ADVANCED HEALTH CARE OF AURORA

A licensure survey was completed on 5/3/23 to 5/9/23. One deficiency was cited.

Based on record review and interviews, the facility failed to provide adequate supervision and an environment as free from accidents hazards as possible for one (#7) of three residents reviewed for accidents out of 27 sample residents. The facility failed to ensure proper transfer procedure was completed by staff to prevent a fall with injury for Resident #7. Resident #7, who had a diagnosis of medically complex conditions, was admitted to the facility on 3/2/23. The facility failed to follow safety measures during resident transfers. The facility failed to provide two person assistance with transfers as documented in the 3/2/23 baseline care plan dated and the 3/7/23 facility assessment. Due to facility's failure to provide two person assistance with transfers and adequate supervision for transfers for Resident #7, she had a fall on 3/6/23 when transferring from the bed to wheelchair resulting in her being sent to the hospital for a head laceration requiring two sutures. Furthermore, the facility did not provide proper transfer education with staff after the incident on 3/6/23. Findings include:I. Facility policyThe Fall Prevention policy, revised on 9/28/22, received from the nursing home administrator (NHA) on 5/9/23 at 11:52 a.m. It revealed in pertinent part, "to ensure optimal patient safety, safety interventions will be implemented and monitored with appropriate documentation. The admitting nurse/nurse manager will be responsible for ensuring that interventions were initiated and communicated with staff to follow through."II. Resident #7A. Resident statusResident #7, age 80, was admitted on 3/2/23. According to the May 2023 computerized physician orders (CPO), the diagnosis included pneumonia (lung infection), sepsis (systemic infection), urinary tract infection (infection in the bladder), type two diabetes (abnormal insulin levels), lymphedema (abnormal drainage on lymph nodes resulting in swelling) and hypertension (high blood pressure). The 3/7/23 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive two person physical assistance for transfers and bed mobility. One person extensive assistance with toileting and personal hygiene. She required set up assistance with eating. B. Resident and representative interview Resident #7 was interviewed on 5/4/23 at 10:20 a.m. She said she fell in the facility and hit her head on the bedside table or wall, which cracked her head open. The facility sent her to the emergency room and they stitched my head up. She said she was admitted to the hospital for her head injury along with pneumonia they found during testing. She said she was in the hospital for three weeks before coming back to the facility. Resident #7 was interviewed again on 5/9/23 at 2:00 p.m. She said she had only been in the facility a few days when she fell. She stated there was only one certified nurse aide (CNA) in the room transferring her from one place to another. When transferring from the bed to the wheel chair when she lost her balance and fell hitting her head. There was only one CNA in the room and there was not a gait belt on. Resident #7 stated her head was covered with blood and they sent her to the hospital via ambulance. Resident #7 said she needed two people for transfers because she was weak and scared to fall. Resident #7's son was interviewed on 5/9/23 at 2:30 p.m. He said the facility informed him of his mother's fall the day it happened. He was told she was transferring from the bed to the wheel chair with one person's assistance when she lost her balance and fell. He was told the CNA was standing in front of Resident #7 at the time of fall. He stated his mother required two person assistance at the time of the fall related to weakness. She was transported to the hospital due to the head injury she sustained during the fall. She stayed in the hospital for a few weeks because when they were conductingtesting they also found her to have pneumonia. C. Record reviewThe admission nursing observation dated 3/2/23 revealed Resident #7 had faint pedal pulses, bilateral lower extremity pitting edema, urinary incontinence due to the inability to reach the toilet timely related her to decreased mobility. The fall risk section of observation tool revealed Resident #7 had decreased muscular coordination, requiring use of assistive devices. The baseline