Deficiency Text Not Available

Basedonobservation interview and record review, thefacilityfailedensure the dignity of all residents was maintained at all times when stafffailedtoensure one resident's (Resident #23) catheter (a sterile tube inserted into the bladder to drain urine) bagwas coveredwithadignitybag when visible to others. A sample of 17 residents was reviewed in a facility with a census of 65. Reviewofthefacilityspolicytitled ResidentRights Rules andRegulations, updated10/01/21, showedthefollowinginformation -Residentshavetherighttobetreatedwithdignityandrespect -Residentshavetherighttoprivacyandrespectregardingaccommodations personalcare medicaltreatment writtenandtelephonecommunications andvisitswithotherindividuals 1. Reviewoftheresidentsfacesheet(brieflookatresidentinformation showedthefollowinginformation -admission date of 10/15/22; -Diagnosesincluded acutemetabolicacidosis(aconditioninwhichtoomuchacidaccumulatesinthebody. ReviewoftheresidentsadmissionMinimumDataSet(MDS afederallymandatedassessmenttoolfilledoutbyfacilitystaff, dated10/31/24, showedthefollowinginformation: -Indwellingcatheteruse -Diagnosesincluded benignprostatichyperplasia(BPH - an ageassociatedprostateenlargementthatcancauseurinationdifficulty and kidneyfailure Reviewoftheresidentscareplan lastreviewedon11/24/24, showedthefollowinginformation -Monitorresidentforcomplicationsofindwellingurinarycatheterandreporttochargenurse -Positionthedrainagebagtofacilitate flowofurine -Changecatheterandprovidecathetercareperorders -Uselegbagwhenambulatingperresidentschoice. Observationon11/19/24, at9:48 AM, showedtheresidentsroomdooropen with catheterbagdrainingpaleyellowurinehungontherightsideofhisherbedvisiblefromthehallway Observationon11/20/24, at9:21 AM, showedtheresidentsroomdooropen with catheterbagdrainingpaleyellowurinehungontherightsideofhisherbedvisiblefromthehallway Observationon11/20/24, at12:09 PM, showedtheresidentsroomdooropen catheterbagdrainingpaleyellowurinehungontherightsideofhisherbedvisiblefromthehallway Observationon11/21/24, at8:20 AM, showedtheresidentsroomdooropen catheterbagdrainingpaleyellowurinehungontherightsideofhisherbedvisiblefromthehallway Duringaninterviewon11/21/24, at1:10 PM, CertifiedNursingAssistant RegisteredMedicationTechnician(CNARMT Asaidcatheterbagsshouldbeindignitybagsatalltimes Duringaninterviewon11/21/24, at2:29 PM, RegisteredMedicationTechnician(RMT Bsaidnooneshouldbeabletoseeurineincatheterbagsfromthehall Catheterbagsshouldbeindignitybagsatalltimes Duringaninterviewon11/22/24, at9:55 AM, LicensedPracticalNurse(LPN Csaidnooneshouldbeabletoseeurineincatheterbagsfromthehall Catheterbagsshouldbeindignitybagsatalltimes unlessthestaffcanpositionthebaginawaythatitisnotvisiblefromthehall Duringaninterviewon11/22/24, at12:34 PM, theDirectorofNursing(DON) saidsheexpected stafftohavecatheterbagscoveredwithdignitybagsatalltimes Duringaninterviewon11/22/24, at1:19 PM, theAdministratorsaidheexpected stafftohavecatheterbagscoveredatalltimes

Based on observation, interview, and record review, the facility failed to provide care to all residents per standards of practice when staff failed to transcribe a physician order change in breathing treatments and failed to administer the breathing treatments as order for one resident (Resident #1). The facility census was 70. Review of facility policy, Physician Orders, reviewed November 2024, showed the following: -In most circumstances, orders should be entered electronically by the practitioner; -Verbal or telephone orders may be given to providers (for example, a nursing facility) only if there is an emergency situation when the electronic entry may delay care, or if computer access is not available to the practitioner; -Upon receipt of a written or faxed order, staff will scan the order into the resident's electronic medical records (EMR). The orders will be entered into the EMR as applicable. 1. Review of Resident #1's face sheet showed the following: -admission date of 12/02/24; -Diagnoses included high blood pressure, anxiety, heart disease, and recent history of pneumonia. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/08/24, showed the following: -Cognitively intact; -No rejection of care; -Diagnoses included asthma (A condition in which the airways narrow and swell and may produce extra mucus. This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when breathing out and shortness of breath.), chronic obstructive pulmonary disease (COPD - An ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs.), or another chronic lung problem. Review of the resident's care plan, last reviewed 12/10/24, showed the following: -Respiratory treatment as ordered; -Supplemental oxygen use as ordered. Review of the resident's December 2024 Treatment Administration Record (TAR) showed the following : -An order, dated 12/02/24, for albuterol 2.5 milligrams (mg) every 8 hours as needed (PRN); -Staff did not administer the medication on 12/02/24; -Staff did not administer the medication on 12/03/24. Review of the resident's nursing notes, dated 12/04/24, showed the resident reported to staff that he/she had breathing treatments at home twice a day. The resident told staff he/she had not had any treatments since being admitted to the facility and was starting to feel congested. The nurse requested breathing treatments twice a day (scheduled). The doctor replied for staff to go ahead and schedule the albuterol (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease (COPD - An ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs.)) breathing treatments twice a day, per resident request. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN. (Staff did not update the order to reflect the new order from the physician for treatments scheduled twice a day.); -Staff did not administer the medication on 12/04/24; -Staff did not administer the medication on 12/05/24; -Staff did not administer the medication on 12/06/24; -Staff did not administer the medication on 12/07/24; -Staff administered the medication twice on 12/08/24; -Staff administered the medication once on 12/09/24; -Staff did not administer the medication on 12/10/24; -Staff administered the medication once on 12/11/24. Review of resident's physician's note, dated 12/12/24, showed the resident reported to the doctor a recent cough, and difficulty catching breath upon exertion. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN. (Staff did not update the order to reflect the new order from the physician for treatments scheduled twice a day.); -Staff administered the medication once on 12/12/24; -Staff administered the medication once on 12/13/24; -Staff did not administer the medication on 12/14/24; -Staff administered the medication once on 12/15/24. Review of the resident's chest x-ray, completed on 12/16/24, showed findings related to pulmonary vascular congestion (PVC - an excessive accumulation of fluid in the blood vessels of the lungs, which can make breathing more difficult). Review of the resident's physician's notes showed, dated 12/16/24, showed diagnosis of PVC. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN. (Staff did not update the order to reflect the new order from the physician for treatments scheduled twice a day.); -Staff did not administer the medication on 12/16/24; -Staff did not administer the medication on 12/17/24; -Staff did not administer the medication on 12/18/24; -Staff did not administer the medication on 12/19/24; -Staff did not administer the medication on 12/20/24; -Staff did not administer the medication on 12/21/24; -Staff did not administer the medication on 12/22/24; -Staff did not administer the medication on 12/23/24; -Staff did not administer the medication on 12/24/24; -Staff did not administer the medication on 12/25/24; -Staff administered the medication once on 12/26/24; -Staff administered the medication once on 12/27/24; -Staff did not administer the medication on 12/28/24. Review of the resident's nursing note, dated 12/28/24, showed the resident requested breathing treatments to be scheduled twice a day, instead of as needed. A nurse practitioner replied on 12/29/24 that it was okay to schedule the breathing treatment twice a day for one week on a trial basis. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN; -An order, dated 12/29/24, for albuterol 2.5 mg scheduled twice a day, on a trial basis, with a stop date of 01/05/25; -Staff administered the medication twice on 12/29/24; -Staff administered the medication twice on 12/30/24; -Staff administered the medication twice on 12/30/24. Review of the resident's January 2025 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN; -An order, dated 12/29/24, for albuterol 2.5 mg scheduled twice a day, on a trial basis, with a stop date of 01/05/25; -Staff administered the medication once on 01/01/25 and did not administer any additional PRN doses; -Staff administered the medication twice on 01/02/25; -Staff administered the medication twice on 01/03/25; -Staff administered the medication twice on 01/04/25; -Staff administered the medication twice on 01/05/25. Review of the resident's January 2025 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN; -The order for scheduled albuterol was was discontinued on 01/05/25; -Staff administered the medication twice on 01/06/25; -Staff did not administer the medication on 01/07/25; -Staff administered the medication twice on 01/08/25; -Staff administered the medication once on 01/09/25; -Staff administered the medication twice on 01/10/25. Review of the resident's January 2025 TAR showed the following: -An order, dated 01/10/25, for albuterol 2.5 mg scheduled twice a day; -Staff administered the medication twice on 01/10/25; -Staff administered the medication twice on 01/11/25; -Staff administered the medication twice on 01/12/25; -Staff administered the medication twice on 01/13/25; -Staff administered the medication twice on 01/14/25; -Staff administered the medication once on 01/15/25. Observation and resident interview on 01/16/25, at 1:20 P.M., showed the following: -The resident had contracted pneumonia before being admitted to the facility and had some breathing difficulties since that time; -He/She had breathing treatments twice a day at home, immediately prior to being admitted to the facility; -The resident had an oxygen concentrator in his/her room; -The resident said if he/she goes too long between breathing treatments, he/she will start to feel congested. The breathing treatments help him/her cough up liquid, which relieves congestion and he/she feels better. During an interview on 01/16/25, at 1:03 P.M., Certified Medication Tech (CMT) A said when a resident requested a change in medication, he/she notified the nurse and the nurse notified the doctor or other provider. During an interview on 01/16/25, at 3:30 P.M., Licensed Practical Nurse (LPN) B said he/she put in the change from albuterol as needed to albuterol twice daily on 12/04/24 after the resident requested the change. However, the facility was having computer problems that day, and the change in order must not have been saved. For requests of medication changes, the usual facility process is for the charge nurse to discontinue the as needed medication, then put in the new order. To make sure orders and messages are completed, the night shift charge nurse prints off and double-checks if the new order is in the system. During an interview on 01/16/25, at 2:05 P.M., the Director of Nursing (DON) said staff sent a message to the resident's physician on 12/04/24 about changing the albuterol breathing treatments from as needed to scheduled twice daily. Although the nursing note says the task was completed, no staff updated the doctor order. She did not know why the change was accepted by the doctor, but no staff put in any new orders until the second request was made by the resident on 12/29/24 (25 days after the first request was made). During an interview on 01/16/25, at 4:00 P.M., the Administrator said doctors usually put orders into the facility records themselves. If not, then the charge nurses should put the new order in the EMR. The charge nurse or nurse manager should double check to make sure any new orders have been completed. He did not know why staff failed to completely put in the order for albuterol twice a day when first requested on 12/04/24. He said he did not know why different staff failed to double-check to assure orders were fully completed. MO00247213

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Basedonobservation interview andrecordreview thefacilityfailedtoprovidepressure ulcer care consistent with standards of practice when the facility failed to consistently document regarding all wounds and failed to care plan regarding new wounds in a timely fashion for one oneresident (Resident#23) withe multiple pressure wounds. A sample of 17 residents was reviewed in a home with a census of 65. ReviewofthefacilityspolicytitledPressureUlcerWoundAssessmentandTreatment, lastrevisedon11/24, showedthefollowinginformation -Basicpreventionincludestoencouragehydration offermoisturizingcream provideincontinencecare repositioninbedorchart accordingtotheindividualpatientneeds caregoals tissuetolerance andresponsetotreatment avoidpositioningoncurrentpressureulcerwound. ReviewoftheNationalLibraryofMedicinesarticle titledReviewofCurrentManagementofPressureUlcers, dated[DATE], showedthefollowinginformation -Eachdressingchangeshouldbeaccompaniedbyconcurrentwoundreassessment -FoamdressingsareidealforstageIwounds 1. ReviewofResident #23'sfacesheet(brieflookatresidentinformation showedthefollowinginformation -admission date of [DATE]; -readmission date of [DATE]; -Diagnoses included acutemetabolicacidosis(toomuchacidintheblood. Reviewoftheresidentsnurse'snote dated[DATE], showedthenursewasnotifiedofanareaofconcerntoresidentsback ThreespotsofstageII(partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) nature observedalongthespine Staff notified the NursePractitioner(NP inperson and verbalreceived to coverwithOptifoam(absorbentfoamdressing andchangeeverythreedays. Reviewoftheresidentsphysiciansprogressnote dated[DATE], showedthefollowinginformation -Pressureinjuryofback stageI (intact skin with a localized area of non-blanchable erythema (redness)), applyOptifoamforcushioningandprotection and changeeverythreedays Staff to repositioninbedoftenandoffloadpressurefromback. ReviewoftheresidentsadmissionMinimumDataSet(MDS - afederallymandatedassessmenttoolfilledoutbyfacilitystaff, dated[DATE], showedthefollowinginformation -Atriskforpressureulcers -DidnothaveoneormoreunhealedpressureulcersatstageIorhigheronadmission; -Pressurereducingdeviceforchairandbed Reviewoftheresidentsphysiciansprogressnote dated[DATE], showedthefollowinginformation -Pressureinjuryhad worsenedandwas unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured) onthoracicspine -Staff to cleanseareaandcoverwithmepilexag(antimicrobialfoamthatabsorbsdrainage and apply Optifoamoveritforcushioning Reviewoftheresidentsnurse'snote, dated [DATE], showed the nurseperformeda skinassessmentonresident. The residentdidnothaveanyskindiscolorationoneitherheels. (The nurse did not document related to the resident's wound on his/her back.) Reviewof the resident's bathsheet, dated [DATE], showed staff noted an abrasion, decub(ulcer, andincisionpresent Staff did not indicate the location on the showersheet Review of the nurse'snote, dated [DATE], showed an aidenotifiednurseofresident's heel The heelassessedandshowedblackenedareatoleftheel Staff notified the DirectorofNursing(DON andNP. Staff placed Optifoamplacedonleftheel. Reviewoftheresidentsphysiciansprogressnote dated[DATE], showedthefollowinginformation -Pressureinjuryhasworsenedandunstageableonthoracicspine. Threecircularareasofpressure surroundedwitherythemawoundsurfaceisslough (non-viable yellow, tan, gray, green or brown tissue) and kyphoscoliosis(abnormalcurvatureofthespine present -Staff to cleanseandcoverwithMepilexAg and applyOptifoamoveritforcushioning Staff to repositionfrequentlyandoffloadfromback -Pressureinjurytoleftheelunstageablehasdeveloped and rightheelwithoutrednessorinjury -Staff to offloadheelsfrombedsurface frequentrepositioninginbed andOptifoamforprotection Reviewofthe resident's woundassessments dated [DATE], showedthefollowinginformation -On[DATE], oneacquiredstageIIpressureulcertotheresident'srightheelmeasuring2 centimeters(cm by2.5 cmwitha0.1 cm depth Theappearancewasduskyredandthesurroundingtissuewaspeelingandpink noodor -Oneacquiredunstageablepressureulcertotheresident'sleftheelmeasuring4 cmby4.4 cmwitha0.1 cm depth Theappearancewasnecrotic(deadblack thesurroundingtissuewaspeeling. (Staff did not document an assessment of the wounds on the resident's back.) Reviewoftheresidentscareplan revisedon[DATE], showedthefollowinginformation -Onepressurewoundtoleftheelandonepressurewoundtorightheel -Considerationsincluded heelelevation pressurerelievingdeviceimplementation hydrationmanagement incontinencemanagement nutritionpromotion and positionchange -Careincluded Bradenscale(assessmenttooltoassessapatientsriskofdevelopingpressureulcers asneeded floatheelsusingpillowsoroffloadingbootsasneeded keepskincleananddry treatmentasordered andweeklyasneededskinmonitoringbyaprofessionalnurse. (Staff did not careplanregarding the wounds on the resident's back.) Reviewofthe resident's shower sheet, dated [DATE], showedstaff documented abrasion decub andincisionpresent Theshowersheetdoesnotindicatelocation Reviewoftheresidentsnurse'snote, dated [DATE], showedthefollowinginformation: -Perwoundnurse residentsbacktoremainopentoair forthenextfewdaysastheareaisverymacerated -Woundscleansed skinprepapplied andtheresidentrepositionedonhisherrightsidewithheelprotectorsonbothfeetandapillowundertheresidents calvestofloatfeet -Residentshouldberepositionedasmuchaspossiblewithbilateralheelsalwaysfloating andheelprotectorsonwhenup Reviewoftheresidentswoundassessment dated [DATE], showedthefollowinginformation -OneacquiredstageIpressureulcertotheresident'sdistal(bottom backmeasured0.5 centimeters(cm by1 cmwitha0.1 cmdepth Theappearancewasreddened with noodor -OneacquiredstageIIpressureulcertotheresidentsmedial(middle back measured1 cmby1.4 cmwitha0.1 cmdepth Theappearancewasgraywhite surroundingtissuewasredandmacerated with noodor -OneacquiredstageIIpressureulcertotheproximal(nearertothecenter backmeasured1.5 cmby1.8 cmwitha0.1 cm depth Theappearancewasgraywhite