Example 3 Policy entitled Hand Hygiene last reviewed March 2023 and references of CDC and WHO Hand Hygiene Guidelines states indication for hand washing and hand antisepsis include in part: Before: Putting on gloves Right after: Having contact with residents skin, having contact with body fluids (even when gloves are worn) taking off gloves, moving from parts of the residents body that could be contaminated to clean parts o the resident's body. On 03/13/24 at 10:29 AM, Surveyor observed CNA C conduct morning cares on R14. After gathering supplies CNA C washed hands, donned gloves, removed soiled incontinence product and cleaned frontal peri area with washcloth. CNA C brought the basin to bathroom, dumped water and refilled the basin with clean water. Without removing gloves and conducting hand hygeiene, CNA C washed the frontal peri area again. After completing peri care, CNA C opened the door with soiled gloved hands to alert the nurse that R14 was ready for medicated cream. CNA C, without removing dirty gloves and conducting hand hygiene, performed the following: dumped basin of water, gathered and bagged dirty linens, opened dresser drawer and took out clean clothing, dressed and placed hoyer sling under R14 and took walkie talkie out of pocket and requested assistance for transfer. While waiting for assistance, CNA C removed gloves and without conducting hand hygiene, touched top of water jug and placed within reaching distance of R14. CNA C hooked up the sling for transferring R14 to the wheelchair. After R14 was in the wheelchair, CNA C donned clean gloves and without conducting hand hygiene, wet a clean washcloth, washed resident's face, placed toothpaste on toothbrush and handed the toothbrush to R14 for self brushing. Example 4 On 03/13/24 at 12:16 PM, Surveyor observed CNA C conduct incontinence cares on R14 while in bed. CNA C donned gloves, rolled R14 and removed soiled incontinence product. Without removing gloves and conducting hand hygiene, CNA C proceeded to leave the room touching the handle of door to get some washcloths and a towel to provide peri care. After returning to room, CNA C removed gloves and without conducting hand hygiene, donned a clean pair of gloves. After repositioning R14 to side and conducting peri care, CNA C proceeded to use the left hand to apply barrier cream to R14's buttock area. CNA C removed left glove, and without conducting hand hygiene, donned a clean left glove. Another staff member who was assisting CNA C, left the room, not closing the door securely. CNA C used unclean gloved hands to close the door tightly. CNA C proceeded to do the following: secured clean incontinent product, picked up 2 stuffed animals, and tucked them under bed covers with R14, touched bed remote, grabbed bedside table and placed closer to R14, left room to dispose of garbage and linens, removed gloves and went to a clean linen closet to grab a washcloth. No hand hygiene was conducted during this observation. On 03/13/24 at 1:31 PM, Surveyor interviewed CNA C regarding observation of no hand hygiene during morning cares and afternoon cares which included incontinence care. CNA C confirmed that appropriate glove removal and hand hygiene was not conducted during both observations and stated the expectation would be to remove gloves and conduct hand hygiene after moving from soiled to clean areas. On 03/13/24 at 3:43 PM, Surveyor shared observation of lack of hand hygiene/glove removal with DON B by CNA C with R14. DON confirmed expectation would be to remove gloves and conduct hand hygiene per policy. Example 5 On 3/13/24 at 8:27 AM, Surveyor observed morning care for R26. Surveyor observed CNA G and F perform hand hygiene and go to R26's bedside. CNA F removed R26's hospital gown. CNA G bagged the dirty gown and linens. CNA F went to the bathroom and donned gloves. Neither CNA F or CNA G performed hand hygiene before donning the gloves. CNA G washed and dried R26's upper body. CNA F applied deodorant under R26's left arm and CNA G applied deodorant under R26's right arm. CNA F dressed R26 with a clean shirt. CNA F did not remove dirty gloves or perform hand hygiene. CNA F and G rolled R26 towards the door to wash R26's back of urine with a soapy washcloth. CNA G rinsed and dried R26's back and rolled a chuck pad that was wet of urine from under R26. CNA G went to the bathroom for additional clean washcloths. CNA G did not remove gloves or perform hand hygiene when obtaining the clean washcloths. CNA G returned to bedside, lowered R26's brief, wet a wipe to remove cream from R26's groin. CNA G washed and rinsed R26's groin and CNA F dried R26's groin. CNA G placed the dirty linens in a bag and went back to the bathroom for more clean washcloths from drawer. CNA G did not remove gloves or perform hand hygiene after washing R26's groin and before retrieving additional