person centered care plan dated 3/2/23 received from the NHA on 5/8/23 at 11:23 a.m. revealed Resident #7 required two person assistance with transfers, weight bearing as tolerated and no other safety measures were implemented on admission. The care plan dated 4/3/23 identified potential for complications related to recent fall with scalp laceration. Goal was to decrease the potential risk for falls during the duration of the residents stay. Interventions placed per care plan effective date 4/3/23 were to educate the patient on: high low bed to decrease risk of injury, notify physician, physical and occupational therapy. Resident #7 needs identified were gait training and strengthening with physical therapy (PT) and occupational therapy (OT). The PT evaluation note from 3/3/23 revealed Resident #7 was a modified assistance with staff performing 50% assistance with transfers. The OT evaluation dated 3/3/23 revealed resident was minimum to maximum assistance with transfers. On 3/6/23 at 10:22 a.m. a registered nurse (RN) documented she went to assist a certified nurse aide (CNA) who requested assistance with Resident #7 as she was slipping out of her recliner. The resident almost had a fall on the floor when the CNA, the RN and a physical therapy assistant (PTA) assisted the resident back into the recliner. The resident was unable to provide any assistance to get her back in the chair. The resident reported she was sitting in the recliner and began sliding forward to grab something causing the foot rest to tip the recliner chair forward. On 3/6/23 at 8:03 p.m. the RN documented Resident #7 had a witnessed fall in her room. The nurse assessment revealed the resident sustained a laceration to the back of the head. The resident was alert, vitals signs and all extremities found to be baseline. The resident denied pain. The resident was sent out to the emergency room for evaluation. On 3/6/23 at 10:12 p.m. the licensed practical nurse (LPN) note revealed around 7:20 p.m. the resident had a witnessed fall. The CNA stated the resident fell while she was transferring from the bed to the wheelchair, the resident lost her balance and fell backwards. The LPN requested an RN for assessment. The resident sustained a head laceration injury and was alert till she was transferred to hospital. Fall incident event, risk observation and care plan update dated 3/6/23 provided by the NHA on 5/9/23 at 11:23 a.m. revealed Resident #7 had a witnessed fall in her room while transferring with CNA present. She lost her balance and fell backwards. The resident hit her head on the wall and sustained a laceration to her head. She was transferred to the hospital. Fall observation post fall revealed the resident was alert and oriented to person, place and time. Indicated the resident had one to two falls in the past three months, adequate visions, regularly continent, balance problems with standing/walking, taking antihypertensive medication, predisposing diseases of hypotension. Evaluation concluded resident fall risk score of seven which placed resident in the low fall risk category. Care plan update two person assist for all transfers was selected.-Two person assist with transfers was already indicated staff failed to implement a new intervention for fall prevention post fall. Admission records dated 3/6/23 from the hospital indicated Resident #7 was admitted to the hospital for a fall with head laceration. The resident presented in the emergency department with significant scalp bleeding. The resident required two nylonsutures to control bleeding. CNA task documentation in point of care (POC) revealed the following for staff assistance with transferring:On 3/3/23 transfers were one to two person physical assistance; On 3/4/23 transfer were one person physical assistance; On 3/5/23 transfers were one person physical assistance;On 3/6/23 transfers were one person physical assistance;On 3/27/23 readmission transfers were two person physical assistance; and, On 3/28/23 transfers were one to two person physical assistance.