Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the transmission of communicable diseases and infections within the facility on one unit (Unit One) out of a total of two units affecting two Residents (Residents #3 and #6). Specifically, the facility failed to ensure that Personal Protective Equipment (PPE) used to touch surfaces in a resident's environment who had an active COVID-19 (a highly contagious respiratory disease) infection was changed in accordance with professional standards of practice prior to touching surfaces in another resident's environment who was not infected or was recently recovered with COVID-19 placing the non-infected resident at increased risk of contracting COVID-19 infection. Findings include: Review of the undated facility policy titled Transmission Based Precautions indicated the following: -When cohorting (placing residents who have the same infection in a room together) is not achievable, it is very important to consider . the roommate is a high risk for becoming infected Review of the facility policy titled Transmission Based Precautions, dated 8/8/23, indicated the following: -For some diseases that have multiple routes of transmission (e.g. SARS-CoV-2 [the virus that causes COVID-19]) more than one transmission-based precaution category may be used. -This will be determined by guidance from regulatory agencies such as CDC [Center for Disease Control and Prevention], DPH [Department of Public Health] and CMS [Centers for Medicare and Medicaid Services]. Review of the CDC guidance titled Infection Control Guidance: SARS-CoV-2, dated 6/24/24, indicated the following: -HCP [healthcare providers] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH approved particulate respirator with N95 filters or higher [a mask that provides protection from small particles or viruses in the air], gown, gloves, and eye protection Review of the DPH Memorandum to Long-Term Care Facilities titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 5/10/23, indicated the following: -Appendix A: Personal Protective Equipment Used When Providing Care to Resident's in Long Term Care >COVID-19 Positive Residents Recommended Staff PPE: -Full PPE upon entering room to include .gown and gloves if there is any contact with potentially infectious material. -Gown and gloves must be changed between residents. Resident #3 was admitted to the facility in September 2023, with diagnoses including Type 2 Diabetes ((long-term condition where the pancreas is unable to produce enough insulin to regulate blood glucose [sugar] levels resulting in higher than normal blood sugar levels) and Chronic Kidney Disease, Stage 3 (mild to moderate loss of function in the kidneys causing impairment to the body's ability to remove waste and extra fluid from the blood). Review of Resident #3's medical record indicated the Resident tested positive for COVID-19 on 10/8/24. Review of Resident #3's October 2024 Activities of Daily Living (ADL: tasks required to care for oneself daily including transferring in and out of bed, eating, grooming, using the toilet, etc.) flow sheet indicated: -the Resident required set-up or clean-up assistance for eating. Review of Resident #3's Physician orders indicated the following: -an order to maintain Isolation Precautions (measures used to reduce transmission of microorganisms in healthcare and residential settings), initiated 10/8/24 with no stop date Resident #6 was admitted to the facility in January 2022, with diagnoses including Neoplasm (tumor or abnormal growth of cells) of the Brain and Cellulitis (potentially serious bacterial infection that affects the deep layers of the skin and underlying tissues of the skin) of the Left Lower Limb. Review of Resident #6's vaccination history indicated no vaccination for COVID-19 had been received. Review of Resident #6's medical record indicated he/she had not tested positive for COVID-19 during the Unit One outbreak period of 9/27/24 through 10/16/24 or the preceding 30 days. Review of Resident #6's medical record indicated that he/she was at risk for respiratory distress related to Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs). Review of Resident #6's October 2024 ADL flow sheet indicated: -the Resident was independent for eating Review of the Isolation Droplet/Contact Precautions sign hanging outside Resident #3 and #6's room indicated the following: -In addition to Standard Precautions (infection prevention measures that apply to all resident care, regardless of suspected or confirmed infection status) staff and Providers must: >gown: change between each resident >gloves: change between each resident During a meal tray pass on 10/16/24 at 12:34 P.M., the surveyor observed CNA #1 wearing an N95 mask, gown, gloves and goggles enter the room of Resident #3 and Resident #6. CNA #1 was observed to be handed the meal tray for Resident #3 and proceeded to set up the meal tray for Resident #3. CNA #1 returned to the room doorway and was handed the meal tray for Resident #6 and then proceeded to set up the meal tray for Resident #6 including touching cups and dishes as she removed the dish and cup covers and the plate warmer without removing or changing the gown and gloves used to set up and touch items on Resident #3's meal tray. During an interview on 10/16/24 at 12:38 P.M., CNA #1 said that Resident #3 was positive for COVID-19 and Resident #6 was negative for COVID-19. CNA #1 said she had set up Resident #3's tray touching Resident #3's overbed table while wearing the gown and gloves and then using the same gown and gloves to set up Resident #6's tray and should not have. CNA #1 further said she should have set up Resident #6's meal tray first and then set up Resident #3's meal tray to prevent the potential cross-contamination. During an interview on 10/16/24 at 2:05 P.M., the Director of Nursing (DON) said the expectation for meal tray pass in a room with one resident who has COVID-19 and one who is negative for COVID-19 would be that the staff member would put on the required PPE, serve the negative resident first and then serve the positive resident. The surveyor reviewed the observation of CNA #1 with the DON and the DON said CNA #1 should not have served Resident #3 and then Resident #6 due to the potential for cross-contamination.

