Based on observation, record review, and interview, the facility failed to ensure nail care was provided for a dependent resident for 1 (#18) of 16 sampled residents reviewed for ADLs. The administrator identified 37 residents resided in the facility. Findings: Resident #18's significant change assessment, dated 02/10/25, showed diagnoses of congestive heart failure, BIMS was 15 (cognition intact), and they required substantial assistance for personal hygiene. On 04/07/25 at 12:54 p.m., Resident #18 was observed to have jagged fingernails and a brown substance under their fingernails. An undated document titled Nursing Care Standard for Orderlies and Aides, showed fingernails were to be clean and trimmed. On 04/07/25 at 12:57 p.m., Resident #18 was asked if staff provided nail care. They stated staff had not provided nail care in the past week. On 04/07/25 at 1:05 p.m., CNA #1 was asked when nail care was provided. They stated on shower days or when they were long and dirty. CNA #1 stated Resident #18's fingernails looked bad and needed done.

Based on record review and interview, the facility failed to ensure the physician was notified of insulin being held for 1 (#19) of 5 sampled residents reviewed for notification. LPN #3 identified eight residents received insulin. Findings: A quarterly resident assessment, dated 11/22/24, showed Resident #19 had diagnosis which included diabetes mellitus and BIMS score of 14 (cognition intact). Resident #19's physicians order, dated 01/17/25, showed Lantus insulin (medication to control blood sugar) 50 U, subcutaneous daily. Hold for FSBS below 120. A MAR, dated March 2025, showed the Lantus insulin had not been administered on 03/03/25, 03/09/25, 03/11/25, 03/14/25, 03/21/25, 03/28/25 and on 03/29/25 due to the resident not eating breakfast. There was no documentation Resident #19's physician had been notified. On 04/08/25 at 12:21 p.m., LPN #1 stated they would hold insulin if a resident was not eating their meal or if their blood sugar was below 120. They stated they would notify the physician and document it in the progress notes. LPN #1 stated there was no documentation the physician had been notified when the insulin had been held.

Based on record review and interview, the facility failed to ensure: a. BP monitoring for a PRN antihypertensive medication for 1 (#3); and b. medications were available for 1 (#11) of 5 sampled residents reviewed for medications. The administrator identified 37 residents resided in the facility. LPN #3 identified three residents had orders for clonidine. Findings: 1. Resident #3's quarterly resident assessment, dated 11/18/24, showed a diagnosis of hypertension and a BIMS score of five (severe cognitive impairment). A physician's order, dated 12/23/24, showed to administer clonidine (antihypertensive agent) tablet 0.1 mg three times a day as needed for SBP (the maximum blood pressure during contraction of the heart) greater than 160. A January 2025 MAR, showed Resident #3's BP had not been monitored three times daily on 01/01/25 - 01/31/25. A February 2025 MAR, showed Resident #3's BP had not been monitored three times daily on 02/01/25 - 02/28/25. A March 2025 MAR, showed Resident #3's BP had not been monitored three times daily on 03/01/25 - 03/31/25. An April 2025 MAR, showed Resident #3's BP had not been monitored three times daily on 04/01/25 - 04/08/25. 2. Resident #11's physician's orders, dated 02/06/25, showed Rexulti 1 mg (antipsychotic) once daily, levothyroxine 75 mcg (thyroid agent) daily, and midodrine 5 mg (antihypotensive) three times daily. A February 2025 MAR, showed Rexulti was unavailable for administration on 02/07/25, 02/08/25, and 02/09/25. A physician's order, dated 02/11/25, showed metoprolol tartrate tablet 50 mg (beta-blocker) twice daily. An admission resident assessment, dated 02/12/25, showed Resident #11 had diagnoses which included psychosis, disorder of thyroid, and atrial fibrillation, and BIMS of 5 (severe cognitive impairment). A physician's order, dated 03/11/25, showed midodrine 5 mg (antihypotensive) three times daily before meals. A March 2025 MAR, showed: a. levothyroxine was unavailable for administration on 03/17/25 and 03/18/25, b. metoprolol was unavailable for administration on 03/15/25, 03/16/25, 03/17/25, and 03/18/25, and c. midodrine was unavailable for administration on 03/05/25, 03/12/25, 03/15/25, and 03/16/25. On 