Based on observations, interviews, and review of the facility RESIDENT BILL OF RIGHTS, the facility failed to ensure Room Locator (RL) #1 was free of odors. This was affected one of 54 Room Locators. Findings Include: A review of the facility RESIDENT BILL OF RIGHTS , with a history date of 1/23 revealed, .A. Facility residents shall have the right to: . 32. A safe clean, comfortable home like environment. On 03/02/2023 at 8:40 AM during the surveyor's walk through of the facility observing various rooms, RL #1 was observed with a strong odor. The odor appeared to be that of urine. The facility Administrator, Employee Identifier (EI) #1 was observed in the hall and asked to come to RL #1. When EI #1 entered RL #1, she was asked what she noticed. EI #1 said the smell or urine. EI #1 was asked why there was a smell of urine in RL #1. EI #1 said she was not sure if it was the mattress. When asked if it was the mattress, would it have gotten that way overnight, and she said no. EI #1 was asked how noticeable the smell of urine was, and she replied it was noticeable. EI #1 was asked what the concern with RL #1 smelling of urine. EI #1 said it should not be like that it was the resident's home. On 03/02/2023 at 8:50 AM, EI #4, Certified Nursing Assistant (CNA), EI #4 was observed in RL #1. EI #4 was asked what she smelled in RL #1; she said urine. EI #4 was asked how often did RL #1 smell of urine and said often. EI #4 was asked what could help take the smell of urine away; she said clean linens and possibly wiping down the bed. EI #4 was asked what was the concern of RL #1 smelling of urine and she said it was the resident's home and should not smell that way. On 03/02/2023 at 9:00 AM, EI #3, the housekeeping supervisor was asked to come to RL #1, she was asked what she noticed. EI #3 said it smelled horrible, like urine. EI #3 was asked who was responsible for ensuring rooms did not smell like urine. EI #3 said all staff, CNAs, nurses and housekeeping. EI #3 was asked what was the concern with RL #1 smelling of urine. EI #3 said this was the resident's home and it should be a safe clean home like environment, the smell of urine was not clean. On 03/02/2023 at 9:10 AM an interview with EI #5, housekeeping staff revealed RL #1 smelled of urine often. EI #5 was asked what was the concerns with RL #1 smelling of urine. EI #5 said it was the resident's home and should not smell that way, it was not clean. On 03/02/2023 at 9:20 AM, a follow up interview with EI #3 revealed the concern with RL #1 smelling was that it was not a safe clean environment. On 03/02/2023 at 10:00 Am an interview was conducted with EI #2, the Director of Nursing, she was asked what was the policy on rooms being clean. EI #2 said it was the resident's rights, they should have a safe, clean comfortable homelike environment. When asked if urine odor should be strong in RL #1 she said it should not. EI #2 was asked what the concern was with a resident's room smelling horrible, be it of urine or other body fluids. She said it was not a clean comfortable environment. On 03/02/2023 at 10:30 AM a follow up interview was conducted with EI #1, the administrator. EI #1 was asked what the facility policy was on a clean comfortable environment. EI #1 said residents should have a clean comfortable homelike room with no uncomfortable odors. EI #1 was asked what was included in a clean homelike environment. EI #1 said no excessive clutter, floors clean, no overflowing trash and no uncomfortable odors. EI #1 was asked what would uncomfortable odors be and she said urine, bowel movement, saliva or trash. EI #1 was asked what the concern was with an uncomfortable odor. EI #1 said the residents could be uncomfortable and it was their home and should not smell that way. This was cited as a result of the investigation of complaint/report number AL00042790.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the admission Minimum Data Set (MDS) for Resident Identifier (RI) #233 was completed in a timely manner. This deficient practice affected one out of 18 resident MDS's reviewed. Findings Include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/19, page 2-16, revealed the following: . RAI OBRA-required Assessment Summary . Assessment Type/Item Set . admission . MDS Completion Date (Item Z0500B) No Later Than . 