Skyview Care And Rehab At Bridgeport

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

order revealed documentation that a blood glucose check had not been completed for any of the scheduled times on 10/21/2025 or for the 7:00 AM and 11:00 AM times on 10/22/2025.

A record review of Resident 17's Progress Notes for the month of October 2025 revealed no evidence of

the facility notifying the provider of the inability to obtain blood glucose checks per the provider's orders on 10/21/2025 and 10/22/2025.

An interview on 11/13/25 at 11:10 AM with the NP revealed the NP was in the facility on 10/21/2025 at around 11:30 AM and overheard the staff discussing that they had run out of blood glucose monitoring strips. NP stated they were told by facility staff that they had ordered the strips, and the strips were to arrive

in the facility later that day, and that if the strips did not arrive by suppertime, the facility was going to go to

the pharmacy to purchase some. NP revealed that when they arrived back at the facility on 10/22/2025, the NP was made aware that the facility had not obtained any of the strips, and the facility could not provide justification for why no one had notified the NP about the blood glucose monitoring strips not arriving the evening prior.

An interview on 11/13/25 at 12:20 PM with the DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility. The DON also confirmed that the pharmacy did not have any strips available, that the facility did not attempt any other method of obtaining strips, and the facility did not reach back out to the NP after being unable to obtain the strips the evening of 10/21/2025.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Skyview Care and Rehab at Bridgeport

505 O Street Bridgeport, NE 69336

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 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

blood glucose was 528 and the NP had to order an extra dose of insulin to help lower the level. NP stated Resident 14 was a very fragile diabetic and that missing blood glucose checks, and insulin doses could have easily caused Resident 14 significant harm. An interview on 11/13/25 at 12:20 PM with the DON confirmed the code NA on the MAR indicated not applicable. The DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility. The DON also confirmed that the pharmacy did not have any strips available and that the facility did not attempt any other method of obtaining strips, which resulted in Resident 14 not having their blood glucose level checked for four consecutive scheduled times. The DON also confirmed that Resident 14 did not receive their scheduled insulin doses during that timeframe.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Skyview Care and Rehab at Bridgeport

505 O Street Bridgeport, NE 69336

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 0675 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident only taking a few bites than refusing.- On 11/11/2025 at 1:45 AM, it was noted the writer had asked

the Director of Nursing (DON) if it would be possible to obtain comfort medication for day as the resident is not taking any medication, so the resident could remain comfortable.- On 11/11/2025 at 9:15 PM, resident's buspirone was documented as not given with a reason of resident refused.- On 11/12/2025 at 12:37 AM, resident's hydrocodone was documented as not given with a reason of resident refused. An observation on 11/12/2025 at 9:45 AM revealed Resident 6 had been laying in bed. Resident 6 had been displaying non-verbal indications of pain, including facial grimacing and groaning. Posturing appeared to be rigid. An

observation on 11/12/25025 at 11:10 AM revealed Resident 6 could be heard groaning from down the hallway. Resident 6 continued to be displaying non-verbal indication of pain including facial grimacing, furrowed brows, tense/rigid body posturing, restless legs, and loud/constant groaning. An interview on 11/12/2025 at 11:20 AM with the DON and Registered Nurse (RN) - A confirmed resident's assessment of non-verbal pain indications would rate at 6/10. RN-A stated they had difficulty administering Resident 6's medications, including their pain medications as the resident would only accept a few bites of the crushed medication. The DON revealed unaware if the resident not swallowing their medications had been reported to the Nurse Practitioner (NP) but stated comfort cares had been discussed, but no changes to the resident's regimen had been made due to an issue with the Power of Attorney (POA). Further record review of Resident 6's Progress Notes revealed the following:- On 11/12/2025 at 10:03 AM, RN-A had documented the resident would only take a few bites of their medication that had been crushed and put in pudding.- On 11/12/2025 at 11:34 AM, the DON documented they had spoken to the POA about change in medication, the DON followed up with the NP about comfort care medication being approved by the family.

