Based on interview, and record reviews, the facility failed to notify the Physician of a significant change in condition for one Resident (#60) out of a total sample of nine residents. Specifically, the facility failed to notify Resident #60's Physician of a significant weight loss prior to his/her discharge from the facility. Findings include: Review of the facility policy titled, Weighing and Measuring, dated June 2022 and revised November 2024, included but was not limited to: -Residents are weighed and measured per the following protocol to provide a baseline and an on-going record of the resident's body weight: *To determine and monitor nutritional status and medical condition. -Residents are weighed: >On admission. >Weekly for the first 4 weeks after admission. >Monthly thereafter. >Per physician ' s order. -Procedure: >Record weight in the vital signs section of the Electronic Medical Record (EMR). >Check current weight against prior recorded weight. >Notify the licensed nurse if weight is 3 or more pounds different. >Re-weigh the resident within 72 hours to verify the accuracy of the weight. >Record the re-weight in the vital signs section of the EMR. >Changes of 5% in 30 days, must be evaluated for significant change. Review of the facility policy titled Change in Resident Condition or Status, dated June 2006, and revised March 2025, included but was not limited to: -It is the policy of this facility to immediately notify the resident . consult with his/her attending physician .of changes in the resident's condition or status. -The licensed nurse will notify the resident's physician .when: *There is a significant change in the resident's physical status that is a deterioration in health. Resident #60 was admitted to the facility in April 2024 with diagnoses including fall, right femur fracture and fracture of the right radius. Review of the medical record indicated Resident #60: -was cognitively intact as evidence by a Brief Interview of Mental Status (BIMS) score of 15 out of a total possible score of 15. -was prescribed a No Added Salt diet of regular texture and thin liquids. -Meal consumption for 4/9/25 - 5/2/25, was recorded 75-100%. -A Physician's order for weekly weights, effective 4/16/25 -Weight recordings for the Resident in the Vital Signs EMR section included: >4/10/25: 123.2 pounds (lbs.). >4/11/25: 122.4 lbs. >No weight documented the week of 4/13/25 - 4/19/25 >4/23/25: 116.4 lbs. (6.8 lbs. weight loss = 5.52% weight loss in 13 days = significant weight loss). >No evidence of a re-weight obtained on or after 4/23/25. -No evidence of Physician notification of the Resident's significant weight loss. Review of the Resident's Person-Centered Care Plan included but was not limited to: >Problem- Nutrition Intake Documentation, start date 4/9/25. >Goal: Record Resident's food consumption at every meal and snack, target date 5/9/25. >Approach: Record Resident's food consumption at every meal and snack, start date 4/9/25. Review of Resident #60's Nutritional Evaluation dated 4/14/25, indicated but was not limited to: -ideal body weight (IBW): 116 lbs. -usual body weight (UBW): 120-122 lbs. -had increased nutritional needs due to healing. Review of the Nutrition Note dated 4/28/25, included but was not limited to the following: -weight was 116.4 lbs. -has been eating 75-100% of meals. -No new recommendations. -No evidence of Physician notification pertaining to weight loss. During an interview on 5/2/25 at 12:18 P.M., the Director of Nursing (DON) said that the Registered Dietician (RD)was not available in the facility today. During an interview on 5/2/25 at 2:39 P.M., the surveyor and the DON reviewed Resident #60's medical record and the DON said the Resident had experienced a 5% weight loss in 13 days according to the documented weights in the Resident's medical record. The DON said a 5% weight loss was a significant weight loss in 13 days. The DON said that she was unaware of when a re-weight should be done. The DON said that there was no re-weight recorded in the Resident's medical record. The DON said that a 5% weight loss was a significant change and should have been reported to the Resident's Physician for possible interventions needed or to determine why weight loss had occurred. The DON said that Nurses should document Physician notification for a change in condition in the Resident's EMR. The DON said she was unable to provide evidence that the Resident's Physician or Nurse Practitioner (NP) had been made aware of the Resident's significant weight loss. The DON said that Resident #60 was discharged home earlier that day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled Psychotropic (medication that effects mental processes, emotions or behaviors) Medication Management and Informed Consent, dated April 2014 with revision date of March/2025, included but was not limited to: -Psychotropic medications shall not be administered to a resident without an informed written consent. -Documentation of Informed Consent is required for any medication that is used in the treatment of a psychiatric diagnosis or symptoms. This includes drugs to treat depression, anxiety disorders, attention deficit/hyperactivity disorders or other psychiatric indications. -The written informed consent shall be kept in the resident's medical record. -Behaviors or symptoms will be monitored and documented each shift. -Potential adverse drug reactions and side effects will be monitored and documented. Resident #65 was admitted to the facility in April 2025 with diagnoses including Depression. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #65: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. -was understood by others and understands others. -was taking Antidepressants medication. -the Resident had signed an informed consent for antidepressant medications, Duloxetine and Trazodone, dated 4/12/25 with risks (side effects) including: sedation, drowsiness, dry mouth, blurred vision, urine retention, tachycardia (heart rate over 100 beats per minute), muscle tremors, agitation, headache, skin rash, photosensitivity (skin sensitivity to sunlight), excess weight gain, heart disease, glaucoma, chronic constipation, seizure disorder, edema (swelling). Review of Resident #65's May 2025 Physician orders included but were not limited to: -Duloxetine capsule, delayed release 60 mg (milligram) one capsule, oral once a day 9:00 A.M., effective 4/12/25. -Trazodone tablet, 50 mg, two tablets (total =100 mg), oral at bedtime 9:00 P.M., effective 4/12/25. -No evidence of intervention for side effects monitoring of the Psychotropic medications. Review of the Resident #65's April 2025 and May 2025 MARs indicated: -The Resident had been administered Duloxetine and Trazodone, as ordered by the Provider for a 21-day period. Review of the Pharmacist's Monthly Medication Record Review for Resident #65 dated 4/26/25, indicated: -Medications reviewed. No irregularities noted at this time. Review of Resident #65's Person Centered Care Plan included but was not limited to: -Problem: ADL's functional status/Rehabilitation potential, initiated 4/12/25. >Goal: Avoid significant decline or adverse changes in status related to my (the Resident's) continued placement over the next 30 days, target date 5/12/25. >Goal: My immediate needs will be met and care needed will be provided based on admission physician orders and professional standards of quality care through my next review date, target date 5/12/25. >Approach: Physician orders for care include prescriptions for: *Duloxetine capsule, delayed release 60 mg (milligram) one capsule; oral once a day, 9:00 A.M., effective 4/12/25. *Trazodone tablet, 50 mg; two tablets -100 mg; oral at bedtime 9:00 P.M., effective 4/12/25. *No evidence that Psychotropic medication side effect monitoring had been in place. During an interview on 5/2/25 at 3:18 P.M., the Director of Nursing (DON) said that Resident #65 was being administered psychotropic medications as ordered by the Physician. The DON said that Resident #65 was being monitored for behaviors but not for the side effects for psychotropic medications. The DON said that the facility Nurses should be monitoring and documenting psychotropic medication side effects, like the facility policy indicated, but they were not. The DON said that not monitoring the Resident for psychotropic medication side effects could place the Resident at risk for unwanted side effects or complications. Based on interview, and record review, the facility failed to provide care consistent with professional standards of practice relative to the management and monitoring of psychotropic medications (medication that affect how the brain works and causes changes in mood, awareness, thoughts, feelings and behaviors) for two Residents (#159 and #65), of five applicable residents reviewed for unnecessary medications, out of a total sample of nine residents. Specifically, the facility failed to: 1. For Resident #159, ensure monitoring of potential side effects of Lexapro (antidepressant medication) medication, placing the Resident at risk for unidentified medication side effects and/or complications. 