14th calendar day of the resident's admission (admission date + 13 calendar days) . RI #233 was admitted to the facility on [DATE]. RI #233's admission MDS had an Assessment Reference Date (ARD) of 4/27/22. The status of the MDS was Open. No information was entered at Z0500. On 5/17/22 at 09:09AM, Employee Identifier (EI) #2. RN/MDS Coordinator, reported she was working on the admission MDS for RI #233 and it had not been completed. EI #2 reported the MDS was started 4/27/22 and it should have been completed around 5/2/22. EI #2 stated RI #233's MDS was not be completed timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of a facility policy MDS ASSESSMENT, the facility failed to ensure the Minimum Data Set (MDS) for Resident Identifier (RI) #32 dated 2/25/22 was coded for anticoagulation medication. This affected one of one resident records reviewed for anticoagulation medication. Findings Include: A review of a facility policy titled MDS ASSESSMENT, with a date of 11/17 revealed POLICY: The facility shall conduct interdisciplinary assessments using the MDS item sets a .These assessments provide information on the resident's condition . RI #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include unspecified Atrial Fibrillation. A review of RI #32's Physician orders revealed . Order Date 2/18/22 . ELIQUIS 2.5 mg (milligram) . By MOUTH TWICE DAILY . A review of an admission MDS with an Assessment Reference Date of 2/25/22, Section N revealed not coded for anticoagulation medication. On 5/17/22 at 1:15 PM an interview was conducted with Employee Identifier (EI) #3, Registered Nurse (RN), MDS Assistant. EI #3 was asked, how was RI #32 receiving anticoagulation medication. EI #3 replied, RI #32 was receiving Eliquis two times a day. EI #3 was asked when did the medication start. EI #3 replied 2/18/22. EI #3 was asked if Eliquis should be coded on the MDS, she replied, yes. EI #3 was asked, why was the anticoagulation medication not coded on the 2/25/22 MDS, EI #3 replied it was an oversight. EI #3 was asked, what would the concern be with anticoagulation medication not coded. EI #3 replied, possibly not an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and a review of the facility policy COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure Resident Identifier (RI) #58 was care planned for a Urinary Tract Infection (UTI) upon readmission to the facility on 3/23/22. This affected one of 18 resident care plans reviewed. Findings Include: A review of a facility policy COMPREHENSIVE PERSON CENTERED CARE PLANS, with an effective date of 3/18 revealed POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. 9. Upon a change in condition, the Comprehensive Person Centered Care Plan . will be updated . RI #58 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Urinary Tract Infection. A review of RI #58's Physician Orders List revealed . Order Date 3/23/22 Start Date 3/24/22 . Stop Date 3/30/22 . Sulfamethoxazole DS tablet . A review of a facility form titled Departmental Notes revealed . 3/23/22 . Resident received back to the facility . for UTI . 3/25/22 . ABT (antibiotic therapy) continues for UTI . 3/28/22 . continues on ABT for UTI . A review of RI #58's care plans did not reveal a care plan for UTI. On 5/17/22 at 1:11 PM, an interview was conducted with the MDS (Minimum Data Set), Coordinator, Employee Identifier (EI) #2. EI #2 was asked when should a care plan be updated. EI #2 replied, when there was a new concern. EI #2 was asked, when was RI #58's care plan updated for a UTI. EI #2 replied, it had not been. EI #2 was asked what was the concern with not having a care plan for UTI. EI #2 replied, possible recurring infection.

Based on interviews, discussion during the resident group meeting, and review of the facility's admission Agreement, the facility failed to ensure mail was delivered to residents on Saturdays. This deficient practice had the potential to affect all 90 out of 90 residents residing in the facility. Findings Include: A review of the facility's admission AGREEMENT, with an effective date of 9/16/19, revealed: . RESIDENT BILL OF RIGHTS . A. Facility Residents shall have the right to: . 26. To send and receive mail promptly and unopened. On 5/16/22 at 10:00AM, a group meeting was held with 18 residents present. No one stated they received mail on Saturdays. In an interview on 5/16/22 at 11:29AM, Resident Identifier (RI) #40 stated no one received mail on Saturday because the main office staff were not present on Saturdays. On 5/16/22 at 03:44PM, Employee Identifier (EI) #4, Social Services Director, reported if resident mail is delivered by postal service on Saturday, the resident received the mail on Monday because the mail was given to the resident by Social Services and they do not work Saturdays or Sundays. EI #4 stated mail was delivered to the residents Monday through Friday and mail received on Saturday was delivered to the resident on Monday. EI #4 stated residents had a right to receive mail on Saturdays. EI #4 stated the Residents' Rights were not being followed on Saturdays. On 5/17/22 at 10:24AM, EI #7, Business Office Manager, reported she worked as the receptionist on some Saturdays. EI #7 stated if a resident received mail on Saturday, she put the resident's mail in the Social Services box. EI #7 stated she did not deliver the mail received on Saturdays to the residents. On 5/17/22 at 10:29AM, EI #5, Restorative Certified Nursing Assistant (CNA), reported she covered as the receptionist on some Saturdays. EI #5 stated if a resident received mail on Saturday, she would set it aside for Social Services. EI #5 stated if a resident asked for their mail, she would ask the nurse about it first. EI #5 stated residents had a right to receive mail on Saturdays. On 5/17/22 at 10:34AM, EI #8, Housekeeper, reported she worked as the receptionist on Saturdays. EI #8 stated if a resident received mail on Saturday, she would set it aside for Social Services. EI #8 stated Social Services did not work on Saturdays. It was EI #8's understanding that Social Services had to observe resident mail first. On 5/17/22 at 12:56PM, EI #6, Restorative CNA, stated she worked some Saturday mornings as the receptionist. EI #6 stated if residents received mail on Saturday, it would go into the box on the desk and Social Services would get it Monday and distribute it. EI #6 stated residents should get their mail on Saturdays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and a review of the facility policies titled NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, and GUIDE FOR WOUND EVALUATION, the facility failed to provide evidence Resident Identifier (RI) #74's responsible party was notified when: 1) RI #74 developed an open area to the right ankle on 6/15/2021; and 2) when the area to RI #72's right ankle was observed to have worsened on 6/27/2021. These deficient practices affected RI #74, one of three residents sampled for notification. Findings include: Review of a facility policy titled NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, with a HISTORY date of 11/2017, revealed the following: POLICY: . the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulation. RESPONSIBILITY: All Licensed Nursing Personnel. PROCEDURE: . 2. Document in the Interdisciplinary Team (IDT) notes: . c. Notification of responsible party. Another facility policy titled GUIDE FOR WOUND EVALUATION, with a HISTORY date of 11/2017, revealed the following: . COMMENTS: Other considerations: . Family notification . PROCEDURE: . 3. Contact . family members . as indicated . RI #74 was admitted to the facility on [DATE] and discharged to the ER (Emergency Room) on 06/29/2021. RI #74's diagnoses while at the facility included: Diabetes Mellitus with Hyperglycemia and Local Infection of the Skin and Subcutaneous Tissue. A review of RI #74's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 06/02/2021, revealed RI #74 did not have a Pressure Ulcer or Diabetic Foot Ulcer during this assessment period. 1) RI #74's June 2021 Physician Orders revealed the following: . Start Date . 06/15/21 . CLEAN WOUND TO RT (Right) OUTER ANKLE WITH NS (Normal Saline), PAT DRY W (With)/4X (by)4, APPLY ZEROFORM, COVER W/MEPILEX BORDER FOAM AS NEEDED . A review of RI #74's Departmental Notes revealed there was no evidence RI #74's responsible party had been notified of the new wound care order. On 07/06/2021 at 7:52 PM, the surveyor conducted a telephone interview with RI #74's responsible party. When asked if RI #74 was admitted with any skin break down, RI #74's responsible party said no. The surveyor asked RI #74's responsible party was she notified about any opened areas on RI #74 or any skin breakdown on RI #74's ankles. RI #74's responsible party said no. RI #74's responsible party said she was never notified that the facility was providing any type treatment to RI #74's ankles. On 07/08/2021 at 11:41 AM, the surveyor conducted an interview with Employee Identifier (EI) #2, LPN (Licensed Practical Nurse) who provided care to RI #74 on the 7 A - 7 P shift. The surveyor asked EI #2, when RI #74 was admitted what was on RI #74's ankles. EI #2 said nothing that she could recall. EI #2 was asked when she first noticed RI #74 had an open area on his/her right ankle. EI #2 replied, it was about mid-June. When asked where would it be documented that the responsible party had been notified, EI #2 said it should be in the nurses notes. A review of RI #74's June 2021 eTAR (electronic Treatment Administration Record) revealed the treatment to RI #74's right outer ankle began on 06/15/2021. On 07/08/2021 at 03:11 PM, the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1, according to RI #74's treatment record, when did RI #74 develop the open area to his/her right outer ankle. EI #1 said 06/15/2021. The surveyor asked EI #1 where would there be evidence the responsible party was notified of the new wound, and the care order. EI #1 said it should have been in the nurse notes. When asked to show the surveyor where the responsible party was notified of the new order, EI #1 looked in RI #74's Departmental Notes and said she did not see where the responsible party had been notified. 