Based on staff interviews and record review, the facility failed to develop a comprehensive person-centered plan for one out of 10 sampled Residents (R) (R3). Specifically, the facility failed to address the resident's medical needs related to the use of an antiviral medication. Findings include: Review of the medical records for R3 revealed that she had a physician's order for Acyclovir (an antiviral) 10 ml every eight hours for recurring Herpes Simplex of right gluteus with a start date of 3/11/2024, and a stop date of 3/18/2024. Interview with Licensed Practical Nurse (LPN) DD on 3/16/2024 at 10:50 am revealed she was familiar with R3 and her care. She stated that R3 was taking an antiviral for Herpes. LPN DD stated that there was no care plan for the antiviral. She confirmed that there should be a care plan, and that the Minimum Data Set (MDS) Coordinator was responsible for care plans. She stated that the MDS coordinator was not working today because she does not work on the weekend. Interview with LPN EE on 3/16/2024 at 10:59 am revealed R3 was on an antiviral for Herpes. She stated that R3 started on it on 3/11/2024. LPN EE stated that R3 has break outs sometimes, but it has been a while since the last break out. She stated that there was not a care plan for the antiviral. She confirmed that there should be a care plan, but she did not see one. LPN EE further stated that the MDS Coordinator was responsible for care plans. Interview with the Director of Nursing (DON) on 3/16/2024 at 11:15 am revealed the MDS coordinator was responsible for adding diagnoses. DON verified that there was not a diagnosis of herpes listed on R3 medication list. He stated that they do not do care plans for medications unless it is a psychotropic medication. DON stated that they did not have a care plan policy. DON confirmed that there was not a care plan to address the antiviral order. Interview with the DON on 3/16/2024 at 12:51 pm revealed the facility has never developed care plans pertaining to a resident's diagnosis that requires care and services such as medications to manage the condition. DON stated the MDS Coordinator was responsible for care plans and surveyor needed to speak with her. Additionally, the DON stated again that the facility did have a policy related to care plans. Telephone interview on 3/16/2024 at 12:58 pm with the Registered Nurse (RN) AA, MDS Coordinator revealed that she developed care plans related to residents' medical diagnosis and/or medication usage. She stated she only does a general care plan for a resident who have orders for psychotropic medications. RN AA, MDS Coordinator stated she had not been informed that a care plan was required for diagnosis and medications but if she was required to do so, she would follow through with getting it done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to assess, measure, and document the status of a pressure wound and obtain a physician's order for treatments for one out of 10 sampled Residents (R) (R16) reviewed for pressure ulcer/injury. This deficient practice had the potential to result in complications of the wound and further impair the resident's skin integrity and infection. Findings include: Record review revealed R16 was admitted with the diagnoses that included cerebral palsy, profound mental retardation, congenital quadriplegia, and contractures of multiple joints. Record review revealed R16's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/2023, revealed a Brief Interview Mental Status (BIMS) without a score, which indicated R16 was severely cognitively impaired. Further review of the MDS revealed the resident was at risk for developing pressure ulcers. Record review revealed R16 had an order with a start date of 11/16/2023 and a discontinued effective date of 12/13/2023 for wound care to right ischium wound - once daily, cleanse with normal saline, apply Hydrogel to open wound only, cover with non-stick gauze, overlay with Duoderm, continue until clear. This order was discontinued by the facility's physician. Record review of a physician progress note date 12/13/2023 did not reflect the wound status or reasoning for the discontinuation of the order for the Hydrogel to the right ischium wound. Record review of physician progress note dated 12/21/2023 revealed the right ischium decubitus was healing gradually. Continue Hydrogel topical application, until clear. There was not a current order for Hydrogel in the record which was verified by the Director of Nursing (DON). Further review of the record revealed R16 was discharged from the facility to the hospital on 1/4/2024 and readmitted to the facility on [DATE]. Review of the facility's document titled Resident Extremity Check Sheet Suite 2 dated 1/10/2024 3pm-11 pm Shift indicated R16 had a wound on buttock. Record review revealed a physician progress note dated 1/10/2024 that read the right ischial decubitus was open. Continue other routine medications and wound care. Further review of the record revealed residents did not have an active order for wound care which was verified by the DON. Review of nurse's progress note dated 1/14/2024 that read wound dressing change to right hip and sacral area, skin remains excoriated. There was no evidence of an order related to this dressing change. Further review of the record revealed progress notes dated 1/15/2024, 1/17/2024, 1/18/2024 that indicated right buttock was noted with padded dry dressing in place for protection. There was no evidence of an order related to this dressing in place for