Every finding on record at 4Angels of Byromville Healthcare Center

Based on observations, staff interviews, record review and review of the facility's policy titled Enteral Nutrition, the facility failed to ensure appropriate treatment and services were provided by not checking placement and residual per physician's orders for one of one resident (R) R6 receiving tube feed. This deficient practice had the potential to cause feeding intolerance, aspiration and worsening of R6's medical conditions.Findings include:Review of the facility's policy titled Enteral Nutrition revised November 2018 documented Policy Interpretation and Implementation:. 11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include: a. the enteral nutrition product; b. the specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.; c. administration method (continuous, bolus, intermittent); d. volume and rate of administration; e. the volume/rate goals and recommendations for advancement toward these; and f. instructions for flushing (solution, volume, frequency, timing and 24-hour volume). 13. Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as: a. aspiration; b. tube misplacement or migration; c. skin breakdown around insertion site; d. perforation of the stomach or small intestine leading to peritonitis; e esophageal swelling, strictures, fistulas; and f. clogging of the tube. Review of the facility's Electronic Medical Records (EMR) revealed R6 was readmitted to the facility on [DATE] with diagnosis included but not limited to dysphasia (difficulty swallowing). Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) of R6 was rarely/never understood, Section K (Swallowing/Nutritional Status) R6 had feeding tube. Review of care plan dated 02/05/2026 documented Focus: R6 was on tube feedings with interventions to: Observe/document/report as needed (PRN) any signs and symptoms (s/sx) of: aspiration- fever, shortness of breath (SOB), tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Review of Physician's Orders dated 07/24/2025 documented included but not limited to Enteral Feed Order five times a day Enteral: Give Jevity 1.5 240 milliliter (Ml) every four hours (q4hr) and Flush before and after feeding 100 ml no feeding after midnight Verbal Active. Enteral Feed Order five times a day Flush Peg-tube with 100 ml water (H2O) before and after each feeding Verbal Active 07/24/2025. Check and record residual every (q) shift notify medical doctor (MD) if exceeds 50 ml and hold feeding every day and night shift verbal active 03/26/2025. Check tube placement before initiation of formula, medication administration, and flushing. If abnormal results, call medical doctor (MD), responsible party (RP), and enter a progress note. every day and night shift Verbal Active 03/26/2025. Observation on 04/08/2026 at 02:11 PM during R6's gastrostomy tube feed/care revealed Licensed Practical Nurse (LPN) BB did not check for placement of the gastrostomy tube and she did not check for residual before she administered medication and feed to R6. LPN BB flushed R6's gastrostomy tube with 100 mls of water, administered Jevity feed 233 mls, then administered 100 mls water without checking residual and placement of the gastrostomy tube. Interview on 04/08/2026 at 02:15 PM with Licensed Practical Nurse (LPN) BB revealed she confirmed she did not check for placement of the gastrostomy tube and she did not check for residual before she administered flushes, medication and feed to R6. She stated there were physician's orders to check for placement of the tube and to check for residual, but she did not. She stated she should have checked the placement of the tube to ensure the tube was in the stomach because the tube could dislodge and the feed would go R6's abdominal cavity and cause infection and worsening of her medical condition. LPN BB further stated that she should have checked the residual to see how much feed was left in the stomach before giving her more feed, because R6 could get too much feed and aspirate. Interview on 04/09/2026 at 10:19 AM with the Director of Nursing (DON) revealed she stated her expectations were for the nurses to check residual and placement of the gastrostomy tube before administering feedings, medications and flushes. She stated the nurses should check for residual because the resident could have too much residual and the nurses should hold the feed. The DON stated that if the nurses did not check for residual and they fed the resident or administered medication or flushes, the resident could get too much fluid and aspirate. The DON further stated that the nurses should check for placement of the gastrostomy tube because the tube could be out of place and not be in the stomach, so if the nurses administer feeds, medications or flushes, it would go straight to the lungs and the resident could aspirate.

