Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 1 of 2 residents reviewed for EBP in a final sample of 13 residents. (Resident identifier is #176.) Findings include: Observation on 1/2/25 at approximately 10:00 a.m. on the unit revealed an EBP sign and Personnel Protective Equipment (PPE) cart outside of Resident #176's room next to the entrance door. Review on 1/2/25 of Resident #176's active physician's order revealed an order for a Peripherally Inserted Central Catheter (PICC) line with a start date of 1/2/25. Observation on 1/3/25 at approximately 6:00 a.m. in Resident #176's room revealed that Staff A (Licensed Nursing Assistant (LNA)) was wearing a mask, gloves, and no gown while in Resident #176's room and assisting Resident #176 out of the bathroom. Observation also revealed that Staff A was taking off dirty linens and then putting on clean linens wearing the same mask, gloves, and no gown. Interview on 1/3/25 at approximately 6:05 a.m. with Staff A confirmed the above finding. Staff A stated that he/she assisted Resident #176 with toileting and changing Resident #176's linens. Interview on 1/3/25 at approximately 6:40 a.m. with Staff B (Infection Preventionist) confirmed that Resident #176 was on EBP for the PICC line (central line). Staff B stated that gown and gloves should be worn by staff when assisting a resident on EBP with toileting and changing linens. Review on 1/3/25 of the facility's policy titled, Enhanced Barrier Precautions, copyright year 2024, revealed .Initiation of Enhanced Barrier Precautions: .Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colorized with a MDRO [Multidrug-Resistant Organisms] .Implementation of Enhanced Barrier Precautions: .PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .High-contact resident care activities include: .e. changing linens f. changing briefs or assisting with toileting .References: Centers for Disease Control and Prevention [CDC]. Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes .Centers for Disease Control and Prevention . Implementation of Personal Protective Equipment in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-Resistant Organisms . Review on 1/3/25 of the CDC's Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug Resistant Organisms (MDRO's), updated July 2022 revealed: .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. MDRO's may be indirectly transferred from resident-to-resident during these high-contact activities. Nursing home resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's. The use of gown and gloves for high-contact resident care activities is indicated, .Enhanced Barrier Precautions, Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: .Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator .

Based on interview and record review, it was determined that the facility failed to ensure that a resident receiving dialysis services received medications according to physician orders and failed to ensure monitoring of a dialysis fistula site for 1 of 1 resident reviewed for dialysis in a final sample of 12 residents (Resident Identifier is #11). Findings include: Review on 1/17/24 of Resident #11's January 2024 Medication Administration Record (MAR) revealed the following physician's order: Hydralazine HCL [Hydrochloric Acid] oral tablet 100 mg [milligrams] give 1 tablet by mouth three times a day for Hypertension, start date 12/28/23. Review revealed that the times for administration were 8:00 a.m., 2:00 p.m., and 8:00 p.m. Further review of the MAR revealed that the following 2:00 p.m. doses were all marked as AW (Away From Facility): 1/2 (Tuesday), 1/4 (Thursday), 1/6 (Saturday), 1/9 (Tuesday), 1/11 (Thursday), 1/13 (Saturday), 1/16 (Tuesday). Interview on 1/17/24 at approximately 3:00 p.m. with Staff A (Unit Manager) and Staff B (Director of Nursing) confirmed the above finding and revealed that Resident #11 attended dialysis at the above times. Review on 1/18/24 of the facility policy titled NSG261 Dialysis: Hemodialysis (HD) Provided by a Certified End-Stage Renal Disease (ESRD) Facility revision date 8/7/23 revealed: . Practice Standards 1.5 After receiving dialysis, Center staff must provide monitoring and documentation of: 1.5.1 The patient's vascular access site(s) to observe for bleeding or other complications; . Shared Communication Between the Center and the Certified ESRD Facility: . 2.2.4.1 Timely medication administration (initiated, administered, held or discontinued); . Review on 1/18/24 of Resident #11's medical record revealed that there was no documentation of staff assessing Resident #11's dialysis fistula site. Interview on 1/18/24 at approximately 10:30 a.m. with Staff A confirmed that the site is not assessed by nursing every shift, it is done prior to Resident #11 going to dialysis and when Resident #11 returns to the facility from dialysis. Interview on 1/18/24 at approximately 12:30 p.m. with Staff H (Nurse Practitioner) revealed that he/she was not aware of Resident #11 missing doses of a medication while Resident #11 was at dialysis.

