Health inspection·December 13, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy for 1 of 5 residents (Resident #3) reviewed for resident rights, in that: Residents Affected - Some The facility failed to ensure CNA A and LVN B completely closed Resident #3's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #3's face sheet, dated 12/12/2024, revealed an admission date of 05/28/2007 and, a readmission date of 05/07/2014, with diagnoses which included: Dementia (decline in cognitive abilities), Epilepsy (Neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions), Moderate intellectual disabilities, and Psychosis (Difficulties determining what is real and what is not real). Record review of Resident #3's Quarterly MDS assessment, dated 09/10/2024, revealed the resident had a BIMS score of 00, which indicated he was severely cognitively impaired. Resident #3 was always incontinent of bladder and bowel and, required total care with his ADLs. Record review of Resident #3's care plan, dated 02/09/2022, revealed a problem of I have bowel/bladder incontinence related to Disease Process and at risk for skin breakdown, with an intervention of INCONTINENT: provide incontinent care as needed for incontinent episodes. Observation on 12/12/24 at 10:25 a.m. revealed CNA A and LVN B did not completely close the privacy curtains while they provided incontinent care for Resident #3, exposing the resident who could be seen from the room's door. During an interview with CNA A and LVN B on 12/12/2024 at 10:40 a.m., they confirmed the privacy curtains was not completely closed while they provided care for Resident #3 but it should have been. They stated they received resident rights training within the year. During an interview with the DON on 12/12/2024 at 2:20 p.m., the DON confirmed privacy must be provided during nursing care and Resident #3's privacy curtains should have been closed completely. She stated the staff had received training on resident rights within the year and the training was provided by the ADONs and herself. They also checked the staff skills annually and as needed. Review of Facility's policy titled Certified Nurse Aide Standards of Clinical Practice dated Page 1 of 13 676138 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0583 January 2023, revealed we believe that each resident has the right to be treated with dignity and respect and that privacy be maintained during procedures. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676138 Page 2 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 18 residents (Residents #30 and #59) reviewed for care plans. 1. The facility failed to revise Resident #30's comprehensive care plan to reflect the resident's change in cognitive status. 2. The facility failed to revise Resident #59's comprehensive care plan to reflect the resident's discontinued use of anti-depressant medication. These deficient practices could cause confusion for staff members responsible for providing direct care for residents and medication administration and place residents at risk of receiving improper care. The findings were: 1. Record review of Resident #30's face sheet, accessed on 12/11/2024, revealed the resident was an [AGE] year old female admitted to the facility on [DATE] and again on 08/11/2024 with diagnoses including hypokalemia (a condition where the potassium levels in the blood are lower than normal), cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die), and type II diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin, leading to high blood sugar levels). Record review of Resident #30's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, indicating the resident had full cognition. Record review of Resident #30's comprehensive care plan, last review completed 12/06/2024, revealed a focus area indicating: I have impaired cognitive function or impaired thought process r/t CVA. LOW BIMS SCORE 8. Date Initiated: 06/11/2024. Created on: 06/11/2024. Created by: ADON. Revision on: 06/27/2024. The goal was to maintain the current level of cognitive function, and interventions/tasks included keeping the resident's routine consistent and to provide consistent caregivers as much as possible to reduce confusion, administer medications as ordered, ask yes/no questions and break tasks into one step at a time. During an interview on 12/12/2024 at 12:45 PM, the ADON stated Resident #30's comprehensive care plan did not reflect her current cognitive status and should have been updated to indicate her improved cognition. The facility hired a new social worker within the past two months who completed the most recent assessment for this resident and did not make her aware there had been a change in the resident's cognition level. During an interview on 12/12/2024 at 1:30 PM, the DON stated Resident #30's cognition had been moderately impaired due to a stroke but it had improved since her last assessment and the resident's comprehensive care plan should have been updated by the ADON, who was responsible for updating care plans, to reflect the change. 