Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 20 sampled residents (#10, #35, and #191) observed during personal cares. Failure to practice infection control standards related to hand hygiene/glove use and enhanced barrier precautions has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 06/12/25. This policy, revised May 2024, stated, . Hand hygiene is indicated and will be performed under the conditions listed . Before applying and after removing personal protective equipment (PPE), including gloves . After assistance with personal body functions (e.g., elimination) . Review of the facility policy titled Enhanced Barrier Precautions occurred on 6/12/25. This policy, revised June 2025, stated, . Enhanced barrier precautions (EBP) are used to limit or prevent the spread of resistant organisms during high-contact resident care activities. These may be indicated for residents with . indwelling medical devices (e.g. central lines . ) . when performing transfers . EBP should be used for the duration of the affected resident's stay in the facility . until the resolution or discontinuation of the indwelling medical device that placed them at higher risk . - Observation on 06/10/25 at 9:15 a.m. showed two certified nurse aides (CNAs) (#2 and #3) applied gloves and the CNA (#3) removed Resident #10's brief, soiled with bowel movement, provided perineal cares, and placed a new brief under the resident. The CNA (#3) removed the soiled gloves, and without performing hand hygiene, applied new gloves. Both CNAs (#2 and #3) repositioned Resident #10, adjusted/secured the brief, and removed their gloves. The CNA (#3) handed the phone to the resident, placed a wedge under the resident's legs, placed a nasal cannula, attached the call light to the resident's side pillow, and then performed hand hygiene. - Observation on 06/10/25 at 9:00 a.m. showed a CNA (#1) applied gloves, removed Resident #35's soiled brief, performed perineal cares, and removed the soiled gloves. Without performing hand hygiene, the CNA (#1) applied new gloves, applied barrier cream to the resident's buttocks, and placed a new brief under the resident. The CNA (#1) removed the soiled gloves, and without performing hand hygiene, applied new gloves, adjusted/secured the resident's brief, adjusted the resident's pants, removed the gloves, and then performed hand hygiene. - Review of Resident #191's medical record occurred on all days of survey. Medical diagnoses included osteomyelitis (infection of the bone) and staphylococcus (infection of the skin). The current care plan stated, . on Enhanced Barrier Precautions r/t [related to] indwelling device PICC Line [a peripheral central catheter inserted into a vein in the upper arm] . use appropriate PPE when providing high level ADL's [activities of daily living] . use hand hygiene when visiting me . Observation on 6/09/25 at 4:04 p.m. showed an EBP sign on Resident #191 door. An unidentified CNA and a nurse (#5) entered Resident #191's room without performing hand hygiene or applying PPE. The CNA assisted Resident #191 out of a chair and the nurse (#5) applied a gait belt, and walked the resident to the bathroom. OPbservation showed the nurse (#5) touched areas of the resident's body, the walker, and the door during toileting cares and transfer assistance. The nurse (#5) admitted she should have performed hand hygiene and applied PPE prior to entering the room. During an interview on 6/11/25 at 3:48 p.m., an administrative nurse (#4) stated she expected staff to follow appropriate EBP.

