Based on observation, interview and record review, the facility failed to ensure staff wore appropriate PPE (personal protective equipment) in enhanced barrier precaution rooms when providing direct care for residents and failed to prevent cross-contamination during personal cares for 3 of 5 residents (R19, R16, and R14) reviewed for infection control in the sample of 14. The findings include: 1. R19's face sheet, provided by the facility on 8/29/24, showed she had diagnoses including muscular dystrophy, dysphagia (difficulty swallowing), protein-calorie malnutrition, gastro-esophageal reflux disease, and gastrostomy status (a g-tube). R19's ADL care plan initiated on 6/28/24 showed she is limited in her ability to transfer herself due to deconditioning/weakness related to muscular dystrophy and anemia. R19's Nutritional Status care plan initiated on 6/28/24 showed she has a g-tube and is on Enhanced Barrier Precautions: Follow instructions outside of resident's door. On 8/27/24 at 9:57 AM, V9 went into R19's room with surveyor. V5 (CNA) had her arms around R19's waist, putting a gait belt around R19. V5 secured the gait belt and assisted R19 with transferring from her bed to her wheelchair and then from her wheelchair to her recliner. R19 was not feeling well on 8/27/24 and V5 had both hands on R19's gait belt. V5's arms were touching R19 on her sides and her back during the transfers. V5 did not have a gown or gloves on during the transfers. A sign on R19's doorway showed she was on enhanced barrier precautions and staff should Wear gloves and a gown for the following high-contact resident care activities .Transferring . On 8/28/24 at 11:55 AM, V11 (Social Services) was observed in R19's room. V11 did not have a gown or gloves on. V11 was sitting on R19's unmade bed, talking to R19, who was sitting in her recliner. 2. R16's face sheet, provided by the facility on 8/29/24 showed he had diagnoses including vascular dementia with anxiety, and a personal history of stroke. R16's care plan initiated on 7/7/22, showed he needed assistance with ADLs (activities of daily living) due to cognitive loss, weakness, limited mobility, deconditioning, activity intolerance related to CHF (congestive heart failure), pain, and limited range of motion. On 8/27/24 at 9:42 AM, R16 was sitting in his wheelchair, propelling himself into his bathroom. V12 (Certified Nursing Assistant-CNA) was passing by R16's room and asked him where he was going. R16 said he was going in to use the bathroom. V12 asked R16 to hold on a minute and he would go get someone to assist him. V12 propelled R16 back out of the bathroom and told him he would be right back. V12 walked down the hall and came right back with V10 CNA. V10 entered R16's room without performing hand hygiene or donning PPE (personal protective equipment). The sign on R16's doorway showed Enhanced Barrier Precautions- Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also Wear gloves and a gown for the following High-Contact Resident Care Activities .Dressing .Transferring .Changing briefs or assisting with toileting . V10 closed the door to R16's room and walked back out after a couple of minutes. At 9:48 AM, V10 returned to R16's room because the call light had been activated. V10 entered R16's room without performing hand hygiene or donning PPE. This surveyor knocked on the door and entered R16's room. V10 was observed cleaning R16 after he had a bowel movement. V10 did not have a gown on, only gloves. At 9:50 AM, V9 (Registered Nurse-RN) said R16 was on enhanced barrier precautions due to a wound on his right toe. V9 said staff only need to put PPE on when coming in contact with the affected area. On 8/28/24 at 12:16 PM, V13 (RN/Infection Preventionist) said enhanced barrier precautions involves modified contact precautions for anyone with an indwelling device or wound. V13 said the expectation is that staff would don gown and gloves if providing high-contact direct care. V13 said staff should be putting on a gown and gloves when providing toileting care, adding, We are trying to protect him from being exposed to anything he might come in contact within his environment. V13 said even though the wound is on his foot, staff should be donning a gown and gloves. V13 said when transferring a resident, if they are requiring extensive assist, then a gown is needed along with gloves. V13 said It is probably not appropriate for staff to be sitting on R19's bed because that is her environment. On 8/29/24 at 9:06 AM, V11 (Social Services) said she should not have sat on R19's bed to prevent cross-contamination, especially since her bed was not made, because she (R19) is on enhanced barrier precautions. The facility's policy and procedure titled Enhanced Barrier Precautions (EBP), with a review date of May 2024, showed 1. It is well-known that residents residing in congregate long-term care settings are at increased risk of becoming colonized and/or infected with MDROs (Multidrug-resistant organisms). 