Based on observation, interview, record and policy review, the facility failed to provide care consistent with professional standards of practice relative to ensuring interventions ordered and/or recommended for the treatment of an existing wound were implemented for one Resident (#73) of two applicable residents with pressure ulcers reviewed, out of a total sample of 18 residents, with a pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure to the skin). Specifically, the facility failed to ensure that: 1. A specialty (pressure reducing) mattress was at the correct setting as ordered by the Physician, 2. Pressure relief devices (heel booties) were implemented as ordered by the Physician, 3. Recommendations from the Wound Physician for lab work were reviewed by the facility staff for implementation. Findings include: Review of the facility policy Skin Management Program, revised 6/13/19, indicated the purpose was to minimize the development of any type of ulcers and other skin issues through the systemic and regular inspection of the resident's skin, and to ensure early detection and intervention for all skin problems. The policy also included the following: -A care plan will be developed and implemented, and revised as necessary -Additional measures may be taken to protect bony prominences of bedfast or chair bound residents. These measures include the use of heel and elbow protectors . Resident #73 was admitted to the facility in July 2024, with diagnoses including Myasthenia Gravis (chronic autoimmune disease that causes weakness in voluntary muscles by disrupting with communication between the nerves and muscles), Diabetes (condition in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood), limitation of activities due to a disability, and presence of pressure ulcer of the sacral area (triangular bone in the lower back situated between the two hipbones of the pelvis). Review of the Pressure Ulcer Risk Care Plan, initiated 7/31/24, indicated Resident #73 was admitted to the facility with a sacral ulcer and included the following intervention: -Air (specialty) mattress as ordered (initiated 7/31/24) Review of the Minimum Data Set (MDS) Assessment, dated 8/6/24, indicated Resident #73: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of 15 -had bilateral range of motion deficits of the lower extremities -had a Stage 3 Pressure Ulcer (full thickness loss of skin that extends to the deepest layer of skin made up of fat and connective tissue) that was present on admission Review of the September 2024 Physician's orders included the following: -May refer to Wound Physician, initiated 7/31/24 -Specialty air mattress set at 200 pounds (lbs.), ensure proper setting every shift, 8/16/24 -Booties to bilateral lower extremities, every shift, initiated 8/31/24 -Weekly weights, initiated 9/10/24 Review of the Wound Physician Evaluations, dated 8/6/24 through 9/10/24 included the following recommendations: -8/6/24: Recommend Glycosylated Hemoglobin level (HgbA1c: protein that forms when glucose in the blood sticks to hemoglobin molecules in red blood cells and shows blood sugar regulation over 2-to-3-month period of time), -8/13/24: Recommend PreAlbumin level (measurement of protein in the blood) and HgbA1c level, -8/20/24: Recommend PreAlbumin and HgbA1c levels, -8/27/24: Recommend PreAlbumin and HgbA1c levels, -9/3/24: Recommend HgbA1c level, PreAlbumin was obtained on 8/28/24 (15 days after it was originally recommended), -9/10/24: Recommend HgbA1c level Review of Resident #73's clinical record indicated: -No documented evidence that the Wound Physician's recommendation to obtain a HgbA1c level was addressed by the facility or that a level was drawn since the original recommendation was made on 8/6/24. -Last obtained weight was 173.6 lbs. on 9/12/24 On 9/16/24 at 2:45 P.M., the surveyor observed Resident #73 lying in bed with his/her feet pressed against the foot board of the bed. On 9/18/24 