**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to identify triggers and effective interventions related to a diagnosis of Post-Traumatic Stress Disorder (PTSD) for Resident #36. This affected one resident (#36) of 21 residents reviewed for care plans. The facility census was 71. Findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with a diagnosis of PTSD. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was severely impaired cognitively, exhibited inattention and disorganized thinking behaviors, and had rejected care. Review of the care plan, date revised 02/28/24, revealed PTSD was identified as a diagnosis for Resident #36 but there was no part of the care plan developed to identify triggers and interventions for the PTSD. Review of progress notes dated 10/18/24 to 05/20/25 in the medical record revealed Resident #36 had a history of being combative with staff. Interview with Social Services Designee (SSD) #581 on 05/21/25 at 9:39 A.M. confirmed a comprehensive care plan to identify and address PTSD triggers and interventions was absent from Resident #36's medical record. Review of the facility policy Care Conferences, revised 03/20/24, revealed the facility's interdisciplinary team shall periodically review the resident's care plan and make necessary revisions based on the goals, preferences and needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, and review of facility policy, the facility failed to ensure timely incontinence care was provided to Resident #15, #36 and #48. This affected three residents (#15, #36, and #48) out of three residents reviewed for incontinence care. The facility census was 71. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 10/16/23. Diagnoses included dementia, generalized muscle weakness, abnormalities of gait and mobility, aphasia, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was severely impaired cognitively; exhibited inattention and disorganized thinking, which fluctuated; had rejected care ; needed substantial/max assistance from staff to go from sitting to standing and for transfers to toilet; was dependent on staff to transfer from bed/chair to chair; was frequently incontinent of bladder and occasionally incontinent of bowel and was not on any toileting program. Review of Resident #36's care plan created on 10/26/23 revealed the resident had alteration in elimination related to frequently incontinent of bladder and bowel. Fluctuations in elimination could vary due to impaired cognition. Interventions included to monitor for skin redness/irritation and provide incontinence care as needed A continuous observation was conducted on 05/20/25 from 6:20 A.M. to 10:24 A.M. of Resident #36 sitting in her wheelchair either in the common area across the nurse's station or in the unit dining room for breakfast. Resident #36 was asleep in her wheelchair the majority of the time during the observation. No staff attempted to toilet or check and change the resident, and at 10:24 A.M. there was a large puddle of urine observed under Resident #36's wheelchair with staff observed placing bath blankets on the floor to soak up the urine then Certified Nursing Assistant (CNA) #543 took Resident #36 back to her room. An interview on 05/20/25 at approximately 10:30 A.M. with Certified Nursing Assistant (CNA) #528 confirmed Resident #36 was incontinent and should be offered to be toileted every two hours. She indicated the resident would often say no to being toileted, however, the staff were to make a toileting attempt unless the resident continued to refuse. During the interview, CNA #528 confirmed the resident wore briefs and there were times when she could not complete check and changes every two hours. CNA #528 did not give a reason why check and changes couldn't always be completed every two hours. An interview on 05/20/25 at 11:04 A.M. with CNA #543 revealed he had noticed the puddle of urine under Resident #36's wheelchair so he took her back to her room to be changed. CNA #543 stated he had relieved CNA #753 who told him all residents on CNA #753's assignment had been checked and changed as needed between 7:00 A.M. to 9:00 A.M. CNA #543 verified Resident #36's brief was saturated with urine and the urine had leaked onto the floor in the common area and that's why there was a puddle of urine beneath Resident #36. CNA #543 stated when he wheeled her back to her room, Resident #36 had urinated again and the urine again leaked onto the floor beneath her. An interview on 05/20/25 at 11:18 A.M. with CNA #753 revealed Resident #36 was a heavy wetter and she thought the resident was last toileted or changed around 7:30 A.M. but was not certain of the time. CNA #753 verified Resident #36 was assigned to her care. Interview on 05/20/25 at 3:57 P.M. with Administrator revealed the facility did not have a policy on how often care was to be given to a resident. She stated the staff knew residents should be checked every two hours or as needed for care needs. Review of the policy titled Skin: Incontinence Care Protocol last revised September 2017 revealed the facility would provide incontinence care for residents in order to maintain skin integrity, prevent skin breakdown, control odor, provide comfort, and to maintain resident self-esteem. 