Based on interview and record review, it was determined that the pharmacist failed to report irregularities to the facility for 2 out of 7 residents reviewed for drug regimen review in a final sample of 12 residents (Resident Identifiers are #7 and #14). Findings include: Resident #7 Review on 1/17/24 of Resident #7's January 2024 Medication Administration Record (MAR) revealed the following order: Lorazepam oral tablet 0.5 mg [milligrams] give 0.5 mg by mouth every 6 hours as PRN [as needed] for Anxiety, start date 11/27/23. Review on 1/17/24 of Resident #7's medical record revealed that the pharmacist completed Drug Regimen Reviews on 1/17/24, 12/11/23, and 11/27/23 and failed to identify the above PRN psychotropic medication did not have a stop date indicated. Resident #14 Review on 1/17/24 of Resident #14's January 2024 MAR revealed the following order: Ativan tablet 0.5 mg [Lorazepam] give 1 tablet sublingually every 4 hours as needed for anxiety, start date 9/19/23. Review on 1/17/24 of Resident #14's medical record revealed that the pharmacist completed Drug Regimen Reviews on 1/17/24, 12/11/23, and 11/24/23 and failed to identify the above PRN psychotropic medication did not have a stop date indicated. Interview on 1/17/24 at approximately 2:45 p.m. with Staff B (Director of Nursing) confirmed the above findings. Interview on 1/18/24 at approximately 11:00 a.m. with Staff C (Pharmacist) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure that orders for psychotropic drugs were limited to 14 days and that consents were obtained for the use of psychotropic medications for 2 of 2 residents reviewed for psychotropic/opioid side effects in a final sample of 12 residents reviewed (Resident Identifiers are #7 and #14). Findings include: Resident #7 Review on 1/17/24 of Resident #7's January 2024 Medication Administration Record (MAR) revealed the following order: Lorazepam oral tablet 0.5 mg [milligrams] give 0.5 mg by mouth every 6 hours PRN [as needed] for Anxiety, start date 11/27/23. Further review of Resident #7's medical record revealed that there was no stop date indicated for the PRN psychotropic medication and consent was not obtained from the resident for the use of Lorazepam. Resident #14 Review on 1/17/24 of Resident #14's January 2024 MAR revealed the following order: Ativan tablet 0.5mg [Lorazepam] give 1 tablet sublingually every 4 hours as needed for Anxiety, start date 9/19/23. Further review of Resident #14's medical record revealed that there was no stop date indicated for the PRN psychotropic medication and consent was not obtained by Resident #14's Durable Power of Attorney for the use of Ativan. Interview on 1/17/24 at approximately 2:45 p.m. with Staff B (Director of Nursing) confirmed the above findings. Review on 1/18/24 of the facility policy titled 3.8 Psychotropic Medication Use revealed: . 8. PRN (as needed) psychotropic medications should be ordered for no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and also by a pharmacist every month .

Based on record review, observation, interview, and policy review, it was determined that the facility failed to follow its policies for managing healthcare personnel with symptoms of SARS-CoV-2 (COVID-19) working in the facility (Staff identifier I). Findings include: Interview on 1/17/24 at approximately 10:50 a.m. with Staff F (Food Services Director) revealed they had been notified that Staff I (Dietary Aide) came to work on 12/20/23 with nasal congestion symptoms and continued to work their full shift, including meal preparation in the kitchen. Review on 1/17/24 of the facility's payroll log revealed Staff I had worked on the evening of 12/20/23 for 3.75 hours. Review on 1/17/24 at approximately 10:30 a.m. of the facility's contact tracing list revealed Staff I tested positive for COVID-19 on 12/21/23. Further review of the contract tracing list revealed that Staff I had no COVID-19 testing done on 12/20/23 Review on 1/19/24 of the facility's policy titled Active Screening Process for Visitors, Employees and Visiting HCP [Healthcare Personnel], dated 3/15/2002, revealed: Screening Employees, Visiting Healthcare Providers and Visitors - 2. Centers may evaluate and, where indicated, test all staff, including HCSG presenting with mild symptoms to determine whether to deny or permit entrance. Employee Precautions and Screening - 1. During the work shift: Any employee who develops signs and symptoms of a respiratory infection while on the job, should: a. immediately stop work, and self-isolate at home. Review on 1/19/24 of the CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html, updated September 23, 2022, revealed, .Evaluating Healthcare Personnel with Symptoms of SARS-CoV-2 Infection HCP with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays .If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining work restrictions and confirming with a second negative NAAT. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or a second negative antigen test taken 48 hours after the first negative test. For HCPs who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses.