-The documentation on 3/6/23 when the resident had a fall (see below) indicated the staff only had one person assisting the resident. III. Staff interviewsThe transition nurse (TR) was interviewed on 5/9/23 at 11:08 a.m. She said she assisted Resident #7 on 3/6/23 when she was slipping out of the recliner after reaching for something. She said Resident #7 was only given verbal education on recliner function/safety and no other interventions were implemented since she physically did not reach the floor. The director of nursing (DON), assistant director of nursing (ADON) and the regional director of nursing (RDON) were interviewed on 5/9/23 at 11:10 a.m. They acknowledged that the 3/6/23 facility assessment indicated Resident #7 was a two person physical assistance with transfers. The DON verbalized the following for proper transfer technique for staff: a gait belt should be placed on the resident, the CNA should be standing behind the resident to support them once the resident was standing with balance and have a hold of the gait belt. She acknowledged Resident #7 fell backwards indicating the CNA was not behind the Resident #7 at the time of the fall. The DON provided documentation on 5/9/23 at 1:26 p.m. for a disciplinary action the CNA received from the facility post Resident #7 fall for failure to provide care with a secondary staff member for a resident who required two person assistance with transfers since admission. The statement provided by the CNA revealed she was assisting Resident #7 with a transfer from the bed to the wheel chair to go to the restroom. The CNA stated she was standing behind the resident during the transfer.-However, nursing documentation revealed Resident #7 fell backwards indicating CNA was not behind the resident. The DON was interviewed on 5/9/23 at 2:39 p.m. She said Resident #7's initial admission fall assessment on 3/2/23 fall score was four indicating she was at low fall risk and no interventions were initiated. Resident #7's fall score on readmission on 3/27/23 was seven, still low fall risk. The DON acknowledged the baseline care plan dated 3/2/23 safety section did not indicate any fall interventions set in place. The baseline care plan had one and two person assistance for transfers selected. The DON said the staff error on the side of more assistance so a two person assistance was preferred for most residents. CNA #1 was interviewed on 5/9/23 at 2:28 p.m. He said he checked the white board in the resident's room to see if the resident was a one or two person transfer. He said the physical therapist would let the staff know if needed whether the resident was a one person or two person transfer. He said he always wore a gait belt as part of his uniform and always used a gait belt to transfer. He said he would stand behind a resident when transferring, depending on the resident's transfer status. He said some residents required both staff members for transfers and may need to stand beside the resident. He said if he needed a second staff member to do a two person transfer he would call them on the headset. CNA #2 was interviewed on 5/9/23 at 2:51 p.m. He had worked at the facility for two years and on the evening shift. He said he learned about how to transfer a resident by the daily resident sheet, talking with the CNAs at shift change and talking with the resident. There was a white board in the resident's room and under transfers it listed how many people to use and the equipment to use. He said he did use a gait belt to help prevent falls. He said each resident that was a fall risk wore a wristband. He said using a gait belt assisting the resident, he stood in front of the resident to help get them out of a chair and then he would stand to the side as he assisted them to walk. The wall mounted computerized clinical kiosk was observed and there was no place to review the resident's transfer status. CNA #3 was interviewed on 5/9/23 at 3:13 p.m. She said she did not receive training on how to complete a resident transfer nor did she receive any kind of inservice. She was not sure if it (not receiving the training) was because she had been a CNA for so long. The DON was interviewed on 5/9/23 at 3:25 p.m. She said the facility did not complete a facility wide transfer education for nursing staff after Resident #7's fall with an injury. The physical therapist assistant (PTA) was interviewed on 5/9/23 at 3:26 pm. She said a resident who was maximum assistance was considered a two person assist with transferring. Once a transfer status was verified by PT it was written on the communication boards in the resident's room and verbally told to the resident's nurse at time of determination.

A recertification survey was completed from 5/3/23 to 5/9/23. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/3/23 to 5/9/23. No deficiencies were cited.

