Based on interviews, record reviews, and facility policy review, the facility failed to complete a significant change assessment and submit a required Level II Preadmission Screening and Resident Review (PASRR) for one (1) of two (2) residents reviewed for PASRR (Resident #16). Specifically, the facility failed to submit a PASRR Level II and complete a significant change assessment after Resident #16 was diagnosed with major mental illness, including bipolar disorder and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. Findings Include: A review of the facility's Pre-admission Screen policy revealed: Preadmission Screening and Resident Review (PASRR) aims to ensure individuals are not inappropriately placed in nursing homes for long-term care and to provide them with the services they need in those settings . A record review of Resident #16's Pre-admission Screen (PAS), dated 7/25/11, revealed no major mental illness at the time of screening. A record review of Resident #16's record revealed that a Level II PASRR was submitted on 4/1/22 related to an intellectual developmental disability. A record review of Resident #16's admission Record revealed an admission date of 8/9/2011, with new diagnoses of bipolar disorder and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms with an onset date of 7/17/23. Further record review of Resident #16's clinical record revealed that a Level II PASRR was not submitted in response to the new diagnoses of major mental illness, and a significant change assessment was not completed as required. On 05/13/25 at 9:42 AM, during an interview, Registered Nurse (RN) #1, charge nurse, confirmed that a significant change assessment was not completed for Resident #16 following the new diagnoses of bipolar disorder and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. She acknowledged that it should have been done. On 05/13/25 at 3:43 PM, during an interview, the Social Services staff member stated that Resident #16 had the above mental health diagnoses and acknowledged that a significant change should have been completed at that time. She stated that completing a significant change ensures the resident receives the appropriate services and that staff are informed of the resident's needs. A record review of Resident #16's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/10/25 revealed the resident was severely cognitively impaired.

Based on interviews, record reviews, and facility policy review, the facility failed to implement the comprehensive care plan as developed for one (1) of two (2) residents reviewed for skin conditions (Resident #34). Specifically, the facility failed to carry out weekly skin evaluations as required by the resident 's care plan and physician orders. Findings include: A record review of the facility's Comprehensive Care Plan policy with a revision date of 1/2025 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing . A record review of Resident #34's Comprehensive Care Plan initiated 4/22/25 revealed skin impairment related to moisture-acquired skin damage to the buttocks. The care plan directed staff to Monitor and Document weekly. A record review of Resident #34's weekly skin evaluations revealed they were not completed during April 2025. A record review of Resident #34's electronic Treatment Administration Record (eTAR) revealed: Weekly skin assessments every Wednesday date initiated 10/1/24. Wednesday 4/16/25 was not initialed as completed. In an interview with the Director of Nursing (DON) on 5/13/25 at 4:03 PM, she stated that weekly skin evaluations should be completed and documented weekly. She stated the purpose of the skin evaluation is to help staff identify any new breakdowns and to evaluate and treat skin accordingly. She confirmed that Registered Nurse (RN) #1 did not follow the care plan. On 05/14/25 at 3:09 PM, during an interview, RN #1 (Charge Nurse) acknowledged it was her responsibility to complete the weekly skin evaluations and stated she did not follow the care plan. On 5/14/25 at 1:05 PM, in an interview, RN #2, the facility's Minimum Data Set (MDS) Nurse, stated the care plan is created to guide staff in delivering care. She confirmed RN #1 did not follow the care plan related to weekly skin evaluations. She stated Resident #34 cannot receive quality care if the care plan is not followed. A record review of Resident #34's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 2/28/25 revealed the resident was severely cognitively impaired. A record review of Resident #34's weekly skin evaluation dated 5/7/25 noted moisture-associated skin damage to the buttocks, further supporting the need for ongoing evaluation and documentation as outlined in the care plan. A record review of Resident #34's admission Record revealed an admission date of 3/16/22 with diagnoses including non-pressure chronic ulcer of other part of left foot with unspecified severity and atherosclerosis of native arteries of other extremities with ulceration.