2. Review of medical record for Resident #15 revealed an admission date of 11/22/24. Diagnoses included Alzheimer's disease, dementia, and major depressive disorder. Review of Resident #15's quarterly MDS assessment, dated 02/28/25, revealed the resident was severely impaired cognitively; exhibited fluctuating inattention and disorganized thinking behaviors; had delusions; rejected care one to three days during the assessment reference period; was dependent on staff for toilet hygiene; was dependent on staff for transfers; and was always incontinent of bowel and bladder. Review of the care plan created on 12/04/24 revealed Resident #15 had an alteration in elimination. Interventions included monitor for skin redness/irritation, provide incontinence care as needed, and monitor for a pattern if resident able to participate. Interview on 05/19/25 at 10:55 A.M. with the son and daughter of Resident #15 revealed a concern regarding their mother not receiving timely incontinence care since the resident's room would have a urine odor at times. Interview on 05/19/25 at 12:39 P.M. with the husband of Resident #15 revealed he didn't feel the resident was being changed in a timely manner. When he visited, he would put his finger in the resident's brief to check if she had a bowel movement. He stated sometimes the brief did have a bowel movement in it, and he had concerns the resident may have been sitting in the bowel movement for an extended period of time. A continuous observation was conducted on 05/20/25 from 6:20 A.M. to 10:27 A.M. of Resident #15 who was awake and sitting in her broda chair either in the common area or the unit dining room. At no time during the observation period did a staff member remove the resident from the common area or the dining room to check the resident to see if she needed any incontinence care. Observation and interview on 05/20/25 at 10:27 A.M. with Certified Nursing Assistant (CNA) #603 revealed CNA #603 began to wheel Resident #15 to her room for incontinence care and left the resident in the room and stated she would be back with the other CNA. CNA #603 verified she had not previously provided incontinence care to Resident #15 that morning. Observation of incontinence care on 05/20/25 from 10:36 A.M. to 10:53 A.M. revealed Resident #15 was cleaned by CNA #528 for a moderate amount of urine and medium sized brown stool. The brief was wet but not oversaturated at the time of observation. Observation of the bilateral groin area that would be covered by an incontinence brief revealed Resident #15's skin in the surrounding areas was dark pink to light red with no excoriation or open areas noted. A clean brief was applied and Resident #15 was transferred back into her chair at 10:53 A.M. CNA #528 offered no information about when the resident had last been checked and changed for incontinence care. CNA #528 verified Resident #15 had been incontinent of stool and urine and skin in the groin area covered by the dirty brief was brighter pink than the rest of her skin. CNA #528 confirmed residents who were incontinent should be checked and changed every two hours, but there were times when she couldn't complete incontinence care within two hours. Interview on 05/20/25 at 3:57 P.M. with Administrator revealed the facility did not have a policy on how often care was to be given to a resident. She stated the staff knew residents should be checked every two hours or as needed for care needs. Review of the policy titled Skin: Incontinence Care Protocol last revised September 2017 revealed the facility would provide incontinence care for residents in order to maintain skin integrity, prevent skin breakdown, control odor, provide comfort, and to maintain resident self-esteem. 3. Review of the medical record for Resident #48 revealed an admission date of 04/30/21 with diagnoses including calculus of kidney, acute respiratory failure with hypoxia, abnormalities of gait and mobility, oropharyngeal dysphagia, low back pain, cholelithiasis, acute kidney failure, calculus of kidney, anxiety disorder, recurrent major depressive disorder, and muscle weakness. Review of the annual minimum data set (MDS) 3.0 assessment completed on 03/04/25 revealed Resident #48 had moderate cognitive impairment, required moderate assistance rolling left and right in bed, and was dependent for toileting hygiene and transfers. Further review of the MDS revealed Resident #48 was frequently incontinent of bladder and bowel. Review of the care plan dated 05/03/21 through 06/19/25 revealed Resident #48 had an alteration in elimination, was high risk for altered skin integrity, and had a self-care deficit in the performance of activities of daily living (ADLs) related to bowel and bladder incontinence, malnutrition, kidney failure, fragile skin, and impaired mobility. Interventions included keeping Resident #48 clean and dry, providing incontinence care as