Every finding on record at Alhambra Hospital Med CTR Dp/Snf

Based on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) of the resident's medical records for four (4) of 4 sampled residents (Residents 6, 10, 14, and 21) observed for medication administration by not locking the screen prior to walking away from the computer. This deficient practice had the potential to expose Residents 6, 10, 14, and 21's medical records to others and violated the residents' right for privacy and confidentiality. Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following diagnosis of chronic respiratory failure (occurs when the respiratory system cannot supply enough oxygen to the blood or remove enough carbon dioxide from it), and tracheostomy (a surgically created hole in the front of the neck that opens directly into the windpipe) status. During a review of Resident 6's History and Physical (H&P), dated 12/24/2025, the H&P indicated the following but not limited to diagnoses of dysphagia (difficulty swallowing), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 6's Minimum Data Set (MDS – a resident assessment tool), dated 6/25/2026, the MDS indicated the resident is persistent vegetative state (a condition where a patient is completely unaware of themselves or their surroundings, yet retains basic physiological functions like breathing, heart rate, and sleep-wake cycles)/ no discernible consciousness (a person shows no observable or measurable signs of awareness of themselves or their surroundings). The MDS also indicated that the resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/ taking off footwear, and personal hygiene. During a medication administration observation in the hallway on 7/16/2026 at 8 AM, Licensed Vocational Nurse 1 (LVN 1) was observed preparing medications for Resident 6. LVN 1 was then observed walking away from the computer and leaving the monitor on. The computer monitor was observed with Resident 6's medical records. During an interview on 7/16/2026 at 9 AM, LVN 1 stated he left the monitor on/ open when it was not in use, and he should have closed or locked the screen so that Resident 6's medical information is not exposed and to maintain privacy and confidentiality. During an interview on 7/16/2026 at 9:10 AM, the Director of Nursing (DON) stated the monitor, or screen should be off when it is not in use to protect the resident's information. The DON also stated it is a Health Insurance Portability and Accountability Act (HIPAA - standards protecting sensitive health information from disclosure without patient's consent) violation and a confidentiality issue if it was left open by LVN 1 and other resident or visitors who pass by can see Resident 6's medical information from the monitor left open and unattended by the facility staff. 2. a. During a review of Resident 21's admission Record, the admission record indicated Resident 21 was admitted to the facility on [DATE]. During a review of Resident 21's Diagnosis, not dated, the Diagnosis record indicated Resident 21 with the diagnoses including but not limited to acute and chronic respiratory failure with hypoxia (lack of oxygen in the tissues to sustain bodily function), tracheostomy status, and dependence (when resident is unable to wean off a ventilator [a piece of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs] and breathe independently) on respirator [ventilator] status. During a record review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 was comatose (in a state of deep unconsciousness for a prolonged period as a result of a severe injury or illness) and in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident 21 was dependent on toileting hygiene, shower/bathe self, and personal hygiene. During an observation on 7/16/2026 at 8:04 AM during medication administration with LVN 2, LVN 2 walked away from the computer after preparing Resident 21's medications and into Resident 21's room. The computer screen displayed resident's name, age, date of birth , room number, medical record number (a unique identifier assigned to a patient by a healthcare facility to link all their medical records within that system), height, weight, drug allergies, and medications displayed on the screen. LVN 2 did not log off (to disconnect or stop using a computer system or program so no other individual can access) from her account and did not turn off the computer screen before walking away from the computer. 2. b. During a review of Resident 10's admission Record, the admission record indicated Resident 10 was admitted to the facility on [DATE]. During a review of Resident 10's Diagnosis, not dated, the diagnosis indicated Resident 10 with the diagnoses including but not limited to chronic respiratory failure, persistent vegetative state, and tracheostomy status. During a record review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was comatose and in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident 10 was dependent on toileting hygiene, shower/bathe self, and personal hygiene. During an observation on 7/16/2026 at 8:32 AM during medication administration with LVN 2, LVN 2 walked away from the computer after preparing Resident 10's medications and went into Resident 10's room. The computer screen displayed the resident's name, age, date of birth , room number, medical record number, height, weight, drug allergies, and medications displayed on the screen. LVN 2 did not log off from her account and did not turn off the computer screen before walking away from the computer. 2. c. During a review of Resident 14's admission Record, the admission record indicated Resident 14 was admitted to the facility on [DATE]. During a review of Resident 14's Diagnosis, not dated, the diagnosis indicated Resident 14 with the diagnoses including but not limited to acute (sudden) and chronic respiratory failure, tracheostomy status, and gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage) status. During a record review of Resident 14's MDS, dated [DATE], the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 14 was dependent on toileting hygiene and shower/bathe self. During an observation on 7/16/2026 at 8:51 AM during medication administration with LVN 2, LVN 2 walked away from the computer after preparing Resident 14's medications and went into Resident 14's room. The computer screen displayed resident's name, age, date of birth , room number, medical record number, height, weight, drug allergies, and medications displayed on the screen. LVN 2 did not log off from her account and did not turn off the computer screen before walking away from the computer. During an observation on 7/16/2026 at 9:11 AM during medication administration with LVN 2, LVN 2 walked away from the computer after administering Resident 14's medication to get a vital sign (clinical measurements, specifically pulse rate and blood pressure that indicate the state of a resident's essential body functions) machine. The computer screen displayed resident's name, age, date of birth , room number, medical record number, height, weight, drug allergies, and medications displayed on the screen. LVN 2 did not log off from her account and did not turn off the computer screen before walking away from the computer. During an interview on 7/16/2026 at 9:22 AM with LVN 2, LVN 2 stated she was not supposed to leave the computer screen open since it exposed the residents' personal information. LVN 2 stated she was supposed to close the screen for Residents 10, 14, and 21, but she did not close the screen after walking away from the computer during medication administration for the three residents. During an interview on 7/17/2026 at 9:45 AM with the DON, the DON stated staff were supposed to lock screen before walking away from the computer to maintain patient privacy and confidentiality. During a record review of the facility's policy and procedure (P&P) titled, Medication Administration, reviewed 3/2023, the P&P indicated computerized work stations must be locked and logged off when unattended. During a record review of the facility's P&P titled, Privacy and Confidentiality of Patients – General Guidelines, reviewed 7/2023, the P&P indicated all personnel are also obligated to protect the confidentiality of any Protected Health Information (PHI). The facility must maintain the confidentiality and security of PHI in any form – electronic, on paper or oral.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for four (4) or eight (8) sampled residents (Residents 1, 3, 8, and 14) reviewed under respiratory in accordance with the facility policy by:Failing to ensure Resident 1 [NAME] Suction Catheter (t-piece- used to deliver oxygen therapy and suction in an intubated resident) was changed when there were dry blood and mucus- build up on 7/14/2026.Failing to ensure Resident 3 t- piece was connected to the cool aerosol to administer oxygen to the resident per physician's (MD) order.Failing to ensure Resident 8's did not have mucus flowing out of the t-piece onto a towel. Failing to ensure Resident 14's Yankauer (a rigid, curved suction tool used to clear fluids, secretions and debris from the mouth and throat) was placed in a storage bag and another used Yankauer was left on Resident 14's bed. These deficient practices have the potential for Resident 1, 3, 8 and 14 to develop a respiratory infection, cause complications, associated with oxygen therapy, and result in the spread of diseases and infection. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses hypoxia (a condition where your body's tissues and organs do not receive enough oxygen to function properly), chronic respiratory failure (occurs when the respiratory system cannot supply enough oxygen to the blood or remove enough carbon dioxide from it), and ventilator dependent (an individual's body requires a mechanical device to breathe or sustain adequate oxygen levels). During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 5/19/2026, the MDS indicated the resident is independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and upper body dressing but requires substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self and is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with lower body dressing and putting on/ taking off footwear. The MDS indicated the resident is receiving tracheostomy (a surgically created opening [stoma] in the windpipe [trachea] through the front of the neck) care and is on an invasive mechanical ventilator (life-saving medical treatment that delivers oxygenated air directly into the lungs using a machine called a ventilator). During an observation on 7/14/2026 at 9:52 AM, Resident 1 was observed with dry blood and mucus build up in the resident's t-piece. During an observation on 7/14/2026 at 3:34 PM, Resident 1 was observed with dry blood and mucus build up in the t-piece. During a concurrent observation and interview on 7/14/2026 at 3:45 PM, Resident 1's t-piece was observed with dry blood and mucus build up. The Director of Nursing (DON) stated the dry blood and mucus in the resident's t- piece and it can obstruct the flow of air or get dislodge and block the resident's airway. During an interview on 7/16/2026 at 10:36A M, Respiratory Therapist 1 (RT 1) stated the t- piece should be changed twice weekly and as needed per policy. RT 1 also stated as needed, meaning if there is blood or mucus built up then the t- piece would need to be changed. During a record review on 7/15/2026 at 3:55PM, the facility's Policy and Procedure (P&P) titled Subacute Respiratory Equipment Changing Timetable and Responsibilities, revised 7/2020, the P&P indicated the [NAME] Suction Catheter should be changed twice weekly and as needed. The P&P also indicated all resident equipment will be changed to decrease the risk of infection. 2. During a review of Resident 3's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of respiratory failure and ventilatory support (attaching a breathing machine to the tracheostomy tube [a curved plastic or metal tube placed into a surgically made hole in the neck to keep the airway open and help a person breathe]) tracheostomy. During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident comatose (in a state of deep unconsciousness for a prolonged period as a result of a severe injury or illness) persistent vegetative state (occurs when a patient emerges from a coma but lacks cognitive function and awareness, while retaining sleep-wake cycles and basic bodily functions )/no discernible consciousness (there is no observable or measurable evidence that an individual is aware of themselves or their environment). The MDS also indicated that the resident is dependent on oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting off footwear, and personal hygiene. The MDS indicated the resident is on tracheostomy care and on an invasive mechanical ventilator. During a review of Resident 3's Physician Orders, dated 5/12/2026, the Physician orders indicated aerosol (a fine mist of liquid droplets suspended in a gas used for medical respiratory therapy) ongoing at 35% Fraction of Inspired Oxygen (FIO2) t-piece cool aerosol, keep peripheral oxygen saturation (SPO2 – a percentage that measures how much oxygen your red blood cells are carrying) greater than (>) 92%. During an observation on 7/14/2026 at 9:18 AM, Resident 3 was observed with t- piece not connected to the cool aerosol. During an interview on 7/15/2026 at 3:56 PM, the DON stated the t-piece should be always connected to the cool aerosol because the resident can go into respiratory distress if it is not connected. The DON also stated the staff are not following the MD order for the respiratory therapy if the t- piece was not connected to the cool aerosol or to the oxygen. During a review of the facility's P&P titled Nursing Scope of Practice, reviewed 2/2017, the P&P indicated the scope of nursing is direct and indirect patient care services such as administration of medications and therapeutic agents, necessary to implement a treatment, ordered by and within a scope of licensure of a physician. During a review of the facility's P&P titled Sub-Acute Unit Respiratory Service, review date 10/2018, the P&P indicated to provide and maintain adequate oxygenation and ventilation for residents with respiratory insufficiency and/or acute respiratory distress. 3. During a review of Resident 8's admission Record, the admission record indicated Resident 8 was admitted to the facility on [DATE]. During a review of Resident 8's Diagnosis, not dated, the Diagnosis record indicated Resident 8 with the diagnoses including but not limited to acute and chronic respiratory (sudden onset with short duration and a long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body) failure with hypoxia, gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage), and tracheostomy status. During a record review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 was comatose and in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident 8 was dependent on toileting hygiene, shower/bathe self, and personal hygiene. During a record review of Resident 8's Care Plan, reviewed 4/2026, the Care Plan indicated Resident 8 had potential for infection related to tracheostomy tube. It indicated, the nursing staff interventions were to provide tracheostomy care every shift and suction every two (2) hours and as needed. During a record review of Resident 8's Subacute Monthly Orders, dated 6/23/2026, the order indicated tracheal suction every 2 hours and as needed. During an observation on 7/14/2026 at 11:39 AM in Resident 8's room, Resident 8 was lying in bed, and mucus was noted in the inner t-piece and overflowing out from the t-piece down Resident 8's body and onto the towel on the bed and on the call light (a visible and audible alarm activated by a call button). During a concurrent observation and interview on 7/17/2026 at 8:08 AM with Minimum Data Set Nurse (MDSN), MDSN stated the t-piece needed to be changed and the mucus needed to be suctioned. MDSN stated Resident 8 should be suctioned every 2 hours and suctioned as needed and Resident 8 needed to be suctioned. MDSN stated the mucus flowing out from the t-piece was an infection control issue and hygiene issue since the clothing was soiled. During an interview on 7/17/2026 at 9:36 AM with the DON, the DON stated Resident 8 needed to be suctioned every 2 hours and suctioned as needed since having excessive mucus was an aspiration (inhaling small particles of food or drops of liquid into the lungs) precaution. The DON stated Resident 8 was at high risk for aspiration due to the resident's diagnosis and being in the subacute unit (a specialized healthcare setting that provides subacute care which is a level of medical care that is less intensive than acute care but more specialized than typical skilled nursing care). The DON stated Resident 8's excessive mucus was not the standard of practice at the facility. 