Pinnacle Rehabilitation & Health Center

F-F677 example 1

2. Review of Resident R130's clincial record revealed:

3/7/25 - Resident R130 was admitted to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 16 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085020 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 3/10/25 - A review of Resident R130's care plan for ADL self-care deficit documented [Resident R440's] will be clean, dressed and well-groomed daily to promote dignity and psychosocial wellbeing for ninety days. Resident R440's interventions Level of Harm - Minimal harm or included assist with daily hygiene, grooming, dressing, oral care, and eating as needed. potential for actual harm 3/13/25 - Resident R130's admission MDS assessment documented the resident was severely cognitively impaired Residents Affected - Some and required substantial maximum assistance for personal hygiene and grooming.

4/8/25 9:26 AM and 4/11/25 11:07 AM - Observations confirmed that Resident R130's nails on both hands were long, with dark encrusted debris underneath each nail. E16 (RN UM) confirmed that Resident R130 needed nail care.

4/11/25 11:07 AM - E16 (RN UM) stated Well last week the CNA was trying to do [Resident R130's] nail care and she ecame combative so it couldn't get done. E16 also confirmed Resident R130's ADL care plan had not been revised to reflect refusal of nail care. E16 stated, No she has not been care planned for refusing nail care.

40260

3. Review of Resident R119's clinical record revealed:

5/13/24 - Resident R119 was admitted to the facility.

5/20/24 - An admission MDS was completed.

5/22/24 - The admission Resident Care Conference Attendance Sheet for Resident R119's post admission care plan meeting lacked evidence of attendance or input from a physician, a registered nurse, a CNA, or dietary staff.

4/17/25 8:34 AM - In an email communication, the surveyor notified E1 (NHA) and E2 (DON) that there was

a lack of evidence of input by all IDT members at the initial care plan meeting. E1 responded that the facility will ensure participation from these parties immediately and ongoing in all care plan meetings, including the initial meetings.

4. Review of Resident R120's clinical record revealed:

5/14/24 - Resident R120 was admitted to the facility.

5/20/24 - An admission MDS was completed.

5/20/24 - The admission Resident Care Conference Attendance Sheet for Resident R120's post admission care plan meeting lacked evidence of attendance or input from a physician, a registered nurse, a CNA, or dietary staff.

4/17/25 8:34 AM - In an email communication, the surveyor notified E1 (NHA) and E2 (DON) that there was

a lack of evidence of input by all IDT members at the initial care plan meeting. E1 responded that the facility will ensure participation from these parties immediately and ongoing in all care plan meetings, including the initial meetings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085020 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 46988

Level of Harm - Minimal harm or 5. Review of Resident R91's clinical record revealed: potential for actual harm 2/27/25 - Resident R91 was admitted to the facility. Residents Affected - Some 3/5/25 - An admission MDS was completed for Resident R91.

3/7/25 10:00 AM - The admission Resident Care Conference Attendance Sheet for Resident R91's post admission care plan meeting lacked evidence of attendance or input from a physician, a CNA, or dietary staff.

4/14/25 11:57 AM - An interview with E5 (SW) confirmed that all members of the interdisciplinary team were not present or provided input on 3/7/25 for Resident R91's care plan meeting. E5 confirmed input from the physician, CNA, and dietary was not provided.

4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085020 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on interview and record review it was determined that for two (Resident R112 and Resident R644) out of forty three Residents Affected - Few residents reviewed in the investigative sample, the facility failed to ensure received treatment and care in accordance with professional standards of practice and physician orders. Findings include:

1. Review of Resident R112's clinical record revealed:

Cross refer

F-F760

9/12/24 - Resident R644 admitted to the facility with diagnoses including but not limited to, heart failure and chronic obstructive pulmonary disease.

10/2/24 - C2 (contractor NP) entered order in Resident R644's EMR stating, DC (discontinue) PICC (peripherally inserted central catheter) RUE (right upper extremity) .

