Wells Ltc Nursing & Rehabilitation

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in the facility’s handling and storage of drugs and biologicals, specifically related to the medication destruction closet and narcotic safe. Observations on 2/23/2026 at 9:10 a.m. showed the ADON’s office door open with no staff present, while the medication destruction closet inside that office had a locked padlock and door handle but an unlocked deadbolt. Inside the closet, a safe containing narcotic medications awaiting destruction was present but was not permanently affixed and could be picked up and moved. Later that day at 12:24 p.m., the DON unlocked the padlock and door handle, opened the narcotic safe, and demonstrated that the safe could be tilted forward, confirming it was not permanently secured to the shelf. During interview, the ADON reported she had been trained by the previous ADON for about one week and understood only that medications were supposed to be in the closet locked; she did not know they were required to be in a locked safe that was permanently affixed to the shelf. Review of facility policies showed that only authorized licensed nursing and/or pharmacy personnel were to have access to controlled drugs, that controlled substances were to be stored in a locked container separate from non-controlled medications, and that all unused controlled substances were to be retained in a securely locked area with restricted access until disposal. Another policy specified that controlled substances and other drugs subject to abuse must be separately locked in permanently affixed compartments. The facility failed to ensure these requirements were met for the medication destruction closet and narcotic safe between 12/04/2025 and 1/15/2026, and the report states this failure could put residents at risk of unauthorized use of medication and accidental ingestions or use of unprescribed medication.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that controlled drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled, resulting in missing hydrocodone-acetaminophen tablets for one resident. The resident was an older adult with obstructive hydrocephalus, malignant neoplasm of the brain, dementia, and significant functional dependence, including being rarely or never understood and dependent on staff for bed mobility, transfers, and toileting. The resident had a care plan for pain that included monitoring and documenting for side effects of pain medication, and an active physician order for hydrocodone-acetaminophen 5-325 mg, one tablet twice daily for pain related to brain cancer. After the resident expired in the facility, 43 remaining tablets of hydrocodone-acetaminophen 5-325 mg were turned over to the ADON. According to the provider investigation report and staff interviews, the ADON logged these tablets on the drug destruction log, paired the count sheet with the medication using a rubber band, and placed them in a locked closet in her office rather than in the safe located inside that closet. At that time, nurses brought discontinued narcotic medications to the ADON, who logged them and placed them in the closet, not in the safe. The ADON reported she had been trained to store the medications in the closet, and acknowledged that her office door could be bumped open and that staff accessed her office refrigerator and bathroom at all hours when she was not present. When the pharmacist and DON later pulled medications for destruction, the hydrocodone-acetaminophen tablets for this resident, although listed on the destruction log, were not found in the closet or lock box. Interviews with the DON and administrator confirmed that at the time of the incident, the ADON office door could be opened by bumping it with a hip and the closet door lock could be easily bypassed with a butter knife. They also confirmed that the narcotic medications awaiting destruction were not stored in the safe and that staff were allowed access to the ADON office, and the facility did not review camera footage to identify who might have taken the narcotics. The facility’s own policies required that only authorized personnel have access to controlled drugs, that controlled substances be stored in a locked container separate from non-controlled medications, and that unused controlled substances be retained in a securely locked area with restricted access until disposal, which was not followed in this case.

Penalty

Inspection fine: $19,120

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents for a resident with known exit-seeking behaviors. The resident was an adult male with dementia, impaired memory, impaired decision-making, and a documented history of elopement risk and wandering. He had been assessed as an elopement risk, was disoriented to place, had a history of attempts to leave the facility unattended, and was admitted to and residing on a secured male unit specifically due to active exit-seeking behaviors and elopement attempts. On the day of the incident, staff reported that residents from the secured male unit, including this resident, attended a Christmas party in the main dining room. CNAs working the unit stated that all or most residents were taken to the party, with one CNA remaining on the unit because one resident did not attend. After the party, residents were assisted back to the secured unit. At some point after the return from the party, the resident was allowed into the secured unit’s courtyard without staff supervision. Staff interviews indicated that an aide had let the resident out into the courtyard unsupervised, despite his known elopement risk and the facility’s practice that residents in the courtyard must be supervised. The courtyard was enclosed by a wooden fence with a gate equipped with a magnetic lock and keypad. On the day of the incident, the gate’s magnetic lock was not functioning properly, and the gate was unlocked, allowing the resident to exit the courtyard and leave the facility grounds. The maintenance supervisor reported that he had conducted a generator test earlier that day and had reactivated the magnetic locks on the doors and courtyard gate, and that they were working at that time. However, after this check, the gate lock failed and the resident was able to walk out through the open gate. The facility was unaware that the resident was missing until a speech-language pathologist, who had left for the day, saw him walking in a nearby library parking lot near a main highway, picked him up, and returned him to the facility. At the time he was found, the resident stated he was looking for his car. The facility’s failure to ensure the courtyard gate remained secured and to provide continuous supervision for a known elopement-risk resident in the courtyard led to the elopement event.

