Every finding on record at East Jefferson General Hospital - SNF

Based on interviews and record reviews, the facility failed to ensure the physician was immediately notified of a significant change in a resident's weight for 1 (Resident #45) of 1 sampled resident reviewed for weights. Findings:Review of the Facilities Nursing Standards of Practice and Documentation policy, dated 10/2024 revealed, in part, on the day weights are obtained on all patients, the primary nurse will compare the admission weight to the current weight and determine if criteria has been met to notify the attending physician and dietician. The attending physician will be notified of a weight change from time of admission +/- 10 %. Review of Resident #45's Electronic Medical Record revealed an admit date of 12/12/2025. Further review revealed Resident #45 had diagnoses of, in part, congestive heart failure (a condition where the heart muscle is too weak to pump blood efficiently), end stage renal disease, and was receiving hemodialysis (life-sustaining treatment for kidney failure to filter blood). Review of Resident #45's Electronic Medical Record revealed, in part, Resident #45 had a weight of 138 pounds on 12/12/2025, a weight of 147 pounds on 12/15/2025, and a weight of 154 pounds on 12/16/2026 which was an 11.6% weight gain since Resident #45's admission. In an interview on 02/24/2026 at 5:25PM, S5Registered Nurse indicated she did not report Resident #45's above mentioned weight gain to the nurse practitioner or physician. In an interview on 02/24/2026 at 5:43PM, S6Registered Nurse indicated she did not report Resident #45's above mentioned weight gain to the nurse practitioner or physician. In an interview on 02/25/2026 at 9:50AM, Resident #45's Nurse Practitioner indicated he was not notified of Resident #45's above mentioned weight gain. Resident #45's Nurse Practitioner further indicated if he was made aware of Resident #45's weight gain he would have notified Resident #45's Nephrologist (medical doctor who specializes in managing diseases of the kidneys). In an interview on 02/25/2026 at 10:30AM, Resident #45's Nephrologist indicated he was not notified of Resident #45's above mentioned weight gain. In an interview on 02/25/2026 at 1:30PM, S2Director of Nursing indicated Resident #45's weight gain should have been reported to the nurse practitioner or doctor, and was not, as required.

Based on observation, interviews, and record review, the facility failed to ensure respiratory staff wore personal protective equipment [PPE] (garments and gear designed to protect the wearer's body from infections and hazards) when entering the room of a resident on contact isolation precautions for 2 (S7Respiratory Therapist [RT], S8RT) of 7 staff members observed for proper PPE usage. Findings:Review of the facility's Isolation Precautions policy and procedure, revised on 01/2025, revealed, in part, staff should follow contact isolation precautions (an infection control measure consisting of the use of specific PPE in order to prevent the spread of bacteria and viruses with a resident or their environment) when coming into contact (directly or indirectly) to residents with a known or suspected infections of epidemiological important microorganisms (a type of bacteria, virus, parasite, or fungi that significantly impacted public health due to their high potential for transmission or high potential to have caused outbreaks) or their environment. Further review revealed PPE was defined as a fluid resistant gown and gloves that should have been worn upon entering a resident's room.Review of Resident #62's electronic medical records, dated 02/10/2026 revealed, in part, Resident #62 was on contact isolation precautions for Carbapenem-Resistant Enterobacteriaceas (a bacteria that cause infections such as pneumonia [an infection in the lungs], bloodstream infection, and wound infections; that is resistant to antibiotics.)Observation on 02/23/2026 at 9:41AM revealed signage on Resident #62's door which indicated staff were to practice contact isolation precautions when entering Resident #62's room. Further observation revealed the signage indicated everyone must put on a gown and gloves. Further observation revealed S7RT and S8RT entered Resident #62's room without putting on a gown and gloves. In an interview on 02/23/2026 at 10:58AM, S3Charge Nurse, confirmed Resident #62 was on contact isolation precautions, and S7RT and S8RT went into Resident #62's room without putting on gowns or gloves. In an interview on 02/23/2026 at 11:03AM, S7RT indicated Resident #62 was on contact isolation precautions and she (S7RT) did not put on a gown or gloves before entering Resident #62's room.In an interview on 02/23/2026 at 11:04AM, S8RT indicated Resident #62 was on contact isolation precautions and she (S8RT) did not put on a gown or gloves before entering Resident #62's room.In an interview on 02/24/2026 at 11:05AM, S2Director of Nursing (DON) indicated S7RT and S8RT should have put on a gown and gloves before entering Resident #62's room because he was on contact isolation precautions.In an interview on 02/25/2026 at 10:52AM, S9Infection Preventionist (IP) indicated S7RT and S8RT should have put on a gown and gloves before entering Resident #62's room because he was on contact isolation precautions.

