**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement infection control practices to prevent the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility for 11 out of 11 sampled residents by failing to: 1.Ensure personal protective equipment (PPE-equipment used to prevent or minimize exposure to hazards) was accessible and readily available to staff while providing direct care to residents at high risk of acquiring MDRO. 2. Ensure 11 residents were placed on Enhance Barrier Precaution (EBP- use of a gown and gloves for residents with wounds, indwelling devices such as a urinary catheter (a flexible tube that collects urine from the bladder and to a drainage bag), gastrostomy tube (GT-a tube inserted through the wall of the abdomen directly into the stomach for food and medication administration) and tracheostomy (a surgical opening in the neck for breathing). a. Resident 247 who had a left heel deep tissue injury (DTI- when blood flow to an area is diminished or absent causing a pressure injury). b. Resident 246 who had an indwelling urinary catheter, colostomy (surgical opening for large intestine through the belly to allow stool to leave the body through the large intestine) and stage 4 (full thickness [damages extend below all layers of the skin] skin and tissue loss) pressure ulcer (localized damage to the skin and/or underlying soft tissue) on the sacral area (bottom of the spine) extending to buttocks and back. c. Residents 36, 37,38, 1, 9 and 346) who had GTs. d. Resident 1 who had a tracheostomy, and a Stage 3 (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) pressure ulcer. e. Residents 96 and 246 with stage 4 pressure ulcers g. Resident 17 with an open wound on the right hip i. Resident 42 who had a pressure ulcer on the sacrum, right and left buttocks, right and left heel. 3.Ensure there was a signage for isolation posted or isolation cart (where personal protective equipment was stored with gown and gloves), placed outside residents' rooms before entering the residents' room to alert staff and visitors of EBP and prevent the spread of infection. 4. Have policies and procedures regarding the application of EBP for residents known to be colonized (presence of microorganism) with MDRO and residents with open wounds and/or indwelling medical devices. 5.Develop comprehensive EBP care plan for 11 residents with open wounds and indwelling medical devices such as indwelling urinary catheter, tracheostomy, and GT. On 5/16/2024 at 3:11 p.m., the Administrator (ADM), and the Director of Nursing (DON), were notified of an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious, injury, harm, impairment, or death to a resident) due to the facility's failure to implement infection control practices to prevent the spread and transmission of MDRO. On 5/17/2024 at: 3:31 p.m., the facility submitted an acceptable IJ Removal Plan. On 5/17/2024 at 6:45 p.m., the IJ was removed after on-site validation of the implementation of the IJ Removal Plan through observations, interviews, and record review. The IJ Removal Plan included the following: 1.Resident 247,246,36,37,38,1,9,346,96,17 and 42 were placed on EBP. EBP signages were posted on all the resident's rooms and isolation carts were available outside each room. 2. All residents identified had a physician order with reason for EBP. 3. Comprehensive plan of care were initiated for all 11 identified residents. 4. Self-responsible residents were informed of EBP, and resident representatives were informed for residents who were not responsible. 5. In-services with teach back were initiated to all staff regarding EBP. 6.On 5/16/2024 EBP policy and procedure was initiated and reviewed by Interdisciplinary Team (IDT-team members from different departments working for the resident's benefit) which included the ADM, the DON, the Social Services Designees, the Activities Director, the Infection Preventionist (IP), the Director of Staff Development (DSD) and representatives from the rehabilitation department. 7. The DON in serviced the IP designee for the following identified noncompliance: Line listing (a table that contains key information about each case in an outbreak [sudden rise in the incidence of a disease]), infection control rounding, and EBP. 8. EBP brochures were available to families, visitors, vendors, and staff at the front lobby of the facility. 9.Adherance monitoring of EBP including donning (putting on) of PPE during high contact activities will be performed by IP, charge nurse, and Registered Nurse supervisor daily every shift. 