04/08/25 at 11:26 a.m., CMA #2 was asked what the policy was for medication administration. They stated they looked at the MAR, popped the medication out, administered it to the resident, and then sign them out. CMA #2 was asked what the process was for re-ordering medications. They stated they went through the medication carts twice a week and re-ordered any medication with less than 12 pills left. CMA #2 stated if they re-ordered a medication by 10:00 a.m., it would be delivered to the facility the same day around 4:00 p.m. They stated if a medication was not available, they would mark it as not available and order it. CMA#2 stated Resident #11's Rexulti had to be re-sent to the pharmacy because the pharmacy did not receive it. They stated they were probably out of the levothyroxine, metoprolol, and midodrine. CMA #2 was asked how staff knew when to administer Resident #3's clonidine. They stated per their BP and the parameters. CMA #2 was asked when they monitored Resident #3's BP. They stated it should be every shift. On 04/08/25 at 11:46 a.m., the DON was asked how staff knew when to administer PRN clonidine to Resident #3. They stated by checking the BP every shift. The DON was asked to locate every shift BPs. They stated it should be documented every shift in the EMR. The DON was unable to locate Q shift BPs.

**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 for one (#4) of four sampled residents reviewed for care plans. Faciilty census was 43. Findings: Resident #4 was admitted to the facility on [DATE] and had diagnoses which included, pain, and high blood pressure. The clinical health record did not contain documentation a comprehensive care plan had been completed. On 06/25/24 at 9:03 a.m., LPN #1 was asked if Resident #4 had a comprehensive care plan. They stated it had not been completed they only had the care plan reference sheet.

Based on observation, record review, and interview, the facility failed to ensure dependent residents were assisted to be changed for one (#2) of two sampled residents reviewed for ADLs. The administrator identified 36 residents resided in the facility. Findings: Resident #2 has diagnosis which included dementia. A care plan, dated 08/31/23, documented Resident #2 required staff assistance with ADLs due to confusion and left below the knee amputation. It documented to assist Resident #2 with toileting every two hours. It documented the resident had occasional incontinence of bladder. On 12/05/23 at 8:39 a.m., Resident #2 was observed sitting up in their wheelchair in the sitting area. The resident's pants were observed to be wet from their lower abdomen, down their left inner thigh, to the knee area. From 12/05/23 at 8:39 a.m. to 10:52 a.m., Resident #2 was observed to sit in their wheelchair in the sitting area. The resident's clothes were observed to dry over time. Several staff were observed to walk by the resident during this time. Staff were not observed to check or change the resident. On 12/05/23 at 10:52 a.m., CMA #1 and CNA #2 were asked how often they checked the residents. They stated every two hours. They were asked when was the last time Resident #2 was checked. CMA #1 stated, We normally don't check on [Resident #2]. [Resident #2] lets us know. On 12/05/23 at 1:51 p.m., the DON was asked how staff ensured residents were changed when they were wet. She stated staff were suppose to check residents according to their care plan.

Based on record review and interview, the facility failed to implement a dementia focused care area on a comprehensive care plan for one (#140) of 12 sampled residents reviewed for care plans. The administrator identified 36 residents resided in the facility. Findings: Resident #140 had diagnosis which included dementia. A [MDS] and Care Plan policy, undated, read in part .a trigger sheet will be completed for each resident, identifying problems and potential problems .a care plan will be completed for each resident. A new admission's care plan will be completed within 21 days of admission . Resident #140's Care Plan, undated, did not document a focus problem for dementia care. On 12/05/23 at 12:34 p.m., LPN #4 was asked how do they ensured a focused care area was included on a care plan. They stated they followed the care areas triggered by the MDS. They were asked if there was a focus care area for dementia on Resident #140's current care plan. They stated, No.

