Based on observation, interview, and record review, the facility failed to adhere to infection control procedures during a wound dressing change for one Resident (#26) of a sample size of 22 residents. Findings include: The surveyor was provided as the facility policy the form titled Competency Assessment Dressing, Dry/Clean, dated 2018, which indicated but was not limited to the following: -The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. -Verify that there is a physician's order for this procedure. -Assemble the equipment and supplies needed. Date and initial all bottles and jars upon opening (unless product is single use). Wipe nozzles of wound cleanser with alcohol wipe or facility disinfected wipe. -Explain procedure to resident and provide privacy. -Clean bedside stand. Establish a clean field. -Place the clean equipment on the clean field. -Wash and dry your hands thoroughly. -Put on a clean gloves. Loosen tape and remove soil dressing. -Pull glove over dressing and discard into plastic or biohazard bag. -Wash and dry your hands thoroughly. -Open dry, clean dressing by pulling corners of exterior wrapping outward, touching only the exterior surface. -Using clean technique, open other products (i.e., prescribe dressing; dry, clean gauze.) -Wash and dry your hands thoroughly. -Put on clean gloves. -Cleanse the wound with the ordered cleanser. If using gauze use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually from the center outward). -Use dry gauze to pat the wound dry. -Apply the ordered dressing and secure with tape or boarded dressing per order. -Discard disposable items into designated container. Resident #26 was admitted to the facility April 2024 with diagnoses which included: Left heel pressure wound and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 4/8/24, indicated Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated he/she had moderate cognitive impairment. Further review of Section M: Skin Conditions of the MDS assessment indicated the Resident had a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers/injuries on admission and was receiving care and treatment for the areas. Review of current physician orders indicated but was not limited to the following: -Left heel: cleanse with wound wash, pat dry followed by (f/b) calcium alginate, f/b abdominal gauze (ABD) pad, and stretch wrap daily for wound care, effective 5/2/24. On 7/3/24 at 1:20 P.M., the surveyor observed Nurse #3 perform a dressing change on Resident #26's left heel and made the following observations: -Nurse #3 transferred Resident #26 into bed. -Nurse #3 washed hands and donned a pair of gloves. -Nurse #3 set up the following supplies on the over bed tray table, which she did not clean the table or and/or establish a clean barrier: a. Opened the ABD pad and placed it on the outside of the package, with a portion of it in contact with overbed tray table. b. Removed a small stack of gauze pads from the package and placed directly on the over bed tray table. c. Calcium alginate which remained on the inside of the package, uncut. d. Placed a pair of scissors on the over bed tray table. e. Placed a bottle of wound cleanser, not labeled, or dated. -Nurse #3 pulled the bedside curtain partially closed leaving the Resident's feet and affected heel visible from the hallway and the door to the room was open. -Nurse #3 was then observed using the scissors to cut off the old dressing that was on the Resident's left heel and then placed the scissors on the bed side table. -Nurse #3 sprayed the gauze with wound cleaner and cleaned the wound. -Nurse #3 changed her gloves but did perform hand hygiene. -Nurse #3 used the same scissors which were used to cut off the dirty dressing to cut a small piece of the calcium alginate to size without cleaning them. Nurse #3 then placed the trimmed piece of calcium alginate on the wound, applied the ABD pad, wrapped the ankle, and applied a dated piece of tape. During an interview on 7/3/24 at 2:20 P.M., the Director of Nurses (DON) said her expectations are the nurse would wear the appropriate personnel protective equipment (PPE), prepare the supplies, and have a clean barrier or sanitize the surface, and provide full privacy to the resident during the dressing change. She said the nurse is expected to wash her hands and change gloves before starting the dressing change, and after removing dirty dressing, and before cleaning the wound and applying the new dressing. The DON said she would also expect the nurse to clean the scissors after being used to remove the old dressing, before cutting the calcium alginate to size. The DON said the nurse did not follow protocol.

Based on record review, interview, and policy review, the facility failed to ensure residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic medications prior to their use for one Resident (#50), out of a total sample of 22 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Use Consent, effective date 11/17, indicated but was not limited to: - Prior to administering psychotropic medication the prescriber will discuss with the resident or resident representative the reason for prescribing the medication, dosage, anticipated effects of the drug therapy and the most commonly noted side effects. The discussion may take place by phone. - At the time of the discussion, or thereafter, but prior to the administration of the prescribed medication a facility representative must complete (for each medication) the Informed Consent for Psychotropic Administration form. This included obtaining all required signatures. - Written consent must be obtained each time a new prescription is ordered and renewed once a year. Resident #50 was admitted to the facility in August 2020 with diagnoses which included unspecified dementia without behavioral disturbance and major depressive disorder. Resident #50's Health Care Proxy was invoked on 9/23/2020. Review of Resident #50's discontinued Physician orders, dated 10/13/2021 through 2/28/2023, indicated an order for: - Trazodone (anti-depressant) 25 milligrams (mg) by mouth two times a day started on 10/13/2021 and discontinued on 2/28/2023. - Trazodone 25 mg by mouth one time per day as needed started on 10/13/2021 and discontinued on 10/27/2021. Review of Resident #50's clinical record indicated his/her Health Care Proxy signed an Informed Consent For Psychotropic Administration dated 10/13/2021 for the previously discontinued orders. Review of Resident #50's current Physician's Orders, dated 2/28/2023 through review on 5/16/2023, indicated an order for Trazodone 25 mg by mouth two times a day started on 2/28/2023. Review of the Medication Administration Record (MAR) indicated Resident #50 received the medication as ordered from 2/28/2023 through review on 5/16/2023. Further review of the clinical record failed to include an Informed Consent For Psychotropic Administration Form was obtained from the Health Care Proxy for administration of the current physician's orders for the anti-depressant medication dated 2/28/2023. During an interview on 5/16/2023 at 1:46 P.M., the Assistant Director of Nursing (ADON) reviewed the clinical record and was unable to locate the signed Informed Consent For Psychotropic Administration Form for the administration of the Trazodone medication. The ADON said the expectation would be for the signed consent to be completed prior to initiation of the medication on 2/28/2023 due to the new order.