and thesurroundingskinwasredandmacerated with noodor (The first documented assessment for wounds staff originally identified on [DATE].) Reviewoftheresidentsphysicianprogressnote dated[DATE], showedthefollowinginformation -Pressureinjurytoleftheelnowsoftandfluidfilled and continued tobeblackincolor. -Unstageablepressureinjuryonthoraciclumbarspine. Staff to cleanseareaandcoverwithMepilexAg applyOptifoamoveritforcushioning and offloadfromback -Rightheelcontinued withoutrednessorpressure Offloadheelsfrombed frequentrepositioning andOptifoamtoleftheel -Planstoadmitresidenttohospice Reviewoftheresidentswoundassessment dated [DATE], showed followinginformation -OneacquiredstageIpressureulcertotheresident'sdistalbackmeasured0.5 centimeters(cm by1 cmwitha0.1 cmdepth Theappearancewasreddened with noodor -OneacquiredstageIIpressureulcertotheresidentsmedialmeasured1 cmby1.2 cmwitha0.1 cmdepth Theappearancewasgraywhite surroundingtissuewasredandmacerated with noodor -OneacquiredstageIIpressureulcertotheproximalbackmeasured1.5 cmby1.5 cmwitha0.1 cm depth Theappearancewasgrayyellow thesurroundingskinwasredandmacerated with noodor -OneacquiredstageIIpressureulcertotheresidentsrightheelmeasuring3 cmby2.4 cmwitha0.1 depth Theappearancewasduskyred andthesurroundingtissuewaspeelingandpink with noodor -Oneacquiredunstageablepressureulcertotheresidentsleftheelmeasuring3.5 cmby5 cmwitha0.1 depth Theappearancewasnecroticthesurroundingtissuewaspeeling Reviewoftheresidentsphysicianprogressnote dated[DATE], showedthe residentonhospiceservicesandcontinued withslowdecline. Observationon[DATE], at9:52 AM, LicensedPracticalNurse(LPN C andtheWoundCareInfectionPreventionistNursewereintheresidentsroomperformingwoundcare TheWoundCareInfectionPreventionistNursetookofftheresident'sheelprotectors and removed protectivedressingtotheresidentsrightheel The residenthadaquartersizedopeningwitherythematotherightheel LPNCremoved protectivedressingtotheresident'sleftheel Theresidenthadanareaofeschar (dead or devitalized tissue), biggerthanahalfdollarinsize Theresidentrolledontohisherleftside towardtheWoundCareInfectionPreventionistnurse Atthistime astrongwoundodorwaspresent LPNCremoved the Mepilexdressingtotheresident'sbackwounds Twobiggerthanquartersizeareasobservedwith95 percentsloughand5 percenteschartoeachwound The tissuesurroundingthewoundswere darkredpurplecoloring Athirdwoundontheback approximatelyquartersize minimallyobserved withnonblanchableredness Duringaninterviewon[DATE], at1:10 PM, CertifiedNursingAssistant RegisteredMedicationTechnician(CNACMT Asaidthefollowing -Heshenoticedtheresident'swoundsshortlyaftertheresidentcamebackfromthehospital -Ifheshenoticed achangeontheresidentsskin itwas reportedtothechargenurse -Aidescompletetheshowersandshoulddocumentanyskinissuesonthebathsheets. Thosesheetsarethenturnedintothechargenurse whosignsandassessesanyissues Afterthechargenursemakestheirassessment thebathsheetisturnedintotheDON -Woundsandwoundcarewouldbefoundonthecareplan Duringaninterviewon[DATE], at2:49 PM, RegisteredMediationTechnician(RMT Bsaidthefollowing -BathsheetsshouldbecompletedbytheCNAcompletingtheshower Afterthatscompleted itsturnedintothenurse Fromthere thenursewouldsignitandassessanyissues Afterthechargenursemakestheirassessment thebathsheetisturnedintotheDON -Aidesshouldalwaysreportanynewskinconcernsandorworseningofskintothechargenurseimmediately -Hesheliked tofollowupwiththenurseafterthenurseassessestheconcernstoinquireaboutanynewinterventionsfortheresident Duringaninterviewon[DATE], at9:55 AM, LPNCsaidthefollowing -Floornursesareresponsibleforprovidingdailywoundcare -Heshewas notsurehowoftentheWoundCareNurseperformed assessmentsmeasurements -Ifheshenoticedawoundtobedeterioratingandornotimprovement heshewouldreportittotheWoundCareNurse DON orNP Oneofthemwouldobservethewoundandmaybechangethetreatment -Heshewas notsureiftheresidentstreatmenthad everbeenmorethanMepilexAg. Heshedid notfeelheshehad enoughexperiencetosaywhetherornotthetreatmentshouldbeupgraded -Heshewas notsureifwoundsandwoundcareshouldbeincludedonthecareplan. Duringaninterviewon[DATE], at12:07 PM, theWoundCareInfectionPreventionistNursesaidthefollowing -Shewasmadeawareoftheresident'swoundsthefollowingdayafterdiscovery -Shedoesweeklywoundroundstoincludemeasurementsandassessmentsforchanges -Whenshelearnedoftheresident'swoundsthetreatmentwasjustOptifoamdressings. It has sincebeenchangedtomepilexfoam -Shefeelsthewoundsdeclinedquickly buttheyaresomebetternow -Ifshedidntseemuchimprovementinawoundwithinaweek shewouldlettheNPknow. Duringaninterviewon[DATE], at12:34 PM, theDONsaidthefollowing -Theresidentisalsoonhospiceasofthisdateandtheywillgetinvolvedinthewoundtreatment -Sheagreesthatifthereisnoimprovementinawoundwithinaweek theNPneedstobereachedouttoforachangeintreatment -Theresidentshouldbewearingheelprotectorsandberepositionedfrequently Duringaninterviewon[DATE], at1:19 PM, theAdministratorsaidthefollowing: -Ifawoundisnotimproving thereneedstobeacommunicationwiththeprovidertoseewhatcourseofactionneedstobetakennext -Pressuretotheaffectedareaneedstobelimited -Weeklywounddocumentationandmeasurementsareexpected

Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff continued to transfer one resident (Resident #14) with a lift that required resident participation after to two prior falls using the same lift and after the resident showed a decline in his/her ability to bear weight. A sample of 17 residents was reviewed in a facility with a census of 65. Review of the facility's policy titled Resident Handling, revised on 04/22, showed the following information: -Mobility and transfer decision flow chart is utilized when selecting appropriate assistive equipment and devices during assessment of resident capabilities for care planning and prior to patient handling activity. When indicated on the patient care plan, the required assistive devices may be varied according to the decision flow chart. -Because resident conditions and physician or mental status may be continually changing throughout the day, staff members are encouraged and empowered to make an updated assessment with individual handling activities. -Staff members should be familiar with the resident's current status and be able to verbalize the reason(s) a particular device was selected for the activity. -Charge nurses are responsible for routinely observing resident handling activities and verifying the appropriate selection and use of safety devices. -Injury incidents, near miss incidents, or early signs and symptoms of muscle strains or other musculoskeletal injury resulting from resident handling activities are reported per policy. -Resident handling incidents are analyzed for trends or patterns and appropriate follow up, changes in policy, staff education, or equipment maintenance initiated as required. Review of the facility's Mobility and Transfer Decision Flow Chart, dated 08/05/19, showed the following information: -Team members are empowered to use the Limited Lift Flow Chart in real time when determining the proper way to lift, transfer, reposition, or ambulate a resident; -When/if there is uncertainty in answering a question on the flow chart, the next level down in the chart higher level of safety should be utilized until the next question is answered. The charge nurse or care plan team should be consulted for clarification; -One person assisting using the sit-to-stand (a mechanical device that helps people with limited mobility move from a seated position to a standing position) or full lifts (Hoyer- a mechanical device that helps move people with limited mobility by placing the resident in a sling and suspending the resident in the air with the lift, and then lowering the resident on/in the destination) are authorized unless the resident's clinical needs, risks, or behaviors indicate otherwise, such as a resident who becomes very frightened or agitated during a transfer may require additional staff to ensure safety; -Partial or non-weight bearing residents that are unable to bear weight, are dependent on staff, and/or uncooperative or resistive to care require a maximum assist and a total lift device, such as a Hoyer. 1. Review of the Resident #14's face sheet (brief look at resident information) showed the following information: -admission date of 06/10/22; -Diagnoses included fracture of the left pubis (a bone in the pelvis that protects the bladder, intestines, and internal sex organs), and subsequent encounter for fracture. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 10/26/24, showed the following information: -Severely impaired cognition with inattention and disorganized thinking; -Substantial to maximal assist from staff for all activities of daily living (basic tasks that people need to perform to live independently in a household, such as bathing, dressing, toileting, and mobility) -No falls since admission; -Diagnoses included heart disease, kidney failure, and Alzheimer's disease. Review of the resident's care plan, revised on 03/13/24, showed the following information: -Staff to assist with ADL's as needed. Staff will need to use the decision flow chart to help with transfers; -Substantial assistance from staff, sit-to-stand, and wheelchair required; -Fall risk assessments to be completed every 90 days; -Interventions for falls included call light within reach, proper use of sit-to-stand, reeducate staff in the use of the sit-to-stand, low bed, fall mat, and non-skid footwear. Review of the resident's nurses note, dated 09/06/24, showed the following information: -Will ask therapy to see resident for possible downgrade to a Hoyer lift. Resident is not able to bear weight at times for the sit-to-stand. Director of Nursing (DON), and Nurse Practitioner(NP) notified. Review of the resident's nurses notes, dated 09/07/24 to 10/06/24, showed no follow-up note regarding lift concerns. recorded. Review of the resident's nurse note, dated 10/07/24, of a fall communication form, showed the following information: -The resident was being transferred to bed via sit-to-stand when the resident unhooked his/herself. Staff member lowered the resident to the ground as resident slid out of the lift onto the floor; -Interventions included change in transfer mechanism via transfer tree protocol. Review of the resident's fall team meeting, dated 10/21/24, showed the following information: -The resident fell out of the sit-to-stand on 10/07/24; -The resident was a high fall risk; -New interventions included education on the use of a sit to stand. Review of the resident's nurses note, dated 11/07/24, of a fall communication form, showed the following information: -The certified nurses aide (CNA) was using the sit-to-stand to lift the resident from the recliner to the wheelchair. As the CNA lifted the resident, the resident slid his/her arm out of the sling and then fell onto the floor landing on his/her right side. The resident was assessed and assisted back to the wheelchair with a Hoyer lift; -New interventions include education on proper sling to use for the sit-to-stand transfer for this resident. Review of the resident's fall team meeting, dated 11/11/24, showed the following information: -The resident fell out of the sit-to-stand on 11/07/24; -No new interventions put into place; -The resident was reeducated on the use of the sit-to-stand. Review of the resident's care plan showed staff did not update the care plan regarding the need for a transfer method change to prevent future falls. During an interview on 11/20/24, at 10:32 A.M., Registered Nurse (RN) D said the following: -The resident had been a sit-to-stand transfer, but he/she is now on hospice services due to a decline; -There has been mention of switching the resident to a Hoyer lift; -He/She plans to speak with the nurse practitioner (NP) about the transfer downgrade today and get that updated in the resident's chart. Observation on 11/20/24, at 1:25 P.M., showed the following: - Registered Medication Technician (RMT) I and Certified Nurse's Aide (CNA) J prepared to transfer the resident with the sit-to-stand lift from the wheelchair to the recliner. CNA J put a sit-to-stand sling around the resident and secured the sling around the resident. -CNA J began operating the sit-to-stand lift and the sit-to-stand lift started to rise. The resident's upper body lifted and resident was unable to come to a standing position. CNA J lowered the resident back into the wheelchair. -On the second attempt, CNA J began operating the sit-to stand lift. The sit-to-stand lift started to rise and the resident's upper body lifted and resident was unable to come to a standing position. CNA J lowered the resident back into the wheelchair. -On the third attempt, CNA J began operating the sit-to stand lift and the sit-to-stand started to rise. The resident's upper body lifted and resident was unable to come to a standing position. CNA J lowered the resident back into the wheelchair. -RMT J said morning transfers are usually a struggle for the resident. Nothing was passed in report regarding a decline and/or need to transfer the resident any other way. -CNA J said the resident should probably have non-slip socks on to assist with this transfer. (CNA J did not don non-slip socks onto the resident.) -On the fourth attempt, CNA J began operating the sit-to stand lift. The sit-to-stand started to rise, the resident's upper body lifted and resident was unable to come to a standing position. CNA J lowered the resident back into the wheelchair; The resident said he/she was tired. -On the fifth attempt, CNA J began operating the sit-to stand lift, the sit-to-stand started to rise and the resident's upper body lifted. The resident was unable to come to a standing position. CNA J lowered the resident back into the wheelchair. -RMT I said it might just be better to switch the resident to a Hoyer lift. He/she will fill out a stop and watch and the nurse will take care of it. -CNA J removed the sling from around the resident, and the resident continued to sit in his/her wheelchair. During an interview on 11/21/24, at 8:16 A.M., CNA/RMT E said the following: -Staff are expected to transfer the residents with one staff; -There are several residents on the hall that are high fall risks that are either sit-to-stand or Hoyer transfers; -He/She knows from previous jobs that mechanical lifts should be done with two staff members, however this facility only lets one staff complete the task, due to staffing and cost; -Often times the transfers are not safe due to the staffing ratio and the needs of the residents. During an interview on 11/21/24, at 1:10 P.M., CNA/RMT A said the following: -If a resident is a frequent faller the aides are told to keep a closer eye on them. Other fall interventions include fall mats and low beds; -The resident is transferred with a sit-to-stand. He/she has not had any issues doing so other than with holding on at times. -He/she is aware that the resident has fallen out of the sit-to-stand before. -If a staff member doesn't feel safe, or notices that the resident is unable to bear weight, they should use the decision flow chart and downgrade the residents transfer for that occurrence. -Staff should be able to see how a resident is transferred in the care plan. During an interview on 11/21/24, at 2:49 P.M., RMT B said the following: -The resident's transfer status depends on his/her mood for the day. -Most of the time the sit-to-stand is used. Staff operate the sit-to-stand with one staff member. -He/she was aware that the resident had fallen out of the sit-to stand before. The resident chicken wings his/her arms and slides right out of it due to not being able to bear total weight; -If he/she noticed the resident was unable to bear weight, he/she would downgrade the resident's transfer status to a Hoyer lift for that occurrence; -He/she has never seen the resident attempt to unhook themselves from the lift. He/she is unsure if the resident is capable of that. During an interview on 11/22/24, at 9:55 A.M., Licensed Practical Nurse (LPN) C said the following: -The resident has been a sit-to-stand transfer; -Staff can use the sit-to-stand for transfers if the resident is able to bear weight on at least one leg and has the ability to hold on; -If a resident seemed to be having trouble coming to a standing position, he/she would expect the staff to use the decision flow chart and downgrade the residents transfer status for that occurrence; -He/She was not aware if therapy had given any input on how the resident should be transferred; -He/she has not been made aware of any changes in the residents condition lately. During an interview on 11/22/24, at 10:26 A.M., Physical Therapist (PT) K said the following: -He/she had been asked to evaluate the resident before. He/she always recommended that the staff follow the decision flow chart, which means the staff should decide how much assistance the resident needs; -Knowing the resident, he/she would say that a decline will continue due to his/her mental and physical limitations; -A nurse did come to him/her this week and asked his/her thoughts on the resident's transfer status. At that time, he/she recommended the status be downgraded and care planned to a Hoyer lift. -When a transfer status is care planned, then that is what the staff should use at all times instead of the decision flow chart. -If the resident were to fall out a sit-to-stand, an intervention of education would not be appropriate, due to the resident's mental limitations. During an interview on 11/22/24, at 12:34 P.M., The Director of Nursing (DON) said the following: -She expected the staff to use the decision flow chart for determination of transfer status. -A resident must be able to bear weight if they are going to use the sit-to-stand. -A sit-to-stand can be operated with one staff member. She does encourage two staff members as it is safer. -The resident has sustained falls out of the sit-to-stand and the Hoyer lift potential has been discussed. -Transfer status should be care planned in this case. During an interview on 11/22/24, at 1:19 P.M., The Administrator said the following: -Staff are expected to use the sit to stand with one staff member. They are able to obtain help if it is needed; -Residents should be able to bear weight if they are using a sit-to-stand; -He was not aware of any current issues with the resident's transfer status; -Transfer status as well as any fall interventions should be care planned.

