Health inspection·August 28, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide Range of Motion (ROM, full movement potential of a joint) and mobility (ability to move) treatments and services to prevent and/or limit a decline in joint (where two bones meet) for two of four sampled residents (Resident 1 and Resident 3) by failing to ensure to: -Complete a Joint Mobility Assessment (JMA, a tool that evaluates a joint's ability to move through its full range of motion by measuring flexibility, stiffness, and quality of movement) accurately and quarterly for Resident 1. -Follow the Physical Therapy recommendations as indicated in Resident 1's JMA. -Provide Passive Range of Motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 1's right hand as ordered by the resident's physician. -Provide ROM exercises as ordered by Resident 3's physician. These failures had the potential for Resident 1 and Resident 3 to develop a decline in ROM, and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion).Findings:1.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and contracture. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/2/2024, the MDS indicated the resident had severe cognitive impairment (a significant decline in the ability to think, understand, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent on help for showering, bathing herself, lower body dressing, putting on footwear, and taking off footwear. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 8/6/2024 for the Restorative Nursing Assistant (RNA, nursing aide who helps residents maintain their function and joint mobility) to perform PROM exercises to the resident's bilateral (both) upper extremities (BUE, both arms) seven times a week as tolerated every day. The Order Summary Report indicated the goal was to increase the Resident 1's ROM and prevent a decline in the resident's ROM. During a review of Resident 1's JMA dated 11/1/2024, the JMA indicated the resident had contracted bilateral lower extremities (BLE, both legs), limited ROM in the BLE, and no new deterioration (decline) noted in BLE and BUE. The JMA indicated Resident 1 was to continue the RNA program for PROM exercise and to be monitored by the nursing staff. The JMA indicated to notify nursing staff (unidentified) if Resident 1 had any change of condition or pain. During a review of Resident 1's RNA Administration dated 3/1/2025 to 3/31/2025, the RNA Administration indicated the RNA was to perform PROM to the residents BUE seven times a Page 1 of 8 055161 055161 08/28/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some week as tolerated every day. The RNA Administration indicated there was no documentation present on 3/9/2025 and 3/16/2025. During a review of Resident 1's RNA Administration dated 4/1/2025 to 4/30/2025, the RNA Administration indicated the RNA was to perform PROM to the residents BUE seven times a week as tolerated every day shift. The RNA Administration indicated there was no documentation present on 4/10/2025, 4/19/2025, and 4/20/2025. During a review of Resident 1's RNA Administration dated 5/1/2025 to 5/31/2025, the RNA Administration indicated the RNA was to perform PROM to the residents BUE seven times a week as tolerated every day shift. The RNA Administration indicated there was no documentation present on 5/15/2025 and 5/21/2025. During a review of Resident 1's JMA dated 5/27/2025, the JMA indicated the resident had minimal - severe loss of lower extremity PROM. The JMA indicated the resident had a diagnosis/condition that put her at risk for contracture development. The JMA indicated a recommendation for Resident 1 to receive a Physical Therapy (PT) evaluation, and RNA services for PROM of the BUE. During a review of Resident 1's RNA Administration dated 6/1/2025 to 6/30/2025, the RNA Administration indicated the RNA was to perform PROM to the residents BUE seven times a week as tolerated every day shift. The RNA Administration indicated there was no documentation present on 6/14/2025. During a review of Resident 1's RNA Administration dated 7/1/2025 to 7/31/2025, the RNA Administration indicated the RNA was to perform PROM to the residents BUE seven times a week as tolerated every day shift. The RNA Administration indicated there was no documentation present on 7/6/2025 and 7/13/2025. During an observation on 8/28/2025 at 11:03 AM, in Resident 1's room, RNA 2 was observed performing PROM exercises for Resident 1. RNA 2 was observed providing PROM to Resident 1's right upper extremity. RNA 2 was observed providing PROM to Resident 1's right shoulder, right elbow, and right wrist. RNA 2 was observed performing PROM of Resident 1's left upper extremity. RNA 2 was observed providing PROM to residents left shoulder, left elbow, left wrist, and left hand. During an interview on 8/28/2025 at 11:23 PM with