2. MDROs present significant infection control obstacles in their treatment and prevention of transmission. 3 Understanding that transmission can occur from colonized residents, Enhanced Barrier Precautions (EBP) is a measure to mitigate the spread to un-affected residents .5. EBP also applies to residents living in a long-term care setting who have indwelling devices (such as urinary catheters) or chronic wounds. These residents are at increased risk during high-contact cares due to potential transfer of MDROs to or from a staff's hands/clothing. a. Regardless of MDRO status, any residents with indwelling devices or chronic wounds will have EBP during the duration of the device or wound. The policy showed When a resident is known to be colonized with an MDRO or has an indwelling device/chronic wound: a. A sign will be placed outside their door, along with a PPE cart. i. This sign will list the cares requiring EBP .c. ABHR (alcohol-based hand rub) will be made available in the room for hand hygiene before, between, and after cares .e. High contact cares requiring gown, glove use include .iii. Transferring .v. Changing linens. vi. Toileting/changing briefs. 3. On 8/27/24 at 9:38 AM, R14 was in bed while V4 CNA (Certified Nursing Assistant) was providing morning care. R14's night gown, incontinence pad, and wet washcloths were on the floor next to his bed. V4 did not have any gloves on, picked up the dirty linen and placed it in a pile on the floor in front of the armoire. V4 used hand sanitizer then put R14's tennis shoes on. V4 put a round pad on R14's left lower leg. V4 raised the head of bed and then lowered his bed. V4 did not have gloves on and picked up the pile of dirty linen from the floor and carried it out of the room. On 8/28/24 at 1:35 PM, V2 DON (Director of Nursing) stated, the soiled/dirty linen should not go on the floor. You don't know what is on it and then it will get on the floor and can go all over. It is cross contamination. It is absolutely an infection control problem. The Face Sheet dated 8/29/25 for R14 showed medical diagnoses including left sided hemiplegia, psoriasis, vascular dementia, mild cognitive impairment, peripheral vascular disease, atherosclerotic heart disease, cerebral infarction, pulmonary hypertension, hypokalemia, occlusion of right carotid artery, osteoarthritis, mononeuropathy of left lower limb, Vitamin D deficiency, gastroesophageal reflux disease, hypertension, dysphagia, hyperlipidemia, weakness, and sick sinus syndrome. The MDS (Minimum Data Set) dated 7/17/24 for R14 showed dependence for toileting hygiene and lower body dressing; substantial/maximal assistance for upper body dressing and personal hygiene. Incontinence of bowel and bladder. The facility's Incontinence Care policy (8/29/24) showed thorough perineal care, as detailed below, is to be peformed during AM cares and HS cares. The policy did not state where dirty/soiled linen should go to prevent cross contamination when care is provided.

Based on observation, interview, and record review the facility failed to properly label and store food in the refrigerator; ensure thermometers were inside the refrigerator; and ensure leftovers were properly cooled. This affects all residents residing in the facility. The findings include: The CMS 671 dated 8/29/24 showed there were 22 residents. On 8/27/24 at 8:59 AM, during a kitchen tour with V6 (Dietary Manager) there was a small refrigerator, under the steamer. The digital thermometer on the exterior of the refrigerator showed 37 degrees. There was no thermometer inside the refrigerator. V6 said the dietary staff use the digital reading from the exterior for the temperature logs. He said temperatures were monitored to ensure the quality of the food and prevent foodborne illness. There was a stand-up refrigerator with beverages inside. The external digital reading was 39 degrees. There was not a thermometer inside the refrigerator. At 9:03 AM, there was a Cooling Temperature Log affixed to the outside of the walk-in cooler. (The last documented items was Meatloaf on 5/20/24. This document's instructions showed, Record temperature every hour during the cooling cycle. Record corrective actions, if applicable. The food service manager will verify that the food service staff is cooling food properly by visually monitoring food service employees during the shift and reviewing, initially and dating this log daily.) Inside the walk-in cooler there was a metal container, covered with saran wrap, labeled Ham, 8/24/24. V6 said the ham was left over from Saturday. V6 said the ham should be entered on the cooling log. The surveyor and V6 exited the cooler and viewed the Cooling Temperature Log. V6 said the ham was not on the cooling log, but it should be. V6 said the cooling log is done to ensure food is safely cooled and prevent the risk of foodborne illness. Inside the walk-in