Based on interviews, record reviews, and facility policy reviews, the facility failed to ensure that care and services were provided in accordance with professional standards of practice for one (1) of two (2) residents reviewed for skin conditions (Resident #34). Specifically, the facility failed to ensure that weekly skin assessments were completed and documented as ordered by the physician and in accordance with facility policy, resulting in a lack of monitoring for skin breakdown. Findings include: A record review of the facility's Skin Assessment policy dated 1/2025 revealed: It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury, prevention and management. The policy includes the following procedural guidelines .: A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. A record review of Resident #34's weekly skin evaluations revealed that they were not completed during April 2025. A record review of Resident #34's weekly skin evaluation dated 5/7/25 revealed moisture-associated skin damage to the buttocks. A record review of the Weekly Skin Report dated 4/25/25 revealed Resident #34 was not listed as having a buttocks abrasion; however, it was listed on the 5/2/25 report. On 5/13/25 at 4:03 PM, in an interview with the Director of Nursing (DON), she stated the weekly skin evaluations should be completed and documented weekly. She stated she expects staff to perform and document them consistently. She explained that the purpose of the skin evaluations is for staff to identify any new skin breakdown and to evaluate and treat the skin accordingly. She stated that Registered Nurse (RN) #1 told her that she had completed the evaluations on a scratch sheet but forgot to enter them into the computer and could no longer locate the notes. The DON stated that if there is no documentation, it indicates the task was not completed. On 5/14/25 at 11:00 AM, an observation of wound care and a weekly skin evaluation was conducted by RN #1. Care was provided within standards of practice. During the skin evaluation, RN #1 assessed the buttocks area, which revealed four areas of healed pink skin and one open area. There were no signs of infection or drainage noted. On 5/14/25 at 3:09 PM, in an interview, RN #1 (Charge Nurse) stated it is her responsibility to complete the weekly skin evaluations. She stated she typically writes the results on the back of the report and enters them into the computer afterward. She acknowledged that the purpose of the evaluations is to identify any skin conditions, wound progression, or deterioration. She confirmed that although she performed the evaluations, she failed to enter them into the computer. A record review of Resident #34's Electronic Treatment Record (ETAR) revealed: Weekly skin assessments every Wednesday and cleanse moisture acquired skin damage to buttocks with normal saline, pat dry, apply calazine cream, apply nonadherent gauze and cover with bordered gauze twice daily. This review revealed that care for the open area on the buttocks was initiated on 4/21/25. A record review of Resident #34's Progress Notes dated 4/21/25 revealed: Cleanse open area to buttocks with normal saline, pat dry, apply calazine cream, apply nonadherent gauze and cover with bordered gauze twice daily and as needed until healed. A record review of Resident #34's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 2/28/25 revealed the resident was severely cognitively impaired. A record review of Resident #34's admission Record revealed an admission date of 3/16/22, with diagnoses including non-pressure chronic ulcer of other part of left foot with unspecified severity and atherosclerosis of native arteries of other extremities with ulceration.

Based on observation, interviews, record reviews, and facility policy reviews, the facility failed to ensure incontinent residents received appropriate care and services to prevent the possibility of a urinary tract infection for one (1) of two (2) residents observed for incontinent care (Resident #8). Specifically, the facility failed to provide timely incontinence care and maintain cleanliness, which placed the resident at risk for skin breakdown and urinary tract infection. Findings Include: A record review of the facility's Perineal Care policy with a revision date of 1/2025 revealed: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible and to prevent and assess for skin breakdown . On 05/13/25 at 3:15 PM, an observation of peri-care being performed by Certified Nursing Assistant (CNA) #1, assisted by CNA #2, revealed CNA #1 removed Resident #8's brief, which was heavily soiled with amber-colored urine and emitted a strong urine odor. The resident's wheelchair and pants were also soaked in urine. On 05/13/25 at 3:32 PM, in an interview, CNA #1 confirmed the brief was heavily soiled with amber-colored urine. She confirmed the resident 's chair and pants were also heavily soiled. She stated she was assisting CNA #2 and did not know when the resident was last checked or changed. On 05/13/25 at 3:36 PM, CNA #2 confirmed in an interview that the chair, pants, and brief were heavily soiled with urine. She stated she changed Resident #8 around 10:30 AM, right before lunch. CNA #2 acknowledged she was supposed to check the resident every two hours but had not done so because she was busy. She confirmed that the resident had not received peri-care for over four and a half hours. CNA #2 stated she is expected to provide peri-care every two hours. She acknowledged the resident could develop a urinary tract infection and skin infection from the delay in care. On 05/14/25 at 11:50 AM, the Director of Nursing (DON) stated in an interview that Resident #8 should be checked and changed every two hours if soiled. She further stated that if a resident is a heavier wetter, they should be checked every hour. She confirmed that her expectation of CNAs is to check and change residents every two hours to ensure they remain dry and clean. The DON acknowledged that residents left soiled for extended periods are at risk for skin breakdown and skin infections. A record review of Resident #8's admission Record revealed an original admission date of 08/22/06, with diagnoses including acute kidney failure and mild intellectual disabilities. A record review of the Minimum Data Set (MDS) for Resident #8, conducted 3/20/25, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired and reliant on staff for care.

