**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 18 sampled residents, that the facility did not ensure that a resident with pressure ulcers (PU) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, treatments were not put in place to prevent new pressure ulcers from developing. Resident identifier: 122. Findings include: Resident 122 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of third cervical vertebra, central cord syndrome at C3 level of cervical spinal cord, traumatic subarachnoid hemorrhage without loss of consciousness, and pressure ulcer of sacral region, unspecified stage. Review of records was completed on 2/7/24. A review of the hospital discharge orders dated 1/5/24 revealed the following: discharge wound care instructions. Wound Dressing Location: Coccyx-Remove dressing, cleanse w/ [with] NS [normal saline] and gauze. -Apply Triad cream to wound bed. -Cover w/ PUP [pressure ulcer prevention] dressing. This order is to be carried out daily. On 1/5/24 a physician's order was started for Wound care Coccyx: 1-Remove dressing 2-cleanse with NS and gauze 3- Apply Triad cream to wound bed 4- Cover with PUP dressing Change daily and PRN [as needed] Special Instructions: DX [diagnosis]: wound care Once A Day 07:30 - 09:30. The physician's order was discontinued on 1/6/24. On 2/7/24 at 9:31 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the hospital initiated resident 122's transfer sending over discharge documents which included the orders three different times and at the last minute the hospital held the transfer. The DON stated the orders were entered in preparation of the transfer of resident 122 and when the transfer was pulled the orders needed to be discontinued. A review of resident 122's admission Oral and Skin assessment dated [DATE] revealed a drawing of the backside of the human form with a circle on the area of the coccyx with a label of red. A review of resident 122's admission Nursing Observation Detail List Report dated 1/6/24 revealed the following: Resident 122 had received a Braden Risk Score of 15, which indicated moderate risk of development of pressure ulcers due to limited ability to walk, must be assisted into chair or wheelchair, and unable to make frequent or significant changes to body position independently. A care plan for risk for developing pressure ulcers related to impaired mobility was initiated on 1/6/24. Interventions identified in the care plan included: Standard wheelchair cushion, weekly skin assessment by Licensed Nurse, assist/prompt turn every 2 hours, barrier ointment, air mattress. A review of resident 122's Baseline Person Centered Care Plan Form dated 1/6/24 revealed a care plan for risk of/or actual alteration in skin integrity was circled. With the goal to decreased risk of developing (additional) areas of altered skin integrity. The following treatments were checked: barrier ointment, assist/prompt turn every 2 hours, dressing per MD order. This care plan was crossed out on the form. On 1/6/24 at 6:15 PM a nursing progress note revealed .Pt [patient] educated on the importance of offloading and getting out of bed to prevent skin breakdown . No documentation was located for wound care prevention for 1/6/24, 1/7/24, and 1/8/24. On 1/9/24 a wound care progress note revealed an initial wound evaluation was done on resident 122. A stage 2 pressure ulcer wound was located on coccyx. Plan of care for coccyx: Venelex and barrier cream cover with bordered foam. Change once daily and PRN. Rotate every 1 - 2 hours to offload pressure. Orders discussed with wound nurse. On 1/9/24 at 1:27 PM a nursing progress note revealed resident 122 was seen by wound care Physicians Assistant (PA). Coccyx pressure ulcer: apply Venelex and barrier cream. Cover with bordered foam dressing. Change once daily and PRN. Start air mattress. Rotate Q (every) 1-2 hours to offload pressure. On 2/07/24 at 11:47 AM an interview was conducted with Admissions/Discharges (AD). AD stated during the admissions process she would put in all the orders from the discharging facility. AD stated that she would call and get a nursing report from the discharging facility and then give the report to the floor nurse. AD stated when the newly admitted resident arrived she will do a full body skin assessment, pain interview and a (Brief Interview of Mental Status) BIMS. AD stated there is a admission Skin Assessment Form to document any notes and findings, the form would be uploaded to the resident's medical record. AD stated she would put in a nursing progress note if the skin assessment needed to be explained in more detail or clarify an order. AD stated that she did not do resident 122's entrance assessment. On 2/07/24 at 11:43 AM an interview was conducted with Registered Nurse (RN) 1. RN 1 stated admissions would do the first assessment and put in orders for the arriving resident. RN 1 stated once the resident was set up in the room she would then do a full skin assessment and document any finding in a nursing progress note. RN 1 stated if any skin issues were found she would review the admitting orders, if there were none she would inform the physician and wound care PA of her findings to get any further instructions. On 2/07/24 at 9:31 AM, an interview with the Regional Director of Clinical Services (RDCS) was conducted. RDCS stated that resident 122 skin assessment stated redness to buttock on 1/6/24 and on 1/9/24 the Wound Care PA classified coccyx with a stage 2 Pressure Ulcer. On 2/07/24 at 9:31 AM, an interview with the DON was conducted. The DON stated that resident 122 was admitted on a Saturday and the Wound Care PA did not come until Tuesday. The DON stated that resident 122 scored a 15 on the Braden Risk Score which put her at moderate risk. The DON stated resident was scheduled to have skin assessments on Fridays, a standard wheelchair cushion, Assist/Prompt turning every 2 hours, barrier ointment, and an air mattress. On 2/07/24 at 11:59 AM, a follow up interview was conducted with the DON. The DON stated she would expect, if there were not orders from the hospital, nursing staffing was to contact the physician and/or wound care provider for any additional treatment. The DON stated that she was not able to find wound care prevention for 1/6/24, 1/7/24 and 1/8/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, insulin pens were open and available for use past the expiration date. Resident Identifiers: 122 and 171. Findings included: 1. On [DATE] at 8:18 AM, an observation was made of the 500 hallway medication cart with Registered Nurse (RN) 1, the following medications were located inside: a. A pre-filled pen of Lispro Injection Kwikpen 100 unit/ml (milliliters). Medication was opened and available for use and labeled with an open date of [DATE] and resident 122's name. b. A pre-filled pen of Victoza 0.6 mg (milligrams)/0.1 ml (18 mg/3 ml). Medication was opened and available for use and labeled with an open date of [DATE] and resident 171's name. c. A pre-filled pen of Lispro Injection Kwikpen 100 unit/ml. Medication was opened and available for use and labeled with an open date of [DATE] and resident 171's name. On [DATE] at 8:22 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the insulin's in the medication cart were actively being used for the residents. And if an insulin was needed, the nurses would go to the medication room and get a new one. RN 1 stated when they got a new one they dated it and placed it in the cart. RN 1 was unsure how long insulin was good for after being opened. On [DATE] at 8:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated insulin was kept in the medication cart for the residents that were on it, and if they ran out then there was more in the medication room. LPN 1 stated the nurses were supposed to date the insulin when they got it from the medication room. On [DATE] at 9:30 AM, an interview as conducted with the Director of Nursing (DON). The DON stated once an insulin pen was opened the nurses should date, time and put the expiration on it. The DON stated the insulin should only be in the medication cart for 28 days when opened. The DON stated the insulin's in the cart are being used by the residents and there should not be any expired insulin in the carts. On [DATE] at 11:45 AM, the DON provided a form titled, [Local Pharmacy] Packing List that documented resident 122 had been provided insulin at the facility on [DATE] and [DATE] and stated she did not know where the expired insulin had come from. When this survey and the DON went to look at the insulin in the cart, it had already been discarded by the facility.