Based on record review, interviews, and policy review, the facility failed to ensure the Physician signed and dated all orders for 12 Residents (#11, #51, #80, #105, #71, #50, #108, #21, #52, #5, #56, and #67), out of a total sample of 22 residents. Findings include: Review of the facility's policy titled Medication Orders, dated April 2014, included but was not limited to: -Supervision by a Physician: -Physician orders/Progress notes must be signed and dated every thirty (30) days. (Note: this may be changed to every sixty (60) days after the first ninety (90) days of the resident's admission) 1. Resident #11 was admitted to the facility in November 2019 with diagnoses which included schizophrenia, multiple sclerosis, major depressive disorder, and failure to thrive. Review of the clinical record, Electronic Medical Record (EMR), and the Order Review History report, indicated the Registered Nurse Practitioner (RNP) last signed the Resident's orders on 5/12/2019. There were no additional orders signed by the Physician. 2. Resident #51 was admitted to the facility in August 2021 with diagnoses which included kidney failure, dementia, and anxiety. Review of the clinical record, EMR, and the Order Review History report, indicated there were no signed physician orders since admission. Additional review indicated the Order Review History was blank (signifying orders were not signed). The next due date for Order Review indicated not specified. 3. Resident #80 was admitted to the facility in August 2022 with diagnoses which included Parkinson's disease, major depressive disorder, and anxiety. Review of the clinical record, EMR, and the Order Review History report, indicated there were no signed physician orders since admission. Additional review indicated the Order Review History was blank (signifying orders were not signed). The next due date for Order Review indicated not specified. 4. Resident #105 was admitted to the facility in July 2022 with diagnoses which included dementia, major depressive disorder, fibromyalgia, and anxiety disorder. Review of the clinical record, EMR, and the Order Review History report, indicated the Physician only electronically signed Resident #105's medical orders on 5/16/2023. 5. Resident #71 was admitted to the facility in January 2019 with diagnoses which included morbid obesity and diabetes mellitus with other diabetic kidney complications. Review of the clinical record, EMR, and the Order Review History report, indicated the RNP electronically signed Resident #71's medical orders on 5/12/2021. There were no additional medical orders signed by the Physician for Resident #71 until 5/16/2023. 6. Resident #50 was admitted to the facility in August 2020 with diagnoses which included major depressive disorder and insomnia. Review of the clinical record, EMR, and the Order Review History report, indicated the RNP electronically signed Resident #50's medical orders on 5/12/2021. There were no additional medical orders signed by the Physician for Resident #50 until 5/16/2023. 7. Resident #108 was admitted to the facility in December 2022 with diagnoses which included Parkinson's disease, anxiety, and dementia. Review of the clinical record, EMR, and the Order Review History report, indicated the Physician only electronically signed Resident #108's medical orders on 5/16/2023. 8. Resident #21 was admitted to the facility in November 2019 with diagnoses which included post-traumatic stress disorder, dementia, and schizoaffective disorder. Review of the clinical record, EMR, and the Order Review History report, indicated the RNP electronically signed Resident #21's medical orders on 5/12/2021. There were no additional medical orders signed by the Physician for Resident #21 until 5/16/2023. 9. Resident #52 was admitted to the facility in October 2022 with diagnoses which included end stage renal disease, muscle weakness, and history of falls. Review of the clinical record, EMR, and the Order Review History report, indicated the Physician only electronically signed Resident #21's medical orders on 5/16/2023. 10. Resident #5 was admitted to the facility in November 2022 with diagnoses which included essential hypertension, chronic obstructive pulmonary disease, and cerebrovascular disease. Review of the clinical record, EMR, and the Order Review History report, indicated the RNP electronically signed Resident #5's medical orders on 5/12/2021. There were no additional medical orders signed by the Physician for Resident #5 until 5/16/2023. 11. Resident #56 was admitted to the facility in July 2020 with diagnoses which included aphasia following cerebral infarction, non-pressure chronic ulcer of the skin, and dementia. Review of the clinical record, EMR, and the Order Review History report, indicated the RNP electronically signed Resident #56's medical orders on 5/12/2021. There were no additional medical orders signed by the Physician for Resident #56 until 5/16/2023. 12. Resident #67 was admitted to the facility in September 2022 with diagnoses which included heart failure, dementia, major depressive disorder, and anxiety. Review of the clinical record, EMR, and the Order Review History report, indicated the Physician only electronically signed Resident #67's medical orders on 5/16/2023. During an interview on 5/16/23 at 9:15 A.M., the surveyor and Nurse #1 reviewed the EMR to verify the physician signed off on the orders. Nurse #1 said she was unaware when physicians signed orders. During an interview on 5/16/23 at 9:20 A.M., Nurse Manager (NM) #1 said she did not have a list which indicated when the physician should review and sign their orders. NM #1 said she was not sure why the physician's orders were not signed. During an interview on 5/16/23 at 9:23 A.M., the surveyor and Assistant Director of Nurses (ADON) reviewed the Order Review History for Resident #11. The Order Review History indicated that the Physician's orders were overdue by 674 days. The ADON said the physician's orders appear to not be signed. During an interview on 5/16/23 at 10:05 A.M., the Director of Nurses (DON) said she recognized that the Physician did not sign the orders of his Residents.