Based on record review and interview, the facility failed to ensure laboratory orders were obtained per physician's orders for one (#38) of three sampled residents reviewed for laboratory orders. The administrator identified 36 residents resided in the facility. Findings: A Lab policy, undated, read in part, .This facility will provide, or obtain clinical laboratory services .This facility will be responsible for the .timliness [sic] of services . Resident #38 had diagnosis which included presence of aortocoronary bypass graft and cerebral infarction. A physician order, dated 11/01/23, documented to obtain a CBC and CMP in two weeks. On 12/05/23 at 9:00 a.m., LPN #2 was asked how staff ensured lab orders were obtained. They stated the facility had a lab tech who worked one day a week, and if the lab order needed to be obtained on a different day, the nurses would collect it, and take it to the lab. On 12/05/23 at 1:53 p.m., the DON was asked to provide Resident #38's lab results from the order on 11/01/23. She stated, They were not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure comprehensive MDS assessments were completed timely for three (#27, 38, and #140) of 12 sampled residents reviewed for assessments. The administrator identified 36 residents resided in the facility. Findings: A [MDS] and Care Plan policy, undated, read in part, .(MDS) will be completed upon each new admission within 14 days of admission. A MDS will also be completed upon .Annual Assessment . An admission Summary report, documented Resident #38 was admitted [DATE] and Resident #140 was admitted [DATE]. The facility's EHR documented Resident #27's quarterly assessment was completed 08/07/23. The resident's comprehensive assessment was due in November. The facility's EHR documented comprehensive assessments were not completed for Resident #27, 38, or #140. No copies were provided for Resident #27, 38, or #140. On 12/05/23 at 12:21 p.m., MDS coordinator #1 was asked how they ensured MDS assessments were completed timely. They stated they have a list of what assessments were due and they would highlight them when they were completed. They stated the EHR was not prepared when the new update for the MDS assessments came out and it still wasn't working. They stated they were behind and couldn't complete them. On 12/06/23 at 11:13 a.m., MDS Coordinator #1 was asked to provided any paper copies of the late MDS assessments that were not in the EHR.

Based on record review and interview, the facility failed to ensure quarterly MDS assessments were completed timely for four (#15, 32, 19, and #2) of 12 sampled residents reviewed for assessments. The administrator identified 36 residents resided in the facility. Findings: A [MDS] and Care Plan policy, undated, read in part, .Quarterly reviews and updates will be completed as mandated . The facility's EHR documented Resident #15's last completed assessment was 07/28/23. It documented a quarterly assessment, dated 10/27/23, had not been completed. The facility's EHR documented Resident #32's last completed assessment was 07/09/23. It documented a quarterly assessment, dated 10/09/23, had not been completed. The facility's EHR documented Resident #19's last completed assessment was 07/26/23. It documented a quarterly assessment, dated 10/23/23, had not been completed. The facility's EHR documented Resident #2's last completed assessment was 08/31/23. It did not document another assessment had been completed. No copies were provided for Resident #15, 32, 19, or #2. On 12/05/23 at 12:21 p.m., MDS coordinator #1 was asked how they ensured MDS assessments were completed timely. They stated they have a list of what assessments were due and they would highlight them when they were completed. They stated the EHR was not prepared when the new update for MDS assessments came out and it still wasn't working. They stated they were behind and couldn't complete them. On 12/06/23 at 11:13 a.m., MDS Coordinator #1 was asked to provided any paper copies of the late MDS assessments that were not in the EHR.