2. For Resident #65, ensure the monitoring of potential side effects of Duloxetine (antidepressant medications) and Trazodone (antidepressant medication) use in accordance with professional standards of practice, placing the Resident at risk for unidentified medication complications and/or side effects. Findings include: Review of the facility policy titled Psychotropic Medication Management and Informed Consent, effective 4/2014 and last revised 3/2025, indicated: -Psychotropic medications is any medication that may affect brain activities associated with mental processes and behavior. -When psychotropic medications are used in the facility, the facility will identify target behaviors or symptoms. -Behaviors and symptoms will be monitored and documented each shift. -A care plan targeting these behavior(s) or symptoms will be initiated. The care plan will identify both non-pharmacological and pharmacological interventions. -Potential adverse drug reactions and side effects will be monitored and documented. Resident #159 was admitted to the facility in April 2025 with diagnoses including Depression. Review of the Minimum Data Set (MDS) Assessment, dated 4/15/25, indicated for Resident #159: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score of 15. -was understood by others and understands others. -was taking an Antidepressant Medication -has a diagnosis of Depression Review of Resident #159's May 2025 Physician orders indicated: -Lexapro (Escitalopram Oxalate) tablet, 10 milligrams (mg), Amount to Administer: 1 tab, oral once a day, initiated 4/9/25. Review of Resident #159's April 2025 and May 2025 Medication Administration Records (MARs) indicated the Resident was administered Lexapro daily as prescribed by the Physician. Review of Resident #159's Signed Informed Consent Form dated 4/9/25, for Antidepressant Medication Administration indicated: -Lexapro 10 mg for Depression -Common side effects included: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia (an abnormal heart rhythm with a fast heart rate of more than 100 beats per minutes at rest), muscle tremor, agitation, headache, skin rash, photosensitivity (an increased sensitivity of the skin to sunlight or other types of light, causing an unusual reaction like a rash or sunburn) (skin), excess weight gain. *Special Attention: Heart disease, glaucoma, chronic constipation, seizure disorder, edema. -Consent Form was signed by the Resident. Further review of Resident #159's medical record failed to indicate Physician orders or nursing interventions to monitor for potential side effects from Lexapro medication use. During an interview on 5/2/25 at 9:05 A.M., Nurse #2 said that a Resident who received Lexapro medication had to be monitored for medication side effects that include nausea, anxiety, headaches, confusion, dizziness, and sleepiness. Nurse #2 said that she knew the side effects of Lexapro because she is familiar with the medication. Nurse #2 said that Lexapro side effects should have been monitored and documented for Resident #159 every shift on the Residents MAR, but they were not. During an interview on 5/2/25 at 9:40 A.M., the Director of Nursing (DON) said that there should have been a Physician order for Resident #159 to be monitored for antidepressant side effects. The DON said that Resident #159 should have had a care plan addressing the need for care and services related to Lexapro use, but there was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide an environment free from accidents and hazards related to the storage of medications for one Resident (#63) out of a total sample of nine residents. Specifically, for Resident #63, the facility failed to: -safely and properly store prescribed topical medications when the medications were left within reach at the Resident's bedside, and he/she had a diagnosis of Dementia, putting the Resident at risk of inappropriately accessing and using the medications. -ensure the medications was not readily accessible to the Resident and other unauthorized individuals, when Resident #63 did not have an assessment or Physician's order for self-administration of medications and the medications were observed unattended and within close proximity of the Resident in his/her bedroom. Findings include: Review of the facility policy titled Storage of Medication, revision date December 2019, included but was not limited to: -Medications and biologicals are stored safely, securely and properly . -The medication supply is accessible only to licensed nursing personal, pharmacy personal or staff members lawfully authorized to administer medications. Review of the facility policy titled Self Administration of Medication, dated June 2012, revision date March 2022, included but was not limited to: -Each