**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for 1 of 1 (CNA A) employees reviewed for abuse and neglect.The facility did not follow their policy on abuse when they screened CNA A for hire. CNA A had worked in the facility from 2/25/2025 through 6/27/2025. This failure could place residents at risk for possible abuse, neglect or exploitation. Findings included: Record review of an undated personnel file for CNA A indicated a hire date of 2/24/2025.Further review revealed a national background check had been conducted on 2/24/2025. It revealed CNA A had an offense date of 11/29/2023 and disposition date of 1/8/2025 charged with assault causing bodily injury statute: 22.01 (A) (1) - misdemeanor sentenced to 12-month probation; a $200 fine and $297.00 court costs. Record review of CNA A's time sheets revealed she worked 14 out of 30 days in June 2025. An interview on 7/1/2025 at 2:27pm CNA A she said had been employed at the facility since February 2025. She worked the 6a-6pm shift in the memory care unit. She said she had a deferred adjudication assault case that happened in 2023. But she received probation in January 2025. She said she preferred not to discuss the details of her case. She said she received a call on Friday (7/27/25) and HR terminated her. She said it was an unknown person from their corporate office and HRC called her around 3:54pm due to her having a background that prevented them from keeping her employed at the facility. She said the previous HRC was supposed to get a letter from her probation supervisor about her case and this was why she was allowed to be hired. An interview with HRC on 7/1/2025 at 2:58pm, revealed he was employed on 6/17/2025. He said he was responsible for new hire requests for background through a third-party company. He stated he realized that CNA A's background was not clear after Investigator requested her personnel record on last Friday (6/27/2025). He stated he called his corporate office, notified the Administrator and corporate member (last name unknown) told him that they would be terminating CNA A due to her having an assault in her background. He stated they called CNA A on Friday evening and informed her of the termination. He said since he had only been employed less than two weeks, he had not done an audit of the personnel records. He stated his audit of personnel records began on Friday (6/27/2025). He said he did not find any other employees that were unemployable. An interview with the Interim Administrator on 7/1/2025 at 3:15pm revealed he was told by the HRC that CNA A had an assault in her background, and he did not think that the previous HRC was supposed to hire her. He said the HRC immediately called corporate, and they terminated her. He said someone with an assault background could have abused the residents.Record review of Form 672 revealed census of 19 residents on the Memory Care unit where CNA A worked.Record review of the State of Texas, Health and Safety Code, Chapter 250, Section 250.006 Convictions Barring Employment revealed (Revision 24-1, Effective [DATE]): A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility or may not be employed by an individual employer before the fifth anniversary of the date the person is convicted of: an offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony.Record review of the facility's abuse policy revealed: It was the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriations of resident property.The components of the facility abuse prohibition plan are discussed herein: 1. Screening -(A) Potential employees will be screened for a history of abuse, neglect exploitation and misappropriation of property.(B) Background, reference and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #81) whose comprehensive person-centered care plans were reviewed. The facility failed to ensure that Resident #81's diagnosis of depression was a focus area in the resident's comprehensive care plan. This deficient practice could affect residents by failing to ensure residents received appropriate care for their health conditions. The findings included: Record review of Resident #81's face sheet dated 08/21/2024 revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels) and hyperlipidemia (a condition characterized by high levels of fats in the blood). Record review of Resident #81's admission MDS dated [DATE] revealed a BIMS of 04, indicating severely impaired cognition. Further review of this MDS revealed Depression (other than bipolar) was checked in Section I - Active Diagnoses. Record review of Resident #81's comprehensive care plan, updated 02/11/2025, revealed the diagnosis of depression as was not listed as a focus area. During an interview on 03/27/2025 at 2:47 PM, MDS RN B stated a focus area of Depression was missing from Resident #81's comprehensive care plan, and this diagnosis should have been noted as a focus area. The resident recently discontinued use of all psychotropic medications, and when the focus area listing the medications was removed from the care plan, the diagnosis of depression was inadvertently removed as well. RN B usually did not list the diagnosis and medications together in one focus area and she did not know why she had done so this time. RN B was responsible for updating care plans, and they were updated quarterly or when there was a significant change requiring an update. It was important the diagnosis of depression was a focus area to ensure the resident was monitored for signs and symptoms of the depression and received appropriate treatment and care. The MDS RN received yearly training on the latest updates to MDS and care plans. During an interview on 03/27/2025 at 3:30 PM the Regional Nurse Consultant stated Resident #81's diagnosis of depression needed to be a focus area in the resident's care plan even if the resident was not taking medication to ensure all her needs are addressed. Record review of the facility's policy Comprehensive Care Plans implemented 10/24/2022 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, as well as to help prevent the development of communicable diseases and infections, for 1 of 3 residents (Resident #47) reviewed for infection control. The facility did not ensure that LVN (A) followed proper infection control practices, including hand hygiene /glove changes, while checking Resident #47's blood sugar. This failure could place residents at risk of contracting disease and infection. The findings included: Record review of Resident # 47's Face sheet, dated 3/27/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Type 2 diabetes (a disorder when the body cannot use insulin correctly and sugar builds up in the blood), Hyperlipidemia (excess of lipids or fats in your blood) and Hypertension (a common condition that affects the body's arteries). Record review of Resident # 47's quarterly