Based on observation, review of facility policy, and staff interviews the facility failed to follow standards of infection control and prevention for 3 of 22 sampled residents (Residents #16, #29 and #88) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), dressing changes, and hand hygiene, has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 04/24/25. This policy, revised April 2024, stated, . Enhanced Barrier Precautions (EBP) is a strategy in nursing homes to decrease transmission of . important multidrug-resistant organisms (MDROs). Additionally, residents at risk for MDROs, specifically those with an indwelling medical device . will be required to use EBP. (EBP) expands the use of Personal Protective Equipment (PPE) . refers to the use of gown and gloves during high-contact resident care activities . When to use: . All residents with any of the following: . Indwelling medical devices (e.g. central lines, urinary catheters .) . During high-contact resident care activities: . Indwelling medical device care or use: central line, urinary catheter . Gloves and gown prior to the high-contact care activity . Review of the facility policy titled Dressing Change occurred on 04/24/25. This policy, revised October 2015, stated, . Procedure: . 3. Set up clean field and place supplies on clean field. - Observation on 04/02/25 at 11:13 a.m. showed Resident #16 seated in a wheelchair in his/her room with a peripherally inserted central catheter (PICC) line to the right arm. A sign on the wall outside of the room indicated EBP. A staff nurse (#6) entered the room with two syringes and an intravenous (IV) medication bag, performed hand hygiene, gathered additional supplies, applied gloves, removed the PICC line dressing, removed gloves, performed hand hygiene, and applied a new dressing. The nurse (#6) flushed the PICC line and started the IV medication The staff nurse (#6) failed to wear a gown during the PICC line dressing change and administration of the IV medication. - Review of Resident #29's medical record occurred on all days of survey. The current care plan stated, . I have a foley catheter . Enhanced Barrier Precautions . Observation on 04/23/25 at 6:35 a.m. showed Resident #29 resting in bed. A sign on the wall outside of the room indicated EBP. A nurse (#5) entered the resident's room with a bag of dressing supplies from the medication cart. The nurse set the bag on the bedside table, performed hand hygiene, applied a gown and gloves, obtained supplies from the bag, and performed the dressing change to Resident #29's arm and lower legs. The nurse (#5) returned the bag of dressing supplies to the medication cart with other dressing supplies, emesis bags, and a catheter kit. The staff nurse (#5) failed to disinfect the bedside table before placing the bag of dressing supplies on it and failed to disinfect the bag prior to returning it to the medication cart with medical supplies. - Observation on 04/22/25 at 8:13 a.m. showed Resident #88 seated in a wheelchair. A nurse aide (NA) (#4) applied gloves, placed Resident #88's dentures in his/her mouth, removed her gloves, and without performing hand hygiene, wheeled the resident to the dining room for breakfast. The NA (#4) failed to perform hand hygiene after removing gloves and before exiting Resident #88's room. During an interview on 04/23/25 at 4:20 p.m., two administrative nurses (#1 and #2) confirmed they expected staff to perform hand hygiene after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 19 sampled residents (Resident #45, and #56). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION H - BLADDER AND BOWEL The Long-Term Care Facility RAI User's Manual, revised October 2023, page H-2, states, . Check next to each appliance that was used at any time in the past 7 days. H0100A, indwelling catheter . - Review of Resident #56's medical record occurred on all days of survey. The physician's orders dated 12/23/23, included Foley Catheter [indwelling catheter] to gravity drainage; . Review of the significant change in status assessment MDS, dated [DATE], Section H0100A, indwelling catheter, lacked documentation to indicate the presence of an indwelling catheter. During an interview on 03/19/24 at 12:55 p.m., a clinical manager (#1) confirmed Resident #56's MDS section H0100A lacked the documentation for the presence of an indwelling catheter. SECTION O - SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS The Long-Term Care Facility RAI User's Manual, revised October 2023, page O-7, states, . Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. - Review of Resident #45's medical record occurred on all days of survey. The current care plan identified, . I am at the end of my life/receiving hospice service related to Alzheimer's Disease. Review of the admission MDS, dated [DATE], Section O110K1, hospice, lacked the documentation to indicate the presence of hospice services. During an interview on 03/19/24 at 5:14 p.m., an administrative nurse (#2) confirmed Resident #45's MDS section O110K1 lacked the documentation for the presence of hospice services.