protection. Record review revealed a physician progress note dated 1/19/2024 at 4:20 pm that read: Patient has a decubitus wound on right ischial, which is open. Will Apply Hydrogel ointment to open wound once daily until clear. Continue wound care. Record review revealed Client Doctor Orders for active orders between 1/1/2024 and 3/15/2024 that indicated an order for Hydrogel wound care apply to open wound on right ischium, once daily until clear. Start date 1/19/2024. Order status active. Further review of the record revealed there was no evidence of documentation in the record related to measurements of the pressure wound, staging of the wound, or wound characteristics such as wound bed, odor, drainage, or peri wound. Review of R16's electronic and paper record revealed there was no evidence of documentation related to the status of the wound on resident's right ischium which was verified by the DON. Record review revealed there was no evidence of a treatment for R16's right ischium wound from 12/13/2023 until 1/19/2024. There was no evidence of documentation in the record to indicate whether the wound was healed during this period. Record review revealed R16 had a current physician order with a start date of 1/19/2024 for hydrogel wound care - apply to open wound on right ischium and cover with non-stick gauze once daily until clear. During an interview on 3/16/2024 at 9:59 am with Licensed Practical Nurse (LPN) DD revealed R16 had a wound on his right ischium for a while and she was not exactly sure when the wound first appeared, but she was aware that resident returned from the hospital with the wound. LPN DD further stated that she did not stage or document the characteristics such as drainage, odor, appearance of wound bed or peri wound. LPN DD further stated she documents daily related to the dressing being intact and the dressing was changed. LPN verified there was not an order in the record for wound care upon residents return from the hospital on 1/9/2024 until 1/19/2024. LPN DD also further stated that skin assessment should be documented every day on a paper document and scanned into the electronic record. LPN DD stated the wound on resident's right ischium was much larger at one time. LPN DD retrieved a skin assessment dated [DATE] that indicated resident had a wound on his right buttock. LPN DD verified there were not any assessments in the record or box of files dated from 1/9/2024 until the one she found dated 1/15/2024. LPN DD stated she had worked at the facility for nine years and she had not received training related to wound care at the facility and was not certain how often wounds needed to be measured or the characteristics of the wound assessed and documented. During an interview on 3/16/2024 at 11:39 am with the DON verified R16 returned to facility from the hospital on the evening of 1/9/2024. After reviewing the record, DON verified the progress note from the physician on 1/10/2024 that stated resident had right ischium decubitus that was open. DON also verified the physician orders did not have a treatment order for the right ischium wound until 1/19/2024. DON further stated the wound to resident's right ischium was an old area, resident had the area prior to discharging from the facility to the hospital on 1/4/2024. DON further stated that it was the physician's responsibility to write a treatment order for the residents wound if she wanted it treated. DON also verified there was not any documentation in the record related to measurements of the wound or documentation related to the wound status. DON stated that the nurses only document wounds as needed, and the measurements are not done routinely on a schedule. DON stated he had not visualized the wound since resident's readmission and was not sure of the R16's wound status. During a telephone interview on 3/16/2024 at 3:09 pm with the Facility's physician FF revealed the wound on resident's right ischium was not a new wound and she did not write an order for the wound care to area when she assessed him on 1/10/2024 after readmission to the facility because the resident should have had an order already in place. The Facility's physician FF further stated she could not recall if there was an order on the chart or not but there should have been an order to treat the wound because the resident had the wound for a while, and it was not new. The Facility's physician FF stated the nurses are responsible for measuring and staging wounds in the facility. She stated she was not sure how often the wounds are measured or how often the nurse should document the wounds' status. During a follow up interview on 3/17/2024 at 7:53 am with the DON revealed, that at one-point R16 wound healed and the order was discontinued. DON stated, apparently there was something there but was not sure of the size and that the nurses were doing the treatments during the time there were no orders. DON stated if there was a wound, there should have been an order in place prior to applying a dressing. DON stated the RN service Director oversees the wound and was responsible for measuring, staging, and documenting the characteristics of the wound. DON verified after the wound treatment was discontinued on 12/13/2023 there was not another order written until 1/19/204. DON further stated that he does not know that much about wound himself and there needs to be an education over wound treatment. The DON and Administrator revealed the facility did not have policies related to wound care or treatment of a pressure ulcer.

