEDURAL GUIDELINE #35 - INDWELLING URINARY CATHETER CARE, revealed the following elements: A. Purpose 2. To help avoid urinary tract infections. B. Guidelines for Maintaining the Urinary Drainage System 5. Check that urine is draining freely through the system. 7. Keep the urine-collecting bag below the level of the bladder at all times to prevent backflow of old urine into the bladder. Maintain position of urine-collecting bag according to manufacture guidelines. Record review of facility policy and procedure titled _PCPS134 Hand Hygiene and Artificial Nails revised date 1/19/18 revealed in part:, Appropriate hand hygiene practice is the single most important factor in preventing the transmission of pathogens, some of which could be multi-drug resistant organisms, in healthcare settings. Strict adherence to hand hygiene practices has a direct correlation with reduction in incidence of healthcare acquired infections (HAIs), and therefore, directly contributes to patient safety. Proper use of gloves during patient care can also prevent transmission of infectious agents in high-risk situations. 4.1 Hand Hygiene is indicated 4.1.3 Patient Zone. 4.1.3.3 After body fluids exposure risk- After contact with body fluids or excretions mucous membranes, non-intact skin, and wound dressings; even if gloves were worn. 4.1.4 Before donning gloves and after glove removal, even if there was no patient contact. 4.1.5 Before moving from a contaminated-body site to a clean-body site during patient care, even if gloves were worn. 4.7 Glove Use 4.7.1 In no way does glove use modify hand hygiene indications or replace hand hygiene practices by using alcohol-based products or by hand washing with soap and water. 4.7.3 Change gloves during patient care if moving from a contaminated body site to another body site. Hand hygiene must be performed when changing gloves. 4.7.7 Double gloving for routine patient care(even when caring for patients on contact isolation) is not recommended. However, id double gloving is practiced, the healthcare provider must remove both sets of gloves and perform hand hygiene when changing gloves between tasks or upon completion of patient care. Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities (Fifth Edition 2016): Page #145, Section II - Infection Control, Procedural Guideline Section #6 Hand Washing, revealed the following elements: B. Guidelines and Precautions 2. Hand-washing should be done at the following times: e. After contact with blood, body fluids and contaminated items (Procedural Guideline #7). f. Whenever hands are obviously soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective infection control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for one of one resident (Resident #63) reviewed for infection control as evidenced by: RN #21 did not perform hand hygiene during incontinent care for Resident #63 This deficient practice affected one resident and placed him at risk of infections from cross contamination. Findings include: Resident #63 Record review of Resident #63's face sheet revealed admission date 10/16/19, 69yrs old with diagnosis to include: malignant neoplasm of head and neck, respiratory insufficiency, high blood pressure disorder, pain following surgery or procedure, coronary heart disease, type 2 diabetes, acquired stenosis of right external ear canal, brain cancer, abnormal brain function, acute kidney failure and debility. Record review of Resident #63's electronic record revealed he did not have a completed MDS or Care Plan for his Foley catheter. Resident #63 admitted [DATE]. Observation on 10/18/19 at 2:45 P.M. of Resident #63's incontinent and buttock wound care provided by RN #21 and PCA # 9 assisting revealed RN #21 had already set up her supplies on a white chux, on the resident's overbed table. RN #21 with assistance from PCA #9 turned Resident #63 to his left side facing the window, removed his indwelling foley catheter bag from the right side and passed it to PCA #9 who was positioned on the left of the bed. During this time surveyor noted yellow urine in the catheter tubing and 50cc in the outer collection measuring meter. Surveyor asked RN #21 if there was urine in the tubing that back flowed and RN #21 and PCA #9 responded simultaneously Yes. RN #21 unfastened the resident's brief and bowel movement approximately half dollar coin diameter with 1 inch depth was noted at the rectum. RN #21 opened a new package of wipes and removed 1wipe, cleaned the anus area one swipe and bowel movement got on her gloved index finger. RN #21 went back into wipe package with the bowel movement on her glove and removed another wipe and wiped his anus area again. RN #21 went back into the wipe package 5 times with the bowel movement on her glove and the last time used the same wipe for the left and right side of his buttocks wiping up and around the wound dressing to his right buttock, with same bowel movement soiled gloves on. RN #21 then washed her hands and double gloved them. RN #21 opened her wound care supplies that was on the table, removed his old dressing and removed her top/first layer of gloves (provided no hand hygiene), cleaned the stage 2 (dime size)wound to the right buttock and proceeded with the wound care treatment, never changing her gloves. RN #21 folded the old brief, that had scant bowel movement on it, inward toward Resident #63 and applied the new brief. RN #21 and PCA #9 then rolled him to the right side where PCA #9 further removed old brief and applied new brief then, removed his indwelling foley catheter bag from the left side and passed it to RN #21 who was positioned on the right of the bed during this time surveyor noted yellow urine in the catheter