**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to utilize personal protective equipment (PPE) for enhanced barrier precautions (EBP) for one of two residents (Resident (R) 61) reviewed for EBP out of a sample of 18 residents. This created the potential for transmission of infection to staff and other residents. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions dated February 2025, revealed, Providers and partners must wear gloves and a gown for the following high-contact patient care activities: . device care or use: central line, urinary catheter, feeding tube . Review of R61's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed admitted on [DATE] with diagnoses gastrostomy (an opening in the stomach for a feeding tube), and dysphagia (difficulty swallowing) following cerebral infarction (stroke). Review of R61's Care Plan under the RAI (Resident Assessment Instrument) tab of the EMR revealed a problem area of requires tube feeding related to dysphagia/protein calorie malnutrition created 10/04/24. Review of R61's Orders tab of the EMR dated 10/04/24 indicated, give all medication via peg [feeding] tube .Klonopin (anti-anxiety medication) 1mg [milligram] every six hours dated 03/31/25, and Seroquel (anti-psychotic medication) 25mg three times daily, dated 01/08/25. During an observation on 05/14/25 at 1:24 PM, Registered Nurse (RN)1 brought crushed Klonopin and Seroquel into R61's room. R61's door had an EBP sign on it which indicated to wear gown and gloves RN1 washed her hands and donned gloves. RN1 checked the feeding tube for placement, flushed the tube with water, administered each medication separately, ending by flushing the tube with water, and securing the abdominal binder. RN1 did not wear a gown during the administration of R61's medications per the gastrostomy tube. During an interview on 05/15/25 at 2:22 PM, Certified Nurse Aide (CNA)1 stated staff were to wear a gown and gloves when doing any contact activity with a resident who has a feeding tube. During an interview on 05/15/25 at 3:07 PM, RN1 stated that EBP were followed when providing wound care, any line care (for intravenous medications) and maybe feeding tubes. When asked if a gown was to be worn when doing a dressing change for a feeding tube site or administering medications via a feeding tube, RN1 stated she was unsure in a nursing facility setting, that a gown was not used for those activities. During an interview on 05/15/25 at 3:09 PM, Unit Manager (UM)2 stated EBP was utilized whenever anything was administered through a feeding tube, when providing wound cares, or with any contact activities of daily living (ADLs) with someone with wounds, lines, feeding tubes, etc. During an interview on 05/15/25 at 3:12 PM, the Assistant Director of Nursing (ADON) stated that residents on EBP had signs on their doors and caddies with PPE on their side of the room. It was expected that nurses wore gowns and gloves when they administered medications via a feeding tube, flushed a feeding tube, or changed a feeding tube dressing. During an interview on 05/15/25 at 3:21 PM, the Director of Nursing (DON) reported the expectation that staff follow EBP with any prolonged contact with residents with catheters, drains, feeding tubes, or colonization with a MDRO (multi-drug-resistant bacteria). This included wearing a gown and gloves with a feeding tube dressing change or administering medications via a feeding tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the quarterly MDS assessment with an ARD of 10/28/23, revealed R35 had a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired. R35 also was assessed as having incontinence of bowel and bladder, sometimes has moderately impaired ability to make concrete requests, and is non-interviewable. Review of the EMR for R35 revealed diagnoses of a displaced bimalleolar fracture of the left lower leg, a history of falling, and unspecified dementia. On 10/31/23 at 2:37 PM during an interview, R35's FM11 stated that when she arrived at the facility on Saturday, 10/21/23 at 11:15 AM, R35 was soaking wet and needed to be cleaned and changed. FM11 stated that she activated the call light for staff assistance. FM11 stated that a staff member responded 1.5 hours later at 12:45 PM. An unidentified staff member entered the room and removed the soiled adult diaper on R35 and replaced it with a clean adult diaper but did not provide perineal care for R35. The unidentified staff member then stated to R35 and FM11, I will never come back to this facility, it is too unorganized. Cross Reference: F725-Sufficient Nursing Staff. Based on interview and record review, the facility failed to ensure care was provided in a dignified and timely manner for 3 (Resident (R)15, R23, R35) of 4 residents reviewed for dignity out of a total sample of 20 residents. This resulted in R15's colostomy (a pouch on the outside of the body to hold stool) bag exploding and R23 feeling mad about having to wet herself but having to go with the flow. Findings include: 1. Review of a Face Sheet, found in R15's electronic medical records (EMR) under Face Sheet, indicated R15 was admitted to the facility on [DATE] with a diagnosis of Encounter for attention to colostomy. Review of R15's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R15 was cognitively intact. During an interview on 10/31/23 at 10:06 AM, R15 said on the weekends there are not enough staff. He has had to wait over an hour at times to get assistance. R15 said there have been times that his colostomy bag exploded before he could get help to empty it but has been able to contain the feces with a brief. During an interview on 11/02/23 at 1:02 PM, Licensed Practical Nurse (LPN) 7 said staffing on the weekends is very bad. She said the staff tries to work together as a team, but it is difficult to make sure call lights are answered timely. She said last weekend she remembered it took her quite a while to assist R15 with his colostomy. She said R15 was nice about it. LPN7 said she had time-consuming wound care to complete and so R15 had to wait until she was available. 