Based on interview and record review, it was determined that the facility failed to ensure that a resident's formulated advance directives would be followed for 1 out of 13 residents reviewed for advance directives (Resident identifier is #16) . Findings include: Review on 1/10/23 of Resident #16's Electronic Health Record (EHR) revealed the following physician's order: FULL CODE, DPOA [Durable Power of Attorney] Activated - [pronoun omitted], dated 7/20/22. Review on 1/10/23 of Resident #16's chart revealed the following: A pink portable Do Not Resuscitate (DNR) form signed by a physician, dated 10/2/20. Interview on 1/10/23 at approximately 1:00 p.m. with Staff A (Registered Nurse) revealed that in an emergent situation, Staff A would use the closest source of information to determine code status. If I was at the nurses' station, I would refer to the chart. If I was by my medication cart I would refer to the EMR [Electronic Medical Record]. Review on 1/11/23 of the facility policy titled, Health Care Decision Making, with an effective date of 6/1/96 and revision date of 3/1/22, revealed .It is the right of all patients/residents .to participate in their own health care decision-making, including the right to decide whether they wish to request, accept, refuse, or discontinue treatment .Upon admission, determine whether the patient has an advanced directive and/or portable medical orders such as POLST [Physicians Orders for Life- Sustaining Treatment], MOLST [Medical Orders for Life-Sustaining Treatment], etc.If the patient/patient representative has a copy with them, make copies, place in medical record, and notify the inter professional team .

Based on observations and interviews it was determined the facility failed to ensure a clean and comfortable environment free of holes and scrapes to bedroom walls. These environmental concerns were observed in 10 out of 14 resident rooms. Findings include: Observations on 1/10/23 from approximately 9:30 a.m. to 10:30 a.m. of 10 out of 14 resident rooms revealed large black scrapes, markings, and gashes/holes on the residents' bedroom walls. The markings varied from 3-inches to 12-inches in length on the walls behind the residents' beds. There were several gashes/dents in various locations on the walls in residents' rooms that ranged from 1-inch to 3-inches. Interview on 1/12/23 at approximately 1:20 p.m. with Staff E (Administrator) confirmed the above findings. Interview on 1/11/23 at approximately 8:00 a.m. with Staff G (Licensed Nursing Assistant) revealed that the markings observed in the residents' rooms have been like this for a while. Interview on 1/11/23 at approximately 10:00 a.m. with Resident #3 revealed they wished the scrape marks on their room's wall could be repaired to look nicer.

Based on interview and record review, it was determined that the facility failed to ensure that all identified areas of injury from unknown origin were reported to Administrator, State Survey Agency (SSA), and other state officials for 1 of 1 residents reviewed for injuries of unknown origin in a final sample of 13 residents (Resident Identifier is #14). Findings include: Observation on 1/10/23 at approximately 10:39 a.m. of Resident #14 revealed bilateral outer ankle abrasions, multiple abrasions to bilateral shins, purple discoloration to the top of left foot bend and yellowing bruise to left upper shin. Interview on 1/10/23 at approximately 10:39 a.m. with Resident #14 revealed they did not know how they obtained the areas of injury to both lower extremities. Review on 1/11/23 at approximately 8:15 a.m. of Resident #14's progress notes revealed no mention of areas of injury to both lower extremities. Interview on 1/11/23 at approximately 2:16 p.m. with Staff C (Unit Manager) confirmed the above injuries of unknown origin to Resident#14's bilateral lower extremities. Staff C confirmed that no one had reported the injuries to Resident #14's bilateral lower extremities. Review on 1/12/23 of facility policy titled Abuse Prohibition, revised on 10/24/22, revealed .6.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. 6.1.1 The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law .