Based on observation, interviews, record review, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of property and exploitation for one (1) of fourteen (14) sampled residents. Resident #40 Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, with a revision date of 4/17, revealed, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents .Policy Explanation and Compliance Guidelines .9. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion . A review of the facility's Vulnerable Adult Act, undated, revealed, .Any nursing home resident is considered to be a vulnerable adult .the following situation are considered CRIME OF ABUSE against vulnerable adults .theft or misuse of a resident's personal belongings, personal funds, or bank accounts . A record review of the Reportable Incident Form dated 12/18/23, revealed the Director of Nursing (DON) began an investigation because Resident #40 reported that she had several incidents where she had given staff members money or allowed them to use her debit card. Resident #40 stated that she helped Certified Nurse Aide (CNA) #2 because she had three small children. The resident stated that she gave them money of her own free will. The resident stated that she sent CNA #3 to a local sandwich shop to get her something and she allowed her to buy something for herself. Both CNAs denied taking money from the resident and both CNAs were placed on suspension pending the completion of the investigation. The facility held a Quality Assurance and Performance Improvement (QAPI) meeting to discuss the allegation and the recommendation was to continue the investigation. In-services of the Abuse and Neglect Policy were initiated for staff. A record review of the Face Sheet revealed the facility admitted Resident #40 on 8/12/23 and she had current medical diagnoses including Right Heart Failure and Morbid Obesity. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2023, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she was cognitively intact. On 1/23/24 at 10:46 AM, in an observation and interview with Resident #40, she reported that CNA #2 frequently entered her room while on the phone with her boyfriend and she would overhear her complaining to him about needing money to care for her two children and the one she was presently pregnant with. The resident expressed that she understood what it is like to raise children independently while struggling financially, so she volunteered to assist CNA #2 by sending her some money via Cash App (a mobile payment service). She stated that CNA #2 provided her Cash App username, and she gave her $75.00. An observation of the information on Resident #40's cell phone revealed a Cash app transaction for $75 to CNA #2 on 9/25/23 at 11:51 AM. The resident stated that the CNA returned to her room again after the baby was born, and they began to talk about her baby. She stated that during the chat, CNA #2 mentioned that she had nothing for her newborn baby and so she ordered CNA #2 a $50 (Proper Name) online retail gift card, so she could buy some things for her baby. She stated that the card was mailed to the facility, and when it arrived, she gave it to CNA #2. An observation of the resident's (Proper Name) of online retailer account on her cell phone revealed a transaction, dated 11/28/23 for $50.00. The resident also stated that she told the DON about the gifts, but it was not to get anyone in trouble; however, she knew that CNA #2 got suspended for a few days. Resident #40 stated that when CNA #2 returned to work, she came into her room and gave her home address to Resident #40, indicating that she should send all future purchases for the baby to her home address rather than to the facility. An observation of Resident #40's Notes application on her cell phone revealed a mailing address had been entered on 12/17/23. Resident #40 stated that she would also allow CNA #3 to use her bank card to purchase herself (Resident #40) and CNA #3 food. An observation of electronic transactions on Resident #40's cell phone revealed transactions on 12/3/23 for $18.33 to (Proper Name) of sandwich shop and $10.87 to (Proper Name) of a liquor store which she stated was purchased with her card by CNA #3. The resident stated that she did not drink or smoke and indicated that the transaction for the liquor store was for CNA #3. In addition, the resident stated that she provided CNA #3 with her bank card for gas for her car on 11/27/23. An observation of the transaction on Resident #40's cell phone revealed a transaction for $26.02 (Proper Name) of local convenience store and was dated 11/28/23. The resident pointed out that the transaction occurred on 11/27/23 but did not post to her account until 11/28/23. CNA #3 On 1/24/24 at 1:51 PM, in