resident who desires to self administer medications may do so if the facility's interdisciplinary team (IDT) has determined that the practice would be safe for the resident and other residents of the facility. -The resident may request to self administer medications at any time during their stay. -An assessment is conducted by the IDT of the residents cognitive, physical and visual ability to carry out this responsibility. -The results of the IDT assessment are recorded on the Self Administration of Medications document in the resident's medical record. Resident #63 was admitted to the facility in April 2025 with diagnoses including Dementia, anxiety, insomnia, fall and left femur fracture. Review of Resident #63's Medical Record included but was not limited to: -Resident #63's Minimum Data Set (MDS) Assessment had not yet been completed. Review of Resident #63's May 2025 Physician's orders indicated: -Venelex (topical medicated ointment for wound healing) apply to bilateral heels twice a day, effective 4/29/25. -Cleanse buttocks/perianal area with soap and water, then apply Antifungal cream twice a day until healed, effective 4/29/25. On 5/1/25 at 11:14 A.M., the surveyor observed that Resident #63 was alone in his/her room, lying in bed with the head of the bed elevated and an over-the-bed table positioned in front of him/her. The surveyor observed two tubes of medications located on the Resident's over-the-bed table and within the Resident's reach. The surveyor also observed that there were no staff members within the immediate vicinity of the Resident's room. The surveyor observed the medications located on the Resident's over-the-bed table prescription labels read as follows: -Venelex Wound Dressing ([NAME]/Castor Oil) Ointment 30 gm (grams) apply topically twice a day to bilateral heels. -Miconazole Nitrate (antifungal cream) 2% apply topically twice a day to buttocks/perianal area. On 5/2/25 at 9:10 A.M., the surveyor observed Resident #63 alone in his/her room, seated in a wheelchair and eating breakfast. The surveyor did not observe any facility staff to be within the immedicate area. The surveyor observed two tubes of medications (Venelex Ointment and Miconazole Nitrate) on the Resident's nightstand and within the Resident's reach. During an interview at the time, Resident #63 said he/she did not know what the two tubes were. During an interview on 5/2/25 at 9:15 A.M., Nurse #1 said that medications kept at a Resident's bedside required an assessment for self-administration and a Physician's order. The surveyor and Nurse #1 observed the two prescription medication tubes (Venelex Ointment and Miconazole Nitrate) remained on Resident #63's nightstand. Nurse #1 said that Resident #63 did not have a Physician's order or assessment to keep medications at the bedside. Nurse #1 said that the medications should not had been left at the bedside because the Resident had Dementia and could use the medications inappropriately. During an interview on 5/2/25 at 10:16 A.M.,Unit Manager (UM) #1 said that Residents required a Physician's order and a Self-Administration of Medications Assessment in order to keep medications at the bedside. UM #1 said that when medications were kept at the bedside the medications should be kept in a drawer for safe keeping and not out in the open or within a Resident's reach. UM #1 said that Resident #63 did not have a Physician's order or a Self-Administration of Medications Assessment to keep ointments at the bedside. UM #1 said that Resident #63 would be unlikely to pass the Self-Administration of Medications Assessment due to the Resident's diagnosis of Dementia. UM #1 said that the ointments should not have been left in the Resident's room and within the Resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an effective infection control and prevention program to stop the spread of organisms and infections for two Residents (#59 and #159) out of a total sample of nine residents, and during the medication administration process related to fingerstick blood glucose testing. Specifically, 1. For Resident #59, the facility staff failed to implement appropriate hand hygiene during wound care for the Resident on Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug-resistant organisms [MDRO's-bacteria that are resistant to three or more types of antimicrobial drugs]) during high contact resident care) as ordered by the Physician. 