at 2:17 P.M., the surveyor observed the Resident lying in bed watching television. A specialty mattress was in place and was observed to be set at 150 lbs. The surveyor did not observe evidence of booties to his/her lower extremities. On 9/19/24 at 9:00 A.M., the surveyor observed Resident #73 lying in bed with a specialty mattress in place that was set to 150 lbs. The surveyor further observed that the Resident did not have booties on his/her lower extremities and a pillow was placed under his/her calves. On 9/19/24 at 10:15 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 assisting another CNA with the Resident's care. The privacy curtain was partially drawn, and the surveyor observed the Resident's bare feet resting on the bed. The surveyor observed the Resident was seated in a wheelchair and was assisted by the staff to the shower room. During an interview on 9/19/24 at 10:29 A.M., CNA #1 said Resident #73 required assistance with activities of daily living (ADL: activities of personal care which include bathing, dressing, personal hygiene) and transfers. CNA #1 said the Resident has a wound on his/her bottom and utilized a specialty mattress which the Nurses monitor for function. CNA #1 said the Resident required frequent positioning and had pillows placed under his/her arms and legs. When the surveyor asked if booties were utilized for the Resident's feet, CNA #1 said she was unaware of any booties for the Resident's feet. The CNA was observed to look in the Resident's room and said she did not see any booties for the Resident. During an interview on 9/19/24 at 10:36 A.M., Nurse #1 said the Resident's specialty mattress was set by his/her weight and was monitored every shift by the Nurses to ensure it was at the correct setting. Nurse #1 said the Resident also had an order for booties to be worn. At the time, the surveyor and Nurse #1 observed the Resident's room (the Resident not in the room) and the specialty mattress remained set to 150 lbs. After reviewing the Physician's order for the mattress, Nurse #1 said the specialty mattress should be set to 200 lbs. and not 150 lbs. Nurse #1 said she was not sure about the booties for the Resident's lower extremities, but if the Resident had refused them and another intervention was put into place, it should be documented in the Resident's clinical record. Review of the September 2024 Medication Administration Record (MAR) with Nurse #1, indicated the following were signed off as administered every shift from 9/1/24 through 9/19/24 7:00 A.M. to 3:00 P.M. [Day], 3:00 P.M. to 11:00 P.M.[Evening], and 11:00 P.M. and 7:00 A.M.[Night] shifts: -Specialty air mattress set at 200 pounds (lbs.), ensure proper setting every shift -Booties to bilateral lower extremities, every shift, initiated 8/31/24 There was no documented evidence in the clinical record that the Resident had refused the Physician ordered interventions (booties and air mattress) with the only exception on 9/4/24 on the 7:00 A.M. to 3:00 P.M.[Day shift] when it was documented that the Resident did not want the booties to be put on. During an interview on 9/19/24 at 11:32 A.M., the Assistant Director of Nurses (ADON) said she completes wound rounds with the Wound Physician weekly on Tuesdays, and she documents the measurement of the wounds and any recommendations for care made at that time. The ADON said the recommendations made by the Wound Physician would be relayed to the Resident's Physician and would be documented in the clinical record. The ADON said the Physician does not usually decline recommendations made by the Wound Physician. During an interview on 9/19/24 at 12:00 P.M., the Corporate Nurse said there was a problem with how Resident #73's recommendations from the Wound Physician were relayed to the facility staff. The facility staff were unable to provide evidence that the recommendation for the HgbA1c lab work was addressed by the Physician prior to survey exit.

