Health inspection·March 14, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on interview and record review, the facility failed to ensure one of 49 sampled residents (Resident 37) reported loss of personal belongings was investigated. This failure resulted in not recovering Resident 37's lost of personal belongings and had the potential for the recurrence of lost personal belongings of other residents. Findings: During an interview on 3/12/24 at 10:53 a.m. with Resident 37, Resident 37 stated he had reported a loss of clothing (two shirts and two pajama pants) to social services over four months ago and the issue had not yet been resolved. During an interview on 3/13/24 at 1:40 p.m. with Social Service Designee (SSD), SSD stated, I am aware of the lost personal belongings, some shirts [for Resident 37]. SSD stated Social Service Manager (SSM) and I handle the grievance process together and the SSM was handling this issue with Resident 37. During an interview on 3/13/24 at 1:53 p.m. with SSM, SSM stated he recalled Resident 37 verbally telling him about his loss of two shirts and two pajama bottoms around December 23, 2023. SSM stated it slipped his mind and he had not documented, investigated, or replaced Resident 37's reported loss of personal items. During a review of the facility's policy and procedure (P&P) titled, Investigating Incidents of Theft and /or Misappropriation of Resident Property, dated 4/2021, the P&P indicated, All reports of exploitation, theft or misappropriation of resident property are promptly and thoroughly investigated. Page 1 of 11 555877 555877 03/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure five of 49 sampled residents (Resident 15, Resident 32, Resident 108, Resident 259, and Resident 260) were provided a copy of the facility's admission policies and procedures (P&P) upon admission. This failure had the potential for residents to be unaware of the facilities policies, financial obligations, and their rights. Findings: During an interview on 3/11/24 at 3:54 p.m. with Social Service Designee (SSD), SSD stated she is responsible for completing admission packets with resident and family upon admission. SSD stated the Administrator would fill out the packet but she would review it with the Resident and family and obtain their signatures. During a concurrent interview and record review on 3/12/24 at 8:15 a.m. with SSD, the facility's New Admissions in the Last 30 days who are still residing in the facility was reviewed. SSD stated Resident 15 was admitted on [DATE] and the California Standard admission Agreement for Skilled Nursing Facilities . (CSAG) was completed on 3/11/24 (31 days after admission). Resident 32 was admitted on [DATE] and the CSAG had not been completed (33 days after admission). Resident 108 was admitted on [DATE] and the CSAG had not been completed. (20 days after admission). Resident 259 was admitted on [DATE] and the CSAG was completed on 3/11/24 (10 days after admission). Resident 260 was admitted on [DATE] and the CSAG had not been completed (18 days after admission). During an interview on 3/12/24 at 8:25 a.m. with Administrator In Training (AIT), AIT stated she completes the admission packet and the admission packet should be reviewed with the family and resident within forty-eight hours after admission. During a review of the facility's P&P titled, admission Policies, dated 12/2006, the P&P indicated, Written policies and procedures governing admissions to the facility will be maintained on a current basis to ensure fair and impartial admission practices. 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. 3. The objectives of our admission policies are to: a. provide uniform guidelines in the admission of residents to the facility; b. admit residents who can be adequately care for by the facility; c. reduce the fears and anxieties of the resident and family during the admission process; d. review with the resident/or his/her representative (sponsor), the facility's policies and procedures relating to resident rights, resident care, financial obligations, visiting hours, etc.; and e. assure that appropriate medical and financial records are provided to the facility prior to or upon the resident's admission. 4. It shall be the responsibility of the administrator, through the admissions department, to assure that the established admission policies, as they may apply, are followed by the facility and resident. 555877 Page 2 of 11 555877 03/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of 49 sampled residents (Resident 22 and Resident 309) were provided assistance with ADLs (ADL-tasks of everyday life including eating, dressing, getting in or out of a bed or chair, and bathing) when: Residents Affected - Few 1. Resident 22 was not provided assistance with the use of her hearing aides. This failure resulted in Resident 22 not being able to communicate with the staff regarding her needs. 