Every finding on record at Grand Terrace Health Care Center

Based on observation, interview, and record review, the facility failed to ensure an effective system wide infection control program for the prevention, control, and investigation of infections and communicable diseases for 14 of 19 sampled residents (Resident 6, 11, 23, 31, 36, 41, 44, 45, 49, 51, 52, 53, 70, and 77), when: 1. For five residents (Resident 6, 23, 77, 41, and 49), the facility staff did not wear an isolation gown (gown-cloth covering protection from neck to below knee) while providing high contact care to residents who are on Enhanced Barrier Precautions (EBP-an infection control intervention that involves wearing gown and gloves during high contact resident care activities). 2. For six residents (Resident 41, 45, 49, 52, 53, and 70), Licensed Vocational Nurse (LVN 1) did not clean the glucometer (a small machine used to check blood glucose) before and after use. 3. For eight residents (Resident 6, 23, 77, 36, 51, 11, 31, and 44), the facility staff did not provide Personal Protective Equipment (PPE-equipment used to protect staff and residents from germs or infections) cart or precaution poster (a sign used to identify resident who are on EBP) in front of resident's rooms. 4. For Resident 11, Intravenous (IV- in the vein) tubing was missing a label with date, time, and initials. 5. For Resident 31, indwelling foley catheter (foley- a soft tube that stays inside the bladder used to drain urine) was observed on the floor. 6. For two residents (Resident 11 and 31), Registered Nurse (RN 1) did not clean the Peripherally Inserted Center Catheter (PICC- a long, thin tube placed in a vein in the arm that goes up to a large vein near the heart to give medications or fluids) line with alcohol swab prior to administering IV medication. These failures in infection prevention practices had the potential to result in cross-contamination (transfer of harmful bacteria from one person to another), healthcare-associated infections (infections that occur while receiving care in the healthcare facility), bloodstream infections, urinary tract infections, and other serious complications, placing residents at risk for illness, delayed recovery, hospitalization, or worsening of their medical conditions.Findings: 1a. A review of Resident 6's face sheet (FS- a document with resident demographics, brief medical history, and emergency contacts), the FS indicated, Resident 6 was admitted on [DATE] with diagnoses of diabetes (DM- High blood sugar), pleural effusion (fluid in the lungs), chronic obstructive pulmonary disease (COPD-a long term lung condition that makes it hard to breathe because the airways are damaged and narrowed), and congestive heart failure (CHF-a condition where the heart muscle is unable to pump blood effectively enough to meet the body's needs). A review of Resident 6's Order, dated February 23, 2026, indicated Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indications: Indwelling Foley Catheter every shift. During an observation on March 2, 2026, at 9:52 AM, in room [ROOM NUMBER], CNA 1 was observed transferring Resident 6 from bed to wheelchair without a gown while touching Resident 6. During a concurrent observation and interview on March 2, 2026, at 10:12 AM, with CNA 1, in front of room [ROOM NUMBER], there was a purple dot next to Resident 6's name and an EBP poster. CNA 1 stated, if a resident is on EBP the staff is required to wear a gown when providing care. CNA 1 stated she was not informed that Resident 6 was on EBP and was not aware of what the purple sticker next to resident's name meant. During an interview on March 2, 2026, at 10:29 AM, with LVN 2, LVN 2 stated the facility staff are able to determine which residents are on EBP based on the purple dot next to the resident's name and the EBP poster. LVN 2 confirmed Resident 6 was on EBP. During a follow-up interview on March 2, 2026, at 10:40 AM, CNA 1 stated she should have been wearing a gown when transferring Resident 6 from bed to wheelchair. During an observation on March 4, 2026, at 5:50 AM, in room [ROOM NUMBER], CNA 3 was observed changing and removing linens from Resident 6's room without a gown. 1b. A review of Resident 77's FS, the FS indicated, Resident 77 was admitted on [DATE], with diagnosis of DM. A review of Resident 77's Order, dated March 1, 2026, indicated Enhanced Barrier Precautions D/T [due to] wound every shift. During an observation on March 4, 2026, at 5:52 AM, in room [ROOM NUMBER], CNA 3 was observed changing and removing linens from Resident 77's room without a gown. During an interview on March 4, 2026, at 5:54 AM, with CNA 3, CNA 3 stated, he was removing the linens from Resident 6 and Resident 77's room. CNA 3 confirmed Resident 6 and Resident 77 are on EBP, and he should have been wearing a gown. 1c. A review of Resident 23's FS, the FS