Based on record review and interviews, the facility failed to provide adequate supervision and an environment as free from accidents hazards as possible for one (#7) of three residents reviewed for accidents out of 27 sample residents. The facility failed to ensure proper transfer procedure was completed by staff to prevent a fall with injury for Resident #7. Resident #7, who had a diagnosis of medically complex conditions, was admitted to the facility on 3/2/23. The facility failed to follow safety measures during resident transfers. The facility failed to provide two person assistance with transfers as documented in the 3/2/23 baseline care plan dated and the 3/7/23 minimum data set (MDS) assessment. Due to facility's failure to provide two person assistance with transfers and adequate supervision for transfers for Resident #7, she had a fall on 3/6/23 when transferring from the bed to wheelchair resulting in her being sent to the hospital for a head laceration requiring two sutures. Furthermore, the facility did not provide proper transfer education with staff after the incident on 3/6/23. Findings include:I. Facility policyThe Fall Prevention policy, revised on 9/28/22, received from the nursing home administrator (NHA) on 5/9/23 at 11:52 a.m. It revealed in pertinent part, "to ensure optimal patient safety, safety interventions will be implemented and monitored with appropriate documentation. The admitting nurse/nurse manager will be responsible for ensuring that interventions were initiated and communicated with staff to follow through."II. Resident #7A. Resident statusResident #7, age 80, was admitted on 3/2/23. According to the May 2023 computerized physician orders (CPO), the diagnosis included pneumonia (lung infection), sepsis (systemic infection), urinary tract infection (infection in the bladder), type two diabetes (abnormal insulin levels), lymphedema (abnormal drainage on lymph nodes resulting in swelling) and hypertension (high blood pressure). The 3/7/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive two person physical assistance for transfers and bed mobility. One person extensive assistance with toileting and personal hygiene. She required set up assistance with eating. B. Resident and representative interview Resident #7 was interviewed on 5/4/23 at 10:20 a.m. She said she fell in the facility and hit her head on the bedside table or wall, which cracked her head open. The facility sent her to the emergency room and they stitched my head up. She said she was admitted to the hospital for her head injury along with pneumonia they found during testing. She said she was in the hospital for three weeks before coming back to the facility. Resident #7 was interviewed again on 5/9/23 at 2:00 p.m. She said she had only been in the facility a few days when she fell. She stated there was only one certified nurse aide (CNA) in the room transferring her from one place to another. When transferring from the bed to the wheel chair when she lost her balance and fell hitting her head. There was only one CNA in the room and there was not a gait belt on. Resident #7 stated her head was covered with blood and they sent her to the hospital via ambulance. Resident #7 said she needed two people for transfers because she was weak and scared to fall. Resident #7's son was interviewed on 5/9/23 at 2:30 p.m. He said the facility informed him of his mother's fall the day it happened. He was told she was transferring from the bed to the wheel chair with one person's assistance when she lost her balance and fell. He was told the CNA was standing in front of Resident #7 at the time of fall. He stated his mother required two person assistance at the time of the fall related to weakness. She was transported to the hospital due to the head injury she sustained during the fall. She stayed in the hospital for a few weeks because when they were conducting testing they also found her to have pneumonia. C. Record reviewThe admission nursing observation dated 3/2/23 revealed Resident #7 had faint pedal pulses, bilateral lower extremity pitting edema, urinary incontinence due to the inability to reach the toilet timely related her to decreased mobility. The fall risk section of observation tool revealed Resident #7 had decreased muscular coordination, requiring use of assistive devices. The baseline person centered care plan dated 3/2/23 received from the NHA on 5/8/23 at 11:23 a.m. revealed Resident #7 required two person assistance with transfers, weight bearing as tolerated and no other safety measures were implemented on admission. The care plan dated 4/3/23 identified potential for complications related to recent fall with scalp laceration. Goal was to decrease the potential risk for falls during the duration of the residents stay. Interventions placed per care plan effective date 4/3/23 were to educate the patient on: high low bed to decrease risk of