2. Resident 309 did not receive Restorative Nursing Assistant (RNA- nursing interventions that promote the ability to adapt and adjust to living as independently and safely as possible) treatments for three days. This failure had the potential for Resident 309 to have a decline in his ability to perform activities of daily living. Findings: 1. During a concurrent observation and interview on 3/11/24 at 10:37 a.m. in Resident 22's room, Resident 22 touched inside her ears and stated she was hard of hearing and wears hearing aides, and did not have them on. During an interview on 3/13/24 at 9:02 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she thought Resident 22 wore hearing aides when she first arrived at the facility but was not sure. CNA 1 stated she did not know where the hearing aides were located and stated Resident 22 was not wearing her hearing aides. During a review of Resident 22's Minimum Data Set (MDS - assessment of all residents in nursing homes), dated 1/28/24, Resident 22's Section B - Hearing, Speech, and Vision indicated, Resident 22 wears hearing aides. During a review of Resident 22's Plan of Care (POC), dated 1/23/24, the POC indicated, Problems/Strengths Hearing - Hearing deficit: Goals Will wear hearing aids x (times) 90 days. During an interview on 3/13/24 at 9:41 a.m. with Director of Nursing (DON), DON stated Resident 22 should be wearing her hearing aides. During a review of the facility's policy and procedure (P&P) titled, Assistive Devices and Equipment, dated 1/2020, the P&P indicated, Our facility maintains and supervises the use of assistive devices and equipment for residents. 3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. 2. During a review of Resident 309's Record of admission (ROA), dated 3/6/24, the ROA indicated, Admitting .Diagnoses . Strain of muscle(s) and tendon(s) .Paraplegia. During an interview with Resident 309 on 3/12/24 at 8:45 a.m. Resident 309 stated he had not received any therapy since admission on [DATE]. Resident 309 stated he was admitted to the facility for rehabilitation therapy (restoring someone to health through therapy). 555877 Page 3 of 11 555877 03/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 3/13/24 at 8:50 a.m. with DON, Resident 309's Physician Telephone Order (PTO), dated 3/7/24 was reviewed. The PTO indicated, RNA 5x/wk x 15 min per day [five times a week for 15 minutes each day] for 30 days as tolerated for RUE [right upper extremity] PROM [passive ROM- range of motion- how far a part of the body can move. Passive ROM- the patient does not perform any movement themselves; the RNA moves the limb around the stiff joint, gently stretching muscles] /AAROM [Active-assistive ROM- requires some help to move the joint to ensure further injury or damage does not occur] and BLE [bilateral lower extremity both legs]. DON stated Resident 309 should have received RNA treatments and did not. During a concurrent interview and record review on 03/13/24 at 9:46 a.m. with Occupational Therapist (OThelp clients meet goals to develop, recover, improve, and maintain skills needed for daily living and working) Resident 309's Interdisciplinary Progress Notes (IPR), dated 3/7/24 was reviewed. The IPR indicated, Screened for RNA ROM. OT stated she evaluated Resident 309 on 3/7/24 and recommended Resident 309 have PROM. OT stated she informed the Nurse Practitioner (NP), the Minimum Data Set Nurse (MDSNcollects and assesses information for the health and well-being of residents) and the Quality Assurance Registered Nurse (QARN) on 3/7/24 of her recommendation for RNA. OT stated she received a telephone order from the NP for RNA, and OT entered the order in Resident 309's medical record. During a concurrent interview and record review on 3/13/24 at 10:47 a.m. with RNA 1 and the Director of Staff Development (DSD), Resident 309's electronic medical record (EMR) was reviewed. The EMR did not indicate RNA was provided to Resident 309 on 3/8/24, 3/11/24, and 3/12/24. RNA 1 and the DSD stated if the RNA treatment was done, it would be documented in the EMR. DSD and RNA 1 confirmed the EMR did not indicate an RNA treatment for Resident 309 on 3/8/24, 3/11/24, or 3/12/24. RNA 1 stated RNA treatments should have been provided to Resident 309 on those three days and documented in the EMR. During a concurrent interview and record review on 3/13/24 at 2:25 p.m. with RNA 1, the facility's RNA Daily Worksheet (RNADW), dated 3/10/24-03/16/24 were reviewed. The RNADW indicated, . [Resident 309] ROM RUE PROM/AAROM/BLE PROM as tolerated 5X/wk x 15 min x 30 days. RNA 1 stated the RNADW is a document the facility uses to communicate with the RNAs about resident RNA treatments. RNA 