Based on staff interviews, record reviews, and review of the facility's documents titled, [name of facility] Skilled Unit Facility Assessment and (LPN) Licensed Practical Nurse: the facility failed to evaluate its resident population and identify the resources needed to provide the necessary care and services to meet the needs of one out of 10 sampled Residents (R) (R16) requiring wound care. In addition, the facility failed to update the Facility Assessment to accurately reflect all required components of an infection control plan. The facility had a census of 19 residents. Findings include: Review of the facility- provided [name of facility] Skilled Unit Facility Assessment dated January 15, 2023, revealed the facility provided pressure ulcers services to residents residing in the facility. The care required by the resident population considering types of disease states, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population: wound care. The staff competencies that are required to provide the level and types of care needed for resident population: Wound Nurse. Review of facility-provided job description titled, (LPN) Licensed Practical Nurse undated, revealed the responsibilities includes: administer nursing care to behavioral health patients, communicate with collaborating physicians or specialist regarding patient care, facilitate referrals to other healthcare professionals and medical facilities, maintain accurate documentation and patient medical records, coordinates medical services as needed and required, ensures that each resident receives the required care regarding physical health and dental services within the appropriate timeframes. 1.Review of R16's Face Sheet, dated 3/4/2024, provided by the facility, revealed R16 was admitted with multiple diagnoses that included but not limited to a pressure ulcer to his right ischium. Review of R16's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/2023, revealed a Brief Interview Mental Status (BIMS) without a score, which indicated R16 was severely cognitively impaired; Further review revealed the resident was at risk for developing pressure ulcers. During an interview 3/16/2024 at 9:59 am with Licensed Practical Nurse (LPN) DD, revealed she had worked at the facility for nine years and she had not received training related to wound care and was not sure how often the wound needed to be assessed or measured. She further revealed she was not sure who was responsible for staging the wound. She only changed the dressings as ordered by the physician. During an interview 3/16/2024 at 3:27 pm with LPN EE revealed she had worked at the facility for seven years. She further stated the facility had provided her with training related to wound care when she was first hired. LPN EE stated she was aware that the physician order for dressing changes must be followed, and she had to assess the resident for nonverbal signs of pain. She stated she was aware that the color of the wound bed, odor, drainage of the wound needed to be documented. LPN EE then stated she received that training prior to coming to the facility at the facility. During a follow up interview on 3/16/2024 at 3:39 pm with the Director of Nursing (DON) and Administrator revealed the facility did not have a policy related to wounds and nurses had not been trained to care for wounds that they were aware of. DON stated he had not conducted any nurse competencies or skill checkoffs to ensure nurses were competent in performing wound care. During an interview on 3/17/2024 at 9:10 am the Administrator revealed there was not a policy related to wound care, therefore the competency and education related to wound care for the nurse would not be completed. The Administrator verified that the Facility Assessment provided indicated that nurses would have the skills, training, and competency to provide wound care. A policy was requested related to the Facility Assessment. The Administrator informed surveyor the facility did not have a policy. 2. Review of the Facility Assessment dated 1/15/2023 did not include its policies or protocols to include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for residents. An interview on 3/16/2024 at 1:56 pm with the Administrator stated the facility does not have a policy for the Facility Assessment. He stated the facility follows the state and federal guidelines as it relates to the facility assessment. The Administrator stated he was not aware that the facility assessment did not address infection control or the infection preventionist.