10/3/24 - Resident R644's Resident Care Conference Attendance Record documented that E23 (RN) and F3 (Resident R644's daughter) participated in this discharge planning conference. The paperwork stated, PICC will be pulled by nursing .

10/5/24 - Resident R644 was discharged home on hospice services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085020 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 4/11/25 2:08 PM - During a telephone interview, F3 (Resident R644's daughter) stated, .When my mom [Resident R644] arrived home after discharge from Evergreen, her PICC line was still in. It was supposed to be taken out at Level of Harm - Minimal harm or Evergreen prior to discharge. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085020 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 39058

Residents Affected - Few Based on observation, record review and interview, it was determined that for one (Resident R35) out of 11 resiedents reviewed for accidents the facility failed to implement a care planned fall intervention. Findings include:

Review of Resident R35's clinical record revealed:

6/27/24 - Resident R35 was admitted to the facility.

6/27/24 - An admission MDS documented the resident required extensive to total assistance with most ADLs, including transfers and mobility. The resident was dependent for bed mobility, toileting, and dressing.

9/25/24 - Resident R35 was readmitted to the facility from the hospital with diagnoses including a right broken leg from

a fall at the facility.

A care plan revised on 10/2/24 included a new intervention for fall mats to be placed at the bedside when Resident R35 is in bed.

10/3/24 - A fall risk assessment scored Resident R35 at 17, indicating a high risk.

On the following dates, no fall mats were observed at the bedside while Resident R35 was in bed:

4/8/25 at 7:46 AM

4/11/25 at 2:27 PM

4/15/25 at 10:25 AM

On 4/15/25 from approximately 10:55 AM to 11:00 AM, during an interview and observation with E15 (CNA) and E16 (CNA) it was confirmed there were no fall mats at the bedside or in the room.

4/15/25 11:10 AM - An interview with E16 (Unit Manager) and E2 (Director of Nursing) it was revealed that

the intervention for fall mats was listed on the task list. E2 confirmed that fall mats should have been placed at the bedside while Resident R35 was in bed and stated the issue would be addressed immediately.

On 4/16/25 at 8:23 AM, during a final observation, Resident R35 was in bed with fall mats appropriately in place.

4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085020 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47621

Residents Affected - Few Based on record review and interview, it was determined that for one (Resident R644) out of eleven residents, the facility failed to ensure that Resident R644 was free of medication error. On 9/13/24, Resident R644 was inadvertently given the incorrect medications (amlodopine 10mg, benzapril 40mg, Coreg 25 mg and selevamer 800mg). This medication error resulted in harm as Resident R644's blood pressure significantly dropped and she was sent emergently to the hospital for evaluation and treatment. This harm is being cited as past non-compliance. Findings include:

Facility's Medication Administration policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Procedure: 3. Identify resident by photo in the MAR (medication administration record) . 10. Compare medication source with MAR to verify resident name, medication name, form, dose, route and time . Rev. 1/2025

Review of Resident R644's clinical record revealed:

9/12/24 - Resident R644 admitted to the facility with diagnoses including but not limited to, heart failure and chronic obstructive pulmonary disease.

9/13/24 9:30 AM - E23 (staff RN) documented in Resident R644's EMR progress notes, Resident's vital signs checked and resident noted to be hypotensive 65/26 in LUE (left upper extremity) .

9/13/24 9:37 AM - C6 (EMT) documented in Resident R644's prehospital care report, . The staff relayed the patient [Resident R644] was given amlodipine 10 mg, benzaprine 40 mg, Coreg 25 mg and sevelamer 800 mg this morning at 8:20 AM. The staff relayed that those medications are not prescribed for the patient and the patient was suppose to be given amlodipine 5 mg, clonidine 0.1mg, furosemide 40 mg and losaratan 100 mg. The staff relayed that they checked the patient's blood pressure an hour after the medication mix-up and found the patient to be hypotensive and 911 was activated .

9/13/24 9:48 AM - Resident R644's blood pressure (BP) documented on the prehospital care report as 50/20.