2. For Resident #159, the facility staff failed to don (put on) appropriate Personal Protective Equipment (PPE: items such as gown and glove worn to minimize exposure to hazards, contaminants, and organisms) when changing the Resident's bed linens with the Resident in the bed, and the Resident was ordered on EBP for open skin areas on bilateral arms. 3. The facility failed to ensure that staff performed hand hygiene after doffing (removing) PPE and before donning new PPE to prevent the potential for cross contamination during medication administration and fingerstick blood glucose testing for two residents. Findings include: 1. Review of the facility's policy titled, Hand Hygiene, dated June 2012, revision date January 2025, included but was not limited to: -It is the policy of this facility to follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene .and reduce the risk of health care associated infections. <wash hands with soap and water when they are visibly dirty or contaminated <if hands are not visibly soiled, use an alcohol-based hand rub . -Appropriate hand hygiene should be performed: <after removing gloves. Resident #59 was admitted to the facility in April 2025 with diagnoses including fall and skin tears. Review of Resident #59's May 2025 Physician orders included: -Maintain EBP, effective 4/24/25. -Monitor left upper arm skin tear and apply a dry protective dressing (DPD) every three days, effective 4/25/25. Review of Resident #59's Person-Centered Care Plan included but was not limited to: -Problem: Impaired skin integrity related to skin tear, initiated 4/23/25. >Goal: Area will improve with decreased risk for . infection through next review, with interventions that included treatments to be provided as ordered by the Physician. On 5/1/25 at 8:20 A.M., the surveyor observed signage posted in Resident #59's doorway that indicated: >STOP ENHANCED BARRIER PRECAUTIONS STOP >EVERYONE MUST: -clean their hands including before entering and when leaving the room. -wear gloves and a gown for the following high contact resident care activities: *Wound Care: any skin opening requiring a dressing. On 5/1/25 at 9:09 A.M., the surveyor observed Nurse #1 perform wound care for Resident #59's left upper arm skin tear as follows: -Nurse #1 cleansed her hands with hand sanitizer and donned clean gloves and a gown. -Nurse #1 entered the Resident's room, introduced herself and educated the Resident about wound care. -Nurse #1 removed the old dressing from the Resident's left upper arm. -Nurse #1 discarded the old dressing into the trash receptacle. -Nurse #1 cleansed the Resident's skin tear with Normal Saline Solution (NSS) and a gauze pad. -Nurse #1 used a clean gauze pad to dry the skin tear wound area on the Resident's left upper arm. -Nurse # 1 doffed her gloves and discarded the gloves into the trash receptacle. -Nurse #1 donned a new pair of gloves without performing hand hygiene prior to applying the new pair of gloves. -Nurse #1 placed a dry protective dressing over the Resident's left upper arm skin tear. During an interview at the time, Nurse #1 said that Resident #59 required EBP because the Resident had a wound. Nurse #1 said that she did not cleanse her hands between her glove change, but she should have. Nurse #1 said that her hands should be cleansed with hand sanitizer or soap and water every time gloves are changed because not cleansing her hands between glove changes could spread infection to the Resident. During an interview on 5/1/25 at 3:44 P.M., the Infection Preventionist (IP) Nurse said that Nurses were educated on wound care and hand hygiene upon orientation and then competencies are conducted throughout the year. The IP said that Nurse #1 should have cleansed her hands when gloves were removed and prior to putting on new gloves. The IP said that the failure to cleanse hands between glove changes could spread infections to the Resident. 3) Review of the facility policy titled Hand Hygiene, revised 1/2025, indicated the following: -appropriate hand hygiene should be performed: >after removing gloves Review of the facility policy titled Personal Protective Equipment, revised 1/2025, indicated the following: -[Putting on] Unsterile Gloves >perform hand hygiene >obtain glove(s) . -Removing gloves > .discard glove . >perform hand hygiene -Putting on the Gown: >wash hands >unfold the gown with opening facing you . -Removing the gown > .discard the gown in the appropriate receptacle >wash hands . On 5/1/25 at 8:05 A.M., the surveyor observed the Infection Preventionist (IP) during a medication administration as follows: -The IP completed control testing on a glucometer. -The IP set up to complete a finger stick blood glucose test on a resident. -without performing hand hygiene, the IP donned a gown and gloves and entered the resident's room, and completed the finger stick blood glucose