Based on interviews and record reviews, the facility failed to ensure a resident was weighed daily per physician's orders for 1 (Resident #45) of 1 sampled resident reviewed for daily weights. Findings:Review of Resident #45's Electronic Medical Record revealed an admit date of 12/12/2025. Further review revealed Resident #45 had diagnoses of, in part, congestive heart failure and end stage renal disease, and was receiving hemodialysis (life-sustaining treatment for kidney failure to filter blood). Review of Resident #45's Physician's Orders revealed, in part, an order for daily weights with a start date of 12/12/2025. Review of Resident #45's Electronic Medical Record revealed, in part, Resident #45 did not have weights completed for 12/17/2025, 12/18/2025, and 12/19/2025. In an interview on 02/24/2026 at 3:40PM, S2Director of Nursing indicated there was no documented evidence staff obtained a weight for Resident #45 on 12/17/2025, 12/18/2025, and 12/19/2025, as ordered. In an interview on 02/24/2026 at 5:50PM, S2Director of Nursing offered no explanation as to why weights were not obtained for Resident #45 for the above-mentioned dates. In an interview on 02/25/2026 at 1:30PM, S2Director of Nursing indicated weights were not obtained as ordered on 12/17/2025, 12/18/2025, and 12/19/2025 for Resident #45, and should have.

Based on observation, interviews, and record reviews, the facility failed to ensure expired intravenous (IV) fluids were not available for use in 1 (Medication Supply Room a) of 1 (Medication Supply Room a) medication supply room observed for expired supplies. Findings: Review of the University Healthcare System (UHS) Policy, titled UHS Expired Supplies and Supply Rotation, last updated 04/2024, revealed in part, to ensure patients are protected from infection and other potential harm from expired or compromised supplies and devices, UHS Hospital assures that supplies are stacked to the most optimal par levels, and supply items have not passed their expiration dates. Further review revealed, in part, under Definitions, Patient Supply- any item that is used on a patient directly or indirectly will remain within the current unexpired date. (Blood tubes, IV catheter, IV solution, X-ray film). Review of the UHS Policy titled, UHS Medication Expiration Dates, last updated 03/2024, revealed in part, the active inventory for medications shall not contain expired medications. Further review revealed, in part, when medications are received, the dates of expiration shall be checked. Further, the bulk storage sections and the IV room shall be checked routinely by personnel for pharmaceuticals that are expired. Observation on 02/12/2025 at 1:51PM, accompanied by S3Staff Registered Nurse (S3Staff RN), of the Medication Supply Room a, located in the automated dispensing cabinet (ADC), bin #28, revealed one (1) 1000 milliliter (ml) bag of Potassium Chloride 10 mill equivalence (meq), with an expiration date of April 2024. Further observation revealed one (1) 1000 ml bag of Potassium Chloride 10 mill equivalence (meq) was available for resident use. In an interview on 02/12/2025 at 1:54PM, S3Staff Registered Nurse (RN) indicated the Medication Supply Room a automated dispensing cabinet was checked by the pharmacy department personnel as per their guidelines. S3Staff RN further indicated it is responsibility of the skilled nursing staff to assure supplies / intravenous fluids (IV)/ medications are within the acceptable date and are not expired and available for resident use. In an interview on 02/12/2025 at 2:15PM, S1RN Director of Nursing (DON) indicated she was informed by S3Staff RN of one (1) 1000 ml bag of Potassium Chloride 10 meq with an expiration date of April 2024, was located in the Medication Supply Room a, in the ADC, bin #28. S1RN DON further indicated there should not have been any supplies / IV fluids/ medications located in the Medication Supply Room a that were expired and available for resident use. In an interview on 02/12/2025 at 2:46PM, S2Pharmacy Operations Manager (POM) indicated the pharmacy staff supply the ADC with medications and IV fluids and are responsible for ensuring all medications and IV fluids are within the current date and are not expired. S2POM indicated the one (1) bag of 1000ml Potassium Chloride 10 meq, dated April 2024, was expired and should not have been available for resident use. 42708