Based on observation and interview it was determined that the facility did not ensure that the residents' medical records were secure and confidential. Specifically, observations were made of a computer screen and paperwork left unattended and displaying residents' personal information. Findings included: On 2/6/24 at 7:50 AM, paperwork with resident information which included, resident names, medical diagnoses, and code status was left face up on top of the medication cart in the 500 hallway. Registered Nurse (RN) 1 was observed to leave the resident information on top of the cart unattended. Other residents were observed near the medication cart. On 2/6/24 at 8:10 AM, a computer on the medication cart in the 500 hallway was observed. The computer was open to a resident's medical record. Paperwork with resident information which included resident names, medical diagnoses, and code status was left face up on top of the medication cart. RN 1 was observed to leave the medication cart and the 500 hallway. Other residents and family members were observed in the 500 hallway and near the medication cart. On 2/6/24 at 8:45 AM, an interview was conducted with RN 1. RN 1 stated the computer and any medical records needed to be locked or covered if not in use to protect resident privacy. On 2/7/24 at 9:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated when a nurse left the cart they should not leave anything on top, the computer should not be left open to resident information, and the cart should be locked. The DON stated they should not leave anything that has resident information on it that other residents or family members could see.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Specifically, a staff member was observed to not perform hand hygiene in between residents during meal service, unwrapped and touched the ends of the straws with ungloved hands then placed them in resident's beverages, and picked up a syrup container from the floor and placed it on a resident's table. Findings included: On 2/6/24, the following observations were made during lunch service in the resident dining room: a. At 12:05 PM, CNA 1 was observed to unwrap Resident 171's straw with ungloved hands. Resident 171 touched the top of the straw and inserted it into the resident's beverage. No hand hygiene was performed. b. At 12:06 PM, CNA 1 was observed to run his hands through his hair then deliver a tray of food to Resident 171 without hand hygiene being performed. c. At 12:10 PM, CNA 1 was observed to touch the shoulders of Resident 119, place his hands into his pockets before delivering a food tray to a resident without hand hygiene being performed. d. At 12:11 PM, CNA 1 was observed to unwrap Resident 110 straw with ungloved hands. CNA 1 was observed to touch the top of the straw and inserted it into the resident's beverage without hand hygiene being performed. e. At 12:12 PM, CNA 1 was observed to touch the handles of Resident 4's wheelchair and then deliver a food tray to a resident without hand hygiene being performed. On 2/7/24, the following observations were made during breakfast service in the resident dining room: f. At 8:34 AM, CNA 1 was observed to pin a napkin to a resident's shoulders. CNA 1 was observed to then unwrap a straw with ungloved hands, CNA 1 touched the top of the straw and placed it into a different resident's beverage without hand hygiene being performed. g. At 8:40 AM, CNA 1 was observed to pick up a syrup container from the floor of the dining room and placed it back on the table next to a resident's plate. On 2/7/24 at 10:08 AM, an interview was conducted with CNA 1. CNA 1 stated that there was no formal training to assist the residents in the dining room and that it was standard practice for staff to unwrap the straws without gloves on and place them in the resident's beverages. CNA 1 stated if things fell on the floor they should be thrown away. On 2/7/24 at 10:15 AM, an interview was conducted with CNA 2. CNA 2 stated that staff unwrap the straws for residents, but hand hygiene should occur in between residents. On 2/7/24 at 10:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that CNA's helped the residents in the dining room and that staff were trained in assisting the residents. The DON stated it was standard practice to remove the paper from the bottom of the straw while leaving the paper on the top for the resident to remove. Hand hygiene was performed between residents and anything that fell onto the floor should be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 16 sampled residents, the facility did not ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident admitted with pressure sores did not have measurements obtained for 6 days and no treatments were provided during that time. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] with diagnoses which included sepsis, acute respiratory failure with hypoxia, spinal stenosis, open wound of lower back and pelvis without penetration into retroperitoneum, and urinary tract infection. On 7/5/22 at 10:40 AM, an interview was conducted with resident 7. Resident 7 stated she had a wound on her back for the last year. Resident 7 stated that the facility staff were helping to heel it up. Resident 7 was observed her to be in a wheelchair with a cushion in the seat, there were pillows on either side of her and an air mattress was on her bed. Resident 7 was observed to have a wooden stool under her heels while sitting in the wheelchair. Resident 7's right heel was observed resting on the stool and there was no observed bandage on resident 7's right heel. On 7/6/22 at 11:58 AM, a continual observation was conducted of resident 7. Resident 7 was observed to be sitting in a wheelchair with a wooden board on the floor under her feet. Resident 7's right foot was pressed against the wooden board. At 12:53 PM, Physical Therapist Assistant (PTA) 1, 2 therapy students, and a family member were observed to enter resident 7's room. Resident 7 was observed to have her feet on a board. A therapy student was observed to place gripper socks on resident 7's feet and a tennis shoe on the right foot. There was no observed bandage on resident 7's right heel. Resident 7's medical record was reviewed on 7/7/22. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 7 had 2 unstageable pressure ulcers. The MDS further revealed resident 7 was at risk for developing pressure ulcers. The MDS revealed resident 7 had a pressure reducing device to chair and bed. The MDS revealed resident 7 was on a repositioning program, nutrition or hydration intervention management program, pressure ulcer care, applications of non surgical dressing and ointments/medications. Resident 7 was assessed on the MDS as having a Brief Interview for Mental Status score of 15 which indicated that resident 7 was cognitively intact. A care plan dated 6/10/22 revealed there was an actual impaired skin integrity related to unstageable sacral pressure ulcer and unstageable heel pressure ulcer. A goal developed was that the wound would heal without signs or symptoms of infection within 30 days. Interventions included to encourage and assist to reposition at lease every 2 hours, barrier ointment, pressure reducing cushion to wheelchair, air mattress to bed, request supplements and increased protein to promote healing per Registered Dietitian recommendation and physician orders. Interventions further revealed minimize irritation and pressure to affected area, keep affected area clean and dry, measure wound area at least weekly to monitor response to treatment, monitor for increased redness, change in skin temperature or abnormal exudates and treatment per current physician's orders. The facility matrix revealed resident 7 had a stage III pressure ulcer. An admission progress note revealed on 6/1/22 at 5:20 PM, . She has an unstageable pressure ulcer on her coccyx due to slough. She has an Abrasion on her R (right) heel that was an ulcer per the patient. She has abrasions on both her ankles on the posterior aspect. All wounds have been cleaned and redressed. She has a small abrasion on her RLQ (right lower quadrant) abd (abdomen) she say is from her briefs. She has very thin skin. An admission skin assessment form dated 6/1/22 in resident 7's medical record was signed by the Admissions/discharge nurse. The form revealed an ulcer on resident 7's right heel. There were no other ulcers identified on the form. The same form in the professional wound specialist notes signed by the Admission/discharge nurse had an ulcer on the coccyx area. According to the Professional Wound Specialist Wound Care Progress note measurements were completed on 6/7/22. The note revealed resident 7 had a sacrum pressure ulcer that was unstageable 7 centimeters (cm) by 12.5 cm and unable to determine the depth. Resident 7 had a right heel pressure ulcer that was unstageable 1 cm by 2.5 cm with an unable to determine depth. There were no measurements documented prior to 6/7/22 for the pressure ulcers. Physician's order dated 6/1/22 through 6/7/22 revealed there were no orders for treatments for resident 7's right heel ulcer. Physician orders dated 6/7/22 and discontinued on 7/5/22 were Right heel pressure ulcer 1. Remove dressing and cleanse if needed 2. Apply Medihoney 3. Apply boarder foam on Tuesday, Thursday and Saturday. Resident 7's Medication and Treatment Administration Record was reviewed for June 2022. There was no treatments completed 6/1/22 through 6/7/22 for resident 7's right heel. A progress note dated 6/2/22 at 10:50 PM revealed dressing to sacral area was changed and the wound had two areas of eschar with surrounding redness and open area. A progress note dated 6/5/22 at 11:09 PM revealed there was a pressure ulcer on her coccyx. Resident 7 had an abrasion on her right heel that was an ulcer per the patient. Resident 7 had an abrasion on both of her ankles on the posterior aspect. Coccyx wounds had been cleaned and redressed. On 6/7/22 the facility wound Physician's Assistant (PA) documented Patient was seen by [name removed] PA and wound specialist new orders: 1. For pressure ulcer on sacrum-Apply santyl to necrotic tissue and Cavillon barrier around the wound. Cover with boarder gauze and change once daily 2. For pressure ulcer on right heel-Apply medihoney and boarder foam 3X [times]/week. 3. For psoriasis areas on legs bilaterally-mix triamcinalone and abx (antibiotic) ointment and apply to legs Q (every) shift On 7/6/22 at 3:44 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 7 had a pressure sore on her coccyx area and was seen by the wound specialist every Tuesday. RN 1 stated the wound specialist performed measurements and changed treatment orders. On 7/6/22 at 3:51 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that upon admission the process was for the nurse to complete an admission skin assessment and place it into the wound book and also input the information into the electronic medical record. The ADON stated that the Director of Nursing usually attended rounds with the wounds specialist every Tuesday. The ADON stated that resident 7 was admitted with 2 pressure ulcers. The ADON stated the first would was on the sacrum and measurements were completed on 6/7/22. The ADON stated that resident 7 was admitted on [DATE] which was a Wednesday so there were no measurements until the wound specialist came on Tuesdays. The ADON stated it looked like the wound specialist would have been here on 6/7/22 for the first time and would have measured them. The ADON stated resident 7 had admission orders from the hospital to follow up with wound clinic and there was an order for the coccyx wound. The ADON stated that orders for the right heel started on 6/7/22. The ADON stated that the admission/discharge nurse completed the skin assessment upon admission. The ADON stated she was unable to find orders for the right heel from 6/1/22 through 6/7/22. the ADON stated that there were no measurements completed until 6/7/22. On 7/6/22 at 4:04 PM, an interview was conducted with the Admission/Discharge Nurse. The Nurse stated he wrote in a progress note on 6/1/22 regarding resident 7's wounds upon admission. The Nurse stated resident 7 told him the right heel was an abrasion. The Nurse stated he documented an ulcer on the right heel on the admission skin assessment form so that the wound specialist would look at it. The Nurse stated that the wound specialist did not look at abrasions so he documented an ulcer. The Nurse stated he could not remember what the wound on the right heel looked like upon admission. The Nurse stated there was a dressing on the right heel and he changed the dressing according to the hospital orders. The Nurse and ADON were unable to find orders for the right heel to have a dressing. The Nurse stated he cleaned the right heel with wound cleanser and put a boarder dressing on it. The Nurse stated he could not do a dressing change without a physician's order. The Nurse stated there were no physician's orders for resident 7's right heel until 6/7/22. On 7/6/22 at 4:35 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated resident 7 sometimes used a bin or trash can under her foot right foot while in her wheelchair. CNA 2 stated the trash can or bin were used to take the pressure off her legs. CNA 2 stated when resident 7 was in bed, she used a heel riser. CNA 2 stated resident 7 had an air mattress and was repositioned every 2 hours when she was in bed. CNA 2 stated resident 7 had pillows in her wheelchair to assist with her readjusting. On 7/6/22 at 4:36 PM, an interview was conducted with CNA 3. CNA 3 stated resident 7 used a little footboard with pillows on it when she was in her wheelchair. CNA 3 stated resident 7 used the pillows and footboard so her feet did not dangle when she was sitting in the wheelchair. CNA 3 stated resident 7 had a pressure ulcer on her backside. CNA 3 stated resident 7 used a u shaped donut in her wheelchair. CNA 3 stated resident 7 had a pillow under her legs while she was in bed and a pillow on the board. CNA 3 stated resident 7 usually wore a shoe and socks when she was in her wheelchair. On 7/7/22 at 8:40 AM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident was admitted a wound assessment was completed. The DON stated staff were to follow discharges orders from the hospital for wound care. The DON stated the wound specialist came every Tuesday to look at any wounds. The DON stated nursing staff did a weekly skin assessment sheet that was given to the DON so that wounds were addressed. The DON stated if a wound was noticed upon admission with no admit orders then the facility nurse practitioner looked at the wound and provided orders. The DON stated that she was able to text the facility wound specialist and receive new orders. The DON stated resident 7 was admitted with an unstageable pressure sore on her coccyx and right heel. The DON stated that both wounds were unstageable according to the wound specialist. The DON stated the right heel was healing quiet well. The DON stated the wound orders for the right heel were recently changed to be open to air and offload pressure. The DON stated she was not sure if the