injury, notify physician, physical and occupational therapy. Resident #7 needs identified were gait training and strengthening with physical therapy (PT) and occupational therapy (OT). The PT evaluation note from 3/3/23 revealed Resident #7 was a modified assistance with staff performing 50% assistance with transfers. The OT evaluation dated 3/3/23 revealed resident was minimum to maximum assistance with transfers. On 3/6/23 at 10:22 a.m. a registered nurse (RN) documented she went to assist a certified nurse aide (CNA) who requested assistance with Resident #7 as she was slipping out of her recliner. The resident almost had a fall on the floor when the CNA, the RN and a physical therapy assistant (PTA) assisted the resident back into the recliner. The resident was unable to provide any assistance to get her back in the chair. The resident reported she was sitting in the recliner and began sliding forward to grab something causing the foot rest to tip the recliner chair forward. On 3/6/23 at 8:03 p.m. the RN documented Resident #7 had a witnessed fall in her room. The nurse assessment revealed the resident sustained a laceration to the back of the head. The resident was alert, vitals signs and all extremities found to be baseline. The resident denied pain. The resident was sent out to the emergency room for evaluation. On 3/6/23 at 10:12 p.m. the licensed practical nurse (LPN) note revealed around 7:20 p.m. the resident had a witnessed fall. The CNA stated the resident fell while she was transferring from the bed to the wheelchair, the resident lost her balance and fell backwards. The LPN requested an RN for assessment. The resident sustained a head laceration injury and was alert till she was transferred to hospital. Fall incident event, risk observation and care plan update dated 3/6/23 provided by the NHA on 5/9/23 at 11:23 a.m. revealed Resident #7 had a witnessed fall in her room while transferring with CNA present. She lost her balance and fell backwards. The resident hit her head on the wall and sustained a laceration to her head. She was transferred to the hospital. Fall observation post fall revealed the resident was alert and oriented to person, place and time. Indicated the resident had one to two falls in the past three months, adequate visions, regularly continent, balance problems with standing/walking, taking antihypertensive medication, predisposing diseases of hypotension. Evaluation concluded resident fall risk score of seven which placed resident in the low fall risk category. Care plan update two person assist for all transfers was selected.-Two person assist with transfers was already indicated staff failed to implement a new intervention for fall prevention post fall. Admission records dated 3/6/23 from the hospital indicated Resident #7 was admitted to the hospital for a fall with head laceration. The resident presented in the emergency department with significant scalp bleeding. The resident required two nylon sutures to control bleeding. CNA task documentation in point of care (POC) revealed the following for staff assistance with transferring:On 3/3/23 transfers were one to two person physical assistance; On 3/4/23 transfer were one person physical assistance; On 3/5/23 transfers were one person physical assistance;On 3/6/23 transfers were one person physical assistance;On 3/27/23 readmission transfers were two person physical assistance; and, On 3/28/23 transfers were one to two person physical assistance.-The documentation on 3/6/23 when the resident had a fall (see below) indicated the staff only had one person assisting the resident. III. Staff interviewsThe transition nurse (TR) was interviewed on 5/9/23 at 11:08 a.m. She said she assisted Resident #7 on 3/6/23 when she was slipping out of the recliner after reaching for something. She said Resident #7 was only given verbal education on recliner function/safety and no other interventions were implemented since she physically did not reach the floor. The director of nursing (DON), assistant director of nursing (ADON) and the regional director of nursing (RDON) were interviewed on 5/9/23 at 11:10 a.m. They acknowledged that the 3/6/23 MDS assessment indicated Resident #7 was a two person physical assistance with transfers. The DON verbalized the following for proper transfer technique for staff: a gait belt should be placed on the resident, the CNA should be standing behind the resident to support them once the resident was standing with balance and have a hold of the gait belt. She acknowledged Resident #7 fell backwards indicating the CNA was not behind the Resident #7 at the time of the fall. The DON provided documentation on 5/9/23 at 1:26 p.m. for a disciplinary action the CNA received from the facility post Resident #7 fall for failure to provide care with a secondary staff member for a resident who required two person assistance with transfers since admission. The statement provided by the CNA revealed she was assisting Resident #7 with a transfer from the bed to the wheel chair to go to the restroom. The CNA stated she was standing behind the resident during the transfer.