An interview on 11/13/2025 at 12:22 with the NP revealed the NP had been unaware until informed by this surveyor now that Resident 6 had not been taking their oral medications. The NP revealed Resident 6 did have a baseline behavior of mumbling, but being able to hear the resident from down the hallway would be outside their normal and would identify this as a non-verbal indication of pain. The NP also identified Resident 6's restless legs as being uncomfortable from withdrawals from the fluvoxamine and methocarbamol, as the resident needs these medications due to their tight spasticity in their legs.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Skyview Care and Rehab at Bridgeport

505 O Street Bridgeport, NE 69336

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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

forms for Resident 2 revealed the following:- Documentation Resident 2 had received a bath on 10/18/2025.- Documentation Resident 2 had refused a bath on 10/23/2025.- Documentation Resident 2 had received a bath on 10/28/2025, 10 days since their previous bath. A record review of a Resident Refusal of Shower/Bed Bath revealed a date of 10/23/2025. An interview on 11/13/2025 at 2:25 with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) confirmed Resident 2 had gone from 10/18/2025 to 10/28/2025 without a bath.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Skyview Care and Rehab at Bridgeport

505 O Street Bridgeport, NE 69336

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Further record review of Resident 17's October 2025 MAR revealed an order for carbamide peroxide otic solution 6.5 %, instill 5 drops in the right ear two times a day for wax build up for 8 administrations. This order had a start date of 10/27/2025.

An interview on 11/13/25 at 12:20 PM with the DON confirmed that the order entered on 10/21/2025 was entered incorrectly. The DON stated that once the facility realized this, they discussed it with the NP, and

they received a new order to start the carbamide peroxide treatment again.

E.

A record review of Resident 3's Order Summary Report dated 11/12/2025 revealed the resident was admitted to the facility on [DATE REDACTED] and had a diagnosis of Major Depressive Disorder.

A record review of Resident 3's Provider Order Form dated 10/7/2025 revealed an order to start fluoxetine 10 mg by mouth daily for Major Depressive Disorder.

A record review of Resident 3's October 2025 MAR revealed the following: - fluoxetine HCl oral tablet 10 mg, give 1 tablet by mouth one time a day related to Major Depressive Disorder. This order had a start date of 10/09/2025 and a discontinued date of 10/14/2025. - fluoxetine HCl oral tablet 10 mg, give 1 tablet by mouth one time only for depression for 1 Day. This order had a start date of 10/16/2025 at 1:45 PM and was documented as administered the same day. - fluoxetine HCl oral tablet 10 mg, give 1 tablet by mouth one time a day for depression. This order had a start date of 10/17/2025.

A record review of Resident 3's Progress Notes for the month of October 2025 revealed no evidence of a reason for their fluoxetine to have been discontinued on 10/14/2025.

An interview on 11/13/25 at 12:20 PM with the Regional Nurse Consultant (RNC) confirmed the fluoxetine was discontinued on 10/14/2025, a one-time dose was given on 10/16/2025, and the medication was re-entered on 10/17/2025. The RNC also confirmed the order should not have been discontinued on 10/14/2025.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Skyview Care and Rehab at Bridgeport

505 O Street Bridgeport, NE 69336

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 0686

An interview on 11/12/2025 at 3:50 PM with Registered Nurse (RN) – A revealed they were unsure of what setting Resident 18's air mattress should be set on and referred the question to the nearby DON.

Level of Harm - Actual harm Residents Affected - Some

An interview on 1/12/2025 at 3:51 PM with the DON revealed the resident's air mattress should be set according to their weight.

A follow up interview on 11/12/2025 at 3:52 PM with RN-A confirmed Resident 18's bed was set to 170-230 pounds, which exceeded Resident 18's current weight status of 136 lbs. Additionally, RN-A confirmed Resident 18 had been in this position since after returning from lunch, sometime around 1:00 PM, and should be repositioned every two hours.

Further observation on 11/12/2025 at 3:52 PM revealed Resident 18 continue to complain of pain. RN-A asked Resident 18 if they would like Tylenol for their pain. RN-A did not offer to reposition Resident 18 until

after being prompted by this surveyor, which Resident 18 accepted assistance with repositioning. RN-A was assisted by the DON to reposition.

A follow up interview on 11/12/2025 at 4:01 PM with Resident 18 revealed repositioning helped some with their rear pain.

D.

A record review of Resident 3's Order Summary Report dated 11/12/2025 revealed the resident was admitted to the facility on [DATE REDACTED]. The report also revealed the resident had an order to cleanse the right superior aspect of ear, both areas with wound cleanser, and apply bacitracin-zinc with a cotton tipped applicator twice a day. The order had a start date of 11/6/2025.

