**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection for 2 (Resident #57, Resident #217) of 2 residents reviewed for infection control. 1.CNA A failed to perform hand hygiene (hand washing) after removing soiled gloves and before putting on clean gloves on 08/14/24 08:26 AM, during incontinence care for Resident #57. 2. The facility failed to ensure Resident #217's foley catheter bag was not touching the floor. This failure could place residents in the facility at risk for the development and transmission of infections. Findings included: Review of Resident #57's face sheet reflected Resident #57, a [AGE] year-old female, admitted to the facility 01/29/24 with congestive heart failure (progressive deterioration of the heart muscle), atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), protein-calorie malnutrition, non-rheumatic aortic valve stenosis (narrowing of blood vessels), anxiety (feelings of fear), hypokalemia (low potassium), muscle weakness, and pain in unspecified joint. Review of Resident #57's care plan, dated 06/10/24, reflected Resident #57 is incontinent of bladder and to provide perineal care (genital area) after each incontinence episode. Review of Resident #57's MDS dated [DATE] reflected Resident #57 had a BIMS score of 10, was severely impaired vision, incontinent, and dependent on staff for toileting and personal hygiene. Observation on 08/14/24 at 08:26 AM revealed CNA A washed her hands in the resident's restroom and applied clean gloves. She opened the brief and used a clean wipe for each swipe, down each side of the labia, then the center. Resident #57 rolled to the side and used a clean wipe to clean her bottom. CNA A removed the brief, dropped it in a trash can near her, and removed the soiled gloves. Hand hygiene was not performed before putting on clean gloves. A clean brief was placed under the Resident #57 and secured on each side. CNA A removed her gloves, pulled down Resident #57's top and pulled the resident's blanket up to cover her. CNA A washed her hands in the resident's restroom before leaving the room. During an interview with CNA A 08/14/24 at 08:35 AM, she stated she normally uses hand sanitizer between glove changes, but she forgot it this time. In an interview with the ADON 08/15/24 at 09:57 AM, she stated CNA A should have used hand hygiene to prevent infection. During an interview with LVN 08/14/24 2:05 PM, she stated CNA A should have washed her hands or used hand sanitizer before putting on clean gloves. During an interview with the Infection Prevention Nurse 08/14/24 09:02 at AM, she stated CNA A should always practice hand hygiene when removing soiled gloves. The facility's Handwashing/Hand Hygiene policy, revised August 2019, reflected Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial). The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Perform hand hygiene before applying non-sterile gloves. When removing non-sterile gloves . perform hand hygiene. Review of Resident #217's face sheet reflected Resident #217, an [AGE] year-old male, admitted to the facility 08/09/24 with atherosclerotic heart disease (fat buildup in blood vessels of the heart), hypertension (high blood pressure), chronic kidney disease (progressive failure of kidney function), and benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate gland), pacemaker (implanted device to regulate heart rhythm), urinary tract infection (infection of urinary system). Review of Resident #217's care plan, dated 08/13/24, reflected Resident #217 had a foley catheter and to monitor input/output, for signs of discomfort, and symptoms of urinary tract infection. Review of Resident #217's MDS, dated [DATE], reflected Resident #217 had a BIMS score of 7, an indwelling foley catheter, was incontinent of bowel, and dependent on staff for toileting and personal hygiene. Observation on 08/13/24 at 01:08 PM revealed Resident #217 sitting in a recliner in his room. He had just finished lunch and his bedside table was in front of him. Resident #217's foley catheter bag was hanging from the rim of a small trash and the bottom of the foley bag was touching the floor. It was in a privacy bag. The trash can was on the resident's right side, between the recliner and bedside table. During an interview with LVN 08/14/24 at 08:52 AM, she stated Resident #217's foley bag touching the floor was an infection control issue. In an interview with Infection Prevention Nurse 08/14/24 at 02:06 PM, she stated the foley bag should not hang from the trash can or touch the floor. During an interview with ADON 08/15/24 10:02 AM, she stated the foley bag should not touch the ground or hang from the trash can, because the foley was attached to Resident #217 and this can cause infection. Review of the facility policy revised August 2019, and titled Care, Urinary Catheter, stated Be sure the tubing and drainage bag are kept off the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 3 (Resident #27, #60, and #64) of 4 residents reviewed for accident prevention. The facility failed to obtain physician orders or a physician assessment as of 08/13/2024 for Residents #27, #60, and #64 for the usage of a Bolster mattress prior to installing the mattress to assist in fall prevention. This failure could prevent residents from having an environment that was free and clear of accidents and hazards. Findings included: Record review of Resident #27's Face Sheet, dated 08/15/2024, reflected she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified dementia (memory decline), lack of coordination, and repeated falls. Record review of Resident #27's Quarterly Minimum Data Set (MDS) dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 06 (severe cognitive impairment) and for ADL care it reflected assistance for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #27's physician orders dated 08/14/24 reflected no orders for a bolster mattress and no physician assessment was observed in the facility system records. An observation on 08/14/24 at 11:03 AM of Resident #27's bed revealed she was sleeping on a bolster mattress, which had the upper and lower sides of the mattress had raised sides of at least 6 inches. Record review of Resident #60's Face Sheet, dated 08/14/2024, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified Alzheimer Disease (memory loss), muscle weakness, and repeated falls. Record review of Resident #60's Quarterly Minimum Data Set (MDS) dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 04 (severe cognitive impairment) and for ADL care it reflected assistance for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #60's physician orders dated 08/13/24 reflected no orders for a bolster mattress and no physician assessment was observed in the facility system records. An observation on 08/13/24 at 10:44 AM of Resident #60's bed revealed she was sleeping on a bolster mattress which had the upper and lower sides of the mattress had raised sides of at least 6 inches. Record review of Resident #64's Face Sheet, dated 08/14/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified dementia, muscle weakness, and abnormalities of gait and mobility. Record review of Resident #64's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 03 (severe cognitive impairment) and for ADL care it reflected assistance for transfers, toileting, and bathing and the resident required moderate assistance. An observation on 08/13/24 at 10:15 AM of Resident #64's bed revealed she was sleeping on a bolster mattress which had the upper and lower sides of the mattress had raised sides of at least 6 inches. Record review of Resident #64's physician orders dated 08/14/24 revealed no orders for a bolster mattress no physician assessment was observed in the facility system records. In an interview on 08/14/24 at 1:45 PM, the DON and the Administrator were made aware that Residents #60 and #64 were observed to have bolster mattresses on their beds; however, no physician orders or physician assessments were found in the system of records for these residents. The DON stated the bolster mattresses were needed for the resident because of their history for falls. She stated that an assessment was completed, and the mattress did not pose a risk for any of the residents. The DON advised that she submitted a request to the physician for the residents to have the mattresses on 08/14/24. She stated the reason physician orders were needed was to ensure that the mattresses were safe for the residents. The Administrator stated that there was an assessment completed and signed by the physician in the resident's care plan discussion regarding their history of falls. Record review of facility policy on Verbal orders, dated 02/2014, stated Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order.