4. During a review of Resident 14's admission Record, the admission record indicated Resident 14 was admitted to the facility on [DATE]. During a review of Resident 14's Diagnosis, not dated, the diagnosis record indicated Resident 14 with the diagnoses including but not limited to acute and chronic respiratory failure, tracheostomy status, and gastrostomy status. During a record review of Resident 14's MDS, dated [DATE], the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 14 was dependent on toileting hygiene and showering/bathing self. During a record review of Resident 14's Care Plan, dated 5/26/2026, the Care Plan indicated Resident 14 had the potential for infection related to tracheostomy tube. It indicated, the nursing staff interventions were to provide tracheostomy care every shift and suction every 2 hours and as needed. During an observation on 7/14/2026 at 8:17 AM in Resident 14's room, Resident 14 was lying in bed. The Yankauer was left uncovered attached to the suction tube and another used Yankauer with dried mucus was left on Resident 14's bed. During a concurrent observation and interview on 7/14/2026 at 8:35 AM with Registered Nurse 1 (RN 1), RN 1 stated the Yankauers on the resident's bed were dirty and the attached Yankauer was supposed to be kept in a bag. RN 1 stated the used Yankauer should be discarded in the appropriate trash bin and not left on Resident 14's bed. RN 1 stated both Yankauers placed Resident 14 at risk for infection. During an interview on 7/17/2026 at 9:40 AM with the DON, the DON stated the Yankauer was supposed to be placed in a bag to avoid cross contamination since it was going inside the resident's mouth. The DON stated the detached used Yankauer was supposed to be disposed of and not left on Resident 14's bed. The DON stated disposal of the used Yankauer could prevent staff from reusing the detached Yankauer since there was no date labeled and it was already opened. During a review of the facility's policy and procedure (P&P) titled, Suctioning: Tracheostomy and Endotracheal, reviewed 3/2023, the P&P indicated assess need for further suctioning at least every 2 hours, or more frequently if secretions are copious (an abnormally large or excessive production of bodily fluids). During a review of the facility's P&P titled, Sub-Acute Infection Control Policies, revised 6/2026, the P&P indicated all used equipment must be considered contaminated and is collected/handled in a safe manner in order to protect other patients, visitors, staff and the hospital environment.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) receive the necessary services to maintain good personal and oral hygiene for two (2) of 2 sampled residents (Residents 7 and 12) reviewed for ADLs to ensure:Resident 7's oral hygiene was maintained when resident's tongue was observed dry with white coating and red spots on the tongue bed. Resident 12 did not have dry nasal mucus outside the left nostril (outer opening of the nose). This deficient practice had the potential to result in a decrease in quality of life, oral health, and higher risk or oral infections for Resident 7 and had the potential to result in a negative impact on Resident 12's self-esteem. Findings: 1. During a review of Resident 7's admission Record, the admission record indicated Resident 7 was admitted to the facility on [DATE]. During a review of Resident 7's Diagnosis, not dated, the diagnosis indicated Resident 7 with the diagnoses including but not limited to chronic respiratory failure (a long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), persistent vegetative state (condition where resident has woken from a coma but still lacks awareness), and candidal stomatitis (also known as oral candidiasis or oral thrush, is a fungal infection of the mouth caused by overgrowth of Candida species). During a record review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 6/10/2026, the MDS indicated Resident 7 was comatose (in a state of deep unconsciousness for a prolonged period as a result of a severe injury or illness) and in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident 7 was dependent (helper does all of the effort, resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity) for oral hygiene, toileting hygiene, and personal hygiene. During a record review of Resident 7's Care Plan, dated 6/10/2026, the Care Plan indicated Resident 7 needs assistance with oral care and intervention was to ensure good oral hygiene and monitor dental condition and refer to dentist if indicated. During an observation on 7/14/2026 at 3:44 PM in Resident 7's room, Resident 7 was lying in the bed with his mouth open. Resident 7's tongue was observed dried, with whitish discoloration or coating on top of the tongue bed and the tongue tip was noted with redness. During an observation on 7/16/2026 at 11:08 AM in Resident 7's room, Resident 7 was lying in bed with his mouth open. Resident 7's tongue was observed dried. During a concurrent observation and interview on 7/16/2026 at 11:13 AM in Resident 7's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 7 always has his mouth open. CNA 1 stated Resident 7's tongue is a little dirty and dried. CNA 1 stated we needed to do oral care as needed and Resident 7 needs oral care right now. CNA 1 stated Resident 7 is unable to perform oral care for himself. During a concurrent interview, and record review on 7/16/2026 at 2:24 PM, with Minimum Data Set Nurse (MDSN), photos of Resident 7's mouth taken during observation on 7/14/206 at 3:44 PM and 7/16/2026 at 11:13 AM were reviewed. MDSN stated basing off the photo of Reisdent 7's mouth and tongue taken on 7/14/2026 and 7/16/2026, Resident 7 had white spots, darkish red spots, and the resident's tip portion of tongue looked dry. MDSN stated Resident 7 had a history of candida stomatitis. MDSN stated mouth care for Resident 7 needed to be provided very consistent and routine daily and/ or as needed oral care to prevent another occurrence of candida stomatitis or other mouth diseases. MDSN stated oral hygiene was also important for Resident 7 since Resident 7 had a tracheostomy (a surgical procedure to create an opening through the neck into the windpipe to provide direct airway, bypassing the mouth and nose) since anything in his mouth could go down and affect the resident. MDSN stated Resident 7 was dependent on staff for oral care. During an interview on 7/17/2026 at 9:44 AM with the Director of Nursing (DON), the DON stated oral hygiene was a basic standard of care. The DON stated Resident 7 was unable to perform oral hygiene by himself. The DON stated good oral hygiene was needed to prevent any abnormalities from not cleaning or maintaining oral care of the resident. The DON stated poor oral hygiene could result in Resident 7's candida stomatitis coming back. 2. During a review of Resident 12's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnosis of respiratory failure (occurs when the respiratory system cannot supply enough oxygen to the blood or remove enough carbon dioxide from it) with vent dependent (an individual's body requires a mechanical device to breathe or sustain adequate oxygen levels). During a review of Resident 12's History and Physical (H&P), dated 12/18/2025, the H&P indicated the resident has the following but not limited to diagnoses of dysphagia (difficulty swallowing), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and status epilepticus (any single continuous seizure lasting more than 5 minutes, or two or more seizures occurring without the person fully regaining consciousness in between). During a review of Resident 12's Care Plan with focus self-care deficit, revised 5/2026, the Care Plan indicated the resident is unable to do self-daily hygiene and grooming. The Care Plan also indicated the residents daily personal care needs will be met during the facility stay. During a review of Resident 12's Care Plan with focus impaired communication, revised 5/2026, the Care Plan indicated to ask simple yes or no questions and resident is able to mouth words. During a review of Resident 12's MDS, dated [DATE], the MDS indicated the resident is independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated, the resident is dependent with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During an observation on 7/14/2026 at 9:44 AM in Resident 12's room, Resident 12's observed with a dry nasal mucus outside the left nostril. Resident mouth words stating it makes him uncomfortable. During an observation and interview on 7/15/2026 at 3:53PM, the DON stated Resident 12 should have been cleaned and the dry nasal mucus should not have been on Resident 12's nose. DON also stated it is a dignity issue and can affect the resident's self-esteem. It is not in the policy but should be in the policy. During an interview on 7/16/2026 at 10:19AM, the facility's undated Policy and Procedure (P&P) titled Residents Rights, was reviewed. The DON stated the P&P indicated the facility must promote care for the residents that enhances their dignity which includes cleaning the residents face of any mucus or secretions. During a review of the facility's undated P&P titled Residents rights, the P&P indicated the facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Based on observation, interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 1) reviewed for unnecessary medications (medication prescribed or consumed without a valid clinical indication for an excessive duration, at too high a dose, or when potential risks outweigh the benefits) was free from unnecessary medication use by failing to monitor signs and symptoms of bleeding, notify the physician and hold Resident 1's Xarelto (a prescription blood thinner used to treat and prevent dangerous blood clots) on 7/14/2026 and 7/15/2026 due to the presence of tracheostomy bleeding, as indicated on the resident's care plan and facility's policy and procedures (P&P). This deficient practice had the potential to increase Resident 1's risk of experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to anticoagulant medication (medications that delay or prevent the body from forming dangerous blood clots) which can lead to complications, harm, and hospitalization.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the diagnoses of hypoxia (a condition where the body's tissues and organs do not receive enough oxygen to function properly), chronic respiratory failure (occurs when the respiratory system cannot supply enough oxygen to the blood or remove enough carbon dioxide from it), and ventilator dependent (an individual's body requires a mechanical device to breathe or sustain adequate oxygen levels). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/19/2026, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and upper body dressing and required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self. The MDS also indicated Resident 1 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with lower body dressing and putting on/ taking off footwear. The MDS indicated Resident 1 was receiving tracheostomy (a surgically created opening [stoma] in the windpipe [trachea] through the front of the neck) care and was on an invasive mechanical ventilator (life-saving medical treatment that delivers oxygenated air directly into the lungs using a machine called a ventilator). During a review of Resident 1's Care Plan, dated 5/19/2026, the Care Plan indicated the resident is at risk for bleeding, bruising, and complications of anticoagulant therapy. The care plan also indicated Resident 1's risk factors included use of Xarelto. The care plan interventions included were to assess and monitor signs and symptoms of bleeding closely and report to Medical Doctor (MD) any abnormal signs and symptoms. During a review of Resident 1's Care Plan, dated 5/19/2026, the Care Plan indicated the resident is at risk for tracheal bleeding associated with routine tracheostomy tube change and use of anticoagulant. The care plan interventions included were to assess for signs of/ presence of tracheal bleeding closely and notify MD. During an observation on 7/14/2026 at 9:52 AM, Resident 1 was observed with dried blood and mucus buildup in the [NAME] suction catheter (t piece directly attached to the tracheostomy tube used to deliver oxygen therapy and suction an intubated resident). During an observation on 7/14/2026 at 3:34 PM, Resident 1 was observed with dried blood and mucus buildup in the t piece. During a concurrent observation and interview on 7/14/2026 at 3:45 PM, Resident 1's t-piece was observed with dried blood and mucus build up. The Director of Nursing (DON) stated that there were dried blood and mucus in Resident 1's t-piece. During a review of Resident 1's Physician's Order/Active Orders, the Physician's Order/Active Orders indicated Rivaroxaban (Xarelto) 10 milligrams (mg - unit of measure) via feeding tube every afternoon (PM). During a review of Resident 1's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 7/15/2026 at 5:04 PM, the MAR indicated Xarelto 10 mg was administered to the resident. During a review of Resident 1's Physician's Order/Active Orders, the Physician's Order/Active Orders indicated Rivaroxaban (Xarelto) 10 mg via feeding tube every afternoon (PM). During a concurrent review and interview on 7/16/2026 at 11:53 AM, Resident 1's Long Term Care (LTC) Progress Notes, dated 7/14/2026, and MAR, dated 7/14/2026 and 7/15/2026 at 5:04 PM, were reviewed. Registered Nurse 1 (RN 1) stated the progress notes indicated to hold Xarelto as needed for tracheostomy bleeding. RN 1 also stated that Resident 1 was experiencing tracheostomy bleeding on 7/13/2026, so the physician should have been notified and Xarelto should have been placed on hold. RN 1 further stated that the anticoagulant should have been held on 7/14/2026 and 7/15/2026, but it was administered when it should not have been. During an interview on 7/17/2026 at 9:15 AM, the Director of Nursing (DON) stated Resident 1's Xarelto should have been on hold on 7/14/2026 and 7/15/2026 and should not have been administered to Resident 1. During a review of the facility's P&P titled, Pharmacy Monitoring of Physician Dosing of Anticoagulants, revised 9/2020, the P&P indicated to monitor patients for signs and symptoms of bleeding or bruising. If present, the physician shall be notified.

Based on observation, interview, and record review, the facility failed to ensure proper food handling practices in accordance with the facility's policy and procedure (P&P) by failing to ensure:Cook wore a beard net when preparing vegetables on 7/14/2026.Dry food items were labeled with use-by date.Fruits and vegetables in the refrigerator had a use-by date.Opened bags of cilantro and beansprouts had a use-by date.The interior of the ice machine was free of brown smudges and black particles.These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.Findings: During a concurrent observation and interview on 7/14/2026 at 7:45 AM, the [NAME] was observed preparing vegetables. The [NAME] was also observed with a beard and was not wearing a beard net. Lead [NAME] (LC) stated that the [NAME] has a long beard and should be wearing a beard net but was not. The LC further stated that hair from the beard could fall into the food and contaminate it. During a concurrent observation and interview on 7/14/2026 at 7:48 AM in the dry storage area, the LC stated that the pure white sugar, low-sodium brown gravy mix, plain gelatin, sugar-free lemon gelatin dessert mix, strawberry gelatin mix, and raisins were not labeled with a use by date. The LC further stated when food items are not labeled with a use by date, the food items may be used past their safe period, which can lead to foodborne illness. The LC also stated all food items should be labeled with a use by date before storage. During a concurrent observation and interview on 7/14/2026 at 8 AM in the refrigerator, the refrigerator was observed with jalapeno, green tomatoes, green bell peppers, red potatoes, yam, apples, pineapples, daikon radish, and tomatoes without use by dates. Open bags of bean sprouts and cilantro were also observed without use by dates. The LC stated that all items should have a use by date before being placed into storage. During a concurrent observation and interview on 7/14/2026 at 8:18 AM in the kitchen, the interior of the ice machine was observed to have brown smudges and black particles. The LC stated that the ice machine should not have any brown smudges or black particles because it is required to be clean. The LC further stated this is an infection control concern and can lead to foodborne illness. During a concurrent review and interview on 7/15/2026 at 2PM, the facility's P&P titled, Food Receiving, Storage and Discard, revised 4/2021, was reviewed. The Director of Food and Nutrition (DFN) stated all food should be wrapped, labeled, and dated with a use by date before placing into the storage. The DFN further stated the dry food items should have a use-by date because the absence of proper labeling can lead to foodborne illness. During a concurrent review and interview on 7/15/2026 at 2:10 PM, the facility's P&P titled, Storage and Handling of Ice, revised 3/2020, was reviewed. The DFN stated that the ice machine should be cleaned weekly and stated not knowing when it was last cleaned. The DFN also stated the facility does not have a cleaning log for the ice machine. The DFN further stated the brown smudges and black particles observed inside the ice machine could contaminate the ice used for residents. In addition, the DFN stated a cleaning log should be maintained to ensure the ice machine is cleaned weekly. During a review of the facility's P&P titled, Storage and Handling of Ice, revised 3/2020, the P&P indicated the ice machine will be maintained routinely to ensure that ice is clean and free from microorganisms. The P&P also indicated a designated employee cleans and drains areas on each ice machine and disinfects weekly. During a review of the facility's P&P titled, General Rules - Food and Nutrition Services, revised 9/2020, the P&P indicated beards, moustaches and sideburns must be neatly trimmed. The P&P also indicated hair net for these types of hairs should also be worn during food preparation. During a review of the facility's P&P titled, Food Receiving, Storage and Discard, revision 4/2021, the P&P indicated all food should be wrapped, labeled, and dated before placed in storage. The P&P also stated check expiration date for food items in its original packaging, if it is not visible; rewrite the expiration date on its outer box.