**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 20 sampled residents (Resident #35 and #79). 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 A: IDENTIFICATION INFORMATION & SECTION J: HEALTH CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, page A6, stated, . Coding Instructions for A0310E, Is This Assessment the First Assessment (OBRA, Scheduled PPS, or OBRA Discharge) since the Most Recent Admission/Entry or Reentry? . Code 1, yes: if this assessment is the first of these assessments since the most recent admission/entry or reentry. Pages J-30 and J-31, stated, . J1700. Fall History on Admission/Entry or Reentry. Complete only if . A0310E = 1 . Coding Instructions for J1700A, Did the Resident Have a Fall Any Time in the Last Month Prior to Admission/Entry or Reentry? . Code 1, yes: if resident or family report or transfer records or medical records document a fall in the month preceding the resident's entry date item (A1600). Review of Resident #79's medical record occurred on all days of survey and identified the resident experienced a fall on 04/22/24. An X-ray performed on 05/03/24 identified a left femoral neck fracture. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident #79's completed MDSs are as follows: * 05/03/24, Discharge Return Anticipated (an OBRA assessment) * 05/07/24, Entry (back to the facility) * 05/13/24, Quarterly (an OBRA assessment) Review of the 05/13/24 quarterly MDS identified the facility coded A0310E as 0, no even though this is the first assessment since reentry on 05/07/24. Review of J1700A identified the facility coded 0, no falls in the last month prior to reentry. Resident #79's medical record identified a fall on 04/22/23. The facility failed to accurately code A0310E and J1700A on Resident #79's quarterly MDS. SECTION N: MEDICATIONS The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, revised October 2023, pages N-6 and N-7, stated, . N0415: High-Risk Drug Classes: Use and Indication . Coding Instructions . N0415E1. Anticoagulant (e.g., [for example] warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period . Review of Resident #35's medical record occurred on all days of survey and showed a physician's order for Eliquis, an anticoagulant. The annual MDS, dated [DATE], showed staff failed to identify Resident #35 received an anticoagulant during the look-back period. During an interview on 06/13/24 at 10:01 a.m., an administrative staff member (#8) confirmed staff failed to code the MDS for an anticoagulant.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received the necessary services to maintain oral hygiene for 1 of 3 sampled residents (Resident #28) dependent on staff for oral cares. Failure to provide oral care for a dependent resident may result in poor hygiene, increased oral/dental problems, and potential for adverse health effects. Findings include: Review of the facility policy titled STANDARDS OF CARE occurred on 06/13/24. This policy, dated May 2023, stated, Each of the following is part of the routine care provided by caregivers . Oral care will be done in the morning and at bedtime. Daily Morning Cares . Provide oral care . Review of Resident #28's medical record occurred on all days of survey. The current care plan stated, . I have ADL [activities of daily living] deficit related to: inability to communicate needs, Impaired mobility . ORAL CARE: I require complete help with mouth care. Observation on 06/11/24 at 8:51 a.m. showed two certified nurse aides (CNAs) (#3 and #4) provided Resident #28's morning cares. The CNAs failed to provide oral cares. Observations on 06/12/24 at 8:23 a.m., 8:52 a.m., and 11:21 a.m. showed a nurse (#5) provided cares to Resident #28. A dry white substance covered part of the resident's upper and lower lips and a wet white substance on the inside of the lips when he/she opened his/her mouth on each of these observations. The nurse failed to provide oral cares. During an interview on 06/12/24 at 3:18 p.m., an administrative staff member (#1) stated she expects staff to provide oral cares twice a day and as needed.