Removal Plan

• Update Resident #1's comprehensive care plan to add interventions after the elopement (monitor for emotional distress for 72 hours, complete head-to-toe assessment for injuries/abnormalities, notify physician and family, provide additional staff training on elopement and review policy/procedure, ensure resident is supervised while in the courtyard and not left unattended, and update the elopement risk assessment).
• Complete an incident report for the elopement and notify the physician and family.
• Complete a comprehensive assessment.
• Complete emotional distress assessments.
• Complete a new elopement risk assessment.
• Provide staff in-service training titled 'Secured unit outside supervision'.
• Provide staff in-service training titled 'Elopement and Wandering Residents'.
• Initiate every-15-minute head counts on the male secured unit.
• Install a camera at the courtyard gate and monitor it with a log until the gate is repaired.
• Conduct elopement drills for day and night shifts.
• Repair the exterior gate by replacing the magnetic lock and z-bracket to restore proper function.
• Ensure residents on the male secured unit are supervised when outside in the courtyard.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the appropriate temperature range and sufficient water pressure for resident-use hot water in two of four halls, specifically Halls C and D. Multiple residents reported ongoing issues with lack of hot water and low water pressure, which had persisted for months. Residents were unable to receive scheduled showers or proper bathing due to these deficiencies, and staff had to resort to carrying hot water from the kitchen or laundry in basins to provide bed baths. Observations confirmed that water temperatures in resident rooms were below acceptable levels, with one measurement showing 72 degrees at the sink. Residents affected by this deficiency included individuals with significant medical histories, such as type 2 diabetes, morbid obesity, hypertension, cerebral infarction, nonrheumatic mitral valve insufficiency, cardiomegaly, bradycardia, schizoaffective disorder, and generalized anxiety disorder. These residents were dependent on staff for bathing and personal hygiene. Interviews revealed that residents missed scheduled showers and expressed dissatisfaction with the lack of hot water and water pressure, with some noting that their families were also concerned about the situation. Resident Council meeting notes documented repeated complaints about water issues over several months without resolution. Staff interviews corroborated the residents' accounts, indicating that the water issues had been ongoing for an extended period. Maintenance logs and interviews with the Maintenance Supervisor and a plumber detailed recurring problems with lime buildup in pipes, malfunctioning backflow valves, and the need for a new water filtration system. The facility's own policy required a safe, clean, and homelike environment, but the persistent water issues prevented staff from providing basic hygiene care as scheduled, impacting the residents' quality of life.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the environment remained free from accident hazards for one resident. During observations on two consecutive days, two aerosol cans of air freshener were found on the nightstand in the resident's room. The resident reported that one can belonged to him and the other was left by staff. The label on one of the cans indicated it should be kept out of reach of children. The resident stated that staff had left the cans in his room and that no other residents had wandered into his room. At the time of the observations, the resident was either present or absent from the room, but the cans remained accessible. Record review showed that the resident had diagnoses including type 2 diabetes, morbid obesity, hypertension, and a history of stroke, and was dependent on staff for bathing. Facility policy required hazardous items, such as toxic chemicals, to be identified and secured to ensure resident safety. Interviews with the DON and Administrator confirmed that residents should not have access to aerosol products in their rooms, and such items should be stored securely. Both acknowledged that the presence of air fresheners in the resident's room was not in accordance with facility policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain complete and accurate medical records for two residents regarding their scheduled bathing care. Certified Nurse Aide (CNA) C documented in the medical records that both residents received a bath on a specific date, when in fact, neither resident received the care as scheduled. This was confirmed through interviews with the residents, who reported not receiving their showers due to ongoing water issues in the facility, such as low water pressure and lack of hot water. Both residents were scheduled for showers three times weekly and required staff assistance, as indicated in their care plans and nurse aide task records. Further investigation revealed that CNA F, who worked on the relevant date, acknowledged that only three out of five scheduled residents received their baths, and that she had mistakenly documented that the two residents in question had received their showers. The residents themselves confirmed during interviews that they did not receive their scheduled showers, and one resident noted that his family was concerned about missed showers. The facility's shower schedule and care plans corroborated the residents' accounts and the CNA's admission of documentation errors. Interviews with facility leadership, including the Director of Nursing (DON) and the Administrator, confirmed that the expectation is for nurse aides to accurately document care provided, and to notify nursing staff if a resident refuses care. Both leaders stated that documenting care as provided when it was not is considered falsification of records. The facility's policy on charting and documentation requires that records be objective, complete, and accurate, which was not followed in these instances.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during incontinent care for a resident. During an observation, a CNA provided perineal care to a resident with multiple medical conditions, including hemiplegia, prostate cancer, stroke, and dysphagia, who was dependent on staff for personal hygiene and was always incontinent. The CNA was observed removing and changing gloves multiple times throughout the care process without washing or sanitizing her hands between glove changes, despite having hand sanitizer available. Interviews with the CNA confirmed that she did not perform hand hygiene between glove changes during the care episode, acknowledging the risk of infection associated with this lapse. The CNA had previously received training and was deemed proficient in perineal care and hand hygiene, as documented in her records. Facility leadership, including the ADON and DON, stated that staff are trained annually on infection control practices, including the requirement for hand hygiene before, during, and after care, and specifically between glove changes. A review of the facility's hand hygiene policy indicated that hand hygiene is required after glove removal and that the use of gloves does not replace hand washing or hand hygiene. The policy also specifies the use of alcohol-based hand rubs for most clinical situations and outlines the indications for hand hygiene, including after contact with contaminated surfaces and between work on soiled and clean body sites. Despite these policies and training, the observed failure to perform hand hygiene between glove changes during resident care constituted a breach in infection control protocols.