10. The DON and/or designee will perform random adherence monitoring for all facility staff until substantial compliance was observed. 11. Adherence monitoring tool will be kept in a binder upon completion and will be reviewed weekly by IDT to ensure identification of need for continued education of all staff. Facility staff will be in serviced as needed. 12. Possible admission inquiry to the facility will be reviewed by DON, admission coordinator, and or Administrator for MDRO, wounds, indwelling medical devices and EBP will be initiated accordingly. 13.Residents admitted without wound and or indwelling medical devices but acquire during facility stay will be placed on EBP. Findings: 1. A review of Resident 247's admission Record indicated, Resident 247 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (mild loss of strength on one side of the body) following cerebral infarction (when blood flow to the brain is disrupted), type II diabetes mellitus (abnormal blood sugar), difficulty in walking, and muscle weakness. A review of Resident 247's Physician Order Summary Report dated 5/15/24, indicated Resident 247 had a diagnosis of left heel deep tissue injury. The Physician Order Summary Report indicated apply heel protectors to bilateral heels daily. A review of Resident 247's History and Physical (H&P) dated 5/18/24 indicated Resident 247 had the capacity to understand and make decisions. During an observation on 5/14/2024 at 8:30 a.m., outside Resident 247's and 246's room there was no EBP signage and no isolation cart readily available for staff to use before entering the residents' room. During an observation on 5/15/2024 at 4:30 p.m., outside Resident 247's room, the Physical therapist (PT- licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) 1 was behind the closed privacy curtain at Resident 247's bedside. PT 1 was observed walking out from behind the closed privacy curtain wearing only gloves, and no gown. During an interview on 5/15/24 at 5:00 p.m., with PT 1, stated she was wearing gloves when providing physical therapy treatment to Resident 247. PT 1 stated she should have worn a gown and gloves to prevent the risk of cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) to other residents, and staff. During an interview on 5/16/2024, at 2:04 p.m., with the Infection Prevention Nurse (IPN), the IPN stated, Residents 247, 246, 36, 37, 38, 1, 9, 346, 96,17 and 42 were not on EBP. The IPN stated PPEs should be readily accessible to staff who care for these residents. The IPN stated unfortunately, there were no PPEs available in front of residents' rooms, for staff to use before entering the rooms. The IPN stated if staff did not follow the EBP there will be an increased risk of infection cross-contamination from affected residents to staff, other residents, and the community. The IPN stated he had not implemented EBP for Resident 247,246 ,36, 37, 38, 1, 9, 346, 96 17 and 42 with wounds and indwelling medical devices. The IPN stated residents with indwelling urinary catheters, g-tubes, tracheostomy, and draining wounds should all be placed on EBP. The IPN stated there were no EBP care plans for all 11 residents with open wounds and indwelling medical devices. The IPN also stated the facility did not have any policies and procedures on the application of EBP for residents with MDRO and those with open wounds and/or indwelling medical devices. 2. A review of Resident 246's admission Record indicated Resident 246 was admitted to the facility on [DATE] with diagnoses including paraplegia (no feeling in lower body), type II diabetes mellitus, Stage 4 pressure ulcer on the left heel, Stage 4 pressure ulcer unspecified part of the back, Stage 4 pressure ulcer of the sacral (lower back) Stage 4 pressure ulcer of the right buttock, Stage 4 pressure ulcer of the right heel, rash and other nonspecific skin eruptions, indwelling urinary catheter and a colostomy. A review of Resident 246's H&P dated 4/29/2024 indicated Resident 246 had the capacity to understand and make decisions. A review of Resident 246's Physician Order Summary Report dated 4/27/2024 indicated cleanse left ischium (lower hip), and right buttock pressure ulcer with Normal Saline (cleansing solution), pat dry, pack lightly with calcium alginate ( type of wound dressing, cleanse left lower extremity extending to foot, right foot with hibiclens( cleansing solution), pat dry, apply bacitracin (antibiotic), nystatin powder ( antibiotic), cover with xerofoam ( type of dressing) every day shift. A review of Resident 246's Treatment Administration Record (TAR) dated 5/1/2024 indicated Resident 246 had a left ischium (lower hip bone) pressure ulcer stage 4, left lower extremity extending to left foot pressure ulcer stage 4, right lower extremity extending to right foot pressure ulcer stage 4, right buttock pressure injury stage 4, right ischium pressure injury stage 4, dorsal pressure injury stage 4, indwelling urinary catheter, and colostomy. 