Based on staff interview, record review, and review of the PBJ (Payroll Based Journal) [NAME] Report for First Quarter (Q1) of Fiscal Year 2024, the facility failed to submit direct care staffing data to the Centers for Medicare and Medicaid (CMS). The facility census was 19 residents. Findings include: Review of the PBJ Data Staffing Report CASPER Report for Q1 2024, October 1 through December 31, revealed the facility failed to submit data for the quarter. During an interview on 3/16/2024 at 11:00 am with the Director of Nursing (DON) revealed, the facility did send the PBJ information into CMS and that he would look for proof. During an interview on 3/16/2024 at 11:30 am with the Administrator revealed that he had submitted the PBJ information to CMS each quarter. He stated he did not know where the return receipt was located, but he would look for it. During an interview on 3/16/2024 at 1:00 pm with the Administrator revealed, he could not find the return receipt for the information that was sent to CMS and that the facility did not have a policy related to PBJ. During an interview on 3/16/2024 at 3:30 pm with the Administrator, he presented one receipt for the staffing data that was sent to CMS on 10/13/2023. He stated he sent the last report to CMS in January 2024, but was unable to locate the receipt.

Based on staff interview, record review, and review of the facility's policies titled Infection Prevention And Control and Infection Control Policy Surveillance and Reporting Infections the facility failed to provide evidence that infection control surveillance data was collected for 20 out of 20 months (June 2022 through February 2024) reviewed. The facility had a census of 19 residents. Findings include: Review of the policy titled Infection Prevention And Control dated 9/30/2023 under the section titled POLICY revealed, [Facility name] maintain comprehensive Infection Prevention and Control (IPC) programs that protect hospitalized individuals, visitors, staff, and others from Healthcare Associated Infections (HAIs). Under the section titled, Infection Surveillance revealed, 1. IPC Teams use a line listing form to record and track all infections. IPC data is gathered using multiple sources including, but not limited to: Culture and sensitivity reports, antibiotic dispensing reports, 24-hour nursing reports, infection reporting forms, and nursing rounds. 2. IPC Teams report all HAIs each month. These reports show the number of infections by type, site and service or treatment area. 4. This surveillance approach enables IPC Teams to quickly: (a) Detect infection trends, clusters, and outbreaks. (b) Drill down to identify causative factors. (c) Implement new or additional control measures. (d) Monitor the effect or results of these new or additional control measures. Review of the policy titled Infection Control Policy Surveillance and Reporting Infections dated 12/22/2023 under the section titled PURPOSE revealed, To provide an ongoing system of surveillance, data collection, analysis of data and dissemination of findings in order to identify and control infections/hospital acquired infection and to initiate prevention strategies to minimize the risk of transmission of infections. A. The Infection Control Nurse(s) shall perform surveillance, implement prevention, and control measures, and report infections to the Infection Control Team and appropriate authorities. B. Surveillance is conducted through 1. Review of pertinent laboratory reports. 3. Review of monthly line listings from each client unit. Review of the document titled Skilled Nursing Data revealed no data was obtained for June 2022. Review of the document titled Skilled Nursing Data revealed there was no Line Listing, Mapping, Epidemiology Report Form, and Monthly Surveillance for Tuberculosis Form from June 2022 through February 2024 for a total of 20 months. Interview on 3/16/2024 at 9:23 am with Licensed Practical Nurse (LPN), HH stated the facility followed protocols for infection control. She accumulates a report every month of how many infections there were based on the antibiotic's usage. The LPN stated she obtains the number of antibiotics used for the month from pharmacy. She stated the only source information used is obtained from the residents Electronic Medical Record. She revealed she completed the monthly calculations with the number of infections, daily census, and the resident days per month to arrive at the average facility infection rate. She stated that was the extent of what she did with the infection control. The LPN stated there was no communication with the nursing staff to verify the residents' signs and symptoms or source of infection. The LPN stated she could not provide the surveyor with Line Listing, Mapping, Epidemiology Report Form, or