Health inspection·December 9, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 10 (Resident #5) residents reviewed for dining services in 1 of 1 dining room. The facility failed to promote Resident #5's dignity on 10/28/2025 while dining when staff did not serve the resident her lunch tray at the same time as other residents at the same table. This failure could affect all residents who eat in the dining room, by contributing to poor self-esteem, and unmet needs. Findings included: Review of Resident #5's Face Sheet dated 10/28/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5's diagnoses included heart failure, type 2 diabetes mellitus with unspecified complications (high blood sugar), hypertension (high blood pressure), cerebral infraction (stroke), convulsions (sudden and uncontrolled electrical disturbance in the brain that causes changes in behavior, movements, feelings, and consciousness), lack of coordination, anxiety (feeling of uneasiness or worry), and depression (mood disorder that causes persistent feeling of sadness). Record review of Resident #5's Quarterly MDS dated [DATE] revealed Resident #5 had a BIMS of 12 which indicated moderate impairment. The MDS also revealed that the residents were independent with eating. Record review of Resident #5's care plan dated 6/28/2025 revealed [Resident #5] had unplanned/unexpected weight gain related to overeating. The goal reflected [Resident #5] would not develop complications from weight gain such as skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, and impaired mobility. Interventions were to monitor/record eating habits, and patterns to assist in determining cause of overeating. Monitor/record/report to MD PRN situations leading to increased food consumption, reasons for weight gain, and significant weight changes. Weigh as ordered. Observation of dining services on 10/28/2025 at 11:45am revealed that Resident #5's tablemate got her meal tray. Resident #5 was still waiting for her meal tray; staff were passing trays to other tables. During an interview on 10/28/2025 at 12:03pm it was revealed that Resident #5 had to wait most of the time to get her meal tray. Resident #5 said that staff put her meal tray on the cart with the hall trays on 10/28/2025. She said she would like her meal tray when her tablemate got her tray. She said she did not feel good when she had to wait to get her food. Observation of dining services on 10/28/2025 at 12:09 pm revealed Resident #5 received her meal tray. Resident #5's tablemate had already finished her lunch by the time Resident #5 got her meal tray. During an interview on 10/29/2025 at 2:23 pm with the DM revealed he had been trained on resident rights. He said the policy for passing meal trays was staff were to serve one table at a time before moving to the next table. He said the nursing staff were to give the kitchen staff a list of residents eating in the dining room. He said a resident may feel upset because everyone was eating except them. He said nurses were supposed to monitor to ensure residents were getting their meal tray with their tablemates. He said the nurses Page 1 of 8 676236 676236 12/09/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monitored by checking the meal trays to ensure all residents had a tray at that table. He said that Resident #5 did not get her meal tray with her tablemate due to staff not putting Resident #5 on the list of dining room residents. During an interview with the ADM on 10/28/2025 at 3:04pm it was revealed that the facility did not have a meal tray policy. During an interview on 10/29/2025 at 1:28pm with CNA C revealed she had been trained on resident rights. She said the policy for meal tray pass in the dining room was to serve all residents at the same table at the same time. She said that the DM would get a list of residents every week who ate in the dining room. She said if a resident decided to eat in the dining room at the last minute the resident would have to wait to get their meal tray until the hall trays came out. She said staff do not tell the DM that a resident wanted to eat in the dining room. She said the nursing staff were responsible for making sure all residents at the same table had their food before moving on. She said that the nurses monitored to ensure all residents had their meal tray. She said the nurses monitored through observations. She said if a resident did not get their meal tray with their tablemate the resident may feel left out. She said that Resident #5 was not on the list to eat in the dining room, so she had to wait until her hall tray s came out to get her food. During an interview on 10/29/2025 at 2:44pm with the DON she and staff have been trained on resident rights. She said there was not a policy for meal trays being passed in the dining room. She said if staff knew that a resident was coming to the dining room staff should try to serve all residents at the same table at the same time. She said all the staff were responsible for ensuring all residents at a table had their meal tray before moving to the next table. She said if a resident did not get their meal tray with their tablemate that could cause the resident to get uncomfortable, and it violated their dignity. She said the nurse was supposed to monitor to ensure residents got their meal tray at the same time as their tablemate. She said she did not know why Resident #5 did not get her meal tray at the same time as her tablemate. During an interview on 10/29/2025 at 3:04pm with the ADM revealed she and staff have been trained on resident rights. She said dining room tray pass was to serve all residents at the same table. She said that the nurses were responsible for ensuring all residents at the same table got their meal tray together. She said that if a resident did not get their meal tray with their tablemate the resident may get upset. She said nursing management was responsible for monitoring all residents at the table to get their meal tray. She said that management monitored by observations of dining services. She said she did not know why Resident #5 did not get her meal tray with her tablemate. She said Resident #5 usually ate in the dining room. The Dining Policy was requested from the ADM on 10/28/2025 at 3:47pm. The policy was not received upon exit. Record review of the Resident Rights Policy dated 7/13/2017 revealed residents had the right to be treated with respect and dignity. 