Highlands Health And Rehabilitation Center

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

of the Physician's Order dated 9/16/2025, revealed catheter care every shift. Review of the admission MDS dated [DATE REDACTED], revealed Resident #10 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Resident #10 had a feeding tube and an indwelling catheter. Observation in Resident #10's room on 10/14/2025 at 9:42 AM, CNA C performed hand hygiene, donned gown and gloves, raised

the resident's bed, obtained wet wipes placed on side of resident's bed without a barrier, removed the resident's brief, placed 2 trash bags on top of the resident's bed, performed catheter care, removed gloves, discarded the trash bags into the resident's trash, and donned gloves without performing hand hygiene.

CNA C failed to place wet wipes on a barrier and failed to perform hand hygiene after removing gloves. 4.

Review of the medical record revealed Resident #13 was admitted to the facility on [DATE REDACTED], with diagnoses including Multiple Sclerosis, Dementia, Depression, and Failure to Thrive. Review of the quarterly MDS dated [DATE REDACTED], revealed Resident #13 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Review of the Physician's Order dated 7/25/2025, revealed clean left ankle with wound cleanser (used when performing wound care), apply calcium alginate (used in wound care for absorbing drainage) to wound bed, pat dry with 4 by 4 (4x4) gauze and cover with protective dressing every other day.

During an observation and interview on 10/13/2025 at 2:00 PM, LPN B entered Resident # 13's room to perform wound care. The treatment cart was in the resident's room with supplies on a barrier on the top of

the treatment cart. LPN B removed the soiled dressing from the resident's left ankle and cleansed the wound with gauze moistened with wound cleanser. LPN B removed gloves, performed hand hygiene, donned gloves and applied dressing. LPN B removed PPE, performed hand hygiene and discarded the barrier and supplies. LPN B pushed the treatment cart into the hallway. LPN B was asked if gloves should be changed and hand hygiene performed after the removal of a soiled dressing. LPN B stated Yes, gloves should be changed after removing the dressing. LPN B was asked if she should take the treatment cart into

the resident's room when providing care. LPN B stated No, it should not but the resident did not have space for supplies on her over the bed table. LPN B was asked, would it be better to obtain an additional table if available instead of using the treatment cart in the resident's room. LPN B stated Yes, it would. LPN B failed to perform hand hygiene after the removal of the soiled dressing, used the treatment cart in the resident's room and failed to clean the outside of the treatment cart after use. During an interview on 10/13/2025 at 4:19 PM, the Director of Nursing (DON) was asked, when staff should wear PPE for EBP. The DON stated, Staff should wear PPE when providing care to residents with wounds, peg tubes, and catheters. The DON was asked if staff should perform hand hygiene after the removal of a soiled dressing. The DON stated, Yes,

the nurse should change gloves and perform hand hygiene after removing the dressing. The DON was asked if staff should perform hand hygiene in between changing of gloves. The DON stated, Yes, staff should perform hand hygiene before and after the removal of gloves. The DON was asked if treatment carts should be taken into resident's rooms when performing care. The DON stated, No, they should not.

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