Based on observation, record review, review of facility policy, resident interview, and staff interview, the facility failed to ensure activities of daily living (ADLs) were appropriately completed for 1 of 1 sampled resident (Resident #9) and 1 supplemental resident (Resident #296) observed with poor oral care and/or grooming. Failure to ensure residents are assisted to maintain oral hygiene and grooming may result in lack of personal hygiene and decreased self-esteem. Findings include: Review of the facility policy titled ORAL CARE occurred on 03/19/24. This policy, dated May 2000, stated, OBJECTIVE: 1. To keep the teeth, gums and mouth in good condition. 2. To clean and freshen mouth. Review of the facility policy titled SHAVING THE RESIDENT occurred on 03/19/24. This policy, dated January 2000, stated, . Shaving the Female Residents. 1. Observe for facial hair during bathing procedure & [and] PRN [as needed]. - Review of Resident #9's medical record occurred on all days of survey. The resident's care plan stated, . I require assist with dressing and personal hygiene . Resident to shave as needed . The record identified Resident #9 receives weekly baths/showers on Thursdays and has an electric shaver. Random observations on all days of survey showed Resident #9 seated in her room with visible facial hair on her chin. Review of Resident #9's progress notes, dated 03/14/24 to 03/18/24, identified: - 03/14/24 at 11:05 p.m. - Needed 2 person [usually 1 person] assist this shift. MD [medical doctor] informed. - 03/16/24 at 9:29 a.m. and 5:48 p.m. - . Noted confusion. resident noted productive cough and congestion . increased confusion . reminded verbally and with written signage to stay in room. - 03/18/24 at 2:31 p.m. resident continues with increased confusion. - Review of Resident #296's medical record occurred on all days of survey. Diagnoses included dislocation of a shoulder joint. The resident's care plan stated, . Resident requires set up assistance with oral Care [sic] . I require staff assist with dressing and personal hygiene . Resident to shave as needed . The record identified Resident #296 receives baths/showers twice a week on Mondays and Thursdays and has an electric shaver. Observation on 03/18/24 at 7:33 a.m. showed Resident #296 seated in a wheelchair in her room wearing a shoulder immobilizer sling to the right arm. While interviewing the resident she appeared to have dried saliva between her lips and debris noted in her teeth. When asked if she had brushed her teeth today, the resident stated, I have been here since Monday [since admission 7 days ago] and I have brushed my teeth once, and further stated, I don't have a toothbrush. Do they throw them [toothbrushes] away after using them once? Further observations of Resident #296 showed the following: * On 03/18/24 at 4:59 p.m., resident reported she still does not have a toothbrush in her room and staff had not offered assistance with oral cares. * On 03/19/24 at 8:37 a.m., visible facial hair on the resident's chin. When asked if the chin hair were a concern, the resident stated, I shave them when I am at home. I have a shaver in my bag and pointed across the room. The resident reported she is right hand dominant and is not very good with her left hand. Observation showed the resident with debris/food present in her teeth. * On the afternoon of 03/19/24, resident reported she still does not have a toothbrush in her room and staff had not offered assistance with oral cares. During an interview on 03/19/24 at 10:45 a.m. an administrative staff member (#4) stated shaving is completed with scheduled bathing, and due to transmission precautions, Residents #9 and #296 received bed baths. The facility failed to ensure Resident #9 and Resident #296 completed ADLs for teeth brushing and/or chin hair removal, and staff assisted as needed for proper grooming/appearance.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 4 of 14 sampled residents (Resident #7, #38, #45, and #54) and 1 supplemental resident (Resident #4) observed during personal cares. Failure to follow infection control practices during cares and/or related to hand hygiene/glove use has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled HAND HYGIENE occurred on 03/19/24. This policy, dated November 2017, stated, . If hands are not visibly soiled and/or the resident does not have infectious diarrhea, an alcohol based hand hygiene product may be used. If hands are visibly soiled . soap and water must be used for hand hygiene. - Observation on 03/17/24 at 11:17 a.m. showed a certified nurse aide (CNA) (#5) donned gloves, removed and bagged Resident #54's soiled pants, removed her soiled gloves, and then donned a new pair of gloves before performing other tasks. The CNA (#5) failed to perform hand hygiene after removing Resident #54's soiled clothing and prior to performing other tasks. - Observation on 03/17/24 at 2:43 p.m. showed two CNAs (#8 and #9) donned gloves and completed personal cares for Resident #45. After completion of cares, CNA (#9) held onto the tip of a straw and offered Resident #45 a drink of water. The CNA (#9) failed to