9/13/24 9:53 AM - Resident R644's blood pressure (BP) documented on the prehospital care report as 50/26.

9/13/24 3:25 PM - C7 (hospital ER DO) documented on Resident R644's ER visit summary, .Reason for visit: drug overdose, Diagnosis: hypotension .You were seen here in the emergency room for your low blood pressure

after taking the wrong medication. We did an evaluation that included blood work and gave you IV fluids . Blood pressure 110/51 .

9/14/24 1:31 AM -E27 (LPN) documented in Resident R644's EMR progress notes, .Resident returned from [hospital] via stretcher accompanied by 2 EMTs . VS 132/78 (BP), 72 (HR), 18 (Respirations), 97.9 (temperature), 98 (pulse oximetry) on O2 (oxygen) .

Resident R644 spent approximately 16 hours in the hospital ER receiving IV fluids and having her vital signs monitored. Resident R644 returned to the facility on [DATE REDACTED] at 1:31 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085020 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 9/18/24 - Resident R644's admission MDS documented a BIMS score of 14, which was reflective of normal cognition.

Level of Harm - Actual harm 4/11/25 2:03 PM -During a telephone interview, C6 confirmed that E27 (LPN) admitted to accidentally giving Resident R644 her roommate's medications. Residents Affected - Few 4/11/25 3:12 PM - A review of the facility's incident investigation provided a typed and signed statement from E27 (staff LPN) stating,Around 8:15 AM, I pulled Resident R644 roommate's medications. I was looking at the name in

the room, there was only one name in there. I took her blood pressure, and it was normal. I called her [Resident R644's roommate's name]. I said to Resident R644, 'I have your medication' and she said I need my medication in pudding. I did not know she [Resident R644] was hard of hearing. I gave medication and then I went to the roommate

in B bed and that's when I realized I gave A bed, B bed's medication. I looked at the arm bands after I realized I made a mistake. At 8:20 AM the unit manager contacted the provider and provider stated to recheck the vital signs in a n hour. I re-checked her in about an hour later. Her blood pressure was 74/55 automatic blood pressure machine and then re-checked again still low. At 9:21 AM the unit manager contacted the provider and received orders to send to the ER for evaluation.

4/14/25 11:30 AM - An attempt to contact E27 for an interview was unsuccessful.

4/16/25 3:30 PM - A review of all the documentation of the corrective action plan completed by the facility included:

-Timely reporting to the state Agency

-Additional education regarding medication administration for E27

-Additional monitoring of E27 including a 3-person med pass with the Pharmacist to verify her knowledge of med administration and shadowing during all med passes until she was cleared for normal duty. E27 was terminated on 1/1/25 for failing to perform the requirements of the job.

-Notification of the family informing them of the medication error

It was verified by the surveyor that the corrections were completed as of 9/18/24 through document review and interview.

4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085020 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47621 potential for actual harm Based on record review and interview, it was determined that for two (Resident R14 and Resident R639) out of twelve residents Residents Affected - Some reviewed for infection control, the facility failed to initiate and maintain appropriate precautions per CDC guidelines. Additionally the facility failed to follow standard precautions. Findings include:

CDC's Infection Control Appendix A: Type and duration of Precautions Recommended for Selected Infections and Conditions .Multidrug-resistant organisms, infection or colonization (e.g., MRSA, VRE, VISA/VRSA, ESBLs, resistant S.pneumoniae) Contact + Standard . February 7, 2025

Facility's Infection Prevention and control Program Policy: .Policy Explanation and Compliance Guidelines: . 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Rev 1/2025

Facility's Enhanced Barrier Precaution Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced Barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices).

1.Review of Resident R14's clinical record revealed:

12/13/20 - Resident R14 was admitted to the facility with diagnoses including but not limited to, multiple sclerosis, seizures and S/P colostomy.

10/5/23 - 10:23 AM - C3 (consultant medical director) documented in Resident R14's progress note, .History of present illness: Patient is a [AGE] year old male with past medical history significant for HTN (hypertension) . colostomy .