Admission/discharge nurse took measurements of resident 7's wounds upon admission. The DON stated there were orders on 6/1/22 for the coccyx ulcer. The DON stated resident 7 had an air bed, floating heels while in bed, cushion in wheelchair, boost, juven, repositioning every 2 hours, patient education and barrier ointment. The DON stated there were no orders for the right heel from 6/1/22 to 6/7/22. The DON stated she was not sure about the board on the floor she used when sitting in her wheelchair. On 7/7/22 at 8:58 AM, an interview was conducted with PTA 1. PTA 1 stated resident 7 had nerve pain and the board helped. PTA 1 stated the board helped fit resident 7's height. PTA 1 stated resident 7 was generally flat footed and a pillow was alternated on the board for her comfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 13 sampled residents, that the facility did not ensure that a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections. Specifically, a resident with signs and symptoms of a urinary tract infection (UTI) was not assessed or treated for those symptoms. Resident identifier 12. Findings included: Resident 12 was admitted to the facility on [DATE] with diagnoses which consisted of rhabdomyolysis, urinary tract infection, mood (affective) disorder, dehydration, obesity, gastro-esophageal reflux disease, pain left knee, repeated falls, diarrhea, and edema. On 7/05/22 at 10:25 AM, an interview was conducted with resident 12. Resident 12 stated that she had just finished a course of antibiotics for a UTI approximately 3 or 4 days ago. Resident 12 stated that this was the third UTI she had experienced this year. Resident 12 stated that her symptoms of a UTI still persisted and she complained of burning, pain, urgency, and increased frequency with urination. Resident 12 stated that she required assistance with toileting when she was admitted , but that she was able to toilet herself now. Review of resident 12's admission Minimum Data Set (MDS) Assessment on 6/18/22 revealed that resident 12 was occasionally incontinent of urine and bowel. The assessment further documented that resident 12 was a one person extensive assist for toileting. Review of resident 12's physician orders revealed the following: a. Cephalexin 500 milligrams (mg) by mouth four times a day. The order was initiated on 6/12/22, and discontinued on 6/14/22. b. Sulfamethoxazole-trimethoprim 800-160 mg by mouth two times a day. The order was initiated on 6/21/22, and discontinued on 6/28/22. c. Urinalysis (UA) with Culture & Sensitivity (C & S), ordered on 6/17/22 d. Torsemide 10 mg by mouth daily. The order was initiated on 6/14/22. Review of resident 12's Medication Administration Record (MAR) documented that the Cephalexin was administered on 6/12/22 through 6/14/22 for a total of 10 doses administered. The MAR documented that the Sulfamethoxazole-Trimethoprim was administered on 6/21/22 through 6/28/22 for a total of 15 doses administered. On 6/17/22, resident 12's UA documented the following out of range values: large leukocyte, greater (>) than 30 [NAME] Blood Cells (WBC), 20 Red Blood Cells (RBC), 1 plus (+) bacteria, and 1+ mucus. On 6/21/22, the urine culture documented >100,000 Enterobacter cloacae carbapenem resistant that was susceptible to Trimethoprim/Sulfamethoxazole. Review of resident 12's progress notes revealed the following: a. On 6/12/22 at 3:23 PM, the note documented, Patient admitted to us from [name of hospital] today. She arrived at 1400 [2:00 PM] via wheelchair. She is alert and oriented x [times] 4 [person, place, time and situation]. She is here due to weakness and UTI. She is currently being treated with Keflex- for 2 more days. b. On 6/16/22 at 12:57 AM, the note documented that the resident was no longer on antibiotics and the UTI had resolved. c. On 6/16/22 at 4:28 PM, the note documented that resident 12 was alert and oriented with some confusion at times and a little slow to respond. d. On 6/17/22 at 3:02 AM, the note documented a new order to obtain a UA with C&S for bladder spasms and tenderness. e. On 6/17/22 at 2:06 PM, the physician note documented, Patient endorses increased urgency and urinary incontinence as well as dysuria. The resident was documented as alert and oriented. f. On 6/20/22 at 2:38 PM, the note documented, Pt [patient] admits for weakness et [and] a UTI. She was on an abx [antibiotics] but it has been completed. Yet she is c/o [complaining of] frequency, burning, et [and] painful urination et believes she has a UTI et is asking to see the NP [nurse practitioner]. UA was sent several days ago et C & S pending. g. On 6/21/22 at 4:15 PM, the note documented that the urine culture results were received and that the physician ordered to start the resident on an antibiotic for 7 days for a UTI. h. On 6/24/22 at 4:55 PM, the note documented, Bactrim DS being given through 6/28/22 for UTI. She is still c/o painful urination et frequency. i. On 6/25/22 at 10:12 PM, the note documented, Pt continues on PO Bactrim for UTI. States that she is no longer having any s/s [signs and symptoms] of UTI. j. On 6/26/22 at 10:59 AM, the note documented that the resident was alert and oriented x 4. k. On 6/26/22 at 3:51 PM, the note documented that the resident was alert and oriented x 4. l. On 6/27/22 at 9:54 PM, the note documented, Pt continues on Sulfamethoxazole-trimethoprim for UTI until 6/28. Pt reports she no longer has burning or frequency with urination. m. On 6/28/22 at 4:20 PM, the note documented that the resident was alert and oriented x 4. n. On 6/28/22 at 8:49 PM, the note documented, Pt took last dose of sulfamethoxazole trimethoprim for UTI tonight. o. On 6/29/22 at 4:35 PM, the note documented that the resident was alert and oriented x 4. p. On 6/30/22 at 6:53 PM, the note documented that the resident was alert and oriented x 3-4 and was able to verbalize needs. q. On 7/1/22 at 1:45 PM, the note documented that the resident was alert and oriented x 3. r. On 7/3/22 at 1:03 PM, the note documented that the resident was alert and oriented x 3 and was a one person assist for transfers, activities of daily living, toileting, and grooming. s. On 7/6/22 at 7:22 AM, the note documented a late entry for 7/2/22 AM shift, . A/OX2 [alert and oriented x 2], with episodes of confusion and forgetfulness, . t. On 7/6/22 at 3:05 PM, the note documented that the resident was alert and oriented x 2 with some confusion and responded in a low voice. On 7/7/22 at 8:58 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that she assisted resident 12 yesterday with toileting approximately 4 to 5 times. CNA 1 stated that resident 12 was voiding more often. CNA 1 stated that she told the licensed nurse that the resident was calling more often and was reporting that she felt like she was urinating more frequently than normal. CNA 1 stated that the resident did not report any burning or pain with urination. On 7/7/22 at 8:59 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she monitored for a UTI with any complaints of increased frequency and burning with urination or confusion. LPN 1 stated that if the resident showed any signs and symptoms (s/sx.) they would obtain a urine sample. LPN 1 stated that a UA for s/sx of a suspected UTI was a standing physician order. LPN 1 stated that they continued to monitor for s/sx post antibiotic treatment for 3 days after the completion of an antibiotic. LPN 1 stated that she did not receive in report that resident 12 was experiencing any s/sx of a UTI. On 7/7/22 at 9:34 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that the nursing staff should monitor for any s/sx of a UTI and chart their assessment in the progress notes. The CRN stated that after the completion of the antibiotics the licensed nurse should chart in a progress note any continued s/sx of a UTI. The CRN stated that s/sx of a UTI were increased frequency of urination, odor, change in color, altered mental status, or decreased urine output. The CRN stated that the licensed nurse should notify the physician of any reports of increased frequency. The CRN stated that the resident was on Torsemide and this could contribute to increased frequency, but that it was something that should be ruled out as a potential UTI. The CRN stated that the licensed nurse had standing orders for a dipstick test of the urine and if it was positive for luekocytes, blood, and nitrates they could send a UA. The CRN stated that the licensed nurse would document the dipstick results in a progress notes. The CRN confirmed that there was no documentation of a dipstick test results and stated that since it was not there she assumed they did not complete one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 16 sampled residents that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, a medication was not administered for 3 days due to being unavailable from the pharmacy. Resident identifier 9. Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which consisted of pleural effusion, nondisplaced fracture of second cervical vertebra, heart transplant status, immunodeficiency, benign paroxysmal vertigo, chronic respiratory failure, squamous cell carcinoma of skin, type 2 diabetes mellitus, fluid overload, hypomagnesemia, hyperlipidemia, insomnia, adult failure to thrive, long term use of anticoagulants, and a history of deep vein thrombosis. Review of resident 9's physician orders revealed the following: a. Calcium/Vitamin D3 600 milligrams (mg) - 10 micrograms (mcg). The order was initiated on 6/14/22, and discontinued on 6/20/22. b. Calcium/Vitamin D3 600/200 mg every day. The order was initiated on 6/20/22. Review of resident 9's Medication Administration Record (MAR) revealed that the Calcium/Vitamin D3 600 mg - 10 mcg was not administered on 6/16/22, 6/17/22, and 6/19/22. The medication was documented as Drug/Item unavailable and that the pharmacy was notified. The medication was marked as administered on 6/15/22 and 6/20/22. On 7/6/22 at 3:58 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that she would look at the normal stock items for Calcium to see if the Calcium/Vitamin D3 600-10 mcg was a stock item. The CRN stated that the policy for a drug that was unavailable was to let the order go red in the electronic medical records; then call the pharmacy to have them deliver; and then administer the medication late. The CRN stated that the licensed nurse should notify the physician and document in the progress notes. The CRN stated that the pharmacy delivery was the same day, and it should not have taken that long to receive the Calcium medication. On 7/7/22 at 9:06 AM, a follow-up interview was conducted with the CRN. The CRN stated that the Calcium stock was not the 10 mcg of Vitamin D3, and the medication would have to be ordered from the pharmacy. The CRN stated that it was possible that the licensed nurse administered the house stock Calcium on 6/15/22 until the correct order arrived.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 16 sampled residents, that the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, a resident was treated with an antibiotic for a Urinary Tract Infection (UTI) without verifying that the antibiotic used was susceptible to the microorganism identified. Resident identifier 9. Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which consisted of pleural effusion, nondisplaced fracture of second cervical vertebra, heart transplant status, immunodeficiency, benign paroxysmal vertigo, chronic respiratory failure, squamous cell carcinoma of skin, type 2 diabetes mellitus, fluid overload, hypomagnesemia, hyperlipidemia, insomnia, adult failure to thrive, long term use of anticoagulants, and a history of deep vein thrombosis. On 6/20/22, resident 9's admission Minimum Data Set (MDS) Assessment documented that resident 9 was a two person extensive assist for toilet use. The assessment further documented that resident 9 was always incontinent of urine and occasionally incontinent of bowel. Review of resident 9's physician orders revealed the following: a. Urinalysis (UA) with Culture and Sensitivity (C & S) for cloudy urine. The order was initiated on 6/21/22. b. Bactrim DS 800-160 milligrams (mg) two times a day. The order was initiated on 6/22/22 and discontinued on 6/29/22. Review of resident 9's Medication Administration Record (MAR) revealed that the Bactrim DS was administered on 6/22/22 through 6/29/22 for a total of 15 doses administered. On 6/21/22, resident 9's UA documented the following out of range values: Hemoglobin moderate, Protein was 30 (1 plus), Leukocytes esterase was large, [NAME] Blood Cells (WBC) greater (>) than 30, Red Blood Cells (RBC) >30, and Bacteria 3 plus (+). On 6/21/22 the urine culture documented 25,000 colony-forming unit (cfu)/ milliliter (ml) of Aerococcus urinae. The culture results did not contain a susceptibility report. On 7/6/22 at 3:58 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that the sensitivity report for the UA on 6/21/22 may be located in medical records and still and needed to be scanned into the electronic records. On 7/7/22 at 8:59 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she monitored for a UTI with any complaints of increased frequency and burning with urination or confusion. LPN 1 stated that if the resident showed any signs and symptoms (s/sx) of a UTI they would obtain a urine sample. LPN 1 stated that a UA for s/sx of a suspected UTI was a standing physician order. LPN 1 stated that they continued to monitor for s/sx post antibiotic treatment for 3 days after the completion of an antibiotic. On 7/7/22 at 9:06 AM, an follow-up interview was conducted with the CRN. The CRN stated that they did not do a sensitivity on the culture from 6/21/22. The CRN stated that they did not know if the Bactrim DS was the appropriate antibiotic to treat the infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 5 sample staff members, the facility did not ensure that unvaccinated staff members were tested for COVID-19 on a routine basis. Specifically, a unvaccinated staff member was not tested for COVID-19 according to the county transmission rate. Staff Identifier: 1 and 2. Findings included: The facility staff vaccine matrix was reviewed. Staff member 1 and staff member 2 were documented as having exemptions for the COVID-19 vaccination. The facility provided a form with community and transmission levels for COVID-19 which revealed the following: On 4/6/22, the transmission rate was yellow. On 4/15/22, the transmission rate was yellow. On 4/22/22, the transmission rate was yellow. On 4/27/22, the transmission rate was yellow. On 5/5/22, the transmission rate was orange. On 5/13/22, the transmission rate was red. On 5/19/22, the transmission rate was red. On 5/26/22, the transmission rate was red. On 6/2/22, the transmission rate was red. On 6/7/22, the transmission rate was red. On 6/16/22, the transmission rate was red. On 6/23/22, the transmission rate was red. On 6/30/22, the transmission rate was red. Staff member 1 was not tested 4/1/22 though 6/4/22. Staff member 1 was tested on [DATE], 6/13/22, 6/14/22, 6/26/22 and 7/5/22. According to Staff member 1 time sheet, she worked on 4/9/22, 4/10/22, 4/30/22, 5/13/22, 5/14/22, 5/15/22, 5/27/22, 5/28/22, 6/5/22, 6/12/22, 6/13/22, 6/19/22, 6/26/22, and 6/27/22. Staff member 2 worked 4/17/22, 4/20/22, 4/23/22 and there was no documentation of COVID testing during that week for staff member 2. Staff member 2 worked 6/21/22, 6/22/22, 6/23/22 and was tested on ce that week on 6/23/22. A policy and procedure without a date titled Testing Plan for Testing Residents and HCP (Health Care Personnel) for SARS-CoV-2 revealed, .In nursing homes located in counties with substantial to high community transmission, these HCP should have viral test twice a week. If these HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift. On 7/7/22 at 11:22 AM, an email from the facility Administrator was provided. The Administrator stated these two have not been very consistent with testing even though they have been reminded many times by text, email, and face to face. On 7/7/22 at 12:12 PM, an interview was conducted with the Corporate Resource Nurse (CRN) and Director of Nursing (DON). The CRN stated unvaccinated staff testing depended on the community transmission rate and associated color level. The CRN stated the current county transmission rate was red and testing was to be completed twice weekly.

Based on observation, interview and record review it was determined the facility did not follow policy and procedures for staff with COVID-19 vaccination exemptions. Specifically, staff with COVID-19 vaccination exemptions were not wearing personal protective equipment according to the facility's policy and procedures. Findings included: On 7/6/22 at 8:07 AM, the Administrator provided a list of staff that were vaccinated and unvaccinated. Registered Nurse (RN) 1 was listed as full time RN with an exemption. On 7/6/22 at 8:04 AM, an interview was conducted with RN 1. RN 1 was observed wearing a surgical mask and eye protection in the resident hallways and rooms. On 7/6/22 at 8:35 AM, an observation was made of RN 1. RN 1 was discussing a resident's appointment with the transportation staff (TS). RN 1 was observed wearing a surgical mask and eye protection in the resident hallways and rooms. On 7/6/22 at 3:44 PM, an observation was made of RN 1. RN 1 was observed at the nurses station with staff members and residents walking by. RN 1 was observed to be wearing a surgical mask and eye protection. A COVID-19 Vaccination Plan (Staff) [F888] version: C0321 provided by the Administrator on 7/5/22 at 12:38 PM revealed, Additional Precautions and Contingency Plans for Unvaccinated/Not Completely Vaccinated Staff . Requiring staff who have not completed their primary vaccination series to use NIOSH-approved N95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients. On 7/7/22 at 12:12 PM, an interview was conducted with Corporate Resource Nurse (CRN) and Director of Nursing (DON). CRN stated unvaccinated staff should be wearing an N95 mask the entire time they were working. CRN stated she was not sure what type of mask RN 1 was wearing. Additional information was provided on 7/8/22 at 1:20 PM. The Administrator stated that the Corporate Resource Nurse (CRN) provided a general company policy and procedure that required unvaccinated staff to wear N95 masks during the recertification survey. The Administrator stated that the policy and procedure changed to it is recommended for the last 2 to 3 months. The Administrator provided page 9 of version: CO321 which revealed .It is recommended that staff who have not completed their primary vaccination series to use a NIOSH-approved N95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 7 out of 16 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, staff entered rooms on Transmission Based Precautions without the required Personal Protective Equipment (PPE) donned, staff wore PPE incorrectly, staff did not donn the required PPE during transport of a resident on contact precautions, staff did not inform outside providers of an infectious resident prior to their scheduled appointment, staff did not disinfect eye protection upon exit of droplet precaution rooms, and the facility tracking and trending was not completed for all infections and communicable diseases. Resident identifiers: 2, 9, 69, 70, 71, 117, and 124. Findings included: 1. Resident 117 was admitted to the facility on [DATE] with diagnoses which included multiple fractures of the pelvis, congestive heart failure, type 2 diabetes mellitus, hyperlipidemia, atrial fibrillation, depression, obesity, sleep apnea, thrombophilia, and benign prostatic hyperplasia. On 7/5/22 at 9:39 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 117 was a new admission on quarantine with contact/droplet precautions for one week due to not being fully vaccinated for COVID-19. LPN 2 stated that the required PPE in quarantine rooms was a gown, gloves, surgical mask and goggles. LPN 2 stated that she did not donn a N95 mask to enter resident 117's room. LPN 2 was observed wearing a surgical mask and eye goggles. An observation was made outside of resident 117's room of signs posted for quarantine with instructions for donning and doffing PPE. The sign stated to donn a gown, N95 mask, eye protection and gloves. A PPE cart was located just outside of resident 117's door and contained gloves, cloth gowns, N95 masks, hand sanitizer, Lysol wipes, and clean quick disinfectant. Review of resident 117's physician orders revealed an order for . Quarantine x [times] 7 days, if negative rapid antigen test on day 7. The order was initiated on 7/1/22 with an end date on 7/7/22. Review of resident 117's vaccination records revealed a COVID-19 vaccine on 2/10/21 and 3/10/21 with a COVID-19 vaccine booster on 2/14/22. No documentation was found of resident 117's second booster for COVID-19. On 7/5/22 at 9:47 AM, an observation was made of Certified Nurse Assistant (CNA) 4 exiting resident 117's room. CNA 4 was observed wearing gloves, a surgical mask and eye protection. CNA 4 stated she entered the room, stood by the door and asked the resident what he needed, and then came back out to place a gown on. CNA 4 was observed to donn a reusable gown and re-entered resident 117's room. CNA 4 did not donn an N95 mask to enter the room. On 7/5/22 at 9:50 AM, an observation was made of CNA 5. CNA 5 was observed to donn a gown, N95 mask, gloves and eye protection and then enter resident 117's room to assist CNA 4. On 7/5/22 at 9:59 AM, CNA 4 exited resident 117's room. CNA 4 did not change their surgical mask or disinfect their eye protection. CNA 4 walked away from the room and then returned at 10:03 AM. CNA 4 then donned a gown, gloves, and a N95 mask before entering resident 117's room. CNA 4 stated, for the record, I can't breathe in these. CNA 4 was indicating the N95 mask. On 7/5/22 at 10:08 AM, CNA 5 was observed to exit resident 117's room. CNA 5 performed hand hygiene, doffed the N95 mask, performed hand hygiene again, donned a surgical mask, and then cleansed their eye protection with the clean quick disinfectant. An immediate interview was conducted with CNA 5. CNA 5 stated that they hung the disposable gown inside the room and that was why she did not doff it outside of the room. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which consisted of fracture around the internal prosthetic right knee joint, status post right total knee arthroplasty, spinal stenosis, polyneuropathy, chronic kidney disease, major depressive disorder, atherosclerosis of aorta, hyperlipidemia, chronic lymphocytic leukemia, insomnia, and gastro-esophageal reflux disease. On 7/5/22 at 9:39 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 2 had a new outbreak of shingles that was identified over the weekend. LPN 2 stated that resident 2 was on contact precautions only. An observation was made outside of resident 2's room of signs posted for droplet precautions with instructions for donning and doffing PPE. The droplet was crossed out on the sign and a handwritten Contact was written. The sign stated to donn a gown, N95 mask, eye protection and gloves. A PPE cart was located outside of resident 2's room and contained gloves, disposable gowns, N95 masks, hand sanitizer, Lysol wipes, and clean quick disinfectant. Review of resident 2's physician orders revealed an order for Valacyclovir 1 gram orally every 8 hours for Shingles. The order was initiated on 7/3/22 with an end date of 7/10/22. No documentation could be found of an order for contact precautions. Review of resident 2's physician orders revealed the following: a. On 7/3/22 at 11:20 AM, the note documented, Pt. [patient] reported burning/stinging pain to R [right] scapula, back