Penalty

Inspection fine: $80,850

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from abuse and neglect, specifically in the male secure unit, due to insufficient staffing and inadequate supervision. Multiple incidents of resident-to-resident abuse occurred, including physical altercations and sexual abuse. In one case, a resident with severe cognitive impairment was pushed by another resident, resulting in a fractured toe and other injuries. Other incidents included residents being hit or slapped by peers, with some residents having documented histories of behavioral disturbances and aggression. Staff interviews and records revealed that these behaviors were known, yet interventions and monitoring were not consistently implemented or effective in preventing further incidents. The report details that only one CNA was often assigned to the male secure unit, which was insufficient to monitor and manage the residents' behaviors. Staff reported that aggressive and inappropriate behaviors had been communicated to nursing leadership, but no additional support or changes were made. In several cases, residents with known behavioral issues were not provided with adequate supervision or behavioral interventions prior to the incidents. Documentation shows that staff were aware of escalating behaviors, such as verbal threats and physical aggression, but responses were delayed or limited to after-the-fact monitoring and separation of residents. A particularly severe incident involved a resident sexually assaulting his roommate, who was cognitively impaired and unable to recall the event. The assault was discovered during a routine room check, and the victim was subsequently sent to the hospital for evaluation. Prior to this, the perpetrator had a documented history of sexually inappropriate comments and behaviors, but interventions were limited to staff training and general supervision. The lack of effective preventive measures and insufficient staffing contributed directly to the occurrence of these abusive events.

Penalty

Inspection fine: $80,850

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and a hazard-free environment to prevent accidents and resident-to-resident abuse for all eight residents reviewed. Multiple incidents occurred in which residents with severe cognitive impairments and behavioral issues were not properly monitored, resulting in physical and sexual abuse. For example, one resident with Alzheimer's disease and a history of psychotic disorder was pushed to the floor by another resident, resulting in a fractured toe. Another resident was hit in the head twice by a roommate, and a separate incident involved a resident being slapped in the face from behind by another resident. These events were witnessed by staff, and in some cases, staff were the only ones present on the unit, indicating inadequate staffing and supervision. Further review revealed that residents with known histories of aggression, wandering, and inappropriate behaviors were not consistently provided with the necessary supervision or interventions to prevent altercations. Several care plans documented the need for monitoring, behavior management, and interventions such as 1:1 supervision, but these measures were not always implemented or effective. Staff interviews indicated that there were times when only one CNA was present on the secured unit, and staff expressed concerns that incidents could have been prevented with more personnel. Documentation also showed that some aggressive behaviors were not promptly reported to facility leadership, and there was a lack of communication regarding the transfer of residents to behavioral hospitals following incidents. A particularly severe incident involved a resident with a history of sexually inappropriate behavior who was found sexually assaulting another resident with moderate cognitive impairment. The assaulted resident was confused and did not recall the event, and both residents required medical evaluation. Staff interviews and documentation indicated that the resident with a history of sexual behaviors had previously made inappropriate comments and had engaged in similar behaviors before, but interventions to prevent further incidents were insufficient. The facility's failure to provide adequate supervision and to implement effective interventions placed all residents in the secured unit at risk of injury and harm.