-However, nursing documentation revealed Resident #7 fell backwards indicating CNA was not behind the resident. The DON was interviewed on 5/9/23 at 2:39 p.m. She said Resident #7's initial admission fall assessment on 3/2/23 fall score was four indicating she was at low fall risk and no interventions were initiated. Resident #7's fall score on readmission on 3/27/23 was seven, still low fall risk. The DON acknowledged the baseline care plan dated 3/2/23 safety section did not indicate any fall interventions set in place. The baseline care plan had one and two person assistance for transfers selected. The DON said the staff error on the side of more assistance so a two person assistance was preferred for most residents. CNA #1 was interviewed on 5/9/23 at 2:28 p.m. He said he checked the white board in the resident's room to see if the resident was a one or two person transfer. He said the physical therapist would let the staff know if needed whether the resident was a one person or two person transfer. He said he always wore a gait belt as part of his uniform and always used a gait belt to transfer. He said he would stand behind a resident when transferring, depending on the resident's transfer status. He said some residents required both staff members for transfers and may need to stand beside the resident. He said if he needed a second staff member to do a two person transfer he would call them on the headset. CNA #2 was interviewed on 5/9/23 at 2:51 p.m. He had worked at the facility for two years and on the evening shift. He said he learned about how to transfer a resident by the daily resident sheet, talking with the CNAs at shift change and talking with the resident. There was a white board in the resident's room and under transfers it listed how many people to use and the equipment to use. He said he did use a gait belt to help prevent falls. He said each resident that was a fall risk wore a wristband. He said using a gait belt assisting the resident, he stood in front of the resident to help get them out of a chair and then he would stand to the side as he assisted them to walk. The wall mounted computerized clinical kiosk was observed and there was no place to review the resident's transfer status. CNA #3 was interviewed on 5/9/23 at 3:13 p.m. She said she did not receive training on how to complete a resident transfer nor did she receive any kind of inservice. She was not sure if it (not receiving the training) was because she had been a CNA for so long. The DON was interviewed on 5/9/23 at 3:25 p.m. She said the facility did not complete a facility wide transfer education for nursing staff after Resident #7's fall with an injury. The physical therapist assistant (PTA) was interviewed on 5/9/23 at 3:26 pm. She said a resident who was maximum assistance was considered a two person assist with transferring. Once a transfer status was verified by PT it was written on the communication boards in the resident's room and verbally told to the resident's nurse at time of determination.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to:-Ensure the surface disinfectant time was followed for proper disinfection; -Ensure resident rooms were cleaned and disinfected properly; and,-Ensure staff performed proper hand hygiene. Findings include:I. Professional reference According to the Center for Disease Control (CDC), Hand Hygiene Basics retrieved on 5/15/23 from: http://www.cdc.gov/handhygiene/basics.html (2019) read in pertinent part, "healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood,body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in a healthcare settings)."II. Facility policy and proceduresThe Disinfection Room Cleaning and Pest Control policy, revised 8/6/2020, was received from the nursing home administrator (NHA) on 5/9/23 at 11:52 a.m. revealed in pertinent part, "procedures to provide guidelines for cleaning and disinfection the environment in order to minimize the spread of healthcare-associated infection due to environmental contamination. An EPA (Environmental Protection Agency) registered hospital grade disinfectant must be used according to the manufacturer's specification. Place contaminated waste promptly into designated containers." According to the Midlab HP202 product label, undated, received from the NHA on 5/9/23 at 11:52 a.m. revealed in pertinent part, "virucidal activity SARS-related coronavirus 2 (virus caused COVID-19), influenza virus type A, the cleaner requires one minute dwell (surface disinfectant) time. Hepatitis B has a five minute dwell time. Methicillin resistant staphylococcus aureus (MRSA) has a ten minute dwell time." The Handwashing policy and procedure, revised 9/28/22, received from