**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents reviewed for PASRR requirements, (Resident #6). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of anxiety disorder, depression and psychotic disorder. The MDS included a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of the active diagnosis list in the clinical record revealed the following diagnosis: a. Alcohol use, unspecified with alcohol-induced psychotic disorder, unspecified b. Major depressive disorder c. Anxiety disorder Review of the MDS dated [DATE] revealed the following diagnosis: a. Anxiety disorder b. Depression c. Psychotic Disorder Review of the Physicians Progress Note signed and dated 4/16/25 included: a. Alcohol-induced psychotic disorder with delusions b. Generalized Anxiety Disorder c. Other specified depressive episodes Review of the PASRR dated 6/1/2017 lacked inclusion of psychotic disorder. The clinical record lacked an updated PASRR to include psychotic disorder. Interview on 4/29/25 at 1:47 p.m., with the MDS Coordinator revealed Resident #6 has not had any changes for a while and the diagnosis should have been on the PASRR. The facility does not have a policy and follows the guidelines for PASRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility record review and staff interviews the facility failed to assess and provide appropriate intervention to a left lumbar skin tear which resulted in a decline to cellulitis which required use of antibiotic for 1 out of 1 residents reviewed (Resident #39). The facility reported a census of 43 residents Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #39 documented diagnoses of anemia, hypertension, depression, and dementia. The MDS showed a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of the Braden Scale assessment dated [DATE] showed Resident #39 scored a 16 which indicated at risk for skin impairment. Review of the facility provided form named Non Decub Skin Condition Report revealed Resident #39 received a skin tear from a fall on 5/5/24 in the left lumbar region measuring 9.5 centimeters (cm) by 4.5 cm. The next entry of wound assessment was 5/12/24. Review of the Progress Notes for Resident #39 lacked documentation of wound assessments for the following date: 5/7/24, 5/8/24. Review of the Progress Notes for Resident #39 showed an order for Cephalexin 500 milligrams four times a day for five days. Review of the Treatment Administration Record (TAR) for Resident #39 for May 2024 failed to show wound treatments being completed daily for left lumbar region skin tear. Interview with DON on 5/15/24 at 11:48 AM reports the facility does not have a skin or pressure ulcer policy. Interview with DON on 5/15/24 at 4:00 PM revealed the expectation of the nursing staff regarding skin tears or skin issues would be to notify the doctor, initiate standard treatment order, request an order or treatment plan from the physician. The DON agreed the standard treatment should have been on the treatment sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility record review and staff interviews the facility failed to process and initiate medication orders until two days after the orders were received for 1 of 13 residents reviewed (Resident #22). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 documented diagnoses of heart failure, renal insufficiency and a history of malignant neoplasm of the bladder. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. 1. The Provider ' s written order dated and faxed 3/7/24 revealed Resident #22 ordered to receive Diflucan 150mg one time a week for three weeks. The Order Entry for Resident #22 showed the facility failed to enter the Diflucan order into the electronic orders until 3/9/24, two days after the order was received. The electronic order showed Diflucan was ordered for a yeast infection. Review of April and March 2024 Medication Administration Record (MAR) for Resident #22 revealed Resident #22 received the first dose of Diflucan on 3/10/24, three days after the order was received. 2. The Urology provider ' s written order dated and faxed 4/22/24 revealed Resident #22 ordered to receive Cipro (Cipromycin) 500 (milligrams) mg twice a day by mouth for 7 days. The Order Entry for Resident #22 showed the facility failed to enter the Cipro order into the electronic orders until 4/24/24, two days after the order was received. The electronic order showed Cipro was ordered for a urinary tract infection. Review of April and May 2024 Medication Administration Record (MAR) for Resident #22 revealed Resident #22 received the first dose of Cipro on 4/24/24, two days after the order was received. In an interview on 5/16/24 at 7:15 AM, Staff D (Licensed Practical Nurse) reported the practice of when orders are received via fax the orders are processed the same day, then doubled checked by the next shift, then tripled checked by the shift after that. Staff D reported when she entered the Cipro order on 4/24/24, Staff D didn ' t know why the order wasn ' t processed sooner. Staff D reported medications are usually started the same day as they are ordered. Staff D reported the pharmacy usually delivers medications the same day, or a staff member will retrieve the medication from the pharmacy. In an interview on 5/16/24 at 8:10 AM, the Director of Nursing (DON) reported that she expected staff to process orders the same day as orders are received. The DON reported medications are usually started on the same day as they are ordered. When asked if the Cipro and Diflucan orders should have been processed the same day as the order was received, the DON replied, absolutely, especially the antibiotic.The facility lacked a policy related to medication and processing of orders. The DON reported the facility followed standard practice but would provide a copy of the policy if she found a policy. No policy received during the survey.

3.Observation on 5/15/24 at 9:20 AM observed Staff C, LPN with wound care to buttocks. Resident #32 observed sitting on the couch and able to stand up with a walker. Staff C washed hands and applied gloves, with gloved hands Staff C opened up the mepilex and wrote the date on it with black permanent marker, Staff C placed the mepilex on the table. Staff C then removed gloves and applied new gloves, Staff C failed to do hand hygiene between changing gloves, Staff C proceeded to clean the buttock area. Staff C then removed gloves and applied new gloves, Staff C failed to do hand hygiene between changing gloves. Staff C placed mepilex on buttocks and helped Resident #32 pull up her pants. During interview on 5/15/24 at 9:20 AM Staff C stated she should have used the hand sanitizer in between changing gloves while doing wound care. Review of the undated facility provided policy titled Infection Control Program revealed the following information: The facility will investigate, control, and prevent infections in the facility; Staff will be educated, trained and monitored for proper hand washing as follows: When coming on duty. When hands are visibly soiled. Before and after assisting a resident with personal care(oral care, bathing etc.). Before and after changing a dressing. Based on observation, facility policy and staff interview, the facility failed to provide proper hand hygiene during incontinence care, wound care and medication administration with 3 of 3 residents (Resident #11, #13 and #32) observed. The facility reported a total census of 43 residents. 1. Observation on 5/15/24 at 10:10 AM Resident #13 showed during incontinence care Staff A, Certified Nursing Assistant (CNA) held the resident on her right side while Staff B, CNA cleansed urine and bowel movement from the resident ' s buttock. Staff B with soiled gloves assisted the resident onto her left side and held the resident in place while Staff A cleansed urine and BM from the other side of the buttock. Staff A replaced the soiled incontinence brief and removed soiled gloves. Staff A failed to perform hand hygiene, then placed her hands on the blankets to cover the resident. Staff B removed gloves, failed to perform hand hygiene, then placed a bag of soiled clothes into the garbage. Staff B retrieved the bag and placed the bag into a laundry receptacle. Staff B failed to perform hand hygiene, then touched the bed controls, call light device and assisted the resident with eye glasses. 2. Observation on 5/16/24 at 7:01 AM showed Staff D, Licensed Practical Nurse (LPN) administered artificial tears to Resident #11 then removed gloves, threw the gloves into the garbage, then placed her hands into her pants pocket without performing hand hygiene. In an interview on 5/16/24 at 8:10 AM, the DON acknowledged staff should remove gloves and perform hand hygiene after contact with urine and BM during incontinence care. In an interview on 5/16/24 at 9:28 AM, the Infection Preventionist (IP) agreed the staff should remove gloves then immediately perform hand hygiene after contact with urine, BM, bodily fluid or other potentially infectious material.