Palma Real

The facility failed to ensure CNA A performed hand hygiene for at least 20 seconds prior to assisting Resident #1's transfer from her bed to the wheelchair.

This failure could place residents at risk for healthcare associated cross-contamination and infections caused by improper wound care.

Findings include:

Record review of Resident #1's face sheet dated 10/27/25 reflected a [AGE] year-old-female with an original admission date of 06/10/21.

Diagnoses included arteriovenous malformation of cerebral vessels (abnormal tangle of blood vessels in the brain that creates irregular connections between arteries and veins), cerebral infarction (ischemic stroke occurs when the blood flow to a part of the brain is obstructed), high blood pressure, and COPD (chronic obstructive pulmonary disease).

Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 10 (cognition moderately impaired). Resident #1 required substantial/maximal assistance (helper does more than half the effort) with bed to chair transfer.

During an observation of handwashing before the bed to chair transfer of Resident #1 on 10/27/25 at 11:20am, CNA A was observed lathering her hands for approximately 6 seconds. In an interview on 10/27/25 at 11:30am, CNA A stated she was nervous and believed she washed her hands for 20 seconds or more. CNA A stated handwashing should be 20 seconds to prevent cross contamination to residents. CNA A stated the last hands-on in-service for handwashing was in September 2025. In an interview on 10/27/25 at 2:39pm, the DON stated all staff should lather their hands for at least 20 seconds to prevent cross contamination.

The DON stated washing hands inappropriately could put residents at risk for infection. In an interview on 10/27/25 at 2:50pm, the ADON who was the Infection Preventionist stated, staff should scrub their hands for at least 20 seconds to ensure all germs were washed off and to prevent cross contamination to the residents.

The ADON stated it could put residents at risk for infection.

The ADON stated there was a hands-on handwashing skills in-service on 09/22/25 and CNA A had no issues.

The ADON stated CNA A was probably nervous.

Record review of the facility's Handwashing/Hand Hygiene policy dated and reviewed in August 2019 reflected: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of infections.Washing Hands2.

Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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