Based on record review and interview, the facility failed to ensure MDS assessments were transmitted timely for seven (#15, 32, 19, 2, 27, 38, and #140) of 12 sampled residents reviewed for assessments. The administrator identified 36 residents resided in the facility. Findings: The facility's EHR documented comprehensive assessments were not completed for Resident #27, 38, or #140. The facility's EHR documented quarterly assessments were not completed for Resident #15, 32, 19, or #2. On 12/05/23 at 12:21 p.m., MDS coordinator #1 stated the EHR was not prepared when the new update for MDS assessments came out and it still wasn't working. They stated they haven't been able to complete MDS assessments after 10/01/23. They stated if they managed to get the assessments completed and locked, the assessments were being rejected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to honor a resident's choice by performing CPR when the resident had a DNR and ensured staff were aware of code status, immediately, when a resident had no breathing or pulse for one (#42) of 16 sampled residents reviewed for advance directives. The DON identified 28 residents had DNRs. Findings: An undated facility policy, titled Residents Right to Self Determination, read in part, .Advance Directions will be documented on the Minimum Data Set, the front of resident chart, and other chart areas as appropriate .There will be an updated list of those with Advance Directives, DNR, etc. available. This list will be placed on the Front Wing and the [NAME] Wing. All employees will be aware of placement of these cards through orientation. The Charge Nurse will carry a listing of names in his/her pocket, if they wish . Resident #42 had was admitted to the facility on [DATE] with diagnoses which included diverticulitis, hypertension, and chronic kidney disease stage 3. Resident #42 had a signed DNR dated [DATE]. A physician's order, dated [DATE], read in part, .DO NOT RESUSCITATE . Resident #42's daily skilled note, dated [DATE], documented the resident tested positive for COVID-19. Resident #42's daily note, dated [DATE] at 3:25 a.m., read in part, .[2:04 a.m.] THIS NURSE ENTERED ROOM TO CHECK RESIDENT. RESIDENT FOUND WITH NO SPONTANEOUS MOVEMENT. DID NOT RESPOND TO VERBAL OR TACTILE STIMULI. NO BREATH SOUNDS OVER ALL LUNGS FIELDS. NO PULSE PALPABLE. NO HEART SOUNDS HEARD OVER ENTIRE PRECORDIUM. CPR STARTED .[2:11 a.m.,] 911 NOTIFIED. STAFF COLLECTED CHART. DNR PAPERS FOUND AT THIS TIME. CPR STOPPED .[2:26 a.m.] 911 CALLED AND NOTIFIED OF DNR. AMBULANCE CANCELED . On [DATE] at 8:37 a.m., LPN #1 was called and asked about the incident from [DATE]. LPN #1 stated they had found the resident not breathing. LPN #1 stated they looked in the chart and computer quickly to see code status. LPN #1 stated they didn't match up. LPN #1 stated one documented the resident was a full code, and the other documented the resident was a DNR. LPN #1 stated they started CPR and called 911. LPN #1 stated they did CPR until another nurse, LPN #2, brought the order for a DNR. LPN #1 stated they stopped CPR. LPN #1 stated they performed CPR for how ever long it was documented in their notes. (Progress note documented seven minutes.) LPN #1 stated they called the ambulance and notified them the resident was a DNR. LPN #1 was asked how it was determined to stop CPR. LPN #1 stated since the resident was a DNR, CPR wasn't supposed to be started. LPN #1 stated they notified the physician and everyone else they were supposed to notify. LPN #1 doesn't recall what the physician's or family's response was. LPN #1 was asked if the facility had an inservice or had been provided education after the incident. LPN #1 stated the facility might have had an inservice but they didn't attend too many inservices because they were generic. On [DATE] at 11:00 a.m., LPN #4 was asked how they identified the code status of a resident. LPN #4 stated the DNR was on the chart and had a physician order. LPN #4 was asked what were they to do if the information didn't match. LPN #4 stated they would want to make sure what the code status was but if they weren't sure, they would start CPR. LPN #4 was asked what they were to do if a DNR was located after CPR had been initiated. They stated, I would say to stop performing CPR. LPN #4 was asked who determined when CPR was to stop. They stated they weren't sure. LPN #4 was asked if there had been an inservice recently related to code status of the residents. LPN stated there had been but wasn't sure of the details. On [DATE] at 1:28 p.m., the DON was asked how staff were to identify the code status of a resident. The DON stated the staff have to look at the charts for the yellow sheets. The DON stated the yellow sheets were the DNRs. The DON stated, We have lists and stickers but they can't rely on that, they have to look in chart. The DON was asked what the staff were to do if they find conflicting information. The DON stated, There shouldn't be any conflict. If you don't find a DNR, you do CPR. The DON was asked how staff ensured a resident's choice to be a DNR didn't receive CPR. The DON stated, If they find a DNR, they don't do CPR. The DON stated if the staff were unsure of code status, they were to check for a DNR. The DON stated if they didn't find a DNR, they were to initiate CPR. The DON was asked if they recalled an incident where a resident who had a DNR was provided CPR. The DON stated they recalled Resident #42. The DON stated the nurse had sent a nurse aide to ask about Resident #42's code status and was first told the resident didn't have a DNR, then was told the resident did have a DNR. The DON stated, That's all I know about it.

