Based on observations, interviews, record reviews, and review of the facility's policies titled Standard Precaution/Use of PPE [personal protective equipment], and Transmission-Based Precautions (Contact, Enhanced Barrier Precautions [EBP], Droplet, Airborne), the facility failed to maintain infection control measures for one of 24 sampled residents (R) (R4). Specifically, the facility failed to ensure that enhanced barrier precautions were maintained during enteral feeding/medication administration for R4. The deficient practice increased the risk for infections for residents with enteral feeding tubes. Findings include: Review of the facility's policy titled, Standard Precaution/Use of PPE [personal protective equipment], revised 12/27/2024, under Intent revealed, It is the policy of this facility that: 1) all patient blood and body fluids will be considered potentially infectious 2) standard precautions are indicated for all patients. Under the section titled Guideline revealed, .Wear a gown that is appropriate to the task to protect skin and prevent soiling or contamination of clothing during procedures and resident-care activities when contact with blood, body fluids, secretions, or excretions is anticipated . Review of the facility's policy titled, Transmission-Based Precautions (Contact, Enhanced Barrier Precautions [EBP], Droplet, Airborne), revised 12/27/2024 under the section titled Enhanced Barrier Precautions (EBP) revealed, .EBP expand the use of PPE [personal protective equipment] and refer to the use of gown and gloves during high-contact activities.Examples of high contact patient care activities requiring gown and glove use for Enhanced Barrier Precautions include: Device care or use: . feeding tube.Gown and gloves would not be required for patient care activities other than those listed above . Review of R4's admission Record revealed diagnoses that included but not limited to paraplegia, aphasia, encounter for attention to gastrostomy, and history of traumatic brain injury. Review of R4's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Review Date (ARD) of 2/28/2025 for Section C (Cognitive Pattern) revealed, the Brief Interview for Mental Status (BIMS) was not able to be completed due to impaired cognition; and Section K (Swallowing/Nutritional status) revealed, R4 had an enteral feeding tube. Review of R4's Care Plan, revised 5/22/2025 included tube feeding status and enhanced barrier precautions. Review of R4's Resident's Consolidated Order revealed, an order for valproic acid (anti-seizure medication) 250 mg (milligrams)/five (5) ml (milliliters) give 10 ml via (by way of) percutaneous (PEG) tube four times per day (QID) dated 5/4/2023 and [Name of dietary supplement] 2.0 oral liquid administer one carton three times per day (TID) dated 7/25/2024, and enhanced barrier precautions dated 5/4/2023. During an observation on 5/21/2025 at 9:16 am, R4's bedroom had signage indicating that he was on EBP. Licensed Practical Nurse (LPN) 1 donned (put on) gloves prior to administering valproic acid and [Name of dietary supplement] via PEG tube to R4. LPN1 did not don a gown prior to procedure. During an interview on 5/22/2025 at 2:01 pm, LPN1 confirmed that she did not wear a gown on 5/21/2025 during enteral feeding tube administration but should have. LPN1 stated that R4's door did not have a PPE cart at the entrance to his room, and she forgot. During an interview on 5/22/2025 at 2:45 pm, Director of Nursing (DON) revealed, that it was her expectation that nursing staff ensured EBP were followed for R4 due to enteral feeding status. The DON confirmed that LPN1 should have donned both gloves and a gown during any procedure involving the enteral feeding tube.

Based on observation, interview, record review, and review of the facility's policy titled Storage Areas, the facility failed to ensure shakes were dated for two of two nourishment rooms (First and Second Floor). The deficient practice had the potential for the spread of food borne illness to affect 69 out of 72 residents that received an oral diet. Findings include: Review of the facility's policy titled, Storage Areas, dated 12/27/2024 under Guideline revealed, Items should be covered, sealed, labeled, and dated appropriately. During an inspection on 5/19/2025 at 10:39 am with the Dietary Manager (DM) in the nourishment room on the first floor, the refrigerator contained five four-ounce cartons of [Name of shakes]. Manufacturer's information on each of the cartons of the shakes read, Use thawed product within 14 days. There was no documentation on the shakes or elsewhere indicating when the shakes were pulled from the freezer and placed under refrigeration, which was confirmed by the DM. The DM revealed that the shakes must be used within 14 days of refrigeration. During an inspection on 5/19/2025 at 10:48 am with the DM in the nourishment room on the second floor, the refrigerator contained three four-ounce cartons of [Name of shakes]. There was no documentation on the shakes or elsewhere indicating when the shakes were pulled from the freezer and placed under refrigeration, which was confirmed by the DM. During an interview on 5/22/2025 at 2:15 pm, the Registered Dietitian (RD) revealed, the health shakes had a shelf life of 14 days once pulled from the freezer, and it was important to document the date they were placed into refrigeration to ensure they were not expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy titled Foley Catheter Care, and staff interviews, the facility failed to ensure catheter care was provided in a manner to prevent urinary tract infections for one resident (R) (R#52) of six residents with indwelling urinary catheters. Findings include: Review of the facility policy titled Foley Catheter Care dated 2020 revealed: Intent - to promote hygiene, comfort and decrease risk of infection for patients with an indwelling catheter and is performed daily and PRN (as needed). Please see Lippincott Nursing Practice [NAME] for additional information on how to complete the procedure. [NAME] (2019) documented to avoid contaminating the urinary tract, always clean by wiping away from and never toward the urinary meatus. The policy does not include information about cross contamination and/or using a clean washcloth/wipe for each stroke. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed R#52 with a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition intact. The resident had an indwelling catheter and diagnosis of Urinary Tract Infection (UTI) within the last 30 days. Further review of the clinical record revealed R#52 was admitted on [DATE] and was noted on 3/24/22 with vaginal bleeding, which was identified to be a urethral laceration, which has since resolved. Review of the Physician Order dated 3/24/22 revealed R#52 had order for indwelling urinary catheter to bedside drainage, Size: 18F (French); Balloon Size: 10 milliliters (mL) for diagnosis of obstructive uropathy. Observation on 4/09/22 at 10:15 a.m. revealed Certified Nursing Assistance (CNA) AA performed catheter care on R#52. CNA AA washed her hands, donned gloves, and prepared two basins with hot water; each basin contained one washcloth. CNA AA allowed R#52 to wash her face with one of the two washcloths and placed that washcloth back in the basin. She then added liquid soap to that basin. CNA AA soaped up the washcloth and washed the resident all over along the lower abdomen in the creases and down each side of the peri area, and down the catheter tubing. CNA AA placed the washcloth back in the basin with soapy water, squeezed out the washcloth and repeated the previous actions with the same washcloth. The was no sequence when wiping the entire area including the catheter tubing. The entire peri area and catheter tubing was wiped at random while frequently placing washcloth back into the soapy water and squeezing out washcloth. CNA AA used the washcloth from the clean water with the same actions and in same the same manner as with the soapy water washcloth. No other washcloths were used. Catheter tubing was secured with anchoring device to leg. Review of the CNA Orientation Skill Checklist - Core Competency dated 10/15/21 for CNA AA revealed competency checked off for: peri care - female, male, and catheter. Completed steps for the check off procedure was not listed in the competency file. Interview with CNA AA on 4/10/22 at 7:20 a.m. revealed that she has received in-service on catheter care and is familiar with cleaning in one direction down each side extending outward and down the tubing and using a different washcloth for every stroke of cleaning. CNA AA stated she was nervous and usually brings more washcloths. Interview with the Administrator on 4/10/22 at 9:47 a.m. revealed that the CNA's do not document catheter care. They know to do catheter care because it is on the Activities of Daily Living (ADL) plan of care, but it is not documented anywhere. Interview with the Administrator, the Resident Care Coordinator (RCC), and the MDS Coordinator on 4/10/22 at 11:00 a.m. revealed that CNA AA has been here since the building opened and she was nervous. She normally does catheter care appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy titled Psychotropic Medications, and staff interview, the facility failed to document the intended duration of therapy for one resident (R) (#116) that had an order for PRN antianxiety medications beyond 14 days of six residents reviewed for unnecessary medications. Findings include: Review of facility policy titled Psychotropic Medications dated 2019 revealed Guideline: PRN (as needed) Orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the patient's medical record and indicate the duration for the PRN order. Review of the admission Minimum Data Set (MDS) dated [DATE] documented R#116 with a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition intact. The resident was admitted to the facility on [DATE] and received an antianxiety medication for five days of the seven-day assessment period. Review of Physician Order dated 3/9/22 revealed R#116 had an order for Ativan 1 milligram (mg) every six hours PRN with no end date and the medication was not ordered for a specific number of days. Review of the Medication Administration Record (MAR) revealed R#116 received Ativan 1 mg on the following days: 3/10/22 (twice), 3/11/22 (twice), 3/12/22, 3/13/22 (twice), 3/14/22, 3/15/22, 3/16/22, 3/17/22 (twice), 3/18/22, 3/19/22, 3/20/22, 3/21/22 (twice), 3/22/22, 3/23/22 (twice), 3/24/22, 3/25/22, 3/26/22 (twice), 3/27/22 (twice), 3/28/22 (twice), 3/29/22, 3/30/22, 3/31/22, 4/1/22 (twice), 4/2/22 (twice), 4/3/22, 4/4/22, 4/5/22 (twice), 4/6/22, 4/7/22 (twice), 4/8/22, 4/9/22 (twice), and 4/10/22. Review of the document titled Psychotropic & Sedative /Hypnotic Utilization by Resident from the pharmacy for records updated between 4/1/22 and 4/2/22 revealed R#116 was ordered Ativan 1 mg every six hours PRN on 3/9/222 with next evaluation being 3/23/22. Review of the Physician and Nurse Practitioner Progress Notes from 3/9/22 to 4/10/22 revealed no documentation of increased anxiety or rational for the continued use of the PRN Ativan. Observation of medication administration with Licensed Practical Nurse (LPN) BB on 4/10/22 at 8:20 a.m. revealed R#116 had requested his antianxiety medication. Upon entrance to the resident's room, R#116 did not remember requesting the antianxiety medication. However, LPN BB administered Ativan 1 mg by mouth without question along with his other medications in the medication cup. Interview with the Administrator, Resident Care Coordinator (RCC), and MDS Coordinator on 4/10/22 at 11:00 a.m. revealed that PRN anxiety medications are usually ordered for 14 days. MDS Coordinator stated R#116 has problems with cognition (even with BIMS score of 15) and he is always forgetting that he asked for medication and his wife will remind him that he asked for the medication. The RCC stated she would go ahead and get the order changed for the 14-day PRN. DONE