1 stated RNA 2 should have printed the RNADW on 3/8/23 with dates 3/3/2024-3/9/2024 and provided RNA treatment to Resident 309 on 3/8/24. RNA 2 should have printed out the RNADW on 3/11/24 and provided RNA treatment to Resident 309 on 3/11/24 and 3/12/24. During a concurrent interview and record review on 03/14/24 at 08:42 a.m. with QARN, the RNADW dated 3/10/24-3/16/24 were reviewed. QARN stated she was not aware if RNA treatment was provided to Resident 309 on 3/8/24, 3/11/24, and 3/12/24 and she confirmed that RNA treatments were not documented. During a review of the facility's Criteria-Based Job Description (JD), for RNA, revised 6/30/21, the JD indicated, 3c. Promotes restorative nursing care as directed and instructed for individual patients . 4c. Records pertinent patient care activity information on appropriate flow sheets in an accurate/timely manner. 555877 Page 4 of 11 555877 03/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to develop and implement an action plan in the facility's Quality Assessment and Performance Improvement (QAPI), when the Pharmacist had identified significant medication errors during his monthly Medication Regiment Review (MRR) for 13 of 49 sampled residents (Resident 13, Resident 14, Resident 24, Resident 25, Resident 31, Resident 37, Resident 38, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, and Resident 51). This failure resulted in residents not receiving accurate medications and had the potential to cause adverse reactions from medications. Findings: During a concurrent interview and record review on 3/14/24 at 8:31 a.m. with Director of Nursing (DON), the facility's Consultant Pharmacist's Medication Regimen Review (CPMRR), book dated 5/2023, 6/2023, 7/2023, 11/2023, and 12/2023 were reviewed. The CPMRR indicated the following medication errors per month: 5/20/2023, 3 errors Resident 48 - Order: Novolin R (insulin - control blood sugar) 100 u/ml (unit/milliliter) per low dose sliding scale: BS (blood sugar) < . 121-150=2 units, 150-200=3 units . 251-300 units=6 units . 1). A dose of 2 units was inappropriately administered for a documented BS of 154 mg/dl which is an insufficient dose. 2). A dose of 4 units was insufficiently administered for a documented BS of 263 mg/dl. Resident 49 - Order: Ibuprofen (pain medication) 600 mg (milligram) 1 tablet q (every) 8 h (hour) prn (as needed) pain 1 to 4 3). Medication was inappropriately administered once when pain scale was 6. 6/2023, 7 errors Resident 24 - Order: Clonidine (treat high blood pressure) 0.1 mg q 8 h (hold for SBP [systolic blood pressure]<110) 1. Clonidine was given on 5/25/23 at 6 am when SBP was 109 2. Clonidine was given on 5/23/23 at 2 pm when SBP was 108 3. Clonidine was given on 6/1/23 at 10 pm when SBP level was not being recorded. Resident 37 - Order: Novolin R (insulin) inject subQ (subcutaneously [beneath the skin]) before meals and at bedtime BS<120 = 0 units. 151-200 = 6 units; 201- 250 = 8 units;.301-350 = 12 units; . 4. 10 units of insulin was given on 5/22/23 at 11 am when BS was 248 555877 Page 5 of 11 555877 03/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0867 5. 4 units of insulin was given on 5/20/23 at 4 pm when BS was 362 Level of Harm - Minimal harm or potential for actual harm 6. 7 units of insulin was given on 6/5/23 at 4 pm when BS was 177. Residents Affected - Many Order: Acetaminophen/Oxycodone (APAP-pain medication) 325-5 mg one tab (tablet) q4h prn pain 5-10 (NTE [not to exceed] 3 grams of APAP in 24 hours) 7. Acetaminophen/Oxycodone 325-5 mg was given on 5/15/23 when pain level was 2. 7/2023, 5 errors Resident 47 - Order: Novolin R subQ before meals and nightly BS< 120 = 0 units; 121-150 = 4 units; 151-200 = 5 units. 1. 4 units of insulin was given on 7/7/23 at 11:30 am when blood sugar was 172; 2. 5 units of insulin was given on 7/7 23 at 9 pm when blood sugar was 128 Resident 38 - Order: Ibupropen 800 mg - one tab by mouth every 8 hours as needed for pain 1-4 3. Ibuprofen was given on 6/21/23 when pain level was 5; 4. Ibuprofen was given on 6/23/23 when pain level was 5; 5. Ibuprofen was given on 7/2/23 when pain level was 6. 11/2023, 19 errors Resident 51 - Order: Acetaminophen/Hydrocodone (pain medication) 325-5mg - one tablet by mouth every 6 hours as needed for pain 3-5. 