a phone interview with Certified Nursing Assistant #3 (CNA), she claimed that 12/3/23 Resident #40 asked her to pick up lunch from (Proper Name) of sandwich shop. CNA #3 agreed to go but declined to get lunch for herself. She stated that she went out multiple times for Resident #40 and used the resident's bank card to buy food for her because she did not think it was a problem. CNA #3 denied using the resident's card at the convenience and the liquor store. CNA #3 verified that she understood the meaning of exploitation and vulnerable adults, but she disputed that using the resident's card to buy the resident something did not resemble exploitation. She stated she was suspended pending a facility investigation. However, following the investigation, she stated that she was asked to come back to work but was unable to do so due to her child's illness. A record review of the Time/Attendance Detail report revealed CNA #3 clocked in on 11/27/23 at 2:57 PM and clocked out 7:37 PM. She clocked back in at 8:01 PM and clocked out at 10:30 PM. On 12/3/23, CNA #3 clocked in at 2:57 PM and out at 7:41 PM, and clocked in at 8:04 PM and out at 10:21 PM A record review of the Transaction Details for Resident #40's prepaid banking card revealed a transaction dated 11/28/23 at 7:49 AM for $26.02 to (Proper Name) of local convenience store. A record review of the banking transactions on 12/3/23 for Resident #40 revealed a transaction for $10.87 for (Proper Name) liquor store and $18.33 for (Proper Name) sandwich shop. A record review of the Vulnerable Adult Act document revealed CNA #3 was trained by the facility regarding the vulnerable adult act on 2/12/2016. CNA #2 On 1/24/24 at 2:26 PM, in a phone interview with CNA #2, she acknowledged that she was suspended from her position as a CNA because she received $75.00 via cash app from Resident #40 on 9/25/23. She stated that it all began when she entered the resident's room to provide care. She stated that after the resident saw she was pregnant, she asked if she could buy something for the baby. CNA #2 stated that she told the resident she did not want her to do so, but the resident insisted and sent the money away. CNA #2 stated that it slipped her mind to notify the Administrator that she had received the money. CNA #2 acknowledged that she did not return the money to Resident #40. CNA #2 denied that Resident #40 had given her a $50.00 (Proper Name) online retail gift card. She was unable to explain how Resident #40 had her home address. CNA #2 confirmed that she returned to work after the facility's investigation was completed and she currently worked the 3 PM to 11 PM shift. A record review of the Time/Attendance Detail report revealed CNA #2 clocked in on 11/28/23 at 3:18 PM and clocked out 8:52 PM. She clocked back in at 9:06 PM and clocked out at 11:36 PM. On 12/17/23, CNA #3 clocked in at 3:05 PM and out at 11:33 PM. A record review of the Cash App screenshot on Resident #40's cell phone revealed a payment of $75 on 9/25 (2023) at 11:51 AM to CNA #2's Username. A record review of the Order Details dated 11/28/23, revealed a transaction for $50 for a gift from an online retailer with the Purchase Details indicating the gift card was from Resident #40 with a Message of Hope you enjoy this gift card! A record review of the Notes application screenshot on Resident #40's phone revealed a note dated 12/17/23 at 4:39 PM of a home address. A record review of the Application for Employment for CNA #2, dated 3/31/23, revealed the home address indicated on the application matched the home address that was entered in the Notes application of Resident #40's cell phone. A record review of the Vulnerable Adult Act document revealed CNA #2 was trained by the facility regarding the vulnerable adult act on 4/18/2023. In an interview on 1/25/24 at 8:20 AM, with the Administrator, she confirmed knowledge of the incident involving CNA #2, CNA #3, and Resident #40. She revealed that she did not believe that Resident #40 was exploited by the CNAs based on her understanding of the company policies and because Resident #40 had a high BIMS score. The Administrator explained that the previous Director of Nursing (DON) wrote the entire investigation, and she was not involved in the initial investigation because she had been out of the building for three (3) days. Upon her return to the facility, she said she and the DON consulted with their Board Attorney and all agreed that the resident was of sound mind with a high BIMS score and that she was not exploited. As a result, she could not substantiate the complaint and approved CNA #2 and CNA #3 to return to work after their 3-day suspension. She explained CNA #2 returned to work, however CNA #3 elected not to return to work.

