Based on observations and interview, the facility failed to maintain an effective infection prevention and control program by failing to ensure staff utilized appropriate personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) while administering medication and bolus tube feeding for 1 (#14) out of 1 (#14) resident sampled for tube feeding. Findings: On 06/17/2025, a review of the facility's policy titled, Enhanced Barrier Precautions (EBP's), with an effective date of 09/27/2024, read in part: Purpose: to ensure EBP's are implemented appropriately. Definitions: EBP's involve gown and glove use during high-contact resident care activities for residents known to be colonized with a MDRO (Multidrug Resistant Organism), as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). High-contact resident care activities include: .Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Review of Resident #14's electronic medical record revealed an admission date of 01/08/2025 with diagnoses which included, but were not limited to unspecified protein-calorie malnutrition and dysphagia oral phase. Review of Resident #14's physician's orders revealed orders written on 04/21/2025 - EBP, NPO***PEG (Percutaneous Endoscopic Gastrostomy) tube status, Jevity 1.5 cal liquid per PEG via gravity - give 400 ML (milliliters) per PEG TID (3 times a day), PEG tube water flushes at 150 ml per PEG via gravity every 4 hours and PEG Protocol. On 06/17/2025 at 6:16 a.m., an observation was made of S3LPN (Licensed Practical Nurse), administering medication and bolus feeding via PEG tube to Resident #14. S3LPN entered Resident #14's room and did not utilize a gown while administering his medication and bolus feeding. On 06/17/2025 at 7:17 a.m., an interview was conducted with S3LPN, she confirmed she did not use a gown while administering Resident #14's medication and bolus feeding per PEG tube. S3LPN confirmed she should have used a gown while providing care to Resident #14 because he was on EBP. During an interview with S2ICP (Infection Control Preventionist) on 06/17/2025 at 8:45 a.m., she confirmed a gown and gloves should be worn when administering medication and bolus feeding via PEG tube to residents on EBP.

Based on record review and interview, the facility failed to electronically submit accurate payroll information for direct care staffing as required. This deficient practice had the potential to affect 2 (#11 and #14) of the 2 (#11 and #14) residents residing in the facility. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year 2025, Quarter 2 (January 01 - March 31) revealed the following: -Failed to Submit Data for the Quarter -One star staffing rating, triggered. On 06/16/2025 at 4:14 p.m., during an interview with S1ADM (Administrator), she stated she had reported to the PBJ for the second quarter. Upon review of the documentation submitted, she confirmed the information she provided in April 2025 was for the dates ranging from 10/01/2024 to 12/31/2024. She confirmed the information that should have been submitted in April 2025 was for the dates ranging from 01/01/2025 to 30/31/2025, and further confirmed the required information was not submitted to the PBJ.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure clean bed linen was provided to 1 (#1) out of 1 (#1) residents investigated for environment. The sample resident size was 9. Findings: Review of Resident #1's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Candidiasis, Cerebral Infarction, Spastic Hemiplegia and Pressure Ulcer Sacral Region. On 07/23/2024 at 10:27 a.m., an observation was made of Resident #1's bedroom. The resident was not in his room, his bed was made. The resident's pillow case revealed 2 nickel sized, and 6 small dots of a dried brown colored stain. On 07/23/2024 at 11:40 a.m., a second observation of Resident #1's bedroom was conducted with S3CNA. S3CNA confirmed the resident's bed was made this morning and the pillow case had multiple brown stains on the pillow case. She confirmed the pillow case should have been changed when the bed was made. On 07/24/2024 at 12:45 p.m., an interview was conducted with S2DON, she confirmed stained bed linens should be changed, when found while making a bed.