2. Review of a Face Sheet, found in R23's EMR under Face Sheet, indicated R23 was readmitted to the facility on [DATE] with a Displaced fracture of right femur [leg]. Review of R23's admission MDS with an ARD date of 10/31/23 indicated the resident had a BIMS score of 10 out of 15 indicating R23 was moderately impaired cognitively Review of a Care Plan, found in R23's EMR under Care Plan, dated 09/25/23, indicated R23 had Urinary Incontinence . Goal included .Patient will be clean and dry with prompt toileting, incontinence care as needed . Approaches included, Assist with toileting per patient's needs. During an interview on 10/31/23 at 4:45 PM, R23 said this past Sunday she could not get anyone to answer her call light. R23 said she had to be assisted to the bathroom because she is not able to bear full weight on her broken leg. R23 said she had to wet herself. She said it made her feel mad, but she just went with the flow. She said that was not the first time it happened. R23 said there is not enough help on the weekend. During an interview on 11/01/23 at 1:10 PM, R23's family member (FM) 9 was in the room and said her sister had visited on a weekend and it had taken 25 minutes for someone to answer R23's call light. She said R23 had to go in her brief. During an interview with the Director of Nursing (DON) on 11/01/23 at 3:00 PM, the interviews with R15 and R23 were shared. The DON was unaware of call lights not being answered timely. Follow up with DON on 11/02/23 at 1:17 PM indicated she had not spoken with R15 and R23 about their care. During an interview on 11/02/23 at 2:44 PM, Certified Nursing Assistant (CNA) 4 said she had stopped working on the weekends in the first part of October and now works Monday through Thursday. She said when she did work the weekends, resident's would complain to her about how long it took to answer the call light. She said there are multiple call outs both on the weekends and the weekdays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to order medication in a timely manner and failed to administer medication when it was available for 1 (Resident (R)15) of 2 residents reviewed for antibiotic use. Findings include: During an interview on 10/31/23 at 10:14 AM, R15 said the cream for his shingles ran out over the weekend and he had not gotten any since. He said the nurse told him the pharmacy does not deliver on the weekend. Review of a Face Sheet, found in R15's electronic medical record (EMR) under Face Sheet, indicated R15 was admitted to the facility on [DATE] with a diagnosis of Encounter for attention to colostomy. Review of R15's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R15 was cognitively intact. Review of a Prescription Order, located in R15's EMR under Orders, indicated Primary Clinical Category Acute Infections, dated 10/25/23, documented erythromycin ointment .Apply 0.25 inches to affected area on right upper eyelid and forehead 3x daily Dx: (diagnosis) Shingles. The pharmacy fill date was documented to be 10/25/23 at 11:59 AM and 10/30/23 at 11:27 AM. Review of R15's Medication Administration Record (MAR), located in R15's EMR under Reports, indicated the erythromycin was not administered on 10/29/23 through 10/31/23. The documented reason indicated Drug/Item Unavailable and awaiting pharmacy. Review of a Resident Progress Note, located in R15's EMR under Progress Notes, dated 10/29/23 at 7:26 PM, indicated Patient is aware that ointment has been reordered. Currently awaiting pharmacy delivered [sic]. Will continue treatment until blisters have crusted/healed as ordered by MD. RP [responsible person] and provider notified. Review of a Resident Progress Note, located in F15's EMR under Progress Notes, dated 10/20/23 at 12:31 PM, indicated Patient was made aware that erythromycin was ordered. We will continue with treatment until healed. Provider notified. During an interview on 11/01/23 at 12:16 PM, the [NAME] Unit Manager (UM2) confirmed the missed doses of the eye ointment on 10/30/23 and 10/31/23. She said the resident was ill on 10/29/23 and refused the ointment. UM2 said the pharmacy delivered medication late in the evening so that is why it was not administered on 10/30/23. During a second interview on 11/01/23 at 12:50 PM, R15 said he did not refuse the eye ointment on the weekend, he said they ran out on Saturday. He only refused the oral medications because he was sick to his stomach. R15 said the nurse told him the medication was out and the pharmacy did not deliver on the weekend. During an interview on 11/01/23 at 2:32 PM, Licensed Practical Nurse (LPN) 12 confirmed he had overlooked the eye ointment and failed to administer it on 10/31/23. He said the night shift nurse reported the eye ointment had been ordered so he did not look in the top drawer of the medication cart for it. During an interview on 11/02/23 at 9:39 AM, the Pharmacist said the facility should have a backup pharmacy that could deliver on the weekends. She said if they had been made aware he was completely out of the ointment, they could have arranged something for them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 10/31/23 at 2:37 PM, R35's FM4 stated that on Saturday, (10/21/23), R35 was soaking wet and needed to be cleaned and changed. The call light was activated. FM4 stated that a staff member responded 1.5 hours later. On 10/31/23 at 9:31 AM, R35 stated on weekends mostly, it takes a long time to get call light answered. R35 stated the nurses tell him they do not have time to get ice for his Juven, which tastes better when cold. R35 stated the nurses tell him they do not have time to assist him with his CPAP (assisted breathing for sleep apnea) at night. 