3. A review of Resident 346 admission Record indicated Resident 346 was admitted to the facility on [DATE] with diagnoses including GT, type 2 diabetes mellitus, abnormalities of gait (trouble walking) and mobility. A review of Resident 346's H&P dated 5/13/2024 indicated Resident 346 has the capacity to understand and make decisions. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 346's room there was no EBP signage and no isolation cart, were readily available before entering the residents' room. 4. A review of Resident 96's admission Record indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including GT, type II diabetes mellitus, abnormalities of gait and mobility. A review of Resident 96's H&P dated 4/25/2024 indicated Resident 96 has the capacity to understand and make decisions. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 96's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. During an observation on 5/15/2024 at 10:30 a.m., the Treatment Nurse performed wound care on Resident 96 only wearing gloves and not the complete PPE required for EBP. During an observation on 5/15/2024 at 3:00 p.m., Occupational Therapist (OT- profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) 1 wore gloves while performing active range of motion exercises (AROM- full movement potential of a joint [where two bones meet]) to Resident 96 but without wearing a gown. During an interview on 5/16/2024 at 11:06 a.m., OT 1 stated he was not aware Resident 96 was on EBP. OT 1 stated, he should have worn the complete PPE including gloves and gown when performing AROM to Resident 96. During an interview on 5/16/2024 at 2:17 p.m., the DON stated if infection control practices were not observed such as EBP, there was a high risk for cross contamination and the possibility of spreading MDROs to other residents and staff. 5. A review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including right hip open wound, atrial fibrillation (an irregular and very rapid heart rhythm), muscle wasting and atrophy (the wasting or thinning of muscle mass due to disuse or nerve problems). A review of Resident 38's Progress Notes, dated 7/1/2023, indicated, Resident 38 had the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 4/9/2024, indicated Resident 38 was independent with eating and oral hygiene. The MDS indicated Resident 38 needed set up or clean up assistance with toilet hygiene, upper body dressing, repositioning from sitting to lying, lying to sitting on the side of the bed, sitting to standing, transferring from bed to chair, and transferring to the toilet. The MDS indicated Resident 38 needed supervision or touching assistance with showering, rolling from left to right, transferring to the shower and walking. The MDS indicated Resident 38 needed partial and moderate assistance with lower body dressing, putting on and taking off footwear and personal hygiene. The MDS indicated Resident 38 required nutrition through a feeding tube (a medical device that delivers liquid nutrition). The MDS also indicated Resident 38 received care for a surgical wound. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 38's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. During an interview on 5/16/2024 at 12:01 p.m., with Resident 38 in the hallway, Resident 38 stated he received wound care dressing changed weekly with a special dressing on the right hip. Resident 38 stated on 5/15/2024 the treatment nurse (name unknown) only wore gloves when she did Resident 38 wound care dressing change. During an interview on 5/16/2024 at 12:03 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she never wears a gown when she changed Resident 38's wound dressing. 6. A review of Resident 37's admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including GT, and gastroesophageal reflux disease (GERD-condition in which the stomach contents move up into the esophagus [food pipe]). A review of Resident 37's MDS dated [DATE] indicated Resident 37 had severe cognitive (ability to think, understand, learn, and remember) impairment in daily decision making. The MDS indicated Resident 37 was dependent (helper does all the effort) in oral hygiene, upper body dressing, eating and dependent with shower/bathe self, lower body dressing. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 37's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. 7. A review of Resident 36's admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including GT, GERD, and dementia (loss of memory, language, problem-solving and other thinking abilities). A review of Resident 36's MDS dated [DATE] indicated Resident 36 had moderate cognitive impairment for daily decision making. The MDS indicated Resident 36 was dependent for personal hygiene, toileting, and shower/bathing. The MDS indicated Resident 36 had a feeding tube. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 36's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. 8. A review of Resident 17's admission Record indicated Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including difficulty walking, and open wound to the right hip. A review of Resident 17's H&P dated 1/31/2024 indicated Resident 17 had the capacity to understand and make decisions. A review of Resident 17's MDS dated [DATE] indicated Resident 17 had intact cognitive skills with daily decision making. The MDS indicated Resident 17 required partial to moderate assist with lower body dressing and set up help with toileting and independent with eating. A review of Resident 17's TAR dated 4/30/2024 indicated Resident 17 had an open wound to the right hip. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 17's room there was no EBP signage and no isolation cart for use to enter Resident 17's room, to prevent the spread of infection. 9. A review of Resident 9's admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including GT, and intellectual disabilities. A review of Resident 9's H&P dated 2/28/2024 indicated Resident 9 does not have the capacity to understand and make decisions. A review of Resident 9's MDS dated [DATE] indicated Resident 9 had severe cognitive impairment for daily decision making. The MDS indicated Resident 9 had a feeding tube. A review of Resident 9's Treatment Administration Record dated 4/30/24 indicated Resident 9 has a GT. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 9's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. 10. A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses including left and right buttock Stage 3 (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) pressure ulcers (localized damage to the skin and or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure), left lower leg open wound, tracheostomy, and GT. A review of Resident 1's H&P dated 1/6/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's MDS dated [DATE] indicated Resident 1 was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene, rolling from left to right. The MDS indicated, Resident 1 had a feeding tube. The MDS indicated Resident 1 received treatments to the skin and pressure ulcer/injury with the application of a nonsurgical dressing. The MDS indicated Resident 1 received tracheostomy care. During an observation on 5/16/2024 at 9:05 a.m., outside Resident 1's room, there was no EBP signage and no isolation cart, readily available for use to enter the residents' room. 11. A review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including pressure ulcers on the sacral (located below the lumbar spine and above the tailbone), right buttock, left buttock, right heel, and left heel. A review of Resident 42's MDS, dated [DATE], indicated Resident 42's had intact cognitive status and decision-making skills. The MDS indicated, Resident 42 required partial/moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, and upper body dressing. During an observation on 5/14/2024 at 11:48 a.m., outside Resident 42's room there was no EBP signage and no isolation cart, readily available. During a concurrent observation and interview on 5/16/2024, at 11:12 a.m., with LVN 1, LVN 1 entered Resident 42's room holding a medication cup, without wearing gloves or a gown. LVN 1 did not perform hand hygiene prior to entering the room. LVN 1 stated, she was not aware Resident 42 was on of EBP. LVN 1 stated she did not remember if she received in-service training on EBP in the past. A review of California Department of Public Health (CDPH) report titled Enhanced Barrier Precaution for Skilled Nursing Facilities (SNF), 2022 indicated the Centers for Disease Control and Prevention (CDC) introduced Enhanced Barrier