An observation on 11/12/25 at 1:02 PM revealed the Director of Nursing (DON) was at the nurse's station preparing to perform wound care for Resident 3. The DON checked their orders in a binder, then placed the supplies needed into a plastic container and carried them to the resident's room. After the DON performed wound cares to the resident's Moisture Associated Skin Damage (MASD) on their thigh and buttocks, two aides assisted the resident out of their bed and into their wheelchair. While this took place, the DON performed HH via ABHR, opened a package of sterile gauze, put on new gloves, and squirted Skintegrity wound cleanser onto the gauze. The DON used the gauze to cleanse Resident 3's right upper ear, then threw the gauze and their gloves into the trash and performed HH via ABHR. After putting on new gloves,

the DON put Hydrogel onto a Q-Tip and rubbed it onto the area in the crease of the resident's upper right ear. The DON then removed their gown and gloves, put their supplies back into the plastic container, and carried their supplies back to the nurse's station.

An interview on 11/12/25 at 1:58 PM with the DON confirmed they used Hydrogel for the treatment to Resident 3's right ear. The DON stated they did not realize Resident 3's order had been changed from Hydrogel to bacitracin-zinc six days prior.

An interview on 11/12/25 at 1:59 PM with the Registered Nurse Consultant confirmed Resident 3's right ear treatment order had been changed from Hydrogel to bacitracin-zinc in the electronic medical records six day prior.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Skyview Care and Rehab at Bridgeport

505 O Street Bridgeport, NE 69336

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

8 and call provider. Give one time a day before supper. This order had a start date of 9/10/2025. The blood glucose and insulin were documented as NA for the dose on 10/21/2025.-Tresiba (medication used to treat diabetes) FlexTouch Subcutaneous Solution Pen injector 100 UNIT/ML, inject 25 unit subcutaneously one time a day. The order had a start date of 9/20/2025. The blood glucose and insulin were documented as NA

on 10/22/2025.-Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML, inject as per sliding scale: if blood glucose is 176 - 200 = 3; 201 - 225 = 4; 226 - 250 = 5; 251 - 299 = 7; 300 - 350 = 8; 351 - 375 = 9; 376 - 400 = 10; 401 - 402 = 12 call provider. Give two times a day. The order had a start date of 9/10/2025. The blood glucose and insulin were documented as NA for the midday dose on 10/21/2025 and for the AM dose on 10/22/2025. -Monitor blood glucose levels four times a day and PRN. Notify provider if blood sugar is less than 80 or greater than 400 or if the resident is symptomatic. This order had a start date of 9/02/2025. The blood glucose was documented with an X on the 10/21/2025 midday, PM, and HS (hour of sleep) administration times and for the AM administration time on 10/22/2025. The midday time

on 10/22/2025 revealed a blood glucose of 528. A record review of Resident 14's Progress Notes for October 2025 revealed no progress notes documented by the facility staff related to notifying the provider about the resident not receiving blood glucose checks or insulin the evening of 10/21/2025 and morning of 10/22/2025. An interview on 11/13/25 at 11:10 AM with the NP revealed the NP was in the facility on 10/21/2025 at around 11:30 AM and overheard the staff discussing that they had run out of blood glucose monitoring strips. NP stated they were told by facility staff that they had ordered the strips, and the strips were to arrive in the facility later that day, and that if the strips did not arrive by suppertime, the facility was going to go to the pharmacy to purchase some. NP revealed that when they arrived back at the facility on 10/22/2025, the NP was made aware that the facility had not obtained any of the strips, therefore Resident 14's blood glucose level had not been obtained since the previous morning, and the resident had not received any of their scheduled insulin doses. NP stated the strips arrived prior to lunchtime on 10/22/2025 and at that time Resident 14's blood glucose was 528 and the NP had to order an extra dose of insulin to help lower the level. NP stated Resident 14 was a very fragile diabetic and that missing blood glucose checks, and insulin doses could have easily caused Resident 14 significant harm. An interview on 11/13/25 at 12:20 PM with the DON confirmed the code NA on the MAR indicated not applicable. The DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility.