MDS, dated [DATE], revealed a BIMS score of 6, which indicated the resident had severely impaired cognition for daily decision making. Record review of Resident # 47's care plan, dated 10/17/24, revealed that Resident #47 has a need for enhanced barrier precautions with interventions to wear gloves. Record review of Resident #47's order summary, dated 3/27/25, revealed an order for enhanced barrier precautions: PPE required for high resident contact care activities. During an observation on 3/27/25 at 8:35 AM, LVN (A )administered all morning scheduled GT medications to Resident #47 while wearing gloves and then proceeded to check the resident's blood sugar and did not change gloves. During an Interview with LVN (A) on 3/27/25 at 8:50 AM, she stated she should have changed gloves after completing GT medications for Resident # 47 and then proceeded to check his blood sugar without changing gloves. LVN (A)stated she cross-contaminated while providing care to resident #47, therefore increasing his risk for infection and added that this error in deficent practice occurred as she was nervous because she is not used to being observed by a state surveyor. During an interview on 3/27/25 at 11:23 a.m., the ADON stated that LVN (A) should have sanitized or washed her hands between glove changes to disinfect her hands and to get rid of organisms. The ADON stated she had trained all staff a few months ago on infection control practices; however, LVN (A) was recently hired and had not been checked off on infection control practices. The ADON further stated that not practicing proper hand hygiene was a potential for spreading germs and a risk of infection to resident # 47. During an interview on 3/27/2025 at 3:18 PM, the Administrator expressed agreement with the Assistant Director of Nursing's expectations for infection control and prevention. She noted that the building is currently undergoing a transition in leadership, which will help ensure that these issues do not occur again. Record review of the facility's policy titled Infection Prevention and Control Program revealed that hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to store a mop in the proper position in the utility closet. 2. The facility failed to store bowls and cups properly. 3. The facility failed to ensure the food preparation area was free of personal food and beverage items. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 03/25/2025 at 10:58 AM revealed a soiled mop was stored head-side down in the drain compartment of a mop bucket in the utility closet. There was dirty water in the bottom of the bucket. The mop was not in use at the time of the observation. During an interview on 03/25/2025 at 11:19 AM, the regional dietary manager stated the mop should have been stored in an upright position on one of the hooks inside the utility closet to ensure it dried properly and did not harbor bacteria. 2. Observation on 03/25/2025 at 11:31 AM in the dish room revealed there were 14 trays of plastic bowls, each with 11-12 bowls, stored face-down on wet trays. There were also two trays of translucent plastic cups, one with 42 cups and one with 15 cups, stacked on top of each other and face-down on wet trays. During an interview on 03/25/2025 at 11:32 AM, the regional dietary manager stated the trays were missing air-drying nets separating the bowls and cups from the trays. It was important to ensure clean dishes were air-dried to prevent the potential accumulation of germs and bacteria which could lead to foodborne illness. 3. Observation on 03/27/2025 at 10:23 AM in the kitchen revealed a quart-sized plastic container next to the toaster with contents resembling a chopped salad. There was no label or date indicating the contents of the container or a use-by date. Further observation revealed a large Styrofoam cup filled with ice and a brown liquid on a shelf below the container. There was no lid on the cup. During an interview on 03/27/2025 at 11:26 AM, [NAME] C stated the container belonged to her and was salsa for her lunch. The cup with the brown beverage without the lid was also hers. She knew personal food items should not be stored in the food preparation area of the kitchen and had no explanation as to why the items were there. During an interview on 03/27/2025 at 11:27 AM, the DM stated the personal food item belonging to [NAME] C should not have been in the food preparation area of the kitchen and the cup should have been covered. All dietary staff had been trained on the proper place to store personal food and to cover beverages. He conducted training for staff upon hire and monthly. Record review of the facility's policy Janitor's Closet approved 10/01/2018 revealed, Policy: The facility will maintain the janitor's closet in a sanitary manner to minimize the risk of food hazards. The janitor's closet will be cleaned once per week or more often as needed. 8. Mops and brooms must be stored head up. Record review of the facility's policy Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment approved 10/01/2018 revealed, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 9. Air dry all equipment and utensils after sanitizing. Handle cleaned and sanitized equipment and utensils and all single-service articles in a way that protects them from contamination. Record review of the facility's policy Employee Sanitation approved 10/01/2018 revealed, Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. e. Employees will not eat or drink in food storage and preparation areas, or in areas containing exposed food or unwrapped utensils, or where utensils are cleaned or stored. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 6-501.16 Drying Mops. After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. 2-401.11 Eating, Drinking, or Using TOBACCO PRODUCTS. (A) Except as specified in (B) of this section, an EMPLOYEE shall eat, drink, or use any form of TOBACCO PRODUCTS only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection can not result. (B) A FOOD EMPLOYEE may drink from a closed BEVERAGE container if the container is handled to prevent contamination of: (1) The EMPLOYEE'S hands; (2) The container; and (3) Exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to immediately consult with the residents' Physician; and notify her authority, the resident' representative when there was need to alter treatment for 1 of 1 resident (Resident # 1)reviewed for notification . The facility failed to notify Resident #1's physician and Relative # 1 when Resident # 1 experienced a change of condition including low blood sugar on 6/23/2024. This failure placed residents experiencing a delay in medical treatment and worsening of condition symptoms. Findings include: Record review of Resident # 1's face sheet, dated 12/7/2021, revealed she was [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with End