Based on observation, interviews, and record review, the facility failed to ensure dietary staff donned Personal Protective Equipment (PPE) while passing food trays for 1 (Patient #117) of 1 (Patient #117) patient observed for Contact Isolation Precautions. Findings: Review of the facility's Transmission Based Precautions policy and procedure, revised on 09/2024, revealed, in part, in addition to standard precautions, use contact precautions for specified patients known or suspected to be infected or colonized with epidemiological important microorganisms that can be transmitted by direct contact with the patient (hand or skin to skin contact that occurs when performing patient care activities that require touching the patient's dry skin), or indirect contact (touching) with environmental surfaces or patient care items in the patient's environment. 3. PPE: A fluid -resistant gown and gloves will be worn upon entering the patient's room and removed prior to exiting, followed by hand hygiene. Observation on 02/10/2025 at 11:29AM revealed signage on Patient #117's door which indicated Contact Isolation Precautions. Further observation revealed the signage indicated that everyone must put on a gown and gloves. Observation further revealed S6Dietary Aide entering Patient #117's room without putting on a gown. In an interview on 02/10/2025 at 11:29AM, S6Dietary Aide indicated she was only required to put on a gown when the patient was on droplet precautions. In an interview on 02/13/2025 at 9:35AM, S5Infection Preventionist acknowledged the S6Dietary Aide should have put a gown on before entering Patient #117's room, while he was on Contact Isolation Precautions. In an interview on 02/13/2025 at 11:22AM, S1Director of Nursing (DON), acknowledged S6Dietary Aide should have put on a gown before entering Patient #117's room while he was on Contact Isolation Precautions. In an interview on 02/13/2025 at 11:22AM, S4Director of Post-Acute Services confirmed S6Dietary Aide should have worn a gown when entering Patient #117's room while Patient #117 was on Contact Isolation Precautions as required.

Based on observations and interviews, the facility failed to ensure expired intravenous (IV) fluids were available for use in1 (Medication Supply Room a) of 1 (Medication Supply Room a) medication supply room observed for expired supplies. Findings: Observation on [DATE] at 09:29 a.m., of the Medication Supply Room a, revealed eight (8) five hundred (500) milliliter (ml) bags of Dextrose, five percent (5%) in water (D5W) of IV fluids with an expiration date of [DATE]. Further observation revealed the eight bags of IV fluids of D5W were available for resident use. In an interview on [DATE] at 09:40 a.m., S3Staff Registered Nurse (RN) indicated the Medication Supply Room a was checked two times per week by the central medical supply personnel. S3Staff RN further indicated it is responsibility of the skilled nursing staff to assure supplies are within the acceptable date and are not expired and available for resident use. In an interview on [DATE] at 11:10a.m., S2RN Director of Nursing (DON) indicated she was informed by S3StaffRN of the eight bags of D5W 500 ml located in the Medication Supply Room a were expired [DATE]. S2RN DON indicated there should not have been any supplies located in the Medication Supply Room a that were expired and available for resident use. S2RN DON was unable to provide a policy and procedure regarding the availability of expired supplies. In an interview on [DATE] at 11:09a.m., S4Supply Tech indicated the central medical supply department delivers IV fluids to the Medication Supply Room a every few weeks. S4Supply Tech indicated he was unaware the IV fluids in the Medication Supply Room a were expired and available for resident use.

Based on record reviews, observations and interviews, the facility failed to ensure one resident had personal privacy when receiving wound care for 1 (Resident #114) of 3 residents identified in the sample who required wound care. This deficient practice had the potential to affect all residents with wounds as documented on the Resident Census and Conditions of Resident Form (CMS-672). Findings: Resident #114 Review of the medical record revealed Resident #114 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An observation on 06/11/19 at 12:30PM revealed the resident was in her bed in her room with her body covered with bed linen and privacy curtain was opened. Further observation revealed S2RN (Registered Nurse) removed the resident's bed linen, pulled Resident #114's gown upward to her stomach area to gain access to her right leg wound dressing. S2RN did not pull the privacy curtain around the Resident #114's bed. An observation on 06/11/19 at 12:35PM revealed S2RN left Resident #114's room to obtain scissors. The privacy curtain was left opened which exposed Resident #114's female body parts. An observation on 06/11/19 at 12:39PM revealed S2RN returned to Resident #114's room and did not pull the privacy curtains around the Resident #114's bed prior to removing the wound dressing. An observation on 06/11/19 at 12:52PM revealed S2RN left the room to get more wound care supplies without closing the privacy curtains. An observation on 06/11/19 at 12:55PM revealed S2RN returning to the Resident #114's room with wound care supplies and not closing the privacy curtains. An observation on 06/11/19 at 1:10PM, S3Rehabilitation Technician entered the resident room while she was receiving wound care. Further observation revealed the privacy curtain was not closed, and the resident's female body parts were exposed. An observation on 06/11/19 at 1:15PM, S2RN left the room for more wound care supplies without closing the privacy curtains, leaving the resident's female body parts exposed. Further observation revealed S2RN returned to the room with more wound care supplies and did not close the privacy curtain around the resident's bed. An observation on 06/11/19 at 1:22PM revealed wound care performed with the privacy curtain opened. Further observation revealed S4OT (Occupational Therapist) entered the Resident #114's room, exposing the resident's female body part. In interview on 06/11/19 at 1:45PM, S2RN acknowledged the privacy curtain should have been pulled around the resident's bed, while performing wound care. In interview on 06/12/19 at 3:00PM, S1DON acknowledged the privacy curtain should have been pulled around the resident's bed, while performing wound care.

