Based on record review, observation, and interviews the facility failed to implement and maintain an infection prevention control program to help prevent the development and transmission of infection by failing to ensure staff donned proper Personal Protective Equipment (PPE), and performed proper hand hygiene during resident care for of 1 (#218) of 3 (#118, #121, and #218) residents whom required EBP (Enhanced Barrier Precautions). Findings: Review of the facility's policy with a revision date of 06/2024, and titled Isolation Precautions revealed the following, in part: Procedure: Gown and Glove Precautions-Hand Hygiene, Enhanced Barrier Precautions Skilled Nursing Facility 3. Indwelling medical devices may include urinary catheters. 4. EBP is employed when performing the following high-contact resident care activities: d. Providing hygiene f. Changing briefs or assisting with toileting g. Device care or use with indwelling medical devices Review of Resident #218's clinical record revealed an admission date of 03/12/2025 with diagnoses, which included Chronic Kidney Disease and Retention of Urine. On 03/17/2025 at 9:40 a.m., an observation was made of Resident #218's room door with EBP signage. Upon entrance to Resident #218's room an indwelling foley catheter was observed. On 03/18/2025 at 3:15 p.m., an observation was made of S5PCA performing catheter care for Resident #218. S5PCA entered the room, performed hand hygiene and applied gloves. S5PCA proceeded to gather her supplies and water, and placed them on Resident #218's bedside table. S5PCS opened the resident's dresser drawers for cleaning supplies, and then repositioned Resident #218. S5PCA then pulled down Resident #218's pants, opened her lightly soiled brief, and performed catheter care without donning a gown. Without removing dirty gloves and performing hand hygiene S5PCA continued. S5PCA then repositioned Resident #218 to expose her backside and cleaned her buttocks. S5PCA then with same gloves went into resident's dresser drawer and obtained a brief, she applied clean brief, repositioned Resident #218, and pulled up her pants, covered Resident #218 with bed linen, lowered her bed, and then removed gloves. On 03/18/2025 at 3:27 p.m., an interview was conducted with S5PCA following catheter care observation. She confirmed Resident #218 had an EBP sign on her door. She read the signage and stated when a resident had an EBP sign on their door staff were expected to don gloves and a gown prior to performing high contact tasks such as performing catheter care. S5PCA confirmed she did not don a gown prior to performing catheter care on Resident #218 and should have. S5PCA also confirmed she did not change her gloves nor perform proper hand hygiene when going from clean to dirty and should have. On 03/19/2025 at 10:15 a.m., an interview was conducted with S2DON. She stated she expected staff to properly don and doff PPE when a resident is on EBP. S2DON confirmed staff were required to don and doff gown and gloves and use proper hand hygiene when performing catheter care. S2DON confirmed Resident #218 had an indwelling foley catheter. S2DON was informed of the aforementioned observations. S2DON confirmed she expected staff to properly don a gown while performing catheter care. S2DON further confirmed the PCA should have changed gloves and performed proper hand hygiene when going from clean to dirty.

Based on observation, record reviews, and interviews, the provider failed to develop and implement a Comprehensive Person-Centered Care Plan to meet the needs of 4 (#1, #170, and #171, and #218) of 19 total sampled residents. The facility failed to: 1. Ensure Residents #1, #170, #171 were care planned for anticoagulant medication; 2. Ensure Resident #1 was care planned for antidepressant medication; and 3. Ensure Resident #218 was care planned for indwelling foley catheter. Findings: 1. Resident #1 Review of Resident #1's Clinical Record revealed an admission date of 03/13/2025 with diagnoses, which included Major Depressive Disorder, Anxiety Disorder, Angina Pectoris, and Hypertension. Review of Resident #1's active Physician Orders revealed, in part, an order dated 03/13/2025 for Lovenox 30 mg/0.3 mL subcutaneously once daily. Review of Resident #1's March 2025 Medication Administration Record (MAR) revealed Resident #1 received Lovenox 30mg/0.3 mL on 03/14/2025 through 03/19/2025. Review of Resident #1's