1. Acetaminophen/Hydrocodone was given on 10/19/23 at 9:30 pm when pain level was 7; 2. Acetaminophen/Hydrocodone was given on 10/23/23 at 4:58 pm when pain level was 7; 3. Acetaminophen/Hydrocodone was given on 10/24/23 at 9:33 pm when pain level was 7; 4. Acetaminophen/Hydrocodone was given on 10/31/23 at 10:18 am when pain level was 7; 5. Acetaminophen/Hydrocodone was given on 10/31/23 at 4:25 pm when pain level was 8; 6. Acetaminophen/Hydrocodone was given on 11/5/23 at 8:41 am when pain level was 6; 7. Acetaminophen/Hydrocodone was given on 11/6/23 at 8:54 am when pain level was 7; 8. Acetaminophen/Hydrocodone was given on 11/7/23 at 10:20 am when pain level was 7; 9. Acetaminophen/Hydrocodone was given on 11/7/23 at 9:32 pm when pain level was 7; 555877 Page 6 of 11 555877 03/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0867 10. Acetaminophen/Hydrocodone was given on 11/9/23 at 5:41 pm when pain level was 6. Level of Harm - Minimal harm or potential for actual harm Resident 45 - Order - Humulin R inject before meals BS<121 = 0 units; . 201-250 = 4 units; . 351-400 = 10 units. Residents Affected - Many 11. 6 units of insulin was given on 11/7/23 at 6 am when BS was 364; 12. 3 units of insulin was given on 10/25/23 at 11 am when BS was 217 13. 6 units of insulin was given on 11/5/23 at 16:00 (4 pm) when BS was 246. Resident 13 - Order - Furosemide (diuretic - water pill) 40 mg - one tablet oce daily, hold for SBP < 90 . 14. Furosemide was given on 10/14/23 when SBP was 12 could be a documentation error. Order - Percocet 325/5 mg - one tab by mouth every 6 hours as needed for pain 6-10. 15. Percocet given on 11/12/23 at 17:00 (5 pm) without pain level being documented. Order - Novolin R - inject before meals and at night BS < 120 - 0 units . 201-250 = 6 units; 251-300 = 8 units . 16. 8 units of insulin was given on 11/1/23 at 11 am when BS was 202; 17. 10 units of insulin was given on 10/18/23 at 16:00 when BS was 268; 18. 4 units of insulin was given on 10/14/23 at 16:00 when BS was 212; 19. 8 units of insulin was given at 16:00 when BS was 227. 12/2023, 21 errors Resident 13 - Order - Novolin R - inject before meals and at bedtime BS< 120 = 0 units; .151-200 = 5 units; 201-250 = 6 units; . 1. On 11/19/23 at 4 pm, BS was 224, but 4 units of insulin was incorrectly given; 2. On 11/29/23 at 4 pm, BS was 176, but 6 units of insulin was incorrectly given; 3. On 11/23/23 at 9 pm, BS was 178, but 6 units of insulin was incorrectly given. Resident 14 - Order - Acetaminophen 325 mg - 2 tabs po q 6h prn for pain 1-3. 4. Acetaminophen was given on 11/29/23 when pain level was 8. Resident 31 - Order - Humulin R - inject before meals and at bedtime BS<120 = 0 units . 301-350 = 12 units; 351-400 = 14 units; >400 = 16 units and call provider . 555877 Page 7 of 11 555877 03/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0867 5. On 11/16/23, at 4 pm, BS was 399, but 2 units of insulin was incorrectly given; Level of Harm - Minimal harm or potential for actual harm 6. On 11/28/23 at 9 pm, BS was 437, but 14 units of insulin was incorrectly given; 7. On 11/29/23 at 9 pm, BS was 325 but 14 units of insulin was incorrectly given. Residents Affected - Many Resident 45 - Order - Humulin R - before meals and at bedtime BS<121 = 0 units . 251-300 = 6 units . 8. On 11/17/23 at 11 am, BS was 251, but 10 units of insulin was inappropriately given; 9. On 12/13/23 at 11 am, BS was 260, but 4 units of insulin was inappropriately given. Resident 25 - Order - Acetaminophen 325 mg - 2 tabs q6h prn for pain 1-3 . 10. On 12/5/23, Acetaminophen was given without pain level being specified. Resident 46 - Order - Midodrine (treat low blood pressure) 10 mg - one tablet by mouth 3 times daily (hold for SBP >110). 11. On 11/30/23 at 6 am, Midodrine was given when SBP was 121; 12. On 12/01/23 at 6 am, Midodrine was given when SBP was 128; 13. On 11/24/23 at 12 pm, Midodrine was given when SBP was 120; 14. On 11/30/23 at 12 pm, Midodrine was given when SBP was 120; 15. On 12/3/23 at 12 pm, Midodrine was given when SBP was 125; 16. On 12/4/23 at 12 pm, Midodrine was given when SBP was 124; 17. On 12/8/23 at 12 pm, Midodrine was given when SBP was 116; 18. On 12/10/23 at 12 pm, Midodrine was given when SBP was 116; 19. On 12/13/23 at 12 pm, Midodrine was given when SBP was 112; 20. On 11/17/23 at 6 pm, Midodrine was given when SBP was 143; 21. On 11/30/23 at 6 pm, Midodrine was given when SBP was 138. DON stated the pharmacist reviews the monthly medication regimen review and if the pharmacist makes recommendations, the Quality Assurance Registered Nurse (QARN) reviews the recommendations and gives copies to the DON with the recommendations. DON stated she also reviews the recommendations and informs the Director of Staff Development (DSD) to provide in-services to the nursing staff regarding medication administration. During an interview on 3/14/23 at 9:06 a.m. with QARN, QARN stated she reviews the CPMRR and gives 555877 Page 8 of 11 555877 03/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0867 Level of Harm - Minimal harm or potential for actual harm the pharmacy recommendations to the Nurse Practitioner (NP). The NP reviews the recommendations, indicating if he agrees or disagrees with the recommendations and why. QARN gives the DON the NP's recommendations. QARN stated