**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to cover a resident's catheter (tube inserted into the bladder to drain urine) drainage bag with a dignity bag to ensure the dignity of one resident (Resident #2) out of two sampled residents. The facility census was 51. Review of the facility policy titled, Dignity and Respect, undated, showed: - All residents be treated with kindness, dignity, and respect; - Privacy of a resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety; - Residents shall be examined and treated in a manner that maintains the privacy of their bodies. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - Diagnosis of acute cystitis (bladder infection) with hematuria (bloody urine); - The resident with a urinary catheter present upon admission. Observations on 01/21/25 at 11:48 A.M., 01/22/25 at 12:03 P.M., and 01/23/25 at 6:55 A.M., showed: - The resident sat in a wheelchair in the dining room; - A urinary catheter drainage bag, partially filled with yellow urine, hung from the bottom of the wheelchair and not covered with a dignity bag for privacy. Observation on 01/22/25 at 9:10 A.M., 10:18 A.M., and 01/23/25 at 5:15 A.M., showed: - The resident sat in a wheelchair in the common room; - A urinary catheter drainage bag, partially filled with yellow urine, hung from the bottom of the wheelchair and not covered with a dignity bag for privacy. During an interview on 01/22/25 at 11:30 A.M., Certified Nurse Assistant (CNA) D said the resident's catheter drainage bag should have a dignity bag to protect the resident's privacy and dignity. During an interview on 01/23/25 at 1:41 P.M., Licensed Practical Nurse (LPN) C said he/she would expect a resident with a catheter to have the catheter drainage bag in a dignity bag. During an interview on 01/23/25 at 2:45 P.M., the Director of Nursing (DON) said she would expect a resident with a catheter to have their dignity maintained and for the catheter drainage bag to be covered when the resident was in a common area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital for two residents (Residents #2 and #35) out of three sampled residents. The facility's census was 51. The facility did not provide a policy regarding a resident transfer/discharge. 1. Review of Resident #2's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer/discharge to the hospital at the time of the transfer. 2. Review of Resident #35's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer/discharge to the hospital at the time of the transfer. During an interview on 01/23/25 at 2:25 P.M., Licensed Practical Nurse (LPN) B said nurses were responsible for filling out the transfer/bed hold paperwork. The nurse would make a copy and give one copy to the resident and the other copy would go in the resident's chart. During an interview on 01/23/25 at 3:30 P.M., the Administrator said she would expect the appropriate forms be filled out and given to the resident or the resident representatives when a resident was transferred out to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident and/or the legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Residents #2 and #35) out of three sampled residents. The facility's census was 51. The facility did not provide a bed hold policy. 1. Review of Resident #2's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 2. Review of Resident #35's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. During an interview on 01/23/25 at 2:25 P.M., Licensed Practical Nurse (LPN) B said nurses were responsible for filling out the transfer/bed hold paperwork. The nurse would make a copy and give one copy to the resident and the other copy would go in the resident's chart. During an interview on 01/23/25 at 3:30 P.M., the Administrator said she would expect the appropriate forms filled out and given to either the resident or the resident representative when a resident was transferred to the hospital.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all residents. The facility census was 51. The facility did not provide a RN coverage policy. Review of the facility's Facility Assessment, updated 08/01/24, showed: - The facility required three licensed nurses providing direct care for day shift, which included at least one RN for the day shift; - The facility required three licensed nurses providing direct care for the night shift, which included at least one RN for the night shift. Review of the Center for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data Report from the Community Assessment for Public Health Emergency Response (CASPER) REPORT 1705D for the fiscal year quarter 4, 2024 (July 1, 2024 to September 30, 2024) showed: - Triggered four or more days within the quarter with no RN hours; - Seven days in July 2024 for 07/04/24- Thursday; 07/13/24- Saturday; 07/14/24- Sunday; 07/20/24- Saturday; 07/21/24- Sunday; 07/27/24- Saturday; and 07/28/24- Sunday; - Three days in August 2024 for 08/10/24- Saturday; 08/11/24- Sunday; and 08/25/24- Sunday; - Five days in September 2024 for 09/02/24- Monday; 09/14/24- Saturday; 09/15/24- Sunday; 09/21/24- Saturday; and 09/22/24- Sunday. Review of the Nursing Schedules and the Daily Nursing Staffing Sheets for October 10/20/24 - 01/20/25, showed: - No RN worked on 10/20/24, 11/03/24, 11/16/24, 11/17/24, 12/01/24; 12/14/24; 12/15/24, 01/11/25, 01/12/25, and 01/19/25; - No RN worked for 10 days out of 93 days. During an interview on 01/23/25 at 1:37 P.M., the Administrator said a RN had been scheduled on each day shift, but when one of the RN's quit, the RN position was replaced with a Licensed Practical Nurse (LPN). There was a RN on call every weekend, but the RN was not always in the building. The RN was available by phone instead. She was aware there should be a RN on duty at least eight hours a day, seven days a week.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 36 opportunities with two errors made, resulting in an error rate of 5.56% for two residents (Residents #2 and #26) out of seven sampled residents. The facility's census was 51. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: - Medications are administered in a safe and timely manner, and as prescribed. - Insulin pens containing multiple doses of insulin are for single-resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident; - Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident; - The policy did not address insulin pen administration technique. Review of the insulin aspart (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) FlexPen (insulin in a pen-type device) instructions, revised, June 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and zero is seen in the dose window, count to five slowly, the insulin will be visible at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. Review of the insulin Humalog (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) KwikPen (insulin in a pen-type device) manufacture guidelines for administration, revised 07/2023, showed: - Prime the pen before each injection; - Priming Directions of Insulin Pen: turn the dose knob to select two units; hold the pen with the needle pointing up; tap the cartridge holder gently to collect air bubbles at the top; push the dose knob in and continue holding the pen with the needle pointing up; push the dose knob in until it stops, and zero is seen in the dose window; hold the dose knob in and count to five slowly; check for insulin at the tip of the needle; if insulin wasn't present, repeat the priming steps one to three, no more than four times; if insulin still not present, change the needle, and repeat the priming steps; - Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; - If the pen isn't primed before each injection, the patient may get too much or too little insulin. 1. Review of Resident #2's Physician Order Sheet (POS), dated January 2025, showed: - An order for Humalog KwikPen 20 units per milliliter (ml) subcutaneous (an injection just below the skin) with meals, dated 03/20/24. Observation of the resident's medication administration on 01/22/25 at 11:42 A.M., showed: - Licensed Practical Nurse (LPN) B administered 20 units of of Humalog insulin subcutaneously with the resident's Humalog Kwikpen for a blood sugar of 183; - LPN B failed to prime the Humalog Kwikpen per the manufacturer's instructions prior to the administration of the insulin to the resident. 2. Review of Resident #26's POS, dated January 2025, showed: - An order for insulin aspart FlexPen 10 units per ml subcutaneous with meals, dated 01/02/25. Observation of the resident's medication administration on 01/23/25 at 10:35 A.M., showed: - LPN C administered 10 units of insulin aspart subcutaneously with the resident's insulin aspart FlexPen for a blood sugar of 210; - LPN C failed to prime the insulin aspart FlexPen per the manufacturer's instructions prior to the administration of the insulin to the resident. During an interview on 01/23/25 at 10:40 A.M., LPN C said when administering insulin, he/she would prime the insulin pen when it was brand new, and then after that, he/she did not prime the pen before each dose. During an interview on 01/23/25 at 3:30 P.M., the Director of Nursing (DON) said all insulin pens should be primed before each individual dose and for the facility to have a less than five percent medication error rate.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during catheter (a tube that inserted into the bladder to drain urine) care for one resident (Resident #2) out of two sampled residents and during gastrostomy tube (device to deliver food or medicine into the resident's digestive system) care for one resident (Resident #44) out of two sampled residents, and while passing trays during meal times. The facility's census was 51. Review of the facility's policy titled, Wearing Gloves for Food Safety, undated, showed: - Wash hands before and after handling food, utensils, or equipment; - Wash hands after touching hair or your body; - Wash hands when you change tasks; - Wash hands after touching anything that might result in contamination of hands. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), dated 10/03/24, showed: - EBP employs gown, gloves, and face/eye protection; - Foley catheters (a tube inserted into the bladder to drain urine) and feeding tubes or drains need EBP; - The facility will conduct an annual infection control risk assessment; - Residents with an indwelling device will be placed in EBP until the device is removed; - Residents will be evaluated for the need of EBP upon admission, with a significant change, quarterly, with antibiotic use, placement of medical device, or with the development of a new skin condition; - The resident and/or resident representative will be educated on the resident's need for EBP; - Staff training regarding EBP will be conducted upon hire, annually, if changes occur, and as needed; - Routine skill, competency, and/or compliance audits will be conducted by Infection Preventionist or designee; - Staff must remove personal protective equipment (PPE) and perform hand hygiene after working with a resident in EBP before providing care to other residents; - Post signage at the door or designated area and ensure a receptacle is placed at the room exit for removal. Review of the facility policy titled, Care of Indwelling Foley Catheters, dated January 2016, showed: - Catheter care is provided every shift and more often as needed with the purpose to prevent possible urinary tract infections from bacteria; - Wash hands and put on gloves, identify resident and yourself, explain what you are going to do, provide privacy, resident in supine (lay on back) position with legs apart, check catheter and drainage bag for leaks, kinks, level of bag, and ensure catheter bag is securely attached to the bed frame; - Expose perineal area and gently wash around the opening of the urethra with soap and warm water, wash catheter tubing from opening of the urethra outward four inches or farther if needed without pulling on the catheter, using fresh washcloth, continue washing and rinsing the perineal area; - Dry the perineal area; - Remove gloves and dispose in appropriate container, then wash hands. 1. Observations on 01/21/25 of the lunch meal in the main dining room showed: - At 11:36 A.M., Hostess A delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:40 A.M., Certified Nursing Assistant (CNA) G delivered a meal tray to a resident, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:42 A.M., Hostess A delivered a meal tray to a resident, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:45 A.M., CNA G delivered a meal tray to a resident, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:47 A.M., Hostess A delivered a meal tray to a resident, touched his/her hair, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray. Observations on 01/22/25 of the lunch meal in the main dining room showed: - At 11:40 A.M., Hostess A delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:43 A.M., Hostess A delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:44 A.M., CNA H delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:46 A.M., CNA H delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:48 A.M., CNA H delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:51 A.M., CNA G delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:53 A.M., CNA G delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray. During an interview on 01/23/25 at 12:33 P.M., Hostess A said hand washing or sanitizing should be done before passing trays, after every few meal trays were passed, before assisting a resident to eat, and if hands were soiled. During an interview on 01/23/25 at 3:45 P.M., the Director of Nursing (DON) said staff were expected to wash or sanitize their hands after touching soiled surfaces and between each tray when delivering meal trays. 