**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to: 1. utilize the proper personal protective equipment (PPE) for enhanced barrier precautions (EBP) for one of three residents (Resident (R)7) reviewed for EBP; 2. Have EBP signage to convey a resident was on EBP for one of three residents reviewed for EBP (R51); 3. Utilize gloves when touching a pill during the observation of medication administration for one resident (R94) and; 4. Provide proper storage of clean basins for two residents (R59 and R79) out of a sample of 27 residents. Findings include: Review of the facility's Enhanced Barrier Precautions policy, updated 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 the Centers for Disease Control and Prevention (CDC) website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated, Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. 1. Review of R7's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE], and had diagnoses which included but was not limited to: Dementia, encounter for attention to gastrostomy (an opening in the stomach for a feeding tube), and dysphasia (difficulty swallowing) following cerebral infarction (stroke). Review of R7's Care Plan under the RAI (Resident Assessment Instrument) tab of the EMR revealed a problem area of potential for aspiration with a PEG (feeding) tube with an approach created 09/05/24, Provide Enhanced Barrier Precautions. Review of R51's Orders tab of the EMR revealed orders, dated 03/21/25, indicated, check placement of the feeding tube by aspirating stomach contents and checking the mark on the tubing prior to feeding, flushes, or medications, administer Osmolite 1.5 formula at 50 milliliters (mL) per hour for 22 hours starting at 2:00 PM daily, and provide enhanced barrier precautions. During an observation on 04/02/25 at 2:06 PM, Licensed Practical Nurse (LPN)3 was observed in R7's room, without gloves or a gown, hanging an Osmolyte feeding container from a hook on a pole containing a pump (to regulate the amount of feeding infused per hour) next to the R7's bed. LPN3 then applied gloves, removed the feeding container, re-attached the tubing to it, hung the container back on the hook, and inserted the tubing through the pump to run the Osmolyte through. Once the tubing had the Osmolyte run through it, LPN3 attached the tubing to R7's feeding tube in her abdomen and started the feeding at 50 mL per hour. LPN3 wore no gown while she started the feeding. During an interview on 04/03/25 at 12:24 PM, LPN2 stated residents with tube feedings were on EBP. Gowns and gloves were worn by nurses when doing anything with the feeding tube, and certified nursing assistants (CNAs) wore gowns and gloves when providing any cares involving contact with the residents. During an interview on 04/03/25 at 12:28 PM, LPN3 reported R7 was on EBPs because of her feeding tube. LPN3 stated she was supposed to wear a gown and gloves when administering the tube feeding but had forgotten to on 04/02/25. During an interview on 04/03/25 at 3:18 PM, the Director of Nursing (DON) stated he expected staff to utilize EBP and wear gowns and gloves for any direct care of residents with emerging resistant bacteria and indwelling devices to include feeding tubes and catheters. A nurse was expected to wear a gown and gloves when administering formula through a feeding tube. 2. Review of R51's Face Sheet, located under Face Sheet tab in the EMR, indicated R51 was admitted to the facility on [DATE], with diagnosis including but not limited to: retention of urine, unspecified. Review of R51's General Order, located under Order tab in the EMR, dated 02/24/25, indicated, Enhanced Barrier Precautions. During an observation on 04/01/25 at 9:52 AM, R51 was observed sitting in his wheelchair with his urinary catheter bag hanging on the left side of his wheelchair. There was nothing observed to alert staff that the resident was on EBP prior to entering the resident's room. During an observation on 04/01/25 at 11:36 AM, there was nothing observed to alert staff that the resident was on EBP prior to entering the resident's room. During an observation and interview on 04/02/25 at 10:06 AM, LPN1 confirmed residents who have a urinary catheter should be on EBP. LPN1 stated EBP should be used when providing catheter care or changing clothes, and staff are to wear a gown and gloves. LPN1 confirmed there was no signage outside of R51's room to alert staff that the resident was on EBP however there had been one in the past. During an interview on 04/03/25 at 8:30 AM, the DON confirmed that a resident with a urinary catheter should be on EBP, and an EBP sign should be placed on the doorframe prior to entering the resident's room therefore staff are aware of what precautions to take. The DON confirmed that R51 did have a urinary catheter and should be on EBP. 3. Review of R94's Face Sheet, located under the Face Sheet tab in the EMR, indicated R94 was admitted to the facility on [DATE], with diagnoses including but not limited to: polyneuropathy. Review of R94's Prescription Order, located under the Orders tab in the EMR, indicated R94 was to receive pregabalin 75 milligrams (mg), one capsule, twice a day. During a medication observation on 04/01/25 at 9:40 AM, LPN2 was observed removing R94's blister package of pregabalin from the narcotic box. After removal, LPN2 popped one pill into her left hand, placing the medication into a clear medication cup. Afterwards, LPN2 placed the rest of R94's medications into the cup and gave all the medications to R94. During an interview on 04/02/25 at 10:15 AM, LPN2 confirmed that she popped the medication into her hand and stated that she should not have. During an interview on 04/03/25 at 8:40 AM, the DON confirmed that he expected medications to be popped into medication cups, and not hands. 