Based on interview and record review, it was determined that the facility failed to ensure that all identified areas of injury from unknown origin were thoroughly investigated for 1 of 1 residents reviewed for injuries of unknown origin out of a final sample of 13 residents (Resident Identifier is #14). Findings include: Observation on 1/10/23 at approximately 10:39 a.m. of Resident #14 revealed bilateral outer ankle abrasions, multiple abrasions to bilateral shins, purple discoloration to the top of left foot bend and yellowing bruise to left upper shin. Interview on 1/10/23 at approximately 10:39 a.m. with Resident #14 revealed they did not know how they obtained the areas of injury to both lower extremities. Interview on 1/12/23 at approximately 8:50 a.m. with Staff C (Unit Manager) revealed that an investigation had not been initiated for the above injuries. Review on 1/12/23 of facility policy titled Abuse Prohibition, revised on 10/24/22, revealed .6.4 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to follow physicians' orders for 2 out of 13 residents reviewed (Resident identifiers are #15 and #16). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #16 Observation on 1/10/23 at approximately 10:15 a.m. with Resident #16 in his/her room revealed Resident #16 was sitting in a wheelchair with socks on his/her feet. Resident #16's feet were resting on the foot pedals. Further observation revealed a pair of offloading heel boots on a chair across the room. Review on 1/10/23 of Resident #16's medical record revealed the following physician's order: Monitor right heel every shift for deterioration. Offloading heel boots at all times, except during care or therapy. Every shift for Deep Tissue Injury [DTI], start date 4/14/22. Observation on 1/12/23 at approximately 12:00 p.m. of Resident #16 was in the dining room in a wheelchair with socks on his/her feet. Resident #16's feet were resting on the foot pedals. Interview on 1/12/23 at approximately 12:00 p.m. with Staff I (Wound Nurse) confirmed the above findings. Resident #15 Review on 1/11/23 of Resident #15's medical record revealed Resident #15 was admitted to the facility on [DATE]. Further review of Resident #15's medical record on 1/11/23 revealed the following note: Telephone, 3/18/22 provider [pronoun omitted] Ophthalmology Note: [Name omitted] called from [NAME] about switching pt [patient] from Lumigan to Latanoprost due to cost. Per Dr. [Doctor] this is ok [okay] but pt needs to come in and be seen, 1 bottle order with no refills. I spoke with [name omitted], nurse at [NAME] and [pronoun omitted] understood pt needs to be seen and will let [name omitted] know to make an appointment. Interview on 1/12/23 at approximately 11:00 a.m. with Staff F (Director of Nursing) revealed there was no evidence that Resident #15 was seen by an Ophthalmologist.

Based on interview, record review, and facility assessment review, it was determined that the facility failed to provide behavioral health/psychiatry consults for 1 out of 1 residents reviewed for behavioral/emotional health in a final survey sample of 13 residents (Resident identifier is #11). Findings include: Interview on 1/10/23 at approximately 10:00 a.m. with Resident #11 revealed Resident #11 to be weepy. Resident #11 stated, I would rather live in a dump, than in here. Resident was pointing at his/her roommate while making the statement. Review on 1/11/23 of Resident #11's care plans revealed the following care plans, dated 8/3/22: Resident/Patient exhibits or has the potential to demonstrate verbal behaviors related to: History of verbal outbursts directed toward others: Disruptive behavior to roommate, Ineffective coping skills, i.e.[example], poor anger management, date initiated 8/3/22. Interview on 1/12/23 at approximately 9:30 a.m. with Staff J (Unit Manager) revealed that Resident #11 does not like having roommates since Staff J began working at the facility in 2021 and has a care plan for ineffective coping skills. Review on 1/12/23 of Resident #11's medical record revealed that psychiatric services were never offered to Resident #11. Interview on 1/12/23 at approximately 10:30 a.m. with Staff J confirmed that psychiatric services were never offered to Resident #11, since he/she has been working at the facility. Review on 1/12/23 of the facility policy titled, NSG Behaviors: Management of Symptoms, Revision Date 10/24/22 revealed: . Based on the comprehensive assessment, staff must ensure that a patient: Who displays or is diagnosed with behavioral health disorder or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being; .