2. Observation on 01/22/25 at 11:30 A.M., of Resident #2's catheter care showed: - EBP signage posted outside the room; - CNA D and CNA E put on gowns prior to entering the resident's room; - CNA D put on two pair of gloves, got a wipe, wiped the area around the catheter, removed one pair of gloves, got a wipe, wiped the area around the catheter, and removed the gloves; - CNA D did not perform hand hygiene, put on gloves, got a wipe, cleaned the area around the catheter, and removed the gloves; - CNA D did not perform hand hygiene, put on gloves, got a wipe, wiped the resident's buttocks, and removed the gloves; - CNA D did not perform hand hygiene, put on gloves, got a wipe, wiped the resident's buttocks again, and removed the gloves; - After completion of the catheter care, CNA D exited the resident's room with the gown on, went out into the hallway, removed the gown, and performed hand hygiene. During an interview on 01/23/25 at 7:00 A.M., CNA D said staff received training on infection control, catheter care, incontinence care, and the new EBP precautions. Hand hygiene should be done between glove use, before and after care, and when visibly dirty. During an interview on 01/23/25 at 2:33 P.M., CNA E said hand hygiene was done before doing a task, when going from clean to dirty care, when going from a dirty to clean task, and when the task was completed. Hand hygiene was done before passing food trays, between each food tray delivered to a resident, and after the last tray was delivered. Hand hygiene also was done if touching a contaminated surface between tasks. A EBP gown was taken off before exiting the room and placed in the appropriate disposal bins. 3. Observation on 01/23/25 at 5:25 A.M., of Resident #44's gastrostomy tube care showed: - EBP signage posted outside the room; - Licensed Practical Nurse (LPN) I did not put on a gown prior to beginning the gastrostomy tube care; - LPN I provided gastrostomy tube care to the resident. During an interview on 01/23/25 at 10:50 A.M., LPN C said residents with an indwelling device like a catheter or gastrostomy tube require staff to wear EBP when doing care. EBP, such as a gown and gloves, were put on before entering the resident's room and removed before exiting the resident's room. During an interview on 01/23/25 at 3:30 P.M., the Director of Nursing (DON) and the Administrator said they expected hand hygiene and glove use to be done before and after incontinence care and catheter care. If someone double gloved and gloves were soiled, then both pairs of gloves should be taken off and hand hygiene performed before putting on new gloves. Staff were to use EBP precautions for close contact with residents with indwelling catheters, gastrostomy tubes, and wounds. EBP should be taken off prior to leaving a room and placed in an EBP trash can.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected one Certified Nurse Assistant (CNA) (CNA F) out of two sampled CNAs. The facility's census was 51. Review of the facility's policy titled, In-Service Training, Nurse Aide, revised 08/2022, showed: - All personnel are required to participate in regular in-service education; - Annual in-services are no less than 12 hours per employment year; - Nurse aid participation in training is documented by the staff development coordinator, or his/her designee and includes: the date and time of the training; the topic of the training; the method used for the training; a summary of the competency assessment; and the hours of training completed. 1. Review of CNA F's in-service record showed: - A hire date of 07/05/23; - A total of seven hours of annual in-service training for July 2023 through July 2024; - Less than twelve hours of in-service education for July 2023 through July 2024. During an interview on 01/22/25 at 1:30 P.M., the Administrator said the Director of Nursing (DON) provided education more often than monthly, but apparently they had not documented all of the education the DON provided. She expected all CNAs to have at least 12 hours of in-service education per year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for two residents (Resident #1 and #13) out of 14 sampled residents and one resident (Resident #40) outside the sample. The facility's census was 53. The facility failed to provide a policy regarding resident transfer/discharge. Review of the facility's admission agreement titled, admission Agreement, undated, showed the facility will notify the resident or resident's guarantor of the reason for any transfer or discharge and will record the reason in the resident's medical record. 1. Review of Resident #1's medical record showed: - Transferred and admitted to the hospital on [DATE] and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 2. Review of Resident #13's medical record showed: - Transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the transfer/discharge to the hospital at the time of transfer. 3. Review of Resident #40's medical record showed: - Transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the transfer/discharge to the hospital at the time of transfer. During an interview on 11/15/23 at 12:04 P.M., the Assistant Director of Nursing (ADON) said he/she is not aware of a transfer/discharge form. The ADON said the nurses send a facesheet and the physician's orders with a resident when the resident goes to the hospital and nursing calls report to the hospital. The nurses are also required to document the resident went out, but no forms are sent. During an interview on 11/15/23 at 3:25 P.M., the Administrator said she would expect transfer/discharge forms to be issued and signed when a resident transfers out to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident and family and/or legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Resident #1 and #13) out of 14 sampled residents and one resident (Resident #40) outside the sample. The facility's census was 53. The facility failed to provide a bed hold policy. 