2) A review of RI #74's Departmental Notes dated 06/27/2021 at 8:23 PM, revealed the following: . Wound care provided as ordered. Wound to right heel degressing. Area around wound is red and inflammed (Inflamed). Right foot is slightly swollen . On 07/08/2021 at 7:15 PM, the surveyor conducted an interview with EI #3, the RN (Registered Nurse) documenting the above Departmental Note. The surveyor showed EI #3 the Departmental Notes and asked what she meant when she documented the wound to RI #74's right heel was degressing. EI #3 said it should have been documented to the right ankle not heel and what she meant was the wound was getting worst. When asked was the responsible party notified that the wound was getting worst, EI #1 said she did not see where it was documented the responsible party was notified RI #74's wound was getting worse. The surveyor asked EI #3 should the responsible party have been notified. EI #3 said yes. When asked when you notify responsible parties of new changes occurring with the resident, where would there be evidence of that, EI #3 said it should be documented in the nurse's notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instruction (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #82's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/21/2021, did not code RI #82 as receiving an Anticoagulant medication during this assessment period. This deficient practice affected RI #82, one of 31 residents whose MDS assessments were reviewed. Findings include: A review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instruction 3.0 User's Manual, Version 1.17.1, dated October 2019, revealed the following: . Coding Instructions . NO410E, Anticoagulant (e.g. (for example), warfarin, heparin, or low-molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . Do not code antiplatelet medication such as . clopidogrel here . RI #82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include Peripheral Vascular Disease. A review of RI #82's Quarterly MDS assessment, with an ARD of 06/21/2021, revealed RI #82 received an Anticoagulant during this 7-day look back assessment period. A review of RI #82's June 2021 eTAR (electronic Treatment Administration Record) revealed RI #82 received the following: . PLAVIX 75 MG (milligrams) TAKE ONE (1) TABLET BY MOUTH EVERY DAY . CLOPIDOGREL BISULFATE . Other specified peripheral vascular diseases . According the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instruction 3.0 User's Manual (Plavix (Clopidogrel) should not be coded as an anticoagulant medication. On 07/08/2021 at 2:58 PM, the surveyor conducted an interview with Employee Identifier (EI) #4, the RN (Registered Nurse)/MDS Coordinator. The surveyor asked EI #4, when looking at RI #82's medical records, which anticoagulant medication was RI #82 receiving. EI #4 said RI #82 was receiving Plavix, which was not an anticoagulant. When asked what the RAI classified Plavix as, EI #4 said an Antiplatelet. EI #4 said whoever completed the MDS did not know it should not be coded as an anticoagulant. The surveyor asked EI #4 why it would be important to code the MDS accurately. EI #4 said to show the continuous care the resident is receiving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of a facility policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to initiate an Instant Care Plan when Resident Identifier (RI) #74 developed an open area to his/her right ankle on 06/15/2021. This deficient practice affected RI #74, one of three residents sampled for pressure ulcers. Findings include: A review of a facility policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS, with a History date of 03/2018, revealed the following: POLICY: Each resident will have a person centered plan to care to identity problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. RESPONSIBILITY: All members of the Interdisciplinary team DEFINITIONS: . Instant Care Plan - utilized with a change in resident condition not addressed on the comprehensive care plan. PROCEDURE: . 