needed, keeping linen as dry and wrinkle-free as possible, and implementation of the check and change protocol. On 05/18/25 at 2:17 P.M., Resident #48 was heard yelling out for assistance. Interview with Resident #48 at that time revealed she was dripping urine which caused burning and itching on the side of the right leg/hip. Resident #48 further reported that staff were previously alerted of the need for a brief and bedding change, that the assigned aide said she would return with clean sheets but never came back, and Resident #48 could not reach the call light to request assistance again. Interview with Certified Nurse Aide (CNA) #547 on 05/18/25 at 2:20 P.M. confirmed CNA #595 was assigned to Resident #48 but was currently on a break. CNA #547 offered to assist Resident #48 with requested incontinence care. Observation on 05/18/25 between 2:20 P.M. and 2:34 P.M. of incontinence care performed by CNA #547 revealed Resident #48 had a wet brief and wet bedding. Interview on 05/18/25 at 2:34 P.M. with Certified Nurse Aide (CNA) #547 confirmed Resident #48 was laying on wet linen and the call light was not within reach. Interview on 05/20/25 at 11:00 A.M. with CNA #528 confirmed that incontinent residents should be checked and changed every two hours. Interview on 05/20/25 at 3:57 P.M. with the Administrator revealed the facility did not have a policy on how often care was to be given to a resident who was dependent for ADL assistance, including toileting hygiene. During the interview, the Administrator confirmed the staff knew residents should be checked every two hours or as needed for care needs. Interviews on 05/21/25 at 9:18 A.M. with CNA# 606, at 9:33 A.M. with CNA #600, at 9:35 A.M. with CNA #603, and at 9:42 A.M. with CNA #601 confirmed residents who were incontinent and dependent on staff for care were to be checked and changed every two hours and as needed. Interview on 05/21/25 with CNA #595 at 9:52 A.M. confirmed Resident #48 was one of the residents on her assignment on 05/18/25 and that when CNA #595 came on duty at 10:00 A.M. on 05/18/25 Resident #48 was noted to have a saturated brief that soaked through to her bedding and Resident #48 had a complete bedding change somewhere between 10:00 A.M. and 11:00 A.M. CNA #595 confirmed a check and change was not completed by them again, but CNA #547 did check and change Resident #48 later that afternoon. Review of the policy titled Skin: Incontinence Care Protocol last revised September 2017 revealed the facility would provide incontinence care for residents in order to maintain skin integrity, prevent skin breakdown, control odor, provide comfort, and to maintain resident self-esteem.

Based on record review, interview, and review of facility policy, the facility failed to ensure weekly weights were obtained as a documented intervention to monitor nutrition status for Resident #50 who had a significant weight loss. This affected one resident (#50) out of three residents reviewed for nutrition. The facility census was 71. Findings include: Review of the medical record for Resident #50 revealed an admission date of 12/12/24. Diagnoses included Alzheimer's disease, dysphagia (difficulty swallowing), insomnia, diabetes mellitus, and anxiety disorder. Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/03/25, revealed the resident was severely impaired cognitively, exhibited fluctuating inattention, disorganized thinking, and altered level of consciousness behaviors, was delusional, had behaviors not directed toward others four to six days and rejected care one to three days during the assessment reference period, was supervision or touch assistance for eating, had a significant weight loss which was not prescribed, and was on a therapeutic and mechanically altered diet. Review of the dietary assessment narrative, authored by Dietetic Technician Registered (DTR)#751 and dated 05/02/25, revealed Resident #50's current weight of 169.7 pounds had triggered a significant weight loss of 10.4 percent weight loss over 180 days. Review of the facility document Doctor Notification of Weight Change, authored by DTR #751 and dated 05/05/25, revealed the physician had been notified of Resident #50's significant loss of 19.7 pounds (10.4 percent) over the past six months and the facility was going to monitor weights weekly for four weeks, which the physician agreed with on 05/05/25. Further review of Resident #50's weights in the medical record revealed the resident's last weight was 169.7 pounds on 05/01/25 with no additional weights recorded after 05/01/25. Interview on 05/20/25 between 1:32 P.M. and 3:08 P.M. with DTR #751 revealed she had initiated weekly weights for Resident #50 as an intervention for the resident's significant weight loss and confirmed the weekly weights had not been obtained for Resident #50. Review of the facility policy Weight Monitoring, dated 02/15/24, revealed interventions would be implemented, monitored, and modified (as appropriate) consistent with the resident's assessed needs, and weights would be monitored more frequently as clinically indicated.