Penalty

Inspection fine: $80,850

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly on the A and B hallways, which are secured units. Multiple incidents of resident-to-resident abuse occurred, including physical and sexual abuse, as a result of inadequate staffing. Staff interviews and record reviews revealed that there were often only one or two CNAs assigned to halls with residents who had significant behavioral and cognitive impairments, including dementia, psychotic disorders, and histories of aggression or wandering. Staff frequently worked extended shifts, sometimes up to 24 hours, due to call-ins and staffing shortages, further compromising resident supervision and care. Several residents with severe cognitive impairments and behavioral issues were involved in altercations that resulted in injuries and emotional distress. For example, one resident with Alzheimer's disease and a history of psychotic disorder was pushed by another resident, resulting in a fracture. Other incidents included residents being hit or slapped by peers, and one case of sexual abuse that led to a resident being hospitalized. Care plans for these residents indicated the need for supervision, structured activities, and interventions to manage wandering and aggressive behaviors, but the lack of adequate staffing prevented consistent implementation of these interventions. Staff and management interviews confirmed ongoing staffing challenges, with reports of staff working excessive hours and being unable to provide adequate supervision or quality care. Payroll records corroborated that some CNAs worked nearly 24-hour shifts. The facility's own assessment acknowledged that staffing should be based on resident acuity and census, but the actual staffing levels did not meet these needs, especially during periods of increased resident behaviors and acuity. The deficiency resulted in multiple instances where residents were not protected from abuse or harm due to insufficient staff presence and supervision.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from abuse by other residents. In the first incident, a female resident with severe cognitive impairment and multiple medical conditions, including metabolic encephalopathy and a stage 3 pressure ulcer, was sitting in her geri chair near the nurse's station. A male resident with Alzheimer's disease and vascular dementia, who was dependent on staff for most activities of daily living, approached her in his wheelchair and inserted his hand into her shirt, groping her breast. The incident was witnessed by several staff members who intervened immediately, and the male resident admitted to the inappropriate contact during an interview. The female resident confirmed the incident when interviewed by the social worker. In the second incident, a male resident with moderately impaired cognition and a history of aggressive behaviors was involved in an altercation with another male resident diagnosed with Alzheimer's disease, bipolar disorder, and unspecified psychosis. The resident with Alzheimer's was observed on facility camera footage to have his path blocked by the other resident in a wheelchair. In response, he lifted the wheelchair, causing it to fall backward, and then punched the resident in the nose. The injured resident sustained redness to his nose as a result of the altercation. Both residents had documented histories of behavioral issues and required significant assistance with daily activities. Both incidents were directly observed by staff or captured on facility cameras, and the involved residents had care plans indicating cognitive impairment and behavioral risks. The facility's failure to prevent these resident-to-resident abuse incidents constituted noncompliance with regulations requiring protection from abuse, as evidenced by the physical and sexual abuse that occurred.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that pureed diets were prepared to the required consistency for five residents who were on pureed diets due to conditions such as Alzheimer's, dysphagia, and cognitive impairments. These residents included individuals with moderate to severe cognitive impairments and swallowing difficulties, necessitating a pureed diet to prevent choking and ensure nutritional intake. The deficiency was observed on a specific date when the pureed food provided was not of the correct texture, posing a risk to the residents. Observations and interviews revealed that the pureed meat was lumpy and chewy, and the pureed greens were stringy, indicating that the food was not prepared to the smooth, lump-free consistency required for residents with swallowing difficulties. The dietary staff, including the person responsible for pureeing the food, did not taste the food to ensure it met the necessary texture standards. This oversight was confirmed during a test tray observation where both the administrator and dietary manager acknowledged the improper texture of the pureed food. The facility's policy on therapeutic diets, which includes altered consistency diets, was not adhered to, as evidenced by the failure to provide pureed foods that did not require chewing and had a smooth texture with no lumps. The corporate dietician confirmed that the expected consistency for pureed foods was not met, and the deficiency was identified as a risk for choking among residents requiring pureed diets.