Stage Renal Disease (a medical condition in which kidneys cease functioning on a permanent basis), Essential (Primary) Hypertension (high blood pressure), Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar levels), Dependence on Renal Dialysis ( someone's kidneys are no longer working properly and they need regular dialysis to survive), Hyperglyceridemia ( too much cholesterol), Shortness of Breath (difficult breathing), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident # 1's MDS, dated [DATE], revealed she a BIMS score of 5 ( severe cognitive Impairment); Resident # 1 had difficulty focusing attention and altered level of consciousness. Resident # 1 required limited assistance from at least one staff for transfers and bed mobility. Insulin injections were received during the last 7 days. Record review of Resident # 1's care plan, revised 11/30/2023 revealed the following care areas: o Resident # 1 has Diabetes Mellitus and was at risk for unstable blood glucose levels. Goals include resident will be free from any s/sx of hyperglycemia. Resident # 1 will have no complications related to diabetes. Resident # 1 will be from any s/sx hypoglycemia. Intervention include administer medication as ordered per MD, monitor/document /report PRN any s/sx of hypoglycemia (low blood sugar), Sweating, Tremor, Increased heart rate (Tachycardia) Pallor ( loss of skin color) , Nervousness, Confusion, slurred speech, lack of coordination, staggering gait( unsteady walking pattern). o Resident # 1 was on hemodialysis related to end stage renal disease on Monday, Wednesday and Friday at 11:30 am. Days may vary based on holidays and dialysis center schedule. Goals include intervention should any s/sx of complication from dialysis occurs. Interventions incudes monitor vital signs and notify MD of significant. Record review of Resident #1's progress note dated 6/23/2023 at 12:10 pm, LVN A wrote Resident with BGS of 47, this nurse provided snack and drink to resident and stayed at bedside. Rechecked BGS approximately 10 minutes later and sugar was 157. No hypoglycemic symptoms displayed during this episode. Record review of Resident # 1's Blood Sugar Summary for June 2024 revealed: o 6/23/2024 at 7:53 am blood sugar was 167 mg/dl o 6/23/2024 at 11:47 am blood sugar was 47 mg/dl o 6/23/2024 at 6:28 pm blood sugar was 226 mg/dl o 6/23/2024 at 10:01 pm blood sugar was 122 mg/dl Record review of Resident # 1's reviewed on 5/28/2024 revealed: o Novolog injection solution 100 unit/ml-insulin aspart (an insulin analog indicated to improve glycemic control in patients with diabetes mellitus). Directions: inject 10 unit subcutaneous; start date 6/3/2024. End date: open ended o Give a peanut butter and jelly sandwich. Directions: at bedtime for Diabetes Mellitus; start date 5/1/2024. End date: open ended o Ozempic (0.25 or 0.5 mg/dose) Subcutaneous solution pen injector 2mg/3/ml (Semaglutide). Direction: Inject 0.5 mg subcutaneous; start date 4/29/2024. End date: open ended o Novolog Injection Solution 100 unit/ml (insulin aspart). Directions: Inject as per sliding scale; start date 3/27/2024. End date: open ended o ACCUCHECKS before meals and at bedtime. Directions: before meals and at bedtime; start date 6/22/2023. End date: open ended o Glucan emergency injection kit 1 mg (Glucagon rDNA). Directions: Inject 1 dose intramuscular; start date 6/21/2023. End date: open ended In an interview with Relative # 1 on 6/27/2024 at 10:30 am she stated that Resident # 1 was a diabetic. She stated that on 6/23/2024 Resident # 1's sugar was 47. She stated that no one from the facility contact her about Resident # 1's change of condition. She stated that on 6/24/2024 LVN A told informed her that Resident # 1's sugar was low on 6/23/2024. She stated that LVN A stated that Resident # 1's sugar was 47 and she gave Resident# 1 cookie and juice. She stated that LVN A rechecked Resident # 1's sugar and Resident # 1's sugar was 150. She stated that LVN A did not contact Resident # 1's doctor or Relative # 1 because Resident # 1 did not have any signs of distress and Resident # 1 was talking to her and stated she was okay. She stated LVN A stated that she stayed by Resident # 1's side and she made certain Resident # 1 was not in distress and not having signs of Hypoglycemia. Relative # 1 stated that she spoke with the Administrator about Resident # 1's sugar levels. She stated that the Administrator stated that she did not know that Resident # 1's sugar dropped as LVN did not notify her, Resident # 1's doctor or the DON. Observation of Resident # 1 on 6/27/2024 at 2:20 pm. Resident # 1 was in a wheelchair and Relative # 1 was taking her out for fresh air. Resident # 1 was non-interview able as she had limited verbal skills. In an interview with LVNA on 6/27/2024 at 4:40 pm she stated she checked Resident #1's sugar on 6/23/2024 at 11:30 am and Resident # 1's sugar was 47. She stated that Resident # 1 had a can of sprite and cookies by her bed. She stated that she gave Resident # 1 sprite and cookies. She stated that Resident # 1 was talking to her and did not have any sign of distress. She stated that 10 minutes later she rechecked Resident # 1's sugar and it was 152. She stated she did not consider this a change of condition because Resident # 1 talking and was not altered. She stated Resident # 1's sugar was out of range. LVN A stated that she apologized to Resident # 1's family. LVN A stated that if a resident's sugar was at 47 the resident could go into a coma and lose consciousness. LVN stated that she did not contract Resident # 1's doctor or representative. LVN A stated that she did not contact the DON. LVN A stated that she in-serviced on change of conditions. In an interview on 6/27/2024 at 4:00 pm with the DON she stated she found out about Resident # 1's low blood sugar on 6/26/2024. She stated LVN A told her Resident # 1's blood sugar was 47 and Resident # 1 did not display hypoglycemia. The DON stated LVN A gave Resident # 1 snacks and rechecked Resident # 1's blood sugar and it was 157. She stated she told LVN A that since Resident # 1's blood sugar was below 60 she should have notified the NP and family. She stated that LVN A did not notify the NP and family because when LVN A rechecked Resident # 1's blood sugar it was within normal range. The DON stated that if a resident's blood sugar is low the resident may experience sweating, confusion, and tremors. She stated that LVN A has been in-serviced on change of condition. In an interview on 7/2/2024 at 8:20 pm with the ADON she stated that LVN A reported Resident # 1's low blood sugar after the fact. She stated that when she read the 24 hours report she noticed that Resident # 1's blood sugar was low. She stated LVN A checked Resident # 1's blood sugar and it was low. She stated LVN A gave Resident # 1 snack and later rechecked Resident # 1's blood