676138 Page 3 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of Resident #59's face sheet, accessed on 12/12/2024, revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses including dementia (a brain disorder that causes a progressive decline in cognitive function, memory, thinking, and behavior), bipolar disorder (a mental health condition characterized by significant and persistent mood swings between periods of extreme elation and deep depression) and major depressive disorder (a serious mental illness that affects how people feel, think, and act). Record review of Resident #59's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, indicating the resident had full cognition. Section I, Active Diagnoses, indicated I5800 Depression was checked, and Section N, Medications, N0415 High-Risk Drug Classes: Use and Indication, C Antidepressant was not checked. Record review of Resident #59's comprehensive care plan, last review completed 11/27/2024, revealed a focus area indicating: I require anti-depressant medication r/t Dx: Depression. Date Initiated: 8/21/2023. Created on: 08/21/2023. Created by: ADON. The goal was the resident will have no complications related to anti-depressant medication, and interventions/tasks included administering medication per MD orders, educating the resident and/or family regarding all potential side effects and risk associated with psychotropic medications, and monitoring for target/behavior symptoms. Further review of this comprehensive care plan did not indicate a focus area indicating a diagnosis of depression. Record review of Resident #59's consolidated physician's orders for the month of December 2024 revealed there were no orders for any psychotropic medications. During an interview on 12/12/2024 at 12:45 PM, the ADON stated Resident #59's comprehensive care plan was incorrect. The resident was no longer taking any anti-depressant medications and this focus area should have been removed, and the diagnosis of depression should have its own focus area in the care plan to ensure interventions were in place for this diagnosis. During an interview on 12/12/2024 at 1:40 PM, the DON stated Resident #59's care plan should not have included the focus area of anti-depressant medication, which the resident was no longer taking, and instead should have included the diagnosis of depression as a focus area, with goals and interventions for this diagnosis. It was important to update comprehensive care plans to ensure proper care was provided for residents. Record review of facility policy Care Plans revised January 2023 revealed, The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventive measures .the care plan should be initiated upon admission, continued to be developed during the initial 48-72 hours, throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI manual. Additional updates to the care plan may be done as indicated. Record review of the CMS RAI Version 3.0 Manual dated October 2019 revealed .to evaluate the information gained through both the comprehensive assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems .the IDT must evaluate the 676138 Page 4 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0657 information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths and problems. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676138 Page 5 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (Resident #62) reviewed for incontinent care, in that: The facility failed to ensure CNA C thoroughly cleaned Resident #62 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #62's face sheet, dated 12/12/2024, revealed an admission date of 06/19/2018, and a readmission date of 04/01/2024 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Severe obesity, Need for assistance with personal care, Hypothyroidism (under active thyroid), Hypertension (high blood pressure), History of urinary tract infection (an infection in any part of the urinary system). Record review of Resident #62's Quarterly MDS assessment, dated 09/18/2024, revealed Resident #62 has a BIMS score of 11, which indicated mild to moderate cognitive impairment. Further review revealed Resident #62 required extensive assistance to total care with ADLs and was indicated to occasionally be incontinent of bladder and frequently incontinent of bowel. Record review of Resident #62's care plan, dated 02/17/2022, revealed a problem of I have bladder incontinence related to overactive bladder at risk for skin breakdown, with a goal of I will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 12/12/24 at 1:35 p.m. revealed, while providing incontinent care for Resident #62, CNA C did not clean the rectal area of the resident and did not clean the groin areas and