9. Upon a change in condition . an Instant Care Plan will be initiated if applicable: a. A Instant Care Plan can be completed with a change in resident condition if there is no care plan available or until the Comprehensive Person Centered Care Plan is updated. d. Use the Instant Care Plan to reflect an isolated occurrence/problem or several. RI #74 was admitted to the facility on [DATE] and discharged to the ER (Emergency Room) on 06/29/2021. RI #74 had a diagnosis of Local Infection of the Skin and Subcutaneous Tissue. A review of RI #74's admission Minimum Data Set assessment, with an Assessment Reference Date of 06/02/2021, revealed RI #74 did not have a Pressure Ulcer or Diabetic Foot Ulcer during this assessment period. Review of a Physician's Telephone Order for RI #74, dated 06/15/2021, revealed the following order: . CLEAN WOUND TO RT (Right) OUTER ANKLE WITH NS (Normal Saline), PAT DRY W (With)/4X (by)4, APPLY ZEROFORM, COVER W/MEPILEX BORDER FOAM DAILY . On 07/08/2021 at 03:11 PM, the surveyor conducted an interview with Employee Identifier (EI) #1, the Director of Nursing. The surveyor asked EI #1 according to RI #74's treatment record, when did RI #74 develop the open area to his/her right outer ankle. EI #1 said 06/15/2021. The surveyor asked EI #1 when RI #74 developed the opened area to his/her right outer ankle should a care plan have been initiated. EI #1 said yes. When asked where the evidence was that an instant care plan had been initiated, EI #1 said she did not see evidence of one. The surveyor asked EI #1 why it would be important to initiate a plan of care when there were changes in a residents condition or new concerns were identified, EI #1 said basically it would tell you what was going on with the resident and what staff are supposed to do concerning their care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of the facility's Record of Medication Destruction forms, and review of a facility policy titled, MEDICATION DESTRUCTION the facility failed to ensure the Medication Destruction forms contained the required signatures. This was observed on four out of fifteen months of non-controlled drug destruction forms viewed. Findings include: Review of the facility policy titled, MEDICATION DESTRUCTION with a HISTORY date of 9/19 revealed, POLICY: When medications are discontinued by physician order, expired, or a resident is transferred or discharged and does not take medications with them, or in the event of a resident's death, the medications are destroyed. RESPONSIBILITY: . Director of Nursing Services PROCEDURE: . 3. Two nurses are to witness the destruction and sign on the Record of Medication Destruction-Non-Controlled Medication sheet. A review of the facility's forms titled, RECORD OF MEDICATION DESTRUCTION - NON-CONTROLLED MEDICATIONS revealed on [DATE] there were five entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were eleven entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were eight entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were three entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were four entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were six entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were seven entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] at 5:04 PM an interview was conducted with Employee Identifier #1 the Director of Nursing Services (DNS). EI #1 was asked how many signatures were required to be on the record of medication destruction for Non-Controlled medications. She answered two. EI #1 was asked as she reviewed the medication destruction pages from 10/20 through 1/21, how many pages do not have the required signatures. She answered seven. EI #1 was why it was necessary to have the required signatures on the record of medication destruction for Non-Controlled medications. She answered for accountability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility policies tithed, Tube feeding and Resident Rights, the facility failed to ensure (Resident Identifier) RI #5 was treated with dignity while a nurse provided nutritional care. This affected 1 of 32 residents who was observed for dignity. Findings Include: A review of a document titled Resident [NAME] of Rights revealed: Each resident has a right to a dignified existence. A. Facility Residents shall have the right to: .33 To personal privacy . in his or her personal care. A review of a facility policy titled, Tube Feeding with a history date of 11/17, revealed, . Procedure: 1. Provide privacy. RI #5 was readmitted to the facility on [DATE] with diagnoses including Ventricular Tachycardia, Gastrostomy Status, and Cerebral Palsy. A review of RI #5's March 2019 Physician Orders revealed 24 hours tube feeding for the resident was ordered 11/6/2017. On 03/17/2019 at 10:07 p.m., the surveyor observed a nurse pouring water and milk down a tube attached to the resident's stomach. The nurse had the door opened the entire time she fed the resident. The resident was lying on the floor on a mattress