of R arm, and R armpit, red patches/blisters forming, no reports of itchiness or tingling noted. b. On 7/3/22 at 8:47 PM, the note documented, Patient reports a rash on the back of her left arm and on her back. I took pictures and send them to [name omitted] NP [nurse practitioner]. He thinks it is likely to be shingles. New order: 1.Valacyclovir 1000 mg [milligrams] every 8 hours for 7 days. c. On 7/3/22 at 10:24 PM, the note documented that resident 2 received their first dose of Valacyclovir tonight. d. On 7/4/22 at 2:33 PM, the note documented, Pt's complaint today is the rash she has below left scapula that extends downward to her left side and around to her left breast. Area to back is red et [and] irritated with numerous blisters to anterior side/abd [abdomen]. She rates her pain 8/10. No open areas are observed. Valacyclovir started et she's had no ASE [adverse side effects]. She was put on isolation that also has not made her happy. e. On 7/4/22 at 10:06 PM, the note documented, Pt continues on valacyclovir for shingles until 7/10. Remains on contact precautions. Shingles are blistered and don't appear to have popped yet. Pt reports that they are painful on her back, . f. On 7/5/22 at 3:46 PM, the note documented, Pt on contact isolation d/t [due to] dx [diagnosis] of shingles. She has numerous blistered areas to back, around left side et waist, as well as back of left arm. She has had no c/o [complaints of] ASE d/t the Valacyclovir started. On 7/5/22 at 10:01 AM, an observation was made of the transportation staff (TS) wheeling resident 2 down the hallway and into the resident's room. The TS was observed wearing a surgical mask and eye protection. The TS was not wearing a gown or gloves. On 7/5/22 at 10:06 AM, an interview was conducted with LPN 2. LPN 2 stated that resident 2 had just returned from an appointment with an outside provider. LPN 2 stated that they tried to call the provider prior to the appointment to inform them of resident 2's shingles diagnosis, but no one answered. LPN 2 stated that they sent resident 2 to the appointment without verifying if the provider would like to reschedule or keep the appointment. On 7/6/22 at 8:35 AM, the TS was heard speaking to Registered Nurse (RN) 1. The TS informed RN 1 that resident 2 had an appointment with an outside provider today. RN 1 informed the TS that resident 2 was on contact precautions. The TS stated that shingles was not contagious and it was the same physician office as yesterday, only a different provider in the clinic. RN 1 stated that shingles was contagious and that the resident was on contact precautions. The TS stated that she always donned gloves with resident contact so it should be fine. The TS was observed to enter resident 2's room without donning a gown and gloves. On 7/6/22 at 8:52 AM, an observation was made of RN 1 donning gloves and entering resident 2's room. It should be noted that RN 1 did not don a gown as indicated for contact precautions. On 7/6/22 at 8:55 AM, the TS was observed to enter resident 2's room with a surgical mask and eye protection donned. The TS was observed to assist resident 2 with her phone. At 8:59 AM, the TS was observed to wheel resident 2 out of her room, through the hallway, through the lobby area, and outside into the van. The TS was observed to touch resident 2's hand while in the van, when buckling her into the van. It should be noted that the TS did not don a gown and gloves as indicated for contact precautions when working with resident 2. Review of the facility policy for Contact Precautions stated that they were implemented for residents known or suspected to be infected or colonized with microorganisms that could be transmitted by direct contact with the resident or indirect contact with the environmental surfaces within the resident's environment. The PPE recommended in the policy was gloves and gown during the course of providing care or anticipate contact with the resident or the resident's environmental surfaces. The policy further stated to limit the resident transport and movement for essential purposes only, and if the resident was transported outside of the room to ensure that precautions were maintained. 3. Resident 124 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, atrial fibrillation, chronic kidney disease, Non-ST (NSTEMI) myocardial infarction, atrial septal defect, pulmonary hypertension, acute amebic dysentery, sepsis, antiphospholipid syndrome, diverticulitis, gastrointestinal hemorrhage, and chronic pain. Review of resident 124's orders revealed an order for . Quarantine x [times] 7 days, if negative rapid antigen test on day 7. The order was initiated on 7/6/22 with an end date of 7/12/22. Review of resident 124's vaccination records revealed a COVID-19 vaccine on 2/2/21 and 3/2/21 with a COVID-19 vaccine booster on 10/28/21. No documentation was found of resident 124's second booster for COVID-19. On 7/7/22 at 8:43 AM, an observation was made of LPN 1 entering resident 124's room. LPN 1 donned a gown, gloves prior to entering the room. LPN 1 did not donn an N95 mask and was wearing a surgical mask and eye protection. Resident 124's room was observed with a sign that stated quarantine and a PPE cart was located outside of the room. The sign stated to donn a gown, N95 mask, eye protection and gloves. CNA 1 was observed to exit resident 124's room wearing a surgical mask. An immediate interview was conducted with CNA 1. CNA 1 stated that resident 124 was a new admission that arrived yesterday and they were on quarantine. CNA 1 stated that they wore a gown, mask, gloves, and goggles while inside resident 124's room. CNA 1 stated that they did not have to wear an N95 mask, but it was strongly recommended. CNA 1 stated that if the resident was not positive the N95 mask was a recommendation, but not required. CNA 1 stated that the quarantine room was on droplet precautions and universal precautions. CNA 1 stated that she doffed her N95 mask inside the resident room and put on a surgical mask prior to exiting. CNA 1 pointed to her pocket where her N95 mask was located, and stated that she had placed it inside her pocket until she obtained a zip lock bag for it. CNA 1 stated that they used reusable gowns in the quarantine rooms and disposable gowns in the contact precaution rooms. CNA 1 stated that her gown was located just inside the room, hanging on a hook. CNA 1 did not disinfect their eye protection upon exit of the room. On 7/7/22 at 8:59 AM, an interview was conducted with LPN 1 upon exit of resident 124's room. LPN 1 did not switch their surgical mask or disinfect their eye protection. LPN 1 stated that resident 124 was admitted yesterday. LPN 1 stated that the process for new admits and quarantine was that the resident was tested on admission. If the resident was not fully vaccinated or booster they quarantined the resident for 7 days. LPN 1 stated that the PPE required for quarantine rooms was that staff were to wear a gowns, gloves, goggles and N95 mask. LPN 1 stated that she did not donn a N95 mask prior to entering resident 124's room. Review of the facility policy for Droplet Precautions, version A0717, stated that in addition to Standard Precautions to use Droplet Precautions for patients known or suspected to be infected with microorganisms transmitted by droplets during coughing, sneezing, talking, or the performance of procedures. The PPE recommended in the policy stated a mask as outlined under Standard Precautions. The policy did not recommend a NIOSH- approved N95 mask or equivalent or higher- level respirator for droplet precautions. Review of the facility policy for Standard Precautions, version A0717, stated that they were minimum precautions utilized on all patients when there was a potential or actual contact with body fluids. The PPE recommended in the policy was gloves, gown, mask, and eye protection. The policy stated to wear eye protection when care activities would likely generate splashes or sprays of bodily fluids. The policy did not specify the type of mask that was required. The Centers for Disease Control and Prevention (CDC) guidance on Infection Control for Nursing Homes documented under Implement Source Control Measures that source control options for healthcare professional (HCP) included a NIOSH-approved N95 or equivalent or higher-level respirator. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The guidance further stated, If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator) during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions, they should be removed and discarded after the patient care encounter and a new one should be donned. The guidance was last updated on February 2, 2022. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html 4. On 7/5/22 at 2:10 PM, CNA 4 was observed with their surgical mask down below the nose while inside the facility and resident care area. On 7/6/22 at 8:24 AM, CNA 4 was observed with their surgical mask down below the nose while inside the facility and resident care area. On 7/6/22 at 11:46 AM, CNA 4 was observed with their surgical mask down below the chin while inside the facility and resident care area. On 7/7/22 at 11:47 AM, an interview was conducted with the Corporate Resource Nurse (CRN) and the Director of Nursing (DON). The DON stated that for those residents that were on quarantine staff were required to wear a N95 mask, gown, gloves and eye protection while inside the resident room. The DON stated that the process was to doff the PPE by the door and dispose of the PPE inside the resident room. The DON stated that staff should doff the N95 mask outside of the resident room and put on another mask. The DON stated that the staff should be obtaining a new N95 mask for each resident room that was on quarantine or droplet precautions. The DON stated that staff should bag the mask and leave it outside of the room for use in that room later. The DON stated that if staff did not have a bag for storage they should discard the mask and obtain a new one. The DON stated that the used N95 masks should not be stored in a staff members pocket. The DON stated that quarantine was essentially droplet precautions, and an N95 mask was not optional in a droplet precaution room. The DON stated that for a contact precaution room the required PPE was a gown, gloves, surgical mask and goggles. The DON stated that staff should be wearing a gown and gloves for any contact with a resident who was isolated for shingles. The DON further stated that staff who were transporting the resident should also be wearing a gown and gloves. The DON stated that for resident 2's appointments the provider should have been notified prior to the appointment, absolutely. The DON stated that they should have waited to send resident 2 to the appointment until they had heard what the provider's preference was with regards to the shingles diagnosis. 5. The facility antibiotic stewardship documentation was reviewed from March 2022 through June 2022 revealed the following: a. March 2022 a Monthly Infection Control Report revealed there were 2 infections. The infections were 1 conjunctivitis and 1 fungal infection. There were no other infections documented for March 2022. b. April 2022 a Monthly infection control report revealed there were 2 infections. There was 1 Urinary tract infection (UTI) and 1 lower gastrointestinal infection. The map indicated the 2 infections. A form titled Martixcare Infection Tracker revealed there were 31 infections. There were 11 UTI's listed on the tracker. There were 6 of the 11 UTI's listed as unsubstantiated because it did not meet McGeer's Criteria. i. Resident 69 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, diabetes mellitus and overactive bladder. A urine culture was collected on 4/5/22 which revealed Klebsiella pneumoniae was detected. According to the MatrixCare Infection Tracker form for April 2022 resident 69's UTI was unsubstantiated because it did not meet the McGeer Criteria. The form revealed that resident 69's infection onset date was 4/4/22. The UTI was not on the map or counted in the monthly infection control report. The organism was not documented. c. May 2022 a Monthly Infection Control Report revealed there were 0 infection. The Matrixcare Infection Tracker revealed there were 26 infections in May 2022. Of the 26 infections there were 12 UTI's documented with 9 of the UTI's unsubstantiated because they did not meet McGeer's criteria. There was no information on the organism for the UTI's. i. Resident 70 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, Parkinson's disease, and traumatic subdural hemorrhage. A urine culture was collected on 5/17/22 which revealed an organism of Staphylococcus haemolyticus. According to the MatrixCare Infection Tracker form for May 2022 the UTI was unsubstantiated because it did not meet the McGeer Criteria. The form revealed that resident 70's infection onset date was 5/23/22. The UTI was not on the map or counted in the monthly infection control report. The organism was not documented in the antibiotic monthly tracking. ii. Resident 71 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, klebsiella pneumoniae, and diabetes mellitus. A urine culture was obtained on 5/16/22 which revealed Enterococcus faecium organism vancomycin resistant. According to the MatrixCare Infection Tracking form for May 2022 resident 71 had a UTI with an onset date of 5/9/22 and 5/23/22 which were both unsubstantiated because they did not meet McGeer's Criteria. There was no information regarding what organism or what antibiotic was administered. The UTI's were not marked on the monthly tracking or on a map. d. June 2022 Monthly Infection Control Report revealed there were 3 infections in the facility that month. There was 1 UTI, 1 pneumonia, and 1 conjunctivitis. There was no MatrixCare Infection Tracking form for June 2022. i. Resident 9 was admitted to the facility on [DATE] with diagnoses which included pleural effusion, nondisplaced fracture of second cervical vertebra, and heart transplant. A urine culture dated 6/21/22 revealed Aerococcus urinae. At the bottom of the results was a hand written note Meds: (medication) Bactrim for UTI and signed 6/24/22. There was no information regarding this resident's UTI in the June 2022 Monthly Infection Control Report. On 7/7/22 at 11:47 AM, an interview was conducted with the CRN and DON. The CRN stated there was an antibiotic event report that was opened in the resident's medical record, when a resident had an infection, 72 hours later there was a timeout report completed by a nurse manager to make sure there was an end date for the antibiotic, no side effects from medication, and the correct antibiotic was ordered. The CRN stated prior to starting an antibiotic staff used the McGeer's criteria to determine if the infection was facility acquired, community acquired and if it met criteria for an in house infection. The CRN stated McGeer's was used to determine if the infection was unsubstantiated and if it met the criteria. The CRN stated that staff then marked if the infection was substantiated or unsubstantiated. The CRN stated if the UTI was substantiated then an antibiotic was started. The CRN stated if the UTI was unsubstantiated then staff asked the physician if an antibiotic should be continued. The CRN stated staff and the Infection Preventionist (IP) were able to see the antibiotic report to be table to track and trend infections. The CRN stated the IP was able to print a snap shot of infections report which was titled Matrixcare Infection Tracker. The CRN stated that infection tracking was for in house acquired infections only and if they were substantiated. The CRN stated resident 69's UTI was treated and did not meet the criteria to substantiate so that was why her UTI was not tracked on the mapping and counted as an infection.