upper thighs of the resident. During an interview on 12/12/2024 at 1:47 p.m. CNA C stated she did not clean between the resident's buttocks' cheeks area or the groin area. CNA C stated she should have cleaned the rectal area and groins areas. CNA C stated she was nervous. CNA C stated she received training for infection control and incontinent care within the last year. During an interview with the DON on 12/12/2024 at 2:20 p.m., the DON stated the rectal and groins areas had to be cleaned. The DON stated the ADONs and herself were the one training the staff for infection control and incontinent care and that the ADONs and herself would check the staff skills annually and as needed if a problem was noted. During an interview with the DON on 12/13/2024 at 10 a.m., the DON stated they did not have a policy/procedure describing the steps the staff had to execute during incontinent care for a female. Review of Peri-care: What Every Caregiver Needs to Know By mmLearn.org on Fri, Jun 14, 2019 revealed Moving from front to back, use warm water and a clean washcloth (or disposable wipes) to clean the 676138 Page 6 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0690 Level of Harm - Minimal harm or potential for actual harm perineal area. For females, this involves cleaning the inner legs, labia, and groin area while for men it requires cleaning the tip and shaft of the penis, along with the scrotum. Both men and women require cleaning of the anal area, which will involve turning the patient on his/her side. Residents Affected - Few 676138 Page 7 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnnel to have access to the keys for 1 of 4 medication carts ([NAME] Unit Nurse's medication cart) reviewed for storage. The facility failed to ensure LVN-F secured Resident #62's Fiasp Insulin, when it was left unattended on top of the Nurses medication cart. This failure could place residents at risk for drug diversion and accidents and hazards. Findings include: Observation on 12/12/2024 at 11:03 a.m. revealed LVN-F prepared Resident # 62's medications, which included drawing up 16 units of Fiasp Insulin into a syringe, locked the medication cart, and left the vial of Fiasp insulin on top of the medication cart, and entered Resident #62's room to administer her medications. The medication cart was out of sight from LVN-F. During an interview with LVN-F on 12/12/2024 at 11:12 a.m., LVN-F stated the vial of insulin was left out unsecured on top of the medication cart, noting she had left it out for the State Surveyor to view, but then forgot to put it back inside the medication cart before locking it. LVN-F stated medications should always be kept locked up to prevent theft of drugs, and to keep it from being accidently pushed off the cart, breaking on the floor and causing a hazard with broken glass. Interview on 12/12/2024 at 3:23 p.m. with the DON revealed she was aware of the insulin vial being left out on top of medication cart unsecured during medication administration with Resident #62, and stated each Nurse was responsiible for ensuring all medications were secured inside the medication cart unless directly supervised by the Nurse. She stated not keeping medications locked and secured could result in theft of medications. Record review of the facility policy titled Medication Cart Use and Storage revised January 2023 revealed under Guidelines 1. Security- The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use. During administration of medications avoid placing medications of top of the cart unless pulling medications from the cart. The only exception would be if the cart and medications are within the direct line of sight of the authorized personnel. Note: Best practice is to avoid leaving medication on top of the cart. . 676138 Page 8 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to properly store a 16-oz. bag of chips in the dry storage room. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 12/12/2024 at 10:10 AM revealed a 16-oz. bag of chips that had been opened, was rolled down, and stored inside a bag with a zip lock that was not closed. During an interview on 12/12/2024 at 10:11 AM, the DM stated the bag with the zip lock should have been sealed and failure to ensure it was sealed could lead to pests in the dry storage room and potential food borne illness. Record review of the facility's policy number 03.003, Food Storage, revised 06/01/2019, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Code and HACCP guidelines. Procedure: 1. Dry storage rooms. d. to ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. 676138 Page 9 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 1 of 2 Dumpsters (Dumpster #1) reviewed for disposal of garbage. Residents Affected - Few The facility failed to ensure the sliding doors on both sides of the dumpster was completely closed. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: Observation on 12/12/2024 at 10:19 AM revealed the sliding doors on both sides of Dumpster #1 were open, leaving an approximate 6 gap between the door and wall of the dumpster on both sides. During an interview on 12/12/2024 at 10:21 AM, the DM stated the doors on the sides of Dumpster #1 were both open and should not have been. It was important for the doors to be completely shut to prevent rodents from entering the dumpsters and potentially spreading foodborne illness. Record review of the facility's policy number 04.015 Garbage Receptacles, revised 06/01/2019, revealed, This facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. Outdoor receptacles: It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insects and rodents with doors/lids kept closed and no waste outside of the receptacle. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the food establishment. 5-501.114 Using Drain Plugs. Drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place. 676138 Page 10 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. Record review of Resident #88's face sheet dated 12/13/2024 revealed he was an [AGE] year-old man, with an initial admission date of 10/23/2023 with re-admission on [DATE], with diagnoses which included: Cerebral infarction (stroke), Obstructive and reflux uropathy (blockage in urinary tract), unspecified injury of urethra and retention of urine. Residents Affected - Some Record review of Resident #88's Order Summary dated 12/13/2024 revealed orders for: Foley Catheter 14-16 Fr 5-30cc, change monthly and as needed with order date of 06/03/2024; and EBP (Enhanced Barrier Precautions): Practice EBP as indicated (foley care) every shift for foley care with order date of 12/13/2024. Observation by Health Surveyor-I on 12/12/2024 at 9:40 a.m. of catheter and incontinent care being provided to Resident #88 by LVN-B and CNA-E, revealed neither staff wore a gown, just gloves, while providing catheter care, and there was no sign for EBP posted on his door or PPE supply outside Resident #88's room. b. Record review of Resident #10's face sheet dated 12/13/2024 revealed a [AGE] year-old woman with an initial admission date of 05/22/2025 and a re-admission date of 10/13/2023 and diagnoses which included: Dementia (loss of cognitive functioning that interferes with daily life) and Type 2 Diabetes Mellitus (chronic condition leading to high blood sugar levels). Record review of Resident #10's order summary dated 12/13/2024 revealed an order for Right foot 5th: cleanse with wound cleanser apply skin prep and cover with dressing daily and PRN removal /soiling. Observation by Health Surveyor-I on 12/12/2024 at 1:27 p.m. of wound care being provided to Resident #10 by LVN-F revealed LVN-F did not wear a gown, just gloves while providing wound care to Resident #10, and there was no sign for EBP on the door and no PPE supply available outside her room. c. Record review of Resident #89's face sheet dated 12/13/2024 revealed she was an [AGE] year-old woman with an initial admission date of 11/17/2024 and re-admission on [DATE], with diagnoses that included: Hemiplegia and hemiparesis (one-side paralysis or weakness) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia (inability to swallow safely); and artificial opening status (feeding tube into small intestine to for medication administration and nutrition) Record review of Resident #89's Care Plan initiated 11/18/2024 revealed a focus area for feeding tube r/t [related to] dysphagia. Observation on 12/13/2024 at 7:11 a.m. revealed LVN-H did not wear a gown, just gloves while administering medications via a -tube to Resident #89. There was no EBP sign posted on Resident #89's door, and no PPE supply available outside her room. During an interview with LVN-H on 12/13/2024 at 7:39 a.m., LVN-H revealed she had never heard of or had been trained on EBP and did not know what these precautions entailed. LVN-H stated she had received training on medication administration and had passed a competency check done by the ADON on medication administration including via G-tube. This training did not include training on EBP. 676138 Page 11 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of LVN-H's competency checklist dated 9/20/2024 revealed she had been checked off as meeting criteria on infection control, which included isolation techniques, and Medication Administration including by feeding tube. During an interview with ADON-G on 12/13/2024 at 7:45 a.m., ADON-G stated they had not yet implemented Enhanced Barrier Precautions at the facility, and stated she would immediately be getting EBP signs posted, and PPE supply units placed outside all residents room's who require EBP. Interview on 12/13/2024 at 10:40 a.m. with the DON revealed she confirmed that EBP was included in the facility Infection Control Policy to be used during high-contact activities for residents with wounds