**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed ensure the proper personal protective equipment (PPE) was used during wound care to maintain Enhanced Barrier Precaution (EBP) for one resident (Resident (R) 37) of one resident observed during wound care. This had the potential for the resident's wound to become infected. Findings include: Review of the facility policy titled, Enhanced Barrier Precautions (EBP), with a revised date of 05/27/25 indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Under Definition states, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. High-contact resident care activities include: h. Wound care: any skin opening requiring a dressing. Review of R37's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R37 was admitted to the facility on [DATE] with the diagnosis of peripheral vascular disease with atherosclerosis (plaque in the artery walls) of the right and left leg with ulceration of both feet and partial amputation. Review of R37's Physician Order located under the Orders tab in the EMR revealed an order dated 05/24/24 for Enhanced Barrier Precautions every shift. Review of R37's Care Plan with a problem start date of 05/09/24 indicated, Resident is at risk for contacting MDRO [Multi Drug Resistant Organism] r/t [related to] presence of open chronic PAD [Peripheral Artery Disease] wounds. An approach with a start date of 05/09/24 stated use gown and gloves during high contact resident care activities, including but not limited to dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, wound care and any skin opening requiring a dressing. During an observation on 06/10/25 at 12:55 PM revealed the Unit Manager (UM) preparing to complete wound care for R37. R37 had Stage IV Pressure Ulcers to the right and left heel/ankle area. A barrier was not placed under the residents' feet. A sponge was used to raise the lower half of the legs, but R37's heel hit the bed covers while the UM was washing her hands. The wounds were cleaned individually and clean dressings applied. The UM did not wear a gown while completing care to R37's wounds. During an interview with the UM on 06/10/25 at 1:29 PM, the UM stated, I did not put on my EBP. I knew halfway through that I forgot my gown. We have drapes to put down on the surface of the bed, and I did not use one. I am very aware of what I did. During an interview with the Director of Nursing (DON) on 06/12/25 at 11:27 AM revealed It is my expectation that nursing follows policy and procedures for EBP and that they know the orders before entering the room and put on the necessary PPE required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility procedure, record review, observations, and interview, the facility failed to ensure 1 of 1 resident (R)2, reviewed for Positioning and Mobility, was provided assistance to apply splints per his plan of care. Findings include: The facility's splinting policy was requested on 08/25/22 at approximately 10:00 AM and was not received prior to survey exit on 08/25/22. The facility's Applying and Removing the Dynamic Splint Procedure, dated 2019, read, in pertinent part, Splints are used to: Prevent deformities and contractures of the joint . relieve pain . Maintain and improve mobility and range of motion. R2 was admitted to the facility on [DATE], per the undated Resident Face Sheet found in the electronic medical record (EMR) under the Admissions tab, with diagnoses including; history of traumatic brain injury and metabolic encephalopathy (brain dysfunction). Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/22, indicated R2 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 99, indicating the assessment could not be completed due to R2's poor cognition. This MDS indicated R2 had Range of Motion (ROM) impairment to his upper and lower extremities (arms and legs) on one side of his body, and that a splint or brace was not in use for the resident during any of the seven day look back period. Review of R2's Contracture Risk Assessment, dated 08/23/22 and found in the EMR under the Observations tab, indicated a risk score of 13 (moderate risk for developing contractures). Contractures are fixed stiffening of a joint due to muscle or tendon shortening. Review of R2's Activities of Daily Living (ADL) Care Plan, dated 04/20/22 and found in the EMR under the Care Plan tab, indicated R2 received extensive assistance from staff to complete his ADLs due to his metabolic encephalopathy, dementia, and history of traumatic brain injury (TBI). Approaches included: Resident to wear bilateral elbow braces/orthotics as indicated/tolerated to assist with prevention of contractures and Assist resident with putting on and taking off bilateral elbow braces/orthotics as indicated. Review of R2's Orders Report, dated 08/01/22 through 08/25/22 and found in the EMR under the Orders tab, indicated an order to Wear left and right elbow braces for 8 hours per day to reduce elbow contracture. The orders indicated the elbow braces were to be worn during the day shift. R2 was observed lying in his bed and awake on 08/23/22 at 3:41 PM, and on 08/24/22 at 11:58 AM, 1:53 PM, 2:32 PM, and 3:41 PM. R2 was not wearing his elbow splints during any of these observations. During an interview on 08/25/22 at 9:47 AM, Licensed Practical Nurse (LPN)/Unit Manager (UM)1 stated R2 was to be wearing his elbow splints as ordered. During an interview on 08/25/22 at 11:22 AM, Certified Nursing Assistant (CNA)1 verified that she had been taking care of R2 on 08/24/22, but had not been told R2 was supposed to have splints applied to his elbows during the day, and so did not apply them. During an interview with the Clinical Care Coordinator (CCC)/Infection Preventionist (IP), who was representing the Director of Nursing (DON) during the survey, on 08/25/22 at 11:54 AM, she stated, He [R2] should have the elbow protectors on per the physician's order.