cooler, was an uncovered, open, shelved cart. There were 5 trays of individual servings of tiramisu and 2 trays of salads. The trays were not covered. There was a tray of individual cups of ketchup that was uncovered. The residents were served the tiramisu and salads during the noon meal. On 8/28/24 at 9:30 AM, the small refrigerator under the steamer and the front refrigerator still did not have thermometers inside. The walk-in cooler had a tray with left over tiramisu (from yesterday) and individual servings of various salad dressings. These items were uncovered. At 10:02 AM, V6 said food stored in the refrigerator should be covered and labeled. V6 said food is covered to prevent cross-contamination. The surveyor accompanied V6 to the walk-in cooler and pointed out the left-over dessert and salad dressings. V6 replied, That shouldn't be like that. It was from yesterday; I will throw it out. V6 said he doesn't have a cover for the open storage rack (observed yesterday), but stated, We could probably put a bag over the cart until we serve the food. The facility's Spring/Summer 2024 Menu showed on Saturday (8/24/24) baked, glazed ham was served for lunch. The Menu showed Tuesday (8/28/24) was, Lunch Bunch: Village Pizza, salad, and dessert. The facility's Leftover Food Policy dated 2014 showed, Leftover food of adequate quality, appearance, and nutrient retention will be covered, labeled, dated, and used within 72 hours. Procedure: 1. Leftover food will be properly wrapped/covered, labeled, and dated. The product will be refrigerated immediately. 2. Using the two-stage cooling process, leftovers will be cooled to 70 degrees Fahrenheit within 2 hours and then down to less than or equal to 41 degrees within another 4 hours. 3. Cooked foods will be used within 48 hours or frozen for later use . The facility's Storage of Food and Supplies Policy dated 2014 showed, Food and supply storage areas shall be maintained in clean, safe, and sanitary manner. Procedure: .4. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. TCS (Time/Temperature Control for Safety) foods prepared on site must be labeled with the name of the food, the date it should be sold, consumed or discarded .7. Refrigerators and freezers will be equipped with an internal thermometer and monitored. Temperatures will be documented .

Based on interview and record review the facility failed to prevent the diversion of a resident's controlled substance medication. This applies to 1 of 3 residents (R1) reviewed for misappropriation of resident property in the sample of 3. The finding include. R1's Controlled Drug Receipt / Record / Disposition (commonly referred to as a count sheet or controlled substance count sheet) showed the facility received, on R1's behalf, 120 tablets of 50 milligram (mg) tramadol, a schedule IV narcotic pain medication. The count sheets showed the tablets were delivered on 5/13/24 and were dispensed in four separate punch cards, each card containing 30 tablets of tramadol. R1's count sheet showed each individual punch card was delivered with its own accompanying count sheet (4 punch cards, 4 count sheets). The first dose of the first punch card of tramadol, from the delivery on 5/13/24, was dispensed on 5/16/24 at 11:59 AM. The final dose of the first card was given on 5/26/24 at 12:25 PM. The second punch card was started on 5/26/24 at 9:00 PM and the final dose of this card was given 6/5/24 at 11:40 AM. The third punch card was started 6/5/24 at 9:00 PM and completed on 6/15/24 at 5:01 AM (this completes 90 tablets of 120 tablets delivered on 5/13/24). Following the completion of R1's third card of tramadol, the next dose given was on 6/15/24 at 11:50 AM. The dose given on 6/15/24 at 11:50 AM was from a new delivery of 120 tablets of tramadol, which was delivered to the facility on 6/12/24. (The fourth card of tramadol delivered on 5/13/24 was not accounted for.) On 8/14/24 at 12:30 PM, V2 (Director of Nursing) stated the facility was not able to account for R1's missing card of tramadol delivered on 5/13/24. V2 stated the only explanation for this missing tramadol punch card is theft. V2 stated tramadol is double locked and only the nurses on duty have access to the controlled substances. V2 stated the medications maintained by the facility are the resident's property. V2 said controlled substances are the most likely medications to be diverted for either financial gain or personal use. On 8/14/24 at 9:52 AM, V1 (Administrator) stated the facility was not able to locate R1's missing card of tramadol. V1 stated it appears a nurse took R1's count sheet and his punch card of tramadol. V1 stated the medications are the resident's property. The facility's Abuse and Neglect Prevention Protocol Policy showed, Misappropriation of resident property means using a resident's cash, clothing, or personal possessions without authorization by the resident or the resident's authorized representative .

