**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to follow physician orders and maintain infection control practices for 1 of 3 residents observed for direct care. (Resident #64)The findings Include:On 08/18/25 at approximately 4:15 PM, an observation of Resident # 64 was made. He was noted sitting in his wheelchair at the nurses' station in front of the medication cart. Nurse A, a Licensed Practical Nurse (LPN), was kneeling in front of the resident applying Diclofenac External Gel 1% (a topical medication used to treat pain) to the left knee with her bare hand. Nurse A then squeezed the gel into her bare hand and applied it to the resident's right knee and finally squeezed gel into her bare hand again and applied it to the resident's right shoulder. Nurse A then replaced the lid onto the medication and laid the medication on top of the medication cart and performed hand hygiene. The Director of Nursing (DON) was also present during the observation. On 08/18/25 at approximately 4:20 PM, an interview was conducted with Nurse A, who indicated that applying the medication without gloves would be considered an infection control issue. Nurse A further indicated that the medication was over the counter and she placed the tube into her uniform pants pocket. She stated that she liked to do her treatments as she goes down the hall with her residents. Nurse A was asked to clarify if the same tube of medication was used on multiple patients. Nurse A indicated that, because the medication was over the counter, it was not signed out to individual residents and further indicated that she should have dispensed the medication into a medication cup to use on multiple residents instead of her hand.The box that the medication came in had no open date and no resident room number to indicate single resident use. Nurse A was asked where for the dispensing card (pre-marked plastic card used for measuring the appropriate dosage) for the medication. She indicated that she was not aware of a dispensing card. Upon reviewing the medication box, the dispensing card was located inside the box, attached to the pharmaceutical insert in the box.The physician orders on the electronic treatment administration record (ETAR) revealed that the order for the Diclofenac Sodium External Gel 1% was to apply 2 grams to the left knee twice daily, apply 2 grams to the right knee twice daily, and 2 grams to the left shoulder twice daily for arthritis, not to exceed 16 grams in 24 hours. Nurse A confirmed that she did not follow the physician's order by applying the medication to the right shoulder not the left shoulder, Nurse A further indicated that the resident refuses to have the medication to the left shoulder but requests the medication for the right shoulder. When asked if she had contacted the physician to have the order clarified, Nurse A stated that she should have contacted them prior to applying the medication. On 8/18/25 at approximately 4:32 PM, an interview was conducted with the DON, who indicated that the expectation is that the nurse follows the physician orders, to contact the physician if the order needs to be clarified, and to use proper technique, such as gloves and dispensing card, to administer the medication. The facility's policy states, Policies and Practices-Infection ControlPolicy StatementThis facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and ImplementationThis facility's infection control policies and practices apply equally to all personnel, consultants, contractors, resident, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, [NAME] or veteran status, or payor source.The objectives of our infection control policies and practices are to:a. Prevent, detect, investigate, and control infections in the facility;b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; etc .3. The Quality Assurance and Performance Improvement Committee, through the Infection Control Committee, shall establish, review, and revise infection control practices, and help department heads and managers ensure that they are implemented and followed.4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of the employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

Based on observation, record review, staff interview, and policy review, the facility failed to provide treatment and care in accordance with professional standards and facility policy for 1 of 2 residents sampled for non-pressure related skin conditions. (Resident #27) The findings include: An observation of Resident #27 was conducted on 2/27/23 at 1:54 PM. The resident was observed to have an undated dressing on her left lower arm. Another observation of Resident #27 was conducted on 3/1/23 at 12:38 PM in the presence of Employee A (licensed practical nurse). The undated dressing remained on the resident's left lower arm. The nurse removed the dressing and a small (approximately 1/2 inch) clean skin tear was observed under the dressing. The resident was not able to state how the skin tear occurred. The nurse stated she was not aware the dressing was on the resident's arm and was not sure how the resident received the skin tear. She confirmed the dressing she removed was not dated. A review of Resident #27's electronic medical record revealed no documentation of the skin tear, no physician orders for care of the skin tear, and no documentation of how the skin tear occurred. An interview was conducted with employee B (Registered Nurse Unit Manager) on 3/1/23 at 12:47 PM. Employee B stated she did not know where the dressing came from and was not aware of the skin tear on Resident 27. She stated staff should obtain physician orders for the dressing, let the physician know about the skin tear, and let the wound care nurse know about the skin tear so they can follow the area. An interview was conducted with the Director of Nursing (DON) on 3/1/23 at 1:49 PM. The DON confirmed the resident record contained no physician orders for the dressing or record of how the skin tear occurred. Review of the facility policy Skin Tear Management (SHCRC20001.04, revised 10/24/22) revealed, Skin tears are managed by focusing on prediction and prevention. When a skin tear does