Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure one (1) of two (2) residents observed for incontinent care (Resident #41) received appropriate incontinence care to prevent the potential for urinary tract infections and skin breakdown. Specifically, staff failed to completely cleanse the resident during perineal care, resulting in fecal matter remaining on the resident's skin and in the perineal area. Findings Include: A review of the facility's policy titled Perineal Care, revised 05/21/25, revealed: to cleanse and dry the perineal area to promote comfort, prevent infection and skin irritation, and to emphasize good perineal hygiene. On 05/18/25 at 11:59 AM, Resident #41 was observed in bed with a tracheostomy in place. A strong odor of feces was noted in the room. On 05/19/25 at 11:36 AM, Resident #41 was observed in a wheelchair with eyes closed. A strong fecal odor remained in the room. On 05/19/25 at 1:20 PM, an observation of perineal care was conducted by Certified Nursing Assistant (CNA) #1, assisted by CNA #2. The CNAs used a total lift to transfer the resident from a specialized motorized wheelchair to the bed. A moderate amount of yellow feces was observed in the wheelchair. CNA #1 wiped the vaginal area front to back several times and assisted the resident onto her right side. CNA #2 wiped the buttocks front to back. The CNAs then turned the resident and applied a clean brief. The State Agency (SA) surveyor observed feces on the resident's lower left thigh and requested the CNAs check for cleanliness. Upon turning the resident to her right side, the CNAs wiped the left thigh two times, and each wipe revealed feces. CNA #1 then re-cleaned the vaginal area, wiping six additional times until no feces remained. A clean brief was reapplied following this care. On 05/19/25 at 1:52 PM, during an interview, CNA #2 stated it is very important that Resident #41 receive thorough perineal care to prevent odor and bed sores. She confirmed that feces were left on the resident's thigh and vaginal area after the initial cleaning. She admitted she did not see the feces but acknowledged that CNA #1 wiped the vaginal area six additional times to remove it. On 05/19/25 at 1:58 PM, during an interview, CNA #1 stated, It is very, very important that the care is done completely. She confirmed that she left feces in the vaginal area and that she had to wipe it six additional times to properly clean the resident. She stated, I did not provide care properly. On 05/21/25 at 9:40 AM, during an interview, the Director of Nursing (DON) stated that CNAs should provide a bath when a resident has a significant amount of stool. She confirmed that Resident #41 should have been cleaned thoroughly, and failure to do so could lead to infection and skin breakdown. She added that her expectation is that staff do a great job keeping residents clean and dry and confirmed that the facility has high expectations for staff performance. A record review of Resident #41's admission Record revealed an original admission date of 01/10/23 with a diagnosis of Neurogenic bowel, not elsewhere classified. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/25 revealed the resident was severely cognitively impaired and was totally dependent on staff for toilet hygiene, per Section GG.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to secure smoking materials in a safe manner for one (1) of two (2) smokers in the facility. Resident #15 Findings Include: Review of facility policy titled Smoking Program with a revision date of 3/10/2023 revealed under, Procedure . Residents should have smoking materials labeled and locked in the medication room. Residents should not have smoking, vaping, lighters or other smoking devices or material in their possession or in their room . An observation and interview on 4/10/2024 at 9:15 AM, with Resident #15 revealed he was sitting in a motorized wheelchair in his room. A small green box that was labeled (proper name of cigarette brand) was lying on his lap. The contents of the box contained 10 cigarettes and the resident acknowledged that he had a cigarette lighter in his possession as well. An observation and interview on 4/10/2024 at 9:20 AM, with Registered Nurse (RN) #1, confirmed Resident #15 had a pack of cigarettes and a lighter in his possession, which was a fire hazard for the facility. She revealed smoking materials were to be kept locked at the nurse's desk and never in the possession of the resident. An interview with the Director of Nursing (DON) on 4/10/2024 at 4:50 PM, confirmed smoking materials were to be stored in the medication room due to potential accident hazards. Record review of Resident #15's Safe Smoking Assessment dated 3/11/2024 revealed . Resident Observation .Does resident attempt to keep smoking paraphernalia on self or in room? No was answered. Record review of Resident #15's Face Sheet revealed the facility admitted the resident on 11/06/2008 with medical diagnoses that included Quadriplegia and Tobacco use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to ensure an as-needed (PRN) psychotropic medication had a stop date for two (2) of five (5) residents reviewed for unnecessary