Based on record review and interview the facility failed to ensure staff were tested for COVID-19 and results documented during outbreak testing for two (CMA #3 and LPN #3) of five staff reviewed for COVID-19 testing. The Resident Census and Condition Report form, dated 10/16/22, documented 39 residents resided in the facility. Findings: A P&P titled, [Facility Name] Policy and Procedure, revised 08/12/21, read in parts, .The policies and procedures are implemented for that purpose and are subject to change as more is learned about the illness and with the guidance of the CDC and OSDH . On 10/19/22 at 10:45 a.m., the Administrator was asked how many residents are currently COVID positive. They stated, 12. They were asked how many staff are currently COVID positive. They stated, eight. They were asked how often they are testing staff. They stated, twice weekly Mondays and Thursdays are testing days. On 10/19/22 at 3:18 p.m., The Administrator was asked who reviewed the weekly staff testing. The Administrator stated the administrator had been reviewing the testing. A staff line list testing form, dated 10/07/22 to 10/13/22, was reviewed with the Administrator and DON. The DON stated, CMA #3 had tested prior to leaving for vacation. There was no documentation recorded on the line listing sheet CMA #3 had tested for the week. The staff line list only had documentation LPN #3 had tested on e day on 10/13/22 for the week. On 10/19/22 at 3:57 p.m., the DON was asked who tests the staff. The DON stated, they test themselves, then the charge nurse is responsible to read and document the result. The DON was asked who is responsible to ensure testing is completed prior to starting shift. The DON stated, the charge nurse. No other testing documentation was provided for LPN #3 and CMA #3.

Based on record review and interview the facility failed to a. ensure an antibiotic was started in a timely manner for one (#14) of two sampled residents reviewed for antibiotic use, and b. assess, intervene and consult the physician for a resident with a rash for one (#2) of two sampled residents reviewed for impaired skin integrity. The Resident Census and Condition Report, dated 10/16/22, documented 39 residents resided in the facility. Findings: 1. Resident #14 had diagnoses which included, high blood pressure, unspecified dementia, and personal history of urinary tract infections. A physician order, dated 09/21/22 at 3:30 p.m., read in parts, .N/O send to [facility name] for eval and tx .N/O to obtain clean catch U/A .C/S if indicated . A Nurse progress noted, dated 09/21/22 at 3:50 p.m., read in part, .LE at 1522 [3:22 p.m.] office staff reported to this nurse, resident has been in office talking about harming self . A urinalysis lab report, dated 09/21/22 at 5:12 p.m., read in parts, .Nitrite positive .Leukocyte Esterase 3+ .WBC TNTC . A physician order, dated 09/21/22 at 7:21 p.m., read in parts, .N/O Keflex PO 500mg TID x 7 days, Dx UTI . Resident #14's MAR had no documentation that Keflex had been administered until the morning dose on 09/23/22. On 10/18/22 at 3:07 p.m., Resident #14's electronic health record September MAR was reviewed with the DON. The DON was asked why Resident # 14 had not been administered the three doses of Keflex on 09/22/22. The DON reviewed the EHR MAR and stated it documented, not available. The DON was asked what is the policy to start antibiotics. The DON stated, it should be started on a day to capture all the doses. The DON was shown the resident had not discharged to the acute hospital until 09/23/22. On 10/20/22 at 2:20 p.m., the IP nurse was asked if Res #14 was symptomatic with behaviors. The IP stated, the resident was aggressive and combative. The IP nurse was asked how soon should the resident who had behaviors and a positive lab result receive treatment. The IP nurse stated, they should receive it very quickly. 