**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper use of personal protective equipment (PPE) for 1 of 2 residents (R249) during high contact cares. In addition, the facility failed to ensure PPE use while providing wound care for 1 of 2 residents (R249) reviewed for enhanced barrier precautions (EBP). Findings include: R249's quarterly Minimum Data Set (MDS) dated [DATE], indicated R249 was cognitively intact and had acute osteomyelitis (bone infection) on the right ankle and foot and had recently undergone orthopedic surgery for right below the knee amputation, phantom limb syndrome with pain (real pain in a missing limb after amputation), peripheral vascular disease (PVD) (narrowed arteries reduce blood flow to the arms and/or legs), type II diabetes mellitus (DM), hypertension (elevated blood pressure), hyperlipidemia (high cholesterol), neuropathy (nerve pain, tingling, or numbness), and was a carrier or suspected carrier of Methicillin-susceptible Staphylococcus aureus (MSSA) (type of staph bacteria that can cause infections on the skin or other parts of the body). R249's care plan dated 2/26/25, indicated R249 was on EBP due to MSSA, PICC line with six weeks of antibiotics, and chemotherapy medication. Interventions included posting clear signage on the exterior of resident's door with the required PPE, provide education to residents and visitors, PPE available outside of the room, use gown and gloves with high-contact resident care activities. During observation on 3/17/25 at 3:26 p.m., registered nurse (RN)-A along with an unidentified nursing assistant (NA) assisted R249 from his manual wheelchair into his recliner to perform wound care. Neither NA or RN-A wore gown or gloves while assisting R249 with transfer. NA exited the room after assisting with the transfer. R249's legs were elevated using the recliner. RN-A gather the supplies to complete dressing changes then sat in R249's wheelchair to perform R249's wound care. RN-A donned gloves to both hands, but failed to don a gown prior to procedure. RN-A then removed Prevalon boot (heel protectant boot) from R249's left heel wound. RN-A noted there was no dressing in place, she then lifted R249's left leg and foot and placed R249's ankle on her right leg above the knee to provide support while painting the wound with betadine per the provider order. After bandaging the left heel RN-A removed her gloves and discarded the used supplies. RN-A returned to sit in the wheelchair and applied a glove to her right hand. She removed the dressing from R249's right below the knee surgical wound with gloved hand, noted there was no drainage and was seen painting the site with a betadine swab. RN-A redressed, dated and initialed the tape used to secure the gauze wrap, and applied the limb protector with gloved hand. RN-A removed her glove and discarded the used supplies. Signage, PPE supply cart and disposal bin were observed on resident's door and just inside of the door. RN-A was not wearing a gown to protect R249 nor herself from pathogens during this procedure. Interview on 3/17/25 at 3:46 p.m., RN-A stated that she had worn gloves. RN-A confirmed she had not worn a gown during resident high contact cares, she stated I forgot. Unable to complete interview at this time. Interview on 3/17/25 at 3:48 p.m., R249 stated she [RN-A] never wears a gown. Interview on 3/19/25 at 3:02 p.m., RN-A stated when a resident required EBP there should be a sign on the resident's door to alert them. In the resident's plan of care there is a stop sign that indicated the precaution, and if hovered over, it showed the type of precaution specifically. RN-A confirmed R249 did have EBP signage posted on exterior of his door and that there was a PPE cart and disposal bin located inside his doorway. RN-A did not recall receiving any specific EBP training, and stated she may not have been there for it. RN-A stated gown and gloves should be worn for, anything up close and personal where concerns for infection are possible, like peri cares, all personal cares and wound care. RN-A was not aware high contact care included transfers. RN-A stated PPE use was important to prevent infection for the resident with whatever I could be carrying, to keep as clean as possible and not introduce anything new to him. Interview on 3/19/25 at 3:20 p.m., with case manager (CM) and director of nursing (DON). DON stated staff were able to tell which residents were on EBP in the residents EHR, it was flagged on their face page, on the care plan, signage on their door, as well as on the huddle board (white board) in the breakroom that lists all residents on precautions. CM stated they also had supply bins and disposal containers in the residents' rooms. CM also stated they go through the residents on EBP in their morning huddle daily, during shift reports and pass on. DON stated precautions were put into PCC like a medication order, when it was time for wound care to be completed, it alerted the nurse. CM stated training on EBP was provided to care staff at their annual skills fair. DON stated many different audits had been completed, and gown and gloves were expected for all wound care. Both CM and DON agreed they would expect orders to be followed, infection control practices followed, and if there was a question, staff would ask for clarification as they had many tools