indicated, Resident 23 was admitted on [DATE], with diagnoses of DM, osteomyelitis (an infection in the bone) to right foot and ankle, and methicillin resistant staphylococcus aureus infection (MRSA- a type of bacteria that is hard to treat with regular antibiotics). A review of Resident 23's Order, dated February 16, 2026, indicated Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indications: wounds, infection and/or MDRO [Multidrug-resistant organisms—bacteria that is resistant to multiple antibiotics] status every shift. During an observation on March 2, 2026, at 11:12 AM, in room [ROOM NUMBER], CNA 1 was observed assisting Resident 23 with toileting without a gown. During an interview on March 2, 2026, at 11:15 AM, CNA 1 stated she was assisting Resident 23 with removing her diaper because Resident 23 needed to use the bedside commode. CNA 1 verified that Resident 23 was on EBP and stated that she should have worn a gown. 1d. A review of Resident 41's FS, the FS indicated, Resident 41 was admitted on [DATE], with diagnoses of DM, hemiplegia (paralysis on one side of the body) affecting the left non dominant side, dementia (a condition that affects the brain, making it difficult to think, remember, and make decisions). A review of Resident 41's Order, dated February 8, 2026, indicated Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: HX [history] of MDRO every shift. During an observation on March 4, 2026, at 5:33 AM, in room [ROOM NUMBER], LVN 1 was observed taking Resident 41's blood glucose without a gown. During an interview on March 4, 2026, at 5:37 AM, with LVN 1, LVN 1 stated, Resident 41 is on EBP because there is a purple dot next to Resident 41's name. LVN 1 added, she should have worn a gown to take the blood sugar since it is a high contact activity. 1e. A review of Resident 49's FS, the FS indicated, Resident 49 was admitted on [DATE], with diagnoses of DM, CHF, and immunodeficiency (the ability to fight infection is weaker than normal). A review of Resident 49's Order, dated January 12, 2026, indicated Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wounds. During an observation on March 4, 2026, at 6:26 AM, in room [ROOM NUMBER], LVN 1 was observed taking Resident 24's blood glucose without a gown. During an interview on March 4, 2026, at 6:27 AM, with LVN 1, LVN 1 stated she did not see that Resident 49 is on EBP. LVN 1 verified Resident 49 on EBP because there was a purple dot next to Resident 49's name and stated she should have worn a gown for infection control. During an interview on March 5, 2026, at 7:28 AM, with LVN 3, LVN 3 stated, nursing staff are expected to wear PPE for residents on EBP when transferring resident, taking vital signs (measure body basic functions such as heart rate, body temperature, blood pressure, and breathing rate), taking blood sugars, and when staff are assisting with anything that would have high contact with residents. During a concurrent interview and record review on March 5, 2026, at 1:38 PM, with the DSD/IP, Resident 6's Order, dated February 23, 2026, Resident 77's Order, dated March 1, 2026, Resident 23's Order, dated, February 16, 2026, Resident 41's Order, dated February 8, 2026, and Resident 49's Order, dated January 12, 2026, were reviewed. Resident's 6, 23, 77, 41, and 49 Order indicated, the residents were on EBP. The DSD/IP confirmed and verified, Resident's 6, 23, 77, 41, and 49 were on EBP. The DSD/IP stated, the expectation is that any staff who is providing high contact care, for a resident on EBP, should wear a gown and gloves. The DSD/IP added, it is important to wear appropriate PPE to prevent the spread of infection. During a concurrent interview and record review on March 5, 2026, at 2:12 PM, with the Director of Nurse (DON) and Administrator (Admin), the facility's policy and procedures (P&P) titled, IPCP [Infection Prevention and Control Program] Standard and Transmission- Based Precautions, dated February 2026, was reviewed. The P&P indicated, Enhanced Barrier Protection (EBP): expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for indirect transfer of MDRO's to staff hands and clothing then indirectly transferred to residents or from resident-to-resident.Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: i. dressing, ii. Bathing/ showering, iii. Transferring, iv. Providing hygiene, v. changing linens, vi. Changing linens, vi. Changing briefs or assisting with toileting, vii. device care.viii. Wound care. The DON stated that the policy was not followed and should have been for Resident 6, 23, 77, 41, and 49. The DON further stated it is important to follow the policy because the staff should not cross contamination and for infection control. 