2. Resident #2 was admitted with diagnoses which included, cerebral infarction, muscle weakness, and aphasia. A nurse's progress note, dated 10/07/22 at 3:20 a.m., read in parts, .AS PERFORMING Q 2 HR TOILETING NEED FOR RESIDENT, IT WAS REPORTED THAT RESIDENT HAD RASH NOTED TO LEFT SIDE OF BODY. AS REPOSITIONING RESIDENT, REDDENED AREA NOTED TO BUTTOCK, NOTED ESPECIALLY TO RIGHT SIDE. RESIDENT GRIMACED AS AREAS WERE CLEANED, BARRIER CREAM APPLIED . On 10/17/22 at 3:50 p.m., Res #2's back and buttocks were observed. A patch of red raised lesions to the left side of the residents spine around the left hip area was observed. Staff reported the rash felt hard. Res #2 denied any pain at the time. On 10/17/22 at 4:11 p.m., LPN #5 was asked if the physician had been consulted about the rash identified on 10/07/22. LPN #5 reviewed the physician orders for treatment and stated, no. LPN #5 reviewed the CNA report book and provided a copy that was dated 10/07/22, which read in parts, .[Res #2] ointment applied to L side/skin broke out .Bathed/Showered . On 10/20/22 at 2:20 p.m., the IP nurse was asked if there was any measurements or description of the rash documented on 10/07/22. The IP reviewed the nurse's notes and stated, no. The IP was asked if there was documentation the physician had been consulted about the rash. The IP stated, the physician was notified on 10/17/22. The IP was asked if the physician should have been consulted on 10/07/22. They stated, yes.

5. On 10/18/22 at 6:31 a.m., during medication observation pass, CMA #2 was observed to take Res #12's blood pressure with a manual cuff and stethoscope. CMA #2 was observed to place the equipment around the CMA's back of their neck. When CMA #2 left the room they were observed to drape the cuff and stethoscope over the sharps container on the cart. CMA #2 did not sanitize their equipment. At 6:49 a.m., CMA #2 was observed to sanitize the pulse ox and thermometer, then place the stethoscope around their neck and enter Res #25's room. CMA #2 was observed to take Res #25's blood pressure with a manual cuff and stethoscope. CMA #2 was observed to place the equipment around the back of their neck, wash their hands and leave the room. CMA #2 draped the equipment over the sharps container on the cart. CMA #2 was not observed to sanitize their equipment. At 7:32 a.m., CMA #2 was observed to remove the blood pressure cuff and stethoscope from the sharps container, drape it around their neck and enter resident's #2's room. CMA #2 took Res #2's blood pressure, and was observed to place the stethoscope around their neck, then left the room. CMA #2 was observed to place the blood pressure cuff over the sharps container, prepare medications then return to Res #2's room. CMA #2 was then observed to auscultate for gastric tube placement. CMA #2 was not observed to sanitize their equipment. On 10/18/22 at 2:00 p.m., CMA #2 was asked if they had sanitized their blood pressure cuff and stethoscope between Residents #12, #25 and #2. They stated, no. CMA #2 was asked if they had worn their cuff and stethoscope around their shoulders after taking vital signs on the residents. They stated, yes. CMA #2 was asked when should the stethoscope and cuff be sanitized. They stated, everything should be wiped down after it is used. On 10/18/22 at 2:58 p.m., the DON was asked what is the policy for infection control related to cleaning the equipment between residents. The DON stated, they should be cleaning the equipment between residents using the purple wipes. 