**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide privacy during wound care for one of three residents (R) 3, reviewed for wound care out of a total sample of 6 residents. This failure had the potential for R3 to experience embarrassment or feeling exposed during treatment. Findings include: Review of R3's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R3 was admitted to the facility on [DATE]. Review of R3's admission Evaluation - V3, located under the Assessments tab in the EMR and dated 08/14/25 at 6:44 PM, indicated R3 was alert and oriented to person, place, time, and situation. Review of R3's Physician Orders, located under the Orders tab in the EMR, indicated an order dated 08/19/25 for Left Buttock wound, Sacral redness, and Bilateral Buttock redness: Cleanse with NS [Normal Saline], pat dry, and apply Periguard Ointment every day and evening shift for wound healing and as needed for wound healing. During the wound care observation on 08/21/25 at 11:22 AM, R3 stood using a walker for wound care to be provided to R3's buttocks and sacral area. R3 unbuttoned his pants and underwear and lowered both articles of clothing to mid-thigh level. R3's blinds, covering the window, were left open while the wound care was being performed by Registered Nurse (RN) 1. RN1 did not ask R3 if he wanted the blinds to be shut prior to the start of the wound care. Anyone that would walk by the window would be able to see that R3 was having wound care performed to his buttocks. During an interview on 08/21/25 at 11:35 AM, RN1 confirmed she should have closed the blinds before performing wound care to R3's sacral area. During an interview on 08/21/25 at 11:37 AM, R3 was asked about the window blinds that were left open during wound care. R3 stated, Sure, it would bother me if someone saw me. I would prefer them [staff] to close the blinds. During an interview on 08/21/25 at 2:00 PM, the Interim Director of Nursing (IDON) stated, I expect the nurses to provide dignity and respect when performing wound care to a resident by closing the blinds prior to wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and Centers for Disease Control and Prevention (CDC) guidance, the facility failed to follow infection control guidelines during a wound care observation for two of two residents resident (R), R2 and R3, observed for wound care and failed to follow Enhanced Barrier Precautions during a dressing change for R3. This failure had the potential for R2 and R3 to be exposed to infections. Findings include:Review of the CDC webpage titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 02/27/24, revealed to change gloves and clean hands when moving from work on a soiled body site to a clean body site. Review of the CDC webpage titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 04/02/24 revealed EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities and apply to residents with wounds.1. Review of R2's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R2 was admitted to the facility on [DATE] with the diagnosis of peripheral vascular disease and type two diabetes mellitus. Review of R2's admission Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 06/29/25 indicated R2 had been coded as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R2 was cognitively intact. Review of R2's Care Plan, located under the Care Plan tab in the EMR and dated 08/13/25, had a Focus which indicated, Actual ABRASION TO RIGHT KNEE, RIGHT LOWER LATERAL CALF PROXIMAL TO ANKLE, AND TIGHT ANTERIOR SHIN [sic]. Interventions indicated, Administer treatment per MD [Medical Doctor] orders, Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify MD [Medical Doctor] PRN [as needed]. Review of R2's Physician's Orders located under the Orders tab in the EMR indicated an order dated 08/20/25 Right lower calf/proximal to ankle, right knee and right anterior shin: Cleanse sites with NS [normal saline], pat dry. Apply skin prep peri wound cut Dermaginate AG [silver] to size and apply. Cover with bordered foam dressing. During a wound care observation on 08/21/25 at 10:20 AM, Licensed Practical Nurse (LPN) 1 placed a towel down on the top of the bed, and then proceeded to place clean dressing supplies on the towel. LPN1 removed the old dressing to the right knee and cleaned the wound bed with normal saline. Then LPN1 using the same gloves that the old dressing was removed with, applied skin prep to the peri wound and then discarded the gloves, sanitized her hands, and then donned a new pair of gloves on. LPN1 proceeded to perform the dressing change as documented above for each of the other wounds. LPN1 finished the wound care and stepped outside the resident's door in the hallway and removed her personal protective equipment (PPE) which consisted of a gown and gloves. During an interview on 08/21/25 at 11:40 AM, LPN1 stated, I thought placing skin prep around the wound was part of the cleaning the wound. That was why I did not change my gloves. LPN1 was asked about the towel placed on the bed that the clean supplies we placed on. LPN1 stated, I put a barrier down, so I feel it was okay to do. LPN1 stated she should have removed the gown prior to exiting the room and placed it in the bin in the room. 2. Review of R3's undated Face Sheet located under the Profile tab in the EMR indicated R3 was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus. Review of R3's admission Evaluation - V3, located under the Assessments tab in the EMR and dated 08/14/25 at 6:44 PM, indicated R3 was alert and oriented to person, place, time, and situation. Review of R3's Physician Orders, located under the Orders tab in the EMR, indicated an order dated 08/19/25 for Left Buttock wound, Sacral redness, and Bilateral Buttock redness: Cleanse with NS [Normal Saline], pat dry, and apply Periguard Ointment every day and evening shift for wound healing and as needed for wound healing. During the wound care observation on 08/21/25 