Based on interviews, record review, and facility policy review, the facility failed to administer intravenous (IV) antibiotics for Resident #1 as ordered for two (2) of three (3) scheduled doses. Findings Include: Review of the facility's policy, Physician Orders, revised 3/3/2021, revealed, .The center will ensure that Physician orders are appropriately and timely documented in the medical record . Review of the facility's policy, Administering Medications, revised April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .21. If a drug is .given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose . Record review of the admission Record revealed the facility admitted Resident #1 on 3/28/25 with diagnoses including Sialoadenitis and Bacteremia. Record review of the Order Summary Report revealed Resident #1 had a Physician's Order, dated 3/28/25, for ceFAZolin Sodium Intravenous Solution Reconstituted 2 GM (Grams) .Use 2 gram intravenously every 8 (eight) hours for parotitis; sepsis . Record review of the Electronic Medication Administration Record (EMAR) revealed Resident #1 received one (1) dose of Cefazolin Sodium 2 grams IV on 3/29/25 at 0600 (6:00 AM), and the scheduled doses for 3/28/25 at 2200 (10:00 PM) and 3/29/25 at 1400 (2:00 PM) were not documented as administered. Record review of the Omnicell medication dispensing record revealed Cefazolin (1 gram × 2 vials) was removed from emergency stock on 3/29/25 at 10:12 AM by the Director of Nursing (DON). The facility's Omnicell showed pre-stocked Cefazolin 1 gram vials available in emergency stock. Record review of the Progress Notes revealed a General Progress Note, dated 3/28/25 at 19:35 (7:35 PM) for Resident #1, which documented Resident arrived to facility at approx (approximately) 1830 (7:30 PM). A General Progress Note, dated 3/29/25 at 21:29 (9:29 PM) for Resident #1 revealed, .IV ATB (Antibiotics) unable to be administered at 2 gm IM (Intramuscular), this writer informed resident and her daughter, per daughter resident needs sent to ER (Emergency Room) to receive ATB . On 4/29/25 at 10:30 AM, during a phone interview with Resident #1's Resident Representative (RR), she stated Resident #1 did not receive any of the prescribed antibiotics until mid-morning on 3/29/25, and that no further doses were administered. The family requested the resident be transferred back to the local hospital on 3/29/25 later that night so that she could receive her IV antibiotics at the correct times. On 4/29/25 at 2:16 PM, during an interview, the former DON confirmed that although she intended to administer the 10:00 PM dose on 3/28/25, due to personal circumstances, she did not administer that dose and did not inform the Administrator. She acknowledged giving the 3/29/25 6:00 AM dose late, at approximately 10:12 AM but documented the dose on the MAR incorrectly as administered at 6:00 AM. She further stated that the 2:00 PM dose on 3/29/25 was not administered. On 4/30/25 at 9:00 PM, during an interview, the Nurse Practitioner (NP) confirmed that IV antibiotics ordered every 8 hours must be administered as prescribed. She stated that missed or delayed doses could contribute to delayed recovery and increased patient suffering. On 4/30/25 at 2:16 PM, during an interview, the Interim DON confirmed that although she was not present at the time of the incident, the facility's policies require timely medication administration by licensed staff. She confirmed the EMAR and Omnicell record showed only one (1) dose given before the resident's transfer to the ER and acknowledged that the 6:00 AM dose was signed as given but not administered until 10:12 AM, constituting a late and improperly documented dose. She stated this failure violated the facility's expectations and placed the resident at risk for delayed treatment and prolonged infection. The Interim DON also confirmed that the resident's family requested the resident be transferred to the hospital due to the facility's inability to administer the IV antibiotics on schedule.

Based on staff interview, record review, and facility policy review, the facility failed to notify the medical provider until the next day that Resident #1, who was prescribed apixaban (an anticoagulant medication), had a fall for one (1) of three (3) sampled residents (Resident #1). Findings include: A review of the facility's policy titled Notification of Change in Condition, revised 12/16/2020, revealed, .Policy: The Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. Procedure .The nurse to notify the attending physician and Resident Representative when there is a(n): Accidents . A record review of the admission Record revealed the facility admitted Resident #1 on 5/22/24 with current diagnoses including Muscle Weakness. A record review of the facility's fall investigation, dated 2/18/25 at 5:42 PM, revealed Resident #1 had a fall in the dining room and the Nurse Practitioner (NP) was not notified until the following day on 2/19/25. A record review of the facility's Change in Condition (SBAR) form, dated 2/18/25 at 5:42 PM, which was the time of the fall, revealed .C. Review and Notify 1. Primary Care Clinician Notified .2. Date/Time notified .3. Recommendation of Primary Clinician . were blank with no indication of physician notification of the fall and/or change in resident's condition. A record review of the Medication Administration Record (MAR) for February 2025, revealed Resident #1 was administered Apixaban (anticoagulant medication) two times daily for the month of February. A record review of the Discharge Instructions from the local Emergency Department (ED), dated 2/19/25, revealed Resident #1 had a diagnosis of Fall; Left hip pain; Low back pain. On 3/6/25 at 12:45 PM, an interview with License Practical Nurse (LPN) #1 confirmed that Resident #1 was found sitting on the floor attempting to get up on 2/18/25. She assisted the residents' nurse (LPN #2) with an assessment and then assisted the resident to her wheelchair and took her to her room. On 3/6/25 at 1:00 PM, in an interview, the Director of Nurse (DON) confirmed on 2/18/25 Resident #1 had a fall, and the medical provider was not notified until the following day on 2/19/25. She confirmed that it is the facility's policy to notify the medical providers following any type of fall. On 3/6/25 at 1:15 PM, during an interview with the NP, she confirmed that she was notified on 2/19/25 of Resident #1's fall that occurred on 2/18/25. She stated after she was notified, she requested the resident be sent to a local ED for evaluation and treatment. She confirmed if she had been notified immediately after the fall, she would have ordered the resident to be sent to the ED at that time. On 3/6/25 at 1:45 PM, during an interview, LPN #2 confirmed that she was Resident #1's nurse at the time of the fall she did not report the fall incident to the NP on 2/18/25, following the incident.