sugar and it was within normal range. The ADON stated that she could not remember the sugar levels for Resident # 1. The ADON stated she expected the nurses to contact the residents Doctor/NP, family and DON. She stated that LVN A should have contacted the resident's doctor and received orders from the doctor. She stated that staff was in-serviced on change of condition on 6/27/2024. Record review of Notification of Changes policy, dated 10/24/2024, revealed: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician: and notifies consistent with his or her authority, the representative when there is a change requiring notification. Circumstances requiring notification include: 2) Significant change in resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a) Life-threatening conditions or b) Clinical complications Record review of In-service training report: Notification of Change, dated 4/6/2024, revealed For all changes of conditions, please call DON and/or Administrator. Texting is not acceptable. Signed by LVN A on 4/8/2024. Record review of In-Service training report: Notification of Change, dated 6/27/2024, revealed When a resident has any change of condition, the physician, or NP, RP, and DON must be notified. This should be documented in PCC on Change of Condition form and a progress note should be completed with any additional information. Signed by LVN A on 6/27/2024.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for one waste receptacle reviewed for garbage disposal. -The waste receptacle had its top left lid opened when no one was disposing of trash. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents. Findings include: Observation 01/17/2024 at 8:42 AM. The left lid on the outside dumpster was observed to be open. Interview on 01/18/2024 at 9:05 AM with the Dietary Manager. He said the policy on the dumpster was the lids should have been closed. He said it was difficult to close the lids and he said he would talk to the Maintenance director for something to help close the lids. He said the wind may have helped close or open the lid to the dumpster. He said he did not know who was responsible for ensuring the dumpster lid was closed. He said the risk to residents if policy were not followed was it could draw in rodents and pests, and they could then get into the building. Interview on 01/18/2024 at 11:01 AM with the Administrator. She said the policy on the dumpster was the lid should always be closed. She said risk to residents if policy were not followed was residents could be harmed by animals and pests getting in the dumpster. She said she thought the failure occurred because staff were careless. Record review of the Garbage Receptacles dated October 01, 2018, read in part . Outdoor receptacles: It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside of the receptacle .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the walk-in refrigerator in that: -The facility stored unlabeled and unsealed foods in the freezer. This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status. Findings Included: Interview and observations on 01/17/2024 at 8:22 AM with the Dietary Manager. In freezer #1 there were unlabeled bags of what the Dietary Manager identified as diced ham, chicken fried steak, and taquitos. The Dietary Manager said the bags should be labeled. Interview on 01/18/2024 at 9:05 AM with the Dietary Manager. He said he was responsible for ensuring residents are served what they needed and what they were supposed to have. He said he was responsible for the day-to-day things like inventory, ordering, training, and interviewing patients on their preferences He said the food items must be dated with the pick sticker. The pick stick contains ithe information of the date delivered, and the date it was received which he said he physically wrote on the sticker. He said the reason for the failure was the items that were unlabeled were uncooked, they were not labeled and placed in freezer #1. He said the taquitos had not been served since he had been at the facility. He said he discarded the unlabeled foods yesterday (1/17/24). He said he had not been in-serviced on food storage. He said he was responsible for ensuring policy was followed. He said the risk to residents if policy was not followed was a health risk to the residents. He said death was the worst thing to happen if policy was not followed. He said he did not know why the failure occurred, just that those foods had not been served since he had been there. Interview on 01/18/2024 at 11:01 AM with the Administrator. She said she had worked at the facility for five months. She said she oversaw all departments, was abuse coordinator, problem solver and ensured residents were taken care of. She said the policy or procedure for storing food was, everything needed to be dated, and if opened it needed to have an open date and an expiration date. She said the shelf life of items in the fridge was three days. She said she did not know why the items were not dated and that staff did not follow up. She said she last had training on food storage about two months ago. She said the risk to residents if policy were not followed was, they could get sick from food borne illnesses. She said the worst thing that could happen was residents got sick and ended up in the hospital or worse. She said she thought the failure occurred because staff may have been in a rush and did not follow policy. Record review of the Food Storage policy dated October 01, 2018, reflected in part . 2. Refrigerators: D: Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 3. Freezers: E: Store frozen foods in moisture-proof wrap or containers that are labeled and dated . Review of Texas food Establishment Rules accessed https://www.fda.gov/media/164194/download 08/16/2023 revealed in annex 3 page 17: the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer ' s information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 1 (Resident #1) of 5 residents reviewed for dignity. The facility failed to provide dignity and respect for Resident #1 by leaving the residents privacy bag off his foley bag exposing the full urinary bag to open doorway. This failure placed resident and could place other residents at risk for embarrassment and low self esteem. Findings: Record review of Resident #1's Face Sheet revealed an [AGE] year-old male who was admitted on [DATE] with a diagnosis of Unspecified Dementia (Memory Loss), Heart Failure (Loss of heart Function), Pressure Ulcer Sacral Region (Wound to Buttock), Heart Disease (Blocked Arteries in the Heart), Muscle Wasting and Atrophy (Loss of Muscles). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15 indicating the resident was severely cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing and toileting with 2-person assistance. Section H noted indwelling catheter. Record review of Resident #1's Care Plan dated 12/15/2022 revealed . has a Foley Catheter related to BPH with retention, stage IV pressure ulcer to sacrum .Goal .The resident will show no s/sx of urinary infection through review date .Interventions . change catheter every Wednesday and PRN .Change Foley Cath each month on the 15th .Change foley Cath bag the 1st and the 15th of each month . Record review of Resident #1's Physician Orders dated 4/26/2023 revealed . Change Foley Catheter once monthly one time a day starting on the 15th and ending on the 15th every month related to Pressure Ulcer of Sacral Region, Stage 4, Obstructive and Reflux Uropathy, Unspecified . On 8/16/2023 at 10:10am Surveyor observed Resident #1's foley catheter bag without privacy bag on. Catheter bag was observed full of urine, hanging at the end of the bed, face out to doorway. In an interview on 8/16/2023 at 11:27am with the Wound Care Nurse she said she had worked at the facility for two weeks. She said the importance of covering the foley bag was for privacy and dignity with residents. She said she had not been in serviced on privacy and dignity since coming to work at the facility. She said she had not been in serviced on foley catheters since coming to work at the facility. In an interview on 8/16/2023 at 11:35am with CNA A she said she had worked at the facility since June 2023. She said the privacy bag for foley catheters was to prevent others from seeing urine in the bag. She said it was embarrassing to some residents when others could see urine in their foley bag. She said she had not been in serviced on foley care since working at the facility. In an interview on 8/16/2023 at 12:50pm with ADON A she said she had worked at the facility since April 24, 2023. She said she had been a nurse for almost 18 years. She said her duties were to check orders, check CNAs, help nurses, call doctors, help where needed, do in services, and training. She said the privacy bags on the foleys were for dignity issues for the residents, so they had privacy. She said the residents could get upset and embarrassed when others saw urine in the foley bag. In an interview with the DON, she said she had been working at the facility for seven days. She said the reason for privacy bags was to protect resident rights and dignity. She said when privacy bags are not used, residents were embarrassed. She said she did not know when the last in service on foley care was conducted. In an interview on 8/16/2023 at 1:36pm with ADON B she said she had been the ADON at the facility for almost three months. She said she had been a nurse for three years. She said her duties were to oversee nurses for halls three and four. She said they were last in serviced on Foleys yesterday, but she was not at work. She said the importance of having a privacy bag over a Foley was it gave resident dignity, she said staff should have had to cover the bag as it looked gross from the resident's perspective. She said the residents could have become insecure from having their urine exposed. Record review of facilities policy titled, Promoting/Maintaining Resident Dignity read in part . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .Maintain resident privacy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to ensure a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 5 staff (CNA B) observed for hand hygiene. The facility staff failed to use proper handwashing technique when assisting Resident #3. This failure could place Resident #3, other residents and staff at risk for infection. Findings: Record review of Resident #3 s Face Sheet revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety (Memory Loss), Unspecified Protein Calorie Malnutrition (Lack of Nutrition), Type 2 Diabetes (High Blood Sugars), Dysphagia (Difficulty Swallowing). Record Review of residents quarterly MDS dated [DATE] revealed a BIMS score of 0 out of 15 indicating severely cognitively impaired. Resident #3 required total dependence on bed mobility, transfers, dressing and toileting with one person assistance. Section K noted a feeding tube. Record Review of residents Care Plan dated 8/4/2023 revealed . requires tube feeding r/t swallowing problem .The resident will remain free of side effect or complications . On 8/16/2023 at 9:50am surveyor observed CNA B manipulating Resident #3's g tube and gown. CNA B walked to doorway, took off gloves and did not use hand sanitizer or wash hands. CNA B walked out into hallway, touched door handle of linen room, entered linen room, gathered clean linens, and entered resident #3's room. CNA B did not wash her hands or use hand sanitizer, she did not don gloves. CNA B began touching Resident #3's G tube. Surveyor observed leakage coming from G tube and onto Resident #3's gown. Surveyor observed CNA B place a towel under leaking G tube, wipe her hands on the towel and then place gloves on. After care was provided surveyor observed CNA B walk to trash can, take gloves off, gather trash bag, leave room without washing hands or using hand sanitizer, walk over to dirty utility room, punch in door code, enter dirty utility room, leave utility room, come back out and reenter Resident #3's room without washing hands or using hand sanitizer. CNA B then donned gloves and assisted resident. CNA B completed care, discarded gloves, and came out of room without washing hands or using hand sanitizer. In an interview on 8/17/2023 at 09:58am with CNA B she said she had been a CNAs since 2019. She said she knew the process for coming in and out of a resident's room was to wash hands. She said she knew she did not wash her hands both times she came out of Resident #3's room and she did not use hand sanitizer. She said Germs could have spread when hands were not sanitized, and they could carry bacteria and infection. CNA B said she would wash her hands and use hand sanitizer in the future. CNA B said her last in service on handwashing was in nursing school in April 2023. In an interview on 8/17/2023 at 10:00am with ADON B she said she had worked at the facility for 3 months. She said she had been a nurse for 3 years. She said the last time she was in serviced on handwashing was 2 weeks ago. She said she was supposed to use hand sanitizer prior to going into and leaving a resident's room. She said she could wash her hands as well. She said if hands were not sanitized, they could carry different diseases to residents, staff to staff and to visitors. She said the environment could be contaminated. In an interview on 8/16/2023 12:50pm with ADON A she said the importance of hand sanitizer or hand washing prior to going in a resident's room was to prevent carrying germs in. She said cleansing hands between glove changes was important because there may have been a tear or hole in the glove allowing bacteria to pass through. She said hand hygiene was important