medications. Resident #27 and Resident #33 Findings Include: Review of the facility policy titled Medication Management dated 1/2024 revealed, Based on a comprehensive assessment of a resident, the facility must ensure: . PRN (as needed) orders for psychotropic drugs are limited to 14 days. Exceptions: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN (as needed) order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN (as needed) order. Resident #27 Record review of the April 2024 Physician Orders for Resident #27 revealed an order dated, 10/25/23, Xanax (antianxiety) 0.5 - 1.0 MG (milligram) tablet: Administer 0.5 - 1.0 milligram(s) by mouth PRN Q (every) 8 HRS (hours) PRN (as needed) for anxiety with no stop date. Record review of Resident #27's Face Sheet revealed the facility admitted the resident on 11/03/2017 with medical diagnoses that included Quadriplegia, Post-traumatic stress disorder, Generalized anxiety disorder, and Major depressive disorder. Resident #33 Record review of the April 2024 Physician Orders revealed an order dated 8/3/23 for Clonazepam 0.5 mg (milligram) tablet Administer 0.5 milligram(s) by mouth as necessary daily PRN. There was not a stop date for this medication. Record review of Face Sheet revealed Resident #33 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Major depressive disorder, and Generalized anxiety disorder. An interview on 4/10/24 at 4:25 PM, with the facility's Pharmacy Consultant revealed he was aware of the regulations requiring a stop date for PRN psychotropic medications. He stated these residents were a special population that had been on those medications for a long period of time. He confirmed Resident #27's PRN order for Xanax did not have a stop date and confirmed Resident #33 had an active order for PRN Clonazepam, which was a psychotropic medication, that did not have a stop date as required. He also revealed he had not notified the physician that PRN psychotropic medications required a stop date. During an interview on 4/10/24 at 4:30 PM, the DON revealed she was unaware of the requirement for PRN psychotropic medications to have a stop date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by lack of a biohazard container in one (1) of three (3) residents on transmission-based precautions on initial entrance to the facility. Resident #25 Findings include: Record review of facility policy titled, Tracheostomy Care revised 4/11/24, revealed, Procedure: Remove and throw away inner cannula . i. If resident is on MDRO (multi-drug resistant organism) isolation, dispose of in biohazard bag. Record review of facility policy titled, Isolation - Categories of Transmission-Based Precautions, dated 4/1/24, revealed, .Policy Interpretation and Implementation: 1. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. An observation and interview on 04/09/24 at 10:40 AM, revealed signage on Resident #25's door for droplet isolation. An interview with the Respiratory Therapy (RT) Supervisor revealed the resident had bacteria in his sputum that required droplet isolation and gowns, gloves, masks, and goggles were needed when entering room. Record review of lab results of the sputum culture dated 3/15/24, revealed result of Carbapenem-resistant pseudomonas aeruginosa Heavy growth. Record review of the April 2024 Physician Orders revealed an order dated 2/17/24 for Droplet isolation due to carbapenem-resistant pseudomonas aeruginosa in sputum. An observation and interview on 4/10/24 at 10:45 AM, with Licensed Practical Nurse (LPN) #1 revealed there was not a biohazard container for trash in the resident's room and the personal protective equipment (PPE) was being discarded in a regular trash can with a white plastic liner. LPN #1 revealed this resident was in droplet isolation and the infection control staff determined what to use for disposal of items in the isolation rooms and she was unsure why a red biohazard container was not used. An interview with the Infection Preventionist on 4/10/24 at 10:55 AM, revealed only residents in isolation for clostridium difficile colitis (C-diff) used a red biohazard trash system. She revealed Resident #25 tested positive for carbapenem-resistant pseudomonas aeruginosa in his sputum and for that bacteria, the staff contained the trash in a regular trash bag and it was disposed of with the regular trash. During an interview on 4/10/24 at 3:30 PM, the Director of Nursing revealed she thought items from a resident positive for carbapenem-resistant pseudomonas aeruginosa could be disposed of in the regular trash if there was not a large amount of bodily fluid on the items. She confirmed that the inner trachea cannula of Resident #25 contained sputum fluid from the trachea and had the potential to spread infection. She stated the regular trash bag had no identifying information that would alert others of the infectious waste. She confirmed that by not disposing of infectious material properly, the potential for the spread of infection could increase. Record review of Face Sheet revealed the resident was admitted to the facility on [DATE] with the diagnoses of Hemiplegia, dependence on respirator ventilator status, and Tracheostomy status.