6. On 10/20/22 at 2:00 p.m., the IP was asked to review the West Hall Vitals forms used for resident temperature screenings. The screening forms had no documentation temperature checks and signs and symptoms screening had been completed for the following residents: On 10/14/22 day shift #40 and #30 and evening shift #34, On 10/15/22 day shift #40, #17 and evening shift #14, #2, #18, #40, #29, #20, #30, #34 and #3, On 10/18/22 day shift #18, #40 and #30, and On 10/19/22 day shift #17 and evening shift # 31, #27, #25, #12, #16, #34, and #5. On 10/20/22 at 2:00 p.m., the IP was asked to review resident screening forms dated, 10/14, 10/15, 10/18, 10/19. The IP was asked if the residents identified had been screened for s/s on these dates. The IP stated, Doesn't look like it. 7. CNA #3's time card dated 10/01/22 to 10/15/22 documented CNA #3 clocked in six times. There was no documentation on the October employee screening form that CNA #3 had screened in on any of these days. LPN #3's time card, dated 10/01/22 to 10/19/22 documented LPN #3 clocked in 14 times. There was no documentation on the October employee screening form that LPN #3 had screened in on any of those days. CMA #3's time card, dated 10/01/22 to 10/15/22 documented CMA #3 clocked in eight times. There was no documentation on the October screening form that CMA #3 had screened in on any of these days. On 10/19/22 at 3:39 p.m., SS was asked how often did they check the employee screenings to ensure they are completed. They stated, every month. The SS staff was asked who did they report to if there were any concerns. They stated, the Administrator. CNA #3, LPN#3 and CMA #3's screening forms were reviewed with the Administrator and the DON. They were asked if staff should be screening in before entrance to the facility for their shift. They stated, they are supposed to and have been taught repeatedly too. The policy is to enter in the west door, wash hands and screen in. Based on record review, observations, and interview, the facility failed to ensure: a. staff wore appropriate PPE for residents in isolation and while performing COVID-19 testing on the residents, b. infections were tracked to identify any trends, c. ensure blood pressure cuff and stethoscope were sanitized between resident use for three (#12, #25, and #2) of four sampled residents observed during medication administration, d. staff were monitored and screened for COVID-19 signs and symptoms for three (CNA #3, LPN #3 and CMA #3) on entrance to the facility, and e. residents were screened every shift for COVID-19 signs and symptoms for 15 ( #31, #27, #25, #12, #16, #34, 33, #40, #17, #20, #29, #3, #14, #18, and #30) of 17 sampled residents reviewed for COVID-19 screenings. The Resident Census and Conditions report, dated 10/16/22, documented 39 residents resided in the facility. Findings: The facility's Infection Control Tracking Tool policy, dated 11/11/04, read in parts, .Use the building diagram on the reverse side to color cold [sic] infection type and location of infection .Use this tool to identify cross contamination or trends that need intervention .Infection Control officer will verify form and identify trends as needed or monthly . A P&P titled, [Name of facility] Policy and Procedure, Revised 08/12/21, read in parts, .The [facility name] will monitor and screen residents, employees and visitors .effective 04/15/21 .Resident temperatures will be taken 1x/shift with exceptions to residents who would have to be awakened overnight Revised 08/12/21 .All employees will report to work using the west doors .They will immediately succumb to a screening process, temperature check and wash their hands . 1. Resident #4's Care Plan Conference Summary, dated 10/13/22, read in part, .Remains in contact isolation for ESBL UTI . On 10/18/22 at 6:55 a.m., a sign was observed on Resident #4's room. The sign read, Contact Isolation You must wear face mask, gloves, gown, face shield, hair covers and shoe covers. A three drawer dresser was observed directly inside the resident's room. LPN #3 was observed to go into Resident #4's room, placed oxygen tubing in the resident's nose, and obtain the resident blood pressure with a blood pressure cuff and stethoscope. LPN #3 was wearing a surgical mask only. LPN #3 was observed to come back to medication cart and prepare the resident's medication. LPN #3 was observed to don one glove to their right hand, take the medication back to the resident and assist the resident with taking their medication. LPN #3 was wearing a surgical mask and one glove when assisting the resident. On 