after caring for a resident, so germs were not carried out of the room to the next resident. She said hand hygiene was to prevent infection. In an interview on 8/16/2023 at 1:18pm with CNA C she said washing hands and gloving were important prior to resident care for infection control so the resident was not given disease. She said after providing care she took her gloves off and used hand sanitizer as it was important to prevent the spread of infection. She said the last in service on handwashing was today. In an interview on 8/16/2023 at 1:25pm with the DON she said infection control was the basis of everything they did to prevent cross contamination. She said handwashing and sanitization was the number one prevention and she was not aware staff did not sanitize their hands. In an interview on 8/16/2023 at 1:36pm with ADON B she said the last in service on handwashing was 2 weeks ago when they had a couple of residents with Covid. She said the Covid in service included hand washing. She said the process for going into a resident's room was to use hand sanitizer going in and out. She said after 3 hand sanitizers then they washed hands. She said between glove changes they would have washed hands or used hand sanitizer. She said cross contamination with germs can happen if these processes were not followed and residents and staff could have acquired an infection. Record review of facilities policy titled, Hand Hygiene dated 10/24/2022 read in part . All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working within the facility .Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to ensure catheter changing procedures were followed by staff in the direct care for 2 (Resident #1 and Resident #2) of 5 residents reviewed for catheter care. The facility failed to change Resident #1 and Resident #2's foley catheters when ordered. These failures could place residents at risk for infection and blocked urinary catheters. Findings: Resident #1 Record review of Resident #1's Face Sheet revealed an [AGE] year-old male who was admitted on [DATE] with a diagnosis of Unspecified Dementia (Memory Loss), Heart Failure (Loss of heart Function), Pressure Ulcer Sacral Region (Wound to Buttock), Heart Disease (Blocked Arteries in the Heart), Muscle Wasting and Atrophy (Loss of Muscles). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15 indicating the resident was severely cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing and toileting with 2 persons. Section H noted indwelling catheter. Record review of Resident #1's Care Plan dated 12/15/2022 revealed . a Foley Catheter related to BPH with retention, stage IV pressure ulcer to sacrum .Goal .The resident will show no s/sx of urinary infection through review date .Interventions . change catheter every Wednesday and PRN .Change Foley Cath each month on the 15th .Change foley cath bag the 1st and the 15th of each month . Record review of Resident #1's Physician Orders dated 4/26/2023 revealed . Change Foley Catheter once monthly one time a day starting on the 15th and ending on the 15th every month related to Pressure Ulcer of Sacral Region, Stage 4, Obstructive and Reflux Uropathy, Unspecified . Observation on 8/16/2023 at 10:10am Resident #1's Foley bag was dated 6/16/2023 written in black ink. Resident #2 Record review of Resident #2's Face Sheet revealed a [AGE] year-old male with a history of Unspecified Dementia, Moderate with Other Behavioral Disturbance (Memory Loss), Cerebral Infarction (Disrupted Blood Flow to the Brain), Muscle Wasting and Atrophy (Muscle Loss), Atherosclerotic Heart Disease of Native Coronary Artery (Heart Disease). Record Review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating the resident was moderately cognitively impaired. Resident #2 required limited assistance with bed mobility, dressing and toileting. Resident #2 required extensive assistance with transfers and required the assistance of one person. Section H noted indwelling catheter. Record review of Resident #2's Physician Orders dated 6/27/2023 revealed . Foley Catheter: Change 16F with 10ml bulb every night shift starting on the 27th and ending on the 28th every month . Neuromuscular Dysfunction of Bladder. Observation on 8/16/2023 at 10:30am Resident #2's Foley bag was dated 6/27/23 written in black ink. In an interview on 8/16/2023 at 11:05am with the Wound Care Nurse she said she had worked at the facility for 2 weeks. She said the importance of changing the foley catheter bag out every 30 days was to prevent bacteria from growing in the catheter and to prevent infections. She said she had not been in serviced on foley catheter care since working at the facility. In an interview on 8/16/2023 at 11:35am with CNA A she said she had worked at the facility since June of 2023. She said she had been a CNAs for 5 years. She said her duties were to clean, feed, change and reposition residents. She said she transferred residents, showered, and groomed them. She said the reason for changing the foley out was to prevent infection. She said she had last been in serviced on foley care 1 or 2 weeks ago. In an interview on 8/16/2023 at 12:50pm ADON A said she had worked at the facility since April 24,2023 and had been a nurse for almost 18 years. She said her duties were to check orders, check CNAs, help nurses, call physicians, and help where needed. She said she conducted in services and trainings. She said the last in service on foley care was not long ago and was not sure when. She said it was important to change a foley catheter out every 30 days because residents developed residue inside of the foleys and to prevent infection. She said foley catheters can get clogged and urine may not drain from the bladder due to not being changed out. In an interview on 8/16/2023 at 1:25pm with the DON who said she had worked at the facility for 7 days. She said she oversaw nursing care at the facility. She said she transferred from another facility to improve care. She said changing a foley catheter as ordered was for infection prevention. She said if foleys were not changed as ordered there was potential for backflow of urine. She said she did not know when the last in service on foley care was conducted. In an interview on 8/16/2023 at 1:36pm ADON B said she had been ADON at the facility for almost 3 months. She said she had been a nurse for almost 3 years. She said her duties were to oversee halls three and four. She said the importance of changing a foley bag out once a month was to prevent an infection of the urinary tract. On 8/16/2023 at 1:40pm surveyor requested policy on catheter care from the DON and did not receive one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident#1) of 1 resident reviewed for infection control in that: 1. LVN A failed to demonstrate proper hand hygiene and changing of gloves when providing wound care for Resident#1. 