clean washcloths. CNA G covered R26's groin with a towel after applying A and D ointment to R26's groin. CNA F went to R26's cupboard for a clean brief. CNA F did not remove his gloves or perform hand hygiene. CNA F, with dirty gloves still on, donned R26's clean pants up to R26's ankles. CNA F removed his gloves and donned clean gloves. CNA F did not perform hand hygiene when removing his dirty gloves and before donning clean gloves. CNA G donned clean gloves and applied Calameseptine cream to R26's buttocks. CNA G removed his gloves but did not perform hand hygiene. CNA G placed a clean brief on R26. CNA F removed R26's shirt that was wet with urine. CNA F did not remove his gloves or perform hand hygiene and proceeded to assist CNA G with placing R26's clean brief and clean pants. CNA G, with bare hands, removed R26's shirt that was wet of urine from bed and took it to the bathroom. CNA G did not perform hand hygiene and returned to bedside to assist CNA F with donning R26's clean shirt. On 3/13/24 at 1:16 PM, Surveyor interviewed CNA G about the observation. CNA G indicated CNA G has been on staff at facility since 2013 and trains other CNAs as a CNA mentor. CNA G expressed it makes sense to perform hand hygiene when going from dirty to clean and with removal of gloves. On 3/13/24 at 2:55 PM, Surveyor interviewed CNA F about the observation. CNA F indicated CNA F would expect hand hygiene to be done after direct contact with a resident, before and after every time. Further indicating hand hygiene should be done when going from dirty to clean. Gloves should be doffed, hands should be cleaned and clean gloves should be donned. On 3/13/24 at 2:59 PM, Surveyor interviewed DON B about the observation and staff expectation for hand hygiene. DON B expressed staff absolutely should have performed hand hygiene after all resident skin contact and before proceeding to clean next step. Additionally staff should perform hand hygiene with glove change. Example 2 On 03/13/24 at 12:00 PM, Surveyor did continuous observation of CNA I passing lunch trays to residents on the 100 hall who all ate in their rooms. No hand hygiene was provided to or offered to residents prior to the meal. There were no hand sanitizer wipes on the trays delivered to rooms as well. On 03/13/24 at 1:16 PM, Surveyor interviewed Registered Nurse (RN) K, asking, Are all of the residents on this wing able to eat or drink something from their meal trays independently? RN K replied, Yes they can. Surveyor then asked RN K, Is it common practice to offer hand hygiene when you pass meal trays? RN K replied, I don't know, I don't typically pass meal trays. On 03/13/24 at 1:17 PM, Surveyor asked Nurse Technician (NT) L, Is it common practice to offer hand hygiene when you pass meal trays to the residents? NT L replied, Yes we offer them hand sanitizer from the wall in their rooms. On 03/13/24 at 1:20 PM, Surveyor asked CNA I, Is it common practice to offer hand hygiene when you pass meal trays to the residents? CNA I replied, I don't. They don't have wipes available, and the hand sanitizer is on the wall behind the residents in their rooms typically. On 03/13/24 at 1:36 PM, Surveyor asked CNA J, Is it common practice to offer hand hygiene when you pass meal trays? CNA J replied, If they ask for it then we do, but I don't force them. Based on random observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections. Staff did not provide or offer hand hygiene to residents prior to meals. This has the potential to affect all 42 residents. Staff did not perform hand hygiene per standard of practice during cares for residents (R) cares. (R14 and R26) Example 1 Surveyor requested and reviewed the facility policy titled Nutritional Services Procedure Responsibilities for Meal Service which was dated as last reviewed on April 2023. The policy in part reads: Purpose: To provide guidance to staff for serving of meals to the residents of the facility. Procedure: ~Nursing is responsible for having residents ready . ~Staff delivering the tray will offer resident hand hygiene. On 03/12/24 at 12:07 PM, Surveyor observed meal service for lunch on the 300 wing hall. Surveyor observed R26, R35, R29 and R33 being transported to the dining room for lunch. R26, R35, R29 and R33 were served lunch and began eating on their own with no hand hygiene offered by staff. Certified Nursing Assistant (CNA) H remained in the dining room throughout lunch and at no point offered hand hygiene to the residents. On 03/13/24 11:52 AM, Surveyor again observed lunch in the 300 hall dining room. Surveyor observed R35 brought in a wheelchair from exercise activity to table in the dining room on 300 wing. R35 had previously been observed participating in exercise activity in the activity room. CNA F served R35 a salad with dressing, a hamburger on a bun, almond milk and