Based on staff interview, record review, and facility policy review, the facility failed to ensure that resident records were complete and accurate, as evidenced by missing documentation of a post-fall assessment, including vital signs, for one (1) of three (3) sampled residents (Resident #1). Findings include: A review of the facility's policy Fall Management, revised 7/29/2019, revealed, .C. Post Fall Strategies: 1. Resident will be evaluated and post fall care provided . A record review of the admission Record revealed, the facility admitted Resident #1 on 5/22/24 with current diagnoses including Muscle Weakness. A record review of the facility's fall investigation, dated 2/18/25 at 5:42 PM, revealed, Immediate Action Taken included that the nurse assessed vital signs and range of motion (ROM) for the resident. The resident demonstrated active ROM for all extremities and verbally denied pain or discomfort. The resident was assisted back to her wheelchair and taken to her room and placed in her bed. A record review of the electronic clinical record for Resident #1 at the time of survey including the Change in Condition (SBAR) had a Status indicating Errors A record review of the facility's Change in Condition (SBAR) form, dated 2/18/25 at 5:42 PM, which was the time of the fall, revealed the form was incomplete and did not include information including recent vital signs. The form indicated a Medication Alert due to Resident/patient is on other anticoagulant . A record review of the Medication Administration Record (MAR) for February 2025, revealed Resident #1 was administered Apixaban (anticoagulant medication) two times daily. On 3/6/25 at 12:45 PM, an interview with License Practical Nurse (LPN) #1 confirmed that Resident #1 had a fall and she assisted LPN #2 with assessing the resident before taking her to her room. During an interview with the Director of Nursing (DON) on 3/6/25 at 1:00 PM, she confirmed Resident #1 had a fall on 2/18/25, and Resident #1's nurse did not complete a detailed evaluation of the resident, including documentation of vital signs following the fall. She stated it was the facility's policy for an assessment with vital signs to be performed and recorded following a fall. During an interview with LPN #2, on 3/6/25 at 1:45 PM, she confirmed that she did not perform vital signs immediately after the fall, but she did perform an assessment. She stated she was very busy following the fall and failed to record the outcome of her assessment.

Based on interview, record review, and facility policy review, the facility failed to ensure staff competency in medication reconciliation, which resulted in a nurse accessing the wrong resident's records and transcribing incorrect medication orders into the system without verification. This failure led to the prolonged administration of incorrect medications for one (1) of four (4) sampled residents reviewed for medication administration. Resident #1. Findings include: A review of the facility's policy and procedures titled Physician's Orders, revised on 03/03/2021, revealed, The facility will ensure that physician orders are appropriately and timely documented in the medical record. Information received from the referring facility or agency must be reviewed, verified with the physician, and transcribed to the electronic medical record . The nurse transcribing the order is responsible for ensuring accuracy and compliance with physician instructions . A record review of the acute hospital's Discharge Information, dated 11/22/2024, revealed Resident #1's Your Medication List included Acetaminophen 500 milligrams (mg) by mouth every six hours as needed for mild pain, Amoxicillin-clavulanate 875/125 mg by mouth in the morning and one tablet before bedtime for two (2) days, Aspirin 81 mg delayed-release by mouth in the morning, B Complex with Vitamin C by mouth in the morning, Bisacodyl 10 mg suppository rectally daily as needed for constipation, Diphenhydramine and Zinc Acetate Cream applied topically three times daily as needed for itching, Docusate Sodium 100 mg by mouth in the morning and one capsule before bed, Ergocalciferol 1250 micrograms (mcg) (50,000 units) by mouth daily, Fexofenadine 180 mg by mouth in the morning, Lasix 20 mg by mouth every morning, Hydralazine 10 mg in the morning and 10 mg before bedtime, Hydrocodone/Acetaminophen 5/325 mg by mouth every six hours as needed for moderate pain, Hydroxyzine 25 mg by mouth three times a day as needed for itching, Ipratropium/Albuterol 0.5 mg/3 mg/2.5 mg base/3 ml nebulizer solution every six hours for three (3) days, and Phenol 1.4% sore throat spray as needed, and Polyethylene glycol 17 gram packet take seventeen grams by mouth in the morning. A record review of Resident #1's Medication Administration Record (MAR), dated 11/01/2024 through 11/30/2024, revealed Resident #1 received Amlodipine Besylate 5 mg by mouth daily for six (6), Aspirin 81 mg by mouth daily for six (6) days, B Complex by mouth daily for six (6) days, Carbidopa/Levodopa/Entacapone 12.5-50-200 mg by mouth daily for eight (8) days; Cyanocobalamin injection 1000 mcg intramuscular every 30 days for one (1) day, Ergocalciferol 1.25 mg every Friday for one (1) day, Eye-Vites Oral Tablet daily for six (days), Hydrochlorothiazide 12.5 mg by mouth daily for eight (8) days, Lasix 20 mg by mouth daily for six (6) days, Levothyroxine 137 mcg by mouth daily for seven (7) days, Omega-3 fatty acids 1200 mg by mouth daily for eight (8) days, Omeprazole 40 mg by mouth daily for seven (7) days, Potassium Chloride ER 10 meq by mouth for six (6) days, Ropinirole HCL 1 mg by mouth daily for eight (8) days, Vitamin D3 by mouth daily for eight (8) days, Buspirone HCL 15 mg by mouth twice daily for nine (9) days, Gabapentin 600 mg by mouth twice daily for nine (9) days, Multivitamin Oral Tablet two times daily for nine (9) days, Norco 5/325 mg by mouth every six (6) hours as needed for one (1) day (2 doses given), Oxycodone 5 mg every six (6) hours as needed for one (1) day (1 dose given), and Sertraline HCL 100 mg by mouth twice daily for nine (9) days. During an interview on 02/06/2025 at 9:00 AM, Registered Nurse (RN) #2 confirmed she received an email from the Marketer indicating Resident #1's information was available in the computer system. RN #2 admitted that she did not verify the physician's orders or confirm that the correct resident's information was uploaded before entering the orders into the facility's electronic health records (EHR) system. She no longer worked at the facility and was unaware that she had accessed another patient's chart and not the new admission (Resident #1) that was being discharged from the hospital. The nurse stated that she was trained in nursing school to follow the five rights when receiving a resident's information - the right patient, right medication, right route, right dose and right time. RN #2 explained that she was admitting numerous residents and was not thinking' at that time On 2/6/25 at 3:00 PM, the Administrator Assistant confirmed Resident #1 received the wrong medication for several days. She explained that RN #2 was the interim Director of Nursing (DON) at the time the medication error occurred. The Administrator Assistant stated that she was notified by RN#1 stating that the resident had received the wrong medication. A record review of Resident #1's admission Record revealed the facility admitted Resident #1 on 11/21/2024 with current diagnoses including Fracture of the Manubrium. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she was cognitively intact.