Based on observations, staff interviews and review of the facility's policy titled, Medication Labeling and Storage, the facility failed to remove expired medications from one of one medication room reviewed. This deficient practice had the potential to cause decline in the residents' medical conditions.Findings include:Review of the facility's policy titled Medication Labeling and Storage revised February 2023 documented Policy Interpretation and Implementation: Medication Storage: . 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Observation on 04/08/2026 at 12:23 PM during review of the medication room on the100 Hall revealed there were expired medications in the medication room. Observations revealed: 1 bottle [NAME]-Vite tablets had expiration date 07/2025, 1 bottle bisacodyl 5 milligram (mg) tablets had expiration date 03/2026, one bottle Acetaminophen 325 mg tablets (1000 tablets) had expiration date 02/2026 and 2 bottles Zinc 50 mg tablets had expiration date 01/2026. Interview on 04/08/2026 at 12:26 PM with Licensed Practical Nurse (LPN) BB revealed she confirmed there were expired medications in the medication room. She stated the bottles of [NAME]-Vite, bisacodyl, acetaminophen and Zinc tablets were expired, and the medications should not be in the medication room because they were expired. She stated that a negative outcome for the residents would be there was a possibility the residents could get the expired medications and the expired medications would not help the residents' conditions. She further stated the residents would not get the full potential of the medications since they were expired. LPN BB further stated there was the possibility that the residents' conditions could worsen. Interview on 04/09/2026 at 10:19 AM with the Director of Nursing (DON) revealed she stated her expectations were for no expired medications to be in the medication room. She stated that the nurses were responsible for removing expired medications from the medication room. The DON stated if the expired medications were given to the residents, a negative outcome would be that the residents could have allergic reactions, and the medications would not work.

Based on observations, staff interviews, and a review of the facility's policies titled Handwashing/Hand Hygiene, Personal Protective Equipment - Gloves, and Laundry and Bedding, Soiled, the facility failed to implement infection control protocols. Staff did not sanitize their hands between glove changes, carried unbagged soiled linen down the 100 hallway, and wore gloves in the hallway. This deficient practice had the potential to increase the risk of infection for residents.Findings include: Review of the facility's policy titled Handwashing/Hand Hygiene revised August 2019 documented This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation:. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. After removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Procedure:. Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. Review of the facility's policy titled Personal Protective Equipment-Gloves revised July 2009 documented 2. Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed. 8. Wash your hands after removing gloves. Review of the facility's policy titled Laundry and Bedding, Soiled revised September 2022 documented Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Policy Interpretation and Implementation: Handling1. All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting). a. Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used). Observation on 04/08/2026 at 8:55 AM revealed the Director of Nursing (DON) came out of a resident's room, removed her gloves, and donned a new pair of gloves without sanitizing her hands. Further observation at 9:14 AM revealed the DON removed a pair of gloves in the 100 hallway, rolled them in her hands, walked down the hallway with the gloves in her hands, returned to the medication cart, disposed of the gloves in the garbage bin on the medication cart, and donned a new pair of gloves without sanitizing her hands. Observation on 04/08/2026 at 10:38 AM revealed Certified Nursing Assistant (CNA) AA walked out of a resident's room wearing gloves and proceeded along the 100 hallway into a shower room next to the nurse's station. CNA AA was observed opening the shower room door with her gloved hand, then leaving the shower room with the gloves still on, closing the shower room door with her gloved hand, and walking back to a resident's room. CNA AA opened the resident's room door with her gloved hand and entered the room. Further observation at 10:40 AM revealed CNA AA took linen that was not bagged from a resident's room and walked along the hallway to another shower room. Observation on 04/08/2026 at 03:58 PM revealed Licensed Practical Nurse (LPN) BB came out of a resident's room in front of the nurses' station wearing gloves. She removed the gloves, disposed of them in the garbage bin on the medication cart, and then put on a new pair of gloves without sanitizing her hands. LPN BB cleaned the blood sugar machine on the medication cart, removed her gloves, disposed of them in the garbage bin on the medication cart, and then put on a new pair of gloves without sanitizing her hands before attending to a resident sitting in the hallway near the nurses' station. LPN BB did not sanitize her hands between glove changes. Interview on 04/08/2026 at 11:05 AM with CNA AA revealed she confirmed she walked out of a resident's room wearing gloves, went along the 100 hallway into the shower room, opened the shower room door with her gloved hand, left the shower room, closed the shower room door with the same gloves, and walked back to the resident's room. CNA AA stated she opened the resident's room door with her gloved hand and entered the room. She also confirmed she took soiled linen that was not bagged from a resident's room and walked along the hallway to a shower room. She stated she should not have worn gloves out of the resident's room because she could spread germs to other areas, and residents could get infections when gloves were worn outside of residents' rooms. She stated that when soiled or used linen was taken outside of residents' rooms without being bagged, germs from the linen could spread to other residents, and residents could get infections. Interview on 04/08/2026 at 4:30 PM with Licensed Practical Nurse (LPN) BB revealed she confirmed she did not sanitize her hands between glove changes when she left a resident's room wearing gloves, cleaned the blood sugar machine, and before attending to a resident in the hallway. LPN BB stated she should have sanitized her hands between glove changes because failing to do so could spread germs to residents, and residents could get infections. LPN BB further stated staff were not supposed to keep gloves on when leaving a resident's room and going into the hallway or from room to room. She stated it was an infection control issue and could spread germs to residents. LPN BB stated soiled laundry should not be transferred without being in a bag because it could transfer germs to residents, and residents could get infections. Interview on 04/09/2026 at 10:19 AM with the Director of Nursing (DON) revealed she confirmed she did not sanitize her hands between glove changes. She stated her expectation was for staff to wash their hands or sanitize their hands after removing gloves and between glove changes because residents could get infections. The DON further stated her expectation was for staff not to wear gloves in the hallways. She stated gloves were not to be worn out of residents' rooms and into the hallways because the gloves were contaminated and should be placed in the trash before exiting the rooms. She stated it was an infection control issue and that whatever the residents had could be passed on to other residents when gloves encountered other residents or surrounding areas. The DON stated linen/laundry used by residents was considered soiled and should be bagged before being taken out of residents' rooms because if it was not bagged, it could encounter other residents or surrounding areas touched by residents, and residents could get infections.