2. LVN A changed dressing to Resident#1's sacral area while Resident#1 was on soiled bed linens. 3. LVN A did not prepare a sanitary area for clean dressings prior to wound care. These deficient practices could place residents at risk for infection and inadequate wound healing. Findings Included: Record review of Resident#1's face sheet revealed a [AGE] year-old male admitted on [DATE]. Resident#1's diagnoses were Other Frontotemporal Neurocognitive Disorder (Impaired Memory), Dysphagia (Impaired Swallowing), Oral Phase, Muscle Wasting and Atrophy (Inability to Move Muscles), Cognitive Communication Deficit (Difficulty with Communication), Unspecified Dementia (Impaired Thinking), Stage 4 Pressure Wound Sacrum Full Thickness (Deep Wound to Buttocks). Record Review of Resident#1's quarterly MDS dated [DATE] revealed a BIMS score of 3 out of 15 indicating Resident#1 was severely cognitively impaired. Resident#1 required total dependance on Bed Mobility, Dressing, Eating, Toilet Use for Bowel and Bladder with two person's for assistance. Section M read . Resident has unhealed pressure ulcers . Record review of Resident#1's Care plan dated 5/1/2023 read in part .6/6/2023-Stage 3 pressure Wound Sacrum. The residents pressure ulcer/injury will show signs of healing .Decrease in size/measurements and will remain free from signs and symptoms of complications (including infection) by/through next review date . Record review of Resident#1's Wound Physician's note dated 7/7/2023 read in part . Stage 4 Pressure Wound Sacrum .Surgical Excisional Debridement Procedure .Remove Necrotic Tissue . Record review of Resident#1's Physician Orders dated 7/8/2023 read in part . Cleanse wound with wound cleanser or normal saline. Pat dry. Apply Medi Honey (Dressing). Cover with Calcium Alginate (Dressing) and dry dressing as needed for dislodgement or soilage . Observation on 7/10/2023 at 9:04am revealed Resident#1 for pressure ulcer treatment performed by LVN A, resident on his side with urine-soaked linens pushed up alongside Resident#1's back, buttocks and legs. Surveyor noted dressing change performed while resident on soiled linens. Surveyor noted no sanitary area for wound supplies. Surveyor observed clean wound supplies on soiled bedside table with no barrier, and wound cleanser bottle in resident's bed. Surveyor observed LVN A wash and dry hands, apply gloves, remove dressings, remove gloves, don new gloves with no handwashing or hand sanitizer, clean wound, remove gloves, and not wash hands or use hand sanitizer. LVN A donned new gloves and applied new dressings. LVN A did not wash her hands or use hand sanitizer prior to leaving room. In an interview on 7/10/2023 at 9:04am with LVN A, she said she was not certified in wound care and was an agency nurse. She said this was her third time at the facility. She said she had been a nurse for nineteen years and had done wound care in the past, but not consistently. She said she knew about proper handwashing technique and hand sanitizer and she said she had not been performing hand sanitizing. She said she learned about hand washing in nursing school and knew consequences to residents such as infection and prolonged healing if hands are not sanitized. She said the physician was here on Friday and Resident#1 wound was found to be not healing. She said the physician debrided the wound. She said she should have changed the soiled linens before administering wound care. In an interview on 7/10/2023 at 9:30am with the DON, she said they took steps in wound care and the first steps were to assess for pain. She said they should have gathered supplies and placed them on a clean surface like wax paper. She said the wound cleanser is located on the treatment cart and it is applied to 4x4's and taken into the resident's room. She said when dressings were removed the nurse should have removed her gloves, cleaned hands, and reapplied gloves. She said when residents are soiled, incontinent care would be provided prior to wound care to prevent contamination of wound. She said applying hand sanitizer between glove changes is to prevent infection, she said it was policy to do this. In an interview on 7/10/2023 at 12:45pm with LVN B she said she had worked at the facility since November. She said they had done in services last week but could not remember if one of them was on infection control. She said she had been a nurse for 36 years and when residents were soiled, she cleaned them up prior to performing wound care. She said she also placed a barrier under the residents prior to starting wound care. She said when she prepped for the procedure, she cleaned the bedside table and then placed a barrier such as wax paper to put the dressings on and said the reason for this was to prevent infection. She said everything needed to be clean prior to performing the procedure. Record review of facility policy titled, Hand Hygiene, dated 10/24/22, read in part . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Staff will perform hand hygiene .consistent with accepted standards of practice .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections involving 4 of 4 staff (Medication Aide B, ADON A, Treatment nurse and Housekeeper CC) and 4 of 6 residents (Resident #10, #78, #55 and#45) reviewed for infection control in that: -Medication Aide B did not disinfect the wrist blood pressure monitor in between Resident #10 and #78 when checking their vital signs. -Medication Aide B did not wash or sanitize her hands before entering Resident #10 and #78's room to check their vital signs through direct resident touch. -ADON A did not wash her hands or use hand sanitizer after performing colostomy care for Resident#55. -Treatment nurse did not wash her hands or use hand sanitizer after removing soiled brief for Resident#45. These failures could affect residents and place them at risk of infection through cross-contamination. Findings included: Resident #10 Observation of medication pass on 10/25/22 at 9:18a.m., revealed Medication Aide B opening and closing drawers, touching her computer screen without gloves, and then entering into Resident #10's room with a wrist blood pressure monitor without performing hand hygiene. Medication Aide B came out of Resident #10's room without washing or sanitizing her hands or the equipment. Medication Aide B placed the wrist blood pressure monitor on top of the medication cart before documenting the vitals/administering morning meds and went to Resident#78's room. Resident #78 Observation on 10/25/22 at 9:40 a.m., revealed Medication Aide B without washing or sanitizing her hands or the wrist blood pressure monitor checked Resident #78's vitals with the same equipment used on Residents #10. Medication Aide B placed the equipment on top of the medication cart and documented the vitals/administered meds and did not wash her