test. -The IP doffed (removed) gloves and gown without performing hand hygiene. -The IP cleaned and disinfected the glucometer and moved the medication cart to the next resident's room. On 5/1/25 at 8:08 A.M.,the surveyor observed the IP during a medication administration for another resident as follows: -The IP set up the glucometer for testing without performing hand hygiene after leaving the previous resident's room. -The IP donned a gown and gloves without performing hand hygiene and entered the next resident's room where the IP completed a fingerstick blood glucose test on the second resident. -The IP doffed the gown and gloves and exited the second resident's room to the medication cart where he cleaned and disinfected the glucometer. During an interview on 5/1/25 at 2:16 P.M., the surveyor reviewed the IP observations at 8:05 A.M. and 8:08 A.M. with the IP. The IP said after touching potentially contaminated items on the medication cart and after doffing gloves, he should have performed hand hygiene before donning PPE to prevent potential contamination. 2. Resident #159 was admitted to the facility in April 2025 with diagnoses including psoriasis, specified fracture of left pubis and metabolic encephalopathy. Review of the facility policy titled Enhanced Barrier Precautions, effective 4/1/24, indicated: -It is the policy of this facility that all staff providing high-contact resident care activities will implement Enhanced Barrier Precautions (EBP) for residents with any of the following: <Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism (MDRO). -EBP refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities. -High contact resident care activities are defined to be: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as central lines, urinary catheter, feeding tube and tracheostomy/ventilator and wound care: any skin opening requiring a dressing. -A sign indicating the need for EBP will be placed conspicuously to alert staff before approaching the resident for care. Review of the Minimum Data Set (MDS) Assessment, dated 4/15/25, indicated the following for Resident #159: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score of 15. -he/she was understood by others and understands others. Review of Resident #159's May 2025 Physician orders indicated: -EBP for open areas to upper extremity due to severe Psoriasis and is being treated, initiated 5/1/25. Review of Resident #159's May 2025 Medication Administration Record (MAR) indicated: -Apply [NAME] (topical anesthetic) to patient bilateral upper extremity (BUE) due to redness and itching every shift, initiated 4/20/25. -Triamcinolone Acetonide cream (corticosteroid), 0.1%, amount to administer: small amount topical twice a day to BUE, initiated 4/19/25 On 5/1/25 at 8:00 A.M., the surveyor observed signage posted outside of the Resident's door that indicated: >STOP ENHANCED BARRIER PRECAUTIONS: >EVERYONE MUST: -clean their hands including before entering and when leaving the room. >Providers and staff must also: -wear gloves and a gown for the following high contact resident care activities: -changing linens On 5/1/25 at 8:05 A.M., the surveyor observed Resident #159 lying in bed with the head of the bed elevated to 90-degrees. The surveyor observed several open skin areas on the Resident's bilateral arms. Resident #159 said that he/she scratches at his/her arms because his/her arms were itchy. Resident #159 said that staff typically would apply a sleeve on both of his/her arms when he/she was assisted with care. On 5/2/25 at 9:14 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 enter the Resident's room without donning a gown and then exited the room. CNA #1 approached the surveyor and asked the surveyor if she must wear a gown to change Resident #159's bed linens. When the surveyor asked CNA #1 what was the facility policy for residents requiring EBP, CNA #1 said that the facility policy did not require staff to use a gown when changing bed linens for the residents on EBP. The surveyor observed CNA #1 re-enter Resident #159's room without donning a gown. CNA #1 was observed changing Resident #159's bed linens while the Resident remained in the bed. During an interview on 5/2/25 at 9:26 A.M., the Director of Nursing (DON) said she was the staff member that placed an EBP sign and supplies outside Resident #159's bedroom door because the Resident had open areas to both arms. The DON said that staff are not required to wear PPE when changing bed linens for Resident #159 if the bed linen was not soiled. The surveyor and the DON reviewed the facility's EBP sign, and the DON said that CNA #1 should have worn a gown when changing the bed linens because the Resident had open areas on the arms.