occur, the goal is to promote prompt healing and minimize the risk of infection. Occurrence of a skin tear is reported and is investigated by the clinical team. Follow physician's orders for treatment. In the progress notes, record: evaluation and cause of the skin tear, physician and family notifications, the treatment ordered and initiated, and progress or lack of progress in healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and facility policy review, the facility failed to provide appropriate treatment to prevent further decrease in range of motion for 1 of 2 residents reviewed for limited range of motion. (Resident #69) The findings include: An observation of Resident #69 was conducted on 2/27/23 at 12:46 PM. The resident was in bed and contractures were observed to the upper and lower extremities. A review of the quarterly minimum data set, with an assessment reference date of 12/23/22, revealed the resident had functional limitation in range of motion to upper and lower extremities on both sides. The occupational therapy Discharge summary, dated [DATE], revealed the resident had contractures to bilateral upper extremities. Review of the resident's electronic medical record revealed a current plan of care dated 11/10/22 for a passive range of motion restorative nursing program. The interventions included passive range of motion with stretching at the end of the range on shoulder flexion, elbow extension as tolerated, to be completed every day 4 days per week. Review of the documentation of passive range of motion (PROM) for the time period of 1/31/23-2/28/23 revealed the PROM had been completed a total of 7 times on the following dates: 2/5/23, 2/6/23, 2/9/23, 2/13/23, 2/20/23, 2/26/23, and 2/27/23. An interview was conducted with Employee C (Restorative Licensed Practical Nurse) on 3/1/23 at 10:06 AM. Employee C stated she has trouble with restorative therapy getting completed because the staff are pulled to the floor. She stated, It has been a constant battle since I took over the position, and, if the restorative aid is pulled to the floor, I try to complete the range of motion or restorative ordered. She confirmed that any zeros entered on the documentation meant the task was not completed. She stated the resident does not usually tolerate the range of motion well and her contractures have worsened in the last few months. She states that Resident #69 had been referred back to therapy for an evaluation on 2/3/23. An interview was conducted with the Rehabilitation Director on 3/1/23 at 10:30 AM. She stated the resident declined and contracted really fast. She was last discharged from therapy on 12/9/22. She did not recall the resident being referred backed to therapy by restorative staff in the last 30 days. An interview was conducted with the Director of Nursing (DON) on 3/1/23 at 10:55 AM. The DON stated she was aware that staff get pulled to the floor from restorative, but she was not aware restorative tasks were not being completed. Review of the facility policy for Restorative Nursing Program (SHCRC 3006.01) revealed it is the policy of the center to assist each Resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance to State and Federal Regulations. The center's restorative program will include, but not be limited to, hygiene, mobility, elimination, dining-eating, and communication. The programs will be documented on the center's designated restorative care forms/tools in the resident's electronic medical record.

Based on observation, interviews, and record reviews, the facility failed to provide medications in a timely manner for 2 of 5 residents sampled for medication administration. (Residents #85 and #30) The findings include: On 3/1/23 at approximately 9:30 AM, an observation was made of Resident #85's medication administration by Nurse F, a Licensed Practical Nurse (LPN). Nurse F was scheduled to administer a Vitamin B-12 injection, 1000 micrograms subcutaneously, but could not as it was not available from pharmacy. Nurse F stated she would notify the Nurse Practitioner and the pharmacy to have this medication delivered from the back-up pharmacy. On 3/1/23 at approximately 2:00 PM, an observation was made of Nurse D, a Registered Nurse. Nurse D was scheduled to administer the medication Urecholine 10 milligrams to Resident #30 but could not as it was not available from the pharmacy. The nurse stated she would notify the physician or Nurse Practitioner and the pharmacy and have the medication delivered. On 3/1/23 at approximately 2:10 PM an interview was conducted with Nurse B, a Registered Nurse and Unit Manager. Nurse B stated that the medications should be re-ordered when the current supply was down to one week's supply to ensure medications are received in a timely manner. Nurse B was observed to re-order the missing medications while the surveyor observed. Nurse B confirmed that the empty medication card had not been pulled to be faxed to the pharmacy for a refill. On 3/1/23 at approximately 5:09 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that it was her expectation that all medications should be reordered from pharmacy when the medication is down to one week's supply in order to receive the refill medications from the pharmacy in a timely manner. The DON stated that the Vitamin B-12 injection for Resident #85 was incorrectly listed as on hand in the medication record, which is why it was not delivered from the pharmacy. The DON confirmed that Resident #30's Urecholine had not been re-ordered electronically until today at 2:00 PM. On 3/2/23, a review was conducted of the Policy titled,4.5 Reordering, changing, and Discontinuing Orders (last revised January 1, 2022). Under procedure number 2, it states Reorder/Refill Orders: Facilities are encouraged to re-order medications electronically or by fax whenever possible. On 3/2/23 at approximately 12:41 PM, a follow up interview was conducted with the DON and the Corporate Nurse concerning the time frame for re-ordering medications. The DON confirmed that the policy 4.5 did not state what time frame to re-order medications, but stated that the nurses are trained during orientation on when to re-order medications.