tubing again that back flowed. RN #21 and PCA #9 repositioned him, adjusted Resident #63's clothing and his bed linens, while wearing the same soiled gloves used to remove the old brief, then they washed their hands. Upon cleaning Resident #63's over bed table RN #21 picked up the unused wipes package, unused gauze, zinc tube and placed them in her left hand and used her right hand to remove the white chux and pushed it down X 2 in the same trash bag used to throw away the bowel movement wipes, old wound care dressing and old brief. RN #21 then without washing her hands used both her hands to place Resident #63's unused supplies, she had in her left hand, on his handwashing sink counter. RN #21 washed her hands and left the room. During an interview on 10/18/19 at 3:00 P.M., RN #21 stated she had been working for the facility for approximately one year and had not had an in-service on infection control but has had one on hand washing. She stated that she was taught to wash her hands before and after patient procedures and after changing gloves. RN #21 agreed that she should have done some type of hand hygiene after changing gloves. She further stated she double gloved to save time in changing gloves and that she should have changed her gloves when going into the wipe pack to prevent contamination of the other unused wipes in the packet. RN #21 stated she did not realize that she used the same gloves to remove the soiled brief and apply the new brief. RN #21 also said that if urine is in the tubing of the Foley catheter and goes back in the bladder it can cause infection, and that the tubing should be drained of urine then pass it over him. During an interview on 10/18/19 at 5:00 PM, the Nurse Educator stated she expected staff to do hand hygiene before donning and removing gloves, can use soap and water or alcohol based products. Nurse Educator said if gloves are soiled with poop, they change the gloves, if no bowel movement was on the gloves , they can continue with the same gloves and there was no need to change gloves with each new wipe until you get to a different Zone (body area). Nurse Educator further stated the expectation is to change gloves with a new brief because that is a clean item and should be clean. She continued to say before moving the foley catheter, urine in the tubing should be drained first to prevent re-entry of urine up-stream to the bladder. During an interview on 10/18/19 at 5:20 PM, with Director ED present , the DON stated she expected gloves to be changed with each wipe usage especially if soiled, staff should use clean to dirty technique. She stated that she probably would have done it differently, remove dirty then to clean and would have drained the urine out of the catheter tubing then move the bag. During an interview on 10/18/19 at 5:25 PM, the Director ED stated nurses can double glove, and taking off both gloves would be a glove change. Director ED said she expected staff to remove their gloves and either wash or sanitize their hands after touching a dirty area prior to moving to a clean area when performing incontinent care. Record review of facility policy and procedure titled _PCPS134 Hand Hygiene and Artificial Nails revised date 1/19/18 revealed in part:, Appropriate hand hygiene practice is the single most important factor in preventing the transmission of pathogens, some of which could be multi-drug resistant organisms, in healthcare settings. Strict adherence to hand hygiene practices has a direct correlation with reduction in incidence of healthcare acquired infections (HAIs), and therefore, directly contributes to patient safety. Proper use of gloves during patient care can also prevent transmission of infectious agents in high-risk situations. 4.1 Hand Hygiene is indicated 4.1.3 Patient Zone. 4.1.3.3 After body fluids exposure risk- After contact with body fluids or excretions mucous membranes, non-intact skin, and wound dressings; even if gloves were worn. 4.1.4 Before donning gloves and after glove removal, even if there was no patient contact. 4.1.5 Before moving from a contaminated-body site to a clean-body site during patient care, even if gloves were worn. 4.7 Glove Use 4.7.1 In no way does glove use modify hand hygiene indications or replace hand hygiene practices by using alcohol-based products or by hand washing with soap and water. 4.7.3 Change gloves during patient care if moving from a contaminated body site to another body site. Hand hygiene must be performed when changing gloves. 4.7.7 Double gloving for routine patient care(even when caring for patients on contact isolation) is not recommended. However, id double gloving is practiced, the healthcare provider must remove both sets of gloves and perform hand hygiene when changing gloves between tasks or upon completion of patient care. Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities (Fifth Edition 2016): Page #145, Section II - Infection Control, Procedural Guideline Section #6 Hand Washing, revealed the following elements: B. Guidelines and Precautions 2. Hand-washing should be done at the following times: e. After contact with blood, body fluids and contaminated items (Procedural Guideline #7). f. Whenever hands are obviously soiled. Page #197, PROCEDURAL GUIDELINE #35 - INDWELLING URINARY CATHETER CARE, revealed the following elements: A. Purpose 2. To help avoid urinary tract infections. B. Guidelines for Maintaining the Urinary Drainage System 5. Check that urine is draining freely through the system. 7. Keep the urine-collecting bag below the level of the bladder at all times to prevent backflow of old urine into the bladder. Maintain position of urine-collecting bag according to manufacture guidelines.