Based on observation, interview and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for five (5) of 14 sampled residents (Residents 2, 6, 10, 14, and 21) reviewed for infection control as indicated on the facility policy by failing to ensure:1.Licensed Vocational Nurse 1 (LVN 1) used a clean medication cup to administer Resident 6's morning medications on 7/16/2026. LVN 1 also did not use a gastrostomy tube (G-Tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) de-clogger (typically a small syringe-like device or a flexible plastic tool used to clear blockage in a G-Tube) that was placed on top of a contaminated medication cup, to flush Resident 6's G-Tube. 2. Resident 2's G-Tube port was free from residue buildup. Certified Nursing Assistant 1 (CNA1) also failed to remove gloves and perform hand hygiene after providing incontinent care to Resident 2 before proceeding to reposition the resident and touching the clean bed linens. 3. to 5. Staff wore personal protective equipment (PPE - protective clothing, helmets, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) while providing care for Residents 10, 14, and 21 who were on enhanced barrier precautions (EBP - an approach of targeted gown and glove use during high contact resident care activities designed to reduce transmission). These deficient practices have the potential for cross contamination and increased risk for the spread of bacteria, viruses and pathogens (harmful microorganisms) to the residents, visitors, and staff. Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses of chronic respiratory failure (occurs when the respiratory system cannot supply enough oxygen to the blood or remove enough carbon dioxide from it) and tracheostomy (a surgically created hole in the windpipe that provides an alternative airway for breathing) status. During a review of Resident 6's Minimum Data Set (MDS – a resident assessment tool), dated 6/25/2026, the MDS indicated the resident was in persistent vegetative state no discernible consciousness (a condition where a resident is completely unaware of him/herself or its surroundings, yet retains basic physiological functions like breathing, heart rate, and sleep-wake cycles). The MDS also indicated that Resident 6 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/ taking off footwear, and personal hygiene. The MDS also indicated Resident 6's was on a feeding tube. During a medication administration observation and interview on 7/16/2026 at 8:34AM, LVN 1 was observed dropping a medication cup on the floor. LVN 1 was then observed picking up the medication cup and placing it on the workstation on wheels (WOW – computer on wheels that allows access to electronic medical record and dispense medications). LVN 1 was later observed putting the G-Tube declogger on top of the contaminated medication cup. LVN 1 was observed preparing Resident 6's medications on a bedside table. LVN 1 grabbed the contaminated medication cup and was about to put one of Resident 6's medications in it until Surveyor 1 intervened and stopped LVN 1 from placing the medications into the contaminated cup. LVN 1 stated he should have discarded the contaminated medication cup that fell on the floor and should have retrieved a new cup for Resident 6's medication administration instead. During the same medication administration observation and interview at 7/16/2026 at 8:55 AM, LVN 1 was observed giving medications to Resident 6. During the medication administration, LVN 1 was observed using the declogger, to flush the GTube, that was placed on the contaminated medication cup. LVN 1 stated the declogger was already contaminated when it was placed on top of the contaminated medication cup. LVN 1 also stated the declogger should have been discarded and a new one should have been used to prevent infection to the resident. During an interview on 7/17/2026 at 8:56AM, the Director of Nursing (DON) stated the contaminated medication cup and declogger should have been discarded and not used on Resident 6 for infection control reasons. 2. During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses respiratory failure, tracheostomy and g-tube feeding. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident was in a persistent vegetative state/no discernible consciousness. The MDS also indicated the resident was dependent on oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/ taking off footwear and personal hygiene. The MDS indicated the resident was on a feeding tube. During an observation on 7/14/2026 at 9:08 AM, Resident 2 G-Tube port was observed with buildup and residue. During a concurrent observation and interview on 7/15/2026 at 3:55PM, the DON stated Resident 2 G-Tube port has residue buildup. DON stated that it was not acceptable that the G-Tube port had residue buildup. The DON stated these can harbor bacteria which may be flushed through the G-Tube and could lead to Resident 2 getting sick. During an observation on 7/16/2026 at 2:08 PM, CNA 1 was observed providing incontinence care and changing Resident 2's brief. CNA 1 was then observed with the same gloves, after wiping Resident 2 peri-area, and touched Resident 2's clean bed sheets and repositioned the resident. During an interview on 7/16/2026 at 4:01 PM, CNA 1 stated he did not change gloves and performed hand hygiene after providing incontinence care to Resident 2. CNA 1 also stated he should have changed gloves and performed hand hygiene before continuing care for infection control. During an interview on 7/17/2026 at 9:10 AM, the G-Tube port manufactures instructions titled Dale ACE Connector with Legacy Connections, dated 2024, was reviewed. The instructions indicated to change as needed. The DON stated change as needed means change when the G-Tube port is dirty or has buildup. During an interview on 7/17/2026 at 10:11AM, the Infection Control Supervisor (ICS) stated after incontinence care, the gloves should be removed, and the CNA should have performed hand hygiene and replaced gloves before continuing with care for infection control. During a review of the facility's Policy and Procedure (P&P) titled, Nursing Standards of Care, revised 5/2019, the P&P indicated all nursing staff shall be competent in complying with infection control policies and procedures that minimize and/or prevent cross contamination, and knowledgeable of the principles of Universal Precautions. During a review of the facility's P&P titled, Hand Hygiene – Hospital Wide, revised 11/2022, the P&P indicated gloves should be used for hand-contaminating activities. Gloves should be removed and hands washed or sanitized when such activity is completed. The P&P also stated gloves may need to be changed during the care of a single patient such as moving from one procedure to another. During a review of the facility's P&P titled Infection Prevention and Control Plan, revised 2/2026, the P&P indicated to provide patients with an environment that is free, as much as possible form infection-causing exposure. The P&P also indicated to assure a safe environment for patients by following policies dealing with contaminated equipment assuring they are appropriately handled to minimize risk of infection to patients. During a review of the facility's P&P titled Sub-Acute Infection Control Policies, revised 6/2026, the P&P indicated each staff member assigned in the unit is responsible for ensuring that infection prevention and control procedures are performed. 3. During a review of Resident 21's admission Record, the admission record indicated Resident 21 was admitted to the facility on [DATE]. During a review of Resident 21's Diagnosis List form, not dated, the Diagnosis List form indicated Resident 21 with the diagnoses including but not limited to acute and chronic respiratory failure with hypoxia (lack of oxygen in the tissues to sustain bodily function), tracheostomy status, and dependence (when resident is unable to wean off a ventilator [a piece of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs] and breathe independently) on respirator (ventilator) status. During a record review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 5/2/2026, the MDS indicated Resident 21 was comatose (in a state of deep unconsciousness for a prolonged period as a result of a severe injury or illness) and in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident 21 was dependent on toileting hygiene, shower/bathe self, and personal hygiene. During a record review of Resident 21's Care Plan, reviewed 6/2026, the Care Plan indicated Resident 21 needs enhanced barrier precautions due to tracheostomy and gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage). The nursing staff interventions were to perform hand hygiene and use PPE per protocol. During an observation on 7/16/2026 at 8:04 AM during medication administration with LVN 2, LVN 2 walked into Resident 21's room wearing a mask and a glove to administer Resident 21's medication through his gastrostomy tube. LVN 2 did not wear an isolation gown during Resident 21's medication administration via the G-tube. 4. During a review of Resident 10's admission Record, the admission record indicated Resident 10 was admitted to the facility on [DATE]. During a review of Resident 10's Diagnosis List form, not dated, the Diagnosis List form indicated Resident 10 with the diagnoses including but not limited to chronic respiratory failure, persistent vegetative state, and tracheostomy status. During a record review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was comatose and in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident 10 was dependent on toileting hygiene, shower/bathe self, and personal hygiene. During a record review of Resident 10's Care Plan, dated 5/4/2026, the Care Plan indicated Resident 10 needs enhanced barrier precautions due to tracheostomy and gastrostomy. The nursing staff interventions were to perform hand hygiene and use PPE per protocol. During an observation on 7/16/2026 at 8:32 AM during medication administration with LVN 2, LVN 2 walked into Resident 10's room wearing a mask and a glove to administer Resident 10's medication through the gastrostomy tube. LVN 2 did not wear an isolation gown during Resident's medication administration via the G-tube. 5. During a review of Resident 14's admission Record, the admission record indicated Resident 14 was admitted to the facility on [DATE]. During a review of Resident 14's Diagnosis List form, not dated, the Diagnosis List form indicated Resident 14 with the diagnoses including but not limited to acute and chronic respiratory failure, tracheostomy status, and gastrostomy status. During a record review of Resident 14's MDS, dated [DATE], the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 14 was dependent on toileting hygiene and showering/bathing self. During a record review of Resident 14's Care Plan, dated 5/26/2026, the Care Plan indicated Resident 14 needs enhanced barrier precautions due to tracheostomy and gastrostomy. The nursing staff interventions were to perform hand hygiene and PPE per protocol. During an observation on 7/16/2026 at 8:51 AM during medication administration with LVN 2, LVN 2 walked into Resident 14's room wearing a mask and a glove to administer Resident 14's medication through the gastrostomy tube. LVN 2 did not wear an isolation gown during Resident 14's medication administration via the G-tube. During an interview on 7/16/2026 at 9:22 AM with LVN 2, LVN 2 stated she did not wear and was supposed to wear an isolation gown during administering medications for Residents 21, 10, and 14. LVN 2 stated an isolation gown, gloves, and masks were supposed to be worn during medication pass with residents who had G-tubes in order to not contaminate the residents and the staff. During an interview on 7/17/2026 at 9:45 AM with the DON, the DON stated that when administering medications via a G-tube, staff needed to wear PPE such as gloves, gown, and a mask. The DON stated it was a high contact activity with resident care and staff needed to protect themselves and the residents from any contamination. During a record review of the facility's P&P titled, Sub-Acute Infection Control Policies, revised 6/2026, the P&P indicated enhanced barrier precautions are to be used in providing care to patients. This is to protect personnel from contamination with body substances and to prevent transmission of microorganisms between residents. For relatively health residents follow enhanced barrier precautions making sure that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence and ostomy tubes/bags.

Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 18) reviewed for nutrition was provided with a therapeutic diet (a diet ordered by a physician as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet or to increase specific nutrients in the diet, or to provide food the resident is able to eat such as mechanically altered diet [diet where the texture of the food is changed so it is easier and safer to chew and swallow for people with swallowing or chewing difficulties]) as indicated on the physician's order and facility's policy and procedure (P&P).This deficient practice had the potential to cause a choking hazard, result in inadequate food intake, which could compromise nutrition and hydration, and place Resident 18 at risk for aspiration pneumonia (a lung infection that happens when the resident inhales [aspirates] material like food, liquid, saliva, stomach contents, or bacteria into the lungs instead of swallowing it).Findings: During a review of Resident 18's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure (a long-term condition where the respiratory system cannot properly oxygenate the blood or remove carbon dioxide), tracheostomy (a surgically created hole, known as a stoma, in the front of the neck and directly into your windpipe) status, and dependence on ventilator (a medical machine that helps or takes over the breathing process for someone who cannot breathe effectively on their own). During a review of Resident 18's Physician Orders, dated 9/3/2025, the Physician Orders indicated pureed diet (a type of soft diet where all foods are blended into a smooth, pudding like texture so they require no chewing and are easy to swallow) with honey thick liquids (pourable but move significantly slower than thin liquids, resembling the flow of honey).During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool), dated 4/30/2026, the MDS indicated the resident was moderately impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 18 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 18 required tracheostomy care, had difficulty swallowing, and was on a therapeutic diet. During a review of Resident 18's Care Plan, dated 4/30/2026, the Care Plan indicated the resident had a potential or actual alteration of nutrition related to swallowing problem. The care plan interventions included were to provide diet as ordered by physician and assess the diet texture and tolerance of food. During a concurrent observation and interview on 7/14/2026 at 12:45 PM in Resident 18's room, Resident 18's meal tray was observed containing pureed chicken with crusted edges, pureed broccoli. and honey thick milk. Registered Nurse 1 (RN 1) stated the crusted edges on the pureed chicken were hard and could pose a choking hazard for Resident 18. During an interview on 7/15/2026 at 11:45 AM, Lead [NAME] (LC) stated Resident 18 was not supposed to have crusted edges on his pureed food because this presents a choking hazard. During an interview on 7/15/2026 at 12PM, the Director of Food and Nutrition (DFN) stated it was not acceptable for Resident 18 to have crusted edges of pureed diet because this presents a choking hazard for the resident.During an interview on 7/17/2026 at 8:46 AM, the Director of Nursing (DON) stated it was not acceptable for Resident 18 to have crusted edges of pureed diet because this presents a choking hazard for the resident. During a review of the facility's P&P titled, Diet Order Guideline, revised 6/2024, the P&P indicated all diet order should compose of:Therapeutic Nutritional NeedsTexture andLiquid ConsistencySuch as Pureed Diet: pureed foods are easy to swallow, smooth, lump free, not firm, and not sticky, all foods remain intact and hold their shape on a plate, liquids do not separate form solid and foods.