Based on observation, interview, and record review, the facility failed to provide respiratory care per standard of practice when staff failed to obtain physician orders for care of a continuous positive airway pressure machine (CPAP - a treatment for sleep apnea (sleep disorder that causes people to stop breathing or breathe shallowly while they sleep)) and failed to consistently clean the CPAP canister, tubing, and face mask for one resident (Resident #53) with a CPAP. The facility census was 65. 1. Review of Resident #53's face sheet showed: -admission date of 10/25/24; -Diagnosis included chronic respiratory failure with hypoxia (inadequate oxygen in the body tissues). Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 10/31/24, showed the following: -Cognitively intact; -No rejection of care; -Required substantial/maximum assistance of staff with showers and toileting hygiene; -Required partial/moderate assistance of staff with dressing and personal hygiene; -On oxygen therapy and non-invasive mechanical ventilation (CPAP). Review of the resident's care plan, dated 10/25/24, showed the following: -Ineffective breathing pattern: Resident has hypoxemia and chronic respiratory failure. Resident used a CPAP at hour of sleep (HS) and have a pleural drain. Vital signs as ordered, including oxygen saturation, physical assessment, and document any teaching regarding airway; -Oxygen use: Resident to use use oxygen at all times. Oxygen as ordered, instruct resident in pursed lip breathing, elevate the head of bed if requested, and minimize activities to short periods and one at a time. Review of the resident's physician orders an order, dated 11/04/24, for CPAP every HS and remove in the morning. (The orders did not include care and cleaning of the CPAP machine, CPAP tubing, or CPAP mask.) Observation and resident interview on 11/21/24, at 8:15 A.M., showed the following: -The resident lay on his/her bed with oxygen on via nasal cannula; -The resident's CPAP mask and attached tubing lay on his/her bed connected to a CPAP machine located on his/her bedside table; -The resident said he/she had sleep apnea and used the CPAP machine every night; -Prior to admission to the facility, while at home, the resident cleaned his/her machine, the tubing, and the mask every week; -Since admission to the facility, on 10/25/24, nearly one month ago, no one had cleaned his/her CPAP machine, tubing, or mask. During an interview on 11/21/24, at 12:10 P.M., Registered Nurse (RN) F said the following: -He/she rinsed the resident's CPAP tubing with water and hung it up to dry in the resident's room; -He/she was unsure if the facility had specific physician orders to care for the resident's CPAP; -The nurse then checked the resident's electronic health record and said the resident had a physician's order for CPAP use, but no specific order to clean the CPAP machine, mask, or tubing. During an interview on 11/21/24 at 12:15 P.M., Licensed Practical Nurse (LPN) G said the following: -The nurses should obtain physician orders for care/cleaning of the resident's CPAP equipment; -Nurses generally clean the CPAP canister, mask, and tubing with a cleaning solution kept in the clean utility room and then allow to air dry; -He/she was unsure specifically what the cleaning solution consisted of. During an interview on 11/22/24, at 1:00 P.M. LPN H said the following: -The facility did not have any physician orders for care of the resident's CPAP machine; -The night shift should rinse out the CPAP canister with sterile water and change the oxygen tubing running from the oxygen machine to the CPAP every week; -He/she had not cleaned or changed out the resident's CPAP mask or tubing; -He/she had rinsed out the canister with sterile water. During an interview on 11/22/24 at 1:20 P.M., the Director of Nursing (DON) said the nurses should have orders to clean the CPAP machine canister, tubing, and mask daily.

Based on observation, interview, and record review, the facility failed to document assessment for risk for entrapment and obtain informed consent prior to bed rail use for one resident (Resident #23) out of 17 sampled residents. The facility census was 65. Review showed the facility did not provide a policy regarding bed rail use. 1. Review of Resident #23's face sheet (brief look at resident information) showed the following information: -admission date 10/15/22; -Diagnoses included acute metabolic acidosis (too much acid in the blood). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 10/31/24, showed the resident required supervision for rolling from left to right and required substantial to maximum assistance from staff for moving from lying on the back to sitting on the side of the bed. Review of the resident's care plan, revised on 11/13/24, showed the resident used bed rails to assist in turning and repositioning. Review of the resident's medical record showed staff did not document assessment for risk of entrapment and informed consent for bed rails for the resident. Observation on 11/18/24, at 9:30 A.M., showed the resident lay in bed on his/her back with one half bed rail on each side of the bed, in the upright position. Observation on 11/19/24, at 9:48 A.M., showed the resident lay in bed on his/her back with one half bed rail on each side of the bed, in upright position. Observation on 11/20/24, at 12:11 P.M., showed the resident lay in bed on his/her back with one half bed rail on each side of the bed, in upright position. Observation on 11/21/24, at 9:52 A.M., showed the resident lay in bed on his/her back with one half bed rail on each side of the bed, in upright position. During an interview on 11/21/24, at 1:10 P.M., Certified Nursing Assistant/Registered Medication Technician (CNA/RMT) A said the following; -Residents need bed rails if they have an air mattress, so they don't roll out of bed; -There is an assessment that has to be completed by the nurses; -There has to be a physician's order; -Bed rail use should be seen in the care plan; -The Maintenance Director is who is responsible for installing and measuring the bed rails; -He/she believed the bed rails were monitored/reassessed quarterly; -The resident used side rails because he/she used to try to get out of bed a lot and would fall. The bed rails were used as a precaution to keep the resident from falling. During an interview on 11/21/24, at 2:49 P.M., RMT B said the following: -Residents use bed rails for mobility, as well as prevention for falling out of bed; -He/she was not sure if the nurses have to fill out any kind of assessment or informed consent; -He/she was not sure who measured the bed rails; -Some beds come with bed rails already on them. During an interview on 11/22/24, at 9:55 A.M., Licensed Practical Nurse (LPN) C said the following: -The nurses have to get a physician's order for a resident to use the side rails; -The Maintenance Director installs and measures them; -He/she was not sure if there was any required assessment and/or informed consent; -Residents use them for mobility, however some hospice patients are using them so they don't roll out of bed; -The resident has them for mobility. During an interview on 11/22/24, at 9:49 A.M., The Maintenance Director said the following: -He received a work order of when to add and remove bed rails; -He was responsible for installing the bed rails and doing an assessment along with measurements at the time of installation; -He checked the bed rails and re-measures quarterly; -He completed the resident's assessment and measurements on 11/21/24, after being told the rails were already installed. During an interview on 11/22/24, at 12:34 P.M., the Director of Nursing said the following: -Nursing staff will put in a request for the Maintenance Director to install the bed rails; -The nursing staff will fill out an assessment and obtain an informed consent; -Bed rails should be care planned; -The Maintenance Director will install the bed rails and measure them; -The bed rails are re-assessed and monitored quarterly by both nursing and the Maintenance Director. During an interview on 11/22/24, at 1:19 P.M., the Administrator said the following: -He expected the Maintenance Director to install and obtain bed rail measurements; -The Maintenance Director was to assess/monitor the bed rails quarterly; -Bed rails should be care planned; -An assessment and informed consent should be completed.