Based on observation, staff interview, and review of the policy titled, Food Preparation and Service, the facility failed to discard food in the refrigerator by the use by date and failed to label opened food items in the freezer. The deficient practice had the potential to place four residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: Review of the facility policy titled Food Preparation and Service, revised November 2022, revealed the Policy Statement of Food and nutrition employees prepare, distribute and serve food in a manner that complies with safe food handling practices. The Food Storage after opening section stated, Follow the following food storage guidelines after opening: . 6. Salads, Coleslaw, are to be kept for 3 to 4 days. During a tour of the kitchen on 9/10/2024 at 9:50 am, observation in one refrigerator revealed one bag of coleslaw with an expiration date of 9/6/2024, one package of chicken breast lunch meat with an expiration date of 7/14/2024, one head of lettuce with a handwritten stored date of 9/2/2024, and one bag of lettuce with a handwritten stored date of 9/2/2024 and an expiration date of 9/5/2024. Observation of the freezer revealed a bag of two chicken breasts that were not labeled or dated. Interview on 9/10/2024 at 12:20 pm, the Dietary Manager (DM) revealed that all expired food should be discarded on or before the expiration date. She revealed she did not know the facility policy on labeling and dating food and had not received any updated policies since the new owner took possession of the facility in May 2024. Interview on 9/12/2024 at 12:13 pm, the Administrator revealed she would expect the DM to discard all expired food or drink items. The Administrator revealed she was unsure about labeling food items and she thought three days was the most an item should be stored once opened. She stated dietary staff should label and date all food and drink items when opened.

Based on observation, staff interviews, and review of the facility policy titled Laundry and Bedding, Soiled, the facility failed to ensure the storage and processing of linens and clothing to produce hygienically clean laundry and prevent the spread of infections and cross-contamination risk for four of four residents. These failures had the potential to expose residents to infections due to cross-contamination. Findings include: Review of the facility policy titled Laundry and Bedding, Soiled, revised September 2022, revealed the Policy Statement was Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Observations on 9/11/2024 at 2:30 pm in the laundry room revealed two rolling carts with a buildup of dust, trash on the floor, one ladder, one table, old furniture, one cart with nails and paint, and one folded black cloth present on the laundry folding table. All objects were covered with a buildup of dust. Further observation revealed the hand washing sink in the laundry room had a buildup of brown substance. Interview on 9/12/2024 at 2:45 pm, the Administrator verified the findings in the laundry room and stated the condition of the laundry room was unacceptable. The Administrator confirmed the findings in the laundry room were infection control concerns and stated the findings would be corrected.