current Comprehensive Plan of Care revealed no developed care plan or interventions for anticoagulant medication. Resident #170 Review of Resident #170's Clinical Record revealed an admission date of 03/03/2025, with diagnoses, which included Right Leg Pain, Unspecified Fall, and Back Pain. Review of Resident #170's active Physician Orders revealed, in part, an order dated 03/04/2025 for Lovenox 40 mg/0.4 mL subcutaneously once daily. Review of Resident #170's March 2025 Medication Administration Record revealed Resident #170 had received Lovenox 40mg/0.4 mL on 03/04/2025 through 03/19/2025. Review of Resident #170's current Comprehensive Plan of Care revealed no developed care plan or interventions for anticoagulant medication. Resident #171 Review of Resident #171's Clinical Record revealed an admission date of 03/03/2025, with diagnoses which included Diagnostic Heart Failure, Chronic Kidney Disease, and Presence of Artificial Hip Joint Bilaterally. Review of Resident #171's active Physician Orders revealed, in part, an order dated 03/04/2025 for Lovenox 30 mg/0.3 mL subcutaneously once daily. Review of Resident #171's March 2025 Medication Administration Record revealed Resident #171 had received Lovenox 30mg/0.3mL on 03/04/2025 through 03/19/2025. Review of Resident #171's current Comprehensive Plan of Care revealed no developed care plan or interventions for anticoagulant medication. 2. Review of Resident #1's active Physician Orders revealed, in part, an order dated 03/13/2025 for Lexapro 20 mg by mouth daily. Review of Resident #1's March 2025 Medication Administration Record (MAR) revealed Resident #1 had received Lexapro 20 mg on 03/14/2025 through 03/19/2025. Review of Resident #1's current Comprehensive Plan of Care revealed no developed care plan or interventions for antidepressant medication. 3. Review of Resident #218's Clinical Record revealed an admission date of 03/12/2025 with diagnoses, which included Chronic Kidney Disease and Retention of Urine. Review of Resident #218's active Physician Orders failed to reveal orders for indwelling foley catheter. Review of Resident #218's current Comprehensive Plan of Care revealed no developed care plan or interventions for indwelling foley catheter. Review of Resident #218's Physician's Progress Notes revealed, in part, the following: On 03/14/205, Chief Complaint/Clinical Background Resident #218 developed urinary retention and acute cystitis, and had a Foley catheter placed by Urology. Recent Acute Urinary Retention, complicated Cystitis without Hematuria: Resident #218 developed Urinary Retention after her fracture, prior to hospitalization and had foley catheter placed by Urology. Foley catheter to remain in place follow-up with Urology. On 03/18/2025, Plan Acute Urinary Tract Infection while completed antibiotic course. Asymptomatic. Foley placed. On 03/17/2025 at 9:40 a.m., an observation was made of Resident #218. Resident #218 was observed having an indwelling foley catheter. On 03/18/2025 at 10:41 a.m., an observation was made of Resident #218. Resident #218 was observed having an indwelling foley catheter. On 03/18/2025 at 1:32 p.m., an interview was conducted with S2DON. S2DON stated as a resident was admitted the Admit registered nurse would initiate the care plan from admitting diagnoses and problems. She stated all floor nurses were responsible for care plans. S2DON stated care plans were reviewed every shift by the floor nurse and a registered nurse reviewed a report daily to ensure the care plans were reviewed. S2DON further stated there was no one specifically going into the care plans to ensure the nurses' intervention were accurate. S2DON stated as floor nurses identified any problems or concerns they were expected to add the problem and interventions to the care plan when they were reviewing the resident's care plan every shift. S2DON confirmed a resident should be properly care planned with interventions for anticoagulants, antidepressants, and indwelling foley catheters. S2DON reviewed Residents #1, #170, and #171's current Comprehensive Plan of Care, and confirmed residents were care planned for anticoagulant medications. S2DON further confirmed Resident #1 was not care planned for antidepressant medication. S2DON reviewed Residents #218's current Comprehensive Plan of Care, and confirmed she was not properly care planned for indwelling foley catheter, and should have been.