4/1/24 - New EBP guidelines from CMS were effective in long term care facilities.

11/22/24 - C2 (consultant NP) initiated an order in Resident R14's EMR, Enhanced Barrier precautions related to history of ESBL urine, colostomy. Every shift for monitoring.

The facility failed to initiate EBP for Resident R14 until eight months (from 4/1/24 to 11/22/24) after the new guidelines were mandated.

4/16/25 - 12:01 PM - During an interview, E2 (DON) confirmed that Resident R14 has had a colostomy since he has been in the facility.

2. Review of Resident R639's clinical record revealed:

6/21/24 - Resident R639 was admitted to the facility with diagnoses including but not limited to, chronic obstructive pulmonary disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085020 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 10/3/24 - 5:37 PM - C4 (hospital MD) documented in Resident R639's discharge summary, Principal diagnosis: MRSA pneumonia . due to positive MRSA swab . discharge medications: .linezolid 600 mg (milligram) tablet- take 1 Level of Harm - Minimal harm or tablet by mouth 2 times a day for 20 days . potential for actual harm 10/3/24 - C2 (NP) entered order in Resident R639's EMR stating, linezolid tablet 600 mg - give 1 tablet by mouth every Residents Affected - Some 12 hours for infection of lungs for 20 days.

4/16/25 - 10:35 AM - A review of Resident R639's EMR revealed that there was not a contact precautions order in effect while Resident R639 was being treated for MRSA pneumonia with linezolid (antibiotic to treat MRSA pneumonia).

The facility failed to initiate contact precautions for Resident R639 while he was being treated for MRSA pneumonia from 10/3/24 to 10/24/24.

47114

4/8/25 6:16 AM - A random observation revealed a clear plastic trash bag with dirty briefs and gloves was sitting on the floor in front of room [ROOM NUMBER] which had signage on the door that indicated EBP (Enhanced Barrier Precautions).

4/8/25 6:20 AM - E26 (CNA) was observed leaving room [ROOM NUMBER] wearing disposable gloves. E26 picked up the trashbag and proceeded to walk across the hallway to room [ROOM NUMBER] another room with EBP signage on the door, placed the trash bag on the floor and entered the room wearing the contaminated gloves on both hands.

4/8/25 6:41 AM - During an interview E2 (DON) observed the trash bag was sitting on the floor in the doorway of room [ROOM NUMBER]. E2 stated, No this should not be it should go directly to the biohazard room. E2 picked the trash bag up off the floor, E26 opened the door to leave room [ROOM NUMBER] wearing gloves, E2 stopped E26 in the hallway and educated the CNA on wearing gloves, hand washing and that trash should not go from room to room and is to be taken to the biohazard room for disposal. The trash was disposed off by E2.

4/8/25 8:31 AM - An additional observation of room [ROOM NUMBER] with EBP signage revealed a clear plastic bag with dirty linen and a bag with briefs and other trash were sitting on the floor inside of room [ROOM NUMBER]. E16 (RN, UM) entered room [ROOM NUMBER] and picked the bags up off the floor. E16 confirmed and stated, Yes I know the trash bags being left on the floor is an infection control concern. E16 proceeded to take the bags to the biohazard room for disposal.

4/17/25 1:45 PM -Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 085020

F-F880

7/30/24 - Resident R112 was admitted to the facility.

8/27/24 3:12 PM - A physician's order documented that Resident R112 was on contact isolation due to scabies for fourteen days.

11/9/24 - A physicians order was written for Resident R112 consult to dermatology related to scabies.

11/13/24 - A specialist physician's (dermatologist) progress note documented that Resident R112 was not contagious and to remove isolation precautions.

4/15/25 10:30 AM - An interview with C2 (NP) and C5 (NP) confirmed that Resident R112 was on contact precautions from 8/27/24 to 11/13/24.

There was a ten week delay in consulting the dermatologist resulting in Resident R112 being in isolation for 78 days.

47621

2. Resident R644's clinical record revealed:

Cross refer