4. Review of the Face Sheet found in R59's EMR under the Face Sheet tab revealed R59 was admitted to the facility on [DATE], with diagnoses including but not limited to: dementia and poly-osteoarthritis. Review of the Face Sheet found in R79's EMR under the Face Sheet tab revealed R79 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's disease and bilateral primary osteoarthritis of the knee. During an observation of R59 and R79's shared bathroom on 04/01/25 at 2:08 PM, revealed two grey plastic wash basins resting on top of toilet seat uncovered. Further observation revealed each basin had the residents' name on each one. During an observation on 04/01/25 at 2:09 PM, LPN6 stated, Usually the wash bins are stored above for each resident. LPN 6 stated the wash bins were on the toilet seat and they needed to go in the trash. During an interview on 04/03/25 at 5:51 PM, the DON stated, Typically don't like to store them (washbasin) in the bathroom but typically store in the closet. We would not store wash basin on the toilets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (Resident (R) 27) of one sampled resident reviewed for mood and behavior. Failure to code the MDS correctly has the potential to lead to inaccurate assessment and care planning of the resident. (Cross Reference F842) Findings include: Review of the Resident Assessment Instrument (RAI) Manual, dated 10/01/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT (Interdisciplinary Team) completing the assessment . Review of R27's Resident Face Sheet, located under the Resident tab of the electronic medical record, indicated the resident was admitted to the facility on [DATE]. A review of R27'sMinimum Data Set (MDS) assessments, located under the MDS tab of the EMR, revealed: R27's admission MDS, with an Assessment Reference Date (ARD) of 09/22/22, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The assessment recorded the resident had a diagnosis of Post Traumatic Stress Disorder (PTSD). R27's quarterly MDS, with an ARD of 12/21/22, indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The assessment recorded the resident had a diagnosis of PTSD. R27's quarterly MDS, with an ARD of 03/14/23, indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The assessment recorded the resident had a diagnosis of PTSD. R27's quarterly MDS, with an ARD of 05/30/23, indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The assessment recorded the resident had a diagnosis of PTSD. R27's annual MDS, with an ARD of 08/21/23, indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The assessment recorded the resident had a diagnosis of PTSD. During an interview on 08/29/23 at 12:45 PM, R27 denied having a diagnosis of PTSD. The resident stated she had the diagnosis of bi-polar and had this diagnosis for a long time. During an interview on 08/30/23 at 1:05 PM, Social Services (SS)1 stated R27 had a long mental health history. During an interview on 08/30/23 at 1:51 PM, SS1 stated it was a coding issue for R27 to be recorded as having the diagnosis of PTSD. The Regional Health Information Manager (HIM) was present during this interview and stated the MDS coding was supposed to be accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to maintain an accurate medical record for one resident (Resident (R) R27) of one sampled resident reviewed for mood and behavior. The facility entered an inaccurate diagnosis of Post Traumatic Stress Disorder (PTSD) during the length of R27's stay at the facility. Findings include: Review of a policy provided by the facility titled, Introduction to Documentation for Inpatient Medical Records, dated October 2021, indicated . It is the responsibility of each health care center to establish and maintain comprehensive records which accurately reflect all aspects of the organization . Observations, events, assessments/evaluations, treatments, services, and patient responses are accurately recorded and authenticated . Review of R27's electronic medical record (EMR) titled, Resident Face Sheet, located under the Resident tab, indicated the resident was admitted to the facility on [DATE]. Review of R27's EMR titled nursing Progress Notes, dated 08/30/23 at 4:20 PM, indicated . Reviewed resident's inpatient and hospital records interviewed the resident and resident RP [representative] and interviewed the resident's NP [nurse practitioner] and requested that she review resident's inpatient and hospital records related to the diagnosis of PTSD. Resident and RP both report they were not aware of resident ever being diagnosed with PTSD previously and have no knowledge of diagnosis. Resident's NP reviewed record and reported that she is unable to locate the origin/indication of when or why diagnosis of PTSD was initiated from hospital and based on resident and RP statements regarding diagnosis and resident not exhibiting symptoms of PTSD throughout frequent stays at the facility. NP gave order to invalidate diagnosis of PTSD. During an interview on 08/30/23 at 5:13 PM, the Director of Nursing stated he spoke with the resident and RP, and there was never a diagnosis of PTSD. The DON stated he did not know how it was generated.