Based on observation, interview, record and policy review, the facility failed to ensure that Transmission Based Precautions (TBP: used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) were implemented for one Resident #65, out of a total sample of 18 residents. Specifically, the facility staff failed to reduce the potential spread of infection by ensuring that Contact Precautions (precautions intended to prevent transmission of infectious agents which are spread by direct and indirect contact with the patient or the patient's environment) were followed relative to the use of the required personal protective equipment (PPE) for Resident #65 who was diagnosed with and was actively being treated for an infection. Findings include: Review of the facility policy titled Transmission-Based Precautions, revised 8/8/24, indicated the following: -Transmission Based Precautions will be initiated for known or suspected infections for which there are active symptoms, and the route of transmission is known. -TBP categories used in facilities are Droplet Precautions and Contact Precautions .may be used either singly or in combination. Standard Precautions are used in addition to the Transmission-Based Precaution implemented. Review of the Centers for Disease Control and Prevention (CDC) website cdc.gov, titled Precautions to Prevent Transmission of Infectious Agents, indicated the following relative to Contact Precautions: -Application of Contact Precautions for patients infected or colonized with MultiDrug Resistant Organisms (MDROs: microorganisms or bacteria that are resistant to one or more classes of antimicrobial agents) -Healthcare personnel caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. -Donning (putting on) PPE upon room entry and discarding before exiting the room .especially for those who have been implicated in transmission through environmental contamination (for example: Vancomycin-Resistant Enterococcus or VRE: bacteria resistant to some powerful antibiotics and are usually spread from person to person through contact with infected people). Review of the Contact Precaution Signage (CDC and utilized by the facility) included the following: >Stop. Contact Precautions. >Everyone Must: -Cleanse their hands, including before entering and when leaving the room. -Put on gloves before room entry. Discard gloves before room exit. -Put on gown before room entry. Discard gown before room exit. -Do not wear the same gown and gloves for the care of more than one person. -Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Resident #65 was admitted to the facility in August 2024, with diagnoses including left hip joint replacement and cellulitis (potentially serious bacterial infection that affects the deep layers of the skin and underlying tissues). Review of Resident #65's Urinary Tract Infection Care Plan, initiated 9/12/24, indicated the Resident currently had a Urinary Tract Infection and included the following interventions initiated on 9/12/24: -Administer antibiotic therapy as ordered -Maintain Contact Precautions for VRE in the urine Review of the September 2024 Physician's orders included the following: -Maintain Contact Precautions every shift, initiated 9/12/24 -Macrobid (antibiotic) 100 milligrams (mg) every 12 hours, initiated 9/13/24 On 9/18/24 at 11:46 A.M., the surveyor observed a Contact Precaution sign outside of Resident #65's room and a bin containing PPE including gowns and gloves. The surveyor observed that the Resident's call light was initiated and the Resident was seated in a wheelchair next to his/her bed. At 11:48 A.M., the Social Worker (SW) was observed to knock and enter the Resident's room, without donning a gown or gloves. The SW remained in the Resident's room for a short time and was observed to exit the room. During an interview on 9/18/24 at 11:48 A.M., the SW said she responded to Resident #65's call light and that the Resident had requested a snack. The SW said she did not put on a gown or gloves prior to entering the Resident's room. The SW said she was aware that the Resident was on Contact Precautions, but she did not have any contact with the Resident so she was not required to put on PPE. After the interview, the surveyor observed the SW retrieve the requested snacks from the unit kitchenette and re-enter the Resident's room a second time without donning the required PPE indicated on the signage posted at the doorway. During an interview on 9/18/24 at 12:52 P.M., the Infection Preventionist (IP) approached the surveyor and said education was provided to the SW about the requirements for Contact Precautions and the required PPE for Resident #65. The IP said all staff should be performing hand hygiene and putting on a gown and gloves prior to entering a Contact Precaution Room per the instructions on the signage. The IP said she thought there was confusion about the different Precaution signage utilized in the facility and that she would have to complete ongoing education with the facility staff.