10/18/22 at 12:17 p.m., LPN #3 was asked what PPE staff were to wear when going into a resident's room who was in contact isolation. LPN #3 stated the staff were to wear gown, shoe covers, gloves, and goggles. LPN #3 was asked how the staff identified residents on contact isolation. LPN #3 stated they were told or there was a sign on the door. LPN #3 was asked if there were any residents who were on contact isolation on the hall they were working. LPN #3 stated, Let me think on that. LPN #3 was asked if Resident #4 was on contact isolation. LPN #3 was observed looking in the computer, then stated the resident was on contact isolation for the ESBL. LPN #3 was asked when they were observed to take the resident's blood pressure and give the resident their medication this morning, they weren't observed to wear all PPE. LPN #3 stated, I forgot. 2. Resident #11, #9, and #15 had nursing notes, dated 10/12/22, which documented the residents had tested positive for COVID-19. Resident #1 had a nursing note, dated 10/16/22, documented the resident had tested positive for COVID-19. Resident #8 and #18 had nursing notes, dated 10/17/22, documented the residents had tested positive COVID-19. On 10/18/22 at 8:10 a.m., CNA #1 was observed on the COVID-19 unit. The CNA was not observed wearing eye protection. CNA #3 was observed assisting Resident #18 out of bed and to the bathroom. On 10/18/22 at 8:20 a.m., CNA #3 was observed to go into Resident #1's room, and delivered the resident's breakfast tray. Resident #1 requested an additional blanket. CNA #3 was observed to leave the resident's room, go to storage area to get a blanket, and take it back to Resident #1. CNA #3 assisted the resident with covering up. Resident #1 was coughing and CNA #3 was not wearing eye protection. CNA #3 was observed to go into Resident #15, #8, #9 and #11's room to assist the residents with picking up breakfast tray, assist/encourage with breakfast, and assist with putting a jacket on without wearing eye protection. On 10/18/22 at 8:35 a.m., CNA #3 was asked if they had been instructed to wear eye protection. CNA #3 stated they have. CNA #3 stated they were teary eyed this morning and the eye protection kept fogging up so they took them off and haven't put them back on. CNA #3 stated they were not vaccinated. On 10/20/22 at 11:33 a.m., the IP was asked what PPE staff were to wear when taking care of COVID-19 positive residents. The IP stated foot covers, gowns, gloves, N95 mask, hair net, goggles/face shield. The IP was asked what was the exposure risk to staff if they didn't wear eye protection when providing care to COVID-19 positive residents. The IP stated it was a pretty high risk for exposure. 3. On 10/20/22 from 9:31 a.m. to 10:07 a.m., the IP was observed to test Resident's #25, #12, #34, #2, #17, and #143 for COVID-19. The IP was observed to wear a surgical mask and gloves only. On 10/20/22 at 1:27 p.m., the IP was asked what PPE was to be worn when performing COVID-19 testing on the residents. The IP stated, I just learned this. The IP stated they were supposed to wear gown, gloves, mask and goggles. The IP stated, I didn't wear it today. The IP was asked how often they performed the test on residents. The IP stated they tested the residents today, last Monday and last Thursday. The IP was asked what PPE was worn on Monday and Thursday. The IP stated they wore gloves and mask. 4. On 10/18/22 at 1:25 p.m., the DON provided information for tracking and trending of antibiotics and infections. The infections were last tracked in July 2022. It documented 12 UTIs had been identified as a trend. On 10/20/22 at 11:44 a.m., the IP was asked how often they tracked antibiotics to identify any trends. The IP stated it was an every day job. The IP stated they map out infections on the facility map to identify trends. The IP was asked when the last time they tracked infections. The IP stated they have tracked the infections but have not been able to map them out to identify any trends.