Based on observation, interview, and record review, the facility failed to maintain a complete and effective infection control program when staff failed to follow hand hygiene procedures and handle equipment in a manner to prevent transmission of infections agents per standards of practice for one resident (Resident #23) out of 17 sampled residents. The facility census was 65. Review of the facility's policy titled, Infection Prevention Annual Plan and Program Evaluation, dated 05/24, showed the following information: -Maintain a sanitary environment to minimize, reduce, or eliminate the risk of infection and communicable disease; -Ensure safe practices for cleaning and disinfecting environmental surfaces; -Ensure proper handling, storage, and disinfection of multi-patient use medical equipment; -Provide education to new coworkers upon hire and annually for all coworkers to prevent exposure to and transmission of infections and communicable diseases, hand hygiene, and standard precautions. Review of the facility's policy titled, Hand Hygiene, dated 11/24, showed the following information: -Perform hand hygiene on ungloved hands with approved alcohol based hand rub (ABHR) or soap and water; -Five moments for hand hygiene from the World Health Organization (WHO) are as follows: before touching a resident, before a clean or aseptic technique, after body fluid exposure risk, after touching a resident, and after touching a resident's surroundings; -Change gloves during resident care if moving from a contaminated body site to a different body site of the same resident; -Perform hand hygiene and change gloves if you suspect your gloves have been contaminated. 1. Review of Resident #23's face sheet (brief look at resident information) showed the following information: -admission date of 10/15/22; -Diagnoses included acute metabolic acidosis (too much acid in the blood). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 10/31/24, showed the following information: -At risk for pressure ulcers; -Indwelling catheter (a sterile tube inserted into the bladder to drain urine) use. Review of the resident's care plan, last revised on 11/13/24, showed the following information: -Pressure ulcers to bilateral (both) heels. Staff to keep skin clean and dry, provide treatment as ordered, and follow enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes.); -Foley catheter used. Staff to keep clean, change catheter per orders, dignity, position drainage bag to facilitate flow of urine, and follow enhanced barrier precautions. Observation on 11/19/24, at 2:55 P.M., showed the following: -Registered Medication Technician (RMT) L and Licensed Practical Nurse (LPN) M enter the resident's room without performing hand hygiene. Both staff donned gowns and gloves. -RMT L removed the resident's catheter drainage bag and placed it onto the floor near the right side of the toilet. -RMT assisted the resident to a standing position and then pivoted to the toilet. The LPN noticed the catheter drainage bag on the floor, obtained the catheter bag, and placed it back under the resident's wheelchair. Staff did not perform had hygiene or change gloves. -RMT L assisted the resident to a standing position and LPN M obtained wipes and cleansed the resident's bottom. Staff did not perform hand hygiene or glove change. -RMT L assisted the resident back into sitting position on the toilet. LPN M obtained wipes and cleansed the residents front side. RMT L assisted the resident to a standing position. LPN M obtained additional wipes and cleansed the resident's bottom once more. Staff did not complete hand hygiene or change gloves. -LPN M pulled the resident's pants up and RMT L pivoted the resident back into a seated position in his/her wheelchair. -LPN M took off gloves and without performing hand hygiene donned new gloves. -RMT L and LPN M both placed wheelchair pedals onto the resident's wheelchair. -Both staff removed gloves. LPN M sanitized his/her hands. RMT L washed his/her hands in the bathroom sink. -LPN M then obtained the resident's oxygen tubing and assisted placing it inside the resident's nostrils before exiting the room. Observation on 11/21/24, at 9:52 A.M., showed the following: -LPN C stood outside the resident's room with the treatment cart. LPN C had gloves donned and sanitized scissors with disinfectant wipes. Supplies for wound care were gathered and placed on top of the treatment cart. LPN C took off gloves, obtained a gown, and donned the gown prior to entering the resident's room. -The Wound/Infection Preventionist (IP) Nurse was in the resident's room with gown and gloves donned. -LPN C laid the wound care supplies down onto the resident's bedside table, including the previously disinfected scissors, with no clean barrier or re-sanitization. -LPN C sanitized his/her hands, donned gloves, obtained the resident's bed adjusting dial, lowered the resident's bed, removed the resident's heel protectors, and removed the resident's sock to the right foot. -Without performing hand hygiene or changing gloves. LPN C obtained gauze and wound cleanser spray. LPN C moistened the gauze with the wound cleanser and cleansed the residents wound to the right heel. -LPN C removed gloves, sanitized hands, and donned new gloves. LPN C applied the treatment to the resident's right heel wound. LPN C did not sanitize his/her hands or change gloves and moved onto removing the resident's left heel wound previous treatment. The heel protectors and sock were preciously removed by the Wound/IP Nurse. -LPN C cleansed the resident's left heel wound. LPN removed gloves, sanitized hands, donned new gloves, and performed the treatment to the resident's left heel. The Wound/IP Nurse placed the resident's sock and heel protector back on. -Without removing gloves or sanitizing hands, the LPN touched the resident's bed blankets, the bed, the bed adjustor dial, and the resident's oxygen tubing. -The resident rolled toward the Wound/IP Nurse, onto his/her left side. LPN C adjusted the bed pad underneath the resident and removed the resident's pants and brief. -Without performing hand hygiene or changing gloves, the LPN obtained the contaminated scissors and cut the dressing material and laid the scissors back down onto the resident's bedside table with no clean barrier. The LPN touched the resident's bedside table and then removed the previous treatment dressing from the resident'' bottom. The LPN obtained gauze and wound cleanser and moistened the gauze with the wound cleanser. -While cleansing the resident's wound, bowel was seen on the gauze pad. The LPN obtained wipes and cleansed the resident's bottom with the swipe and fold method. -The LPN removed gloves, sanitized hands, and donned new gloves. LPN C obtained the treatment supplies and applied the treatment to the resident's bottom, placed on the resident's brief and pants and allowed the resident to roll onto his/her back to rest. -The LPN did not change gloves or perform hand hygiene. The resident rolled back onto his/her left side toward the Wound/IP Nurse. LPN C removed the dressings to the resident's back wounds and obtained wound cleanser and gauze. LPN C cleaned the wounds with moistened gauze. LPN C removed gloves, sanitized hands, and applied treatment to the resident's back wounds. -The resident rolled back onto his/her back. LPN C covered the resident with his/her blanket, obtained the residents bed pad, along with the Wound/IP Nurse and pulled the resident up into bed. LPN C removed gloves, sanitized hands, and donned new gloves. LPN C obtained the wound cleanser, picked trash up off the floor, obtained his/her scissors from the resident's bed side table, obtained the trash, a box of opened gloves, and then touched the residents nebulizer tubing without performing hand hygiene. During an interview on 11/21/24, at 1:10 P.M., Certified Nurses Aide/ Registered Medication Technician (CNA/RMT) A said the following: -Hand hygiene should be performed before and after care and if going from a dirty surface to a clean surface; -Catheter drainage bags should not be placed on the floor. During an interview on 11/21/24, at 2:49 P.M., RMT B said the following: -Hand hygiene should be performed before and after care and if going from a dirty surface to a clean surface; -Catheter drainage bags should not be placed on the floor. During an interview on 11/22/24, at 9:55 A.M., LPN C said the following: -Hand hygiene should be performed before and after care and if going from a dirty surface to a clean surface; -Catheter drainage bags should not be placed on the floor; -Equipment should be sanitized before and after each use and should be laid on a clean barrier During an interview on 11/22/24, at 12:07 P.M., the Wound/IP Nurse said the following: -Hand hygiene should be performed before and after care and if going from a dirty surface to a clean surface; -Catheter drainage bags should not touch the floor; -She expected staff to change gloves and perform hand hygiene prior to moving onto the next wound treatment; -She expected staff to have a clean barrier laid down for supplies; -Placing supplies on a dirty surface, then using the supplies would be considered cross contamination. During an interview on 11/22/24, at 12:34 P.M., the Director of Nursing (DON) said the following: -She expected hand hygiene to be performed before and after care and if going from a dirty surface to a clean surface; -Catheter drainage bags should not touch the floor; -She expected staff to change gloves and perform hand hygiene prior to moving onto the next wound treatment; -She expected equipment to be