Based on record reviews and interviews, the facility failed to ensure adequate monitoring for side effects with the use of psychotropic and anticoagulant medication was completed for 3 (#1, #170, and #171) of 5 (#1, #168, #169, #170, and #171) residents reviewed for unnecessary medications. The facility failed to ensure: 1. Resident #1 was monitored for side effects of an antidepressant medication; and 2. Residents #1, #170, and #171 were monitored for side effects of anticoagulant medications. This deficient practice had the potential to affect any of the 19 residents residing on the Skilled Nursing Facility unit. Findings: 1. Review of Resident #1's Clinical Record revealed an admission date of 03/13/2025, with diagnoses which included Major Depressive Disorder, Anxiety Disorder, Angina Pectoris, and Hypertension. Review of Resident #1's active Physician Orders revealed, in part, an order dated 03/13/2025 for Lexapro 20 mg by mouth daily. Review of Resident #1's March 2025 Medication Administration Record (MAR) revealed Resident #1 had received the medication on 03/14/2025 through 03/19/2025. There was no documentation of monitoring for antidepressant medication side effects for Resident #1 to review. 2. Resident #1 Review of Resident #1's active Physician Orders revealed, in part, an order dated 03/13/2025 for Lovenox 30 mg/0.3 mL subcutaneously once daily. Review of Resident #1's March 2025 Medication Administration Record revealed Resident #1 had received the medication on 03/14/2025 through 03/19/2025. There was no documentation of monitoring for anticoagulant medication's side effects for Resident #1 to review. Resident #170 Review of Resident #170's Clinical Record revealed an admission date of 03/03/2025, with diagnoses which included Right Leg Pain, Unspecified Fall, and Back Pain. Review of Resident #170's active Physician Orders revealed, in part, an order dated 03/04/2025 for Lovenox 40 mg/0.4 mL subcutaneously once daily. Review of Resident #170's March 2025 Medication Administration Record revealed Resident #170 had received the medication on 03/04/2025 through 03/19/2025. There was no documentation of monitoring for anticoagulant medication's side effects for Resident #170 to review. Resident #171 Review of Resident #171's Clinical Record revealed an admission date of 03/03/2025, with diagnoses which included Diagnostic Heart Failure, Chronic Kidney Disease, and Presence of Artificial Hip Joint Bilaterally. Review of Resident #171's active Physician Orders revealed, in part, an order dated 03/04/2025 for Lovenox 30 mg/0.3 mL subcutaneously once daily. Review of Resident #171's March 2025 Medication Administration Record revealed Resident #171 had received the medication on 03/04/2025 through 03/19/2025. There was no documentation of monitoring for anticoagulant medication's side effects for Resident #171 to review. On 03/18/2025 at 10:43 a.m., an interview was conducted with S6LPN. She stated she was the nurse for Residents #1 and #170. S6LPN reviewed Resident #1's MAR, and confirmed Resident #1 was currently on and Lexapro 20mg and Lovenox 30mg/0.3 mL. S6LPN reviewed Resident #170's MAR, and she confirmed she was currently on Lovenox 40 mg/0.4 mL. S6LPN stated the electronic software system did not have a place to document side effects for antidepressants nor anticoagulants. On 03/18/2025 at 11:00 a.m., an interview was conducted with S7LPN. She stated she was the nurse for Resident #171. S7LPN reviewed Resident #171's MAR, and confirmed Resident #171 was on Lovenox 30 mg/0.3mL. S7LPN confirmed Lovenox was a high risk medication for bleeding, and there was no place to document monitoring in the electronic software system. On 03/18/2025 at 1:32 p.m., an interview was conducted with S2DON. She stated she expected staff to document the monitoring for side effects of antipsychotic medications including antidepressants and of anticoagulant medications. S2DON stated there should be a pop-up box, which appeared when a nurse scanned an antidepressant medication which allowed the nurse to enter a note for monitoring side of effects. S2DON reviewed the electronic software system and stated it did not provide a pop-up box for nurses to document monitoring for side effects for of antidepressants, and it should have. S2DON confirmed there was no place to document monitoring for side effects of anticoagulant medications. S2DON reviewed Residents #1, #170, and #171's March 2025 MAR and Electronic Health Record, and confirmed there was no documentation of monitoring for side effects for Resident #1's antidepressant medication or documentation for Residents #1, #170, and #171's anticoagulant medications, and there should have been. S2DON further confirmed she could not provide any documentation of monitoring for side effects for Resident #1's antidepressant nor Residents #1, #170 and #171's anticoagulant medications.