remove her soiled gloves and perform hand hygiene after providing personal care and prior to offering her a drink of water. - Observation on 03/18/24 at 10:00 a.m. showed Resident #7 with a catheter in place. Two CNAs (#10 and #11) donned gloves and provided perineal care for Resident #7. The CNA (#10) cleansed the rectal area of stool, removed her soiled gloves, and washed her hands. The CNA (#11) placed a new brief on the resident, removed her gloves, performed hand hygiene, and covered the resident with a blanket. The CNAs (#10 and #11) failed to cleanse the front perineal area. - Observation on 03/18/24 at 11:17 a.m. showed a CNA (#3) donned gloves and provided perineal care for Resident #4. The CNA cleansed the rectal area of stool using a wet wipe and without removing the soiled gloves, applied a protective barrier ointment to the resident's bottom. The CNA (#3) failed to remove her soiled gloves and perform hand hygiene after cleaning the rectal area and prior to applying ointment. - Observation on 03/18/24 at 4:18 p.m. showed two CNAs (#6 and #7) donned gloves, transferred Resident #38 onto the bed, lowered the soiled shorts and brief, and provided perineal cares. The CNAs (#6 and #7) removed their gloves and completed the transfer. After providing personal cares for Resident #38, the CNA (#6) offered Resident #38 a drink of water before performing hand hygiene. The CNAs (#6 and #7) failed to perform hand hygiene after removing their visibly soiled gloves, after removing Resident #38's soiled clothing, and prior to performing other tasks. During an interview on 03/19/24 at 4.46 p.m., a managerial nurse (#12) confirmed she expects staff to perform complete perineal cares and to perform hand hygiene after removing soiled gloves and prior to completing other tasks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of professional reference, and record and staff interview, the facility failed to follow professional standards of practice regarding physician's orders for 1 of 1 sampled resident (Resident #21) with an order for a pain ointment. Failure to carry out the physician's orders resulted in Resident #21 experiencing pain and discomfort. Findings include: [NAME], [NAME], and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., Massachusetts, page 68, states, . Carrying Out a Physician's Order . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #21's medical record occurred on all days of the survey. The current physician's orders identified, . apply Voltaren gel [a pain medication] . topically, two times a day as scheduled to right trunk, back and lower legs for chronic pain . Observation of a medication pass on 04/24/23 at 3:34 p.m., showed a container of Voltaren gel sitting on Resident #21's bedside table. When asked if he received his early morning dose of Voltaren, Resident #21 stated, No . I am a little sore right now. When asked if Resident #21 had received his medication, a staff nurse (#4) reviewed the Medication Administration Record (MAR) and stated the MAR showed a nurse administered the Voltaren gel between 4:00 a.m. and 7:00 a.m. During an interview on 04/25/23 at 7:48 a.m., the staff nurse (#3) stated she forgot to apply Resident #21's pain medication between 4:00 a.m.- 7:00 a.m., left the Voltaren container on his bedside table, and documented in the MAR as if she had administered the medication. During an interview on 04/26/23 at 7:45 a.m., an administrative nurse (#2) indicated she expected nursing staff to administer medications as ordered by the physician.

Based on observation, facility policy review, and staff interview, the facility failed to ensure safe and secure storage of medications for 1 of 3 medication carts (Unit 2) observed during medication pass. Failure to store all medications securely may result in unauthorized access to medications. Findings include: Review of the facility policy titled Pharmacy Services occurred on 04/26/23. This policy, revised October 2022, stated, . During the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide . no medications are kept on top of the cart . the cart must be clearly visible to the personnel administering medications . all other sides must be inaccessible to residents or others passing by . Observation on 04/25/23 at 7:52 a.m., showed a staff nurse (#1) preparing the residents' medications in the hallway. The staff nurse (#1) left the medication cart unlocked and unattended in the hallway when she entered the dining room to deliver the medications. The nurse (#1) left eight medication cartridges, two unlabeled cups containing medications and one insulin pen on top of the cart. Observation showed the top drawer open and medications visible. A number of residents, staff members, and construction workers passed by the unlocked/unattended medication cart during the observation. During an interview on 04/25/23 at 8:03 a.m., the staff nurse (#1) confirmed she left the medication cart in the hallway unlocked and unattended. An administrative nurse (#2) indicated she expected the medication cart to be locked when not in clear view and/or within reach of the person administering medications.