Based on staff interview, record review, and facility policy review, the facility failed to provide appropriate corrective action to prevent further potential misappropriation and exploitation by allowing a Certified Nurse Aide (CNA #2) access to a previous victim (Resident #40) for one (1) of 14 sampled residents. Findings include: Review of the facility's policy, Abuse, Neglect and Exploitation, with a revision date of 4/2017, revealed, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .The facility must .8. Resident Protection after Alleged Abuse, Neglect and Exploitation-The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation . A record review of the Reportable Incident Form dated 12/18/23, revealed the Director of Nursing (DON) began an investigation because Resident #40 reported that she had several incidents where she had given staff members money or allowed them to use her debit card. Resident #40 stated that she helped CNA #2 because she had three small children. The resident stated that she gave the money of her own free will. CNA #2 was placed on suspension pending the completion of the investigation. During an interview on 1/23/24 at 10:46 AM, with Resident #40, she stated that she had told the DON about money and gifts she was providing to CNA #2, but it was not to get anyone in trouble. However, she knew that CNA #2 got suspended for a few days. Resident #40 said that when CNA #2 returned to work, she came into her room and gave her home address, indicating that she may send all future purchases for the baby to her home address rather than the facility. On 1/24/24 at 2:26 PM, in a phone interview with CNA #2, she confirmed that she was suspended from her position as a CNA during the investigation related to Resident #40, and she returned to work after the investigation was completed. CNA #2 verified that she currently worked at the facility on the 3 PM to 11 PM shift. On 1/25/24 at 8:20 AM, in an interview with the Administrator, she confirmed knowledge of the incident related to CNA #2. She stated that Resident #40 was not exploited based on her understanding of their company policies and Resident #40's high BIMS score. She advised that the previous DON wrote the entire investigation because she had been out sick. When she returned, she consulted with the facility's Board Attorney and all agreed that the resident was of sound mind with a high BIMS score and was not a victim of exploitation. As a result, she could not substantiate the complaint and approved CNA #2 to return to work after the 3-day suspension. The Administrator added that as part of their correction plan, the CNA #2 was reassigned to another hall in the facility which was located away from the resident. The Administrator stated that although CNA #2 was reassigned, she could not guarantee that CNA #2 would not walk over to the resident's room. A record review of the Face Sheet revealed the facility admitted Resident #40 on 8/12/23 and she had current medical diagnoses including Right Heart Failure and Morbid obesity. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2023, revealed Resident #40 had a BIMS score of 13 which indicated she was cognitively intact.

Based on observation, staff interview, record review and service manual review the facility failed to assess residents for the risk of entrapment, obtain informed consent, and conduct routine preventative maintenance per the manufacturer's recommendations/specifications for bed rails for five (5) of fourteen (14) sampled residents. (Resident #4, #6, #28, #29 and #39) Findings Include: Observations of resident rooms on 1/23/24 from 10:00 AM to 12:17 PM, revealed Residents #4, #6, #28, #29, and #39 had beds that were the brand name of Basic American Matrix 709 Matrix II and had bilateral quarter (1/4) length bed rails. Review of the medical record for Residents #4, #6, #28, #29 and #39 revealed there were no resident entrapment risk assessments and no signed informed consent forms for the use of the bed rails. Record review of the Service Manual for Basic American's Matrix 709 Series, dated 2011, revealed, . When assessing the risk for entrapment, you need to consider your bed, mattress, head and footboards, half rails, assist bars, and other accessories for an entire system A resident/patient's condition could lead to resident patient entrapment. It is extremely important to review the resident patient's physical and mental condition . address any entrapment risk .Recommended Maintenance & Inspection Schedules .Mechanical inspection of assemblies (6 months) .Inspect all fasteners for wear and looseness . During an interview on 01/24/24 at 11:36 AM, with the Director of Nursing (DON), she confirmed there were side rails on most of the beds in the facility. She stated they were not used as a restraint, and there were no consents signed by the resident or the resident representative (RR) for the use of bedrails. During an interview on 01/24/24 at 2:03 PM, with Maintenance Director #1, he stated that he checked bed rails if someone complained about them. He confirmed there was no maintenance