Based on record review, observations, interviews, and review of the facility assessment, the facility failed to ensure two Certified Nursing Assistants (CNA) 1 and CNA8 were competently trained to properly don (put on) personal protective equipment (PPE). CNA1 was observed to enter one resident's (Resident (R) R162) room, who was unvaccinated, a new admission, under droplet precautions, and considered a Person Under Investigation (PUI) for potential COVID-19 exposure, without first donning required PPE. CNA8 was observed to exit R164's room who was also a new admission, on quarantine, unvaccinated, and under droplet precautions, without wearing proper PPE. Findings include: Review of a document provided by the facility titled Job Description. Certified Nursing Assistant, dated 07/01/09, indicated . Attend in-service programs, as assigned, to learn procedures and develop skills and meet state requirements. Review of a document provided by the facility titled Facility Assessment Tool, dated 11/19/21, indicated . Starting with the hiring process, potential employees complete an application and watch the better way video, which is our commitment and standard for delivering customer service. Once a partner is hired, they attend a center orientation, in which many topics are covered. Some of the topics include: The better way, 5 Step service recovery, falls, transfer training, abuse and neglect, fire and life safety, infection control. 1. The Director of Nursing (DON) reported CNA1 was hired on 05/19/93. Review of a document provided by the facility titled Questionnaire for Users of N95 Respirators, dated 10/28/20, indicated CNA1 was able to use a N95 face mask. Review of a document provided by the facility titled Skills fair inservice [sic] training, dated 09/21/21, indicated CNA1 attended an inservice [sic] on PPE. During an interview on 12/20/21 at 12:07 PM, CNA1 stated there were plenty of PPE supplies for her to use. CNA1 was observed to stand on the outside of R162's room. CNA1 had a surgical mask on and a gown. The door to R162's room was closed and had a Centers for Disease Control and Prevention (CDC) poster for droplet precautions on the outside of the door. At 12:13 PM, CNA1 performed hand hygiene with alcohol-based hand sanitizer and donned gloves and took a face shield from the PPE container, which hung the outside door R162's room. CNA1 took R162's lunch tray into the room. At 12:17 PM, CNA1 doffed (took off) her gloves and face shield. CNA1 then took the face shield and placed it into the PPE container hanging from R162's door. CNA1 did not sanitize the face shield prior to placing this item back into the PPE container. CNA1 then took off her gown and face mask and disposed of these items, in a trash container located in the resident's room. CNA1 then walked, without PPE on, to the resident's bathroom, located in the back of the room to wash her hands. At 12:18 PM, CNA1 donned a fresh face mask. CNA1 stated she always wore a surgical mask when entering a quarantined resident room. 2. The DON reported CNA8 was hired on 11/04/21. Review of a document provided by the facility titled Personal Protective Equipment (PPE) Competency Validation, dated 11/04/21, indicated CNA8 was provided training on donning and doffing PPE. This form failed to indicate CNA8 was competent to don a N95. During an observation on 12/21/21 at 9:09 AM, CNA8 exited R162's room and confirmed she performed personal care on the resident, applied lotion, and fed the resident breakfast. CNA8 was observed wearing a surgical mask. During an interview on 12/21/21 at 9:26 AM, when asked about the same face shield being used by multiple staff, the DON stated PPE should be for individual use. During an interview on 12/21/21 at 9:43 AM, the Infection Control Preventionist (ICP) stated staff were to don a N95 mask prior to entering a PUI/quarantined room. The ICP stated CNA8 had not gone through orientation on the use of a N95 nor was CNA8 provided a N95 face mask. During an interview on 12/22/21 at 1:52 PM, the ICP confirmed once again CNA8 was not provided a fit test for the use of a N95. The ICP stated CNA1 had been trained on the use of a N95. Cross reference: F880 Infection Control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of facility policies, and review of Centers for Disease Control and Prevention (CDC) COVID-19 guidance, the facility failed to ensure two Certified Nursing Assistants (CNA) 1 and CNA 8 and one Nursing Assistant (NA) 5 donned (put on) proper personal protective equipment (PPE) prior to providing care to two of two residents (Residents (R) R162 and R164) under quarantine who were new admissions, unvaccinated, and potentially exposed to COVID-19 while previously hospitalized . Findings include: Review of a policy provided by the facility titled Testing Plan, dated 09/02/20, indicated the unvaccinated resident