676236 Page 2 of 8 676236 12/09/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 prepare, store, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1) The facility failed to properly seal food product bags in the dry storage area to prevent exposure to air. 2) The facility failed to store food thickener items six inches off the floor and ensured it was not exposed to air. 3) The facility failed to maintain the proper temperature of the high heat sanitizing dish machine. The failures could have placed residents at risk for food contamination and foodborne illness.Findings included: Observation of the kitchen's dry food storage area on 10/28/2025 at 9:05 am revealed there was a bag of pasta noodles opened and exposed to air There was also a box of food thickener powder that was open, exposed to air, sitting on the floor by the shelf. Observation/Interview with DA A on 10/28/2025 at 9:45 am revealed that he had been washing dishes since 6:00am. He said the temperature on the dish machine was supposed to be 150 degrees Fahrenheit for washing, and 180 degrees Fahrenheit for the sanitizing cycle. Observation revealed that the wash cycle was at 130 degrees Fahrenheit according to the thermometer on the machine. The observation also revealed that the sanitizing cycle temperature was 152 degrees Fahrenheit according to the thermometer on the machine. Observation/Interview with the DM on 10/28/2025 at 11:42 am revealed that when the machine was cold staff needed to run the machine two or three times to get the machine up to the correct temperature. The DM ran the dish machine five times and said it was at temperature. The wash cycle was at 150 degrees Fahrenheit and the sanitized cycle was at 179 degrees Fahrenheit. When the surveyor informed them that the machine reflected the minimum for the sanitize cycle was 180 degrees Fahrenheit and the machine was not at the 180 degrees Fahrenheit the DM said he did not care how many times staff needed to run the machine, the staff needed to run the machine until the machine was at the correct temperature. Observation of DA B on 10/28/2025 at 1:13pm revealed DA B put the dishes in the dish rack and put the dishes in the dish machine. He did not run the machine. The temperature on the dish machine for wash cycle was 130 degrees Fahrenheit and for the sanitize cycle the temperature was 169 degrees Fahrenheit. During an interview with DA B on 10/28/2025 at 1:21pm it was revealed that the temperatures on the dish machine should be 160 degrees Fahrenheit for washing and 180 degrees Fahrenheit for sanitizing. He said he would consider the dishes he just did with the temperature of 130 degrees Fahrenheit and 169 degrees Fahrenheit to be clean. He said if the dish machine was not at the correct temperature the dishes might still have food on them and could get the residents sick. When asked about the dishes not being at the correct temperature he said that was an issue. He said he did not know why he did not check the temperature before he started the dishes, but he normally did. He said that when the temperature was not correct he would notify his manager, and they would shut the machine down and the facility would use paper products. During an interview with the RD on 10/28/2025 at 4:07pm it was revealed that her expectation for storing food was that items were to be 12 inches off the floor. She said she was not sure who was responsible for ensuring items were sealed and off the floor in the kitchen. She said the DM could be responsible or his assistant. She said if things in the kitchen were not sealed it could cause foodborne illness, mold, or contamination. She said the dietary manager was responsible for monitoring to ensure that everything was sealed and not stored on the floor. She said the DM was supposed to be doing weekly inspections. She said she did not know why items were not sealed, and off the floor because the facility only allowed her eight hours a month to oversee the facility kitchen. The RD also did not know what the temperatures of the dish machine should be. She said she thought the DM should have been getting a new dish 676236 Page 3 of 8 676236 12/09/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some machine. She said that if the high heat dish machine was not heating to the appropriate temperature the dishes were not getting sanitized. She said if the dishes were not getting sanitized it could cause a resident to get food poisoning, and cause contamination. She said she did not know why the staff were doing the dishes in the dish machine without it being at the correct temperatures. During an interview with the DM on 10/29/2025 at 11:15am it was revealed that the company for the dish machine came out that morning and checked the dish machine. He said that the technician had to turn the temperature up and now the machine was running at the correct temperatures. He also said that staff did not need to run the machine now before using. During an interview with DA A on 10/29/2025 at 10/29/2025 at 1:54pm it was revealed he had been trained on food storage and on the dish machine. He said that the policy for food storage was that food items could not be stored on the floor and anything that was open had to be labeled and dated. He said everyone in the kitchen was responsible for labeling and dating items in the kitchen. He said if items were not labeled and dated it was a problem he also said not having food labeled and dated could cause the residents to get sick. He said everyone in the kitchen monitored to ensure items were labeled and dated. He said staff monitored by observations. He said he did not know why the times in the dry storage area was on the floor and not sealed. During an interview with the DM on 10/29/2025 at 2:10pm it was revealed he had been trained on food storage and the dish machine. He said the policy for food storage was that all items in the kitchen were to be labeled, dated, and sealed. He said items were supposed to be stored 6 inches off the ground on a rack. He said that if food items were not sealed or stored on the floor the food could become contaminated, and the residents could get sick. He said he was responsible for monitoring to ensure items were sealed and not stored on the floor. He said the cook had just used the thickener and did not put it back. He also said he overlooked the pasta being open when he did his round. He said the required temperature for the dish machine was 150 degrees Fahrenheit for washing and 180 degrees Fahrenheit for the sanitized cycle. He said if the dish machine was not at the correct temperature staff were to notify him, shut the machine down and serve residents on paper products. He said that if the staff used the dish machine and it was not at the correct temperature the residents would be eating the same bacteria from the previous meal. He said he monitored the temperature of the dish machine. He said he monitored by running the machine. He said staff should not have been using the dish machine at all. He also said that it was broken on 10/28/2025 and staff should not have to run the machine five times or more to get the machine up to the correct temperature. During an interview with the ADM on 10/29/2025 at 2:57pm revealed she had been trained on food temperatures and the dish machine. She said all items in the kitchen were to be labeled, dated, and sealed. She said items in the dry storage, refrigerator, and freezer were to be stored on rack and off the floor. She said the DM was responsible for ensuring all items were labeled, dated, and sealed. She also said he was responsible for ensuring food was not stored on the floor. She said if food items were left open or stored on the floor the food could become contaminated, and the residents could get an infection. She said the DM told her staff needed to run the dish machine five times to bring the machine up to the correct temperature. She said for the wash cycle the temperature was 150 degrees Fahrenheit and for the sanitize cycle the temperature was 180 degrees Fahrenheit. She said the DM was responsible for ensuring the machine was at the correct temperature. She said he monitored the dish machine by running the machine. She said she did not know why food items were on the floor and open. She also said she did not know why staff were washing dishes in the dish machine when it was not at the correct temperature. Record review of Temperature Indicating Devices for the Dish Machine, not dated, revealed when a commercial dishwasher is first turned on it will take some time for the water to come up 676236 Page 4 of 8 676236 12/09/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to temperature. This cannot be rushed; there is no use trying to test sanitation temperature with a temperature label until the machine is fully up to temp. Certainly it would be risky to run cycles of dishes before the machine has warmed up. It is also a good idea, once the water is up to temperature, to run a cycle or two empty to warm up the inside of the machine before testing dish sanitation temperature and running actual cycles of dirty dishes. Overshoot the temperature you desire so that when the dishwasher is running cycles of dishes through it, the temperature will always be reaching that temperature you need. So, if you want a wash water temperature of 150 F, set it so that the machine will bring your water up to 160 F. If you want your rinse water at 180 F, set it to 185 F or 190 F. This way when you are sending through load after load of dishes on a busy night you ensure that the water temperatures are getting to where you need them to be to keep your customers safe. Just be sure to stay within the ranges allowable by the FDA Food Code. Record review of Dish Machine Rental Program User Guide, not dated, revealed Operating Temperatures Wash (minimum) 150 degrees Fahrenheit. Sanitizing Rinse (minimum) 180 degrees Fahrenheit. Worry-free rent includes installation and maintenance. Record review of Policy and Procedures: Dietary Services: Food Storage Policy, dated 08/2007, revealed it is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. All foods or food items not requiring refrigeration shall be stored at least six (6) inches above the floor and at least eighteen (18) inches from sprinkler heads, on shelves, racks, dollies or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. All packaged food, canned foods, or food items stored shall be always kept clean and dry. Record review of the FDA Food Code 2022 revealed adequate cleaning and sanitization of dishes and utensils using a ware washing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize. For example, high temperature machines depend on the buildup of heat on the surface of dishes to accomplish sanitization. If the exposure time during any of the cycles is not met, the surface of the items may not reach the time-temperature parameter required for sanitization. Contact time is also important in ware washing machines that use a chemical sanitizer since the sanitizer must contact the items long enough for sanitization to occur. In addition, a chemical sanitizer will not sanitize a dirty dish; therefore, the cycle times during the wash and rinse phases are critical to sanitization. The temperature of hot water delivered from a ware washer sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning.The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 C (194 F) at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 C (165 F) for a stationary rack, single temperature machine, and 82 C (180 F) for other machines are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature. 676236 Page 5 of 8 676236 12/09/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, 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 diseases and infections for 3 of 3 staff reviewed for infection control. 1. CNA E failed to perform hand hygiene when passing lunch trays on the 100 hall. 2. The DM did not conduct hand hygiene before giving Resident #5 her lunch tray, hugged another resident, and went to another resident. The DM then went from one resident to another doing a fist bump and shaking hands in between handing out resident trays and did not conduct handwashing or hand hygiene. 3. CNA F did not sanitize her hands between residents' trays and touched her clothes twice. These failures have the potential to affect all residents in the facility by exposing them to infection that could lead to the spread of viral or secondary infections and communicable diseases. Findings included: An observation on 10/28/25 at 12:15 pm revealed CNA F did not sanitize her hands after giving a resident their meal tray before giving another resident their meal tray. She also did not wash or sanitize her hands after touching her clothes before giving another resident their meal tray. She set up the resident's meal trays, opened their food touched items on their bedside tables.She did not sanitize or wash her hands at all while passing four residents their meal trays. Observation on 10/28/25 at 12:17 PM revealed CNA F was not conducting hand hygiene while passing lunch trays on hallway 100. She was observed coming out of a room and took Resident #1's tray to her room and did not conduct hand hygiene. Then she came out and picked up Resident #2's tray and took it into his room, assisted him with setting it up. She was observed not conducting hand hygiene and came out and took Resident #3's tray to his room. An interview on 10/28/25 at 12:31 PM with CNA F revealed she was trained to wash her hands before and after the meal tray pass. She stated she had forgotten to use hand gel between a couple of the residents. She stated she had received training on infection control and hand hygiene, and not doing hand hygiene between resident rooms could lead to cross contamination. An observation on 10/29/25 at 12:09 PM revealed the DM did not conduct hand hygiene before giving Resident #5 her lunch tray and then hugged another resident and went to another resident to help another resident with his food. The DMfist bumped one resident and shaking hands with a different resident and did not wash or sanitize his hands before passing other residents meal trays. An interview on 10/28/25 at 1:10 PM with CNA F revealed she had been working in the facility for one week. She stated she had been trained on infection control and hand hygiene during orientation, which included placing soiled linen in a bag before bringing it out of the resident's room, and always washing her hands. She further stated the policy for hand washing when providing resident care was to wash hands before the start care and wash hands when finished. She stated when passing meal trays to the residents' rooms, wash hands before and after passing trays, and wash hands between each resident. She stated if staff did not perform handwashing/hand hygiene properly, they could get infection/cross contamination and get sick. The aide stated they were always supposed to put on gloves and wash their hands when the staff remove and change gloves. She stated the DON, and nurses monitored to ensure staff were washing their hands. She stated she did not work yesterday and did not know why a staff member did not conduct hand hygiene between each resident when passing lunch trays. An interview on 10/29/25 at 1:28 PM with CNA E revealed she had worked in the facility for about 9 months. She stated she had been trained in infection control and hand hygiene in orientation, and about 2 months ago. She stated the training included enhanced barrier precautions, airborne, and droplet precautions. CNA E stated she was also enrolled in nursing school, where she was familiar with infection control precautions. She stated the facility policy on hand hygiene included conducting handwashing/hand hygiene every Residents Affected - Some 676236 Page 6 of 8 676236 12/09/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some time you go into a resident room and every time you leave the resident room. She stated she should have used hand sanitizer between reach resident room when passing meal trays. She stated everybody should be washing their hands, and if staff did not conduct proper handwashing/hand hygiene, infection could spread diseases to the residents. She stated the DON monitored for hand washing and would enter the rooms to spot check on the staff members. CNA E stated she was picking up Resident #4's cup that had dropped, and then she started assisting him with eating. She stated she had left the room to get a straw and when she came back his cup had dropped, so she picked it up. CNA E stated she had walked around the bed and started to assist Resident #4 with eating. CNA E stated she should have changed her gloves and hand hygiene after she had come back into the room. CNA E stated the policy for meal tray passes was for the nurse to check that the meals matched what was on the meal