Based on record review and staff interviews, the facility failed to ensure a Registered Nurse (RN) was present at the facility for at least eight (8) consecutive hours a day for one (1) of eight (8) days reviewed. Findings included: A record review of the staffing grid revealed that a Registered Nurse (RN) did not work on 01/21/2025. A record review of the facility's Facility Assessment Tool, dated 07/31/2024, revealed that the facility's staffing plan was based on the resident population and their needs for care and support. The assessment indicated licensed nurses providing direct care were adjusted based on residents' activities and care needs per shift, with two (2) to four (4) licensed nurses per shift and a nurse-to-resident ratio of 1:20 to 1:30. The document also listed other nursing personnel responsible for administrative duties, including the Director of Nursing (DON), two (2) unit managers, a wound care nurse, and one (1) Minimum Data Set (MDS) coordinator. On 02/06/2025 at 8:00 AM, during an interview, the Interim DON stated that she had only worked at the facility for one (1) month. She stated that she had served in this role for two (2) weeks and had been working night shifts all week due to staff shortage. The Interim DON reported that on 01/20/2025, she worked from 8:00 AM to 1:30 PM. She further stated that a night shift nurse called in, and after going home for a few hours of rest, she returned to the facility at 6:00 PM and worked until 7:00 AM. She stated that she advised the Administrative Assistant to notify staff that they should prepare to stay overnight due to the weather and recommended that the maintenance department prepare rooms for staff to sleep in. The Interim DON reported that after working the full night shift, she needed to go home and rest. She further stated that the Administrator later called her to return to the facility on 1/21/25, but she was unable to drive due to severe weather conditions and did not return until the following day. On 02/06/2025 at 3:00 PM, during an interview, the Administrative Assistant confirmed that the facility did not have an RN on duty on 01/21/2025. She stated that the severe snowstorm prevented staff from coming in to assist and that two (2) Licensed Practical Nurses (LPNs) were available. The Administrative Assistant further stated that she and the LPNs remained at the facility to ensure the safety of the residents and the facility was actively recruiting RNs to fill the staffing gap.

Based on interviews, record review, and facility policy review, the facility failed to prevent significant medication errors, resulting in a resident receiving multiple unprescribed medications for up to eight (8) consecutive days, causing excessive sedation and the inability to participate in therapy (Resident #1), and failed to administer prescribed intravenous (IV) antibiotics on multiple occasions (Resident #4) for two (2) of four (4) sampled residents. Findings included: A review of the facility's policy titled Administering Medications, revised April 2019, revealed, .Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders .9. The individual administering medications verifies the resident's identity before giving the resident his/her medications .22. The individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones . Resident #1 On 02/05/2025 at 9:30 AM, during an interview, Resident #1's daughter stated that Registered Nurse (RN) #1 notified her that Resident #1 had received ten (10) days of another resident's medications. She said that the nurse informed her that another nurse had gotten the wrong medication from the computer portal which caused her mother to receive someone else's medication. The daughter reported that she had been calling the facility repeatedly, questioning why her mother was sedated and unable to participate in therapy and that several family members came to visit the resident and reported that she was not alert and oriented as she had been while in the hospital. During an interview on 2/5/25 at 10:00 AM, with RN #1, she explained that medications are sent to the nursing home from the hospital when a resident is discharged from the hospital. She stated that nurses were having to get Resident #1's medications from the Omnicell (a type of automated medication dispensing system) which alerted her to investigate further. RN #1 reported that she compared Resident #1's MAR and the physician's orders and noticed that the admitting physician's orders had another person's name on them, and not Resident #1. The nurse notified the Administrator, Medical Director (MD) and the Nurse Practitioner (NP). The nurse revealed she was told to delete all those medications and to input the correct medications from the correct discharge orders. The resident was assessed for negative adverse reactions. RN #1 revealed that Resident #1 was heavily sedated. During an interview on 2/5/25 at 10:30 AM, the NP confirmed Resident #1 was administered the wrong medications. The NP stated that she notified the Medical Director and assessed the resident, as well as ordered some laboratory tests, which were normal. The NP stated Resident #1 was disoriented and sedated at that time. The NP explained that the facility notified the insurance company and asked for more covered days because Resident #1 had a slight delay in therapy due to being heavily sedated and unable to follow commands. An interview on 2/5/25 at 10:45 AM, with the Speech Therapy (ST) Director revealed Resident #1 was evaluated on 11/22/24. The resident was alert oriented, able to stand, and transfer with one person assist. The resident met criteria to receive physical and occupational therapy to be strengthened after her fracture. The ST Director also said she was told by the Physical Therapy Assistant (PTA) and Occupational Therapy Assistant (OTA) that on 11/25/24 the resident was heavily sedated and needed maximum assistance with transfers and standing. An interview on 2/5/25 at 11:00 AM with the (PTA) and (OTA) revealed Resident #1 was lethargic and not following commands on Monday 11/25/24. The PTA and OTA said Resident #1 needed maximum assistance with two (2) person assistance because she was heavily sedated, and they could not provide therapy. During an interview on 2/5/25 at 11:15 AM, the Admissions Director explained either the Marketer or herself will upload resident admission information into the computer system. The Marketer who uploaded the incorrect resident information for Resident #1 is no longer employed at the facility. She reported that after the information is uploaded, then the admitting nurse will download that information and put everything into the electronic health record (EHR) where it belongs. On 2/6/25 at 9:00 AM, during an interview, RN #2 confirmed she received an email from the Marketer indicating Resident #1's information was available in the computer system. RN #2 admitted that she did not verify the physician's orders or confirm that the correct resident's information was uploaded before entering the orders into the facility's