hands or sanitize the equipment she used. In an interview on 10/25/22 at 9:50a.m., with Medication Aide B, she said she was going room to room checking residents' vitals that needed their blood pressure checked before administering their meds. She said she was aware that she needed to wipe all multi use equipment between residents. The surveyor shared med pass observation from earlier with Medication Aide B. Medication Aide B said she received training on infection control almost every month. She said she was nervous and forgot to sanitize her hands/wrist blood pressure monitor in between residents. She said not washing hands and sanitizing multi use equipment increases the risk for spreading germs and cross contamination. Resident #55 Record review of the admission sheet for Resident #55 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus with hyperglycemia (occurs when a person's blood sugar elevates to potentially dangerous levels that require medical treatment.), colostomy status (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) and functional quadriplegia (complete immobility due to severe physical disability or frailty). Record review of Resident #55's quarterly MDS assessment dated [DATE] revealed his BIMS score was 14 out of 15 indicating intact cognition. Record review of Resident #55's care plan initiated 06/02/2022 revealed the following care plan: Problem: [Resident#55] has constipation r/t decreased mobility neurogenic disorder d/t bed confinement status functional quadriplegia and has a colostomy. Goal: The resident will pass soft, formed stool at the preferred frequency of every 3 days through the review date. Interventions: Change colostomy bag every 3 days Observation on 10/25/22 at 9:54a.m., revealed ADON A provided Resident #55 with colostomy care. ADON A completed colostomy care and with the same soiled gloves, touched the resident's clean gown and brief. ADON A picked up the trash, then removed her right-hand soiled glove (carrying the trash with her left-hand soiled glove) and left the room without washing or sanitizing her hands. This Surveyor followed ADON A. ADON A went to the shower room on hall 400. ADON A opened the shower room with a code, looked inside and said, no barrels. ADON then went through the dining room to hall 300's shower room, still holding the trash with her left hand In an interview on 10/25/22 at 10:03a.m., with ADON A, she said she emptied Resident #55's colostomy, went to the Hall 400 shower room but there were no barrels, so she went to Hall 300 shower room to throw the trash. She said she did not wash or sanitize her hands after leaving Resident #55's room. She said, I had glove on because I was carrying possible soil trash bag with my left hand, so I didn't remove my left-hand glove. My right hand was clean I pressed the code on the shower room door with my right hand. I didn't see the barrels someone might have taken it out, so I went to hall 300 shower room to throw the trash. She said she had been in-serviced on hand washing/ infection control recently. She could not recall the exact date. Resident# 45 Record review of the admission sheet for Resident #45 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 4 9 skin injuries that occur in the sacral region of the body, near the lower back and spine), sepsis (the body's extreme response to an infection) and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review of Resident #45's quarterly MDS assessment dated [DATE] revealed her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. She was totally dependent on two persons physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident #45's care plan initiated 10/29/2021 revealed the following care plan: Problem: Pressure ulcer/injury: The resident has an alteration in skin integrity r/t the presence of a stage 2 pressure ulcer/injury on my sacral with a date of origin of 4/8/22. See skin integrity care plan for risk factors contributing to pressure ulcer/injury development. Stage 2 being treated with medi-honey and CA. 10/18/022-stg 4 to sacrum apply leptospermum honey and calcium Alginate apply gauze island w/boarder. Goal: The resident will remain free from additional pressure ulcers/injuries through next review date. Interventions: evolution of the status of the dressing and surrounding skin (i.e , Q3D dressing changes) as needed. Observation and interview on 10/26/22 at 2:40p.m., revealed Treatment nurse performed wound care on Resident#45 assisted by ADON A. Resident#45 was assisted on her left side prior to starting the wound care. Treatment nurse removed Resident#45's soiled brief and said, there is no trash bag I will be back. The Treatment nurse removed soiled glove from her right hand and carried the soiled brief on her left hand with glove on and left the room. This Surveyor followed the Treatment nurse. The Treatment nurse went to the shower room and disposed the soiled brief in the barrel. In an interview on 10/26/22 at 2:56p.m., with the Treatment Nurse, she said there was no trash bag in the trash can, so she had to take the soiled brief to the shower room to throw it in the barrels. She said she did not wash or sanitize her hands before leaving the room. She said she had the glove on her left hand because she was carrying the soiled brief. In an interview on 10/27/22 at 10:42a.m., with the DON, surveyor shared her observations from earlier. The DON said her expectation for the staff was to either sanitize or wash their hands after glove changes and to wipe down multi use equipment after every resident use. She said she was the facility's infection preventionist. She said she in serviced staff periodically and as needed monthly on different subjects to include infection control and hand hygiene. She said staff were educated to remove gloves prior to leaving the residents room and to not have gloves on the hallway. She said the bacteria could travel from which may or may not be on the gloves and to keep it contained. She said ADON A was going to throw the soiled trash in the shower room, but somebody took the barrels out. She said the Treatment nurse should have placed the brief in the trash can and disinfected the trash can after. She said the staff needed to be re-educated and in-serviced on infection control as it was at risk for spreading infections. In an interview on 10/27/22 at 12:35p.m., with the DON, she said the facility did not have a policy on standard infection control. Record review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy (revised January 2018) read in part: .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne pathogens standards . Record review of facility's Hand Hygiene policy (dated 10/24/22) read in part: .Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with the accepted standards of practice. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .