The Health Center At Research Park

F-F867 for Resident's #334 and #335 and all current residents

in the facility have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations

6. This Behavior Communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine any new or changes in behaviors, intervention implementation, and appropriateness and will be revised as necessary.

7. Upon return from a transfer when ER deems resident appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a Resident Return from Transfer Behavior assessment will be conducted. This will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. For any resident discharged and readmitted a readmission assessment already part of the readmission process is completed to include an abuse and behavior section. On 6/18/2024 Nursing Staff educated that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.

Facility implemented all corrective actions by 6/18/2024.

******************************************************************************

After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff intervention, the survey team verified the facility implemented corrective actions including ongoing monitoring on 06/18/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33739

Residents Affected - Few Based on record review, interview, a review of Facility Reported Incidents, the facility's investigative files, and

review of a facility policies Medication Administration, and AMPharm Delivery Service, the facility failed to ensure controlled medications records were maintained and able to be reconciled when licensed staff failed to add medication to the control sheets and failed to place the controlled medications in the narcotic drawer

after receiving from the pharmacy for Resident Identifier (RI) #57 and RI #47.

This affected RI #47 and RI #57 and was cited as a result of the investigation of complaint/report AL00045923.

Findings Include:

A review of a facility policy AMPharm Delivery Services with an effective date of 11/2021 documented Policy: Nightly delivery is provided to each facility on a preset schedule.

Procedure: .

c. The delivery person shall present the nurse with a delivery manifest for signature . For narcotic deliveries,

the receiving nurse shall verify the medications and counts with the delivery person prior to signing the manifest.

1. Immediately upon receipt scheduled medications shall be secured in the medication cart .

RI #47 was admitted to the facility on [DATE REDACTED].

RI #57 was admitted to the facility on [DATE REDACTED].

The Facility Reported Incident submitted on 10/18/2023 at 7:06 PM indicated Registered Nurse (RN) #5 identified RI #47 and RI #57 had missing oxycodone tablets.

The facility's investigative summary indicated .

Incident type: Misappropriation of resident property

Suspected Offender: Unknown

10/18/23 it was found that (RI #47) had Oxycodone/APAP 5/325 tablets 60 pills were unaccounted for.

10/18/23 it was found that (RI #57) had Oxycodone 5 milligram tablets 30 pills were unaccounted for.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 It is substantiated that the pills are missing. But we don't know for sure what happened to them at this point.

Level of Harm - Minimal harm or On October 18th at approximately 12:45 PM 100 hall charge nurse (RN #5) reported to the DON (Former potential for actual harm Director of Nursing (FDON)) that she called the pharmacy . to inquire about oxycodone for (RI #57's room number). The (pharmacy) reported that the medication had been delivered the night before and was signed Residents Affected - Few off by two individuals. Nurse managers initiated search . No Oxycodone was found that belonged to (RI #57).

On October 18th at approximately 4:30 PM . (RN #5) notified (pharmacy) that (RI #47) was completely out of oxycodone despite (RN #5) faxing the script (prescription) to (pharmacy) the previous day. (Pharmacy) informed (RN #5) the last oxycodone script was filled and delivered . on 10/13/23 of 60 tablets.After a thorough search of the building no medications were found.

An order to (pharmacy) was called in requesting to replace the residents missing medications - replacement provided by Millennium.

Multiple attempts via phone calls and text messages to contact (RN #7) the charge nurse that signed for both cards of oxycodone were left unanswered.

(RN #7) was scheduled to work night shift on October 18th . She arrived late . stated her phone was dead . (RN #7) provided a statement . but denied any involvement in the missing medications. However, she did agree that she was the only nurse that signed for the medications that were delivered .

During an interview with RN #5 on 06/12/2024 at 11:58 AM, she said she had ordered RI #57's oxycodone

on 10/17/2023. RN #5 said on 10/18/2023 she checked the cart to confirm delivery and did not find it. RN #5 said she called the pharmacy and was told it had been delivered the night before and signed by RN #7. She said she and other nurses searched and did not find the medication, so she reported to the Director of Nursing (DON). She said she told the DON she counted with the RN #18, because RN #7 had left early. RN #5 said the counts were accurate. She said later the same day when RI #47 asked for pain medication, she went to the cart for oxycodone and there was none there, she again called the pharmacy and was told the medication delivered on 10/13/2023 and was also signed by RN #7. RN #5 said the facility was unsure about what happened to the medications and that neither resident missed a dose of the pain medication.

An unsuccessful attempt was made to contact RN #7 on 06/12/2024 at 12:15 PM.

On 06/12/2024 at 12:20 PM an interview was conducted with RN #18. RN #18 said she worked the same night as RN #7 but worked the other side of facility. RN #18 said when medications were delivered RN #7 received them and signed for them. RN #18 said she went over and got the medications for her hall later in

the shift. RN #18 said RN #7 left before her shift was over and RN #7 and herself counted the medications and the count was accurate. RN #18 said she became aware of the missing medications when she did her statement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 On 06/14/2024 at 6:44 PM during an interview with the Regional Nurse Manager (RNM), he said RN #5 identified that RI #47 and RI #57's oxycodone was missing. The RNM said RI #47's was delivered and Level of Harm - Minimal harm or signed by RN #7 on 10/13/2023 and RI #57's was delivered and signed also by RN #7 on 10/17/2023. When potential for actual harm asked what happened to the medications, he said they did not have evidence other than RN #7 signed the delivery sheet. The RNM said RN #7 failed to follow the pharmacy processes of documenting and recording Residents Affected - Few the medication when received. The RNM said RN #7 said she left the medications unattended and was terminated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 20304

Residents Affected - Many Based on observation, interview, the facility's policy for Dietary: Menus and Adequate Nutrition, the facility's 2024 S/S (Spring/Summer) Week 2 Menu, the facility's posted Disher Capacity guide, and the facility's recipes for Salisbury Steak, Seasoned [NAME] Beans, Chicken Fettuccini Alfredo, and Buttered Noodles; the facility failed to ensure the residents received nutrition as planned per the facility's menu by allowing the following:

hot water was added to puree food items during Lunch service on 06/12/2024 to extend the volume available,

the amounts of Chicken [NAME] and of Noodles served for the Regular, Mechanical Soft, Dysphagia II, and Puree/Dysphagia I texture diets were less than the amounts indicated on the menu for Lunch on 06/13/2024, and

orange slices were served to most of the residents receiving Consistent Carbohydrate (CCHO) diets, instead of apple slices as indicated by the menu for Lunch on 06/13/2024.

This had the potential to affect all residents receiving Regular, Mechanical Soft, Dysphagia II (Dys II), and Puree/Dysphagia I (Dys I) texture diets and residents receiving CCHO diets from the facility's kitchen; 79 of 79 residents.

Findings include:

The facility's policy for Dietary: Menus and Adequate Nutrition, revised 07/31/2023, included the following:

. Purpose:

The purpose of this policy is to assure menus are developed and prepared, based on reasonable efforts, to meet resident choices and reflect the resident's nutritional . needs, while using established guidelines .

Policy:

1. The community shall ensure that menus:

a. Meet the nutritional needs of resident in accordance with established national guidelines .

c. Be followed .

On 06/12/2024, the facility's 2024 S/S (Spring/Summer) Menu for Week 2, Wednesday, Lunch was observed to have the following change approved by the Registered Dietitian (RD): Salisbury Steak instead of Country Fried Steak. The menu therefore indicated the Pureed/Dys I diet was to receive 3 oz. (ounces) Pureed Salisbury Steak with Gravy and 4 oz. Pureed [NAME] Beans in addition to other items.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 The facility's recipe for Salisbury Steak - 4102 included the following: . Service portion: 1 (one) 3oz steak patty . Puree Steps: Remove desired number of servings and add nutritive liquid, milk, broth, etc. (to indicate Level of Harm - Minimal harm or further, similar items are included). Blend until desired consistency. Add approved thickener to achieve potential for actual harm desired consistency if needed.

Residents Affected - Many The facility's recipe for Seasoned [NAME] Beans - 1038 included the following: . Service portion: 4oz (#8 scoop/disher). Puree Steps: Remove desired number of servings and add nutritive liquid, milk, broth, etc. Blend until desired consistency. Add approved thickener to achieve desired consistency if needed.

On 06/12/2024 at 11:07 AM, the facility's trayline was ongoing for lunch with the AM [NAME] serving the residents' meal plates. At 11:20 AM, observed Salisbury Steak on the steamtable (being substituted for the Country Fried Steak and indicated as approved by the RD by her initials on the menu posted at the steamtable). There were two observations of the puree meat scoop not being filled completely for service. Then an observation of hot water being added to the puree meat and stirred in by AM Cook. Then a third

observation of the scoop not being fully filled with puree meat. At 11:55 AM, there was an observation of hot water being added to the puree green beans by the AM Cook. There were still not enough puree green beans for a serving and it looked more liquid than puree. The Kitchen Supervisor began preparing additional puree green beans. At 12:02 PM, the Lunch trayline service was finished.

On 06/13/2024, the facility's 2024 S/S (Spring/Summer) Menu for Week 2, Thursday, Lunch included the following:

Regular and CCHO diets were to receive 6 oz Chicken Fettuccini [NAME] and 4 oz Buttered Noodles,

Mechanical Soft diets were to receive 6 oz Gr (Ground) Chicken [NAME] and 4 oz Buttered Noodles,

Dys II, and Puree/Dys I texture diets were to receive 6 oz Pur (Pureed) Chicken [NAME] and 4 oz Pur Buttered Noodles, and

CCHO diets were to receive 4 oz Apple Slices.

The facility's recipe for Chicken Fettuccini [NAME] - 4238 included the following: . Service portion: 6 oz Chicken Fettuccini Alfredo. 3oz (#10 scoop) Pasta & [and] 3oz (3-4 strips) Chicken .

The facility's recipe for Buttered Noodles - 2005 included the following: . Service portion: 4 ounces .

On 06/13/2024 at 10:33 AM, Diet Aide #16 was observed portioning Apple Pie for the residents' Lunch. Diet Aide #16 said the CCHO were getting fresh orange slices. Diet Aide #16 said the CCHO (diets) do not get a lot of sugar, so they get fresh fruit. Diet Aide #16 further said one person had a sliced fresh apple because

the resident cannot eat oranges. Observed servings of fresh orange slices and one serving of fresh apple slices.

On 06/13/2024 at 10:47 AM, a Disher [scoop] Capacity chart was observed on the bulletin board in the Kitchen over the Prep Sink, which included the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 [NAME] #6 disher equals 4.66 fluid ounces

Level of Harm - Minimal harm or Grey #8 disher equals 3.64 fluid ounces potential for actual harm [NAME] #12 disher equals 2.78 fluid ounces Residents Affected - Many

On 06/13/2024 at 10:54 AM, the AM [NAME] began putting pans on the steamtable for lunch service. At 11:33 AM, trayline temperatures were being checked and the following was observed:

Two full pans of Chicken (in chunks) and Noodles mixed together with [NAME] Sauce and a 4-ounce serving spoodle,

Mechanical Soft Chicken and Noodles mixed together with [NAME] Sauce and a 4-ounce serving spoodle,

Chicken and Noodles and [NAME] Sauce pureed together with a #6 scoop/disher.

Trayline service was observed until 12:09 PM, when the last serving cart was loaded.

On 06/13/2024 at 12:34 PM, the Kitchen Supervisor was interviewed:

The Kitchen Supervisor was given the facility's 2024 S/S (Spring/Summer) Menu for Week 2, Thursday, Lunch to review as needed. When asked how much Chicken Fettuccini [NAME] was supposed to be served per the menu, the Kitchen Supervisor said 6 ounces. When asked how much Buttered Noodles was supposed to be served per the menu, the Kitchen Supervisor said 4 ounces. The Kitchen Manager was reminded that the Chicken Fettuccini [NAME] was mixed with the Noodles and a 4 oz. spoodle was used to serve the combined items. When asked how much should have been served per portion since the two menu items were mixed together, the Kitchen Supervisor said 10 ounces. The Kitchen Manager then said there is no 10-ounce ladle or spoodle. When asked what could have been done, the Kitchen Supervisor said, I would use the closest scoop/spoodle size. We have an eight-ounce spoodle, I think. But it still would not be the right amount. When asked if the Mechanical Soft Chicken [NAME] mixed with Noodles and served with the 4 oz. spoodle was enough, the Kitchen Manager said no, it was not enough. The Kitchen Manager further said

it should be separated into noodles and the chicken with sauce. When asked if the pureed Chicken [NAME] mixed with Noodles served with the #6 scoop/disher was enough, the Kitchen Manager said no. The Kitchen Manager said not serving the amount as indicated on the menu meant the residents are not getting enough food. When asked why sliced oranges were served to the residents at lunch instead of sliced apples; the Kitchen Manager said we have apples, I do not know why.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 On 06/13/2024 at 1:08 PM, the AM [NAME] was interviewed: The AM [NAME] was asked why she was adding hot water to the puree food at lunch yesterday (Wednesday, 6/12/2024). The AM [NAME] replied, To Level of Harm - Minimal harm or stretch it. The AM [NAME] said she asked her manager (the Dietary Manager) this morning if the Chicken potential for actual harm [NAME] was to be mixed with the Noodles and she said yes. The AM [NAME] agreed that a 4 oz. spoodle was used to serve the Chicken Fettuccini [NAME] mixed with the Noodles. The AM [NAME] was given the Residents Affected - Many facility's 2024 S/S (Spring/Summer) Menu for Week 2, Thursday, Lunch to review as needed. When asked how much Chicken Fettuccini [NAME] should be served per person according to the menu, the AM [NAME] said 6 ounces. When asked how much Buttered Noodles should be served per person according to the menu, the AM [NAME] said 4 ounces. When asked how much should have been a serving since the Chicken Fettuccini [NAME] and Buttered Noodles were mixed together, the AM [NAME] said 10 ounces. The AM [NAME] then said there was not a 10-ounce spoodle. When asked what could have been done, the AM [NAME] said she did not know. When asked if the 4 oz. spoodle used to serve the Mechanical Soft Chicken [NAME] mixed with Noodles was enough for a serving, the AM [NAME] said it should have been 10 ounces. When asked if the #6 scoop/disher used to serve the pureed Chicken [NAME] mixed with Noodles was enough for a serving, the AM [NAME] said it should have been 10 ounces.

On 06/13/2024 at 5:31 PM, the Dietary Manager was interviewed: When asked what instructions were given to food service employees for preparing pureed foods properly and in adequate quantity, the Dietary Manager said they were shown when they were trained for the position. The Dietary Manager said it was not acceptable to add hot water to a pureed food during meal service to stretch it. The Dietary Manager said the problem was diluting the food and reducing the nutrients. When asked how the food service employees knew how much to serve of each food item, the Dietary Manager said they have the menus with portion sizes, spoodles in different ounce capacities, and have color-coordinated scoops/dishers, and a chart. The Dietary Manager said Corporate (the corporate office) developed and approved the menus used at the facility. The Dietary Manager said she had received consultations from the Registered Dietitian two Tuesdays out of the month so far and topics had included temperatures, food dating, cleanliness, organization, portion sizes, and menu items in house. The Dietary Manager was given the facility's 2024 S/S (Spring/Summer) Menu for Week 2, Thursday, Lunch to review as needed. It was noted that the menu listed 6 ounces Chicken Fettuccini [NAME] and 4 ounces Buttered Noodles as separate menu items, but the Chicken Fettuccini [NAME] and the Noodles were mixed together in pans for service on the trayline. When asked if the 4 oz. spoodle used to serve the Chicken Fettuccini [NAME] mixed with Noodles to the Regular Diets was a large enough portion, the Dietary Manager said no. When asked if the Mechanical Soft Chicken [NAME] mixed with Noodles and served with the 4 oz. spoodle was enough, the Dietary Manager said no. When asked if

the #6 scoop/disher used to serve the pureed Chicken [NAME] mixed with Noodles was enough for a serving, the Dietary Manager said no. When asked the concern for residents, the Dietary Manager said that

the residents were not getting enough food, protein, nutrients. The Dietary Manager said fresh apples were available in the kitchen the night before and that morning. When asked why would staff not serve sliced apples to the CCHO diets per the menu today (Thursday, 06/13/24), the Dietary Manager said they might not have had knowledge of the apples. The Dietary Manager said she did not ask the RD to approve a change from apples to oranges.

On 06/13/2024 at 7:20 PM, the Registered Dietitian (RD) was interviewed by phone:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 When asked what instructions were given to food service employees for preparing pureed foods properly and

in adequate quantity, the RD said it should be on the recipe. The RD said it would not be acceptable for the Level of Harm - Minimal harm or [NAME] to add hot water to a pureed food during meal service to stretch it. When asked the problem; the RD potential for actual harm said the calories would not be the same, as there would be fewer calories per serving. The RD further said it could also change the consistency. When asked how the food service employees know how much to serve Residents Affected - Many of each food item, the RD said the portions are on the menus and in the recipes. The RD further said the size of dishers/scoops to use for specific serving sizes (ounces) should be on the recipe. The RD was told that according to the Week 2 menu for Thursday, 6 ounces Chicken Fettuccini [NAME] was supposed to be served over 4 ounces Buttered Noodles, but the Chicken Fettuccini [NAME] and the Noodles were mixed together in a pan for service on the trayline. When told that a 4 oz. spoodle was used to serve the Chicken Fettuccini [NAME] mixed with Noodles to the Regular Diets, the RD said that was not enough. When told a 4 oz. spoodle was used for the serving the Mechanical Soft Chicken [NAME] mixed with Noodles, the RD said that was not enough. When told a #6 scoop/disher was used to serve the pureed Chicken [NAME] mixed with Noodles, the RD said that was not enough. When asked the concern for residents, the RD said the menus were prepared to provide serving sizes to meet the residents' caloric needs. The RD said she was not asked to approve serving oranges to the CCHO diets instead of sliced apples for lunch on Thursday, 06/13/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 20304

Residents Affected - Many Based on observation, interview, the facility's Dish Machine Temperatures-Sanitation log for June 2024, the facility's policies for Dietary- Mechanical Dishwashing and Dietary- Hand Washing Techniques, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility failed to prevent cross-contamination on 06/11/2024 by allowing the following to occur:

Staff going from handling dirty dishes to handling clean dishes and not washing their hands,

Staff using a cloth to dry multiple wet trays instead of air drying,

Access to a hand sink was blocked by a plate lowerator and when staff reached over the equipment to use

the hand sink, water splashed onto the stored plates, and

Staff chewing gum in the kitchen.

The facility further failed to ensure sanitizing of dishware by not checking the dish machine temperatures prior to washing breakfast dishes on 06/11/2024, by the dish machine final rinse not reaching the minimum temperature of 180 (degrees) Fahrenheit (F) on 06/11/2024, and by not recording actual temperatures on the dish machine temperature log.

This had the potential to affect all residents receiving meals from the facility's kitchen, 79 of 79 residents.

Findings include:

The 2022 U.S. FDA Food Code included the following:

. 2-4 Hygienic Practices

2-401 Food Contamination Prevention

2-401.11 Eating, Drinking, or Using Tobacco Products

(A) . an EMPLOYEE shall eat, drink, or use any form of TOBACCO PRODUCTS only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection can not result.

[Annex 2, page 22:

. 2-401.11 Eating, Drinking, or Using Tobacco Products.

2-402.11 Effectiveness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) . (8) 'Confining .eating food, chewing gum, drinking beverages or using tobacco.' ] Level of Harm - Minimal harm or potential for actual harm . 2-301.14 When to Wash.

Residents Affected - Many FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301. 12 immediately before engaging in FOOD preparation including working with . clean EQUIPMENT and UTENSILS, . and: .

(E) After handling soiled EQUIPMENT or UTENSILS; .

4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures.

(A) . in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), or less than: .

(2) For all other machines, 82 C (180 F).

4-901.11 Equipment and Utensils, Air-Drying Required.

After cleaning and SANITIZING, EQUIPMENT and UTENSILS:

(A) Shall be air-dried .

4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles.

(A) . cleaned EQUIPMENT and UTENSILS, . shall be stored:

(1) In a clean, dry location;

(2) Where they are not exposed to splash, dust, or other contamination .

5-204.11 Handwashing Sinks.

A HANDWASHING SINK shall be located:

(A) To allow convenient use by EMPLOYEES in FOOD preparation, FOOD dispensing, and WAREWASHING areas; .

The facility's policy for Dietary- Mechanical Dishwashing, revised and dated effective 10/09/2023, included

the following:

. Purpose: To ensure dishes and utensils are cleaned under sanitary conditions. Dishes shall be cleaned and sanitized after each use.

Policy: .

A. Turn on the machine, checking temperatures to assure proper wash and rinse temperatures .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 1. High temp machine: Wash- 140 F, . Rinse - 180 F .

Level of Harm - Minimal harm or H. Allow clean dishes to air dry completely before storing or store in a manner that allows for air drying. potential for actual harm I. If the same person is loading and unloading the racks, hands must be washed . before touching the clean Residents Affected - Many surfaces of the items in the rack.

Documentation:

1. The temperature of the dish machine shall be recorded three (3) times a day. Temperatures out of specified range shall be reported .

The facility's policy for Dietary- Hand Washing Techniques, revised and dated effective 10/09/2023, included

the following:

. Purpose: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. dietary employees shall clean their hands in a handwashing sink .

Policy: .

6. Frequency of Handwashing:

Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging

in food preparation including working with . clean equipment and utensils . and also in the following situations:

b. After hands have touched anything unsanitary i.e. (that is), garbage, soiled utensils/equipment, dirty dishes .

During a kitchen observation on 06/12/2024 at 9:21 AM, Diet Aide #13 was seen pre-rinsing dirty trays and dishware at the dirty side of the dishwashing machine, while wearing gloves. Diet Aide #13 then went to the clean side of the dishwashing machine and removed clean trays from the rack and stacked them on a cart. Diet Aide #13 did not remove her gloves or wash her hands before touching the clean trays. A handwashing sink was observed just a couple of steps behind Diet Aide #13 in the dishwashing area; however, access to

the handwashing sink was somewhat blocked by a two-compartment plate lowerator, which was filled with plates. At 9:24 AM, Diet Aide #14 entered the dishwashing area and rolled the cart stacked with trays away. At 9:27 AM, Diet Aide #13 took off her gloves, but did not wash her hands. Diet Aide #13 then pulled a rack of dishes from dishwasher to the clean drying area. At 9:28 AM, Diet Aide #13 was loading dirty dishes into a rack and spraying them with water. At 9:29 AM, Diet Aide #13 opened the dishwasher and moved freshly washed dishes to the clean side. Diet Aide #13 then unloaded other clean dishes from a different rack and stacked them on the clean side. Diet Aide #13 did not wash her hands prior to handing the clean dishes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 06/12/2024 at 9:33 AM, the Kitchen Supervisor was asked to observe dishwashing with the surveyor. As dishwashing was going on, Diet Aide #14 was seen nearby starting to load trays from the stacked trays on Level of Harm - Minimal harm or the cart onto the delivery speed racks to be used for lunch service. As Diet Aide #14 removed each tray from potential for actual harm the stack, he repeatedly used a white terry cloth square to dry each tray. Diet Aide #13 was again observed going from the dirty side to the clean side of the dishwashing machine without washing her hands. When Residents Affected - Many asked the problem, the Kitchen Supervisor said Diet Aide #13 should have washed her hands. When asked

the issue with Diet Aide #14's activity, the Kitchen Supervisor said, Wet trays. When asked if the trays should be air-dried, instead of towel-dried, to reduce the risk of cross-contamination; the Kitchen Supervisor said yes. The Kitchen Manager was then observed to be chewing gum. When asked about restrictions for chewing gum in the kitchen, the Kitchen Supervisor looked surprised and said, I didn't know that. This is the first time anyone told me that.

On 06/12/2024 at 9:37 AM, Diet Aide #13 was asked the problem with going from the dirty side of the dishwashing machine to the clean side. Diet Aide #13 thought for a moment and said, I should have washed my hands. I didn't think.

On 06/12/2024 at 9:38 AM. Diet Aide #13 was asked if temperatures had been checked on the dishwashing machine. Diet Aide #13 said it was running about 160 to 170 degrees. Diet Aide #13 was asked to run the dishwashing machine to confirm the temperatures. The Wash temperature was 157 F and the Final Rinse was 171 F. The plate on the dishwashing machine documented the minimum Wash temperature as 150 F and the minimum Final Rinse as 180 F. The Dish Machine Temperatures-Sanitation log sheet for June 2024 had the exact same numbers for the temperatures recorded for all three meals from June 1 to June 11; the repeated temperature for Wash was 160 and for Rinse was 180. Diet Aide #13 said the temperatures did vary, but they just recorded those numbers. Diet Aide #13 said if the temperature was 181 degrees F, they would record 180 degrees F. There were no temperatures yet recorded on the log sheet for June 12. The Kitchen Manager contacted Maintenance to come check the dishwashing machine.

On 06/12/2024 at 9:43 AM, Diet Aide #14 was observed going to the hand sink in the dishwashing area, but

he did not move the two-compartment plate lowerator. Instead, Diet Aide #14 reached over the two-compartment plate lowerator to wash his hands at the sink. Water splash from the sink and his hands hit

the dishes in the two-compartment plate lowerator. The Kitchen Manager observed this also and said it was

a contamination problem.

On 06/12/2024 at 9:45 AM, the Maintenance Supervisor arrived to check the dishwashing machine. The Maintenance Supervisor asked if the Booster Heater was turned on.

On 06/12/2024 at 9:55 AM, the Maintenance Supervisor said someone would have to come work on the dishwashing machine.

On 06/12/2024 at 11:07 AM, a worn, plastic covered sign was observed above the handwashing sink in Dishwashing area, on which was printed, COMPLETE TEMPERATURE LOG AT THE BEGINNING OF EACH DISH CYCLE.

On 06/13/2024 at 10:31 AM, a worn sign in a plastic sleeve was observed above the 3-compartment sink in

the Dishwashing area, on which was printed, PLEASE DO NOT LEAVE BOOSTER ON.

On 06/13/2024 at 11:47 AM, the Kitchen Manager said the Dishwashing machine repair person came yesterday (06/12/2024) and that a new booster heater needed to be ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an interview on 06/13/2024 at 4:52 PM, the Maintenance Supervisor said the dishwashing machine was not getting to temperature for the Final Rinse. He said the Final Rinse temperature should be 180 to 185 Level of Harm - Minimal harm or degrees Fahrenheit. The Maintenance Supervisor further said the dishwasher was new, but the booster potential for actual harm heater was older. He said they would be getting a new booster heater. When asked about the sign posted in

the kitchen about turning off the booster heater, the Maintenance Supervisor said it was probably meant for Residents Affected - Many overnight to save the life of the heating elements. The Maintenance Supervisor additionally said he did not actually know about the sign or its purpose.

During an interview on 06/13/2024 at 5:31 PM, the Dietary Manager said she had been working at the facility for about two months. The Dietary Manager said cross contamination was the problem with going from working on the dirty side of the dishwashing machine and then going to the clean side without washing one's hands. The Dietary Manager said staff could not wear gloves on the dirty side of the dishwashing machine and then merely remove them to go to the clean side. The Dietary Manager further said you have to wash your hands. The Dietary Manager said dishwashing machine temperatures should be recorded three times a day, before washing dishes. The Dietary Manager said the problem with recording the expected temperatures and not the actual temperatures for the dishwashing machine was not knowing what the temperature actually was and you cannot guess that. The Dietary Manager further said if the water was not hot, it was not going to clean and sanitize. The Dietary Manager said the dishwashing machine's Final Rinse should reach 180 degrees Fahrenheit to sanitize the dishes or else the residents could get sick. The Dietary Manager said cross contamination was the problem with using a white terry cloth square to repeatedly to dry resident food trays and that they should be air-dried. The Dietary Manager said the problem with the two-compartment plate lowerator or any equipment being placed in front of the handwashing sink was that it blocked access to the sink. The Dietary Manager said cross contamination from splashed water was the concern with the employee leaning over the two-compartment plate lowerator to wash their hands at the handwashing sink. The Dietary Manager said food service employees were not allowed to chew gum in the kitchen. The Dietary Manager further said when chewing gum, spit can come out of the mouth. The Dietary Manager said the booster heater was the problem with the dishwashing machine and a new was being purchased as soon as possible. The Dietary Manager did not know about the sign posted in the kitchen about turning off the booster heater or the reason for it.

During a phone interview on 06/13/2024 at 7:20 PM, the Registered Dietitian (RD) said infection control was

the concern with staff going from working on the dirty side of the dishwashing machine and then going to the clean side, without washing their hands. The RD further said staff could not wear gloves on the dirty side of

the dishwashing machine and then merely remove them to go to the clean side. The RD said the dishwashing machine's Wash and Final Rinse temperatures should be recorded at the beginning of the cycle. When asked the problem with staff recording the expected dishwashing machine temperatures and not the actual temperatures, the RD said they were not the same thing. The RD said the 180 F minimum temperature of the Final Rinse is needed to sanitize. The RD said repeatedly using a white terry cloth square to dry resident food trays was an infection control concern and that they should be air dried. The RD said infection control was the concern with the two-compartment plate lowerator or any equipment being placed in front of the handwashing sink. The RD further said cross contamination and infection control were problems resulting from the employee leaning over the two-compartment plate lowerator, which contained dishes, to wash their hands at the handwashing sink. The RD said food service employees were not allowed to chew gum in the kitchen due to germs. The RD further said if the gum left their mouth, it could get in the food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49799 potential for actual harm Based on observations, interviews, and review of a facility policy Infection Prevention and Control Program, Residents Affected - Few the facility failed to ensure staff washed their hands and stored resident hygiene supplies in a manner to prevent cross-contamination.

On 06/12/2024 and 06/13/2024 two unlabeled bath basins were observed on the bathroom of adjoining resident rooms for Resident Identifier (RI) #22 and RI #66.

On 06/14/2024 the facility Treatment Nurse failed to perform hand hygiene after cleaning RI #14's wound and before applying the treatment.

This affected RI #22, RI #66, and RI #14.

Findings include:

A facility policy titled, Infection Prevention and Control Program dated 11/20/2023 documented:

.Policy: .

5. Hand Hygiene Protocol:

a. All staff shall perform hand hygiene when coming on duty, between resident contacts, after handling contaminated objects, after PPE (Personal Protective Equipment) removal .

b. Staff shall perform hand hygiene before and after performing resident care procedures.

c. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedure.

11. Facilities with communal bathrooms:

a. Items such as wash basins, bed pans, etc. shall be placed in a bag that is clearly labeled and stored separately .

RI #22 was admitted to the facility on [DATE REDACTED].

RI #66 was admitted to the facility on [DATE REDACTED].

On 06/12/2024 at 10:59 AM, a shared bathroom for RI #22 and RI #66 was observed with two gray wash basins on the bathroom floor.

On 06/13/2024 at 11:00 AM the adjoining bathroom of RI #22 and RI #66 was observed with two unlabeled wash basins on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 49 015458 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015458 B. Wing 06/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Health Center at Research Park 5275 Millennium Drive Huntsville, AL 35806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 06/13/2024 at 11:30 AM Certified Nursing Assistant (CNA) #25 reported that each resident should have their own basin, labeled with their name and room number. CNA #25 said, the basins should be covered and Level of Harm - Minimal harm or in a clear plastic bag. potential for actual harm RI #14 was admitted on [DATE REDACTED] with diagnoses that included Stage Four Sacral Pressure Ulcer. Residents Affected - Few

On 06/14/2024 at 08:18 AM the Treatment Nurse, Licensed Practical Nurse (LPN) #26 was observed providing wound care for RI #14. LPN #26 cleaned RI #14's sacral wound and applied the clean treatment to

the wound. LPN #26 did not perform hand hygiene or change gloves after removing the soiled dressing and

before applying the clean treatment.

An interview was conducted on 06/14/2024 at 06:12 PM with the Risk Manager/Infection Preventionist. The Risk Manager/Infection Preventionist reported, according to the facility policy staff should wash their hands

after all care and each time they are dirty. The Risk Manager/Infection Preventionist stated, staff should remove soiled gloves before they exit the room or when they finished care. The Risk Manager/Infection Preventionist stated, staff should not be wearing contaminated gloves when touching clean items. The Risk Manager/Infection Preventionist stated, the risk of picking up clean items while wearing dirty/soiled gloves was contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 49 015458