and resources available to them. DON and CM were not specific on the expectation of staff to wear PPE during high contact cares, including transfers. A policy effective 3/2025, titled Enhanced Barrier Precautions indicated the policy is in place to reduce the transmission of multidrug-resistant organisms (MDROs). Enhanced barrier precautions is defined as 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. PPE used for these high-contact resident care activities as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care of any skin opening requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure Physicians Orders for Life Sustaining Treatment (POLST - Code Status) were clarified for 1 of 1 residents (R34), who was readmitted from the hospital with orders in conflict with their signed POLST and Advance Directives. Findings include: R34's significant change Minimum Data Set (MDS) dated [DATE], indicated cognitively intact and required partial to moderate assistance for activities of daily living (ADLs). R34's Face Page printed [DATE], indicated resident's code status as DNR-intubation on case-by-case basis but no chest compressions. R34's Health Care Directive (HCD) signed [DATE], indicated I do not want CPR attempted if my heart or breathing stops. I want to allow a natural death. R34's HCD further directed: Keep me comfortable. No extraordinary measures. R34's most recent POLST (signed [DATE] upon admission to the facility), directed if R34 was not breathing or had no pulse as, DNR/DO NOT ATTEMPT RESUSCITATION (Allow Natural Death). R34's POLST further documented resident wished not be intubated (insertion of a tube into a patient's body, especially that of an artificial ventilation tube into the trachea), no artificial nutrition by tube. However indicated the use if antibiotics, IV fluids and cardiac monitor as indicated. R34 was admitted to the hospital, from [DATE] through [DATE], where resident was treated for pneumonia. R34's hospital discharge orders documented R34's Code Status as: Intubation on case-by-case basis but no chest compressions. Limited code - no cardiac resuscitation. During interview on [DATE] at 8:20 a.m., R34 stated if she was found not breathing and heart had stopped, I don't want anything done. When clarified with R34, this included no breathing or feeding tubes. However she was open to having comfort measures such as antibiotics and IV fluids. In and interview on [DATE] at 9:30 a.m., registered nurse (CM)-B verified R34's HCD and POLST both indicated resident's expressed decision was to be DNR and did not wish to have extraordinary means to be implemented. In review of R34's Point Click Care records (electronic medical records), where it documented Intubation on case-by-case basis but no chest compressions. Limited code - no cardiac resuscitation, and the [DATE] hospital discharge orders, CM-B stated R34's orders should have been clarified with the physician before being transcribed. In review of the facility's policy, entitled: No Not Resuscitate Order (effective date 11/2011), indicated the following: 5. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provide the facility with a signed and dated request to end the DNR order. a. Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request. b. Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet. In review of the facility's policy, entitled: Transcription Processing Provider Orders - Long Term Care (effective 11/2021), lacked evidence of what the facility staff person who transcribed orders should do when they have received conflicting orders. In this case, changing R23's end of life choices without consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 2 of the 5 residents (R9 and R23) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R9's face sheet, dated 2/8/24, indicated she was [AGE] years old. The immunization record, undated, indicated she received a PPSV23 on 4/29/08 followed by the PCV13 on 11/2/16. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R9 was offered or received PCV20. R23's face sheet, dated 2/8/24, indicated she was [AGE] years old. The immunization record, undated, indicated she received a PPSV23 on 7/18/15 followed by the PCV13 on 6/23/17. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R23 was offered or received PCV20. During an interview with care manager (CM)-A on 2/7/24 at 7:50 a.m., the CM indicated immunizations were verified upon admission through MIIC (Minnesota Immunization Information Connection). IP stated IP would ask residents and/or their families and consents were obtained if immunizations were needed. CM verified R9 and R23's pneumococcal immunizations as listed above. CM verified they had not been offered or provided education on PCV20. During interview with director of nursing (DON) on 2/8/24 at 11:25 a.m., DON stated immunization reports through MIIC, recommended immunizations were discussed during the admission process but R9 and R23 were missed. A facility policy titled Pneumococcal Immunization, Long Term Care with an effective date of 6/2023 was provided. Policy indicated: Residents will be offered the pneumococcal vaccinations and administered, according to the MDH and CDC recommended interval for the vaccines, unless contraindicated, already immunized, or the resident and/or the resident representative declines the vaccine.