Based on staff interviews and record review, the facility failed to have the Antibiotic Stewardship Program acknowledged by the Pharmacist and Medical Director. This deficient practice had the potential to affect all residents residing in the facility. The facility census was four residents. Findings include: Review of the Antibiotic Stewardship Program documents revealed there were no antibiotic stewardship acknowledgment forms for the Pharmacist or the Medical Director to acknowledge their accountability. Interview on 9/12/2024 at 4:12 pm, the Director of Nursing (DON)/Infection Preventionist (IP) revealed the facility did not have an acknowledgment form for the Pharmacist or Medical Director for the facility's Antibiotic Stewardship Program. Interview on 9/12/2024 at 4:15 pm, the Administrator revealed the facility did not have the acknowledgment forms for the Medical Director and the Pharmacist for the facility's Antibiotic Stewardship Program.

Based on observations and interviews, the facility failed to ensure a safe, clean, and comfortable environment was maintained for four of four resident rooms (Rooms 101, 102, 103, and 107). The facility census was four residents. These deficient practices had the potential to place the residents at risk of living in an unsanitary and unsafe living environment and a potential for diminished quality of life. Findings include: Observations on 9/10/2024 at 8:14 am revealed the ceiling intake vents in resident rooms [ROOM NUMBERS] had heavy dust buildup. Observation on 9/10/2024 at 8:20 am of resident room [ROOM NUMBER] revealed the toilet bowl had a dark gray thick substance buildup and the paper towel holder was broken. Further observations during the survey revealed the buildup remained in the toilet bowl. Observations from 9/10/2024 through 9/12/2024 revealed the heavy dust buildup on the ceiling intake vents in resident rooms [ROOM NUMBERS] remained throughout the survey period. Further observation of resident room [ROOM NUMBER] revealed a light fixture over the sink with a rough brown substance, the sink had grayish chipped areas, the wall base underneath the bathroom sink was peeling and lifting, the back of the room door was cracked, the wall to the left of the room door was noted with the wall base peeling and lifting, and the wall had chipped cracked areas. Interview on 9/11/2024 at 8:35 am, the Administrator stated the substance in the toilet bowl in resident room [ROOM NUMBER] was from the toilet not being used for over a year. She stated the toilet was not replaced prior to admitting a resident in the room because the resident currently in the room did not use the bathroom. She said she planned to replace the toilet when the facility had more residents. The Administrator verified the thick, dark gray buildup in the toilet bowl. During walking observation rounds on 9/12/2024 at 12:15 pm, the Administrator verified the findings in resident rooms [ROOM NUMBERS]. She further stated housekeeping was responsible for cleaning the ceiling vents but if they could not reach the vents, maintenance was responsible for cleaning them. The Administrator stated the Maintenance Director was on vacation and unavailable for an interview. Observations of resident room [ROOM NUMBER] on 9/10/2024 at 9:00 am, 9/11/2024 at 9:10 am, and 9/12/2024 at 12:31 pm revealed brown stained areas on the ceiling tiles, brown discoloration on the ceiling in the shape of a privacy curtain track, and a four-inch crack in the bathroom door. Interview on 9/12/2024 at 12:31 pm, the Administrator confirmed the findings in resident room [ROOM NUMBER]. The Administrator stated the ceiling tiles needed to be painted, and she did not know how to fix the door. Observations of resident room [ROOM NUMBER] on 9/10/2024 at 9:00 am, 9/11/2024 at 9:10 am, and 9/12/2024 at 12:00 pm revealed an eight-inch crack behind the front entrance door of the resident room and no cold running water from the bathroom faucet. Interview on 9/12/2024 at 12:31 pm, the Administrator confirmed the findings in resident room [ROOM NUMBER]. She stated she would discuss the findings with the Maintenance Department.

Based on observation and staff interviews, the facility failed to ensure resident protected health information was inaccessible to non-essential staff. This deficient practice placed the residents at risk of unauthorized staff having access to their protected health information. The facility census was four residents. Findings include: Observation on 9/11/2024 at 2:35 pm revealed two large rolling carts with resident charts containing clinical information were located in the laundry room. The charts were visible and accessible to anyone in the laundry room. Interview on 9/11/2024 at 3:00 pm, housekeeping staff stated the charts belonged to previous residents who were discharged due to the facility closing and further stated the charts were left behind. Interview on 9/12/2024 at 3:45 pm, the Administrator stated she was unaware the resident charts were stored in the laundry room and would take care of them. Interview on 9/12/2023 at 3:48 pm, the Director of Nursing (DON) revealed the facility didn't have a policy on storing medical records.