RNA 2, RNA 2 stated she (RNA2) provided PROM to Resident 1's bilateral shoulders, elbows, wrists, and hands. RNA 2 stated she (RNA2) forgot to perform PROM on Resident 1's right hand. RNA 2 stated she (RNA2) was supposed to provide PROM on Resident 1's right hand but did not. RNA 1 stated it was important to perform PROM on Resident 1's hands so the resident's hands would not contract. During a concurrent interview and record review on 8/28/2025 at 11:55 AM, with PT 1, Resident 1's JMA dated 11/1/2024 and 5/27/2025 were reviewed. PT 1 stated changes in ROM were monitored through the JMAs. PT 1 stated JMA's were done on admission, quarterly, annually, and with a change of condition. PT 1 stated Resident 1 had a JMA done on 11/2/2024 and 5/27/2025. PT 1 stated after Resident 1's JMA dated 11/1/2024, Resident 1 should have had another JMA done in 2/2025 but did not have one done. PT 1 stated a lot could have happened in six months. PT 1 stated Resident 1's ROM could have gotten worse, and her joints could have gotten tighter and more painful. PT 1 stated he (PT1) performed Resident 1's JMA on 5/27/2025. PT 1 stated he (PT1) made a recommendation for Resident 1 to have a PT evaluation. PT 1 stated he (PT1) recommended a PT evaluation to determine the true integrity of Resident 1's joints. PT 1 stated Resident 1's JMA recommendation for a PT evaluation was not carried out. PT 1 stated once he (PT1) determined Resident 1 needed a PT evaluation he should have spoken to the Director of Rehab (DOR) and asked for a PT evaluation order. PT 1 stated it was important that JMA recommendations were carried out to ensure Resident 1 would not get worse. PT 1 stated he (PT1) performed resident JMAs through observation and interview. PT 1 stated he (PT1) performed JMAs by asking Certified Nursing Assistants (CNAs, in general) for information about the residents (in general). PT 1 stated he (PT1) did not touch the residents (in general) during JMAs. PT 1 stated PROM was not performed when Resident 1's JMA was done on 5/27/2025. PT 1 stated the integrity of a joint could not be determined by looking at the resident. During a 055161 Page 2 of 8 055161 08/28/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some concurrent interview and record review on 8/28/2025 at 1:15 PM, with the DOR, Resident 1's JMA dated 11/1/2024 and 5/27/2025 were reviewed. The DOR stated Resident1 did not have a JMA done in 2/2025. The DOR stated that JMAs were supposed to be done on admission, quarterly, annually, and with a change in condition. The DOR stated if a JMA was not done quarterly there could potentially be a gap in the resident's care. The DOR stated if a JMA was not done quarterly they wouldn't know if the resident had any changes in their ROM. The DOR stated when performing a JMA the PT was supposed to use PROM. The DOR stated that when performing PROM, the PT needed to touch the resident. The DOR stated a JMA could not be performed without moving and touching the resident. The DOR stated PROM had to be performed when doing a JMA to feel what had happened in the resident's joint. The DOR stated if a JMA was done without using PROM then the JMA was inaccurate. During an interview and record review on 8/28/2025 at 1:55 PM, with the Director of Staff Development (DSD), Resident 1's RNA Administration dated 3/1/2025 to 3/31/2025, 4/1/2025 to 4/30/2025, 5/1/2025 to 5/31/2025, 6/1/2025 to 6/30/2025, and 7/1/2025 to 7/31/2025 were reviewed. The DSD stated Resident 1 did not have RNA services done on 3/9/2025, 3/16/2025, 4/10/2025, 4/19/2025, 4/20/2025, 5/15/2025, 5/21/2025, 6/14/2025, 7/6/2025, and 7/13/2025. The DSD stated she (DSD) was not sure why RNA services were not done on these dates. The DSD stated it was important that Resident 1 be seen as the RNA as ordered by the physician. The DSD stated there was a potential for Resident 1 to have a decline in ROM if RNA services were not provided as ordered by the physician. 2. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 4/19/2024 with diagnoses that included spinal stenosis (a condition where the spinal canal, the bony tunnel that protects the spinal cord and nerve roots, becomes narrowed), type 2 diabetes, abnormalities of gait and mobility (deviations from a typical walking pattern, characterized by changes in balance, coordination, and the ability to move effectively), muscle weakness, osteoporosis, and repeated falls. During a review of Resident 3's MDS dated [DATE], the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 3 substantial/maximal assistance with eating, oral hygiene, toileting hygiene, showering, bathing herself, upper body dressing, lower body dressing, and personal hygiene. The MDS indicated Resident 3 was dependent on help for putting on and taking off footwear. During a review of Resident 3's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 