Based on observations, interviews, and policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the potential transmission of communicable diseases and infections within the facility for four Residents (#80, #121, #124, and #126), out of a total sample of 17 residents. Specifically, the facility failed to clean and disinfect multi-use equipment after use between Resident #126 and Resident #80 and who were on Enhanced Barrier Precaution (an infection control strategy that uses personal protective equipment (PPE) to reduce the spread of multidrug-resistant organisms between residents) prior to using the same equipment on two other Residents (#121 and #124). Findings include: Review of the facility's policy titled Cleaning of Reusable Equipment, revised October 2020, included the following: -Reusable items that come in contact with skin, but no mucous membranes should be cleaned using the approved facility disinfectant wipes or spray and dried thoroughly before re-use. Review of the facility's policy titled Enhanced Barrier Precautions, dated 4/1/24, included the use of Personal Protective Equipment (PPE) and refer to the use of gown and gloves during high-contact care that provide opportunities to transfer Multi-Drug Resistant Organisms (MDROs: infection causing bacteria that have become resistant to antibiotics and are easily transmitted to others). On 5/16/24 at 8:25 A.M., the surveyor observed Nurse #1 taking the blood pressure of Resident #126. There was a sign outside the Resident's door indicating he/she was on Enhanced Barrier Precaution. The Nurse removed the blood pressure cuff from the Resident, placed the cuff in the blood pressure machine, without cleaning or disinfecting the cuff or the machine, and left the blood pressure machine in the hallway. On 5/16/24 at 8:31 A.M., the surveyor observed Nurse #1 enter Resident #121's room with the blood pressure machine that was in the hallway. He checked the Resident's blood pressure, exited the room with the blood pressure cuff and machine, and left the blood pressure machine in the hallway, without cleaning or disinfecting the cuff and the machine and continued with his medication pass. On 5/16/24 at 8:47 A.M., the surveyor observed Nurse #1 enter Resident #80's room, with the same blood pressure machine and cuff. There was an Enhanced Barrier Precaution sign outside the Resident's door. Nurse #1 applied the blood pressure cuff to the Resident, obtained the Resident's blood pressure, removed the cuff, and placed it in the blood pressure machine. Nurse #1 came out of the room, did not clean or disinfect the cuff or the machine and left it in the hallway, sanitized his hands and continued with his medication pass. On 5/16/24 at 8:59 A.M., the surveyor observed Nurse #1 enter Resident #124's room with the same blood pressure machine and cuff. The Nurse obtained the Resident's blood pressure, removed the cuff, placed the cuff in the blood pressure machine, came out of the room and left the cuff and machine in the hallway, and did not clean or disinfect the machine and the cuff. During an interview on 5/16/24 at 9:08 A.M., Nurse #1 said he should have cleaned and disinfected the blood pressure cuff and the blood pressure machine before and after using it on the Residents but he did not. During an interview on 5/16/24 at 10:48 A.M., the Director of Nurses (DON) said Nurse #1 was the Infection Preventionist and should have cleaned and disinfected the blood pressure cuff and machine per the facility's policy.

Based on interviews, the facility failed to ensure its staff designated an Infection Preventionist (IP) who had completed specialized training in infection prevention and control prior to assuming the role of IP at the facility. Specifically, the facility designated an IP who had not completed specialized training in Infection Prevention and Control before assuming the IP role and continued to work as the designated IP at the facility. Findings include: During an interview on 5/15/24 at 7:54 A.M., the Director of Nurse (DON) said that the facility had a designated IP (Nurse #1) who has been an IP in the facility for two years and would provide proof of specialized training. During an interview on 5/16/24 at 10:00 A.M., the DON said she was not able to provide evidence of the IP's specialized training and or certification. The DON said the IP was working on the floor as a nurse. The facility failed to provide the surveyors with any evidence of the IP's specialized training in infection prevention and control prior to their exit from the facility.