the NHA on 5/9/23 at 11:52 a.m. revealed in pertinent part, "hand washing before and after contact with any patient is the most important measure that can be taken to prevent the spread of infection. Hand washing will occur at the following times; before applying and after removing gloves, before passing medications or giving injections. After contact with any equipment or environmental surface that might have been soiled or contaminated. Adjust water to a comfortable level, wash hands vigorously scrubbing with soap for a minimum of 20 seconds."III. Observations and staff interviewsHousekeeper (HSK) #1 was observed on 5/8/23 at 9:19 a.m. cleaning room 708. She applied gloves, collected disinfectant spray and sprayed the main door inside and out, resident wheel chair, cushion, chairs, television stand, resident reaching tool and recliner. At 9:21 a.m. she wiped items down in the above order using one cloth for all areas. At 9:23 a.m. she sprayed the bedside table, bedroom sink/vanity counter top, bathroom door inside and out. She retrieved a new cloth and wiped down the bedside table, inside the sink bowl then the handles on the faucet then inside sink bowl again, vanity counter top, paper towel dispenser opened and assessed for paper towels. HSK #1 wiped down the bathroom door inside and out with the same towel. She continued cleaning the bathroom, starting with the sink in the bathroom by spraying disinfectant and wiping it down immediately, not waiting for the one minute surface disinfectant time and wiped with the same cloth as above. She obtained the toilet bowl cleaner from the cart and applied it to the toilet bowl, scrubbed bowl immediately. She removed gloves, obtained the broom and swept up large items on the floor in the room. She applied new gloves, without hand hygiene being performed. She wiped down the bedside commode laying on the floor in the bathroom. She used the same cloth to wipe the outside toilet and lid from top to bottom. She removed her gloves and sanitized her hands with an alcohol based hand rub (ABHR). Sprayed the bathroom floor with disinfectant from the bottle along with a mop pad and allowed it to sit for two minutes while she collected trash from the room. She moped the floor and shower floor with the same mop head, but the shower was never sprayed down prior. She replaced the mop with the dirty mop pad on the cart without removing the mop pad and placing it into a dirty bag. She applied gloves and entered the bathroom and picked up on old wound dressing from the shower. HSK #1 stated she would return to vacuum the room later. -HSK #1 failed to disinfect the call light, bed control and television remote that were high touch items. HSK #1 was interviewed on 5/8/23 at 9:35 a.m. She said the facility used HP202 disinfectant spray for all cleaning and it had a surface disinfectant time of one minute. She said once the surface was sprayed with the disinfectant, staff had to wait one minute before wiping it so it could properly disinfect. Staff were to change gloves between resident rooms, and hand hygiene occurred if hands appeared to be soiled. She acknowledged she used the same towel on multiple areas and probably should have used more towels in the room. HSK #1 said staff should work from the cleanest to the dirtiest areas. High touch areas in resident rooms were door handles, their bedside tables, call light and bed controls. She acknowledged she failed to spray the shower down and clean it prior to mopping the shower floor and some high touch areas like the television remote, call light and bed control. HSK# 2 was observed on 5/8/23 at 9:48 a.m. cleaning room 745 She performed hand hygiene with ABHR and applied gloves. She collected disinfectant spray and two towels. She sprayed all the doors, walker, sink and soap dispenser. She failed to wait one minute and started wiping the sink after 33 seconds. She used a new rag for the door to the bathroom. She changed her gloves and did not perform hand hygiene. She continued in the bathroom spraying down toilet top to bottom on the outside. She cleaned the sink with cloth inside the bowl then the handles to the faucet. She then wet a paper towel and wiped the mirror. She collected the toilet bowl brush and cleaner from the cleaning cart. She applied cleaner to the bowl and scrubbed the toilet bowl by brushing hard causing water to splash onto the wall. She returned the toilet bowl brush and cleaner to the cart. She then wiped down the toilet top to bottom on the outside with new cloth. She then touched the toilet paper roll with dirty gloves to make a triangle. HSK #2 then collected the mop pad and the mop. The mop had a disinfectant reservoir for floor cleaner, she mopped the bathroom floor, removed the mop pad and placed it into a dirty bag on the cart. She removed her gloves. She failed to clean the shower in the bathroom.