electronic health records (EHR) system. She no longer worked at the facility and was unaware that she had accessed another patient's chart and not the new admission (Resident #1) that was being discharged from the hospital. RN #2 explained that she was admitting numerous residents and was not thinking' at that time. A record review of the acute hospital's Discharge Information, dated 11/22/2024, revealed Resident #1's Your Medication List included Acetaminophen 500 milligrams (mg) by mouth every six hours as needed for mild pain, Amoxicillin-clavulanate 875/125 mg by mouth in the morning and one tablet before bedtime for two (2) days, Aspirin 81 mg delayed-release by mouth in the morning, B Complex with Vitamin C by mouth in the morning, Bisacodyl 10 mg suppository rectally daily as needed for constipation, Diphenhydramine and Zinc Acetate Cream applied topically three times daily as needed for itching, Docusate Sodium 100 mg by mouth in the morning and one capsule before bed, Ergocalciferol 1250 micrograms (mcg) (50,000 units) by mouth daily, Fexofenadine 180 mg by mouth in the morning, Lasix 20 mg by mouth every morning, Hydralazine 10 mg in the morning and 10 mg before bedtime, Hydrocodone/Acetaminophen 5/325 mg by mouth every six hours as needed for moderate pain, Hydroxyzine 25 mg by mouth three times a day as needed for itching, Ipratropium/Albuterol 0.5 mg/3 mg/2.5 mg base/3 ml nebulizer solution every six hours for three (3) days, and Phenol 1.4% sore throat spray as needed, and Polyethylene glycol 17 gram packet take seventeen grams by mouth in the morning. A record review of Resident #1's Medication Administration Record (MAR), dated 11/01/2024 through 11/30/2024, revealed Resident #1 received Amlodipine Besylate 5 mg by mouth daily for six (6), Aspirin 81 mg by mouth daily for six (6) days, B Complex by mouth daily for six (6) days, Carbidopa/Levodopa/Entacapone 12.5-50-200 mg by mouth daily for eight (8) days; Cyanocobalamin injection 1000 mcg intramuscular every 30 days for one (1) day, Ergocalciferol 1.25 mg every Friday for one (1) day, Eye-Vites Oral Tablet daily for six (days), Hydrochlorothiazide 12.5 mg by mouth daily for eight (8) days, Lasix 20 mg by mouth daily for six (6) days, Levothyroxine 137 mcg by mouth daily for seven (7) days, Omega-3 fatty acids 1200 mg by mouth daily for eight (8) days, Omeprazole 40 mg by mouth daily for seven (7) days, Potassium Chloride ER 10 meq by mouth for six (6) days, Ropinirole HCL 1 mg by mouth daily for eight (8) days, Vitamin D3 by mouth daily for eight (8) days, Buspirone HCL 15 mg by mouth twice daily for nine (9) days, Gabapentin 600 mg by mouth twice daily for nine (9) days, Multivitamin Oral Tablet two times daily for nine (9) days, Norco 5/325 mg by mouth every six (6) hours as needed for one (1) day (2 doses given), Oxycodone 5 mg every six (6) hours as needed for one (1) day (1 dose given), and Sertraline HCL 100 mg by mouth twice daily for nine (9) days. On 2/6/2025 at 3:00 PM, during an interview, the Administrative Assistant confirmed that Resident #1 had received the wrong medication. She stated that she was initially notified by Registered Nurse (RN) #1, who reported the medication error. The Administrative Assistant further stated that at the time of the incident, RN #2 was serving as the interim Director of Nursing (DON). She explained that upon reviewing the resident's medical records from the local hospital, she noticed discrepancies in the physician's orders. Additionally, the Administrative Assistant confirmed that there was no documentation for several days indicating whether Resident #4 had received her prescribed medication. A record review of Resident #1's admission Record revealed the facility admitted Resident #1 on 11/21/2024 with current diagnoses including Fracture of the Manubrium. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she was cognitively intact. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 5/22/2024 and she had a diagnosis of Infection following a Procedure, Deep Incisional Surgical Site, with and Onset Date of 1/7/2025. A record review of the MDS with an ARD of 01/12/2025 revealed Resident #4 had a BIMS score of 8, which indicated her cognition was moderately impaired. Section I revealed the resident had a hip fracture and wound infection, Section M revealed the resident had a surgical wound, and Section N revealed the resident was on antibiotic therapy. A record review of the Order Summary Report revealed Resident #4 had a Physician's Order, dated 1/6/25 for Ceftriaxone (Rocephin) intravenously daily for a wound infection. Resident #4 also had a Physician's Order dated 1/6/25 for Vancomycin intravenous daily for a wound infection. A record review of Resident #4's Medication Administration Record (MAR), dated 01/11/2025 through 01/31/2025, revealed there was no documentation indicating that Vancomycin had been administered on 1/13/25, 1/16/25, or 1/21/25 or that Ceftriaxone had been administered on 01/16/2025 and 01/21/2025. A record review of Resident #4's Medication Administration Record (MAR), dated 02/1/2025 through 2/28/2025, revealed there was no documentation indicating that Vancomycin had not been administered on 2/1/25 or 2/3/25 was coded 9. On 2/5/25 @ 10:15 AM, during an interrview with Licensed Practical Nurse (LPN) #2 clarified that the code 9 indicated to see nurses notes. Record review of the nurses notes revealed no documentation related to antibotics was in the nurses notes. On 2/5/2025 at 1:00 PM, during an interview, LPN #1 confirmed that Resident #4 was receiving intravenous (IV) antibiotics, including Vancomycin and Bactrim, for a wound infection in the right hip. LPN #1 stated that she was unable to administer IV medications because only Registered Nurses (RNs) were permitted to do so. She explained that if a medication did not have a nurse's signature on the Medication Administration Record (MAR), it was because the RN had not signed it. LPN #1 stated that she could not confirm whether the medication had been given, as she was not responsible for administering it. She also mentioned that she often reminded RNs to administer IV antibiotics and to sign the MAR after administration. LPN #1 also confirmed the code 9 on the MAR would indicate to see nurses notes. On 02/06/2025 at 8:00 AM, during an interview, the Interim Director of Nursing (DON) stated that she had only worked at the facility for one (1) month and had been the Interim DON for two (2) weeks. She confirmed that Resident #4's antibiotics were scheduled for the day shift, however, she has had to work on night shift and was unable to administer the IV medication. She reported that if she is at the facility during the day, she administers the antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and facility policy review the facility failed to develop a comprehensive care plan within 21 days of admission (Resident #22) and failed to implement a care plan intervention (Resident #32) for two (2) of 15 sampled residents. Findings include: Review of the facility's policy, Plans of Care, revised on 9/25/17, revealed, Policy: An individualized person-centered plan of care will be established .Procedure .Develop a comprehensive plan of care .within seven (7) days after completion of the comprehensive assessment (MDS) .The Individualized Person Centered plan of care may include .Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Individualized interventions that .promote achievement of the resident's goals . Resident #22 A review of Resident #22's medical record revealed there was no comprehensive care plan. A record review of the admission Record revealed the facility admitted Resident #22 on 3/27/24. A record review of the Minimum Data Set (MDS) revealed Resident #22 had an admission assessment with an Assessment Reference Date (ARD) of 4/03/24 completed. Resident #32 A record review of the Comprehensive Care Plan for Resident #32 revealed Focus (Proper Name) is at risk for decline in ADL (Activities of Daily Living) status .Intervention/Tasks .date initiated 3/30/24 . Mechanical lift x 2 person assist for transfers . A record review of the Order Summary Report, with active orders as of 4/23/24, revealed Resident #32 had a Physician's Order, dated 3/30/24, for Mechanical lift x (times) 2 person assist for transfers. Further review revealed she had diagnoses including Age-related Osteoporosis and Osteoarthritis. On 4/21/24 at 10:58 AM, during an observation, Certified Nursing Aide (CNA) #1 and CNA #2 were manually transferring Resident #32 from her bed to her wheelchair. The CNAs placed Resident #32 into her wheelchair on top of a lift pad that was positioned in the wheelchair. The CNAs did not use a mechanical lift during the transfer. On 4/21/24 at 11:01 AM, during an interview, CNA #1 confirmed they did not use a mechanical lift when transferring Resident #2. She explained the [NAME] (CNA care guide) indicated the type of transfer that was required for the residents, and she verified that she did not look at the [NAME] to determine how Resident #32 should have been transferred. On 4/24/24 at 9:00 AM, during an interview, the Director of Nursing (DON) confirmed the CNAs should have transferred Resident #32 with a mechanical lift and she stated expected the staff to transfer residents according to their physician orders and care plan. On 04/24/24, at 03:45 PM, in an interview with Registered Nurse (RN) #1, she explained she was responsible for initiating care plans. She acknowledged Resident #22 did not have a comprehensive care plan and it should have been developed within 21 days of his admission to the facility on 3/27/24 or within seven (7) days of the admission MDS with an ARD of 4/3/24. RN #1 reported the purpose of the care plan was for staff to be aware of how to take care of the residents. RN #1 confirmed the staff failed to follow the care plan by not using the mechanical lift when transferring Resident #32. A record Review of the admission Record revealed the facility admitted Resident #32 on 5/10/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and facility policy review the facility failed to prevent the potential for an accident as evidenced by, facility staff transferred a resident without using the physician ordered mechanical lift for one (1) of four (4) transfer observations. Resident # 32 Findings include: Review of the facility's policy, Lifting and Moving Residents, dated 11/30/14, revealed, Policy: All residents will be assessed before attempting a transfer or move .Procedure . g. Lifting Aids: Are Hoyer (a type of mechanical lift) Lifts .required for transfer . A record review of the Order Summary Report with active orders as of 4/23/24, revealed Resident #32 had a Physician's Order, dated 3/30/24, for Mechanical lift x (times) 2 person assist for transfers. Further review revealed she had diagnoses including Age-related Osteoporosis and Osteoarthritis. During an observation on 4/21/24 at 10:58 AM, Certified Nursing Aide (CNA) #1 and CNA #2 were manually transferring Resident #32 from her bed to her wheelchair. The CNAs placed Resident #32 into her wheelchair on top of a lift pad that was positioned in the wheelchair. The CNAs did not use a mechanical lift during the transfer. During an interview on 4/21/24 at 11:01 AM, with CNA #1, she explained she was assigned to care for Resident #32 and had asked CNA #2 to assist with the transfer. CNA #1 confirmed they did not use a mechanical lift when transferring Resident #2 because she had good days and bad days, and today she was able to transfer manually with two (2) CNAs. They had placed the lift pad in the wheelchair in case she was unable to be transferred manually later and the evening shift would be able to use the mechanical lift if needed. CNA #1 explained the [NAME] indicated the type of transfer that was required for the residents, and she verified that she did not look at the [NAME] to determine how Resident #32 should have been transferred. During an interview on 4/21/24 at 11:13 AM, with CNA #2, she confirmed she assisted CNA #1 with manually transferring Resident #32 to her wheelchair from the bed without using a mechanical lift. CNA #2 explained that she was not familiar with Resident #32 and had assisted CNA #1 because she had asked for help. During an interview on 4/21/24 at 11:15 AM, with Licensed Practical Nurse (LPN) #1, she confirmed the staff should have used the mechanical lift for the transfer. During an interview on 04/24/24 at 9:00 AM, the Director of Nursing (DON) confirmed the CNAs should have transferred Resident #32 with a mechanical lift and she stated expected the staff to transfer residents according to their physician orders. The DON explained Resident #32 recently had a decline and now required the use of the mechanical lift for transfers. A record Review of the admission Record revealed the facility admitted Resident #32 on 5/10/22. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/24 revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated, mislabeled, exposed, expired, no identifying label, and spoiled produce for one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy, Food and Supply Storage, with an effective date of 11/30/14, revealed, Policy: Food and supplies will be stored under sanitary and secure conditions . Procedure: Food service products will be placed in appropriate storage . designated for each product .Food supplies must be dated .Rotation of stock/inventory .is essential to maintain quality . On 04/21/24 at 9:10 AM, an observation of the kitchen and interview with the Certified Dietary Manager (CDM), revealed the following: Refrigerator #1 contained one (1) casserole pan covered with aluminum foil and peas was handwritten on the foil, with no opened date. When the CDM removed the foil, he reported the contents as Chicken and [NAME] casserole. There were two trays containing portioned cups of what the CDM described as lemon pudding, with no date or label on the tray, and (1) of the cups was uncovered and exposed. There was (1) opened container of low sodium beef base, dated 3/27 and a manufacturer's best by date of 