Based on interview and record review the facility failed to implement policies to identify and prevent the diversion of controlled substances. This applies to 1 of 3 residents (R1) reviewed for controlled substances in the sample of 3. The findings include: R1's Controlled Drug Receipt / Record / Disposition (commonly referred to as a count sheet or controlled substance count sheet) showed the facility received, on R1's behalf, 120 tablets of 50 milligram (mg) tramadol, a schedule IV narcotic pain medication. The count sheets showed the tablets were delivered on 5/13/24 and were dispensed in four separate punch cards, each card containing 30 tablets of tramadol. R1's count sheet showed each individual punch card was delivered with its own accompanying count sheet (4 punch cards, 4 count sheets). The first dose of the first punch card of tramadol, from the delivery on 5/13/24, was dispensed on 5/16/24 at 11:59 AM. The final dose of the first card was given on 5/26/24 at 12:25 PM. The second punch card was started on 5/26/24 at 9:00 PM and the final dose of this card was given 6/5/24 at 11:40 AM. The third punch card was started 6/5/24 at 9:00 PM and completed on 6/15/24 at 5:01 AM (this completes 90 tablets of 120 tablets delivered on 5/13/24). Following the completion of R1's third card of tramadol, the next dose given was on 6/15/24 at 11:50 AM. The dose given on 6/15/24 at 11:50 AM was from a new delivery of 120 tablets of tramadol, which was delivered to the facility on 6/12/24. (The fourth card of tramadol delivered on 5/13/24 was not accounted for.) On 8/14/24 at 9:24 AM, V4 (Licensed Practical Nurse) stated, At the time, we did not have a process in place to prevent a nurse from taking the card (narcotic punch card) and the sheet. I have heard of that being an issue at other facilities . On 8/14/24 at 9:52 AM, V1 (Administrator) stated the theft of a resident's controlled substance was first identified on or about 7/17/24 for R100, a resident in a licensed only (private pay) bed. V1 stated, during the investigation, other instances of missing controlled substances were identified, including R1's missing tramadol. (R1's missing tramadol was not discovered for at least one month and not until an investigation was initiated.) V1 stated she was not aware card counting (A method of accounting for all the controlled substance cards from one shift to the next). On 8/14/24 at 12:30 PM, V2 (Director of Nursing) stated the only explanation for the missing tramadol is theft. V2 stated it appears the nurse who stole R1's tramadol took the count sheet and the entire card of medication. V2 stated she was not aware nurses taking the count sheet and the punch card was a relatively method for individuals to divert controlled substances. V2 stated, at the time of the theft, the facility did not have policies and procedures in place to prevent or identify the theft of an entire punch card and count sheet. The facility's Controlled Substances Accountability Policy (7/19/24) showed, .The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders to apply a hand splint to a resident at risk for contractures. This applies to 1 of 2 residents (R15) reviewed for mobility and range of motion in the sample of 10. The findings include: The EMR (Electronic Medical Record) showed R15 was admitted to the facility on [DATE], with multiple diagnoses including stroke with hemiplegia (paralysis) and hemiparesis of the left side, dementia, and hypertension. R15's MDS (Minimum Data Set) dated July 19, 2023, showed R15 had moderate cognitive impairment, and R15 required extensive assistance from facility staff for bed mobility, dressing, and personal hygiene. The MDS continued to show R15 had a functional limitation in range of motion impairment of the upper extremity on one side. R15's ADL (Activity of Daily Living) care plan dated April 25, 2023, showed, I need assistance with my ADLs due to cognitive loss related to dementia, weakness/pain/limited mobility/deconditioning related to recent stroke with left sided weakness, osteoarthritis, neuropathy. I have some vision loss in me left eye. I am right handed. I cannot move my left arm/leg. The care plan continued to show multiple interventions dated July 5, 2023, including Left hand splint on per physician orders. R15's Physician Order Report showed an order dated July 5, 2023, for a resting hand splint to left hand splint, on in the morning and off at bedtime. On July 24, 2023, at 12:14 PM, R15 was sitting in his wheelchair, eating lunch in the dining room. R15's left arm was resting on his wheelchair arm, and R15 did not have a splint on his left hand. During the entire lunch service, R15 was not observed able to move his left arm or hand. On July 26, 2023, at 10:41 AM, R15 was sitting in his wheelchair in the activity room. R15's arm was resting on his lap, and R15's fingers were flexed. R15 did not have a splint on his left hand. On July 26, 2023, at 11:16 AM, V4 (CNA/Certified Nursing Assistant) said [R15] does not have a hand splint that I know of. I do not put a hand splint on him during the