with the stomach and thigh exposed. The resident had on a thin plastic like brief with a blue pad under him/her. On 03/17/2019 at 02:18 p.m., the surveyor conducted an interview with Employee Identifier (EI) #7, the Licensed Practical Nurse who provided the nutritional feeding to RI #5. EI #7 was asked why did she feed the resident with the door opened. EI #7 replied, she liked to keep an eye on everything. EI #7 was asked should the door be closed when bolus feeding a resident. EI #7 replied, yes. EI #7 was asked why should the door be closed. EI #7 replied for privacy. On 8/18/2019 at 3:24 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing. EI #2 was asked when should a resident, who required bolus feeding, be fed with the door opened. EI #2 replied, they would not be fed with the door opened. EI #2 was asked what did the facility policy say regarding feeding a resident who required bolus feeding. EI #2 was asked why should the door be closed when feeding a resident who required bolus feeding. EI #2 replied it was a dignity issue. EI #2 was asked what was the harm to the resident when a nurse provided bolus feeding with the door opened. EI # replied, it was a dignity issue. EI # was asked when a nurse fed a resident with the door opened was this privacy. EI # replied, no.

Based on observation, interview, review of a facility policy Contact Precautions and record review, the facility failed to ensure staff put on Personal Protective Equipment (PPE) prior to entering Resident Identifier (RI) #89's room to provide care. This affected one of 4 residents on contact isolation. Findings Include: 1. A review of a undated facility policy titled, CONTACT PRECAUTIONS revealed: POLICY: Contact Precautions are a transmission based precaution that will be utilized to reduce the risk of transmission of epidemiologically important micro-organisms by direct of indirect contact. DEFINITION: Transmission Based Precautions are designed for residents documented or suspected to be infected or colonized with highly transmissible or . Three types of precautions utilized are Contact Precautions . PROCEDURE: . 3 Apply protective equipment as indicated upon entering the room. a. gloves . b. gowns . RI #89 was admitted to the facility 2/20/19 with a diagnosis of Pressure Ulcer Sacral Region. A review of a hospital laboratory report, with a collected date of 2/14/19, revealed . Specimen/ Source: Ulcer Buttocks Isolate Escherichia coli (ESBL - Positive) . On 3/17/19 at 3:20 PM, the surveyor observed two CNAs (Certified Nursing Assistants) entering RI #89's room. Neither of the CNAs put on PPE. The surveyor knocked on th door and was invited in. The surveyor observed both CNAs with gloves on providing care to RI #89. The surveyor asked what care was being provided. They replied they were checking and repositioning. The surveyor observed the CNAs making contact with the resident. The surveyor left the room and waited in the hall. Both CNAs then exited the room. At that time Employee Identifier (EI) #4 and EI #5 were asked if RI #89 was on isolation. EI #4 replied, yes. Both were asked what type of infection. EI #4 replied, MRSA (Methicillin-Resistant Staphylococcus Aureus) in a wound. Both were asked what type isolation RI #89 was on. EI #4 replied, contact. EI #4 was asked what PPE were they to put on prior to care. EI #4 replied, gloves only. EI #4 was asked when they were turning or checking the resident, did they make contact by touching the resident. EI #4 replied, yes. Both were asked if touching was contact. EI #5 replied, yes. Both were asked what was the harm in not wearing proper PPE during provision of care. EI #4 and EI #5 replied, spread infection or germs, could pass to other residents. EI #4 and EI #5 were asked if they put on a gown. EI #4 replied, no. Both were asked why not. EI #4 replied, they were taught gloves only. On 3/19/19 at 10:05 AM, EI #3, Registered Nurse/ Infection Control, was interviewed. EI #3 was asked how many residents were on isolation. EI #3 replied, four on precautions. EI #3 was asked what precautions. EI #3 replied, ESBL (Escherichia coli) in urine, MRSA in wounds. EI #3 was asked what organism was RI #89 isolated for. EI #3 replied, ESBL in wound on sacrum. EI #3 was asked when should staff use PPE. EI #3 replied, anytime contact with resident. EI #3 was asked if staff was going in to turn a resident what PPE should they have on. EI #3 replied, gown and gloves. EI #3 was asked how was staff trained for contact isolation. EI #3 replied inservice. EI #3 was asked what was the harm in staff not putting on gowns when providing care for a resident on contact isolation. EI #3 replied, endanger to self and spreading infection to other residents.