Based on interviews and record reviews the facility failed to complete and transmit MDS assessments in the required timeframe for 3 of 3 (#7, #8, and #10) residents reviewed for resident assessment. Findings: Review of the MDS assessments were conducted with S4MDS on 04/30/2024 at 1:31 p.m., which revealed the following: Resident #7 was discharged from the facility on 12/08/2023. A discharge assessment was transmitted on 04/29/2024. Resident #8 was discharged from the facility on 12/08/2023. A discharge assessment was transmitted on 04/29/2024. Resident #10 was discharged from the facility on 12/29/2023. A discharge assessment was not completed nor transmitted. On 04/30/2024 at 1:31 p.m., an interview was conducted with S4MDS. S4MDS stated discharge assessments should be completed 14 days after the discharge was entered and transmitted 7 days after it was signed and completed. S4MDS confirmed the aforementioned discharge assessments were not completed and/or transmitted timely. On 04/30/2024 at 1:48 p.m., an interview was conducted with S1DON. S1DON was made aware of the aforementioned findings. S1DON stated she expects discharge assessments to be completed 1-2 days after discharge. She confirmed the discharge assessments should be transmitted within 7 days of the assessment completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure S5RN and S6PCA wore proper Personal Protective Equipment (PPE) while providing care for 1 (#116) of 2 (#116 and #170) residents with indwelling medical devices. Findings: Review of Resident #116's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Kidney Disease Stage V, Recurrent Nephrolithiasis Requiring Multiple Ureteral Stents, Jackson Pratt (JP) Drain Placement (03/28/2024) and Peripherally Inserted Central Catheter (PICC) to Right Upper Arm. On 04/29/2024 at 9:18 a.m., an observation was made of S5RN administering antibiotics intravenously through Resident #116's right upper arm PICC. S5RN did not don a gown while accessing Resident #116's PICC. On 04/30/2024 at 8:48 a.m., an observation was made of S6PCA assisting Resident #116 reposition in bed. S6PCA did not don a gown while assisting Resident #116 in bed. On 04/30/2024 at 9:01 a.m., an interview as conducted with S3MD. S3MD verbalized she was Resident #116's physician. S3MD confirmed Resident #116 had multiple indwelling devices. She confirmed Resident #116 was not on EBP. She stated she was not aware of CMS's policy for Enhanced Barrier Precautions for residents with indwelling devices. On 04/30/2024 at 9:14 a.m., an interview was conducted with S2IP. S2IP confirmed she was the facility's Infection Preventionist. She confirmed resident #116 was not on EBP. She confirmed the facility did not have a process in place to implement Enhanced Barrier Precautions for any residents. She stated she was unaware of CMS's policy for Enhanced Barrier Precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#67) of 17 residents reviewed in the initial screening for advanced directives. Review of the facility's policy titled Advance Medical Directives Nursing- B. If the patient has an AMD (Advance Medical Directive) and a copy is available, at any time during hospitalization: a. Place the copy of the AMD behind the face sheet in the patient's current medical record. b. Notify the physician of the presence of the AMD. C. Consult SW or House Supervisor (after hours) if: a. The patient has an AMD but a copy is not available. b. The patient has an AMD but would like to review/revise it. c. The patient would like to receive information about AMDs. Findings: Review of Resident #67's clinical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Left Hip Dislocation s/p revision. Review of the most current MDS revealed a BIMS of 14 which indicated Resident #67 was cognitively intact. Review of Resident #67's Physician Orders dated [DATE] revealed the following: [DATE]-Full Code. Review of Resident #67's Resuscitation Order Form dated [DATE] revealed the following: Do Not Resuscitate- Signed by Resident #67's physician. Review of Resident #67's Physician Progress Notes dated [DATE] revealed the following: Full Code On [DATE] at 8:55 a.m., an interview was conducted with S3RN. She reviewed the electronic medical record for Resident # 67 and said she is a full code. She reviewed the Physician Order on [DATE] and confirmed Resident #67 was a full code. She further reviewed the clinical record for Resident #67 and said she had an order for Do Not Resuscitate on the Resuscitation Order Form. She confirmed there was a discrepancy regarding Resident #67's code status and the order should have been changed in the computer and on the Physician Orders. On [DATE] at 09:00 a.m., an interview was conducted with S2DON. She verified the Physician Orders dated [DATE] revealed Resident #67's code status was a Full Code. She confirmed the Physician's Resuscitation Orders dated [DATE] indicated Resident #67's code status was Do Not Resuscitate. She confirmed there were discrepancies in Resident #67's code status in the electronic chart, Physician's Orders and the Physician's Resuscitation Orders. She said the facility did not have a process in place to double check advance directives. On [DATE] at 10:5a.m., an interview was conducted with Resident # 67. She said she wanted staff to perform CPR, but she did not want to be put on a machine if she was found to be brain dead. On [DATE] at 08:15 a.m., an interview was conducted with S1ADM. She said she expected the Physician Orders and the Physician's Resuscitation Orders to match. She said there was no process in place at the present time to ensure the resident's code status was followed.