8/9/2024 for the RNA to perform BUE Active Assisted Range of Motion (AAROM, a type of physical therapy exercise where the resident uses their own muscle strength to move a body part, but receives assistance from a therapist or device to achieve a greater or more comfortable range of motion) seven times a week or as tolerated every day shift. During a review of Resident 3's RNA Administration dated 3/1/2025 to 3/31/2025, the RNA Administration indicated the RNA was to perform BUE AAROM seven times a week or as tolerated everyday shift for Resident 3. The RNA Administration indicated there was no documentation for 3/8/2025, 3/11/2025, 3/18/2025, 3/30/2025. During a review of Resident 3's RNA Administration dated 4/1/2025 to 4/30/2025, the RNA Administration indicated the RNA was to perform BUE AAROM seven times a week or as tolerated every day shift for Resident 3. The RNA Administration indicated there was no documentation for 4/3/2025, 4/10/2025, and 4/28/2025. During a review of Resident 3's RNA Administration dated 5/1/2025 to 5/31/2025, the RNA Administration indicated the RNA was to perform BUE AAROM seven times a week or as tolerated every day shift for Resident 3. The RNA Administration indicated there was no documentation for 5/22/2025 and 5/26/2025. During a review of Resident 3's RNA Administration dated 7/1/2025 to 7/31/2025, the RNA Administration indicated the RNA was to perform BUE AAROM seven times a week or as tolerated every day shift for Resident 3. The RNA Administration indicated there was no documentation for 055161 Page 3 of 8 055161 08/28/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7/2/2025, 7/6/2025, 7/10/2025, and 7/15/2025. During an interview and record review on 8/28/2025 at 1:42 PM, with the Director of Staff Development (DSD), Resident 3's RNA Administration dated 3/1/2025 3/31/2025, 4/1/2025 to 4/30/2025, 5/1/2025 to 5/31/2025, and 7/1/2025 to 7/31/2025 were reviewed. The DSD stated Resident 1 did not have RNA services done on 3/8/2025, 3/11/2025, 3/18/2025, 3/30/2025, 4/3/2025, 4/10/2025, 4/26/2025, 5/22/2025, 5/26/2025, 7/2/2025, 7/6/2025, 7/10/2025, and 7/15/2025. The DSD stated she (DSD) was not sure why RNA services were not done on these dates. The DSD stated it was important that Resident 1 be seen by the RNA as ordered by Resident 3's physician. The DSD stated there was a potential for Resident 3 to have a decline in ROM if RNA services were not provided as ordered by the physician. During an interview on 8/28/2025 at 3:40 PM with the Director of Nursing (DON), the DON stated physician orders for RNA services should be followed. The DON stated RNA services help keep the residents from getting stiff. The DON stated if physician orders for RNA services were not followed the residents could become contracted. The DON stated JMAs are conducted on admission, quarterly, annually and as needed. The DON stated a JMA was used to assess if the resident had a decline in ROM. The DON stated if a JMA was not done quarterly the resident could have had a decline in ROM. The DON stated if there were recommendations for PT when a JMA was done, those recommendations should have been carried out. The DON stated the Resident 1's physician should have been notified of the PT's recommendations. The DON stated if recommendations were not carried out the resident could decline. The DON stated if the JMAs were conducted wrong and inaccurately, the resident would not get the care they needed and would potentially have a decline in ROM. During a review of the facility's Policy and Procedure (P&P) titled Resident Mobility and Range of Motion dated 7/2017, the P&P indicated Residents will not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. During a review of the facility's P&P titled Charting and Documentation dated 7/2017, the P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of the facility's P&P titled Restorative Nursing Services dated 7/2017, the P&P indicated Resident will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies) During a review of the facility's P&P titled Screening dated 6/2023, the P&P indicated It is the policy of this Rehabilitation Department to complete patient screenings periodically, dependent on the facility policy for screens.The Joint Mobility Screening form is to be completed by PT and/or OT.Types of Screens: Admission, Re-admission, Quarterly, Annually, Change of Condition, Post-fall.Quarterly and Annual screens (both Rehabilitation and/or Joint Mobility Screening forms) may be done as per facility policy and in conjunction with the MDS assessment schedule. During a review of the facility's Job Description titled Certified Nursing Assistant dated 10/2020, the Job Description indicated Perform restorative and rehabilitative procedures as instructed in accordance with the individualized