Based on interview, record and policy review, the facility failed to implement updated timing guidance for Pneumococcal Vaccinations and ensure that Pneumococcal Vaccinations were offered and administered as consented to for three Residents (#62, #46 and #6), of 5 applicable residents reviewed, out of a total sample of 18 residents. Specifically, the facility failed to: 1. Ensure the facility policy relative to Pneumococcal Vaccination was reviewed and updated to include current Centers for Disease Control and Prevention (CDC) guidance. 2. For Resident #62, afford the opportunity to consent to or decline the Pneumococcal Vaccine when the Resident was admitted to the facility. 3. For Resident #46, administer the most up-to-date Pneumococcal Vaccine when he/she was eligible and had given consent. 4. For Resident #6, administer the most up-to-date Pneumococcal Vaccine when he/she was eligible and had given consent. Findings include: Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to 65 years (cdc.gov), dated 3/1/24, indicated the following: -For adults 65 and over who have not had any prior Pneumococcal Vaccines, then the patient and provider may choose Pneumococcal Conjugate Vaccine (PCV) 20 or PCV15 (Pneumococcal Conjugate Vaccine 15-valent: vaccine used to protect against 15 types of pneumococcal bacteria that commonly cause serious infections in adults), followed by Pneumococcal Polysaccharide Vaccine (PPSV) 23 one year later. -For adults 65 and over who have had Pneumococcal Conjugate Vaccine 13 (PCV13) and PPSV23 and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the PCV20. 1. Review of the facility Immunization of Residents Policy, dated 8/2017, included the following: -All eligible residents will be offered the pneumococcal vaccines unless medically contraindicated. -Education will be provided on the pros/cons of the vaccine prior to administration. There is a right to refuse the vaccination. -Each resident/representative will be asked on admission if they have previously had the PPSV23 or PCV13 vaccine and their age at the time of the vaccination, and for the records also used to determine vaccination status. -If no prior evidence of vaccination, the PCV13 will be offered per the Physician discretion, education will be provided on the pros/cons of the vaccine and the right to refuse -The PPSV23 will then be offered one year later. If one or more doses of PPSV23 have been previously received, the PCV13 will be offered one year after the last PPSV23 dose. During an interview on 9/18/24 at 10:04 A.M., the surveyor and the Infection Preventionist (IP) reviewed the facility's policy for Immunization of Residents. The IP said she was not aware if there was an updated policy but she would look into the matter. The IP said she used the CDC Vax Tracker Tool when determining if Pneumococcal Vaccinations were due for the facility residents. During a follow-up interview on 9/18/24 at 10:51 A.M., the IP provided the surveyor with a signature page indicating the facility policies were reviewed by the medical team, including the Medical Director on 6/4/24. The IP said she had asked about the updated guidance for the Pneumococcal Vaccines and was waiting for an updated policy. During an interview on 9/19/24 at 11:53 A.M., the IP said the facility was working on a new policy for the Pneumococcal Vaccination. The facility did not provide an updated Pneumococcal Vaccination policy to the survey team by survey exit. 2. Resident #62 was admitted to the facility in March 2024, and was over the age of 65. Review of the CDC Vax Finder Tool indicated Resident #62 was eligible to receive the PCV20 vaccine at the time of admission. Review of Resident #62's clinical record indicated no documented evidence that he/she was offered and had the opportunity to consent or decline the Pneumococcal Vaccine. During an interview on 9/18/24 at 11:26 A.M., the IP said there was no vaccine consent or declination form completed upon admission for Resident #62 and there should have been. During a follow-up interview on 9/18/24 at 12:50 P.M., the IP said she obtained consent from Resident #62's Responsible Party to receive the PCV20 vaccination. 3. Resident #46 was admitted to the facility in August 2023, and was over the age of 65. Review of the CDC Vax Finder Tool indicated Resident #46 was eligible to receive the PCV20 vaccine. Review of Resident #46's clinical record indicated the Resident's Representative consented for him/her to receive the Pneumococcal Vaccine (including the PCV20) on 8/11/23. Further review of the clinical record indicated no documented evidence that the PCV20 vaccine was administered to Resident #46 after consent was obtained. 4. Resident #6 was admitted to the facility in July 2020, and was over the age of 65. Review of the CDC Vax Finder Tool indicated Resident #6 was eligible to receive the PCV20 vaccine. Review of Resident #6's clinical record indicated the Resident's Representative consented for him/her to receive the Pneumococcal Vaccine (specifically the PCV20) on 10/20/23. Further review of the Resident's clinical record indicated no documented evidence that the PCV20 vaccine was administered after consent was obtained. During an interview on 9/18/24 at 10:04 A.M., the IP said Pneumoccal Vaccines were reviewed with Residents or their Responsible Party upon admission. The IP said she uses the CDC Vax Tracker Tool to determine which Pneumococcal Vaccine should be offered, and if eligible, she would provide education on the vaccine and ensure that a consent or declination was obtained. During a follow-up interview on 9/18/24 at 11:26 A.M., the IP said consents for the PCV20 vaccines had been previously obtained for Residents #46 and #6, but the PCV20 vaccines had not been administered and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the oral assessment, a part of the Minimum Data Set (MDS) assessment, was accurately coded for one Resident (#61) out of a total sample of 18 residents. Findings include: Resident #61 was admitted to the facility in 2015. On 8/4/21 at 8:51 A.M., the surveyor observed Resident #61's teeth to be discolored with multiple missing and broken teeth. Review of the Oral assessment, dated 11/2/20, indicated Resident #61 had obvious or likely cavities or broken natural teeth. Review of the Annual MDS, dated [DATE], indicated no oral or dental concerns in Section L: -Oral/Dental Status During an interview on 8/9/21 at 11:23 A.M., Unit Manager #1, formerly the MDS coordinator, said that based on the oral assessment, the MDS dated [DATE] was incorrectly coded.