Based on observations, interviews, and record reviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being as evidenced by failing to ensure a resident's dressing was changed according to facility policy. The deficient practice was identified for 1 (Resident #229) of 25 Stage 2 sampled residents, but had the potential to affect any of the 30 residents who resided in the facility as documented on the Resident Census and Conditions of Residents Form CMS-672. Findings: Review of the facility's policy and wound care algorithm revealed, in part, a skin tear was to be dressed with a Border or Foam dressing which could remain up to 5 days. Observation on 06/05/17 at 01:30pm revealed Resident #229 had a foam dressing on her right forearm dated 05/16/17. In interview on 06/05/17 at 01:30pm, Resident #229 stated she had a skin tear which was bleeding, and a nurse applied the dressing. When asked how long it had been there, Resident #229 was unable to recall. Observation on 06/07/17 at 09:40am revealed Resident #229 had a foam dressing on her right forearm dated 05/16/17. In interview on 06/07/17 at 09:40am, S3/Registered Nurse (RN) stated silicone dressings should be changed every 3 to 5 or 7 days, she was unsure, but would check. S3/RN verified that the dressing Resident #229's arm was dated 05/16/17, and should have been changed prior to today. Observation on 06/07/17 at 10:00am revealed Resident #229 had a dressing to her right forearm dated 05/16/17. Further observation revealed S3/RN removed the dressing on the resident's forearm. In interview at this time, S3/RN verified that the dressing should be changed at least every 5 days, but was not. In interview on 06/07/17 at 12:50pm with S1/Director of Nursing/Skilled Unit (DON/SU) and S2/Senior Director of Quality (SDQ) stated foam dressings are used for skin tears, and should be changed at least every 5 days. When asked if a foam dressing left on since 05/16/17 (22 days) was following facility policy, S1/DON/SU and S2/SDQ both agreed that the time frame exceeded the recommendations of dressing changes, and the dressing should have been changed within the recommended time frame of 5 days. There was no documented evidence and the facility provided no documented evidence that the foam dressing to Resident #229's right forearm was changed within the required 5 days following application.

Based on observation and interview the facility failed to store, distribute and serve food under sanitary conditions as evidenced by the facility failing to ensure all staff that are present in the kitchen/food preparation area had their hair properly restrained at all times (S2/Environmental Services, S3/Dietary Purchasing Manager). This deficient practice had the potential to affect all residents receiving meals prepared by the facility's kitchen as documented by the facility's Resident Census and Condition of Resident's form (CMS-672). Findings: Observation on 7/5/2016 at 9:40am during a general tour of the kitchen revealed S3/Purchasing Manager had no hair net/covering to her hair. Further observation revealed a tour of the refrigerator and freezer and in the presence of food preparation without a hair net in place. Observation on 7/6/2016 at 10:45am revealed S2/Environmental Services, walking through the kitchen where food preparation was occurring, empting the trash can without a hair net in place. In interview on 7/5/2016 at 10:00am S5/Dietary Manager stated all staff should have hair fully covered. She further indicated the policy of the facility is that all personnel who work or enter the kitchen have their hair covered entirely, including facial hair, while in the kitchen In interview on 7/5/2016 at 10:10am S4/Executive Chef indicated all staff should have hair covering while in the kitchen where food preparation is occurring. In interview on 7/6/2016 at 10:48 S2/Environmental Services indicated he had a hair net on but took it off and threw it away when he was near the dumpster in the back of the kitchen. He further indicated he usually discards his hair net after leaving the kitchen but stated he discarded his hair net by the dumpster this time and walked through the kitchen without a hair net in place. In interview on 7/6/2016 at 11:10am S5/Dietary Manager stated she educates staff on wearing hair nets while in the kitchen/food preparation areas. She further indicated all staff that go into the kitchen should have their hair restrained at all times.