Based on observation, interview and record review, the facility failed to cap the purple cone tip of the gastronomy tube feeding (g-tube; a tube inserted through the belly that brings nutrition directly to the stomach) when not connected to resident for two (2) of 2 sampled residents (Resident 17 and 22). This deficient practice had the potential to result in complications including infections and stomach discomfort. Findings: 1.During a record review of Resident 17's admission record indicated the facility originally admitted Resident 17 on 5/6/2025. During a record review of Resident 17's history and physical (H&P) dated 5/7/2025 indicated Resident 17 with diagnosis of respiratory failure ventilator dependent (a person's lungs are unable to provide enough oxygen), dementia (a decline in mental abilities, including memory, thinking, and reasoning, severe enough to interfere with daily life), and hypertension (high blood pressure). During a record review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 5/13/2025, the MDS indicated resident was dependent on shower/bathe self, upper body dressing, lower body dressing, personal hygiene. The MDS also indicated nutritional approaches feeding tube (g-tube) on admission. During a record review of Resident 17's Active Orders indicated order date 6/16/2025 g-tube feeding diet, Vital 1.5 calories (a type of feeding formula) continuous at 65 milliliter per hour (ml/hr., measurements of volume) for 20 hours. During a record review of Resident 17's care plan titled Sub Acute Care Plan date initiated 5/6/2025 indicated expected outcome no signs and symptoms of tube feeding related infection. During observation on 6/30/2025 at 11:23 AM in Resident 17's room observed the purple cone tip of g- tube feeding of Resident 17 was uncapped/ uncovered. 2. During a record review of Resident 22's admission record indicated the facility originally admitted Resident 22 on 8/20/2024. During a record review of Resident 22's H&P dated 8/22/2024 indicated Resident 22 with dysphagia (difficulty swallowing), hypertension, and dementia. During a record review of Resident 22's MDS, dated [DATE], the MDS indicated residents were dependent on shower/bathe self, upper body dressing, lower body dressing, personal hygiene. The MDS also indicated nutritional approaches feeding tube while a resident. During a record review of Resident 22's Active Orders indicated order date 9/24/2024 tube feeding diet: Tube feeding route of administration G-tube. Tube feeding formula type: Jevity 1.2 calories (type of feeding) continuous at 45ml/hr. for 20 hours. During a record review of Resident 22's care plan titled Sub Acute Care Plan date initiated 8/20/2024 indicated expected outcome: no signs and symptoms of tube feeding related infection. During observation on 6/30/2025 at 11:35 AM in Resident 22's room observed the purple cone tip of Resident 22's g- tube feeding was not covered/ uncapped. During a concurrent interview and record review on 7/2/2025at 10:27 AM with the Director of Nursing (DON), the manufacturer's guidelines titled Midline Safety Spike Pump Set Up with Brand 1 undated was reviewed. The guideline indicated under directions of use, replace connector cap. The DON stated the g-tube purple cone tip should be capped when not connected to residents, to prevent it from touching unnecessary surface that can transmit unwanted bacteria, virus that can cause sickness. The DON stated no specific policy and procedure (P&P) regarding the purple cone tip of the G-tube should be covered but it was indicated in the manufacturer's guidelines titled Midline Safety Spike Pump Set Up with Brand 1. The DON stated under directions for use indicated replace connector cap. During an interview on 7/2/2025 at 4:05 PM with License Vocational Nurse (LVN 2), LVN 2 stated the G-tube purple cone tip was supposed to be covered with a cap when not used to prevent cross contamination that can possibly cause sickness like diarrhea and stomach flu to residents. During an interview on 7/3/2025 at 2:31PM with the DON the DON stated all G-tube purple cone tip should be covered when not in use, and it was not in the P&P, but it was in the manufacturer's guideline. The DON also stated it should be indicated the P&P.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for four (4) of four sampled residents (Residents 5, 11, 21, and 6) in accordance with the facility's policy and procedure (P&P) by failing to: 1. and 2. Sanitize (make clean and hygienic) the pulse oximetry (pulse ox- a non-invasive method used to measure the oxygen saturation [the percentage of hemoglobin in the blood that is carrying oxygen] level in a resident's blood) monitor before and after each resident's use for Resident 5 and Resident 11. 3. Ensure facility staff donned (wear) personal protective equipment (PPE- a barrier precaution which includes use of gloves, gown, mask, face shield, shoe covers, head covers, respirators, etc. when you anticipate contact with blood or body fluids or other communicable toxins or agents) before checking Resident 21's gastrostomy tube (G-tube- a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) placement and medication administration. 4. a. Change gloves and perform hand hygiene in between tasks during tracheostomy (a surgical procedure to create an opening in the windpipe through the neck allowing for a tube to be inserted for breathing) dressing change to Resident 6. b.Dispose Resident 6's used tracheostomy drain sponge (a dressing used to absorb and manage fluids leaking from tracheostomy tubes) and inner cannula (a tube inserted in the tracheostomy to help with breathing) in the trash after tracheostomy care. c.Sanitize Resident 6's bedside table after Resident 6's used tracheostomy dressings and inner cannula were placed on top by Registered Nurse 2 (RN 2) after providing tracheostomy care. These deficient practices had the potential to result in the spread of and development of infection through possible cross-contamination (passing of bacteria, or other harmful substances indirectly from one resident to another through improper or soiled equipment, procedures, or products.) Findings: 1. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 5's History and Physical (H&P), dated 12/3/2024, the H&P indicated Resident 5 had diagnoses which included chronic ventilator-dependent respiratory failure (when a resident is unable to breathe independently and requires mechanical ventilation), tracheostomy, and chronic obstructive pulmonary disease (COPD- a long-term lunch disease causing difficulty breathing). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 6/11/2025, the MDS indicated Resident 5 was in a persistent vegetative state (a condition where a resident is awake but shows no signs of awareness)/no discernable consciousness. Resident 5 was dependent (helper does all of the effort) with upper/lower body dressing, personal/toileting hygiene, rolling left and right, and chair/bed-to-chair-transfer. Resident 5 required oxygen therapy (to provide supplemental oxygen to residents who have low blood oxygen levels or other breathing difficulties), suctioning (the process of removing secretions or fluids by means of a tube and a device), tracheostomy care, and an invasive mechanical ventilator (a life support intervention that provides respiratory support to residents unable to breath adequately on their own by delivering positive pressure directly into their lungs through an artificial airway). During a review of Resident 5's Active Orders Report, dated 7/2/2025, the Active Orders Report indicated a physician order, with a start date of 4/1/2023 for pulse ox monitoring every day and as needed. During a review of Resident 5's care plan, dated 6/11/2025, the care plan indicated Resident 5 had a potential for infection related to tracheostomy tube and ventilator dependency. The care plan intervention indicated to suction every two hours and as needed. During an observation in Resident 5's room, on 7/2/2025, at 10:14 AM, Respiratory Therapist 1 (RT 1) entered Resident 5's room and informed him that he was going to be suctioned. RT 1 performed hand hygiene, donned (put on) his PPE, placed the pulse ox monitor on top of Resident 5's bed and inserted Resident 5's right index finger (the finger next to the thumb) in the sensor. RT 1 suctioned Resident 5's tracheostomy and mouth and removed Resident 5's finger from the sensor. RT 1 doffed (removed) his PPE, performed hand hygiene, placed the pulse ox monitor inside his right shirt pocket, and exited Resident 5's room. RT 1 did not sanitize the pulse ox monitor and sensor before and after placing the pulse ox monitor on the bed and checking Resident 5's oxygen saturation level. During an interview, on 7/2/2025, at 11:05 AM, with RT 1, RT 1 stated he did not clean the pulse ox monitor before and after checking Resident 5 and Resident 11's oxygen saturation. RT 1 stated it was important to sanitize the pulse ox monitor before and after use to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). RT 1 stated residents can get sick from getting an infection caused by cross contamination. RT 1 stated the pulse ox monitor and sensor should have been sanitized with alcohol pads and disinfectant wipes. 2. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted on [DATE] and readmitted on [DATE]. During a review of Resident 11's H&P, dated 6/23/2025, the H&P indicated Resident 11 had diagnoses which included chronic respiratory failure with hypoxia (a condition where the respiratory system is unable to adequately oxygenate the blood resulting in chronically low blood oxygen levels), dysphagia (difficulty or discomfort in swallowing), and hypertension (HTN- high blood pressure). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 was assessed having severely impaired (never/rarely made decisions) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 11 was dependent with upper/lower body dressing, personal/toileting hygiene, roll left and right and chair/bed-to-chair transfer. Resident 11 required oxygen therapy, suctioning, tracheostomy care, and an invasive mechanical ventilator. During a review of Resident 11's Active Orders Report, dated 7/2/2025, the Active Orders Report indicated a physician order, with a start date of 10/14/2024 for suction nasal (nose) or trach every two hours and as needed. During a review of Resident 11's Monthly Orders, dated 6/24/2025, the Monthly Orders indicated a physician order under respiratory care to check pulse oximetry daily and as needed. During a review of Resident 11's care plan, dated 6/17/2025, the care plan indicated Resident 11 had a potential for infection related to tracheostomy tube. The care plan intervention indicated to suction every two hours as needed. During an observation on 7/2/2025, at 10:23 AM, RT 1 entered Resident 11's room after suctioning Resident 5. RT 1 informed Resident 11 that she was going to be suctioned, performed hand hygiene, and donned his PPE. RT 1 took the pulse ox monitor out of his right shirt pocket, placed it on Resident 11's pillow, and inserted Resident 11's left index finger in the sensor. RT 1 suctioned Resident 11's tracheostomy and mouth and removed Resident 11's left index finger from the sensor. RT 1 doffed his PPE, performed hand hygiene, placed the pulse ox monitor inside his right shirt pocket, and exited Resident 11's room. RT 1 did not sanitize the pulse ox monitor and sensor before and after placing it on Resident 11's pillow and before and after checking Resident 11's oxygen saturation level. During an interview, on 7/2/2025, at 11:05 AM, with RT 1, RT 1 stated he did not clean the pulse ox monitor before and after checking Resident 5 and Resident 11's oxygen saturation. RT 1 stated it was important to sanitize the pulse ox monitor before and after use to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). RT 1 stated residents can get sick from getting an infection caused by cross contamination. RT 1 stated the pulse ox monitor and sensor should have been sanitized with alcohol pads and disinfectant wipes. During an interview, on 7/2/2025, at 4:04 PM, with the Infection Prevention Director (IPD), the IPD stated facility staff should store the pulse ox monitors in their computer carts and not in the shirt pockets because the shirt pockets can be contaminated. The IPD stated the pulse ox monitor and sensor should be sanitized with an alcohol and bleach wipe before and after resident use. The IPD stated it was important to sanitize the pulse ox monitor and sensor to prevent the risk of transmitting infection from one resident to another. The IPD stated residents can get really sick from infections. During a concurrent interview and record review, on 7/3/2025, at 2:53 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P), titled, Cleaning/Decontamination of Equipment, revised on 1/2008, was reviewed. The DON stated the pulse ox monitor should be sanitized before and after use. The DON stated the pulse ox monitor should be sanitized before placing it inside and after it is removed from the shirt pocket. The DON stated not sanitizing the pulse ox monitors can transmit infectious organisms from one resident to another. The DON stated the P&P for cleaning/decontamination of equipment did not and should include when an equipment needs to be sanitized. During a review of the facility's policy and procedure (P&P), titled, Isolation Precautions, revised on 5/2024, the P&P indicated the following: Indirect contact transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. Examples of opportunities for indirect contact transmission include: Patient care devices (example: electronic thermometers, glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared between patients without cleaning and disinfecting between patients. During a review of the P&P, titled, Sub-Acute Infection Control Policies, revised on 5/2021, the P&P indicated, all used equipment must be considered contaminated and is collected/handled in a safe manner in order to protect other patients, visitors, staff and the hospital environment. 3. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE]. During a review of Resident 21's H&P, dated 1/27/2025, the H&P indicated Resident 21 had diagnoses which included anoxic brain injury (when the brain is completely deprived of oxygen, leading to cell death and potential severe neurological damage), congestive heart failure (CHF- a serious condition in which the heart does not pump blood as efficiently as it should), and hypertension. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 was in a persistent vegetative state. Resident 21 was dependent with oral/toileting hygiene, upper/lower body dressing, personal hygiene, and roll left and right. Resident 21 had an abdominal feeding tube During a review of Resident 21's Active Orders Report, dated 7/2/2025, the Active Orders Report indicated a physician order, dated 8/16/2025 to check G-tube residual every six hours, hold tube feeding for two hours if residual is greater than 100 milliliters (ml- unit of measurement) then resume. During an observation of Resident 21's medication administration on 7/2/2025, at 1:07 PM, inside Resident 21's room, Registered Nurse1 (RN 1) entered Resident 21's room, washed his hands and donned gloves. RN 1 proceeded to unclamp Resident 21's G-tube and inserted a 60 milliliter (ml-unit of measurement) syringe to Resident 21's medication port. RN 1 pulled the plunger back to check for residual and administered the following medications through Resident 21's G-tube: Esomeprazole (medication used to treat conditions involving excessive stomach acid production) 40 mg, with 10 ml of water Baclofen (medication used to treat muscle spasms) 10 mg, with 10 ml of water RN 1 flushed Resident 21's G-tube with 30 ml of water and disconnected the syringe. RN 1 doffed his gloves, washed his hands, and exited Resident 21's room. During an interview, on 7/2/2025, at 1:28 PM, with RN 1, RN 1 stated he did not don a gown before entering Resident 21's room. RN 1 stated he was supposed to don a gown prior to checking G-tube placement and administering Resident 21's medications via her G-tube. RN 1 stated it was important to don a gown before providing direct contact care to protect residents from contamination and infection from bodily fluids. RN 1 stated PPEs were worn to prevent the spread of infection which can cause the residents to get very sick. During an interview, on 7/2/2025, at 4:29 PM, with the IPD, the IPD stated the clothing of facility staff can get in contact with the residents while providing G-tube care and can cross contaminate to other residents in the facility. The IPD stated facility staff were required to wear a mask, gloves, and gown if there was possible contact with bodily fluids while providing care for the residents. The IPD stated facility staff were required to wear a mask, gown, gloves, and possibly face shield when handling G-tubes due to the risk of getting in contact with bodily fluids. The IPD stated it was important for facility staff to don PPE to protect and prevent the residents from getting an infection. The IPD stated RN 1 did not follow the facility policy to don a gown before checking Resident 21's G-tube residual and administering medications via Resident 21's G-tube. During a concurrent interview and record review, on 7/3/2025, at 2:51 PM, with the DON, the sub-acute P&P titled, Sub-Acute Infection Control Policies, revised on 5/2021 was reviewed. The DON stated it was not enough for facility staff to wear just a mask and gloves when handling the residents' G-tube. The DON stated facility staff need to wear a gown while handling the G-tube to protect the residents and staff from splash backs and contamination. The DON stated PPEs prevent the transmission of communicable diseases to the residents in the facility. The DON stated the Sub-Acute Infection Control Policies indicated, Enhanced Standard Precautions (EBP - the use of gown and glove use for nursing home residents with wounds and indwelling devices during specific-high contact resident care activities associated with multidrug-resistant organisms [MDRO] transmission) are to be used in providing care to patients. This is to protect personnel from contamination with body substances and to prevent transmission of microorganisms between residents. The DON stated the P&P did not and should indicate the specific procedures that involves EBP. The DON stated the policy did not indicate what PPEs need to be donned when caring for residents on EBP. During the same concurrent interview and record review, on 7/3/2025, at 2:51 PM, with the DON, the hospital-wide P&P titled, Precautions to Prevent Transmission of Infectious Disease, revised on 1/2010, was reviewed. The DON stated the P&P did not and should include Enhanced Based Precautions for consistency of policies between the sub-acute units and the hospital. The DON stated the policy should include the specific PPE that were required to be donned and the specific procedures that involved EBP. During the same record review of the P&P, titled, Precautions to Prevent Transmission of Infectious Disease, the P&P indicated, Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious agents (e.g. wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). 4. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 6's H&P, dated 1/21/2025, the H&P indicated Resident 6 had diagnoses which included acute on chronic respiratory failure/insufficiency (a sudden worsening of respiratory function in a resident who already has a pre-existing chronic respiratory condition), anoxic encephalopathy (a severe brain injury resulting from a complete lack of oxygen to the brain), and quadriplegia (paralysis that affects all four limbs plus the torso). During a review of resident 6's MDS, dated [DATE], the MDS indicated Resident 6 was in a persistent vegetative state. Resident 6 was dependent with oral/toileting hygiene, upper/lower body dressing, personal hygiene, and roll left and right. Resident 6 required tracheostomy care. During a review of Resident 6's Monthly Orders, dated 6/24/2025, the Monthly Orders indicated a physician order for the following: Trach care daily at 9PM and as needed Clean trach site with hydrogen peroxide (H2O2) 3% solution, then cover with drain sponge Change trach tie and inner cannula Resident 6's Monthly Orders further indicated that Resident 6 did not have the capacity to make healthcare decisions. During a review of Resident 6's care plan, dated 12/4/2024, the care plan indicated Resident 6 had a potential for infection related to tracheostomy tube. The care plan intervention indicated to change the inner cannula daily and as needed, perform trach care every day and as needed, and practice good hand hygiene. During a tracheostomy care observation on 7/1/2025, at 2:13 PM, inside Resident 6's room, RN 2 performed hand hygiene, donned gloves and gown and moved Resident 6's bedside table close to where she was standing. RN 2 placed several clean gauzes, a bottle of hydrogen peroxide, trach tie, and a packet of split gauze on the Resident 6's bedside table. RN 2 removed Resident 6's old drain sponge from Resident 6's tracheostomy site and placed it on the bedside table next to the clean tracheostomy care supplies. RN 2 opened the hydrogen peroxide bottle and poured hydrogen peroxide into the clean drain gauze. RN 2 cleaned around Resident 6's tracheostomy tube with the gauze and placed the used gauze on the bedside table. RN 2 removed and replaced Resident 6's old trach tie and placed the old trach tie on the bedside table. RN 2 opened the packet of split gauze and placed the clean split gauze around Resident 6's tracheostomy tube. RN 2 removed Resident 6's inner cannula and replaced it with a new inner cannula. RN 2 placed the old inner cannula on the bedside table. RN 2 picked up all the used tracheostomy care supplies, placed them in the trash can located by Resident 6's door, doffed her PPE and exited Resident 6's room. RN 2 did not change her gloves before placing Resident 6's clean drain sponge around her tracheostomy tube and before inserting Resident 6's new inner cannula. RN 2 did not clean Resident 6's bedside table after throwing the used dressings and old inner cannula in the trash. During an interview, on 7/1/2025, at 2:25 PM with RN 2, RN 2 stated she did not change her gloves after removing Resident 6's old tracheostomy dressing and inner cannula and before placing the clean dressing and new inner cannula. RN 2 stated she was not familiar with the facility's P&P for changing gloves during tracheostomy care. RN 2 stated the used dressing was supposed to be disposed of in the trash but it was too far away from her during tracheostomy care, so she placed it on top of Resident 6's bedside table. RN 2 stated she should have covered the bedside table before placing Resident 6's clean tracheostomy supplies. RN 2 stated she should have sanitized Resident 6's bedside table after she disposed of the used dressings and inner cannula. During an interview, on 7/2/2025, at 4:16 PM, with the IPD, the IPD stated RN 2 should have doffed her gloves after removing Resident 6's used dressings and inner cannula and donned new gloves before placing the new dressing and inner cannula. The IPD stated it was important for facility staff to follow the hand hygiene policy to avoid the risk of contamination and prevent the spread of infections. The IPD stated there could be an active disease or infection on the used dressing and placing it on the bedside table contaminated the bedside table and could get other residents sick. The IPD stated the used dressings and inner cannula should not be placed on the bedside table. The IPD stated the used dressings and inner cannula should have been placed inside a sealed bag and disposed of in the proper container. The IPD stated the bedside table should have been sanitized after the used dressings and inner cannula was disposed in the trash. During a concurrent interview and record review, on 7/3/2025, at 2:55 PM, with the DON, the DON stated the used tracheostomy dressings should go straight into the regular trash can. The DON stated the facility did not consider used tracheostomy dressings as regulated medical, clinical, or biomedical waste and did not require special handling. The DON stated the used dressing should not be placed on top of the bedside table. The DON stated the facility's P&P, titled, Procedure for Handling Medical Waste, revised on 2/2024, the DON stated the P&P indicated that the purpose of the policy was to, Establish, implement, monitor, and document evidence of an ongoing program for the identification, packaging, storage, and disposal of medical wastes generated the hospital and to ensure that there is minimal risk to patients, personnel, visitors and the community environment of the transmission of communicable diseases. The DON stated the P&P did not clearly indicate were tracheostomy dressing and used tracheostomy supplies like the inner cannula should be disposed. The DON stated it should be included in the P&P to be able to properly handle the used dressing and to make sure the residents, staff, and visitors are safe. The DON stated RN 2 should have sanitized the bedside table with a germicidal wipe after the disposed the used dressings and inner cannula in the trash can. The DON stated RN 2 should have also placed the trash can close to her before starting tracheostomy care. During a review of the hospital-wide P&P, titled, Recommendations, from the Infection Control Manual, revised on 1/2010, the P&P indicated the following: These recommendations are designed to prevent the transmission of infectious agents among patients and healthcare personnel in all settings where healthcare is delivered. As in other CDC/HICPAC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and when possible, economic impact. The CDC/HIPAC system for categorizing recommendations is as follows: Category IB (strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale, Category IC (required for implementation, as mandated by federal and/or state regulation or standard). Standard Precautions: Assume that every person is potentially infection or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care. PPE- observe the following principles of use: a) Wear PPE when the nature of the anticipated patient interaction indicates that contact with blood or body fluids may occur. b) Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. c) Wear a gown for direct patient contact if the patient has uncontained secretions or excretions.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of one (1) of six (6) sampled residents (Resident 24) by failing to ensure two (2) of 6 medications, mixed with water, were completely administered during medication administration. This deficient practice resulted in Resident 24 not being able to take the full amount/dose of the prescribed medications which had the potential to result in harm due to unmet individual medication needs. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (a condition where the lungs are unable to adequately deliver oxygen to the blood or remove carbon dioxide), tracheostomy (a surgical procedure to create an opening in the windpipe through the neck allowing for a tube to be inserted for breathing), and G-tube (gastrostomy tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding. During a review of Resident 24's Minimum Data Set (MDS- a resident assessment tool), dated 5/19/2025, the MDS indicated Resident 24 was assessed having severely impaired (never/rarely made decisions) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 24 was dependent (helper completed the activities for the resident) with oral/toileting hygiene, shower/bathe self, upper/lower body dressing, sit to lying, and chair/bed-to-chair transfer. Resident 24 required substantial/maximal assistance (helper does more than half the effort) with rolling left and right. Resident 24 was on a mechanically altered diet (required change in texture of food or liquids). Resident 24 had an abdominal feeding tube (G-tube). During a review of Resident 24's Active Orders Report, dated 7/3/2025, the Active Orders Report indicated a physician order, with a start date of 12/6/2024, for ascorbic acid (Vitamin C- a vitamin that protects the cells from damage and is essential for the growth and repair of tissues throughout the body) 500 milligrams (mg-unit of measurement) via feeding tube twice daily. Resident 24's Active Orders Report also indicated a physician order, with a start date of 6/24/2025, for glycopyrrolate (a medication used to treat severe drooling caused by certain brain disorders) 1 mg via feeding tube three times a day. During an observation of the medication preparation, on 7/3/2025, at 8:54 AM, Licensed Vocational Nurse 1 (LVN 1) was observed preparing the following medications in individual medication cups: 1. Colace (a medication that softens the stool and relieves occasional constipation) 100 mg /10 milliliter (ml-unit of measurement for volume) solution 2. Eliquis (a medication used to treat and prevent blood clots) 2.5 mg 3. Metoprolol (a medication that slows the heart rate and relaxes the blood vessels to improve blood flow and lowers blood pressure) 50 mg 4. Losartan Potassium (a medication that relaxes the blood vessels and lowers blood pressure) 50 mg 5. Glycopyrrolate 1 mg 6. Vitamin C 500 mg LVN 1 also prepared and placed 10 ml of water in several medication cups. During an observation of the medication administration, on 7/3/2025, at 9:08 AM, LVN 1 poured 10 ml of water into the different medication cups containing Resident 24's medications. LVN 1 swirled each medication cup in her hand before administering each medication via Resident 24's G-tube. LVN 1 did not mix the water with the medication with a tongue depressor or stirrer. LVN 1 administered the following medications to Resident 24: 1. Colace 100 mg /10 milliliter (ml-unit of measurement for volume) solution 2. Eliquis 2.5 mg, with 10 ml of water 3. Metoprolol 50 mg, with 10 ml of water 4. Losartan Potassium 50 mg, with 10 ml of water 5. Glycopyrrolate 1 mg, with 10 ml of water 6. Vitamin C 500 mg, with 20 ml of water During a concurrent observation of Resident 24's medication cups after medication administration and interview with LVN 1, on 7/3/2025, at 9:15 AM, LVN 1 stated there was a white pasty residual left inside Resident 24's glycopyrrolate and Vitamin C medication cups. LVN 1 stated the white pasty residual in the medication cups were glycopyrrolate and Vitamin C medications that did not completely dissolve in the water. LVN 1 stated she did not stir and make sure the medications were completely dissolved before administering the medications to Resident 24. LVN 1 stated Resident 24 was not administered the complete dose of his glycopyrrolate and Vitamin C medications since there was medication left in Resident 24's glycopyrrolate and Vitamin C medication cups. LVN 1 stated Resident 24's medications will be effective if the prescribed dose was not administered. During an interview with the Director of Nursing (DON), on 7/3/2025, at 2:45 PM, the DON stated crushed medication should be mixed with water and stirred to ensure the medication dissolved in the water solution. The DON stated there should not be any residual medication visible in the cup after medication administration. The DON stated Resident 24 did not receive the entire dose of glycopyrrolate and Vitamin C if traces of the medications were left in the medication cup. The DON stated Resident 24 should have received the whole dose of the glycopyrrolate and Vitamin C. The DON stated it was important for Resident 24 to receive all his medications to target the issues that he was diagnosed with. The DON stated the medication would not be as efficient if the entire dose was not received. The DON stated LVN 1 did not follow the facility's policy and procedure (P&P) for medication administration since Resident 24 did not receive the full dose of his medications. During a review of the facility's P&P titled, Medication Administration, approved on 10/2019, the P&P indicated, Before administering a medication, the licensed independent practitioner or appropriate health care professional administering the medication does the following: verifies the medication is being administered at the proper time, in the prescribed dose, and by the correct route.

Based on observation, interview, and record review the facility failed to follow its Policy and Procedure on pressure ulcer (localized damage to the skin and underlying soft tissue caused by prolonged pressure) prevention and wound management for one (1) of two (2) sample residents ( Resident 13) by failing to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer ) was set at the correct setting in accordance with the resident's weight. This deficient practice had the potential for Resident 13's pressure ulcer to worsen and develop complications which will negatively affect the resident's overall wellbeing. Findings: During a record review of Resident 13's admission Record, the admission Record indicated the facility originally admitted Resident 12 on 12/22/2023. During a record review of Resident 13's History and Physical (H&P) dated, 12/22/2023, the H&P indicated Resident 13 with diagnosis of tracheostomy (tracheostomy- a surgically created opening (stoma) in the trachea (windpipe) to allow for breathing and airway management), dependence (the condition where an individual relies on a tracheostomy tube to breathe), sacral ulcer stage four (the most severe stage of a pressure ulcer, characterized by full-thickness skin and tissue loss that extends into muscle, bone, tendon, or other supporting structures), and hypertension ( high blood pressure). During a record review of Resident 13's Minimum Data Set (MDS, a resident assessment tool), dated 6/25/2025, the MDS indicated resident was dependent on shower/bathe self, upper body dressing, lower body dressing, personal hygiene. The MDS also indicated the resident was at risk for developing pressure ulcer/ injuries. The MDS also indicated skin and ulcer/ injury treatment included pressure reducing device for bed and turning/ repositioning program. During a record review of Resident 13's Active Orders, dated 6/30/2025, the Active Orders indicated ongoing air loss mattress for pressure injury management / healing. During a record review of Resident 13's Skin Progress Notes, dated 6/29/2025, the Skin Progress Notes indicated: Site: Coccyx (small bone at the bottom of the spine) Skin Issue: Stage 4 pressure injury. Length: 1.8 centimeters (cm; a unit of length in the metric system), Width: 1.2 cm, Dept: 2.2 cm. During a record review of Resident 13's Care Plan, dated 6/19/2025, the Care Plan indicated Pressure injury stage 4 Sacro coccyx (bones at the base of the spine). The intervention included air mattress for healing. During a record review of Resident 13's Care Plan, dated12/28/2024, the Care Plan indicated potential impaired skin integrity related to skin mobility, altered nutrition status, and chronic disease process. The interventions included were to use resident's own low air loss mattress per family preference for prevention of pressure injury and educate all nursing staff to follow manufacturer's guidelines recommendation of level of firmness based on patients' weight/comfort. During observation on 6/30/2025 at 9:49 AM in Resident 13's room, Resident 13 was observed lying in bed with the LAL mattress setting at four (4), 175 pounds (lbs., when it refers to weight). During an interview on 7/1/2025 at 4:20 AM with Registered Nurse (RN 2), RN 2 stated Resident 13's weight was 123 lbs. The LAL mattress setting should have been set at 2 to 3 (105-140 lbs.) RN2 stated it defeats the purpose of the LAL mattress if it is not on the right setting. RNS 2 stated it is not comfortable for the resident and the wound will take longer to heal. During a concurrent interview and record review of Resident 1's care plan on 7/2/2025 at 1:21 PM with RN 3, RN3 stated the LAL mattress is used to decrease the pressure and to prevent pressure injury. The set up depends on the weight of the resident. RN3 also stated Resident 13's care plan indicated to educate all nursing staff to follow manufacturers guidelines recommendation of level firmness based on patients' weight/ comfort. RN3 stated Med One user guide indicated to use the weight scale to match the resident's weight to the closest weight number in the scale ( top lbs. - bottom is kilo) and using the 0-9 setting on the top of the scale set LED ( green light). During an interview on 7/3/2025 at 2:38 PM with the Director of Nursing (DON), the DON stated the facility did not follow Resident 13's care plan and manufacturer's guideline. The DON stated the mattress could be too firm that it could possibly worsen the pressure injury or prevent it from healing. During a review of the facility's Policy and Procedure (P&P) titled, Low air loss Therapy, dated 9/2022 indicated: Purpose: To reduce the mechanical forces of pressure, shear friction and moisture which contribute to tissue breakdown. To reduce the healing time of existing tissue breakdown. During a review of the facility's P&P titled, Care Plan, Patient Interdisciplinary, dated 6/2024 indicated To provide quality patient care based on the unique needs and diagnosis of patients. The P&P also indicated the plan of care will be based on the patient's unique needs, problems related to the triggered care area from the MDS assessment and diagnosis of the patient and will include patient problems, expected outcomes/realistic goals and interventions.

Based on observation, interview and record review the facility failed to ensure the midline catheter (a specific type of intravenous [IV] catheter designed for administering fluids, medications, and sometimes for drawing blood over an extended period) with 2 lumen injection ports had a swab cap (a disinfecting cap, often used in healthcare settings, designed to cover and disinfect needleless connectors on IV lines) when not in use for one (1) of 12 sampled residents (Resident 9) in accordance to the facility policy. This deficient practice had the potential to result in Resident 9 developing IV complications which can lead to infection and possible hospitalization. Findings: During a record review of Resident 9's admission Record, the admission Record indicated the facility originally admitted Resident 9 on 6/22/2025. During a record review of Resident 9's History and Physical (H&P), dated 6/23/2025, the H&P indicated Resident 9 with a diagnosis of anemia (levels of healthy red blood cells to carry oxygen throughout your body), seizure (a sudden, uncontrolled electrical disturbance in the brain that can )cause changes in awareness, behavior, muscle control, and sensations), and quadriplegia (a medical condition characterized by the complete or partial loss of motor function in all four limbs (arms and legs). During a record review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 6/25/2025, the MDS indicated the resident had severe impairment with cognitive skills for daily decision making and was dependent on shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. During a record review of Resident 9's Active Orders, dated 6/26/2025, the Active Orders indicated peripherally inserted central catheter (PICC, peripherally inserted central catheter, is a long, thin, flexible tube inserted into a vein in the arm, typically near the bend of the elbow, and threaded into a larger vein near the heart) line care per protocol every Thursday. The intervention text included to change midline dressing including injection ports every Thursday and PRN (as needed) if soiled. During a record review of Resident 9's Care Plan, dated 6/24/2025, the Care Plan indicated potential infection related to midline invasive line right arm. The interventions indicated were to cover injection ports with swab caps, change daily, and PRN after every use. During observation on 6/30/2025 at 11:40 AM in Resident 9's room, resident's right upper arm midline two lumen injection port does not have a swab cap. During a concurrent observation and interview on 7/1/2025 at 4:15 PM with registered nurse 2 (RN 2), RN 2 stated Resident 9's midline two lumen injection port was not and should have been covered. During a concurrent interview and record review on 7/2/2025 at 3:45 PM with RN 3, RN 3 stated to prevent infection, the midline injection ports were supposed to be covered with swab cap. RN3 stated facility's policy and procedures (P&P) titled, Midline Catheter Policy dated 10/2021, indicated to reduce the incidence of intravascular catheter related infections following evidence-based guidelines for the use, insertion and management of midline catheter. RN3 also stated P&P also indicated injection cap should be changed when the cap has been removed for any reason. During an interview on 7/3/2025 at 2:35 PM with the Director of nursing ( DON), the DON stated the midline catheter was supposed to be capped because it is the facility's practice to prevent infection.