at 11:22 AM, Registered Nurse (RN) 1 placed a barrier on the overbed table without cleaning it first. RN1 then proceeded to clean the left buttock wound, bilateral buttocks, and sacral areas with NS. RN1 patted these areas dry with a 4x4. RN1 applied Periguard Ointment to these areas using a tongue blade. RN1 wore gloves but did not wear a gown while performing this wound care. During an interview on 08/21/25 at 1:35 PM, RN1 stated, I didn't wear a gown because [R3] wasn't in Enhanced Barrier Precautions. When asked if R3 should be in EBP, RN1 stated, Yes, because [R3] has an open wound. When asked if a tongue blade should have used to apply the ointment to R3's buttocks RN1 stated, That's what I was told to apply it with. During an interview on 08/21/25 at 11:50 AM, the Infection Preventionist (IP) stated, I expect them [nurses] to clean off the bedside table and then place a barrier down to place the clean supplies on. The nurse should change her gloves after cleaning the wound, sanitize or wash her hands then place a clean pair of gloves on before applying skin prep around the wound. A tongue blade should not be used to apply ointment to a resident. When asked if R3 should be in Enhanced Barrier Precautions [EBP], the IP stated, According to the new guidance, a wound that will take more than a few days to heal, that resident should be placed in EBP and the nurse [should] apply the appropriate PPE when caring for the resident. Notified IP that R3 was not in EBP at this time. During an interview on 08/21/25 at 2:00 PM, the Interim Director of Nursing (IDON) stated, . The nurse should establish a clean barrier and clean it with a sanitizing wipe before placing a barrier down and then the clean supplies. Applying the skin prep is not part of the cleaning process but rather a part of dressing a cleaned wound. The nurse should clean the wound as ordered by the physician, then remove the dirty gloves, wash or sanitize her hands and then apply a clean pair of gloves before applying the skin prep around the wound. Asked how a nurse should apply ointment to the buttocks of a resident and the IDON stated, They should use a clean applicator such as a Q tip. Asked if a tongue blade could be used to apply the ointment and the IDON stated, No, it shouldn't. That could have sharp edges or splintering from the wood used and cut the wound more and that is not what you want to do, You want to protect the skin that you are applying the ointment to. Asked if a nurse was dressing a wound such as for R3, the resident should be in Enhanced Barrier Precautions. The IDON stated, Yes, they should be in EBP [Enhanced Barrier Precautions]. Notified the IDON that R3 was not in Enhanced barrier Precautions and the nurse performing wound care only wore gloves. The IDON confirmed the nurse should have also worn a gown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure activities of daily living and activities for dependent residents were completed per standards of practice and resident care plans for 2 out of 3 sampled residents (R) (R1 and R2). -R1 did not receive weekly showers. -R2 did not receive restorative care or weekly showers per standards of practice and the resident's care plan. This is evidenced by: Example 1 R1 was admitted on [DATE] with diagnoses that include post shoulder surgery, weakness, fragile X, fibromyalgia, morbid obesity, hemiplegia, and asthma. R1's brief interview of mental status (BIMS) score was 13/15 indicating intact cognition. Minimum Data Set (MDS) dated [DATE] indicates R1 is understood and understands. R1 is dependent on staff for showering, and received max assist with transfers, toileting, and bed mobility. On 07/07/25, Surveyor reviewed R1's record. In review of Certified Nursing Assistant (CNA) documentation for weekly showers, 2 out of 6 showers were not given. On 5/14/25, documentation indicates the resident refused. On 05/28/25, the documentation was left blank. This was the date R1 was scheduled to receive a shower. There was no documentation of further attempts, the reason for R1 not receiving a shower, or that it was reported to supervising nurse. Example 2 R2 was admitted on [DATE] with diagnoses that include cerebral palsy, cognitive communication deficit and developmental disability. MDS, dated [DATE], notes that R2 sometimes understands and is sometimes understood and has no speech. R2 requires max assist with dressing, toileting, and transfers and moderate assist with bed mobility. R2 was up in wheelchair in hallway, noted to have clean hair/body and dressed. R2's shower review for April, May and June showed R2 is to have showers on Saturday AM shift. On 05/10/25 NA was documented. When asked CNA C what that meant, CNA C replied that is how it is documented if it was not their shower day. This was a shower day for R2. On 05/31/25, which is another Saturday AM, the area was blank. On 6/21/25, NA was recorded, and it was a Saturday AM. Surveyor reviewed restorative care documentation for R2. R2 is dependent for all cares and requires moderate assistance with bed mobility and maximum assistance with transfers and self-care. Surveyor noted on 04/09/25, 05/09/25, and 06/06/25 there was no documentation indicating assistance with bed mobility. On 04/09/25, 05/08/25, and 06/07/25 there was no documentation indicating assistance with ambulation. On 05/31/25, there was no documentation that R2 received scheduled shower, why it was not given, interventions, or that it was reported. R2 had scheduled shower days on 05/10/25 and 06/21/25. Documentation on those days indicated only N/A. Further investigation revealed no documentation of showers given for R2 in the weeks indicating N/A. On 07/07/25 at 3:00 PM, Surveyor interviewed Director of Nursing (DON) B and Nursing Home Administrator (NHA) A regarding cares not being provided to R1 and R2. Administration could not provide further documentation of cares not provided, not reported, or not followed up on.