02/07/24. There were 11 portioned cups of what the CDM described as pureed desserts, dated 4/18, with no identifying label. There was an opened bag of what the CDM described as french toast sticks, dated 4/16. There was one (1) opened bag of celery with manufacturer's best by date of 4/12 in which the celery had a brown discoloration on the ends of the stalks and there were two other unopened bags of celery with a manufacturer's use by date of 4/12/24. There was one (1) unopened bag of green onions with a manufacturer's best by date of 4/16/24. There was one (1) box of lettuce with a manufacturer's delivery date of 4/12 in which the lettuce was spoiled. There was one (1) opened bag of cabbage, dated 4/8, one (1) unopened bag of coleslaw mix, undated, and one (1) unopened bag of coleslaw mix dated 4/2. There were also two (2) unopened bags of coleslaw mix with a delivery date of 2/27/24 and a manufacture's best if used by date of 3/6/24. There was one (1) tray of unlabeled and undated portioned liquids of what the CDM described as thickened liquids, containing what the CDM described as three (3) waters, five (5) teas, two (2) apple juice one (1) orange juice. An observation of the pantry revealed the dry bin containing sugar was opened which left the sugar exposed. During the observation and interview, the CDM acknowledged the foods observed in the refrigerator did not have identifying labels, were undated, and expired and the sugar in the pantry was exposed. The CDM that he was responsible for discarding expired foods and the expired and spoiled foods observed should have been discarded. He also explained that he was responsible for labeling food items when delivered to the facility. Whoever opened a food item was responsibility for labeling and storing that item. The CDM reported the kitchen staff receive training every three (3) months regarding kitchen practices. On 04/22/24 at 10:54 AM, an interview with [NAME] #1 revealed everyone was responsible for labeling and dating foods when opened and the CDM was responsible for labeling foods items upon delivery. The cook reported that all staff are responsible for inspecting the foods daily for expiration dates and confirmed the staff receive in-service training monthly regarding food safety. On 04/24/24 at 3:54 PM, in an interview with the Administrator, she acknowledged she was aware there were improperly stored food items found in the kitchen and she expected all food to be properly dated and labeled and not mislabeled. She stated she expects to have no expired or spoiled foods items stored in the kitchen.

Based on interviews, record review, and facility policy review the facility failed to ensure pain management was provided to treat a newly admitted resident's pain for one (1) of three (3) sampled residents. Resident #1. Findings Include: Record review of the facility's policy, Policies and Procedures: Subject: Pain Management Guideline, with a Revision Date of 08/28/2017, revealed, Policy: The center strives to improve patient/resident comfort and minimize pain in order to help a resident attain or maintain his or her highest practicable level of well-being. Purpose: To ensure residents receive the treatment and care in accordance with professional standards of practice . Record review of the facility's policy, Administering Medications, revised April 2019, revealed, .Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame . Record review of the admission Record revealed the facility admitted Resident #1 on 6/23/23 with a diagnosis of Encounter for Surgical Aftercare following surgery on the nervous system and fusion of the spine, lumbar region. Record review of the Order Summary Report with active orders as of: 06/24/2023 revealed Resident #1 had a Physician's Order with an order date of 6/23/23 for Oxycodone-Acetaminophen Oral Tablet 10-325 MG (milligram) Give 1 tablet by mouth every 6 hours as needed for moderate pain . and an order for Oxycodone-Acetaminophen Oral Tablet 10-325 MG Give 2 tablet by mouth every 6 hours as needed for pain . Record review of the Medication Administration Record for June 2023 revealed Oxycodone-Acetaminophen was not documented as administered to Resident #1. Record review of the Progress Notes for Resident #1 revealed a Discharge Planning/Discharge note, dated 6/24/2023, for Resident was discharged home with her husband .pain medication availability was discussed and attempted to be resolved at that time . On 7/31/23 at 1:40 PM, an interview with License Practical Nurse (LPN) #1, she explained that Resident #1 was admitted late in the day on 6/23/23. Since it was late, all her medication had to be pulled through the automated medication dispenser at the facility that is used after pharmacy hours. She confirmed that Resident #1 was discharged to home on 6/24/23 around 10:30 AM. LPN #1 stated that Resident #1 did not request any pain medication the morning of 6/24/23. On 7/31/23 at 1:53 PM, an interview with Resident #1 revealed she was transferred from the local hospital to the facility about 9:00 PM on 6/23/23. She stated she had back surgery four (4) days prior to the admission to the facility. Resident #1 stated, My pain score was approximately a four (4) on a 1-10 pain scale, and I requested pain medication, but my nurse told me she could not get one from the (Proper Name of automated medication dispenser). Resident #1 confirmed that the nurse informed her that she had no way of retrieving the medication because it was after hours, and the pharmacy was not available. On 7/31/23 at 2:00 PM, an interview with the interim Director of Nurses (DON) confirmed that it is her expectation that if a resident complains of pain, the nursing staff should assist the resident, such as giving them pain medication as prescribed, comfort measures, and phone their physician if further orders are required. The DON confirmed the facility faxed the hard copy of the prescription to the pharmacy and the facility had the medication in their (Proper Name of automated medication dispenser). The nurse on duty would have to call the pharmacy on-call person and obtain a code to obtain the medication out of the medication dispenser. During the interview, the DON confirmed that LPN #2 was educated during orientation on how to receive medication after hours through the pharmacy and medication dispenser and that LPN #2 did not perform her duties assigned. On 8/1/23 at 12:15 PM, an interview with the Nurse Practioner (NP) revealed her expectation is for nurses to medicate the resident if they complain of pain and or provide comfort measures. On 8/1/23 at 12:40 PM, an interview with LPN #2 confirmed that Resident #1 was admitted late on 6/23/23 and she did not remember seeing the hard copy prescription for the narcotic medication. She also mentioned that since it was the night shift, that she was unable to contact the pharmacy to obtain the code for the medication to retrieve out of the automated medication dispenser. LPN #2 revealed Resident #1 did not exhibit any type of sweating, being anxious, or crying regarding her pain.