Based on record review and interviews, the facility failed to ensure alleged violation of abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#11) out of 4 sampled residents. This had the potential to effect a census of 4 residents. Findings: Review of Resident #11's medical record revealed he was admitted to facility on 05/24/2023 with diagnoses that included in part: Right femur fracture, Unspecified Dementia, CVA, Abnormal Gait, Dysphagia and Alcohol Abuse. Review of Resident #11's MDS (Minimum Data Set) revealed the BIMS (Brief Interview for Mental Status) indicating a moderately impaired cognition. Review of the facility's resident grievance/theft-loss report, revealed Resident #11 had grievance dated 06/05/2023 at 3:21 p.m., with subject report of disrespect and physical harm. Further review of the grievance report revealed the allegation of physical harm was not reported to the State Survey Agency. On 08/22/2023 at 3:35 p.m., and interview was with S6RN, SNF coordinator, she reported she did recall an incident of the abuse allegation for Resident #11. She reported she was made aware of the allegation when she returned to work on Monday, as resident had informed CNA on the Saturday before. She stated she had spoken with the resident and asked him to give her the details of what happen. She stated she did ask him who the CNA was, he could only describe her, did not know her name. She reported she had told him if he saw the person or something happened again to be sure to tell a nurse, at that time. She stated she had spoken to him daily for several days, to ask if he had seen the person and each time he told her no. She said for about a week, she would ask the nurses if Resident #11 had reported any concerns to them and each time the answer was no. She reported all residents on that unit were interviewed to see if they had witnessed or had been abused by a staff person, an all other residents denied any issues. She stated she did do a full body assessment on resident #11 on the Monday she was informed of the incident and did not identify any signs of abuse. On 08/22/2023 3:45 p.m., an interview was conducted with S7RN, she reported that on 06/04/2023 she was the evening supervisor, and as she was leaving, S8CNA, approached her at the exit door and stated she might have something to tell her about Resident #11. She informed S8CNA, she was off work and there was an RN on duty she could talk to about any resident concerns. She stated when she returned to work the next day, she had inquired about if anyone had gotten a report from S8CNA about something, and no one knew anything about it. She went to S8CNA to find out if she had reported her concern from the night before to the RN and she stated she had not. S7RN observed Resident #11 sitting alone at a table in the dining room area. She stated she walked over to him and asked him if he had any concerns he would like to talk to her about. She stated he began to tell her what happened. After she had finished getting his story, she began an investigation, and obtained witness statements. On 08/22/2023 at 4:03 p.m., during an interview with S1ADM, she stated she had spoken to state office, to get access for reporting critical incidents. She stated as of 08/14/2023 she did not have access, so she sent an email again and did not get a response until 08/22/2023, but still had no access to reporting critical incidents. She reported she had been the administrator since April 2022 and that she had not applied for critical incident reporting until June 9th, 2023.

Based on record reviews and interviews, the facility failed to ensure Agency CNA's (Certified Nursing Assistant's) completed annual in-service training including Dementia, Resident Rights, Infection Control, and Abuse/Neglect/Exploitation for 3 (S2CNA, S3CNA, S4CNA) out of 4 sampled Agency CNA's personnel files reviewed. Findings: Review of S2CNA's personnel file revealed a first start date at the facility of 09/26/2022. Further review of personnel file revealed no education verification provided for Dementia training, Resident Rights, Infection Control or Abuse/Neglect/Exploitation. Review of S3CNA's personnel file revealed a first start day at the facility of 08/10/2023. Further review of personnel file revealed no education verification provided for Dementia training, Resident Rights, Infection Control or Abuse/Neglect/Exploitation. Review of S4CNA's personnel file revealed a first start day at the facility of 03/04/2023. Further review of personnel file revealed no education verification provided for Dementia training, Resident Rights, Infection Control or Abuse/Neglect/Exploitation. Review of the facility's monthly in service trainings signage sheets failed to reveal S2CNA and S4CNA completed monthly trainings for Resident Rights in February 2023, Abuse/neglect/Exploitation in March 2023, and Dementia training in Month 2023. On 08/22/2023 at 4:30 p.m., during an interview with S1ADM, she confirmed she had no additional in-service trainings for the unlicensed agency staff.