plan of care. During a review of the facility's P&P titled Specialized Rehabilitative Services dated 1/2025, the P&P indicated Our facility will provide rehabilitative services to residents as indicated by the MDS. In addition to rehabilitative nursing care, the facility provides specialized rehabilitative services by qualified professional personnel. Specialized rehabilitative services include the following: Physical therapy; Speech pathology/audiology; Occupational /activity therapy. Therapeutic services are provided only upon 055161 Page 4 of 8 055161 08/28/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0688 the written order of the resident's attending physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055161 Page 5 of 8 055161 08/28/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure to conduct the Joint Mobility Assessment (JMA, a tool that evaluates a joint's ability to move through its full range of motion by measuring flexibility, stiffness, and quality of movement) accurately for one of four sampled residents (Resident 1).This failure had the potential for Resident 1 to experience a decline in Range of Motion (ROM, full movement potential of a joint).Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/2/2024, the MDS indicated the resident had severe cognitive impairment (a significant decline in the ability to think, understand, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent on help for showering, bathing herself, lower body dressing, putting on footwear, and taking off footwear. During a review of Resident 1's JMA dated 5/27/2025, the JMA indicated Resident 1 had minimal - severe loss of lower extremity Passive Range of Motion (PROM, movement at a given joint with full assistance from another person). The JMA indicated the resident had a diagnosis/condition that put her at risk for contracture development. The JMA indicated a recommendation for Resident 1 to receive a Physical Therapy (PT) evaluation, and RNA services for PROM of both upper extremities (BUE, arms). During a concurrent interview and record review on 8/28/2025 at 11:55 AM, with Physical Therapist 1 (PT 1), Resident 1's JMA dated 5/27/2025 was reviewed. PT 1 stated he (PT1) performed Resident 1's JMA on 5/27/2025. PT 1 stated he (PT1) performed resident JMAs through observation and interview. PT 1 stated he (PT1) performed JMAs by asking Certified Nursing Assistants (CNAs in general) for information about the residents (in general). PT 1 stated he (PT1) did not touch the residents (in general) during JMAs. PT 1 stated PROM was not performed when Resident 1's JMA was done on 5/27/2025. PT 1 stated the integrity of a joint could not be determined by looking at the resident. During a concurrent interview and record review on 8/28/2025 at 1:15 PM, with the Director of Rehab (DOR), Resident 1's JMA dated 5/27/2025 was reviewed. The DOR stated when performing a JMA the PT was supposed to use PROM. The DOR stated that when performing PROM, the PT needed to touch the resident. The DOR stated a JMA could not be performed without moving and touching the resident. The DOR stated PROM had to be performed when doing a JMA to feel what had happened in the resident's joint. The DOR stated if a JMA was done without using PROM then the JMA was inaccurate. During an interview on 8/28/2025 at 3:40 PM with the Director of Nursing (DON), the DON stated if the JMAs were conducted inaccurately, the resident would not get the care they needed. The DON stated if the JMA was conducted inaccurately the resident would potentially have a decline in ROM. During a review of the facility's P&P titled Charting and Documentation dated 7/2017, the P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 055161 Page 6 of 8 055161 08/28/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement and maintain infection control procedures for two of four sampled residents (Residents 2 and Resident 3) by failing to:-Ensure Restorative Nursing Aide 1 (RNA 1) cleaned and disinfected a gait belt (safety device worn around the waist that can be used to help safely transfer a person from one surface to another) in between use for Resident 2 and Resident 3.-Ensure RNA 1 used the appropriate cleaning agent to effectively clean and disinfect a cloth gait belt after providing Restorative Nursing Aide services (RNA, nursing aide program that helps residents maintain their function and joint mobility) services to Resident 2 and Resident 3.These failures placed Resident 2 and Resident 3 at risk for potential infections that could cause a decline in the residents' health and quality of life.