Based on document review, observation and interview, the facility failed to maintain infection control practices during a medication pass, impacting one Resident (#35), out of a total of eight residents observed. Findings include: Review of the Blood Glucose Monitoring Systems manufacturer's guidelines indicated the following: -The meter should be cleaned and disinfected after use on each patient. -Disinfecting procedure is needed to prevent the transmission of blood borne pathogens. On 8/4/21 at 3:38 P.M., the surveyor observed the medication pass and observed Nurse #1 perform a Finger Stick Blood Sugar (FSBS) on Resident # 20. After she completed the FSBS, she placed the glucometer on top of her medication cart. Nurse #1 then performed a FSBS on Resident #35 without disinfecting the glucometer in between the two residents. During an interview on 8/4/21 at 3:55 P.M., the surveyor asked Nurse #1 the facility's procedure for disinfecting the glucometer. Nurse #1 said she would have to ask someone because she had never disinfected the glucometer before. During an interview on 8/4/21 at 3:59 P.M., Unit Manager #1 said the glucometer needed to be disinfected after use on each resident.

Based on policy review, document review and interview, the facility failed to implement an Antibiotic Stewardship Program. Findings include: Review of the facility's Antibiotic Stewardship policy, dated 11/19/17, included the following: -Antibiotic will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. -The Infection Prevention Program Coordinator (IP) has the role to inform the team of strategies to improve antibiotic use. This is done though tracking of antibiotic starts, and monitoring adherence to evidence-based criteria (McGeers). -Improvement in the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection .and implementing an antibiotic review process known as antibiotic time out. This review will provide the clinician with an opportunity to reassess the ongoing need for and choice of an antibiotic . During an interview on 8/5/21 at 10:08 A.M., the IP reviewed the Antibiotic Surveillance Tracking Form, and showed the surveyor the tracking forms for the month of April 2021, May 2021 and June 2021. The tracking forms indicated the following: -April 2021: the McGeers Criteria was not met 4 out of 17 times and the antibiotic time out was not done 10 out of 17 times. -May 2021: the McGeers Criteria was not met 5 out of 11 times and the antibiotic time out was not done 3 out of 11 times -June 2021: the McGeers Criteria was not met 7 out of 11 times and the antibiotic time out was not done 4 out of the 11 times The surveyor asked the IP nurse to explain the antibiotic time out. She said that 72 hours after a resident started an antibiotic the nurse was supposed to call the Physician and ask if they would like to continue the use of the antibiotic. Then the surveyor asked the IP nurse to explain the McGeers Criteria. The IP nurse said before the nurse called the Physician, they were supposed to complete the McGeers Criteria, an assessment tool, to ensure the resident had signs and symptoms of an infection. The surveyor then asked what was done with the information after the data was collected, and the tracking form indicated the nurses had not followed the protocols. The IP nurse said she had not really done anything with it except some informal individual education. During an interview on 8/5/21 at 11:00 A.M., the Director of Nurses (DON) said that she was aware that the McGeers Criteria had not been followed and had developed a Performance Improvement Plan, but had not initiated it because she had not had the opportunity to review it with the Medical Director. The DON said she was not aware that the antibiotic time out was not being done.