tickets. An interview on 10/29/25 at 2:19 PM with the DM revealed he had been trained on infection control. he stated the infection control training included the use of gloves, removing gloves, hand hygiene, and to always conduct handwashing. He stated they get infection control training every day. He stated the policy for hand washing stated to wash and sanitize your hands after each resident tray was served. further stated he was taught to conduct handwashing with soap and water after using hand sanitizer up to three times. He stated everybody that came in contact with a resident should wash their hands, and if staff did not wash their hands it could lead to cross-contamination. He stated the supervisors monitored staff to ensure everyone was conducting hand washing/hand hygiene. He stated he monitored handwashing by conducting training with staff members and doing rounds. He stated he did not remember when he touched another resident's tray. An interview on 10/29/25 at 2:44 PM with the DON revealed she and the nurse managers were responsible for ensuring and monitoring how staff were doing hand hygiene and following infection control measures. The DON stated she had been trained in infection control, with the last training one year ago. She stated the training included everything from standard transmission precautions to housekeeping to food/dietary, direct patient care, and infection control included every department in the facility. The DON stated the policy for hand washing when providing patient care staff were supposed to conduct hand hygiene before and after patient care, and with food care. She also stated staff were supposed to conduct handwashing when hands/gloves become soiled with blood or body fluids, such as during brief changes and showers. She stated if a resident asked for a phone, staff were to wash hands/sanitize after handing them the phone. The DON stated handwashing/hand hygiene should be conducted before and after passing trays on a hallway, and they should conduct hand hygiene between each resident. She stated everyone in the facility should be washing their hands, and everyone in every department that came into contact with residents should be washing their hands. She further stated that if staff were not conducting proper hand hygiene, their health could be compromised. She stated that she and the nurse managers monitored to ensure staff were washing their hands. She stated they had been doing training every month, and they selected random staff members to come demonstrate handwashing at a sink. She stated they also used CDC and YouTube videos to ensure night shift staff members receive the same training. The DON did not know why a staff member did not conduct hand hygiene when passing resident trays, as they have hand sanitizer in each resident room. An interview on 10/29/25 at 3:04 PM with the ADM revealed Nursing, the DON, and all of us department heads were responsible for ensuring staff are doing hand hygiene/following infection control measures when providing care for the residents. She stated monitoring of staff on hand hygiene and infection control measures included frequent in-services, and the ADON and DON had their role in ensuring staff were following the practice. She further stated that every time a staff member came out of a resident room they were to use the hand sanitizer. She stated the policy on 676236 Page 7 of 8 676236 12/09/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hand hygiene was to wash hands when they were soiled, conduct a 20-second hand wash, and the staff may use the hand sanitizer when passing resident meal trays. She further stated staff should conduct hand hygiene every time they took the meal trays out and took them to the resident's room. The ADM stated she had taken a 4-hour training on infection control prevention this year. She stated a potential negative outcome from not conducting handwashing/hand hygiene was infection. The ADM stated the facility did not have a meal tray or a dining policy. Review of facility policy titled Handwashing and Hand Hygiene dated October 2023 reflected, All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors, and Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces, after touching a resident, after touching the resident's environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal. Review of facility policy titled, Hand Hygiene dated 04/2025 reflected, It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene.Definitions:Hand hygiene is a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub.Hand washing is the vigorous, brief rubbing together of all surfaces of hands with soap and water, followed by rinsing under a stream of water.Alcohol-based hand rub (ABHR) is a 60-95 percent ethanol or isopropyl alcohol-containing preparation base designed for application to the hands to reduce the number of viable microorganisms.Procedure:1. Wash hands with soap and water for the following situations:a. When hands are visibly soiled2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:a. Before and after direct contact with residentsb. After contact with a resident's intact skinc. Before and after eating or handling foodd. Before and after assisting a resident with meals. Review of facility policy titled IPCP Standard and Transmission-Based Precautions dated 10.2022 reflected, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Transmission-Based Precautions are the second tier of basic infection control and used in addition to Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission.Procedure:1. Standard Precautions are infection prevention practices that apply to the care of all residents,' regardless of suspected or confirmed infection or colonized status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include:b. Hand hygiene; 676236 Page 8 of 8