schedule to check the bed rails periodically. An interview on 01/25/24 at 11:36 AM, with the Administrator, revealed bed rails were used in the facility and there was no maintenance plan regarding checking the bed rails. Resident #4 Record review of the Face Sheet revealed the facility admitted Resident #4 on 4/26/22 and had current medical diagnoses including Atherosclerotic Heart Disease and Hypertension. Record Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/21/23 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated her cognition was moderately impaired. Resident #6 Record review of the Face Sheet revealed the facility admitted Resident #6 on 07/08/05 and had current medical diagnoses including Osteoarthritis. Record review of the admission MDS, with an ARD of 12/12/23, revealed Resident #6 required a staff interview to assess cognition and her cognition skill for daily decision making was severely impaired. Resident #28 Record review of the Face Sheet revealed the facility admitted Resident #28 on 08/28/23 and he had current medical diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Peripheral Vascular Disease. Record review of the Quarterly MDS with an ARD of 11/28/23 revealed Resident #28 had a BIMS score of 6 which indicated his cognition was severely impaired. Resident #29 Record review of the Face Sheet revealed the facility admitted Resident #29 on 10/25/22 and had current medical diagnoses including Type 2 Diabetes Mellitus. Record review of the Annual MDS with an ARD of 10/20/23, revealed Resident #29 had a BIMS score of 14 which indicated he was cognitively intact. Resident #39 A record review of the Face Sheet revealed the facility admitted Resident #39 on 8/11/23 with current medical diagnoses including Hemiplegia following Cerebral Infarction affecting left dominant side. Record review of the Quarterly MDS with an ARD of 11/14/23 revealed Resident #39 had a BIMS score of 14 which indicated he was cognitively intact.

Based on record review and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) reflecting anticoagulant medications for four (4) residents of twelve (12) sampled residents whose MDS Assessments were reviewed for accuracy. (Resident #1, Resident #10, Resident #20, Resident #36). Findings include: A record review of the facility's statement, dated 12/29/21 and signed by the Director of Nursing (DON) revealed, (Proper Name of facility) uses the Resident Assessment Instrument (RAI) manual for Minimum Data Set (MDS) completion. A record review of the Davis's Drug Guide for Nurses Fifteenth Edition 2015 revealed the classification of Clopidogrel (Plavix) is listed as therapeutic: antiplatelet agents and Pharmacologic: platelet aggregation inhibitors. On 12/29/21 at 2:29 PM, during an interview with Registered Nurse (RN) #2 MDS nurse, she reviewed the most recent MDS assessments as well as the corresponding Medication Administration Records (MARs) for Resident #1, Resident #10, Resident #20, and Resident #36 and confirmed they did not receive an anticoagulant medication during the look back periods. She stated Resident #10 was previously on an anticoagulant medication, but several of her medications had been discontinued and that it was just my error to code the resident as receiving an anticoagulant. The MDS nurse stated she is new in the MDS nurse position and it is a learning curve because she incorrectly coded Plavix as an anticoagulant medication. On 12/29/21 at 2:40 PM, during an interview with the DON, she confirmed Plavix should not have been classified as an anticoagulant medication. She stated that the MDS assessments should be coded accurately. Resident #1 A record review of the resident's Face Sheet revealed the facility admitted Resident #1 on 8/28/2011 and diagnoses include Muscle Weakness, Chronic Obstructive Pulmonary Disease, Other Specified Peripheral Vascular Diseases, and Unspecified Atrial Fibrillation. A record review of Resident #1's Physician Orders for the month of December 2021 revealed a physician order with an order date of 10/16/2014 for Plavix 75 mg tablet 1 PO (by mouth) daily. A record review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/21 revealed coding in Section N as Resident #1 received anticoagulant medication for seven (7) days out of the seven (7) day look back period. A record review of Resident #1's Medication Record (Administration Record) (MAR) for December 2021 revealed Plavix 75 mg was administered daily and there were no anticoagulant medications administered. Resident #10 A record review of Resident #10's Face Sheet revealed the resident was readmitted by the facility on 1/11/21 with diagnoses including Acute Embolism and Thrombosis of the left femoral vein. A record review of the Physician Orders for October 2021 revealed Resident #10 does not have an order for an anticoagulant medication. A record review of the MDS with an ARD of 10/6/21 revealed Resident #10 was coded as receiving an anticoagulant for seven (7) days. A record review of the MAR for October 2021 revealed an anticoagulant medication was not given. Resident #20 A record