-HSK #2 failed to allow time for chemicals to disinfect, change gloves after cleaning a soiled area, to clean from cleanest to dirtiest, disinfect high touch areas and perform hand hygiene at appropriate levels. HSK #2 was interviewed on 5/8/23 at 10:04 a.m. She said the disinfectant the facility used was HP 202 and it had a one minute surface disinfectant time to disinfect and kill all the germs. She said changing gloves occurred when gloves appeared soiled. Staff could use soap and water or ABHR for hand hygiene. HSK #2 said high touch areas in a residents room were the call light, phone, bed control, television remote and bedside tables. She acknowledged she did not clean some high touch areas, the shower and she touched the toilet paper with dirty gloves after cleaning the toilet. The NHA, who was the housekeeper director, was interviewed on 5/9/23 at 11:50 a.m. The NHA said housekeeping employees trained with his lead housekeeperfor a week prior to going independent on the floor. They covered infection control topics like isolation rooms for droplet, contact and airborne. Personal protective equipment donning and doffing, gloves, gown, face shield/goggles and mask. Cleaning rooms should be cleaned from the cleanest areas to the dirtiest. In training, staff were educated to ensure the surface disinfectant time was followed to disinfect appropriately. The facility used HP202 as its disinfectant and had a one minute surface disinfectant time for COVID-19. He acknowledged the chemical HP 202 required higher surface disinfectant time to effectively combat other organisms. HP202 chemical was a concentrate, the facility had a dispenser that mixed it for staff so it was at the correct concentration to be effective. The NHA said staff should change their gloves after completing a dirty task in housekeeping prior to going to a cleaner area and between rooms. He acknowledged staff should not be cleaning the sink bowl then faucet or counters as the sink bowl was considered the dirtiest part out of these areas. He acknowledged HSK#2 should not have touched the toilet paper dispensed with soiled gloves she had used to scrub the toilet bowl, nor should HSK #2 use the toilet brush on the bowl to cause splashing. He said towels used to wipe down should be changed when cleaning, a new area of the towel for each surface and then changed out. If the facility had a resident who had an infection, staff were educated on longer surface disinfectant times for the HP 202 chemical to be effective along with staff understanding that they were to clean isolation rooms last to help prevent spread of infection. He said these types of situations were communicated verbally and no written education was given to the staff to communicate increased surface disinfectant times. Licensed practical nurse (LPN) #1 was observed on 5/8/23 at 12:05 p.m. passing medications. LPN #1 entered a resident room to perform a blood glucose check. Upon entering the room, she washed her hands by turning on the water, wetting her hands, applying soap and rubbing her hands together for ten seconds then rinsing her hands for four seconds. She grabbed a paper towel, dried her hands, collected a second towel and turned off the water. She then applied gloves and performed a glucose check. -LPN #1 did not meet the minimum 20 seconds when washing her hands. LPN #1 returned to the cart, charted blood glucose level and collected medication for the same resident. Upon return to residents room, LPN #1 washed her hands with soap and water by turning on water, wetting her hands, applied soap, rubbed her hands together for ten seconds, rinsed the soap off in five seconds and obtained a paper towel to dry her hands and a second towel to turn off water. -LPN #1 did not meet the minimum 20 seconds when washing her hands. LPN #1 was interviewed on 5/8/23 at 4:26 p.m. She said hand hygiene performed by staff was completed by turning on water, wetting hands, applying soap, washing/rubbing hands together for 20 to 30 seconds then rinsing with water, drying with paper towel and turning off faucet with paper towel. She said she did not shake her hands. During medication administration, staff could use ABHR between residents unless administering a shot or checking blood glucose levels then she needed to wash with soap and water. LPN #1 acknowledged she should have washed her hands longer after administration of insulin and glucose checks. The director of nursing was interviewed on 5/9/23 at 11:19 a.m. She said hand hygiene should be performed between residents and when hands were visibly soiled. Staff could use ABHR or soap and water to complete hand hygiene. If soap and water was used, it was a minimum 20 seconds of rubbing hands together with soap and water or singing the alphabet song. Staff were annually assessed for hand hygiene and were educated regularly on infection control. If a specific infection control issue was observed staff were educated for compliance.