Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #18) with Multi-Resistant Staph Aureus (MRSA) (a type of contagious infection resistant to antibiotics) in a wound. Failure to follow infection control practices related to location of a dressing change and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. During the on-site recertification survey, the team determined an Immediate Jeopardy (IJ) situation existed on 04/21/25 at 3:55 p.m. The IJ was identified when a staff nurse performed a dressing change in the medication room and failed to wear Personal Protective Equipment (PPE) (a gown). This finding placed all residents, staff, and visitors at risk for infection and/or spread of infection. *04/22/25 at 10:00 a.m., the survey team notified the administrator and director of nursing (DON) of the IJ situation, provided the IJ template, and requested a plan for removal of the IJ. *04/22/25 at 1:45 p.m., the survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: *Facility issued a directive that the nurse's station (medication room) must not be used for wound care. *The nurse's station (medication room) was deep cleaned. *All residents with wounds will have their wound treatments completed in the resident's room with proper PPE. *1:1 education provided to the staff nurse who performed the wound care regarding appropriate location to perform wound care, the standards of EBP, and the correct use of PPE. *Educated all staff on proper use of PPE and guidelines of EBP. This training was conducted via On Shift (all employee text message) and in person to staff on duty or prior to next scheduled shift. *04/22/25 at 2:20 p.m., the survey team verified the implementation of the removal plan and the IJ removal. The deficient practice remained at an D scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Multidrug-Resistant Organisms, MRSA . occurred on 04/24/25. This policy, dated April 2024, stated, . Residents colonized with a CDC [Centers for Disease Control] targeted MDRO [Multi Drug Resistant Organism] and select epidemiologically important MDROs at the facilities discretion are intended to remain on Enhanced Barrier Precautions for the duration of their stay in a facility. Summary of PPE Use . Enhanced Barrier Precautions . Applies to: All residents with any of the following: Wounds . Infection or colonization with a novel or targeted MDRO . PPE used for these situations: During high-contact resident care activities: Wound care: any skin opening requiring a dressing . Required PPE: Gloves and gown prior to the high-contact care activity . Face protection may also be needed if performing activity with risk of splash or spray . Review of the facility policy titled Enhanced Barrier and Transmission-Based Precautions occurred on 04/24/25. This policy, dated April 2025, stated, . Enhanced barrier precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer for multi drug-resistant organisms (MDROs) to staff hands and clothing. Enhanced barrier precautions are used for residents who are infected or colonized with a CDC-targeted MDRO . Review of the facility policy titled Personal Protective Equipment PPE . occurred on 04/24/25. This policy, dated January 2025, stated, . Wear a gown for direct resident/patient contact if the resident/patient is on Enhanced Barrier Precautions. to protect clothing from potential contamination. Review of the facility policy titled Wound Dressing Change occurred on 04/24/25. This policy, dated November 2024, stated, . Follow EBP (wash hands before entering and exiting the room, wear gloves and gown). Review of Resident #18's medical record occurred on all days of survey. Diagnoses identified chronic osteomyelitis (a bone infection) to the left ankle and foot, MRSA, and group B streptococcus (a type of bacterial infection). Physician's orders included Betadine (an antiseptic solution cleanser used to prevent the growth of and kill bacteria), wet to dry dressings to the wound on the left great toe, and Doxycycline (an antibiotic medication) daily for 14 days for MRSA. The current care plan stated . I require Enhanced Barrier Precautions (EBP) R/T [related to] open wounds, MRSA, & Strep B . wound to left toe . Observation on 04/21/25 at 3:55 p.m. showed a nurse (#12), with gloved hands, performed a dressing change to Resident #18's MRSA infected left great toe in the medication room. The resident's left foot rested on a disposable pad on the floor, and the soiled dressing, removed from the resident's foot by the nurse, also on the pad. Observation showed a spray bottle of wound cleanser nearby. At 4:05 p.m., Resident #18 exited the medication room and the nurse (#12) stated the dressing change should have been completed in the resident's room and not the medication room as the resident is on EBP. The staff nurse (#12) failed to complete the dressing change in the resident's room and failed to wear the appropriate PPE prior to completing the dressing change. During an interview on 04/22/25 at 10:00 a.m., an administrative nurse (#2) confirmed the medication room is considered a clean space. At 2:20 p.m., an administrative staff member stated he/she expected facility staff to perform procedures in the resident's room and wear appropriate PPE.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 5 sampled residents (Resident #35) who required staff assistance and a gait belt with transfers. Failure to provide adequate assistance and/or use the assistive devices appropriately during transfers placed the residents at risk for accidents, falls, and/or injuries. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 04/16/24 at 5:15 p.m. The IJ resulted from staff failure to provide sufficient supervision and use the assistive device (gait belt) in a manner to avoid a fall and/or potential injury. * 04/16/24 at 5:29 p.m., The survey team contacted the State Survey Agency (SSA) to report the findings and discuss potential immediate jeopardy (IJ). * 04/16/24 at 6:30 p.m., The survey team notified the administrator and the director of nursing (DON), of the IJ situation, provided them with the IJ template, and requested they develop a plan for removal of the immediate jeopardy. * 04/16/24 at 6:35 p.m., The SSA notified the CMS (Centers for Medicaid & Medicare Services) location of the IJ situation. * 04/16/24 at 8:40 p.m., The facility provided (via email) an IJ removal plan. * 04/17/24 at 8:30 a.m., The SSA reviewed and accepted the IJ removal plan. The removal plan contained the following: * Inservice and education on appropriate actions/interventions per care plan specific to toileting and transfers to meet residents needs and prevent injury, with the staff member directly involved in the deficient practice, all nursing staff on duty, and on-coming staff. * Review of Resident's transfer requirements as outlined in their individual care plans. * Review of facility policies and resources for questions/concerns. * 04/17/24 at 10:12 a.m., the survey team verified the implementation of the removal plan. The deficient practice remained at a D scope and severity following the removal of the IJ. Findings include: Review of the facility policy titled Fall Prevention and Management - Rehab/Skilled [R/S], Therapy & [and] Rehab occurred on 04/17/24. This policy, dated 04/02/24, stated, . To promote resident well-being by developing and implementing a fall prevention and management program . Proactive Approach before a Fall occurs . 2. Complete the Falls Tool UDA [user defined assessment] for fall screening and identifying fall risk factors. 3. Care Plan the appropriate interventions . 4. Communicate fall risks and interventions to prevent a fall before it occurs . Review of the facility policy titled Care Plan - R/S, LTC [Long Term Care], Therapy & Rehab occurred on 04/17/24. This policy, dated 11/01/23, stated, . Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being . The care plan will emphasize the care of the whole person ensuring that the resident will receive appropriate care and services. Review of Resident #35's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #35 had severely impaired cognition. The current care plan stated, . I am at risk for falls r/t [related to] balance difficulty, weakness and unsteadiness. I do have a hx [history] of falls r/t dementia and poor safety awareness, weakness and ambulatory dysfunction. I will not sustain serious injury through the review date. TOILET USE: I need extensive assist of two with transfers . TRANSFERS: Transfers with assist of two with gait belt . I will at times try to transfer myself in the restroom . Review of nursing progress notes identified the following: * 04/13/24 at 4:43 p.m., . Staff called nurse to resident room and stated that he is in the bathroom on the floor and bleeding from his head and blood on the floor and his hands and arms. Nurse assessed and resident cleansed and noted laceration to right side of forehead and skin tears to right elbow and top of hand. Resident was self transferring and lost balance and fell and then pulled call light. Pressure applied to laceration and vital signs obtained. Call placed to family and provider on call . and rec'd [received] verbal order to send to ER [emergency room] via ambulance. * 04/13/24 at 5:00 p.m., . Call placed to . hospital switchboard and requested to be connected to provider on call . Updated that resident had unwitnessed fall with injury and has a laceration to right side of forehead and skin tears to right elbow and top of hand. She stated to send resident to ER for evaluation of head laceration and because this is the 3rd fall resident has had since 4/11/24 and 2nd within 24 hours. * 04/14/24 12:20 a.m., . Resident returned to facility following ER visit d/t [due to] fall with head laceration. Resident returns with 6 sutures to lacerated area on right side of forehead. Observations showed the following: * 04/14/24 at 12:13 p.m., Resident #35 seated in a wheelchair in the dining room eating lunch. The resident had sutures to the right side of the forehead and a tegaderm [transparent adhesive bandage] to the right forearm. * 04/14/24 at 4:30 p.m., Resident #35 sat in a wheelchair by the dining room and stated he needed to use the bathroom to staff member (#2). The staff member (#2) opened the door to the public bathroom in the hallway for the resident, and asked Are you good? Resident #35 responded Yes. The staff member (#2) walked away. Resident #39, also cognitively impaired, pushed Resident #35 in the wheelchair into the bathroom and closed the door. The surveyor notified the nurse (#3). The nurse (#3) entered the bathroom, stopped Resident #35 from self-transferring to the toilet, placed a gait belt on Resident #35 and assisted the resident to the toilet. Resident #35 used the toilet. The nurse (#3) assisted the resident to stand and pivot back into the wheelchair with a gait belt. * 04/15/24 at 4:35 p.m., Resident #35 sat on the bed and transferred himself from the bed to the wheelchair. No staff were present in the room. * 04/16/24 at 9:35 a.m., Two certified nurse aides (CNAs) (#4 and #5) assisted Resident #35 to transfer from the wheelchair to the toilet. The resident transferred himself to the toilet before they could apply the gait belt. Once the resident was seated on the toilet the CNA (#4) applied a gait belt to the resident. Resident #35 used the toilet and the CNAs (#4 and #5) lifted under Resident #35's arms to assist him to stand, completed perineal cares and both CNAs held the resident under his arms and by the waistband of his pants, to pivot transfer to the wheelchair. During an interview on 04/16/24 at 3:20 p.m., an administrative nurse (#1) confirmed she expected staff to follow the care plan for transfers to ensure resident safety, and to use gait belts appropriately. Facility staff failed to follow the care plan to provide sufficient supervision and assistance with transferring and toileting, and use a gait belt with a resident who was identified as a fall risk, who had a recent fall with injury, and had the potential to for further falls.