day. On July 26, 2023, at 11:19 AM, V5 (LPN/Licensed Practical Nurse) said he was not sure if R15 had a splint. On July 26, 2023, at 12:12 PM, V6 (Occupational Therapist) said R15's hand splint was recommended from therapy for positioning and to prevent a contracture. V6 continued to say R15's left upper extremity is flaccid with no active movement. V6 said without the left hand splint, R15's wrist and fingers are at risk for contractures. V6 continued to say R15's splint should be applied in in the morning when he is up in his wheelchair and then removed at nighttime. V6 said R15 does not need his splint removed during meals because he is unable to use his left hand to feed himself. V6 said facility staff should be reporting to therapy if R15 refuses to wear his splint, but she has not been told he had refused to wear his splint. V6 continued to say R15 always allows V6 to apply his splint. On July 26, 2023, at 1:54 PM, V2 (DON/Director of Nursing) said R15 has an order for a left hand splint, and it should be applied in the morning and left on throughout the day and taken off at night. V2 continued to say it is the CNA's task to apply R15's splint. V2 said the expectation is facility staff are applying R15's hand splint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to offer the COVID-19 vaccine to residents. This applies to 2 of 5 residents (R10 and R15) reviewed for immunizations in the sample of 10. The findings include: 1. The EMR (Electronic Medical Record) showed R10 was admitted to the facility on [DATE], with multiple diagnoses including poliomyelitis, Parkinson's disease, and hypertension. The MDS (Minimum Data Set) dated July 12, 2023, showed R10 had moderate cognitive impairment. R10's COVID-19 care plan dated April 18, 2023, showed I am at risk for infection related to COVID-19 pandemic. The care plan continued to show multiple interventions dated April 18, 2023, including, COVID-19 vaccination per facility protocol. R10's Preventative Health Care Report showed R10 received COVID-19 vaccines on March 4, 2021, March 24, 2021, and December 21, 2021. The report did not show R10 had received an updated COVID-19 vaccine and R10 was not up to date with COVID-19 vaccinations. The facility does not have documentation to show R10 or R10's resident representative was offered the updated COVID-19 vaccine. 2. The EMR showed R15 was admitted to the facility on [DATE], with multiple diagnoses including stroke with hemiplegia (paralysis) and hemiparesis of the left side, dementia, and hypertension. R15's MDS dated [DATE], showed R15 had moderate cognitive impairment. R15's COVID-19 care plan dated April 25, 2023, showed I am at risk for infection related to COVID-19 pandemic. The care plan continued to show multiple interventions dated April 25, 2023, including, COVID-19 vaccination per facility protocol. R15's Preventative Health Care Report showed R15 received COVID-19 vaccines on March 24, 2021, April 15, 2021, and October 15, 2021. The report did not show R15 had received an updated COVID-19 vaccine and R15 was not up to date with COVID-19 vaccinations. The facility does not have documentation to show R15 or R15's resident representative was offered the updated COVID-19 vaccine. On July 26, 2023, at 1:09 PM, V2 (DON/Director of Nursing said, R10 and R15 had not been offered the updated COVID-19 vaccine because the facility was waiting to see if more residents needed the updated COVID-19 vaccine. V2 continued to say the facility usually offers the COVID-19 vaccine in the fall. The facility's policy titled, COVID-19 Infection Prevention and Control Policy, updated on July 18, 2023, showed, Policy Statement: COVID-19 is a respiratory illness (caused by the coronavirus) that is primarily transmitted from person to person via droplets generated by coughing and sneezing. Elderly individuals are at an increased risk of becoming infected due to compromised immunity and comorbidities . COVID-19 Vaccine- Policy: COVID-19 vaccines available in the United States are effective at protecting people from getting seriously ill, being hospitalized , and dying. As with other vaccine-preventable diseases, are protected best from COVID-19 when you stay up to date with the recommended vaccinations, including recommended boosters. For further guidance on current vaccine recommendations refer the CDC (Centers for Disease Control and Prevention): Stay Up-To-Date with COVID-19 Vaccines Including Boosters . COVID-19 Vaccine (Resident): The residents in this facility will be offered and provided the COVID-19 vaccine upon admission, and as requested . Documentation related to the resident's COVID-19 vaccine will be documented in the resident's electronic medical chart . The CDC website (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html) titled COVID-19: Stay Up to Date with Vaccines, updated July 17, 2023, showed for everyone aged six years and older is up to date when they receive one updated COVID-19 vaccine. The website continued to show the updated vaccine became available September 2, 2022 for people aged 12 years and older.