The DON also confirmed that the pharmacy did not have any strips available and that the facility did not attempt any other method of obtaining strips, which resulted in Resident 14 not having their blood glucose level checked for four consecutive scheduled times. The DON also confirmed that Resident 14 did not receive their scheduled insulin doses during that timeframe.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Skyview Care and Rehab at Bridgeport

505 O Street Bridgeport, NE 69336

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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

A record review of Resident 17's admission Record revealed the resident was admitted to the facility on [DATE REDACTED] and had a diagnosis of Type 2 Diabetes Mellitus.

A record review of Resident 17's October 2025 MAR revealed an order to obtain blood glucose checks

before meals and at bedtime and to notify the provider if the resident's blood sugar was less than 60 or greater than 400 or if resident is symptomatic. The order had a start date of 9/10/2025. The order revealed documentation that a blood glucose check had not been completed for any of the scheduled times on 10/21/2025 or for the 7:00 AM and 11:00 AM times on 10/22/2025.

An interview on 11/13/25 at 11:10 AM with the NP revealed the NP was in the facility on 10/21/2025 at around 11:30 AM and overheard the staff discussing that they had run out of blood glucose monitoring strips. NP stated they were told by facility staff that they had ordered the strips, and the strips were to arrive

in the facility later that day, and that if the strips did not arrive by suppertime, the facility was going to go to

the pharmacy to purchase some. NP revealed that when they arrived back at the facility on 10/22/2025, the NP was made aware that the facility had not obtained any of the strips, and the facility could not provide justification for why no one had notified the NP about the blood glucose monitoring strips not arriving the evening prior.

An interview on 11/13/25 at 12:20 PM with the DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility. The DON also confirmed that the pharmacy did not have any strips available, that the facility did not attempt any other method of obtaining strips, and the facility did not reach back out to the NP after being unable to obtain the strips the evening of 10/21/2025.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Skyview Care and Rehab at Bridgeport

505 O Street Bridgeport, NE 69336

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

record review of Resident 6's Order Summary Report revealed the resident was admitted to the facility on [DATE REDACTED]. The report also revealed the resident had an order for staff to cleanse sacrum with wound cleanser, apply skin prep, cut calcium alginate to fit, and cover with border dressing. The order had a start date of 10/28/2025. An observation on 11/13/25 at 3:23 PM revealed the DON performing HH via soap and water at the nurse's station. DON then took a plastic container from the wound treatment cart, gloves, ABHR, and

an electronic tablet and carried the items to Resident 6's room. The DON placed the container on the resident's bedside table, obtained a gown and paper towel from the bathroom, and put on the gown. After

the nurse aides that were in the room performed peri-cares on the resident and positioned the resident onto their right side, the DON placed Skintegrity wound cleanser bottle and a package of sterile gauze from the plastic container onto the paper towel, which had been laid on the resident's bed. The DON then put on gloves, removed the resident's soiled dressing from their sacrum using an alcohol wipe to release the adhesive, removed their gloves, and performed HH via ABHR. DON put on new gloves, cleansed the area with Skintegrity wound cleanser and sterile gauze, laid the wound cleanser bottle back on the paper towel, removed their gloves and performed HH via ABHR. After the DON checked Resident 6's order on the tablet,

they opened new dressings from the plastic container, placed them on the paper towel, and put on new gloves. During this time, the Skintegrity wound cleanser bottle had rolled off the paper towel and was laying

on the resident's bedding next to their pillow, the DON picked the bottle up and placed it directly onto the bedside table. Next, the DON performed the remainder of the wound care, which included opening a package of Sorbalgon and cutting a portion of the dressing off to use on the resident's wound and leaving

the remainder of the dressing in the open packaging inside the plastic container, removed their PPE, and performed HH via ABHR. The DON then picked up the Skintegrity wound cleanser bottle, put it back in the plastic container with the rest of Resident 6's clean wound care supplies and carried the container out of

the room. The plastic container had sealed wound care supplies, the open package of Sorbalgon, as well as wound measuring papers laying exposed inside of it. An interview on 11/13/25 at 3:38 PM with the DON confirmed the Skintegrity wound cleanser bottle was laying directly on Resident 6's bedding and then was placed back into the plastic container with the remainder of Resident 6's clean wound dressing supplies, contaminating the supplies.

Event ID:

Facility ID:

If continuation sheet