Precautions, which recommended gown and glove use for nursing home residents with wounds and indwelling devices during specific high-contact resident care activities associated with MDRO transmission and the use of EBP as a routine approach to infection control in SNF. https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Enhanced-Standard-Precautions.pdf A review of Centers for Disease Control and Prevention report indicated Indwelling medical devices and wounds are risk factors for colonization (the presence of microorganisms on or within body sites without detectable clinical signs and symptoms) with a MDRO dated 5/20/2024. The report indicated once colonized residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices was intended to protect high-risk individuals from acquiring and serving as a source of transmission if they became colonized. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html#:~:text=Enhanced%20Barrier%20Precautions%20are%20intended%20to%20provide%20an%20approach%20for,indwelling%20medical%20devices%20or%20wounds).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure they had a Registered Nurse (RN) at least eight consecutive hours a day, seven days a week from 5/8/2023 to 6/5/2023 (28 days) to provide residents with required care and services to 41 residents residing at the facility and to one of two sampled resident (Resident 1), who had a pressure ulcers (a localized injury to the skin and underlying tissue resulting from prolonged pressure) to the left heel infected with Methicillin-resistant Staphylococcus aureus [(MRSA)-a type of bacteria that is resistant to most antibiotics {medication used to treat infections caused by bacteria}] and was not receiving ordered intravenous [(IV) administered into the veins] antibiotics (medication to treat infection), Vancomycin [an antibiotic used against resistant strains of streptococcus and staphylococcus (single cell microorganisms that cause infections and diseases)] on 5/29/2023, 5/31/2023, and 6/2/2023 (total of 3 doses). 1. This deficient practice placed 41 residents at risk not receiving care and services under RN ' s scope of practice, including residents ' assessment in case of change of condition (COC), carry out physicians ' orders requiring RN ' s implementation, providing the licensed vocational nurse and non-licensed staff supervision to ensure the care and services were delivered as required. 2. This deficient practice resulted in Resident 1 not receiving three doses of IV Vancomycin and being transferred to a general acute care hospital (GACH) on 6/3/2023 for evalution and treatment. 3. This deficient practice placed Resident 1 at risk of developing a super infection (infection occurring after or on top of an earlier infection), sepsis (serious complication of an infection), and death. On 6/2/2023 at 5:34 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ) situation (a situation in which the facility ' s non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) due to lack of RN at the facility at least eight consecutive hours a day, seven days a week starting on 5/8/2023. The IJ was called in the presence of the Business Manager (BM), Facility Owner (FO), Charge Licensed Nurse (CN) and Medical Records Director (MRD). On 6/6/2023 at 1:46 p.m., the facility provided with an Immediate Jeopardy Removal Plan (IJRP) containing the following summarized immediate corrective actions: 1. On 6/3/2023, Resident 1 was transferred to GACH for further evaluation per physician ' s order. 2. On 6/6/2023, RN 1 was hired and immediately started to work on 6/6/2023. RN 1 will provide services at least eight hours a day within a 24-hour period. RN 1 will work 16-hour shifts on 6/6/2023, 6/7/2023, and 6/8/2023. RN 1 will administer medications per physician ' s orders in a timely manner. 3. Facility hired a Director of Nursing (DON) with a start date of 6/8/2023. 4. Facility will continue to utilize contracted staffing registry agencies to provide the facility at least one registered nurse and or licensed nurse daily at least eight hours a day within a 24-hour period. 5. The facility hired a contractual DON with a start date on 6/8/2023 and will continue to utilize DON and a registered nurse from registry on a contractual basis indefinitely until a permanent RN and DON were hired. 6. The facility will not admit new residents until cleared by the Department of Public Health. 