4. On 10/31/23 at 3:49 PM during an interview, R37's FM 1 stated there have been times when there was not enough staff to get R37 up in the chair. 5. On 10/31/23 at 11:04 AM, R19 said the weekends have less staff and you have to wait longer for help. R19 could not give any specific examples of staff shortage affecting her care. 6. On 10/31/23 at 1:48 PM during an interview, R46's FM2, stated a couple of weeks ago on the weekend she found R46 soiled. FM2 stated R46 wears briefs and was wet enough that urine had soaked through to his clothes. FM 2 stated she visited on Sunday afternoon around 3:00 PM and R46 was still in bed and not dressed. FM2 said the facility is always short staffed on the weekends. 7. On 10/31/23 at 11:36 AM, R159 stated that she asked the medication nurse for some water yesterday morning. The nurse did not get it for her but said they will pass the water when they get time. R159 said, I have to wait for a diaper change because they say they are shorthanded, more so during the evening or night. The whole system is screwed up. Review of Resident Council Minutes (RCM) for a meeting held on 08/09/23, with 11 residents and two staff members in attendance, revealed concerns that call lights were not answered in a timely manner, and that residents waited too long for assistance. Review of the RCM on 09/13/23, with eight residents in attendance, revealed concerns that staff took too long to answer the call light. A review of the facility Summary of Grievances report also documented grievances/concerns regarding timely call light response on the following dates in 2023: June 21, July 7,20, October 3, 11th, No documentation, prior to survey exit date, was provided to identify the complainants of the grievances or if the grievances were resolved. During an interview on 11/02/23 at 2:15 PM the Staffing Coordinator (SC) said there is an on-call supervisor who is responsible for finding replacements for weekend call offs and will come into work if necessary. During an interview on 11/02/23 at 2:20 PM the Administrator said the facility has been hiring staff and the goal is to eliminate agency staff. He said there are currently four full time licensed nursing positions and one or two CNA positions to be filled. Based on interview and record review, the facility failed to ensure enough staff was working to ensure care was provided in a timely manner for seven residents (Resident (R)15, R23, R35, R37, R19, R46, and R159) of total sample of 20 residents. Findings include: 1. Review of a Face Sheet, found in R15's electronic medical records (EMR) under Face Sheet, indicated R15 was admitted to the facility on [DATE] with a diagnosis of Encounter for attention to colostomy. Review of R15's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R15 was cognitively intact. During an interview on 10/31/23 at 10:06 AM, R15 said on the weekends there are not enough staff. R15 stated he has had to wait over an hour at times to get assistance. R15 said there have been times that his colostomy bag exploded before he could get help to empty it but has been able to contain the feces with a brief. During an interview on 11/02/23 at 1:02 PM, Licensed Practical Nurse (LPN) 7 said staffing on the weekends is very bad. She said the staff tries to work together as a team, but it is difficult to make sure call lights are answered timely. She said last weekend she remembered it took her quite a while to assist R15 with his colostomy. She said R15 was nice about it. LPN7 said she had time-consuming wound care to complete and so R15 had to wait until she was available. 2. Review of a Face Sheet, found in R23's EMR under Face Sheet, indicated R23 was readmitted to the facility on [DATE] with a Displaced fracture of right femur. Review of R23's admission MDS with an ARD date of 10/31/23 indicated the resident had a BIMS score of 10 out of 15, indicating R23 was moderately impaired cognitively. Review of a Care Plan, found in R23's EMR under Care Plan, dated 09/25/23, indicated R23 had Urinary Incontinence . Goal included .Patient will be clean and dry with prompt toileting, incontinence care as needed . Approaches included, Assist with toileting per patient's needs. Review of a Progress Note, found in R23's EMR under Social Worker Progress Note, dated 10/25/23, indicated She [R23] is alert and able to make her needs/wants known. Resident scored a 10 on her BIMS. During an interview on 10/31/23 at 4:45 PM, R23 said this past Sunday, 10/29/23, she could not get anyone to answer her call light. R23 said she had to be assisted to the bathroom because she is not able to bear full weight on her broken leg. R23 said she had to wet herself. She said it made her feel mad, but she just went with the flow. She said that was not the first time it happened. R23 stated there is not enough help on the weekend. During an interview on 11/01/23 at 1:10 PM, R23's family member (FM) 9 was in the room and said her sister had visited on a weekend and it had taken 25 minutes for someone to answer R23's call light. FM 9 said R23 had to go in her brief. R15 and R23 reside on the Cooper Unit (CU). Review of NHS Healthcare Call offs, given by the facility, indicated on Saturday, 10/28/23 and Sunday, 10/29/23 one CNA called off on the 7:00 PM to 7:00 AM shift on 10/28/23 and one CNA called off on the 7:00 AM to 7:00 PM shift on 10/29/23.