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that call lights were accessible to residents in the secured units, which could prevent residents from notifying staff of their needs. Specifically, the call lights in the bathrooms of three residents were found to be wrapped around support bars, making them unreachable from the floor. This deficiency was observed during a survey conducted on September 3, 2024, affecting residents with varying degrees of cognitive and physical impairments. Resident #16, a male with dementia and Parkinsonism, was observed in a room where the call light was wrapped around the grab bar, making it unreachable from the floor. Despite his moderate cognitive impairment and frequent incontinence, he used the restroom independently and expressed the need for a reachable call light in case of a fall. Similarly, Resident #20, a female with phantom limb syndrome and intact cognition, reported using her bathroom and call light for assistance, yet her call light was also found wrapped around the support bar. Resident #39, a female with dementia and severely impaired cognition, was observed wandering the hall and using various bathrooms, including those with inaccessible call lights. Interviews with staff revealed a lack of awareness and responsibility regarding the accessibility of call lights, with the maintenance director acknowledging the issue but failing to ensure consistent checks. The facility's policy mandates that residents have a means to call for assistance from their beds and bathrooms, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary services to maintain personal hygiene for three residents, leading to deficiencies in care. Resident #19, who has Alzheimer's disease and other health conditions, was observed with dried eye drainage and dirty bed linens. Despite being dependent on staff for personal hygiene, her care plan was not followed, resulting in her face and bed remaining unclean. A CNA admitted to not changing all the linens and acknowledged the resident's eyes had been matted for days. Resident #3, diagnosed with major depressive disorder and mild intellectual disabilities, was observed walking with wet pants, indicating a lack of timely incontinent care. His care plan required staff assistance for toileting and regular checks for incontinence, which were not adequately performed. Interviews revealed that the resident often stayed wet, and there were issues with insufficient linens and towels, contributing to the neglect of his hygiene needs. Resident #9, with severe cognitive impairment, was found with long, dirty fingernails, despite being dependent on staff for personal hygiene. Observations showed the resident attempting to clean his nails, which were visibly dirty. The facility's policy required regular nail care, but this was not adhered to, as confirmed by interviews with staff. The lack of proper nail care posed a risk of scratches and infections, highlighting a failure to meet the resident's hygiene needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish a comprehensive system for recording the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation and compliance with State and Federal laws. Specifically, during the month of January 2024, the facility did not document the required number of witness signatures for drug destruction. The drug destruction records for January 5, 2024, were only signed by the Director of Nursing (DON) and the Pharmacist, lacking the additional witness signature required by the facility's policy and the Texas Administrative Code. Interviews revealed that the DON acknowledged the absence of an Assistant Director of Nursing (ADON) at the time, which contributed to the failure to obtain the necessary signatures. The Administrator admitted to not being involved in the drug destruction process and was unaware that she could serve as a witness. The facility's policy, revised in November 2022, mandates that controlled drug destruction records include the signatures of witnesses, aligning with the Texas Administrative Code requirements. This oversight in documentation could potentially lead to risks such as drug diversion.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices observed during the provision of incontinent care to a resident. A nursing assistant (NA C) did not sanitize or wash her hands between glove changes while providing care to a resident with bowel and bladder incontinence. This resident, who was admitted with diagnoses including diverticulitis, chronic kidney disease, osteoporosis, and bipolar disorder, required substantial assistance with toileting hygiene and was at risk for skin breakdown. During the care, NA C changed gloves multiple times without performing hand hygiene, despite being trained to do so. Interviews with NA C, the Director of Nursing (DON), and the Administrator revealed a lack of adherence to the facility's hand hygiene policy, which mandates handwashing or sanitizing immediately after glove removal. NA C acknowledged her failure to wash or sanitize her hands between glove changes, which could potentially expose residents to infections. The DON and Administrator confirmed the importance of hand hygiene in preventing cross-contamination and the spread of infections, highlighting a gap in the implementation of infection control practices at the facility.