coffee. R35 began eating with no hand hygiene offered by CNA F. R29 was brought to the table and served nacho chips, a barbeque on bread with no crust, apple juice and coffee by CNA D. No hand hygiene was offered to R29 before he began eating. R26 was brought to the dining room by CNA E, who served R26 cottage cheese with mandarin oranges, squash and rhubarb pie per resident order. No hand hygiene was offered to R26 before eating. Surveyor observed R35 handling her hamburger on bun with her bare hands and using utensils to eat her salad. At no point was R35 offered hand hygiene. R29 was observed holding bread/barbeque with one hand and cutting it with utensil with the other hand. R29 was observed eating nacho chips, R29 picked up chips with bare hands. At no time was R29 offered hand hygiene. R33 was brought to table and served chicken strips and fries that R33 picked up and ate with R33's fingers. R33 was not offered hand hygiene. R1 was brought to the dining room and served sloppy joe, squash, and pie. R1 began eating the sloppy joe with R1's hands. At no point was R1 offered hand hygiene. On 03/13/24 at 12:14 PM, Surveyor interviewed CNA E about offering residents hand hygiene before eating. CNA E explained it has never been done and she didn't think about it. Residents are just coming back from exercise and therapy where they were touching things and their hands are not clean. It is important to clean their hands before eating. On 03/13/24 at 12:17 PM, Surveyor spoke with CNA F about resident hand hygiene before eating and why it is not done. CNA responded, Good question, not sure why it is not done. I have worked here 7 months and it has never been done. It makes sense to do so. On 3/13/24 at 2:55 PM, Surveyor spoke with Director of Nursing (DON) B about the expectation of resident hand hygiene before eating. DON B expressed everyone should wash their hands before eating, including our residents. Further expressing he would expect residents to be offered hand hygiene before eating.

Based on observations and interview, the facility did not ensure proper sanitation of the food thermometer while temping lunch to prevent cross contamination which has the potential to affect 25 of 25 residents. Cook C was using Sani T10 Plus and a blue towel for sanitizing the thermometer in between temping food, that did not follow facility protocols to prevent cross contamination. This is evidenced by: On 01/25/23 at about 11:00 am, Surveyor observed [NAME] C put a thermometer in the beef stew, [NAME] C then removed the thermometer from the beef stew and placed it in a cup of clear liquid. Surveyor asked [NAME] C what was in the cup, and [NAME] C indicated sanitizing water. [NAME] C then swished the thermometer in the sanitizing water, removed it from the sanitizing water and wiped it on a blue paper towel. [NAME] C then proceeded to temp a pot pie, removed the thermometer, swished the same thermometer in the same contaminated sanitizing water, removed it and wiped the thermometer with the same blue paper towel. [NAME] C continued to temp the soup, french toast, baby carrots and a hamburger the same way, reusing the contaminated sanitizing liquid. At about 12:30 pm, Surveyor interviewed the Nutritional Services Manager (NSM) D and asked how staff are to sanitize the thermometer in between temping food. NSM D indicated that they should be using alcohol swabs in between each food item. Surveyor then told NSM D of the observation of [NAME] C using a clear liquid to sanitize the thermometer in between temping foods and asked NSM D for the name of the products used. NSM D told Surveyor that cook C was newer and they would talk to [NAME] C. Surveyor checked the employee list and noted [NAME] C was hired on 09/20/22. NSM D brought Surveyor the product information for the sanitizing water that was used by [NAME] C. The clear liquid used was Sani T10 Plus and the blue towel was a food service paper 1 ply all-purpose towel. At about 1:34 pm, Surveyor went back to the kitchen and interviewed [NAME] E. Surveyor asked [NAME] E how they cleaned the thermometer in between temping foods. [NAME] E indicated they use alcohol swabs. On 01/26/23 at about 10:15 am, Surveyor interviewed [NAME] F and asked what they used to sanitize the thermometer in between temping foods. [NAME] F indicated alcohol wipes. On 01/26/23 at about 11:05 am, Surveyor interviewed [NAME] C and asked if they were trained to use the Sani T10 Plus to sanitize the thermometer in between temping foods. [NAME] C indicated that that was what they were trained to use, and the cook that trained her was no longer working there. Surveyor asked [NAME] C if she tested the cup of Sani T10 Plus before using it to clean the thermometer. [NAME] C indicated no that she only tests the buckets of sanitizing water, not the cup she used for sanitizing the thermometer.