Based on staff and resident interviews, record review, and facility policy review the facility failed to notify the resident and the Resident's Representative (RR) in writing the reason for a transfer to the hospital for two (2) of three (3) sampled residents for hospitalizations. (Resident #22 and Resident #35) Findings include: A record review of the facility's Transfer/Discharge Notification & Right to Appeal policy with a revision date of 03/26/2018, revealed, . Notice Before Transfer: Before a center transfers or discharges a resident, the center must: Notify the resident and resident representative(s) of the transfer or discharge and the reasons for the move in writing . Resident #22 On 08/07/2022 at 12:17 PM, during an interview with Resident #22, she explained that she has been to the hospital several times since being admitted . She stated that she is not exactly sure why, as no one tells her anything. She reported she knows her blood pressure got low and she was dehydrated. A record review of Resident #22's admission Record revealed the facility admitted the resident on 02/04/2022 with the diagnosis of Acute and Chronic Respiratory Failure. A record review of Resident #22's Medicare 5-day Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 06/16/2022, Section C revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. A record review of Resident #22's Physician's Order Sheet revealed 06/5/22 12:05 Send to (Proper Name) ER (emergency room) r/t (related to) S.O.B (shortness of breath) & Hypotension . A record review of Resident #22's Discharge MDS with an ARD of 06/05/2022 revealed Section A . A0310. Type of Assessment . F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated . A 2100 Discharge Status was coded as 03. Acute Hospital ., which indicated Resident #22 was discharged to an acute care hospital. A record review of Resident #22's Physician's Order Sheet revealed 07/25/22 0633 (6:33 AM) Send to (Proper Name) ER for Eval (evaluation) and Tx (treatment) as indicated RT (related to) continued low B/P (blood pressure) and for decreased LOC (level of consciousness) . A record review of Resident #22's Discharge MDS with an ARD of 07/25/2022 revealed Section A . A0310. Type of Assessment . F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated . A 2100 Discharge Status was coded as 03. Acute Hospital ., which indicated Resident #22 was discharged to an acute care hospital. Resident #35 On 08/07/2022 at 12:05 PM, during an interview with Resident #35, she explained she did have a bad infection that infected everything and had to go to the hospital a couple of months ago. A record review of Resident #35's admission Record revealed the facility admitted the resident initially on 09/25/2020 and re-entry 11/06/2020 with the diagnoses of Pneumonia, Unspecified Systolic (Congestive) Heart Failure, and Alzheimer's Disease. A record review of Resident #35's Quarterly MDS with an ARD of 07/04/22 Section C revealed a BIMS score of 14, which indicated the resident was cognitively intact. A record review for Resident #35's Physician's Order Sheet revealed 5/24/22 1350 Transfer to (Proper Name) for evaluation R/T N/V/D (nausea, vomiting, diarrhea) . A record review of Resident #35's Discharge Summary MDS with an ARD of 05/24/22 revealed Section A . A0310. Type of Assessment . F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated . A 2100 Discharge Status was coded as 03. Acute Hospital ., which indicated Resident #35 was discharged to an acute care hospital. On 08/08/2022 at 4:00 PM, during an interview with the Administrator, he confirmed that the facility does not provide written notification to the resident or resident representative when the resident is transferred to the hospital. On 08/08/2022 at 4:30 PM, during an interview with the Director of Nursing (DON), he confirmed that written notification of transfer was not provided to the resident or resident representative.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure Percutaneous Endoscopic Gastrostomy (PEG) tube placement was checked prior to flushing the tube for one (1) of two (2) residents observed with feeding tubes. Resident #15. Findings Include: Record review of the facility's Policies and Procedures with the Subject: Medication-Administration Via Enteral Tube, and a revision date 3/6/2019, revealed, .Procedure .Checking for placement of enteral tube .To confirm proper placement .Aspirate by gently pulling back on plunger of syringe to check for stomach contents . On 8/8/22 at 12:03 PM, the State Agency (SA) observed Registered Nurse (RN) #1 flush Resident #15's PEG tube. RN #1 used a syringe with the plunger removed to flush the enteral tube by gravity. She did not use the syringe to aspirate for stomach contents to ensure proper tube placement prior to flushing the tube. On 8/8/22 at 12:10 PM, in an interview with RN #1, she stated she should have checked for proper placement of the PEG tube by aspirating before flushing it. She normally checks for placement when flushing the tube. RN #1 stated that by not checking placement it could have caused the water from the flush to go into the wrong area. On 8/10/22 at 12:23 PM, in an interview with the Director of Nursing (DON), he stated RN #1 should have checked placement before flushing the PEG tube. RN #1's actions could have caused the resident to have complications regarding feeding. Record review of Resident #15's admission Record revealed the facility admitted her on 11/6/2020 with diagnoses including Dysphagia and Aphasia. Record review of Resident #15's Order Summary Report with Active Orders As Of: 08/10/2022, revealed a Physician's Order with an order date of 7/1/22 for Enteral Feed Order every shift check enteral tube placement via aspiration prior to medication administration, flushes, and feedings. Record review of the August 2022 electronic Medication Administration Record (eMAR) for Resident #15 revealed RN #1's initials on the first shift on 8/8/22 for Enteral Feed Order every shift check enteral tube placement via aspiration prior to administration, flushes, and feedings. This indicated that RN #1 had documented that she had checked for proper placement of Resident #15's PEG tube by aspiration prior to administering medications, flushes, or feedings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to ensure that care plan interventions were implemented to prevent complications by not aspirating to check peg tube placement prior to flushing for one (1) of two (2) sampled residents with feeding tubes. Resident # 15 Findings include: Record review of the facility's Policies and Procedures with the Subject: Plans of Care, and revision date of 09/25/2017, revealed, .Procedure .Develop and implement an individualized Person-Centered comprehensive plan of care .The Individualized Person Centered plan of care may include but is not limited to .Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements . Record review of the Comprehensive Care Plan reveals a focus that Resident #15 is at risk for complications R/T (related to) peg tube placement, with a goal that Resident #15 will have decrease in incidence of S/S (signs and symptoms) of peg tube complications thru nursing interventions and included an intervention to check peg tube placement via aspiration prior to meds feeding and flushes. On 8/8/22 at 12:03 PM, the State Agency (SA) observed Registered Nurse (RN) #1 flushing the peg tube of Resident #15. RN #1 removed the syringe plunger and connected the syringe to the tube. She did not aspirate for stomach contents to ensure proper placement prior to flushing the tube. On 8/8/22 at 12:10 PM, in an interview with RN #1, she stated that she should have checked for proper placement of the peg tube prior to flushing the tube. She stated that by not checking proper placement, she could have caused the water from the flush to go into the wrong area. On 8/10/22 at 12:23 PM, in an interview with the Director of Nursing (DON), he stated that RN #1 should have checked placement prior to flushing the enteral feeding tube. He stated that RN #1's actions could have caused the resident to have complications. On 8/10/22 at 12:40 PM, RN #2 stated that the care plan is used to guide care that the resident's receive. She stated that to give adequate care, staff should use the care plan. Record review of Resident #15's admission Record revealed the resident was admitted to the facility on [DATE], with diagnoses including Dysphagia and Aphasia.