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 6/28/2025 with diagnoses including a local infection of the skin and subcutaneous tissue (layer of fat, connective tissue, and blood vessels that lies beneath the skin), acquired absence (the loss or removal of a body part or organ that was not present from birth but occurred later in life due to injury, trauma, disease, or surgery) of the toes on both feet, and Type 2 Diabetes Mellitus (condition in which the body does not metabolize blood sugar correctly) with diabetic neuropathy (nerve damage caused by diabetes). During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 4/19/2024 with diagnoses including spinal stenosis (narrowing of the space within the spine that contains the spinal cord and nerve roots), muscle weakness, and gout (form of arthritis that occurs when uric acid builds up in the blood and causes joint inflammation). During an observation on 8/27/2025 at 11:17 am, in the hallway, RNA 1 was observed assisting Resident 2 with walking exercises using a knee scooter (wheeled mobility aid with a padded platform to support the injured leg and handlebars for steering and braking). RNA 1 held onto Resident 2's cloth gait belt which was fastened around his waist. At the end of the session, RNA 1 removed the cloth gait belt from Resident 2's waist, placed the gait belt on top of a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking) which was in the hallway next to Resident 2's room, walked to the bathroom with the FWW and gait belt, came back into the hallway, and walked to Resident 3's room. RNA 1 did not clean and disinfect the cloth gait belt. RNA 1 walked into Resident 3's room, assisted Resident 3 with dressing activities seated in a wheelchair, transported Resident 3 into the hallway, placed the cloth gait belt previously used on Resident 2 onto Resident 3's waist, and assisted Resident 3 with walking exercising using a FWW in the hallway. At the end of the session, RNA 1 removed the cloth gait belt from Resident 3's waist, performed hand hygiene, and wiped down the cloth gait belt and FWW with disinfecting wipes. During an interview on 8/27/2025 at 11:32 am with RNA 1, RNA1 stated she (RNA1) did not clean and disinfect the cloth gait belt after she (RNA1) used it with Resident 2 and before she (RNA1) used it again with Resident 3. RNA 1 stated she (RNA1) should have cleaned and disinfected the cloth gait belt in between resident use but did not. RNA 1 stated the RNAs (in general) were instructed to use the disinfectant wipes to disinfect all equipment which included cloth gait belts. RNA 1 stated it was important to disinfect shared equipment between residents to prevent the spread of infection. During a concurrent interview and record review on 8/27/2025 at 2 pm, the Infection Preventionist Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) stated all shared resident equipment must be cleaned and disinfected in between and after each resident use. The IPN stated staff (in general) used Super Sani-Cloth disinfectant wipes to disinfect shared equipment which included cloth gait belts. The IPN stated cloth gait belts were made of porous Residents Affected - Few 055161 Page 7 of 8 055161 08/28/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (having small spaces or holes through which liquid or air may pass) material. The IPN reviewed the Super Sani-Cloth disinfectant wipes manufacturing instructions and confirmed the disinfectant wipes could only effectively be used on hard, non-porous surfaces. The IPN stated Sani-Cloth disinfecting wipes were ineffective for disinfecting cloth gait belts because they were made of soft, porous materials. The IPN stated the only way to properly clean and disinfect cloth gait belts was to launder them after each resident use. The IPN stated it was important to clean and disinfect shared equipment properly and according to manufacturer's instructions to maximize infection control, ensure the cleaning was effective, and to prevent the spread of infection. During an interview on 8/28/2025 at 3:40 pm with the Director of Nursing (DON), the DON stated staff (in general) must clean and disinfect all shared equipment in between and after each resident use. The DON stated it was important to clean and disinfect shared equipment using the appropriate cleaning agent and according to manufacturer's instructions to prevent the spread of infection. During a review of the Super Sani-Cloth manufacturer's instructions, titled General Guidelines for Use, dated 2021, the guidelines indicated the disposable wipes disinfected surfaces in two minutes and were to be used on hard, non-porous environmental surfaces. During a review of the facility's Policy and Procedures (P/P), titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 1/2025, the P/P indicated reusable items were cleaned and disinfected or sterilized between residents. The P/P indicated reusable resident care equipment was decontaminated and/or sterilized between residents according to manufacturer's instructions. 055161 Page 8 of 8