7. On 6/5/2023, an in-service was initiated to all staff on who to immediately contact/communicate surrounding daily operations of the facility in the absence of the Administrator and DON. Staff were provided with copies of contact information and contact information was as posted at each nursing station. 8. The DON and or designee will monitor facility compliance daily surrounding services of a RN at least eight hours a day to provide the care requested for all residents at the facility. 9. Any non-compliance issue will be corrected immediately by the DON or designee; reports and findings will be discussed during the daily department heads and or members of interdisciplinary team (team members from different disciplines) for immediate resolution. 10. The Administrator and or designee will do trending/analysis on RN hours daily for at least eight hours a day within 24-hour period and will report to the monthly QAPI (Quality assurance and performance improvement) committee for further evaluation and for recommendations. If there have been no concerns for a period of three months, the item will be removed from the agenda. Findings: During a concurrent observation and interview on 6/1/2023, at 2:30 p.m., with Licensed Vocational Nurse (LVN 1), while touring the facility, the RN was not observed to be present. LVN 1 stated, we do not have an RN working today. During a concurrent interview and record review, on 6/1/2023, at 4:00 p.m., with LVN 1, the facility ' s Nursing Staffing Assignment and Sign-In Sheet dated 6/1/2023 was reviewed. LVN 1 stated, the Assignment sheet indicated there was no RN working on 6/1/2023 on 7 a.m.-3:30 p.m., 3 p.m. -11:30 p.m. and 11:00 p.m.-7 a.m., shifts. During an interview on 6/1/2023, at 4:30 p.m., LVN 1 stated we are calling the nursing staffing registry and requesting for them to send us an RN. LVN 1 stated only an RN must administer IV medications. During an observation on 6/2/2023, at 10:00 a.m., while touring the facility, an RN was not observed to be present in the facility. During a concurrent interview and record review, on 6/2/2023, at 12:00 p.m., with LVN 1, the facility ' s Nursing Staffing Assignment and Sign-In Sheet dated 6/2/2023 was reviewed. LVN 1 stated, the Assignment sheet indicated there was no RN scheduled to work on 6/2/2023 on 7 a.m.-3:30 p.m., 3 p.m. -11:30 p.m., and 11:00 p.m.-7 a.m., shifts. During a review of the facility ' s nursing Staffing Assignment and Sign-In Sheets (SASIS) for the date range from 5/8/2023 to 6/2/2023, the SASIS indicated the following number of hours the RN worked in 24 hours period starting 5/8/2023: 1. On 5/8/2023 and 5/9/2023, there was no documentation to indicate RN signed in for work on any of three shifts, including 7 a.m. to 3 pm, 3 p.m. to 11 a.m. or 11 pm to 7 a.m. 2. On 5/11/2023, RN worked from 6 p.m. to 10 p.m., a total of four hours in 24 hours period. 3. On 5/12/2023, RN worked from 5 p.m., to 9 p.m. a total of 4 hours in 24 hours period. 4. On 5/13/2023, RN worked 6 p.m. to 10 p.m., a total of four hours in 24 hours period. 5. On 5/14/2023, RN worked from 5 p.m. to 9 p.m., a total of four hours in 24 hours period. 6. On 5/16/2023, RN worked from 3 p.m. to 8:30 p.m., a total of five and half hours in 24 hours period. 7. On 5/17/2023, RN worked from 5 p.m. to 9 p.m., a total of four hours in 24 hours period. 8. On 5/19/2023, RN worked from 3:27 p.m. to 8:57 p.m., a total of five hours and 17 minutes in 24 hours period. 9. On 5/20/2023, RN worked zero hours in 24 hours period. 10. On 5/21/2023, RN worked from 12:29 p.m. to 5:44 p.m., a total of five hours and 14 minutes in 24 hours period. 11. On 5/23/2023, RN worked from 5:00 p.m. to 9:00 p.m., in 24 hours period. 12. On 5/24/2023, RN worked zero hours in 24 hours period. 13. On 5/25/2023, RN worked from 2:48 p.m. to 8:00 p.m. a total of five hours and 12 minutes in 24 hours period. 14. On 5/29/2023, RN worked from 4:00 p.m. to 9:06 p.m., a total of five hours and 6 minutes in 24 hours period. 15. On 5/31/2023, RN worked zero hours in 24 hours. 16. On 6/1/2023, RN worked zero hours in 24 hours. 