sanitized before it enters or leaves a residents room, and to have a clean barrier laid down. During an interview on 11/22/24, at 1:19 P.M., the Administrator said the following: -Hand hygiene should be performed before any task, when hands are soiled, and before and after cares; -He expected staff to have clean equipment and clean barriers; -Catheter drainage bags should not touch the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection control program when the facility failed to implement an enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities) policy timely and when staff failed to follow infection control practices, per standard of practice, when proving would care to residents (Resident #1 and Resident #2) putting the wounds at risk for contamination. The facility census was 67. Review of the facility's policy titled, Enhanced Barrier Precautions for Long Term Care, IP02-08, effective 09/2024, showed the following: -It is the policy of the facility to implement EBP for the prevention of transmission of MDROs; -The purpose of the policy was to prevent the spread of MDROs and maintain a home like environment for residents; -EBP are an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBP involve gown and glove use during high-contact resident care activities for resident known to be colonized with a MDRO, as well as those at increased risk of MDRO acquisition (e.g., residents with wound or indwelling medical devices); -High contact resident activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, or device care or use of central line, urinary catheter, feeding tube, tracheostomy/ventilator, or during wound care of any skin opening requiring a dressing; -A resident will be place on EBP with a wound even if the resident is not known to be infected or colonized with a MDRO. Review of the facility's policy titled, Hand Hygiene, IP02-07, revised July 2021, showed the following: -Hand hygiene is the single-most effective method of reducing the transmission of microorganisms in a healthcare setting. The term hand hygiene; -Perform hand hygiene on ungloved hands with approved alcohol based hand rubs (ABHR) or soap and water; -Five moments for hand hygiene from the World Health Organizations (WHO) are before touching a resident; before a clean or aseptic procedure; after body fluid exposure risk; after touching a resident; and after touching a resident's surroundings; -Examples of opportunities for hand hygiene include use ABHR before crossing the threshold/entering a resident's room; before donning sterile or non-sterile gloves; before donning any personal protective equipment (PPE - gown, mask, gloves); before inserting or handling invasive devices; before moving from a contaminated body site to a different body site during the care of the same resident; after contact with the resident's skin, body fluids, excretions, mucous membranes, or dressings; after contact with objects in the immediate vicinity of residents; after doffing of sterile or non-sterile gloves; after doffing of any PPE, and upon crossing the threshold when exiting the patient's room. -Use soap and water when hands are visibly soiled. Review of the facility's policy titled, Cleaning and Disinfecting Patient Care Equipment, IP07-01, revised January 2020, showed the following: -Purpose to provide guidelines for the recognition of clean or soiled equipment and guidelines for storage and treatment after use and to define and establish standards for assuring that non-critical items (as defined by the Centers for Disease Control (CDC)) as those that come in contact with intact skin but not mucous membranes and shared resident equipment is clean before use and that used or contaminated equipment is appropriately cleaned before reuse; -Disinfection is a thermal or chemical destruction of pathogenic and other types of microorganisms. Disinfection is less than sterilization because it destroys most recognized pathogenic microorganisms, but not necessary all microbial forms like bacterial spores. This is most often completed by use of an approved hospital disinfectant or chemical sterilant; -Resident care equipment for use for more than one resident will be disinfected with an organization approved disinfectant after each use; -Follow manufacturer's instructions for cleaning, disinfecting, and maintaining medical equipment; -Always allow for recommended contact time when using disinfectant wipes and solution. 1. Review of Resident #1's face sheet showed an admission date of 03/28/24. Review of the resident's diagnosis and problem list showed the resident's diagnoses included Guillain-Barre syndrome (a rapid onset muscle weakness caused by immune system damaging the peripheral nervous system) , paraplegia (chronic condition that affects the ability to move or feel the legs/feet), polyneuropathy (acute or chronic damage or disease affecting the peripheral nerves), major depressive disorder, and anxiety. Review of the resident's care plan for pressure ulcers, dated 04/02/24, showed staff care planned perineal cares as needed and wound cares as ordered. Review of the resident's quarterly Minimum Data Set (MDS - a federally-mandated comprehensive assessment tool completed by facility staff), dated 07/08/24, showed the following: -Presence of one stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and one stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer; -Presence of moisture associated skin damage; -Pressure ulcer care. Review of the resident's medial sacral (a triangular bone located at the base of the spine) pressure ulcer assessment, dated 09/02/24, showed the following: -Present on admission; -Stage III; -Wound length = 11.0 centimeters (cm); -Wound width = 9.0 cm; -Wound depth = 2.0 cm; -Presence of pain = No; -Wound appearance = Eschar (dead or devitalized tissue that is hard or soft in texture), purple reddened, slough (non-viable yellow, tan, gray, green or brown tissue), tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), unapproximated, undermining (the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface); -Wound surrounding tissue appearance: Bright red, pink; -Surrounding tissue temperature: Warm; -Wound drainage description: Creamy; -Wound drainage amount: Moderate; -Wound drainage odor: No odor. Review of the resident's current medial sacral treatment orders, dated 09/04/24, showed the following: -For tunneling and undermining wet to dry packing with Vashe (a solution used to cleanse, moisten, and aide in debridement of wounds); apply nickel layer of Santyl (an enzymatic debriding agent - used to help remove dead tissue from a wound) to necrotic area; cover with normal saline moistened gauze; then cover with vaseline gauze, ABD (absorbent gauze pad) pad, and tape; -Change two times per day and as needed if soiled/displaced. Review of the resident's left lower buttock pressure ulcer assessment, dated 09/02/24, showed the following: -Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.); -Present on admission; -Wound length = 2.9 centimeters (cm); -Wound width = 1.7 cm; -Wound depth = 1.8 cm; -Presence of pain = No; -Wound appearance = Beefy red, bone visible, muscle visible, tunneling; -Wound tunneling position = 4 o'clock; -Wound tunneling depth = 3.5 cm -Wound surrounding tissue appearance: Dark red, pink, tunneling,weeping; -Surrounding tissue temperature: Warm; -Wound drainage description: Sanguineous (containing blood); -Wound drainage amount: Moderate; -Wound drainage odor: No odor. Review of the resident's current left lower buttock treatment orders, dated 09/04/24, showed the following: -Cleanse wound and surrounding area with wound cleaner, rinse with saline, pack wound with Vashe soaked Kerlix (rolled gauze), cover with ABD pad and secure with tape; -Change the dressing two times per day and as needed. Observation on 09/09/24, at 10:30 A.M., showed the following, -Licensed Practical Nurse (LPN) A and LPN B entered the resident's room to perform wound care to the resident's two pressure ulcers; -LPN A and LPN B washed their hands and donned gloves. Neither nurse donned isolation gowns; -LPN A removed pillows from behind the resident's back, buttocks, and legs, and pulled the resident's slacks and brief down, and assisted the resident to turn more to his/her right side, exposing the resident's buttocks; -The resident had a urinary catheter; -Two dressings were present to the resident's skin, one on the left lower buttock and one to the sacrum, both dated 09/08; -The resident had a small amount of feces present near his/her rectum; -LPN A placed his/her hand on the outside of the resident's soiled brief, and used the brief to remove the feces from the resident's rectum; -Without washing or sanitizing his/her hands or changing gloves, LPN A removed the soiled dressings from the resident's left lower buttocks and coccyx (tailbone) and placed the dressings on the brief; -LPN B sprayed wound cleanser onto the existing sacral wound packing located in the resident's sacral wound and LPN A removed the packing from the wound. The gauze packing was covered in tan colored drainage; -LPN A then placed the resident's soiled brief and dressings into the trash can. A small tear (approximately 1 cm in length) to the back of LPN A's glove over one of his/her fingers was visible; -LPN B dropped the bandage scissors onto the floor, picked the scissors up off the floor with gloved hands, took the scissors to the resident's sink, and washed off the scissors with soap and water; -Wearing the same gloves and without washing his/her hands, LPN B opened a package of rolled gauze and touched