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 3 sampled residents (Resident #28) observed receiving insulin. Failure to administer insulin according to a physician's order may result in adverse health effects for the residents. Findings include: Review of the facility policy titled Insulin Pen occurred on 06/13/24. This policy, revised June 2024, stated, . Prime the insulin pen . Set the insulin dose: a. Turn the dose selector to ordered dose. A click will be heard for each unit dialed. Check the dose a second time. Review of Resident #28's medical record occurred on all days of survey. Diagnoses included type-2 diabetes mellitus with hyperglycemia (high blood sugar). Physician's orders included 46 units of aspart insulin at 12:00 p.m. Observation on 06/11/24 at 11:39 a.m. showed a nurse (#6) primed Resident #28's aspart insulin pen by the medication cart in the hallway outside the resident's room. The nurse entered the resident's room, cleansed an area of the abdomen, and without dialing up the ordered dose of insulin (46 units), removed the insulin pen needle cover, inserted the needle into the resident's abdomen, and pushed the pen's plunger. When asked by the surveyor, the nurse (#6) acknowledged she failed to prepare and administer the ordered 46 units of insulin. The nurse (#6) then attached a new needle to the pen, primed the pen, dialed up the 46 units of insulin, and administered the insulin.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 12 sampled residents (Resident #28 and #79) and one supplemental resident (Resident #43) observed during cares. Failure to practice infection control standards related to use of personal protective equipment (PPE) 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 06/13/24. This policy, revised April 2024, stated,. Enhanced barrier precautions will be implemented for residents with any of the following . indwelling medical devices (e.g. [for example], . feeding tubes [G-tube, a tube inserted into the gastrointestinal tract], tracheostomy [a surgical opening in the trachea that allows a tube to assist with breathing] .) . Infection or colonization with a CDC [Centers for Disease Control and Prevention]-targeted MDRO [multidrug resistant organism] . face protection may also be needed if performing activity with risk of splash or spray (i.e. [that is], . tracheostomy care). PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include . Device care or use . feeding tubes, tracheostomy . Review of the facility policy titled Hand Hygiene occurred on 06/12/24. This policy, dated May 2024, stated, . Hand hygiene is indicated and will be performed . after assistance with personal body functions (e.g. elimination .) . Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 678, stated, . Hand hygiene is important in every setting . It is important for both the nurses' and the clients' hands to be cleansed . after the hands have come in contact with any body substances . ENHANCED BARRIER PRECAUTIONS Review of Resident #28's medical record occurred on all days of survey. The current care plan stated, I am on enhanced barrier precautions r/t [related to] indwelling device: Tracheostomy, G-Tube, and a history of a MDRO. Use appropriate PPE when providing high levels of ADLs [activities of daily living]. Observation on 06/12/24 at 8:52 a.m. showed a nurse (#5) gathered supplies to complete Resident #28's G-tube dressing change. The nurse donned gloves, and without donning a gown, removed the soiled G-tube dressing, cleansed the G-tube site with warm soapy water, removed his/her gloves, performed hand hygiene, donned new gloves, and emptied the basin. The nurse (#5) then donned a gown and acknowledged he/she forgot to apply it earlier and continued with cares. Observation on 06/12/24 at 11:21 a.m. showed a nurse (#5) performed tracheostomy cares for Resident #28. During the cares, the resident began to cough and expelled mucus through the cannula (tube inserted into the tracheostomy hole) across the foot of his/her bed. The nurse (#5) failed to apply face protection before providing tracheostomy cares. During an interview on 06/12/24 at 3:18 p.m., an administrative staff member (#1) stated she expected staff to follow enhanced barrier precaution as stated in the facility policy. HAND HYGIENE Review of Resident #79's medical record occurred on all days of survey. The record identified a colostomy and dependence on staff for colostomy cares. Observation on 06/10/24 at 12:50 p.m. showed a certified nurse aide (CNA) (#7) performed colostomy cares for Resident #79. The resident periodically assisted the CNA by touching/positioning the colostomy bag and the graduate the bowel emptied into. After completing the cares, the CNA removed his/her gown and gloves and performed hand hygiene. The CNA failed to offer/provide hand hygiene to Resident #79. Observation on 06/11/24 at 11:22 a.m. showed a CNA (#2) performed incontinence cares for Resident #43 after a bowel movement. The CNA (#2) transferred the resident to a recliner, unhooked the leg straps and the mechanical lift sling, collected the garbage, and then removed the soiled gloves and performed hand hygiene. During an interview on 06/12/24 at 3:18 p.m., an administrative staff member (#1) confirmed she expected staff to provide Resident #79 hand hygiene after the colostomy cares and expected staff to remove gloves and perform hand hygiene after incontinence cares.