1. Review of Resident #1's medical record showed: - Transferred and admitted to the hospital on [DATE] and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the facility bed hold policy at the time of transfer. 2. Review of Resident #13's medical record showed: - Transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the facility bed hold policy at the time of transfer. 3. Review of Resident #40's medical record showed: - Transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the facility bed hold policy at the time of transfer. During an interview on 11/15/23 at 12:04 P.M., the Assistant Director of Nursing (ADON) said he/she is not aware of a bed hold notice form. The ADON said the nurses send a facesheet and the physician's orders with a resident when the resident goes to the hospital and nursing calls report to the hospital. The nurses are also required to document the resident went out, but no forms are sent. During an interview on 11/15/23 at 3:25 P.M., the Administrator said she would expect bed hold notices to be issued and signed when a resident transfers out to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS, a federally mandated assessment to be completed by the facility) for four residents (Resident #13, #22, #24, and #28) out of 14 sampled residents. The facility's census was 53. The facility failed to provide a policy for MDS assessment. 1. Review of Resident #13's medical record showed: - An admission date on 08/02/23; - Diagnoses of Alzheimer's disease (progressive mental deterioration), pneumonia (an infection that inflames the air sacs in one or both lungs), septicemia (a bloodstream infection throughout body), Diabetes Mellitus (DM, a condition that affects the way the body processes blood sugar), arthritis, osteoporosis (a condition causing loss of bone mass, predisposing a person to fractures), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), gastroesophageal reflux disease (GERD, stomach acid being forced back into the throat region), and renal failure (kidney failure); - Does not currently have pneumonia. Review of the resident's quarterly MDS, dated [DATE], showed: - Pneumonia diagnosis marked under Section I; - GERD not marked under Section I. During an interview on 11/14/23 at 10:35 A.M., Licensed Practical Nurse (LPN) C said the resident did not have pneumonia to his/her knowledge and he/she could not find any evidence to say the resident had pneumonia during that time. 2. Review of Resident #22's medical record showed: - An admission date of 10/12/2021; - Diagnoses of dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (an emotion characterized by feelings of tension and worried thoughts) , stroke, major depressive disorder (a constant feeling of sadness and loss of interest), history of breast cancer, and atrial fibrillation (an abnormal heartbeat); - Not receiving hospice care. Review of the resident's annual MDS, dated [DATE], showed: - Hospice care marked on Section O. During an interview on 11/13/23 at 11:26 A.M., the resident's representative said the resident has not received hospice care. During an interview on 11/15/23 at 12:57 P.M., LPN B said the resident has not received hospice care. The resident was evaluated by hospice but was denied. 3. Review of Resident #24's medical record showed: - An admission date of 09/28/2019; - Diagnoses of acute respiratory failure with hypoxia (impairment of exchange of carbon dioxide and oxygen between the lungs and blood causing lack of oxygen to the tissues to sustain bodily function), pneumonia, and chronic pulmonary edema (excess fluid in the lungs); - An order for regular diet, regular texture, regular consistency dated 08/24/23; - A diagnosis of pneumonia dated 9/28/2019. Record review of the resident's significant change MDS, dated [DATE], showed: - Pneumonia diagnosis marked on Section I; - Mechanical soft diet marked on section K. Record review of the resident's admission MDS, dated [DATE], showed: - Pneumonia diagnosis marked on Section I. 4. Record review of Resident #28's medical record showed: - An admission date of 09/28/18; - Diagnoses of heart disease unspecified (any problem affecting the heart), pneumonia, pulmonary hypertension (increased blood pressure in the lungs), and hypertension (high blood pressure); - A diagnosis of pneumonia dated 10/24/18. Record review of the resident's quarterly MDS, dated [DATE], showed: - Pneumonia diagnosis marked on Section I. Record review of the resident's admission MDS, dated [DATE], showed: - Pneumonia diagnosis marked on Section I. During an interview on 11/15/23 at 3:25 P.M., the Director of Nursing, the Administrator, and the MDS Coordinator said they would expect the MDS to accurately reflect the condition of the resident. The Administrator said the Resident Assessment Instrument (RAI) manual should be followed in regards to MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess residents for the use of bed rails prior to installation or use nor did they obtain informed consent from the resident or if applicable, the resident representative. The facility also failed to provide ongoing monitoring, supervision and routine maintenance of the beds with bed rails in use for six residents (Resident #1, #2, #3, #22, #27, and #42) out of 14 sampled residents. The facility's census was 53. Review of the facility's policy titled, Bed Safety, dated 2007, showed the following: - The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as, input from the resident and family regarding previous sleeping habits and bed environment; - To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and the bed accessories), the facility shall promote the following approaches: - Inspect by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement or bed position.); - Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications; - Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g. avoid bowing, ensure proper distance from the headboard and footboard, etc,); - Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment) e.g. altered mental status, restlessness, etc.); - The maintenance department shall provide a copy of inspections to the administrator and report results to the QA committee for appropriate action. Copies of the inspection results and QA committee recommendations shall be maintained by the administrator and/or safety committee; - The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment; - If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative; - The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use; - After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed); - Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified; - Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails; - When using side rails for any reason, the staff shall take measures to reduce related risks; - Side rails shall not be used as protective restraints. Should a protective restraint be used, our facility's protocol for the use of restraints shall be followed; - The use of physical restraints on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals; - The staff shall report to the director of nursing and administrator any deaths, serious illness and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safety Medical Devices Act. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 09/22/23, showed: - Impaired cognition; - Independent with bed mobility; - Diagnoses of heart failure (the heart does not pump blood as well as it should), atrial fibrillation (abnormal heart beat), arthritis, dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and respiratory failure (a condition making it difficult to breathe on your own). Review of the resident's current care plan showed: - Increased risk of falls related to deconditioning, gait problems, and incontinence. - Maintain a safe environment with enabler rail. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails. Observations of the resident showed: - On 11/13/23 at 3:10 P.M., resident in chair next to bed with a left side quarter U shaped bed rail attached; - On 11/14/23 at 8:30 A.M., left side quarter U shaped bed rail attached to bed; - On 11/15/23 at 9:15 A.M., resident in wheelchair next to bed with a left side quarter U shaped bed rail attached. During an interview on 11/15/23 at 9:15 A.M., the resident said he/she uses the bed rail to turn in bed and pull himself/herself up in the bed. 2. Review of Resident #2's significant change MDS, dated [DATE], showed: - Severely impaired cognition; - Partial to moderate assistance for bed mobility; - Total assistance for bed to chair transfer; - Diagnoses of Alzheimer's disease (progressive mental deterioration), seizure disorder, anxiety disorder (persistent worry and fear about everyday situations), and depression. Review of the resident's current care plan showed: - Increased risk of falls related to weakness and lack of safety awareness; - Maintain a safe environment with enabler rails. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails. Observation on 11/13/23 at 1:33 P.M., showed the resident lay in bed with one-quarter, inverted U shaped bed rails in the upright position on each side of the bed. 3. Review of Resident #3's annual MDS, dated [DATE], showed: - Cognitively intact; - Substantial/maximal assistance for bed mobility; - Diagnoses of chronic pain (any pain lasting longer than 3 months), osteoarthritis (degenerative joint condition that causes pain, swelling and stiffness), and proxysmal atrial fibrillation (causes an irregular heart rhythm). Review of the resident's care plan, dated 05/04/23, showed: - Did not address the resident's use of the bed rails. Review of the resident's medical record showed: - No documentation of bed rail assessment; - No documentation of informed consent for the use of the bed rails. Observations of the resident showed: - On 11/13/23 at 12:45 P.M., the resident lay in bed with bed rails in an upright position on each side of the bed; - On 11/15/23 at 9:00 A.M., the resident lay in bed with bed rails in an upright position on each side of the bed. During an interview on 11/15/23 at 11:25 A.M., the resident said he/she used the bed rails to turn and pull him/herself up in the bed. 4. Review of Resident #22's annual MDS, dated [DATE], showed: - Severely impaired cognition; - Substantial to maximal assistance for bed mobility; - Substantial to maximal assistance for bed to chair transfer; - Diagnoses of Alzheimer's disease, stroke, anxiety disorder, and depression. Review of the resident's current care plan showed: - History of falling; - Intervention of one-half bed rail can be used to assist with turning. Review of the resident's medical record showed: - No documentation of bed rail assessment; - No documentation of informed consent for the use of the bed rails. Observations of the resident showed: - On 11/13/23 at 11:26 A.M., the resident sat in a recliner, with a one-quarter, inverted U shaped bed rail in the upright position on the right side of his/her bed; - On 11/13/23 at 2:45 P.M., the resident lay in bed with a one-quarter, inverted U shaped bed rail in the upright position on the right side of the bed; - On 11/15/23 at 8:05 A.M., the resident transferred from the wheelchair to the bed by Certified Nursing Assistant (CNA) A. CNA A lowered the one-quarter, inverted U shaped bed rail, placed the resident in bed and then raised the one-quarter, inverted U shaped bed rail. The resident did not use the bed rail during the transfer. During an interview on 11/15/23 at 08:15 A.M., CNA A said he/she has not seen the resident use the bed rail, but he/she may be able to use it. 5. Review of Resident #27's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Substantial/maximal assistance for bed mobility; - Diagnoses of heart failure and respiratory failure. Review of the resident's care plan dated 10/09/23 showed: - High risk for falls related to deconditioning, gait and balance problems; - Maintain safe environment with use of enabler rail. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails. Observations of the resident showed: - On 11/13/23 at 11:57 A.M., resident lay in bed with one-quarter U shaped bed rails affixed in upright position attached to each side of the bed; - On 11/15/23 at 10:50 A.M., resident lay in bed with one-quarter U shaped bed rails affixed in upright position attached to each side of the bed. During an interview on 11/15/23 at 10:50 A.M., the resident said he/she uses the bed rails to roll over in bed. 6. Review of Resident #42's quarterly MDS, dated [DATE], showed: - Moderately impaired cognition; - Supervision or touching assistance for bed mobility; - Partial to moderate assistance for bed to chair transfer; - Diagnoses of respiratory failure and anxiety disorder. Review of the resident's current care plan showed: - High risk for falls related to deconditioning, gait and balance problems, and vision; - Maintain safe environment with use of enabler rail as ordered. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails. Observations of the resident showed: - On 11/13/23 at 11:15 A.M., resident lay in bed with one-quarter, inverted U shaped bed rails in the upright position on each side of the bed; - On 11/15/23 at 8:39 A.M., resident lay in bed with one-quarter, inverted U shaped bed rails in the upright position on each side of the bed. During an interview on 11/13/23 at 11:15 A.M., the resident said he/she uses the left side bed rail to get out of bed, does not use the right side right bed rail, and does not recall signing a consent for the side rails. During an interview on 11/15/23 at 7:30 A.M., Licensed Practical Nurse (LPN B) said he/she was unaware of any assessment that the facility did for grab bars or bed rail assessments. During an interview on 11/15/23 at 8:15 A.M., the Maintenance Director said there was something said last year about what type of rails the bed rails are considered. He said he installs the bed rails and checks them regularly but does not complete any type of log or form when he checks them. During an interview on 11/15/23 at 3:25 P.M., the MDS Coordinator and Administrator said they were unaware that grab bars needed to be assessed and thought that only a full set of rails needed an assessment. They were unaware an informed consent needed to be obtained for the rails.

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for twelve residents (Resident #1, #2, #3, #13, #15, #22, #27, #28, #37, #42, #53, and #360) out of 14 sampled residents and one resident (Resident #39) outside the sample. The facility's census was 53. Review of the facility's policy titled, Bed Safety, dated 2007, showed the following: To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and the bed accessories), the facility shall promote the following approaches: - Inspect by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - The maintenance department shall provide a copy of inspections to the administrator and report results to the QA committee for appropriate action. Copies of the inspection results and QA committee recommendations shall be maintained by the administrator and/or safety committee. 1. Review of Resident #1's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/13/23 at 3:10 P.M., resident in chair next to bed with a left side bed rails attached; - On 11/14/23 at 8:30 A.M., left side bed rails attached to bed; - On 11/15/23 at 9:15 A.M., resident in wheelchair next to bed with a left side bed rails attached. 2. Review of Resident #2's medical record showed no maintenance inspection for bed rails. Observation on 11/13/23 at 1:33 P.M. showed the resident lay in bed with bed rails in the upright position on each side of the bed. 3. Review of Resident #3's medical record showed no maintenance inspection for bed rails. Observations of the resident's bed showed: - On 11/13/23 at 12:45 P.M., resident's bed with bed rails attached to both sides of bed; - On 11/13/23 at 9:00 A.M., resident's bed with bed rails attached to both sides of bed. 4. Review of Resident #13's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/13/23 at 12:45 P.M., resident in wheelchair next to bed with bed rails attached to both sides of bed; - On 11/14/23 at 8:30 A.M., bed rails attached to both sides of bed. 5. Review of Resident #15's medical record showed no maintenance assessment for bed rails. Observations of the resident's bed showed: - On 11/13/23 at 11:48 A.M., bed rails attached to each side of the bed; - On 11/14/23 at 09:26 A.M., bed rails attached to each side of the bed. 6. Review of Resident #22's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/13/23 at 11:26 A.M., the resident sat in a recliner with bed rails in the upright position on the right side of his/her bed; - On 11/13/23 at 2:45 P.M., the resident lay in bed with bed rails in the upright position on the right side of the bed; - On 11/15/23 at 8:05 A.M., the resident transferred from the wheelchair to the bed by Certified Nursing Assistant (CNA) A. CNA A lowered the bed rails, placed the resident in the bed and then raised the bed rails. 7. Review of Resident #27's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/13/23 at 11:57 A.M., resident lay in bed with bed rails on each side of the bed; - On 11/15/23 at 10:50 A.M., the resident lay in bed with bed rails on each side of the bed. During an interview on 11/15/23 at 10:50 A.M., the resident said he/she uses the bed rails to roll over in bed. 8. Review of Resident #28's medical record showed: - Grab bar on left side attached to bed; - No maintenance assessment for enabler bars. Observations of the resident's bed showed: - On 11/13/23 at 11:16 A.M., bed rails attached to left side of the bed; - On 11/14/23 at 12:45 P.M., bed rails attached to left side of the bed. 9. Review of Resident #37's medical record showed no maintenance inspection for bed rails. Observations of the resident's bed showed: - On 11/13/23 at 2:45 P.M., resident's bed with bed rails attached to both sides of bed; - On 11/13/23 at 11:55 A.M., resident's bed with bed rails attached to both sides of bed. 10. Review of Resident #39's medical record showed no maintenance inspection for side rails. Observations of the resident's bed showed: - On 11/13/23 at 2:30 P.M., half bed rail on both sides; - On 11/14/23 at 10:00 A.M., half bed rail on both sides; - On 11/15/23 at 8:26 A.M., half bed rail on both sides. 11. Review of Resident #42's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/13/23 at 11:15 A.M., resident lay in bed with bed rails in the upright position on each side of the bed; - On 11/15/23 at 8:39 A.M., the resident lay in bed with bed rails in the upright position on each side of the bed. During an interview on 11/13/23 at 11:15 A.M., the resident said he/she uses the left side bed rail to get out of bed. 12. Review of Resident #53's medical record showed no maintenance inspection for bed rails. Observations of the resident's bed showed: - On 11/13/23 at 11:53 A.M., bed rails attached to each side of the bed; - On 11/14/23 at 9:15 A.M., bed rails attached to each side of the bed. 13. Review of Resident #360's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/14/23 at 9:21 A.M., resident in wheelchair next to bed with bed rails attached to bed; - On 11/15/23 at 2:00 P.M., bed rails attached to bed on both sides. During an interview on 11/15/23 at 8:15 A.M., the Maintenance Director said he installs the bed rails and checks them regularly. There is no set schedule for checking the rails and he does not complete any type of log or form when he checks them. During an interview on 11/15/23 at 3:25 P.M., the MDS Coordinator and Administrator said they were unaware enabling bars were included in the Bed Safety policy or that an official, documented inspection should be completed by the maintenance staff. There is no documentation available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for three residents (Resident #21, #54, and #59) out of 15 sampled residents. The facility's census was 57. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, dated December 2016, showed: - A comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs will be developed and implemented for each resident; - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care plan interventions will be derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The IDT includes the attending physician, a registered nurse who has responsibility for the resident, a nurse aide who has responsibility for the resident, a member of the food and nutrition services staff, the resident and the resident's legal representative, and other appropriate staff or professionals as determined by the resident's needs or as requested by the resident; - Assessments of residents will be ongoing and care plans revised as information about the residents and residents' conditions change. 1. Record review of Resident #21's medical record showed: - admission date of 2/14/22; - Diagnoses of weakness, urinary tract infection (UTI), atrial fibrillation (abnormal heart rhythm), pneumonia, severe sepsis with septic shock (life-threatening complication of an infection), pleural effusion (buildup of fluid around the lungs), acute kidney failure, rheumatoid arthritis (a chronic inflammatory disorder affecting the joints), pain in the right knee, pain in the right foot, and other reduced mobility. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 3/9/22, showed: - Very important for the resident to do his/her favorite activities, go outside to get fresh air; - Somewhat important to listen to music, keep up with the news, and do things with groups of people; - At risk for pressure ulcers (an injury to skin and underlying tissue from prolonged pressure to the skin). Record review of the resident's initial activities review, dated 3/4/22, showed: - Enjoyed spending time with his/her family; - Research of his/her family history; - Participation in group activities, outings, one-to-one activities with the staff, and independent activities such as reading and puzzles. Record review of the resident's Event Calendar Report for April and May 2022 showed: - Invited to activities. - Attended occasionally. Record review of the resident's Nutrition/Dietary Note showed: - On 3/4/22, resident readmitted from the hospital with diagnoses of UTI and pneumonia and a diet order for a regular diet with no caffeine, and no chewing or swallowing issues; - On 4/12/22, a 7.7 percent (%) weight loss for one month; - On 5/17/22, a 7.3 % weight loss for three months. Record review of the resident's care plan, revised on 4/22/22, showed: - Did not address the resident's risk of pressure ulcers, activities, or nutrition/weight loss. During an interview on 5/18/22 at 2:25 P.M., the resident said he/she does not want to go to the music activity that is going on now. He/she will go occasionally. During an interview on 5/19/22 at 8:58 A.M., Licensed Practical Nurse (LPN) B said the Activity Director goes from room to room and asks the residents if they want to go to activities, then staff will help the residents to the activity. Resident #21 has attended activities a few times. During an interview on 5/19/22 at 9:05 A.M., the Activity Director said the resident likes music activities but does not come very often. He/she tries to do one-on-one activities with the resident, but seems to always catch the resident sleeping. 2. Record review of Resident #54's Physician's Order Sheet (POS), dated 5/19/22, showed: - admission date of 4/17/22; - Diagnoses of hypertension (high blood pressure), atrial fibrillation (abnormal heart rhythm), hyperglycemia (high blood sugar), repeated falls, and weakness; - An order, dated 4/17/22, for Eliquis (an anticoagulant medication which increases the risk of bleeding) five milligrams (mg) twice daily; - An order, dated 5/4/22, for no added salt (NAS) diet, regular texture, regular consistency, two gram daily salt restriction. Record review of the resident's admission MDS, dated [DATE], showed: - Very important for the resident to have books, newspapers, or magazines to read, listen to music, do things with groups of people, go outside to get fresh air, and participate in religious services. Record review of the resident's dietary note, dated 5/10/22, showed: - The resident went to the doctor and received new orders for two gram sodium diet; - Educated resident and family on low sodium diet and foods available for resident to order that are low sodium; - Discussed foods to limit since high in sodium such as chips, bacon, sausage, hot dogs, ham, tomato juice, and many processed foods; - Handouts given and family to help resident with menu selections; - Dietary to modify the week's menus. Record review of the resident's care plan, revised on 5/11/22, showed: - Did not address the resident's dietary needs, anticoagulant (blood thinner medication) use, or activities. 3. Record review of Resident #59's POS, dated 5/19/22, showed: - admission date of 4/26/22; - Diagnoses of fracture of left pubis (pelvic bone), presence of right artificial knee joint; and repeated falls; - An order, dated 4/26/22, for rivaroxaban (an anticoagulant medication) 10 mg once daily; - An order, dated 4/26/22, for Tylenol Arthritis extended release (ER) pain medication 650 mg two tablets twice daily for pain; - An order, dated 4/28/22, for acetaminophen (pain medication) 325 mg one or two tablets every six hours as needed for pain; - An order, dated 5/7/22, for oxycodone (pain medication) five mg every three hours as needed for pain. Record review of the resident's admission MDS, dated [DATE], showed: - Frequent, moderate pain; - Day to day activities limited because of pain; - Very important to the resident to go outside to get fresh air and participate in religious services; - Somewhat important to the resident to listen to music and to keep up with the news. Record review of the resident's care plan, revised on 5/13/22, showed: - Did not address the resident's pain, anticoagulant use, or activities. During an interview on 5/19/22 at 2:05 P.M., the MDS Coordinator said every resident gets a discharge and activities of daily living care plan section. The dietary section would be added if a resident received a modified diet. A resident with long term anticoagulant use would be added. Everyone including dietary, activities, and social services has access to the care plans to update and information from their notes can be added to the care plan. Activities care plans are on a case by case basis. Care plans need to be updated for each resident if there has been a significant change, new medication ordered, increased confusion, hospitalization, and quarterly.

