Health inspection·November 10, 2025

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, medical record review, and facility policy review the facility failed to maintain infection control practices by failing to perform hand hygiene during meal tray service. This affected three of three (Resident #39, #40 and #43) residents observed during meal service. This had the potential to affect all thirteen residents residing on the Yass 2 unit. The facility census was 76.Findings include: 1. Record review of Resident #39's medical record revealed an admission date of 02/07/24. Diagnoses include unspecified dementia, Type II Diabetes Mellitus with chronic kidney disease, Crohn's disease, colostomy status, chronic kidney disease stage III, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic heart failure, repeated falls and cognitive communicative deficit.Review of Resident #39's Minimum Data Set 3.0 dated 08/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.Observation on 10/29/25 at 12:15 P.M. revealed during tray service certified nursing assistant (CNA) #100 entered Resident #39's room and assisted with raising the head of the bed (HOB) and then assisted with the meal tray set up and left room without performing hand hygiene. CNA #100 was then observed to open and reach into the meal delivery cart for another tray. A blue hand sanitizer bottle was observed located on top of the meal deliver cart. Interview on 10/29/25 at 12:37 P.M. with CNA #100 verified they had not used hand hygiene during lunch tray pass.2. Record review of Resident # 43's medical record revealed an admission date of 05/04/25. Diagnoses include unspecified mild dementia, unilateral primary arthritis right knee, chronic kidney disease stage III, Type II Diabetes Mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease stage I through IV, peripheral vascular disease, gastro-esophageal reflux disease without esophagitis, and history of falling.Review of Resident #43's Minimum Data Set 3.0 dated 09/19/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had cognitive impairment. Observation on 10/29/25 at 12:20 P.M. revealed CNA #100 did not perform hang hygiene prior to entering Resident #43's room and assisting with raising the HOB and meal tray set up. CNA # 100 left Resident #43's room without performing hand hygiene.Interview on 10/29/25 at 12:37 P.M. with CNA #100 verified they had not used hand hygiene during lunch tray pass. 3. Record review of Resident #40's medical record revealed an admission date of 02/29/24. Diagnoses include unspecified dementia, left hand contracture, hypertensive heart and chronic kidney disease with heart failure and stage I through IV chronic kidney disease, history of falling, orthostatic hypotension, essential primary hypertension, cerebral ischemia, and cognitive communicative deficit.Review of Resident #40's Minimum Data Set 3.0 dated 10/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 03 indicating the resident had severe cognitive impairment.Observation on 10/29/25 at 12:27 P.M. revealed STNA #100 remove a clear plastic bag with linen from a chair to sit near Resident #40 in the dining room and did not perform hand hygiene prior to performing meal tray set up for Resident #39 and feeding the resident.Interview on 10/29/25 at 12:37 P.M. with CNA #100 verified they had not used hand hygiene during lunch tray pass.Review of the facilities Infection Control policy dated 11/28/16 and revised 03/25 verified it is the policy of the community to establish guidelines to follow to facilitate maintaining a safe, sanitary and comfortable environment; to proactively prevent and manage transmission of diseases and infections; to identify, reduce, control or prevent the risks of acquiring and transmitting infections among residents, employees, volunteers, visitors and other. The policy also states hand hygiene policies will be followed by all employees. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 2 of 2