Based on review of Medicare Part A letters/notices and staff interview, the facility failed to ensure the completion of the Centers for Medicare/Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form CMS-10055 for 1 of 2 residents (Resident #78) discharged from Medicare Part A services who remained in the facility. Failure to ensure the resident and/or resident representative received all available options for care and the option to appeal the termination of coverage has the potential to hinder the residents' right to an expedited review of a service termination. Findings include: Review of the Medicare Part A letters/notices for Resident #78 occurred the afternoon of 06/21/23 and identified the facility provided the SNFABN form to Resident #78's representative on 03/21/23. The facility failed to obtain documentation of the resident's wishes for continued services and/or the option to appeal the termination of Medicare Part A coverage prior to termination of Medicare Part A coverage on 03/25/23. During an interview on 06/21/23 at 3:05 p.m., a business office staff member (#1) confirmed staff failed to obtain the resident/resident representative option on the SNFABN form for Resident #78.

Based on record review, review of facility policy, and staff interview, the facility failed to identify a resident's history of trauma, and/or triggers for 1 of 3 sampled residents (Resident #26) reviewed for Post-Traumatic Stress Disorder (PTSD) and/or Trauma. Failure to identify a resident's history of trauma, and/or triggers may cause re-traumatization. Findings include: Review of the facility policy and procedure titled Trauma Informed Care occurred on 06/21/23 at 2:04 p.m. This policy/procedure dated November 2019, stated, .The facility will account for residents' experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Review of Resident #26's medical record occurred on all days of survey and identified a diagnosis of PTSD. The record lack documentation of an assessment and the development of a plan of care that identified the resident's history of trauma, and/or potential triggers which may cause re-traumatization. During an interview on 06/21/23 at 10:21 a.m. an administrative staff member (#5) confirmed the facility failed to address Resident #26's PTSD and/or trauma diagnosis and potential triggers.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 2 medication carts (Friendship Unit) observed during medication storage review. Failure to correctly label an insulin pen increases the risk of the wrong resident receiving the insulin. Finding include: Review of the facility policy titled Insulin Pen occurred on 06/22/23. This policy, dated February 2018, stated, . Insulin pens must be clearly labeled with the resident name. Observation of the medication cart on the Friendship Unit with staff nurse (#7) occurred on 06/21/23 at 4:36 p.m., and showed the following insulin pen for Resident #18: * Basaglar Kwik pen [a long acting insulin], displayed a label with only the first name visible. During an interview on 06/21/23 at 5:50 p.m., two administrative nurses (#4 and #6) confirmed the insulin pen failed to contain the full name of Resident #18.

Based on observation and review of facility policy, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #46) observed during personal cares and application of a dressing. Failure to follow infection control practices regarding hand hygiene during cares and dressing application has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: Review of the facility policy and procedure titled Hand Hygiene occurred on 06/22/23. This policy/procedure, dated December 2017, stated, Procedure: Hand hygiene is to be performed: . h) After removing gloves. Review of the facility policy and procedure titled Dressing Change: Nonsterile occurred on 06/22/23. This policy/procedure, dated June 2023, stated, . Procedure: . 2. Assemble all equipment in apartment [resident room]. 3. Establish clean field for dressing change. 5. Perform hand hygiene and apply and change gloves as appropriate during procedure. Observation on 06/20/23 at 9:10 a.m. showed a certified nurse aide (CNA) (#2) performed morning cares for Resident #46. The CNA (#2) changed gloves while providing care but failed to complete hand hygiene before donning clean gloves. When the CNA (#2) completed the resident's cares and cleaned up the supplies removed her gloves. Without performing hand hygiene, the CNA (#2) handed Resident #46, the phone, bed controls, call light, moved the overbed table, and handed the resident a drink, which the resident drank. The CNA (#2) failed to perform hand hygiene after and before performing other tasks. During this same observation, the nurse (#3) provided the application of a new dressing to Resident #46's sacral area. The nurse (#3), upon entering the room, set the clean supplies for the dressing on top of the soiled linen hamper. When the CNA (#2) finished, the nurse (#3) moved the supplies to the bedside stand. The nurse (#3), working from the bedside stand, donned gloves, cleansed the skin with sterile saline and gauze, removed gloves, donned clean gloves, and applied the foam dressing. The nurse (#3) failed to set up a clean field and failed to perform hand hygiene between glove changes.