Based on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment by failing to ensure one (1) of 12 sampled residents (Resident 19) had a sink in the resident's room with a Formica (hard durable plastic laminate used for countertops, cupboard doors, and other surfaces) that was stripped off and with an exposed rough wood. This deficient practice caused an unsanitary environment and had potential for resident and staff to be placed at risk of injury. Findings: During a record review of Resident 19's admission Record, the admission record indicated Resident 19 was admitted on [DATE]. During a record review of Resident 19's History and Physical (H&P), dated 4/29/2025 indicated Resident 19 with diagnosis of acute chronic hypoxic respiratory failure (a person's lungs are unable to provide enough oxygen), hypertension (high blood pressure), and seizure (involuntary muscle movement). During a record review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 6/10/2025, the MDS indicated resident was severely impaired with cognitive skills for daily decision making and was dependent on shower/bathe self, upper body dressing, lower body dressing, personal hygiene. During an observation on 6/30/2025 at 10:21 AM in Resident 19's room, the resident room's sink had a Formica that was stripped off and had an exposed rough wood. During concurrent observation and interview on 7/1/2025 at 12: 43 PM in Resident 19's room, the Director of Nursing (DON) stated Resident 19's room sink was stripped off its protective barrier and chipped rough wood was exposed. The DON stated this can grow molds or any unwanted growth, that can possibly cause infection control to residents or harm to staff like scrape themselves. During concurrent observation and interview on 7/1/2025 at 4:31 PM in Resident 19's room with the Maintenance Assistant (MA 1), MA 1 stated Resident 19's room sink Formica was stripped. MA stated the wood was chipped possibly caused by water damage. During an interview on 7/2/2025 at 1:56 PM with the License Vocational Nurse (LVN 2), LVN 2 stated exposed rough wood in resident's room sink was not acceptable. LVN 2 stated this can build moisture possible for molds. LVN 2 also stated residents can inhale and possibly cause infection or any sickness to vulnerable residents. During a concurrent interview and record review on 7/3/2025 at 2:44 PM with the DON of the facility's Policy and Procedure (P&P) titled, Management of Environment of Care, dated 1/2023, the DON stated P&P indicated the intent of these program is to enhance the quality of patient's stay. By ensuring that the environment is safe and secure, comfortable, and appropriately furnished . The P&P also indicated to provide a quality patient care in a safe environment that is sensitive to patient's physical, social, spiritual and cultural needs. The DON stated the facility did not meet the standard according to P&P.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to ensure: 1. A box of Kosher salt was not open and unsealed. 2. A container of soy sauce was free of drippings. 3. A container of Japanese curry powder was properly sealed. 4. The can opener was clean, not chipped, and free of rust. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: During an observation in the facility's kitchen on 6/30/2025 at 7:57 AM in the kitchen's preparation area, the following were observed: 1. A box of Kosher salt was not open and unsealed. 2. A container of soy sauce was free of drippings. 3. A container of Japanese curry powder was not properly sealed. 4. The can opener was clean, not chipped, and free of rust. During a concurrent observation and interview on 7/2/2025 at 8:29 AM with the Registered Dietitian (RD), the RD stated the Kosher salt box was unsealed, soy sauce container with residuals, and the Japanese Curry container was not properly sealed. The RD also stated food containers were supposed to be sealed properly and without drippings on the container to prevent food contamination. RD stated there was a possibility that insects could get in and it could attract rodents which could cause stomach upsets, diarrhea, and food poisoning. During a concurrent observation and interview on 7/2/2025 at 8:30 AM with the RD, RD stated the can opener was chipped and rusted. RD also stated this was not acceptable because it can lead to food contamination or poisoning of residents. During a concurrent interview and record review on 7/3/2025 at 9:30 AM with the Kitchen Supervisor (KS), of the facility's Policy and Procedure (P&P) titled, Food Storage, dated 5/2024, KS stated P&P indicated, Food items will be stored appropriately to ensure product safety and quality. The P&P also indicated, Food and supplies are properly covered and labeled. During the same concurrent interview and record review on 7/3/2025 at 9:30 AM with KS, of the facility's P&P titled, Department of Safety Rules, dated 10/2025, KS stated P&P indicated: 1. All work areas are kept neat, orderly, and properly sanitized. 6. Employees must immediately report the following to their supervisor: a) Report unsafe conditions such as broken chairs, frayed electrical wires, broken electrical outlets and defective equipment.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles out of 27 opportunities (observed administered medications) for error, to yield an overall medication error rate of 7.41 percent (%) for one (1) of six (6) sampled residents (Resident 24) observed during medication administration (med pass). Licensed Vocational Nurse 1 (LVN 1) failed to administer the entire dose of glycopyrrolate (a medication used to treat severe drooling caused by certain brain disorders) and ascorbic acid (Vitamin C- a vitamin that protects the cells from damage and is essential for the growth and repair of tissues throughout the body) 500 milligrams (mg-unit of measurement) to Resident 24 as indicated in the Physician's order. This deficient practice resulted in Resident 24 not being able to take the full amount/dose of the prescribed medications which had the potential to result in harm due to unmet individual medication needs. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (a condition where the lungs are unable to adequately deliver oxygen to the blood or remove carbon dioxide), tracheostomy (a surgical procedure to create an opening in the windpipe through the neck allowing for a tube to be inserted for breathing), and G-tube (gastrostomy tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding. During a review of Resident 24's Minimum Data Set (MDS- a resident assessment tool), dated 5/19/2025, the MDS indicated Resident 24 was assessed having severely impaired (never/rarely made decisions) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 24 was dependent (helper completed the activities for the resident) with oral/toileting hygiene, shower/bathe self, upper/lower body dressing, sit to lying, and chair/bed-to-chair transfer. Resident 24 required substantial/maximal assistance (helper does more than half the effort) with rolling left and right. Resident 24 was on a mechanically altered diet (required change in texture of food or liquids). Resident 24 had an abdominal feeding tube (G-tube). During a review of Resident 24's Active Orders Report, dated 7/3/2025, the Active Orders Report indicated a physician order, with a start date of 12/6/2024, for ascorbic acid (Vitamin C- a vitamin that protects the cells from damage and is essential for the growth and repair of tissues throughout the body) 500 mg via feeding tube twice daily. Resident 24's Active Orders Report also indicated a physician order, with a start date of 6/24/2025, for glycopyrrolate (a medication used to treat severe drooling caused by certain brain disorders) 1 mg via feeding tube three times a day. During an observation of the medication preparation, on 7/3/2025, at 8:54 AM, LVN 1 was observed preparing the following medications in individual medication cups: 1. Colace (a medication that softens the stool and relieves occasional constipation) 100 mg /10 milliliter (ml-unit of measurement for volume) solution 2. Eliquis (a medication used to treat and prevent blood clots) 2.5 mg 3. Metoprolol (a medication that slows the heart rate and relaxes the blood vessels to improve blood flow and lowers blood pressure) 50 mg 4. Losartan Potassium (a medication that relaxes the blood vessels and lowers blood pressure) 50 mg 5. Glycopyrrolate 1 mg 6. Vitamin C 500 mg LVN 1 also prepared and placed 10 ml of water in several medication cups. During an observation of the medication administration, on 7/3/2025, at 9:08 AM, LVN 1 poured 10 ml of water into the different medication cups containing Resident 24's medications. LVN 1 swirled each medication cup in her hand before administering each medication via Resident 24's G-tube. LVN 1 did not mix the water with the medication with a tongue depressor or stirrer. LVN 1 administered the following medications to Resident 24: 1. Colace 100 mg /10 ml solution 2. Eliquis 2.5 mg, with 10 ml of water 3. Metoprolol 50 mg, with 10 ml of water 4. Losartan Potassium 50 mg, with 10 ml of water 5. Glycopyrrolate 1 mg, with 10 ml of water 6. Vitamin C 500 mg, with 20 ml of water During a concurrent observation of Resident 24's medication cups after medication administration and interview with LVN 1, on 7/3/2025, at 9:15 AM, LVN 1 stated there was a white pasty residual left inside Resident 24's glycopyrrolate and Vitamin C medication cups. LVN 1 stated the white pasty residual in the medication cups were glycopyrrolate and Vitamin C medications that did not completely dissolve in the water. LVN 1 stated she did not stir and make sure the medications were completely dissolved before administering the medications to Resident 24. LVN 1 stated Resident 24 was not administered the complete dose of his glycopyrrolate and Vitamin C medications since there was medication left in Resident 24's glycopyrrolate and Vitamin C medication cups. LVN 1 stated Resident 24's medications will be effective if the prescribed dose was not administered. During an interview with the Director of Nursing (DON) on 7/3/2025, at 2:45 PM, the DON stated crushed medication should be mixed with water and stirred to ensure the medication dissolved in the water solution. The DON stated there should not be any residual medication visible in the cup after medication administration. The DON stated Resident 24 did not receive the entire dose of glycopyrrolate and Vitamin C if traces of the medications were left in the medication cup. The DON stated Resident 24 should have received the whole dose of the glycopyrrolate and Vitamin C. The DON stated it was important for Resident 24 to receive all his medications to target the issues that he was diagnosed with. The DON stated the medication would not be as efficient if the entire dose was not received. The DON stated LVN 1 did not follow the facility's policy and procedure (P&P) for medication administration since Resident 24 did not receive the full dose of his medications. During a review of the facility's P&P titled, Medication Administration, approved on 10/2019, the P&P indicated, Before administering a medication, the licensed independent practitioner or appropriate health care professional administering the medication does the following: verifies the medication is being administered at the proper time, in the prescribed dose, and by the correct route.

Based on observation, interview, and record review, the facility failed to implement proper gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) feeding practices and procedures for two (2) of two sampled residents (Resident 21 and 19) by failing to: 1. Properly label Resident 21's opened gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage) feeding solution bottle at the bedside. This deficient practice had the potential to result in Resident 21's delayed feedings and incorrect total feeding amount received in a day. 2. Ensure Resident 19's GT water bag flush was labeled completely to include the total number of hours in accordance with the physician's order. This deficient practice had the potential for Resident 19's water flush bag not being replaced on time that might put the resident at risk of suffering common complications of tube feeding. Findings: 1. A review of Resident 21's Admission Record indicated Resident 21 was admitted to the facility on [DATE]. A review of Resident 21's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 4/23/2024, indicated Resident 21 had diagnoses of chronic respiratory failure ventilator (a piece of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs) dependent (when resident is unable to wean off a ventilator and breathe independently), status post (s/p, a term used in medicine to refer to a surgical procedure, diagnosis or just an event) tracheostomy (a surgically created hole in the windpipe that provides an alternative airway for breathing), s/p gastrostomy (GT, a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding and medication administration), and quadriplegia (paralysis of all four limbs). A review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/2/2024, indicated Resident 21's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired. The MDS indicated Resident 21 was dependent (helper does all of the effort. resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, roll left and right, and chair/bed-to-chair transfer. The MDS also indicated sit to lying, lying to sitting on bedside, sit to stand, toilet transfer, and tub/shower transfer was not attempted for Resident 21 and the activities were not performed prior to the current illness, exacerbation, or injury. The MDS indicated Resident 21 had a feeding tube. A review of Resident 21's Physician's Monthly Orders, dated 5/2/2023, indicated GT feeding of Jevity (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term feeding) 1.2 at 60 milliliters (ml, unit of volume)/hour for 20 hours daily from 2 PM to 10 AM via enteral pump (a medical device used to deliver nutrients directly into the gastrointestinal [GI] tract of a resident who is unable to take food or liquids orally). A review of Resident 21's Tube Feeding Care Plan, dated 5/2/2024, indicated Resident 21 was at risk for complication related to tube feeding. Staff interventions were to administer tube feeding of formula and flush water or fluids as indicated on the physician's order, monitor intake and output every shift, and to monitor feeding tolerance. During an observation in Resident 21's room on 6/28/2024 at 11:49 AM, Resident 21's feeding tube was disconnected from resident. The Jevity formula was prepped and primed (fill the tubing with formula) and hung on the enteral feeding pump. The label on the Jevity was dated 6/28/2024 with the start time of 2 PM. During a concurrent observation of Resident 21's Jevity and interview on 6/28/2024 at 11:49 AM with Registered Nurse 4 (RN 4), RN 4 stated the start time for Resident 21's GT feeding was at 2 PM and continued until 10 AM. RN 4 stated Resident 21's feeding ran a total of 20 hours a day. RN 4 stated she labeled the Jevity with a date of 6/28/2024 and start time at 2 PM. RN 4 stated she had eight residents and needed to adjust her time when she passed out the feedings for the residents. During an interview on 6/30/2024 at 2:53 PM with the Director of Nursing (DON), the DON stated the feeding solution could be set up an hour prior to the start time based on the physician's order. The DON stated the licensed nurse should date and time the feeding tube solution at the time the licensed nurse opened the bottle by spiking and priming the solution through the feeding tube. The DON stated correct labeling for feeding solution ensured that the physician's orders were being followed for the resident's diet. The DON stated the policy did not and should have included time frame when enteral feedings needed to be administered since it was based on the physician's orders just like medication administration. The DON stated the feeding solution was set up prior to the one-hour allowance time. The DON stated tube feeding with a start time of 2 PM should be started at 2 PM to avoid mixing up the time when the feeding tube needed to be changed or turned off. During an interview on 6/30/2024 at 5:54 PM with the DON, the DON stated the facility should be scanning the feeding solution when administered which should also be included in the policy. A review of the facility's Policy and Procedure (P&P) titled, Enteral and Oral Feedings, revised 3/2023, indicated enteral feedings will be available for patients who are unable to meet their nutritional requirements via oral route. Nursing staff is responsible for administration of enteral feeding following nursing enteral tube feeding policy and procedures. Policy will include a product hanging time of no more than 24-hours for closed-system with the date and time initiated. Licensed nurse shall mark the hanging time and date on the ready to hang or enteral bag using permanent waterproof ink. A review of the facility's P&P titled, Medication Administration, reviewed 10/2019, indicated medication will be administered to the patient within a one-hour period before the scheduled dosage for all non-time critical medication (non-time critical medications are those where early or delayed administration within a specified range should not cause harm or result in substantial sub-optimal therapy or pharmacological effect). A review of the facility's P&P titled, Nursing Scope of Practice, approval dated, 4/2017, indicated the practice of nursing means those functions, including basic health care, which help people cope with difficulties in daily living which as associated with their actual or potential health or illness problems of the treatment thereof which requires a substantial amount of scientific knowledge or technical skill and includes direct patient care services including the administration of medications and therapeutic agents, necessary to implement treatment, disease prevention ordered by and within the scope of the licensure of a physician. 45456 2. A review of Resident 19's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 19's H&P, dated 11/10/2022, indicated Resident 19's diagnoses included anoxic encephalopathy (or hypoxic-ischemic brain injury, a process that begins with the cessation of cerebral blood flow to brain tissue, which most commonly results from poisoning [for example, carbon monoxide or drug overdose], vascular injury or insult, or cardiac arrest), chronic respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide) ventilator dependent (if a resident is unable to wean off a ventilator and breathe independently), and left middle cerebral artery (MCA, stroke occurs when blood flow from the MCA, one of the largest arteries of the brain is suddenly interrupted [ischemia] or altogether stopped [infarction]) ischemic stroke. A review of Resident 19's MDS, dated [DATE], indicated Resident 19 has intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 19 was dependent with oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, roll left and right, sit to lying, and chair/bed-to-chair transfer. A review of Resident 19's Physician's Order, dated 6/25/2024, indicated to flush GT with water at 50 milliliters (ml, unit of measurement) per hour (/hr) for 20 hours daily from 2 PM to 10 AM [NAME] Enteral Dual Pump (pumps that have a dual flow feature, which allows for the delivery of both formula and water that is used for flushing and hydration) During a concurrent observation in Resident 19's room and interview with Registered Nurse 1 (RN 1) on 6/28/2024 , at 12:20PM, Resident 19 was awake. There was no label on the water bag containing 300 milliliters (ml, unit of measurement) of water that was hung on the intravenous (IV) pole. 50 cubic centimeters (cc, unit of measurement) per hour (h) was written directly on the water bag. RN 1 stated, We need to label the water bag every time we change it to communicate with the staff. During an interview with Registered Nurse 4 (RN 4) on 6/30/2024, at 8:51 AM, RN 4 stated, We need to label the water bag to make sure everything has the correct information and we do not rely on the machine to prevent any mistakes. We always label the bag every time we change it. During an interview with the Director of Nursing (DON) on 6/30/2024 at 5:30 PM, DON stated, Water bag flush should be labeled to make sure the staff were following policy regarding changing the bags. It is important to label the bag to make sure that we are routinely changing the water bags. A review of the facility's P&P titled, Enteral and Oral Feedings, dated, 5/2023, indicated Nursing staff is responsible for administration of enteral feeding following nursing enteral tube feeding policy and procedures. Licensed nurse shall mark the hanging time and date on ready to hang (RTH) or enteral bag using permanent waterproof ink.

Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or resident representatives for six (6) of eight (8) sampled residents (Residents 3, 16, 21, 22, 23, and 19). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to unwanted treatment with the residents' wishes regarding health care. Findings: 1. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE]. A review of Resident 3's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 2/27/2024, indicated Resident 3 had diagnoses of chronic respiratory failure (a long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), chronic vegetative state (condition where resident has woken from a coma but still lacks awareness), and anoxic encephalopathy (a brain injury that results from a lack of oxygen to the brain tissue). A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/27/2024, indicated Resident 3 was comatose (in a state of deep unconsciousness for a prolonged period as a result of a severe injury or illness) and in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident 3 had impairment to both upper extremity (shoulder, elbow, wrist hand) and lower extremity (hip, knee, ankle, foot). The MDS indicated Resident 3 was dependent (helper does all of the effort. resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity) for toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene (including combing hair, shaving, applying makeup, washing/drying face and hands), roll left and right, and chair/bed-to-chair transfer. The MDS also indicated sit to lying, lying to sitting on bedside, sit to stand, toilet transfer, and tub/shower transfer was not attempted for Resident 3 and the activities were not performed prior to the current illness, exacerbation, or injury. A review of Resident 3's medical record from 3/31/2023 to 6/29/2024 there was no Advance Directive in Resident 3's chart or electronic medical record. 2. A review of Resident 16's Admission Record indicated Resident 16 was admitted to the facility on [DATE]. A review of Resident 16's H&P, dated 9/13/2023, indicated Resident 16 had diagnoses of respiratory failure, tracheostomy (a surgically created hole in the windpipe that provides an alternative airway for breathing), and ventilator (a piece of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs). A review of Resident 16's MDS, dated [DATE], indicated Resident 16 was comatose and in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident 16 had impairment to both upper and lower extremities. The MDS indicated Resident 16 was dependent for toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, and roll left and right. The MDS also indicated sit to lying, lying to sitting on bedside, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer was not attempted for Resident 16 and the activities were not performed prior to the current illness, exacerbation, or injury. A review of Resident 16's medical record from 9/11/2023 to 6/29/2024 there was no documented evidence of Advance Directive information for Resident 16. 3. A review of Resident 21's Admission Record indicated Resident 21 was admitted to the facility on [DATE]. A review of Resident 21's H&P, dated 4/23/2024, indicated Resident 21 had diagnoses of chronic respiratory failure ventilator dependent (when resident is unable to wean off a ventilator and breathe independently), s/p tracheostomy, s/p gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or medication administration), and quadriplegia (paralysis of all four limbs). A review of Resident 21's MDS, dated [DATE], indicated Resident 21's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired. The MDS indicated Resident 21 had impairment to both upper and lower extremities. The MDS indicated Resident 21 was dependent for eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, roll left and right, and chair/bed-to-chair transfer. The MDS also indicated sit to lying, lying to sitting on bedside, sit to stand, toilet transfer, and tub/shower transfer was not attempted for Resident 21 and the activities were not performed prior to the current illness, exacerbation, or injury. A review of Resident 21's medical record from 4/26/2023 to 6/29/2024, there was no Advance Directive in Resident 21's chart. A review of Resident 21's electronic medical record indicated on 4/19/2023 there was no Advanced Directive on file and there was no documented evidence Advanced Directive information was provided to the resident or resident's representative. 4. A review of Resident 22's Admission Record indicated Resident 22 was admitted to the facility on [DATE]. A review of Resident 22's H&P, dated 5/16/2024, indicated Resident 22 had diagnoses of respiratory failure with ventilator dependence, Type 2 Diabetes Mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), seizure disorder (burst of uncontrolled electrical activity between brain cells that can cause the body to shake uncontrollably), and cerebrovascular accident (CVA - stroke; damage to the brain from interruption of its blood supply). A review of Resident 22's MDS, dated [DATE], indicated Resident 22 was comatose and in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident 22 had impairment to both upper and lower extremities. The MDS indicated Resident 22 was dependent for oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, and roll left and right. The MDS also indicated sit to lying, lying to sitting on bedside, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer was not attempted for Resident 22 due to medical condition or safety concerns. A review of Resident 22's medical record from 5/15/2023 to 6/29/2024 there was no Advance Directive in Resident 22's chart. A review of Resident 22's electronic medical record indicated on 4/27/2024 at 12:30 PM there was no Advance Directive, there was no documented evidence that the Advance Directive information was provided to the resident's representative, no Advance Directive form signed, and no Advance Directive executed. 5. A review of Resident 23's Admission Record indicated Resident 23 was admitted to the facility on [DATE]. A review of Resident 23's H&P, dated 3/19/2024, indicated Resident 23 had diagnoses of respiratory failure with ventilator support, CVA, and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). A review of Resident 23's MDS, dated [DATE], indicated Resident 23 was comatose and in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident 23 had impairment to both upper and lower extremities. The MDS indicated Resident 23 was dependent for oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, and roll left and right. The MDS also indicated sit to lying, lying to sitting on bedside, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer was not attempted for Resident 23 due to medical condition or safety concerns. A review of Resident 23's medical record from 3/18/2023 to 6/29/2024 there was no Advance Directive in Resident 23's chart. A review of Resident 23's electronic medical record indicated on 3/18/2024 at 3:21 PM there was no Advanced Directive information on file. 45456 6. A review of Resident 19's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 19's H&P, dated 11/10/2022, indicated Resident 19 had diagnoses which included anoxic encephalopathy, chronic respiratory failure ventilator dependent and sepsis (a life-threatening emergency that happens when your body response to an infection damages vital organs and, often, causes death). A review of Resident 19's MDS, dated [DATE], indicated Resident 19 has intact cognitive (skills for daily decision making. The MDS also indicated Resident 19 was dependent oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, roll left and right, sit to lying, and chair/bed-to-chair transfer. During a concurrent interview with the DON and record review of Resident 19's chart from 11/10/2022 until 6/29/2024, at 10:52 AM, there was no Advance Directive form for Resident 19. A record review of Resident 19's electronic health record with the DON, the DON stated that she documented on 6/28/2024 at 4:50 PM, on Resident 19's electronic health record that he had no Advance Directive form on file. During an interview on 6/29/2024 at 7:51 PM with the Director of Nursing (DON), the DON stated a family member was usually with the resident upon admission. The DON stated the resident or responsible party were responsible for signing the admission paperwork which included the Advanced Directive forms. During a concurrent interview and record review of the residents' electronic medical record on 6/29/2024 at 8:10 PM with the DON, the DON stated Resident 21's electronic records indicated there was no Advanced Directive, no Advanced Directive provided, and no Advanced Directive on file. The DON stated the clerk should had waited for Resident 21's family member to sign the Advance Directive forms since Resident 21's family member visited Resident 21 every day. The DON also verified there was no Advanced Directives forms in the electronic records and chart for Residents 3, 16, 19, 22, and 23. During a concurrent interview and record review of the facility's Advance Health Care Directives policy dated 2/2022, on 6/29/2024 at 8:18 PM with the DON, the DON stated each resident should be offered an Advanced Directive. The DON stated the resident's Advanced Directive should be placed in the chart for the staff's reference. The DON stated if the resident was not alert and oriented and did not have a responsible party, then the social service worker should be referred to. The DON stated the residents, and their responsible parties should be made aware of Advanced Directives to provide them an opportunity to make their choices in terms of medical treatment and for the facility to follow the resident's healthcare preferences. The DON stated when the residents and their responsible parties were not provided with the information, the facility may bypass the resident's and/ or resident representative's healthcare preferences. During an interview on 6/30/2024 at 5:49 PM with the DON, the DON stated the residents should have a paper copy of the Advanced Directive Form in their chart or scanned in the electronic medical records. The DON stated Advanced Directives guide the facility staff to meet the plan, wishes, and healthcare decisions for the residents. A review of the facility's Policy and Procedure titled, Advance Health Care Directives (AHCD), reviewed 2/2022, indicated for each adult inpatient admitted , the Admitting Department will complete the Advance Directive Acknowledgement Flow Chart (ADAFC) and obtain the patient's signature. For long-term care patient (Sub-Acute), Admitting will notify Social Services. Social Services will contact family/surrogate decision maker to obtain the information and facilitate it to Nursing.

Based on observation, interview, and record review, the facility failed to provide a dignity bag (a bag used to cover and hold the catheter drainage/collection bag) for two (2) of three (3) sampled residents (Resident 14 and 126) who has a urinary indwelling catheter (tube inserted into the bladder to drain urine to a collection bag). This deficient practice had failed to safeguard the residents' dignity and had a potential to affect the residents' emotional and mental well-being. Findings: 1. A review of Resident 14's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 14's History and Physical (H&P), dated 6/11/2024, indicated Resident 14's diagnoses included focal seizures (also known as auras, occur in one area on one side of the brain, includes involuntary movements called automatism [like rubbing of the hands, lip-smacking, and chewing]), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and bullous pemphigoid (a rare autoimmune disease that causes blisters or sores on your skin) A review of Resident 14's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 6/5/2024, indicated Resident 14 was comatose (in a state of deep and usually prolonged unconsciousness [unable to wake up because of illness or injury]; unable to respond to external stimuli). The MDS also indicated Resident 14 was dependent (helper does all of the effort. resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is required for the resident to complete the activity) in oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, and roll left and right. During an observation inside Resident 14's room on 6/29/2024 at 9:16 AM, Resident 14 was sleeping. Resident 14's Foley catheter (urinary indwelling catheter) drainage collection bag was not placed inside a dignity bag exposing resident's urine in the drainage collection bag. During an interview with the Director of Nursing (DON) on 6/30/2024 at 5:43 PM, the DON stated, We do use dignity bag if the resident was sharing a room. We usually do not use it for residents in the private room, but we should use one. It should be in our policy to use it to make it clear to when to use it and not to use it. The DON stated, We should have a dignity bag if the Foley catheter bag was visible to other visitors, to respect the resident's privacy and dignity. 2. A review of Resident 126's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 126's MDS, dated [DATE], indicated Resident 126's active diagnoses included cerebral vascular accident (CVA or stroke, an interruption in the flow of blood to cells in the brain), chronic respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), and hypertension (high blood pressure). The MDS also indicated Resident 126 has severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 126 was dependent oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, roll left and right. During an observation inside Resident 126's room on 6/28/2024, at 12:54 PM, Resident 126 had 2 visitors inside the room. Resident 126 was sleeping. Resident 126's Foley catheter bag was observed with no dignity bag. During a concurrent observation in Resident 126's room and interview with Registered Nurse 3 (RN 3) on 6/28/2024, at 1 PM, RN3 stated, The Foley catheter bag does not have a dignity bag because Resident 126 was in the private room and so that we can see her urine easily. During an observation outside Resident 126's room on 6/29/2024 at 9:20 AM, Resident 126's Foley catheter bag was observed with no dignity bag and was placed on the side of bed where it can be easily seen outside the residents room from the hallway. During an interview with the DON, on 6/29/2024 at 4:43 PM, the DON stated, Foley catheter should not be placed on the area where visitors could easily see it. The DON also stated the facility staff should have placed a dignity bag if Resident 126's Foley catheter bag was visible to other visitors, and this is important to respect the resident's privacy and dignity. A review of the facility's Policy and Procedure titled, Patient Rights and Responsibilities, dated 7/2023, indicated in order to protect the personal welfare and safeguard the dignity of a patient as a human being, the hospital and the medical staff have adopted the following patient rights and responsibilities: considerate and respectful care, and to be made comfortable. The policy also indicated have personal privacy respected and confidentiality treatment.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: a. Label foods in the kitchen with item 'use by' date (the last date recommended for the use of the product) or open date. b. Discard expired food in the kitchen. c. Ensure drainpipe (a pipe that carries wastewater away from the building) had a 1 inch and more gap from the drain (plumbing fixture installed in the floor designed to direct water to a sewer or municipal storm drain so floor stays dry, and rooms do not flood). d. Ensure a container of salsa was discarded when found in a bin with labeling supplies. e. Ensure drainage on kitchen floor was clear of debris and trash. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea (loose watery stool that occurs more frequently than usual), and fever and can lead to other serious medical complications and hospitalization . Findings: During a concurrent observation in the kitchen and interview with the Registered Dietician (RD) on [DATE] at 9:43 AM, the following were observed: a. An open one-gallon bottle of vinegar not labeled with date opened and used by date. b. An open container of turmeric not labeled with open date and used by date. c. An open container of cinnamon stick labeled with used by date [DATE]. d. An open container of large black pepper grind not labeled with open date and used by date. e. An opened one-gallon bottle of Brand 1 cooking wine not labeled with open date and used by date. RD stated when food items were opened, the food items needed to be labeled with the open date and used by date. RD stated there were no labels to indicate when the items were opened and a used by date to indicate when the items (vinegar, turmeric, ground pepper and cooking wine) needed to be discarded. RD stated once a food item was opened the food item needed to be used within a specific time- period and not by the container's original expiration date, therefore the food item's shelf-life date needed to be written on the used by label. RD stated the cinnamon sticks should have been discarded since the cinnamon sticks were expired since [DATE]. RD stated the cooks should not use expired food items to be served to the residents. RD stated all expired food items needed to be discarded for the safety of the residents. During a concurrent observation in the kitchen and interview with RD on [DATE] at 9:52 AM, RD stated the container of salsa was placed with the kitchen labeling supplies. An unlabeled clear container with green salsa covered with a lid was found lying with the dietary staff's labeling supplies. RD stated the salsa was not supposed to be stored with the labeling supplies. RD stated the container of salsa needed to be discarded since it was mixed with non-food items and was not stored properly. During a concurrent observation in the kitchen and interview with the Engineer Supervisor (ES) on [DATE] at 10:03 AM, ES stated the drainpipe should have a one-inch gap from the drain ES measured the drainpipe and stated there was half an inch between the drainpipe and the drain. ES stated the guidelines indicated the drainpipe should be one inch away from the drain. During a concurrent observation in the walk-in freezer in the kitchen and interview with the Lead [NAME] (LC) on [DATE] at 9:43 AM, the following were observed: a. A clear bag of waffles with no label of item name and used by date. b. An opened clear bag of chicken patties with no label of item name, open date, and used by date. c. An opened bag of green beans with no label of open date and used by date. d. An opened bag of bacon bits with no label of open date and used by date. LC stated food items needed to be labeled with item name, open date, and expiration date when removed from the original packaging. LC stated the bag of chicken, green beans, and bacon bits were opened and were not labeled with item name, open date, and used by date. LC stated the foods needed to be discarded since the food items were opened and expiration date was not written. During a concurrent observation in the kitchen and interview with the RD on [DATE] at 10:20 AM, RD stated there was trash in the kitchen floor drain. A disposable container lid, creamer container, rubber band, and debris were noted lying on top of the drain. RD stated nothing was supposed to be on the drain. RD stated the drain was supposed to be clean and cleared of any trash so water could easily drain in case of any spills. A review of the facility's Policy and Procedure (P&P) titled, Food Receiving, Storage, and Discard, revised ,d+[DATE], indicated all food should be wrapped, labeled, and dated before placed in storage. The P&P also indicated, check expiration date for food items in its original packaging, if it is not visible, rewrite expiration date on its outer box. In addition, the P&P indicated, dry food storage item should be labelled with the open date on the bag or container and discarded by the shelf-life discard date, and any item passed the storage period should be discarded. A review of the facility's P&P titled, Safety Guidelines, Department Specific, undated, indicated check all drain lines air gaps, they shall not be less than one inch. A review of the facility's P&P titled, Safety Policies for Food Service Employee, dated ,d+[DATE], indicated Director of Food and Nutrition Services in accordance with Kitchen Supervisor implements safety and sanitation procedures in all working areas.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for three (3) of three sampled residents (Residents 21, 1, and 19) by failing to ensure: 1. Resident 21's nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril) tubing was changed weekly. 2. Resident 19's suction tubing was not touching the floor. 3. Resident 1's suction tubing was not touching the floor. These deficient practices had the potential for the residents to develop a respiratory infection. Findings: 1. A review of Resident 21's Admission Record indicated Resident 21 was admitted to the facility on [DATE]. A review of Resident 21's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 4/23/2024, indicated Resident 21 had diagnoses of chronic respiratory failure ventilator (a piece of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs) dependent (when resident is unable to wean off a ventilator and breathe independently), status post (s/p, a term used in medicine to refer to a surgical procedure, diagnosis or just an event) tracheostomy (a surgically created hole in the windpipe that provides an alternative airway for breathing), s/p gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage), and quadriplegia (paralysis of all four limbs). A review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/2/2024, indicated Resident 21's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired. The MDS indicated Resident 21 was dependent (helper does all of the effort. resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, roll left and right, and chair/bed-to-chair transfer. The MDS also indicated sit to lying, lying to sitting on bedside, sit to stand, toilet transfer, and tub/shower transfer was not attempted for Resident 21 and the activities were not performed prior to the current illness, exacerbation, or injury. The MDS indicated Resident 21 received oxygen therapy. A review of Resident 21's Physician's Monthly Orders, dated 9/5/2023, indicated Passy Muir Valve (PMV, a medical device used by tracheostomy and ventilator residents that redirects airflow through the vocal folds, mouth, and nose, enabling voice and improved communication) 7 AM to 10 PM, oxygen at two (2) liters (L) NC while on PMV. During an observation on 6/28/2024at 11:49 AM in Resident 21's room, Resident 21 was receiving 2 L of oxygen via nasal cannula. The nasal cannula tubing was not labeled. During a concurrent observation of Resident 21's nasal cannula tubing and interview on 6/28/2024 at 12:07 PM with Registered Nurse 4 (RN 4), RN 4 stated she did not see a date on Resident 21's nasal cannula tubing. RN 4 stated the respiratory therapist was in charge of the nasal cannula tubing. RN 4 stated the nasal cannula tubing was not and should have been labeled with the date the NC tubing w as changed by the respiratory therapist. During an interview on 6/30/2024 at 6:07 PM with the Director of Nursing (DON), the DON stated residents' nasal cannula tubing should be changed weekly. The DON stated Resident 21's nasal cannula tubing should be dated to know when the tubing was last changed. The DON stated the facility did not have a policy to indicate when residents' nasal cannula should be changed. The DON stated the facility should have a policy indicating nasal cannula tubing were to be changed weekly. The DON stated changing the nasal cannula tubing weekly could prevent the resident's from getting an infection. The DON stated the longer the residents continued using the nasal cannula tubing without being changed, this posed a greater risk of infection for the residents since these residents had respiratory conditions. During an interview on 6/30/2024 at 7:21 PM with the Respiratory Therapist 3 (RT 3), RT 3 stated there was not specific date when the nasal cannula tubing was changed. RT 3 stated the nasal cannula tubing needed to be labeled when used for a resident. RT 3 stated nasal cannula tubing were changed every three days and also changed earlier if needed. RT 3 stated changing the nasal cannula every three days or as needed when dirty was done to avoid the residents' from getting an infection. A review of the facility's Policy and Procedure titled, Sub-Acute Infection Control Policies, dated 9/2021, indicated each staff member assigned in the unit is responsible for ensuring that infection prevention and control procedures are performed. 45456 2. A review of Resident 19's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 19's H&P, dated 11/10/2022, indicated Resident 19's diagnoses included anoxic encephalopathy (or hypoxic-ischemic brain injury, a process that begins with the cessation of cerebral blood flow to brain tissue, which most commonly results from poisoning [for example, carbon monoxide or drug overdose], vascular injury or insult, or cardiac arrest), chronic respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide) ventilator dependent (if a resident is unable to wean off a ventilator and breathe independently) and Left middle cerebral artery (MCA, stroke occurs when blood flow from the MCA, one of the largest arteries of the brain, is suddenly interrupted [ischemia] or altogether stopped [infarction]) ischemic stroke. A review of Resident 19's MDS, dated [DATE], indicated Resident 19 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 19 was dependent with oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, roll left and right, sit to lying, and chair/bed-to-chair transfer. During an observation in Resident 19's room on 6/29/2024 at 9:24 AM, Resident 19 was sleeping. The ventilator was turned on. The suction tubing connected on the ventilator was touching the floor. During a concurrent observation in Resident 19's room and interview with LVN 2 on 6/29/2024 at 5:08 PM, Licensed Vocational Nurse 2 (LVN 2) stated, The suction tubing should not be touching the floor because the floor was dirty. It can cause respiratory infection to the resident. We have to change it right away. 3. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's H&P, dated 2/27/2024, indicated Resident 1's active diagnoses included chronic respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and asthma (a condition in which your airways narrow and swell and may produce extra mucus) A review of Resident 1's MDS, dated [DATE], indicated Resident 1 was comatose (persistent vegetative state/ no discernible consciousness). The MDS also indicated Resident 1 was dependent with oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, and chair/bed-to-chair transfer. During a concurrent observation in Resident 1's room and interview with LVN 2 on 6/29/2024, at 5:03 PM, LVN 2 observed Resident 1's suction tubing was laying on the floor. LVN 2 stated, The suction tubing should not be touching the floor because the floor was dirty. It can cause respiratory infection to the resident. We have to change it right away. During an interview with the DON on 6/30/2024, at 5:29 PM, the DON stated, There should be no suction on the floor. Any medical equipment that is used on the residents should never be touching the floor because of infection control issue. It is a potential infection risk for the residents. A review of the facility's Policy and Procedure titled, Sub-Acute Unit Respiratory Services, approval dated, 11/2018, indicated all tubing should not be touching the floor.