Based on observation, staff interview, record review and facility policy review, the facility failed to follow Resident #28's Care Plan for incontinent care, for one of three (1 of 3) care plans reviewed. Findings include: Review of the facility's policy titled, Care Plan-Comprehensive, dated November 2017, revealed the Comprehensive Care Plan was designed to reflect treatment goals and objectives in measurable outcomes that is individualized and person-centered that reflects the resident's goals for desired outcomes. The Care Plan is designed to prevent declines in the resident's status/function. Review of Resident #28's Care Plan revealed a Focus with a Target Date of 12/03/19, for the risk of Urinary Tract Infectoins (UTIs) due to incontinent of bowel and bladder. The Interventnions included provide assistance with incontinent care with one to two staff as needed, and to provide peri care from front to back. An observation of incontinent care for Resident #28, on 09/04/19 at 4:06 PM, revealed Certified Nursing Assistant (CNA) #1 wiped and cleaned the buttock areas after Resident #28 had a Bowel Movement (BM), and then proceeded to turn Resident #28 over and provided incontinent care near the urinary meatus without changing gloves or washing hands. An interview, on 09/04/19 at 4:30 PM, with CNA #1 confirmed she did not follow Resident #28's care plan when she failed to change gloves and/or wash hands in between cleaning the BM and wiping the vaginal area near the urinary meatus. CNA #1 stated this placed Resident #28 at risk for infection and Urinary Tract Infection (UTI). On 09/05/19 at 9:29 AM, an interview with the Director of Nursing, confirmed CNA #1 should have washed her hands and changed gloves after cleaning a BM and before providing incontinent care because of cross contamination. The DON confirmed if a CNA fails to provide care correctly then the resident's care plan is not followed. An interview, on 09/05/19 at 10:45 AM, with the Minimum Data Set (MDS) Registered Nurse (RN) revealed staff should clean a BM first prior to providing incontinent care, and they should change gloves and wash their hands after cleaning a BM. The MDS RN confirmed the care plan is not followed if care is not provided correctly. Record review revealed the facility admitted Resident #28, on 07/9/18 with the included diagnoses of Cardiomyopathy, Atrial Fibrillation, Hypertension (High Blood Pressure) and Chronic Obstructive Pulmonary Disease (COPD). Review of the Significant Change MDS, with the Assessment Reference Date (ARD) of 08/21/19, revealed Resident #28 scored a three (3) on the Brief Interview for Mental Status (BIMS) that indicated severe cognitive impairment. This assessment noted Resident #28 was always incontinent under section HO200 for bowel and bladder.

Based on observation, staff interview, record review and facility policy review, the facility failed to provide Resident #28's incontinent care in a manner to prevent the possibility of a Urinary Tract Infection (UTI) and/or cross contamination for one (1) of three (3) care observations. Findings include: Review of the facility's policy titled, Perineal Care, dated December 2017, revealed the policy did not address changing gloves and washing hands should they become contaminated with feces prior to providing care near the urinary meatus. An observation of incontinent care for Resident #28, on 09/04/19 at 4:06 PM, revealed Certified Nursing Assistant (CNA) #1 wiped and cleaned the buttock areas after Resident #28 had a Bowel Movement (BM) and then proceeded to turn Resident #28 over. CNA #1 provided incontinent care near the urinary meatus without changing gloves or washing hands. CNA #1 wore the same gloves she used to clean Resident #28's BM to provide the incontinent care. An interview, on 09/04/19 at 4:30 PM, with CNA #1 confirmed she did not change gloves and/or wash hands in between cleaning the BM and wiping the vaginal area near the urinary meatus for Resident #28. CNA #1 confirmed this placed Resident #28 at risk for infection and Urinary Tract Infection (UTI). An interview, on 09/04/19 at 4:30 PM, with CNA #2, revealed she confirmed CNA #1 wiped the BM then turned Resident #28 over and then wiped the vaginal area and did not change gloves or wash her hands. Brief Interview for Mental Status (BIMS) that indicated severe cognitive impairment. This assessment noted Resident #28 was always incontinent under section HO200 for bowel and bladder. An interview, on 09/05/19 at 9:29 AM, with the Director of Nursing (DON), revealed she stated CNA #1 should have washed her hands and changed gloves after cleaning the BM and before providing the incontinent care because of cross contamination. The DON confirmed all CNAs are trained to do this all the time. In an interview, on 09/05/19 at 10:45 AM, with the Minimum Data Set (MDS) Registered Nurse (RN), she revealed staff should clean a BM first prior to providing incontinent care and they should change gloves and wash their hands after cleaning a BM. Record review revealed the facility admitted Resident #28, on 07/9/18, with the included diagnoses of Atrial Fibrillation, Cardiomyopathy, Hypertension (High Blood Pressure) and Chronic Obstructive Pulmonary Disease (COPD). Review of the Significant Change MDS, with the Assessment Reference Date (ARD) of 08/21/19, revealed Resident #28 scored 3 on the Basic Interview for Mental Status (BIMS), which indicated severe cognitive impairment. Further review of the MDS revealed Resident #28 was always incontinent of bowel and bladder.