she collects the data from the CPMRR indicating the identified errors. QARN stated she had not created data analysis. QARN stated she had reported the medication errors to QAPI but no action plan had been implemented. Residents Affected - Many During a concurrent interview and record review on 3/14/24 at 10:01 a.m. with Administrator, Administrator in Training (AIT), and QARN, the Quality Assurance and Assessment Committee Agenda (QAACA), dated 1/18/24 was reviewed. The QAACA indicated, the facility had not implemented a corrective action plan or performance improvement project to improve the re-occurrences of medication errors. QARN stated they should have been tracking the trends of medication errors. Administrator stated the Pharmacist had reported to QAPI about the medication errors that were discovered during CPMRR. Administrator stated they had not developed or implemented a corrective action plan to monitor the medication errors found by the pharmacist. During a review of the facility QAPI Plan, dated 1/18/24, the QAPI plan indicated, Our QAPI plan includes the policies and procedures used to: Identify and use data to monitor or performance Establish goals and thresholds for our performance measurement Utilize resident, staff, and family input Identify and prioritize problems and opportunities for improvement Systematically analyze underlying causes of systematic problems and adverse events Develop corrective action or performance improvement activities. When the need is identified, we will implement corrective action plans or performance improvement project to improve processes, systems, outcomes and satisfaction. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 2020, the P&P indicated, Implementation. 1. The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurement; c. identifying and prioritizing quality deficiencies; 555877 Page 9 of 11 555877 03/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0867 d. systematically analyzing underlying causes of systemic quality deficiencies; Level of Harm - Minimal harm or potential for actual harm e. developing and implementing corrective action or performance improvement activities; Residents Affected - Many f. monitoring or evaluating the effectiveness or corrective action/performance improvement activities and revising as needed. 555877 Page 10 of 11 555877 03/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

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 ensure infection control measures were done for two of 49 sampled residents (Resident 10 and Resident 32) when: Residents Affected - Few 1. Certified Nursing Assistant (CNA) 2 did not assists Resident 10 with hand hygiene before eating. This failure had the potential to adversely affect Resident 10's health. 2. Licensed Vocational Nurse (LVN) did not wash her hands before and after wound treatment to Resident 32's wound in the coccyx (tailbone). This failure had the potential to result in infection of Resident 32's wound in the coccyx. Findings: 1. During a concurrent observation and interview on 3/11/24 at 12:31 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 10's room, CNA 2 delivered Resident 10's lunch tray without providing hand hygiene to Resident 10 who eats with her hands. CNA 2 stated she should have provided hand hygiene for Resident 10 before delivering her lunch tray. During an interview on 3/11/24 at 12:58 p.m. with Resident 10, Resident 10 stated she had not had her hands washed before her lunch tray was brought out to her. She also stated she likes to eat with her hands due to difficulty seeing. During a review of the facility's policy and procedure (P&P) titled, Assisting the Resident with In-Room Meals, dated 2013, the P&P indicated, 8. Be sure the resident is prepared to receive the meal (i.e., offered bedpan or urinal, face and hands washed, hair combed. etc.). 2. During an observation on 3/14/24 at 9:53 a.m. in Resident 32's room, Licensed Vocational Nurse (LVN) was changing Resident 32's dressing of the wound to coccyx area. LVN removed the wound dressing, discarded it and then changed her gloves. LVN did not wash her hands after removing the soiled gloves and before putting on clean gloves. During an interview on 3/14/24 at 9:55 a.m. with LVN, LVN stated she did not wash her hands before putting new gloves prior to treatment and washing hands after treatment. LVN also stated, No. I did not. I should have. Sorry. During a concurrent interview and record review with the Director of Staff Development (DSD), the facility's P&P titled, Dressings, Dry/Clean, dated 2013 was reviewed. The P&P indicated, Steps in the Procedure . 7. Pull gloves over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. DSD stated, She should have washed her hands prior to putting on clean gloves. 555877 Page 11 of 11