Based on observation, interview and record review, the facility did not ensure Resident #33 received dialysis services consistent with professional standards of practice and the person-centered care plan. This affected one resident (#33) of one resident reviewed for dialysis. The facility identified one resident (#33) as receiving dialysis services. The facility census was 71. Findings include: Review of the medical record for Resident #33 revealed a readmission date of 11/14/22 with diagnoses including stage four chronic kidney disease and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 05/01/25 revealed Resident #33 had intact cognition and medically complex conditions including renal insufficiency or renal failure. Further review of the MDS revealed Resident #33 received dialysis. Review of the physician orders revealed an order dated 08/07/24 indicating Resident #33 was to have no intravenous (IV) catheters, lab draws, or blood pressure (BP) checks in the right arm. There was no order to routinely assess Resident #33's right arm dialysis fistula graft for patency and adequate blood flow by checking for a thrill (a vibration) or a bruit (a swishing sound). Review of the care plan, date initiated 06/22/20, revealed Resident #33 received dialysis at an off-site facility every Monday, Wednesday, and Friday. Interventions included: if fistula, check thrill and bruit every shift, if no thrill and bruit notify dialysis center, and no labs draws, intravenous (IV) or blood pressure (BP) in the left arm. Review of the May 2025 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) revealed no evidence nursing staff were assessing the dialysis fistula for a thrill or bruit for Resident #33. The TAR indicated lab draws, IV and BP were not to be performed on Resident #33's right arm. Review of the facility documents titled Dialysis Communication Form for the date range of 05/02/25 to 05/19/25 revealed no evidence the facility was assessing Resident #33's fistula for patency, bruit and thrill. An observation and interview was conducted on 05/18/25 at 4:45 P.M. with Resident #33 who presented as alert, oriented and able to answer questions. Resident #33 had a dialysis fistula in her upper right arm. Resident #33 stated she had the fistula in her right arm for a long time and just had another revision with a graft on 05/15/25. When asked if the nursing staff assessed her before dialysis, Resident #33 stated they weigh her and check her blood pressure. Resident #33 did not indicate her dialysis fistula was checked for patency prior to going to dialysis. An interview on 05/21/25 at 10:02 A.M. with Registered Nurse (RN) #503 was conducted to review the facility dialysis communication forms for Resident #33. RN #503 stated Resident #33's weight was obtained and recorded in the electronic medical record and on the top portion of the dialysis communication form prior to Resident #33 going to dialysis. RN #503 stated the dialysis center did a pre and post dialysis assessment and sent any pertinent information back to the facility on that same communication form which was kept in a dialysis binder at the facility. RN #503 confirmed assessment of the fistula was not included in Resident #33's assessment records so there was no evidence it had been assessed every shift as care planned. Interview on 05/21/25 at 5:15 P.M. with the Director of Nursing (DON) confirmed the care plan for Resident #33 did not specify the correct information regarding from which arm to check blood pressures, perform lab draws, or place IVs and that the care plan specified staff were to monitor the fistula for a bruit and a thrill every shift. The DON confirmed there was no documentation in the medical record that the fistula was being assessed each shift in accordance with the care plan. Review of the policy titled Dialysis Management dated 10/11/18 revealed the facility would provide appropriate interventions for residents receiving hemodialysis based on physician orders and the plan of care, including which arm to use for blood pressure monitoring and appropriate assessment of the access site.