Based on observation, interview, and record review, the facility failed to ensure a resident with a pressure ulcer received appropriate treatment during wound care, failed to ensure a pain management program was in place, failed to ensure the resident was handled in a gentle manner, and was provided with appropriate interventions for a Stage IV pressure ulcer, per standards of care and professional guidelines, for two of 10 sampled residents (Resident 1 and 2). These failures had the potential to result in increased pain and suffering, preventing ulcer from healing, and cause harm to the resident. Findings: 1. On April 16, 2015 at 8 a.m., during the initial tour of the subacute unit, Resident 1 was observed lying on a low air loss (LAL) mattress (special air-fluidized bed which relieves pressure on the skin and promotes wound healing). Resident 1 had a [MEDICAL CONDITION] (a tube which is surgically inserted into the airway for purposes of providing oxygen to the airway passages), which was connected to a tracheal collar (a device which delivers continuous aerosol administration of water to the upper airways in order to hydrate airway secretions, and promote cough), and was receiving a tube feeding through a gastrostomy tube (GT- a tube which is surgically inserted through the abdomen into the stomach for purposes of nutrition and medication administration). The resident, whose eyes were open, appeared to have difficulty focusing, and exhibited constant jerking motions of her head. A review of Resident 1's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- standardized assessment tool), dated March 17, 2015, indicated Resident 1 was severely impaired in her ability to make decisions, was unable to walk, was incontinent of bowel and bladder, and was totally dependent on staff for all daily living needs. A review of the recapitulated monthly summary physician orders [REDACTED]. There were no further orders for pain medication. A review of the computerized summary sheet provided by the facility pharmacy, indicated the dates Resident 1 had received [MEDICATION NAME] since her admission to the facility, was June 3, 2012, March 15, 2013, and April 18, 2013. The physician's orders [REDACTED]. A review of the Interdisciplinary Team (IDT) monthly meeting notes from July, 2014-March, 2015, did not address pain level assessment, nor updates on the condition of the coccygeal pressure ulcer. An undated Resident 1's care plan, titled, "Skin Fragile", indicated one of the interventions was to be gentle when handling the patient. Resident 1's care plan, titled, "Alteration in Comfort Related to Pain at Back", dated March 17, 2015, included interventions to assess discomfort and relief post intervention, PRN (as needed) meds as ordered, check effectiveness of medications given, and provide comfort measures. On April 20, 2015 at approximately 9:35 a.m.,Resident 1 was observed receiving a bed bath by LVN 2 and certified nursing assistant (CNA) 1, and was noted to be incontinent of urine. After several minutes, LVN 2 was called away to take care of another matter, and LVN 3 arrived to assist with the bath. When the resident was turned onto her side, the coccygeal dressing was observed to be saturated with urine, and had a large amount of reddish-brown drainage. LVN 3 removed the outer gauze dressing at that time. On April 17, 2015 at 2 p.m., an observation was conducted of Resident 1's wound care for the sacrococcygeal pressure ulcer. LVN 1 failed to ask the resident if she was having any pain, prior to starting the wound care. LVN 1 and CNA 2 turned the resident onto her left side without informing the resident. After donning disposable gloves, LVN 1 removed the old dressing, then removed the Alginate packing. The wound was appeared to be one inch in length, and one half inch wide, with moderate red-brown drainage, and with a separating appearance (the formation or discharge of pus). There was also a small amount of yellow slough (dead tissue) noted in the wound bed, and the perimeter of the wound was reddened. Wearing the same pair of gloves, LVN 1 reached for a bottle of wound cleanser and sprayed the wound, without first informing the resident. At that time, the resident jerked her body. LVN 1 then removed his gloves, and without washing/sanitizing his hands, donned another pair of gloves, and cleaned the inside of the wound with gauze in a hurried manner. The resident jerked her body a second time. LVN 1 did not ask the resident if she was having any pain, and did not stop the treatment in order to assess for pain, but continued conducting the wound care. He removed his gloves, then donned a pair of sterile gloves without washing/ sanitizing his hands, and failed to do so throughout the remainder of the wound treatment. LVN 1 packed the wound with the Alginate dressing, then covered the wound with gauze, securing the dressing with [MEDICATION NAME] tape. The skin of the resident's left buttock had several large reddened wrinkles. LVN 1 placed a Medline Ultra Absorbent ES (extra strength) disposable absorbent pad under the resident, then placed a pillowcase which contained a bath towel, under the resident's perineal area for use as an incontinent brief. LVN 1 failed to inform the resident of his actions throughout the wound care, and conducted the care in a rough, hurried manner, which included wound care, as well as changing and repositioning the resident. An interview was conducted with LVN 1 immediately following the observation. When questioned why he did not use paper tape to secure the dressing, LVN 1 responded it sometimes left a residue on the skin. He then stated the resident was usually wet, which made it easier to remove the [MEDICATION NAME] tape. When questioned regarding the redness and wrinkling of the skin on the resident's left buttock, LVN replied it could be from either the urine or the tape, but redness fades away. When questioned regarding the potential for the resident experiencing pain, LVN 1 replied, "No- she came in with the Stage IV, so it isn't like she would be in a lot of pain." Regarding not informing the resident of his actions prior to rendering care, LVN 1 stated he had informed the resident prior to starting the wound treatment, but did not tell her step by step. When asked about using a bath towel and pillowcase as an incontinent brief, LVN 1 indicated the absorbent pad was very thin, so would not be effective by itself. When pointed out that he did not wash or sanitize his hands during the wound care, LVN 1 responded, "I touched the dirty (outer) dressing, but didn't touch the inside of the wound", then stated he should have cleaned his hands throughout the treatment. LVN 1 added that he had not noticed much improvement in the appearance of the resident's pressure ulcer over the past several months, and that maybe a different treatment plan would help. When the surveyor mentioned his handling of the resident, LVN 1 had a puzzled look. At 2:05 p.m. on April 17, 2015, during an interview, the unit director stated LVN 1 should not have handled the resident in that manner, and should have asked the CNA for assistance with the resident's care. She then stated, "Maybe he's a bit nervous- he should have gotten the CNA- that shouldn't have happened." Review of a coccygeal wound culture result, dated October 31, 2012 (two days after the resident's admission to the facility) and provided by the unit director, indicated the wound was positive for moderate Staphylococcus aureus, and moderate Streptococcus dysgalactiae. On April 20, 2015 at 9 a.m., during an interview, the unit director stated a pressure ulcer is cultured if ordered by the physician. When asked what signs/symptoms of a wound might indicate need for a culture, and if there was any tunneling of Resident 1's wound, the unit director responded a wound culture would be appropriate if the wound developed an odor, increased drainage, or change in color. She then stated she would check the weekly Skin Care Progress Notes for any mention of tunneling. According to the website,woundsource .com (http://www.woundsource .com/patientcondition/ tunneling-wounds-or-sinus-tracts), the article titled, "Tunneling Wounds and Sinus Tracts", dated 2008-2105, indicated a tunneling wound or sinus tract is a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation. When mentioned the resident had been receiving the same wound care since December, 2013, the director stated the resident's wound had gotten smaller in size since her admission. She then stated wound treatment orders should have a stop date in order to allow for reassessment of the wound, and the physician should be notified. A review of Resident 1's Skin Care Weekly Progress Notes, dated January 4, 2015-March 20, 2015, indicated the sacrococcygeal pressure ulcer average measurements were three centimeters (cm) in length, two cm in width, and 1.0-1.3 cm depth. There were no documentation the wound was checked for the presence of tunneling. On April 20, 2015 at 12:50 p.m., an observation of Resident 1's wound care treatment was conducted with LVN 2. The following tunneling measurements were obtained: One cm at 12 o'clock position, 0.8 cm at 3 o'clock, 0.2 cm at six o'clock position, and 0.8 cm at nine o'clock position. LVN 2 stated she obtained tunneling measurements when she was assigned to the resident, and when the weekly skin report was due. LVN 2 failed to wash or sanitize her hands following removal of her gloves throughout the treatment, and also failed to inform the resident of her actions, prior to rendering care. At 4:35 p.m. on April 20, 2015, during another interview regarding Resident 1's pressure ulcer, the unit director stated, "Maybe she needs a Foley catheter (a rubber tubing inserted into the bladder in order to drain urine). We try not to put in Foley catheters unless it's justified- we're afraid of UTI's (urinary tract infection). I'll talk to her doctor about inserting one." When asked if the subacute unit utilized a wound consultant, the director stated there was a wound nurse for the general acute care hospital, but the wound nurse did not come to the subacute unit. When it was mentioned that the last wound culture was performed in 2012, and that the most recent wound treatment order was December, 2013, the director replied the subacute staff did a good job in pressure ulcer wound management, and that she and the staff had seen a great improvement in Resident 1's wound since she was first admitted to the unit. According to the Hartford Institute for Geriatric Nursing website, ConsultGeri.com (http://consultgerirn.org /topics/pressure_ ulcers/and_ skin_ tears/want_to_ know_more), updated December 2012, "Nonadherent dressings should be used on frail skin...If tape must be used, be sure it is made of paper, and remove it gently. Also, tape can be applied to [MEDICATION NAME] a (wound cover that creates a waterproof, bacteria-proof and oxygen-proof barrier, and adhere to wet and dry wounds) strips placed strategically around the wound, rather than taping directly onto fragile surrounding skin." A review of the facility's policy, titled, "Pressure Ulcer Management Protocol", revised September 2013, indicated under the heading, "Special Mattress", to use minimal linen, such as an underpad only, when low air loss mattress is in use. The facility's policy, titled, "Pain Management: Nursing Practice", revised April, 2011, indicated the following: "All patients admitted to (the facility) will be assessed for pain on admission, and pain goal should be met. Pain assessment should be done every shift thereafter by a registered nurse if the patient does not complain of pain. A licensed vocational nurse under supervision of the RN collects data regarding pain..." The section which addressed pain assessment indicated if the patient is cognitively disabled, the observation must focus on emotion, movement, verbal cues, facial cues, and positioning, and assigned points based on criteria, such as face, legs, activity, crying, and consolability. The "Face" category indicated a level 2 pain was frequent to constant quivering chin, and clenched jaw. The "Activity" category indicated level 2 pain was "arched, rigid or jerking (movement)". 2. According to the admission record, Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Skin Breakdown/Decubitus Initial Assessment indicated the resident was admitted with Stage IV sacral pressure ulcer which measures 4 centimeters (cm) by 3 cm by 4 cm. During the provision of care on April 17, 2015 , at 10 a.m., with CN 1 , Resident 5 was noted lying on a specialty bed. The resident was lying on a disposable chux , a pillow case (2 layers) and a towel underneath her buttocks. Resident 5's care plan was developed on admission addressed impaired skin integrity related to a stage IV sacral pressure ulcer. One of the interventions was use of special mattress and/or protective measures/devices. According to the facility policy on Pressure Ulcer Prevention and Management Protocol on special mattress indicated to use minimal linen, such as an underpad only when low air loss mattress is in use. During an interview with CN at the time of observation, she stated there should only be a disposable chux underneath the resident's buttocks to aid in healing of the pressure sore.