should have a negative COVID-19 test prior to admission, placed in a designated area/room, and placed on droplet precautions. Review of a policy provided by the facility titled Core Principles of COVID-19 Infection Control, dated 10/01/20, indicated .Appropriate staff use of Personal Protective Equipment (PPE). Review of the Centers for Medicare & Medicaid Services (CMS), website https://data.cms.gov/covid-19/covid-19-nursing-home-data, the community positivity rate on 12/05/21 indicated a high rate of transmission at 6.74 percent. Review of CDC guidance, dated 09/10/21, indicated . If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE as described . NIOSH-approved N95 or equivalent or higher-level respirators should be used for . Facilities could consider use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP working in other situations where multiple risk factors for transmission are present. One example might be if the patient is unvaccinated, unable to use source control, and the area is poorly ventilated . Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . 1. Review of an undated document provided by the facility titled Resident Face Sheet, indicated R162 was admitted to the facility on [DATE]. At the time of admission R162 was unvaccinated and was placed under quarantine for possible exposure to COVID-19. During an interview on 12/20/21 at 8:34 AM, the Bookkeeping Director stated R162 was an unvaccinated new admission and was under quarantine. During a random observation conducted on 12/20/21 at 12:07 PM, CNA1 was observed outside of R162's room. The door to R162's was shut and had a CDC poster on the door which indicated droplet precautions PPE were to be applied prior to entering into the room. CNA1 was observed wearing a gown and a surgical (disposable) mask. At 12:13 PM, CNA1 performed hand hygiene, with alcohol-based hand sanitizer, and then donned gloves. At 12:15 PM, CNA1 donned a face shield and was handed the lunch meal tray for R162. CNA1 then took the tray into R162's room and shut the door. At 12:17 PM, CNA1 opened R162's door and doffed (took off) her gloves and gown and took off the face shield and placed it back into the PPE container that hung from the resident's door. CNA1 then doffed her surgical mask while in the resident's room. CNA1 then walked to the resident's bathroom located in the back of the room. At 12:18 PM, CNA1 exited the room and donned a fresh surgical mask. CNA1 was asked what type of mask she dons prior to entering a quarantined room, and CNA1 stated she always wore a surgical mask. 2. Review of a document provided by the facility undated titled Resident Face Sheet, indicated R164 was admitted to the facility on [DATE]. At the time of admission R164 was unvaccinated and was placed under quarantine for possible exposure to COVID-19. During a random observation on 12/21/21 at 9:08 AM, NA5 was observed standing outside of R164's room. The door to R164's was shut and had a CDC poster on the door which indicated droplet precautions PPE were to be applied prior to entering into the room. NA5 was observed wearing a gown, surgical face mask, and gloves. During an observation at 9:09 AM, CNA8 came out of R164's room. CNA8 had on a surgical mask not an N95 mask. CNA8 placed the face shield back into the PPE holder. CNA8 stated she only sanitized the padding of the face shield. Observation of the face shield included padding that goes around the top of the shield and touches the forehead of the wearer. The plastic shield was attached to the padding and the plastic shield covered the front of the wearer's face. CNA8 stated she used alcohol-based hand sanitizer to sanitize the padding and confirmed she did not sanitize the plastic shield. NA5 was observed to retrieve the same face shield from the PPE container that CNA8 previously used and entered R164's room. NA5 did not sanitize the plastic face covering of the face shield. During an interview on 12/21/21 at 9:43 AM, the Infection Control Preventionist (ICP) stated staff were to use N95 masks. The ICP stated the face shield was to be sanitized between use. The ICP stated NA5 and CNA8 were newer employees and had completed orientation but did not get an assigned N95 mask yet. During an interview on 12/21/21 at 10:02 AM, the ICP stated new unvaccinated admissions were to have a negative COVID-19 test prior to admission. Review of a document provided by the facility titled Prisma Health Greenville Memorial Hospital Laboratory, dated 12/01/21, indicated R162 had a negative COVID-19 test. Review of a document provided by the facility titled Prisma Health Greenville Memorial Hospital Laboratory, dated 12/05/21, indicated R164 had a negative COVID-19 test. During an interview on 12/22/21 at 5:52 PM, the Director of Nursing (DON) stated staff do not need to wear a N95 face mask since unvaccinated residents were tested for COVID-19 prior to admission. The DON stated staff only needed to wear a surgical mask and a face shield. The DON did not present a professional source for this information during the interview. Review of Centers for Disease Control (CDC) guidance, dated 09/10/21, indicated . In general, all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission . HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator) .