or in-dwelling devices. The DON also confirmed that there were no EBP signs or PPE supplies available outside resident's room who had wounds or in-dwelling devices, and that staff had not been trained on EBP, but had no answer other than it just fell through the cracks for why EBP precautions had not been implemented at the facility. Record review of the facility policy titled Infection Prevention and Control revised April 2024, Under Section II. Categories: Types of Isolation Precautions revealed EBP may be indicated as a recommendation by the CDC (when contact precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Further review revealed: Resident/Patients with the following clinical indication should be under EBP: Significant Wounds such as chronic wounds, ulcers, open PUI or complicated/non-healing surgical incisions or wounds, and/or open wounds requiring a dressing .and Indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Record review of CMS Memorandum dated 3/20/2024 from Director, Quality, Safety and Oversight Group (QSOG), Subject: Enhanced Barrier Precautions in Nursing Home revealed that CMS was issuing new guidance for State Survey Agencies and LTC facilities on use of [NAME] to align with nationally accepted standards. The Memorandum included: EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact care activities regardless of their multidrug-resistant organism status. The new guidance related to EBP is being incorporated into F880 Infection Prevention and Control. Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #88) observed for nursing care and 3 of 19 (residents #10, #88 and #89) reviewed for infection control, in that: 1. The facility failed to ensure CNA E washed or sanitized her hands or changed her gloves, before touching the resident #88's clean brief and after touching the soiled resident's chuck and brief. 2. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented or used while staff provided high-contact resident activities, including: catheter care for Resident #88, wound care for Resident #10, and medication administration via G-tube for Resident #89. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 676138 Page 12 of 13 676138 12/13/2024 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. Record review of Resident #88's face sheet, dated 12/12/2024, revealed an admission date of 10/23/2023, and a readmission date of 06/01/2024, with diagnoses which included: Hypertension (high blood pressure), Need for assistance with personal care, Injury of urethra (thin tube connected to the bladder that carries urine out of the body), Chronic osteomyelitis (bone infection) right ankle and foot, History of urinary tract infection (an infection in any part of the urinary system), Obstructive uropathy (urine cannot drain through the urinary tract). Record review of Resident #88's Significant change MDS assessment, dated 10/21/2024 revealed Resident #88 had a BIMS score of 3, indicating severe cognitive impairment. Resident #88 was coded as always incontinent of bowel and had an indwelling catheter. Resident #88 required total care with his ADLs. Review of Resident #88's care plan, dated 12/22/2023, revealed a problem of I require an Indwelling Catheter, with a goal of I will not experience any complications associated with my catheter to include trauma, infection or pain, dignity concerns through my next review date. Observation on 12/12/2024 at 9:40 a.m. revealed while providing incontinent care for Resident #88, CNA E removed soiled chucks and brief from Resident #88 and, without changing her gloves or sanitizing her hands, placed and fasten new clean brief on Resident #88. During an interview with CNA E on 12/12/2024 at 9:53 a.m., CNA E verbally confirmed she did not wash or sanitize her hands or change her gloves, before touching the clean brief and fastening the brief to the resident. CNA A stated she should have changed her gloves and wash or sanitize her hands prior to placing the new brief on Resident #88. She stated the staff received infection control training regularly. During an interview with the DON on 12/12/2024 at 2:20 p.m., the DON confirmed the CNA should have washed or sanitize her hands and changed her gloves, prior to placing the clean brief under the resident to prevent risk of cross contamination and prevent infection for the resident. She stated the staff received infection control training frequently and their skills were checked yearly. The DON revealed she and her ADONs were doing spot checks to check the skills of the staff. Review of facility's policy, titled Hand washing/hand hygiene, dated January 2023, revealed Use an alcohol-based hand rub [ .] for situations such as this [ .] before moving from a contaminated/soiled to clean care or procedures [ .] after contact with blood or bodily fluid; After handling use dressing, contaminated equipment, etc. 676138 Page 13 of 13