Based on observation, record review, interview and review of facility policy, the facility failed to ensure medications for Resident #233 remained under the direct observation of the nurse administering the medication until ingested by Resident #233. This affected one resident (Resident #233) of eight residents observed for medication administration. The facility census was 71. Findings include: Review of the medical record for Resident #233 revealed an admission date of 05/02/25 with diagnoses including esophageal obstruction, gastrostomy status, acute pyelonephritis, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, duodenal ulcer, sepsis due to enterococcus, fibromyalgia, colostomy status, essential hypertension, and dysphagia. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 05/09/25 revealed Resident #233 had intact cognition, medically complex conditions, and a feeding tube. Review of the active physician orders for Resident #233 revealed medication orders dated 05/16/25 for aspirin chewable tablet 81 milligrams (mg) by mouth once daily and losartan potassium oral tablet,25 mg daily. An order was dated 05/19/25 for Prevacid delayed release capsule 30 mg by mouth twice daily, and an order dated 05/20/25 for gabapentin 800 mg by mouth daily. Review of the Medication Administration Record (MAR) for May 2025 revealed documentation that on 05/20/25 the 81 mg aspirin, 800mg of gabapentin, 25 mg of losartan, and 30 mg of Prevacid had been administered by Registered Nurse (RN) #602. An observation was conducted on 05/20/25 from 9:28 A.M. to 9:35 A.M. in Resident #233's room with Resident #233 and their spouse present in the room. Resident #233's spouse picked up a medicine cup containing one capsule and three tables and said the medication had been left by the nurse (RN #602) about 15 minutes earlier because the resident and spouse were on their way out for a walk. Observation at this time revealed Resident #233's spouse proceeded to pick up each pill and administer the pills one at a time to Resident #233. An interview on 05/20/25 at 9:51 A.M. with RN #602 confirmed the medications were left in Resident #233's room, including aspirin, gabapentin, losartan, and Prevacid because Resident #233's spouse directed her to leave the medications and assured her Resident #233 would take them upon returning to the room. During the interview, RN #602 confirmed it was not the standard procedure to leave medication in a resident's room, and she should have taken the medications back to the medication cart and returned with them later so she could watch Resident #233 consume the medicines. An interview with the Director of Nursing (DON) on 05/20/25 at 10:13 A.M. revealed the DON verified prepared medications should not be left in resident's rooms. Review of the policy titled General Guidelines for Medication Administration effective 06/21/17 revealed nursing staff were to administer the ordered medication and remain with the resident while the medication was being swallowed. The policy further revealed medications were never to be left in a resident's room without orders to do so.

Based on observations, interview and policy review, the facility failed to ensure the kitchen and unit pantries were maintained in a clean and sanitary manner and ensure staff serving food wore hair restraints. This had the potential to affect 68 out of 69 residents that received meals from the facility. Resident #46 was identified as receiving nothing by mouth. The facility census was 69. Findings include: Tour of the kitchen on 08/07/23 at 8:25 A.M. with Dietary Manager (DM) #100 revealed liquid spilled on the bottom of the reach-in refrigerator located near the cooking area; the bakers rack had dried food on the shelves, and the walls near the cooking area and dish area had food splatter on them. Observation in the pantry located on 100 unit on 08/07/23 at 8:34 A.M. with DM #100 revealed a dietary aide serving breakfast without wearing a hair restraint and dried food splatter in the inside of the microwave. DM #100 verified the observations and stated that the microwave should have been cleaned. Observation in the pantry located on 300 unit on 08/07/23 at 8:40 A.M. with DM #100 revealed dried food splatter in the inside the microwave. DM #100 verified findings and stated the microwave should have been cleaned. Observation in the pantry located on the second floor on 08/07/23 at 8:50 A.M. with DM #100 revealed dried food splatter in the inside the microwave. DM #100 verified findings and stated the microwave should have been cleaned. Review of the facility policy dated March 2016 titled, Infection Control- Dietary/Food Handling, revealed the kitchen should be cleaned, and employees should wear hairnets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure medications were transcribed to the resident's medical record from hospital paperwork for Resident #323 and failed to ensure medications were administered according to the physician's order for Resident #72. This affected two residents (Resident #72 and Resident #323) of seven (Resident's (#18, #42, #49, #62, #72, 173 and #323) reviewed for unnecessary medication. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #323 was admitted to the facility on [DATE]. Her admitting diagnoses included urinary tract infection, chronic obstructive pulmonary disease, enterocolitis due to clostridium difficile, atrial fibrillation, and secondary polycythemia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Functionally, she required extensive assistance of one staff for most activities of daily living including toilet use and personal hygiene. Review of the resident's admission orders to the facility from the hospital showed this resident was to receive: • Eliquis (a medication to reduce the risk of stroke and blood clots in people who have atrial fibrillation) 2.5 milligrams (mg) by mouth twice daily • Hydroxyurea (treats cancer by stopping the growth of cancer cells) 500 mg one capsule by mouth to be given two times a day. Review of the facility's physician orders in the facility, showed Eliquis 2.5 mg to be given two times a day but the Hydroxyurea order was not listed. Review of the residents Medication Administration Record (MAR) for the month of May 2021 revealed the resident did receive the Eliquis as ordered but did not receive her hydroxyurea. Further review of this MAR revealed this medication was not listed on the MAR. Interview on 06/16/21 at 1:50 P.M. with the Director of Nursing and Regional Clinical Services Manager #174 verified the MAR and stated that there was no policy stating that what a nurse should do for an admission, it is standards of nursing practice. Phone interview with this resident's physician, Physician #180 on 06/16/21 at 3:56 P.M. revealed the resident was on Eliquis. He then stated, probably discontinued the hydroxyurea because her labs were good. Review of the physician's orders from admission to present revealed no order verbal or written to stop the hydroxyurea. 2. Review of Resident #72's medical record revealed an admission date of 05/29/21 and diagnoses including metabolic encephalopathy, diabetes, sepsis, rhabdomyolysis, chronic kidney stage four, obesity, insomnia, hypertension and depression. Review of an admission/5-day MDS 3.0 assessment dated [DATE] revealed Resident #72 had moderate cognitive impairment, was totally dependent for transfers, required extensive assistance of two staff for bed mobility and required extensive assistance of one staff for hygiene. Resident #72 was on a scheduled pain regimen, and the pain assessment in the MDS indicated Resident #72 had frequent pain and described his worst pain as severe. Review of Resident #72's physician's orders revealed an order dated 05/30/21 for hydroxychloroquine sulfate tablet 200 milligram (mg), give one tablet by mouth two times a day for pain and an order dated 06/01/21 for tramadol hydrochloride tablet 50 mg, give one tablet by mouth every six hours as needed (PRN) for pain greater than a six out of ten. Review of Resident #72's May 2021 and June 2021 MARs revealed hydroxychloroquine sulfate was not documented as administered during the rise time (7:00 A.M. to 10:00 A.M) on 06/04/21, 06/07/21, 06/08/21, 06/09/21 and 06/14/21. Review of the nurses' notes revealed no concerns regarding Resident #72's pain and did not show any medication refusals. Interview on 06/16/21 at 1:35 P.M. with Regional Clinical Services Manager (RCSM) #174 verified the lack of hydroxychloroquine for Resident #72 on 06/04/21, 06/07/21, 06/08/21, 06/09/21 and 06/14/21 and could not explain why these doses were not administered and/or documented. Review of the facility policy titled Documentation: Charting, revised 09/16/19, revealed team members shall document assessments, observations and services provided in the resident's medical record in accordance with state law and facility policy. Documentation may be completed at the time of service or during the shift in which the assessment, observation or care service occurred. This deficiency substantiates Complaint Number OH00122894.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure infection control was maintained during the wound care observation of Resident #28. This affected one (Resident #28) of ten (Resident's #11, #13, #28, #32, #62, #66, #68, #71, #72 and #325) residents reviewed for pressure wounds who received wound care. The facility census was 76. Findings include: Record review revealed Resident #28 was admitted on [DATE] with diagnoses including heart disease, adult failure to thrive and osteoporosis. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had moderately impaired cognition. A skin grid dated 06/15/21 revealed Resident #28 developed an in-facility acquired coccyx wound that progressed to an unstageable pressure ulcer (full-thickness tissue loss that is covered by necrotic tissue). A dietary note dated 06/16/21 revealed a decline in the pressure ulcer was noted, and Resident #28 went on hospice services. Observation on 06/15/21 at 3:50 P.M. of the dressing change on Resident #28 by Registered Nurse (RN) #148 revealed supplies were gathered (except for the foam outer dressing) and placed on a barrier on the bedside table. The table was not disinfected prior to or after the dressing change. RN #148 washed her hands, applied gloves and cleansed the wound. RN #148 the was given a foam outer dressing from Resident #28's top dresser drawer by State Tested Nursing Assistant (STNA) #171 and opened it. RN #148 then dug in her scrub shirt pocket and pulled out a black marker and initialed and dated the foam dressing then laid it on the bedside table. RN #148 then picked up the medication cup of Santyl medicated ointment (removes dead tissue from wounds), swirled her index finger in the cup, gathering all the medication on her gloved finger and applied it to a piece of calcium alginate (highly absorbent dressing). RN #148 was in motion to place it on the cleansed wound bed when this surveyor stopped her. Interview with RN #148 on 06/15/21 at 3:55 P.M. verified she broke infection control by reaching for a permanent marker from her scrub shirt pocket, opening the foam dressing package that was handed to her by STNA #171 who retrieved it from Resident #28 dresser drawer, wrote on the foam dressing then did not wash her hands or change gloves before continuing with the dressing change.