a Monthly Surveillance for Tuberculosis Form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policies titled Infection Prevention And Control the facility failed to provide evidence of a monitoring system to track and trend antibiotic use for 20 out of 20 months (June 2022 through February 2023) of the infection control data reviewed. The facility had a census of 19 residents. Findings include: Review of the policy titled Infection Prevention And Control dated 9/30/2023 under the section titled POLICY revealed, [Facility name] maintain comprehensive Infection Prevention and Control (IPC) programs that protect hospitalized individuals, visitors, staff, and others from Healthcare Associated Infections (HAIs). Under the section titled, Infection Surveillance revealed, 1. IPC Teams use a line listing form to record and track all infections. IPC data is gathered using multiple sources including, but not limited to: Culture and sensitivity reports, antibiotic dispensing reports, 24-hour nursing reports, infection reporting forms, and nursing rounds. 2. IPC Teams report all HAIs each month. These reports show the number of infections by type, site and service or treatment area. 4. This surveillance approach enables IPC Teams to quickly: (a) Detect infection trends, clusters, and outbreaks. (b) Drill down to identify causative factors. (c) Implement new or additional control measures. (d) Monitor the effect or results of these new or additional control measures. Review of the document titled Skilled Nursing Data there was no evidence of antibiotic surveillance data, analysis, documentation of follow up in response to the data or monthly antibiotic reporting for 20 months from June 2022 through February 2023. Interview on 3/16/2024 at 9:15 am with the Administrator stated the last Infection Preventionist abruptly quit in or around December 2023. He stated the facility has a nurse that has been filling in for infection control until the newly hired Registered Nurse starts on 3/18/2024. Interview on 3/16/2024 at 9:23 am with Licensed Practical Nurse (LPN), HH stated she had been filling in for the past 7 months (September 2023) for infection control. She stated the last person that was responsible for the facility's infection control removed all the infection control binders from the office. She stated the facility does not have a policy on the Antibiotic Stewardship Program (ASP). The LPN stated she did not document the percent of residents receiving antibiotics (ABT), percent of new admissions receiving ABT, new [NAME] started, Rate of ABT days of therapy, or the ABT utilization ratio. Interview on 3/17/2024 at 9:43 am with the Director of Nursing stated the facility did not have a policy on the ASP.

Based on staff interviews and review of the facility's policy titled, Infection Prevention And Control, the facility failed to designate a qualified Infection Preventionist who completed specialized training in Infection Prevention and Control. This failure placed all residents at risk for the potential transmission of infections and communicable diseases. The facility had a census of 19 residents. Findings include: Review of the policy titled Infection Prevention And Control dated 9/30/2023 under the section titled POLICY revealed, [Facility name] maintain comprehensive Infection Prevention and Control (IPC) programs that protect hospitalized individuals, visitors, staff, and others from Healthcare Associated Infections (HAIs). Under the section titled Procedures revealed, 2 (a) Committee members, representing a variety of departments and clinical services, are appointed by Hospital Leadership. Members include but are not limited to an Infection Prevention and Control (IPC)/Infection Preventionist (IP). 3 (i) The IPC Practitioners are licensee registered nurses with strong clinical nursing backgrounds. The IPC Practitioners are strongly encouraged and supported by Hospital Leadership to obtain Certification in Infection Control (CIC) and membership in the Association for Professionals in Infection Control and Epidemiology (APIC). Interview on 3/16/2024 at 9:23 am with Licensed Practical Nurse (LPN), HH confirmed that she did not have an IP certification or a CIC certification. Interview was conducted on 3/16/2024 at 10:17 am with the Clinical Director of the Hospital responsible for overseeing the infection control program to ensure that the policy and procedures are followed. He stated that he did not have an IP certification or any type of infection control certification. The Clinical Director of the Hospital stated the previous IP abruptly quit in September of 2023. He stated the facility had hired a Registered Nurse (RN) that will be starting on 3/18/2024. He stated the facility will make certain the RN obtained an IP Certification.