Based on observation, interview and record review, staff did not perform hand hygiene to prevent the spread of infection when warranted while providing care to 1 of 4 residents (R) R28 observed for cares. Certified Nursing Assistant (CNA) C did not perform hand hygiene when warranted when providing incontinence care for R28. This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled Hand Hygiene which is dated 11/02/22. The policy in part reads: 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 within the facility. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. ~After handling contaminated objects ~Before applying and after removing personal protective equipment, including gloves ~After handling items potentially contaminated with .body fluids On 8/16/23 at 10:43 AM, Surveyor observed CNA C assist R28 with care in the resdident's room. CNA C knocked on R28's door, performed hand hygiene and donned gloves. CNA C lowered R28's pants and removed them along with a pillow that was under R28's legs. CNA C removed R28's incontinence brief and performed incontinence care. R28's brief was soiled with bowel movement and urine. CNA C did not remove her gloves and perform hand hygiene. CNA C obtained a clean brief and placed it on R28. CNA C removed gloves but did not perform hand hygiene. CNA C proceeded to placed a pillow under R28's legs and position R28 in bed. CNA C covered R28 with bedding and provided a call light. CNA C raised R28's head of bed and positioned R28's head on a pillow. CNA C offered R28 a fresh glass of water and took R28's water pitcher from her room. CNA C did not perform hand hygiene until she exited R28's room. On 8/16/23 at 11:07 AM, following the observation, Surveyor spoke with CNA C. CNA C indicated she should have removed gloves and performed hand hygiene after removing R28's dirty brief and washing R28. CNA C further expressed it is important to do hand hygiene for infection control. On 8/16/23 at 1:32 PM, Surveyor spoke with Director of Nursing (DON) B, who is the facility Infection Control Preventionist. DON B expressed the expectation is for staff to perform hand hygiene upon entering the resident room and don gloves. Staff should remove the dirty brief and perform care. Staff should then remove their gloves and perform hand hygiene before proceeding to touching items in resident environment.

Based on observation, interview and record review, the facility did not prepare, store and distribute foods in a safe and sanitary manner. The facility practices had the potential to affect all 48 residents. Initial tour of the facility kitchen found the floors in the kitchen, storage areas and dish room with food particles and built-up dirt present on the floors, the steamer and ovens with built up dried matter on the sides and bottom and on the industrial can opener mounted to the food preparation counter. Food temperatures were not taken at point of service in the rehabilitation kitchenette to ensure proper holding temperatures prior to serving food to residents. The food temperature logs were not complete. Dietary Aide (DA) D explained improper sanitization of thermometer procedures when temperatures are taken. This is evidenced by: Example 1 On 8/15/23 at 8:40 AM, Surveyor conducted an initial tour of the facility kitchen with Account Manager (AM) F who manages the dietary operations and has been on staff a few weeks. Surveyor noted the dry storage area floor, the kitchen floor and the dish room floor had visible dirt and food particles present. Surveyor asked [NAME] E about the dirty floors and [NAME] E responded the floors Should be cleaned x2 a day but she was not sure when they were last done as there is no cleaning schedule in place. [NAME] E further expressed there has not been a cleaning schedule in place for several months. Surveyor noted the lower counter where food is prepared with dried food and dirt. The can opener that is mounted on food preparation counter had dirt and grime present. Surveyor spoke with [NAME] E about the counter and can opener. [NAME] E responded, They should be cleaned daily. [NAME] E was not sure when they were last cleaned, possibly last week sometime. Surveyor noted the steamer with dried matter in it and the top and bottom ovens with a build-up of dried on foods on bottom and sides of the oven. [NAME] E again expressed the ovens should be wiped out daily and deep cleaned monthly, but was not sure when last cleaned. On 8/16/23 at 9:10 AM, Surveyor spoke with [NAME] E. [NAME] E showed Surveyor the can opener which is now clean and ovens which are now clean. [NAME] E expressed yesterday ovens, floors and can opener were not cleaned to her expectations and should be cleaned more