the gauze with the same gloves, as he/she cut strips of the gauze using the scissors; -LPN B handed LPN A the pieces of gauze, LPN A used the gauze and wound cleanser to clean the surfaces of the wound to the resident's left buttock and wearing the same gloves. The LPN used different pieces of gauze to cleanse the resident's sacral wound. LPN A then removed his/her gloves, sanitized his/her hands, and donned clean gloves; -LPN A then removed gloves and exited room to get more Vashe from the medication cart; -LPN A reentered the room and sanitized his/her hands and donned gloves; -LPN A placed Vashe moistened gauze into the left lower buttock wound using a swab to pack the gauze into the wound tunnel. LPN A then used the scissors to cut the gauze, placed the scissors on a draw sheet on the resident's bed, covered the wound with an ABD pad, and secured the dressing with tape ; -Without washing his/her hands or changing gloves, LPN A placed Santyl on the necrotic wound edges of the sacral wound using a sterile swab and then placed Vashe soaked, cut gauze into the sacral wound with gloved hands; -LPN B then picked up the scissors off the resident's bed and cut more rolled gauze, while LPN B held onto the gauze, LPN A then placed these pieces of gauze over the packed sacral wound; -Without washing hands or changing gloves, LPN B picked up and unfolded an ABD pad and handed it to LPN A. LPN A placed the ABD pad over the resident's sacral wound and secured with tape. 2. Review of Resident #2's face sheet showed an admission date of 08/07/16. Review of the resident's diagnoses list showed current diagnoses included neuromuscular scoliosis (sideways curvature of the spine), Arnold Chiari Syndrome (a condition present at birth in which the brain tissue extends into the spinal canal), and depression. Review of the resident's pressure ulcer care plan, dated 08/15/19, showed the following: -Due to the resident's curved and twisted spine and his/he paralysis of the left side. He/she used a wheelchair for mobility. This puts the resident at a higher risk for skin breakdown. He/she also leans to the left while sitting up in the wheelchair. He/she had developed a pressure ulcer to the left lower back that is being monitored by the wound clinic; -Monitor skin for redness or breakdown and notify the nurse; -Dressing change and treatment to pressure ulcer as ordered. Review of the resident's current left lateral back pressure ulcer treatment orders, dated 08/01/24, showed the following: -Cleanse wound with wound cleanser, apply nickel-sized layer of Santyl to the wound for enzymatic debridement, pack moistened 4 x 4 gauze into the wound, apply ABD pad, and secure with tape, Review of the resident's quarterly MDS, dated [DATE], showed the following: -Presence of one stage III pressure ulcer; -Pressure ulcer care; -Application of ointments/medicine/dressings to skin (other than to feet). Review of the resident's left lateral back pressure ulcer assessment, dated 09/02/24, showed the following: -Stage IV; -Acquired in facility; -Wound length = 4.9 centimeters (cm); -Wound width = 2.0 cm; -Wound depth = 1.8 cm; -Presence of pain = No; -Wound appearance = Beefy red, bleeding, granulation, pink, slough, undermining; -Wound surrounding tissue appearance: Pink, purple; -Surrounding tissue temperature: Warm; -Wound drainage description: Tan; -Wound drainage amount: Moderate; -Wound drainage odor: No odor; -Comments: Resident seen by wound clinic on 08/01/24 and orders changed. Wound bed looks clean with minimal discomfort noted with dressing changes. Observations on 09/09/24, at 1:19 P.M., showed the following: -LPN B entered the resident's room to perform wound care; -The resident sat in his/her wheelchair; -The nurse did not don an isolation gown; -The nurse placed additional gloves on the resident's over bed table without cleaning the table. The resident's over bed table had smears and a white substance on the surface; -With clean gloves, the nurse removed the resident's soiled back dressing, dated 09/05. The wound did not contain any packing; -The wound dressing contained a moderate amount of tan and green drainage and had an odor; -Wearing the same gloves, the nurse cleansed the wound with gauze and wound cleanser; -The nurse removed gloves and stepped out of the resident's room to obtain more supplies; -While the nurse was out of the room, the resident rested back against his/her wheelchair back and the open wound rested against the vinyl wheelchair back; -The nurse returned and the resident leaned forward. The nurse sanitized his/her hands and picked up a pair gloves off the over bed table. The nurse donned the glove and, using a swab, applied Santyl to the wound; -The nurse then placed gauze into the wound using gloved hands and covered the wound with an ABD pad and tape to secure in place. 3. During an interview on 09/10/24, at 12:04 P.M., LPN A said the following: -Prior to resident wound care, staff should set up a clean field and place items for use on a clean surface; -The nurse would wash his/her hands and don gloves prior to removing soiled dressings; -The nurse should then remove gloves and wash or sanitize hands and don new gloves before cleaning the wound; -The nurse should then remove the gloves and wash or sanitize his/her hands and don new gloves prior to applying clean packing/dressings; -The nurse should then remove his/her gloves and wash his/her hands after completion of the wound treatment; -The nurse should treat each wound separately; -He/she did not recall have a tear in his/her gloves; -The nurse should have sanitized the scissors with a bleach wipe, washed his/her hands and changed gloves; -He/she thought Resident #1's dressings were stuck together with tape and that is why both dressings came off together; -Normally, he/she would treat each wound separately; -If a nurse had to step out of a room in the middle of wound care, the nurse should first place dry gauze over the would to decrease the risk of possible contamination. 4. During an interview on 09/09/24, at 1:45 P.M., LPN B said the following: -During wound care staff should wash hands and don gloves to remove existing dressings, then wash or sanitize hands and change gloves prior to cleansing the wound, then wash or sanitize hands and change gloves prior to placement of the clean dressing, then remove gloves and wash hands prior to exiting room; -He/she should set up a clean field for the dressing supplies and gloves. 5. During an interview on 09/10/24 at 11:33 A.M., LPN C said the following: -On Friday, 09/06/24, during the staff meeting, facility management said staff would start using EBP during wound care and any invasive procedures, and EBP would include gowns and gloves; -EBP is a new thing to the facility; -Prior to resident wound care, staff should set up a clean field and place items for use on a clean surface; -The nurse would wash his/her hands and don gloves prior to removing soiled dressings; -The nurse should then remove gloves and wash or sanitize hands and don new gloves before cleaning the wound; -The nurse should then remove the gloves and wash or sanitize his/her hands and don new gloves prior to applying clean packing/dressings; -The nurse should then remove his/her gloves and wash his/her hands after completion of the wound treatment; -The nurse should treat each wound separately. 6. During interviews on 09/09/24, at 2:00 P.M. and 2:10 P.M., the Director of Nursing (DON) said the following: -The facility had not put in place policies for staff to utilize EBP; -When the facility begins using EBP, staff will use gown and gloves during wound care; -Nurses should wash or sanitize hands and don gloves prior to removing soiled wound dressings; -After removal of soiled dressings, nurses should remove gloves and again wash or sanitize hands; -Nurse should then don a new pair of gloves and clean the wound; -After cleaning of the wound the nurse should remove gloves and wash or sanitize hands; -Nurse should don a new pair of gloves prior to dressing the wound; -Nurse should sanitize equipment, such as bandage scissors, with Sani-cloths (bleach wipes) per the manufacturer's recommendations; -Staff should not place scissors on the resident's bed, and if dropped in the floor, staff should re-sanitize the scissors and remove gloves and wash or sanitize hands; -Staff should place supplies on a clean surface in the resident's room; -If treating multiple wounds, staff should treat each wound separately without cross-contamination. 7. During an interview on 09/09/24, at 2:00 P.M., the Director of Long-Term Care Nursing Operations said the following: -The corporation is in the process of working on their EBP policies; -The policy was near completion and the corporation was also working on an online inservice for EBP; -On Friday, 09/06/24, the facility started talking to staff about EBP; -He/she was aware EBP protocols should already be in place within the facility, but was a work in progress; -Staff should use gloves and gown during wound care and face protection if irrigating wound or risk of splash; -Facility staff have not started using EBP During an interview eon 09/10/24, at 3:11 P.M., the Administrator said the following: -The corporation was working on a policy for EBP; -The facility talked about what would be implemented regarding the use of EBP at the staff meeting on 09/06/24; -Nurses should use basic hand hygiene during wound care; -Expect nurses to wash or sanitize hands and change gloves before, between, and after any procedure; -Nurses should appropriately clean any equipment used as well. MO00241562