Based on observation, interview and record review, the facility failed to maintain infection control practices, including hand hygiene, appropriately changing gloves, and sanitizing equipment after use, to prevent the development and transmission of infection for two residents (Resident #35 and #53) out of 15 sampled residents. The facility's census was 57. Record review of the facility's Handwashing/Hand Hygiene policy, revised August 2019, showed: - Wash hands with soap and water when visibly soiled hands occur and after contact with a resident with an infectious diarrhea; - Use alcohol based hand rub before and after direct contact with residents, before handling clean or soiled dressings, gauze pads, etc, before moving from from a contaminated body site to a clean site, after contact with a resident's intact skin, after contact with blood or body fluids, after contact with objects in an immediate vicinity of a resident, and after removing gloves. Record review of the facility's Cleaning and Disinfection of Resident Care Items and Equipment policy, revised October 2018, showed: - Resident care equipment, which includes reusable and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection and Occupation Safety and Health Administration (OSHA) blood borne pathogen standards. 1. Observation of Resident #35 on 5/18/22 at 10:50 A.M., showed: - Registered Nurse (RN) A did not don (apply) gloves, transferred the resident to the toilet, and removed the resident's brief with his/her bare hands; - RN A did not wash his/her hands and donned two pair of gloves; - RN A cleaned the resident's back peri area after a bowel movement; - RN A removed the top pair of gloves and performed wound care on the resident's coccyx area; - RN A removed the gloves and washed his/her hands. During an interview on 5/19/22 at 12:14 P.M., RN A said most staff should wash their hands when they enter a room and when leaving. Staff should wear gloves and change them between dirty and clean care and sanitize their hands between glove changes. RN A said the facility does not train staff to double glove, and said he/she had double-gloved the day before due to not being able to step away from the resident during his/her care. 2. Observation of Resident #53 on 5/19/22 at 9:50 A.M., showed: - Licensed Practical Nurse (LPN) B washed his/her hands and donned gloves; - LPN B removed a dressing from the resident's leg and foot; - LPN B donned a new pair of gloves and did not wash or sanitize his/her hands; - LPN B took pictures of the wound with a special camera phone and placed the camera phone on the resident's bed; - LPN B picked up the camera phone, took another picture of the resident's wounds, and placed it on the resident's bedside table; - LPN B cleaned the wound on the resident's heel with gauze and saline, and with the same gloves, touched several different unopened packages in the wound kit when searching for the correct dressing; - LPN B, with the same gloves, cleaned the heel wound with betadine swabs (a solution used to help prevent or treat mild skin infections); - LPN B, with the same gloves, picked up the scissors and cut the adaptic dressing (a non-adhering dressing used to protect wounds) to the size for the wound; - LPN B, with the same gloves, placed the remaining adaptic dressing back into the package; - LPN B, with the same gloves, obtained a clean 4x4 gauze and betadine liquid, saturated the 4x4 gauze with the betadine, and placed the dressing onto the heel wound; - LPN B removed the gloves, did not wash or sanitize his/her hands, and donned a clean pair of gloves; - LPN B obtained an ABD pad (highly absorbent dressing that provides padding and protection) and placed it over the soaked gauze on the heel wound; - LPN B placed Kerlix (gauze wrap) over the heel wound to hold the ABD pad and betadine soaked gauze in place; - LPN B, with the same scissors, cut the Kerlix and placed the scissors onto the resident's bedside table; - LPN B removed the gloves, washed his/her hands, and donned a new pair of gloves; - LPN B, with the same scissors, cut the Aquacel (an absorbent dressing that conforms to a wound and creates a soft gel) dressing and placed the scissors onto the resident's bedside table; - LPN B removed his/her gloves, did not wash or sanitize his/her hands, and initialed and dated the dressing with a pen; - LPN B washed his/her hands and donned a new pair of gloves; - LPN B, with the same scissors, cut the Aquacel dressing, placed the dressing onto the resident's leg wound, and wrapped the leg with Kerlix; LPN B with the same scissors, cut the Kerlix and placed the scissors onto the resident's bedside table with no clean barrier; - LPN B picked up the scissors and the camera phone, did not clean them, and placed them into his/her pocket; - LPN B did not wash or sanitize his/her hands, picked up the remaining wound supplies, and took them outside of the resident's room to the wound cart with his/her bare hands. - Observation showed LPN B saved the opened, contaminated packages of dressing supplies and returned them to the treatment cart to be used again. During an interview on 5/19/22 at 10:15 A.M., LPN B said the opened Kerlix would be used again so it is not wasted. He/she said two different scissors should have been used, one for the clean dressing and one for removing the old dressing. The camera phone should have been cleaned and he/she should have washed his/her hands before leaving the room. During an interview on 5/19/22 at 2:05 P.M., the Director of Nursing (DON) said she would expect staff to wash their hands at the beginning of care, according to the procedure performed, possibly in the middle of care and when they exit the room. She would expect staff to clean the scissors and other items after the item is used, in between and after procedure is done, anything from dirty to clean care. Her suggestion would be to use two pair of scissors.