17. On 6/2/2023, RN worked zero hours in 24 hours. During a review of Resident 1 ' s admission Record (Face sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (damage or disease that affects the brain), PU of the left heel, pressure induced deep tissue damage [(DTI) a form of PU affecting the layer of tissue that rests beneath the skin, the skin above will be intact {not broken} but will look purple or red] of the right heel, PU to the left ischium (hip bone near buttocks area) chronic (persistent, long lasting illness) kidney disease and diabetes mellitus type 2 (a condition in which the body fails to process glucose (sugar) correctly). During a review of Resident 1 ' s History and Physical (H&P), dated 10/11/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 2/17/2023, the MDS indicated Resident 1 ' s cognitive (relating to the mental process of knowing, learning, and understanding things) skills for daily decision-making was severely impaired. The MDS indicated Resident 1 required an extensive one-person physical assistance with bed mobility and total dependence of one to two persons on transfers, dressing, toilet use and personal hygiene. The MDS indicated Resident 1 was at risk of developing further pressure ulcers/injuries. During a review of Resident 1 ' s Physician Order (PO) dated 5/18/2023, the PO indicated an order for x-ray of the right calcaneus (heel bone) to rule out osteomyelitis (infection of the bone). During a concurrent interview with Licensed Vocational Nurse 2 (LVN 2) and review of Resident 1 ' s PO dated 5/24/2023, the PO indicated an order for Vancomycin Hydrochloride (HCL) 750 milligrams ([mg]- unit of measurement) IV every 48 hours Resident 1 ' s infected with MRSA left heel PU confirmed by LVN 2. During a review of Resident 1 ' s PO dated 6/2/2023, the PO indicated an order to transfer Resident 1 to GACH for infected non-healing pressure ulcer to left heel and left ischium. During a review of Resident 1 ' s Intravenous Therapy Medication Record (IVMR), the IVMR indicated Resident 1 was administered IV Vancomycin 750 mg on 5/25/2023 at 6 p.m., and 5/27/2023 at 6 p.m. During a review of Resident 1 ' s Medication Administration Record (MAR), dated May 2023, the MAR indicated Resident 1 was administered Vancomycin 750 mg IV on 5/25/2023 at 6:00 p.m. and 5/27/2023 at 6:00p.m. During an interview on 6/2/2023 at 10:28 a.m., with the facility ' s owner (FO), the FO stated he fired the Director of Nursing (DON) on 5/31/2023. The FO stated there was no RN currently employed by the facility. The FO stated the new DON will start on 6/8/2023. The FO stated he was a physician and would take the responsibilities of the RN until one was hired. During an interview on 6/2/2023 at 11:41 a.m. with the Licensed Vocational Nurse (LVN 1), LVN 1 stated facility had the DON in 10/2022. LVN 1 stated the DON would stay around four hours and would come and go throughout the shift. LVN 1 stated the DON resigned around November or December 2022. During an interview on 6/2/2023, at 12:00 p.m., with LVN 2, LVN 2 stated Resident 1 ' s MAR indicated the last documented administration of Vancomycin IV 750 mg was on 5/27/2023 at 6:00 p.m. LVN 2 stated based on Resident 1 ' s PO, Resident 1 should have received next Vancomycin dose on 5/29/2023 at 6:00 p.m., 5/31/2023 at 6:00 p.m., and 6/2/23 at 6:00 p.m. before the resident transferred to GACH on 6/3/23. LVN 2 stated only a registered nurse can administer IV medications and the facility had no RN scheduled to work since 5/29/2023. LVN 2 stated, failure to administer ordered Vancomycin IV medication to Resident 1, can result in further infection, sepsis including death. LVN 2 stated, Resident 1 ' s attending physician was not informed of missed three doses of IV Vancomycin. LVN 2 stated since there was no RN or the DON in the facility, she (LVN 2) did not know what to do regarding missed Vancomycin doses. During an interview on 6/2/2023 at 4:50 p.m. with Resident 1 ' s primary care physician (PCP), the PCP stated the Vancomycin IV medication should have been given every 48 hours as ordered. The PCP stated missed dosed can put Resident 1 at risk for reoccurrence of a pressure ulcer infection and rehospitalization. The PCP stated he might order additional wound cultures (test to find germs that can cause infection) and laboratory tests. During a concurrent observation and interview on 6/2/2023, at 4:52 p.m., with LVN 2, in the medication room, no Vancomycin IV medication in the IV medication cart was observed. LVN 2 stated, there was no Vancomycin IV medication available in the facility, and she would need to contact the pharmacy to dispense the Vancomycin IV medication to the facility. During a review of the facility ' s policy and procedure (P/P) titled, Administering Medications revised 4/2019, the P/P indicated medications should be administered in a safe and timely manner, and as prescribed. During a review of the facility ' s policy and procedure (P/P) titled Director of Nursing Services revised 8/2006, the P/P indicated the nursing services department is under the direct supervision of a Registered Nurse.