review of Resident #20's Face Sheet revealed the facility admitted the resident on 6/25/18 with the diagnoses of Cerebral Infarction, Type 2 Diabetes, High Blood Pressure, Anxiety, Vascular Dementia with Behavioral Disturbances, and Major Depressive Disorder. A record review of Physician Orders for Resident #20 for the month of October 2021 and November 2021 revealed an order for Plavix 75 mg tablet one tablet by mouth daily with a start date of 03/20/20 and no anticoagulant medications were ordered. A record review of annual MDS with an ARD of 11/04/21 revealed Resident #20 received five (5) days of an anticoagulant in the seven (7) days look back reference period. A record review of the MAR for Resident #20 for October 2021 and November 2021 revealed no anticoagulant medication was given in the seven (7) day look back reference period. Resident #36 Review of the Face Sheet revealed Resident #36 was readmitted by the facility on 12/15/20 with diagnoses including history of Transient Ischemic Attack and Cerebral infarction. A record review of Physician Orders for November and December of 2021 revealed a physician's order dated 12/15/20 for Clopidogrel 75 mg tablet give one tab by mouth daily. There were no orders for an anticoagulant medication. A record review of the MDS with an ARD of 12/4/21 revealed it was coded as Resident #36 received an anticoagulant for seven (7) days. A record review of the MAR for November and December 2021 revealed no anticoagulant medication was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not changing gloves after removing a soiled dressing during wound care for one (1) of three (3) residents observed during wound care. (Resident #30). Findings include: Record review of the facility policy titled, Hand Hygiene Policy , reviewed 11/21, revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand Hygiene Table .After handling contaminated objects .Before and after handling clean or soiled dressings, linens, etc After handling items potentially contaminated with blood, body fluids, secretions, or excretions . (marked X) Either Soap and Water or Alcohol Based Hand Rub . Record review of the facility policy titled Infection Prevention and Control Program Policy dated 8/21, revealed .4. Standard Precautions: .b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Record review of the facility policy titled, Wound Treatment Policy Reviewed 2021, revealed Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and /or cross-contaminations .Policy Explanation and Compliance Guidelines: .12. Loosen the tape and remove existing dressing .13. Remove gloves, pulling inside out over the dressing .14. Wash hands and put on clean gloves . During the wound care observation, on 12/28/21 at 11:26 AM, for Resident #30, Registered Nurse (RN) #1 did not change her gloves, wash or sanitize her hands, or don clean gloves after removing the soiled wound dressings and before touching clean supplies to clean and dress the wounds on the left trochanter and sacrum. During an interview with RN #1 on 12/29/21 at 1:19 PM, she stated she had gotten nervous during the procedure and thought she had completed the procedure correctly. She confirmed she should have removed her gloves, performed hand hygiene, and donned a new pair of gloves before touching clean supplies. She also confirmed this infection control breach could cause the resident to have a wound infection. During an interview with the Director of Nursing (DON) on 12/29/21 at 1:32 PM, she stated RN #1 should have changed her gloves and performed hand hygiene after removal of the soiled dressing and before handling clean supplies as per the facility's policies. She confirmed that by not changing her gloves and using hand hygiene, the resident could acquire an infection. A record review of NIPP: Nursing Home Infection Prevention Program .Nipping Infections in the [NAME] Hand Washing with Soap and Water Evaluation Form revealed on 1/19/21, RN #1 performed hand washing skills indicating she has been trained on hand washing. A record review of Validation Checklist Hand Hygiene dated 12/8/21, revealed RN #1 was observed performing hand hygiene correctly. A record review of training dated 7/21/21 revealed RN #1 received training on Skin/wound care, Pressure Injury/Ulcer Prevention. A record review of training dated 11/3/21 revealed RN #1 received training on Pressure Ulcers. A record review of training dated 8/17/21 revealed RN #1 received training on Infection Control. A record review of Physician Orders for the December 2021 revealed an order dated 12/27/21 to Clean unstageable decubitus to sacrum (slough) with NS(Normal Saline)/Wound Cleanser Pat dry apply calcium alginate and cover with a bordered gauze daily and prn (as needed) and an order dated 12/10/21 to Clean Stage II decubitus to left trocanter with NS/Wound Cleanser Pat dry apply hydrogel and cover with a bordered gauze daily. A record review of the Face Sheet revealed Resident #30 was admitted on [DATE] with diagnoses including Unspecified Intellectual Disabilities, Schizophrenia, Hypertension, and Other Seizures.