often. A cleaning list is being developed to ensure more routine cleaning and holding people accountable to clean. AM F was present and also expressed the kitchen was not clean to her expectation and had an overtime build-up of food in the oven. AM F expressed she is developing a cleaning list to hold staff accountable for regular cleaning. Surveyor requested and reviewed the facility policy titled Equipment which is dated as revised on 9/2017. The policy in part reads: Policy Statement: All food service equipment will be clean, sanitary and in proper working order. Procedures: ~All food food-contact will be cleaned and sanitized after every use. ~All non-food contact equipment will be clean and free of debris. Surveyor requested and reviewed the facility policy titled Environment which is dated as revised on 9/2017. The policy in part reads: Policy Statement: All food preparation areas, food service areas and dining rooms will be maintained in a clean and sanitary condition. Procedures: ~The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation. ~The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. Example 2 On 8/16/23 at 7:27 AM, Surveyor observed Dietary Aide (DA) D serving breakfast from the kitchenette on the rehabilitation wing. DA D indicated she has been on staff 2 years and serving foods is part of her responsibilities. Surveyor observed DA D serving pancakes, eggs, oatmeal and, sausage from the steam table. At no point did the Surveyor observe DA D take temperatures of foods on the steam table. Surveyor also observed cold beverages on ice in bin on a cart including milk. Surveyor did not observe DA D take temperatures of the beverages. Surveyor asked DA D about the facility's practice of taking food temperatures at point of service. DA D explained the temperatures should be taken prior to serving residents and logged in the book the kitchen has. DA D stated, Supposed to take before serving and did not, important to ensure foods are at proper temperature, both hot and cold. Surveyor requested and reviewed the food temperature logs. The log for breakfast was void of any temperatures. Surveyor also noted several meals void of temperatures and days that were missing. Surveyor asked DA D how she cleans the thermometer when taking temperatures of foods and fluids. DA D indicated DA D removes a paper towel from the dispenser and wipes the thermometer before inserting into foods, in between foods and after DA D is finished taking temperatures. The thermometer is placed back in the holder when she is done. Surveyor asked DA D if wiping the thermometer probe with paper towel is sanitizing the probe. DA D responded, Probably not sanitizing. DA D further expressed DA D has never used anything but paper towel. On 8/16/23 at 9:10 AM, Surveyor spoke with AM F about the facility expectation for taking food temperatures at point of service. AM F indicated expectations are for staff to take food temperatures at point of service to ensure food temperatures are safe for serving. The temperatures are logged when taken. Surveyor asked AM F about sanitizing of the thermometer used to take food temperatures. AM F expressed the expectation is for staff to sanitize the thermometer with alcohol pad, air dry the thermometer and take food temperatures. The probe should be sanitized between foods and when done using. Surveyor requested the temperature logs and the facility policy that addresses taking of food temperatures. AM F provided the logs to the Surveyor. Surveyor reviewed the logs that dated back to 6/10/23 and noted the following: June 2023: 6/10/23-6/29/23 logs were completed for all three meals. There was no log for 6/30/23. July 2023: No logs were present from 7/01/23 through 7/12/23 or 7/25/23, 7/26/23 or 7/29/23. There was no food or beverage temperatures recorded for dinner on 7/17/23 or 7/28/23. There were no temperatures recorded for lunch or dinner on 7/24/23, 7/27/23. August 2023 to date (8/16/23). There were no logs present for 8/06/23, 8/07/23, 8/08/23, 8/10/23 or 8/14/23. No temperatures were recorded for lunch or dinner on 8/01/23, 8/02/23, 8/03/23, 8/05/23 or 8/12/23. Surveyor reviewed the facility policy titled Taking Food and Liquid Temperatures dated 9/20/2022. The policy in part reads: General Procedure: ~Open an alcohol wipe and wipe the thermometer probe clean. Dispose of the wrapper .Allow the probe to air dry a minimum of 10 seconds before you insert the thermometer into any food item. This allows the thermometer to dry and not contaminate the food .You need to take the temperature of every food item separately . ~Follow the hot holding temperature guide on your temperature log to assure all foods are kept out of the danger zone.