Based on record reviews and interviews the facility failed to ensure that the resident received the ordered frequency of physical therapy as out lined in the plan of treatment for 2 of 5 sampled residents (#4 and #5) out of a total census of 49 residents. This deficiency has the potential to affect all of the residents who receive physical therapy. Findings: Review of Resident #4's electronic medical record(EMR) with S1, RN/Vice President and S3, PT/Director revealed that Resident #4 had been admitted to the SNF from acute care on 3/1/12 at 5:30PM with [DIAGNOSES REDACTED]. Resident was seen by physical therapy(PT) on 3/2/12 at 10:39AM. PT order was 2 times daily for 1 week. During an interview on 03/08/12 at 10:30, S3, PT/Director reviewed the EMR for Resident #4 pointed out the following documentation: 3/2/12 PT at 4:00PM 3/3/12 PT at 10:55AM 3/4/12 PT at 8:45AM and 1:15PM 3/5/12 PT at 1:15PM 3/6/12 PT at 11:05AM 3/7/12 PT at 8:30AM, PT discontinued During an interview at this time, S3, PT/Director was asked why Resident #4 had not received the scheduled 2 times per day PT on 3/3/12, 3/5/12, and 3/6/12. S3, PT/Director stated that he would have to continue to search the EMR to determine the reason why Resident #2 had not received PT as ordered. After further review of the EMR, S3, PT/Director acknowledged that the order for PT 2 times daily had not changed. S3, PT/Director searched further into the EMR and pointed out the following documentation noted by the physical therapist assigned to Resident #4: 3/3/12 Three attempts were made to see the resident, she requested that we return 3/5/12 PT not done secondary to scheduling conflict 3/6/12 PT not done S3, PT/Director stated that he could not give any specific reason as to why the PT had not been done on 3/5/12 and 3/6/12 but that the physical therapists who made the documentation were on duty and could be interviewed. During an interview on 03/08/12 at 11:34AM, S5, PT who made the notation on 3/6/12 was asked why Resident #4 had not received PT twice on 3/6/12. S5, PT stated that Resident #4 could not been be seen because they did not have enough staff. During an interview on 3/8/12 at 11:40AM, S6, PT who made the notation on 3/5/12 was asked why Resident #4 had not received PT twice on 3/5/12. S6, PT stated that on that day they did not have enough staff and that there were too many new patients to see to get to Resident #4 twice. Review of the EMR for Resident #5, with S3, PT/Director revealed the following: admitted [DATE] at 5:46PM with [DIAGNOSES REDACTED]. Seen by PT on 3/3/12 with order for PT 1 time daily for 2 weeks. There was no documentation that that Resident #5 was seen by PT on 3/4/12. S3, PT/Director searched further into the EMR and noted documentation by PT on 3/4/12 that Resident #5 was not seen in PT today. During an interview on 3/8/12 at 12:10PM, S3, PT/Director stated that he could not locate any information in the EMR noting why Resident #5 had not received PT on 3/4/12 in accord with the order for PT once daily. The PT staff assigned to work with Resident #5 on 3/4/12 was not available for interview.

Based on observation and interview the facility failed to ensure that food is prepared under sanitary conditions. This was evidenced by the head cook not wearing head covering while preparing meals. This deficient practice has the potential to affect every resident in the facility. Finding: A tour of the facility was conducted on 3/16/11 at 10:00AM. S1, Director of Dietary Services and the Director of Nursing accompanied the surveyor on the tour. During the tour S1 stated that she wanted to introduce the surveyor to S2, head cook. S2, head cook was located near the fryer preparing the noon meal. A closer observation of S2, head cook revealed that he was not wearing any head covering. Surveyor commented to S1, Director of Dietary Services that S2, head cook was preparing a meal without wearing head covering. S2, head cook left the fryer area, washed his hands and walked over to S1, Director of Dietary Services. Upon his arrival, S1, Director of Dietary Services asked S2 why wasn ' t his head covered. S2, head cook left the area and returned wearing a hair net. S1, Director of Dietary Services commented that S2 knows that he should have a hat or hair net on whenever he is in the kitchen.