2a. A review of Resident 41's FS, the FS indicated, Resident 41 was admitted on [DATE], with diagnoses of DM, hemiplegia affecting the left non dominant side, dementia. A review of Resident 41's Order, dated February 8, 2026, indicated Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: HX of MDRO every shift. A review of Resident 41's Order, dated February 8, 2026, indicated .inject as per sliding scale [a method to determine the amount of insulin (medication given to lower blood sugar)] . subcutaneously [injection into the fatty layer of the skin] before meals and at bedtime. During medication administration observation for Resident 41, on March 4, 2026, at 5:33 AM, with LVN 1, LVN 1 was observed doing a blood glucose check without cleaning the glucometer before taking the blood sugar. LVN 1 did not clean the glucometer after use. 2b. A review of Resident 45's FS, the FS indicated Resident 45 was admitted on [DATE], with diagnoses of DM, hypertension (HTN-high blood pressure), and dementia. A review of Resident 45's Order, dated September 25, 2025, indicated .inject as per sliding scale. subcutaneously before meals and at bedtime. A follow-up medication administration observation for Resident 45, on March 4, 2026, at 5:41 AM, with LVN 1, LVN 1 was observed doing a blood glucose check without cleaning the glucometer before taking the blood sugar. LVN 1 did not clean the glucometer after use. 2c. A review of Resident 70's FS, the FS indicated, Resident 70 was admitted on [DATE], with diagnoses of DM, hyperlipidemia (HLD-high level of fat in the blood), and osteoporosis (weak and fragile bones). A review of Resident 70's Order, dated March 1, 2026, indicated . FSBS [finger stick blood sugar] before breakfast. A follow-up medication administration observation for Resident 70, on March 4, 2026, at 5:57 AM, with LVN 1, LVN 1 was observed doing a blood glucose check without cleaning the glucometer before taking the blood sugar. LVN 1 did not clean the glucometer after use. 2d. A review of Resident 53's FS, the FS indicated Resident 53 was admitted on [DATE], with diagnoses of DM, HLD, and HTN. A review of Resident 53's Order, dated February 27, 2026, indicated .blood sugar checks every morning and at bedtime. A follow-up medication administration observation for Resident 53, on March 4, 2026, at 6:05 AM, with LVN 1, LVN 1 was observed doing a blood glucose check without cleaning the glucometer before taking the blood sugar. LVN 1 did not clean the glucometer after use. 2e. A review of Resident 49's FS, the FS indicated, Resident 49 was admitted on [DATE], with diagnoses of DM, CHF, and Immunodeficiency. A review of Resident 49's Order, dated January 2, 2026, indicated .inject as per sliding scale. subcutaneously before meals. A review of Resident 49's Order, dated January 12, 2026, indicated Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wounds. A follow-up medication administration observation for Resident 49, on March 4, 2026, at 6:26 AM, with LVN 1, LVN 1 was observed doing a blood glucose check without cleaning the glucometer before taking the blood sugar. LVN 1 did not clean the glucometer after use. 2f. A review of Resident 52's FS, the FS indicated, Resident 52 was admitted on [DATE], with diagnoses of DM, HTN, and HLD. A review of Resident 52's Order, dated February 17, 2026, indicated .Blood Glucose Levels.before meals and at bedtime. A follow-up medication administration observation for Resident 52, on March 4, 2026, at 6:29 AM, with LVN 1, LVN 1 was observed doing a blood glucose check without cleaning the glucometer before taking the blood sugar. LVN 1 did not clean the glucometer after use. During an interview on February 4, 2026, at 6:35 AM, LVN 1 confirmed that she did not clean the glucometer in between any of the residents that had blood sugar taken during medication administration and should have. LVN 1 stated it is important to clean the glucometer before and after use for infection control. During an interview on March 5, 2026, at 1:39 PM, with the DSD/IP, the DSD/IP stated, the nursing staff are expected to clean glucometers before and after use. The DSD/IP stated it is important to clean the glucometer because the nursing staff should prevent the spread of infection and it is never acceptable for the nursing staff not to clean the equipment between use. During a concurrent interview and record review on March 5, 2026, at 2:16 PM, with the DON and Admin, the facility's P&P titled, Glucometer Cleaning, Maintenance and Calibration, dated February 2026, was reviewed. The P&P indicated, . Glucometers must be used in accordance with manufacturer instructions and CDC [Centers for Disease Control and Prevention- a health agency that helps protect people from disease and health threats] infection control guidelines.Cleaning & Disinfection .1. before use.2. After each use. The DON stated it is important to follow this policy to prevent cross contamination, and it is never acceptable for a nurse not to clean the glucometer before and after use. 3a. A review of Resident 6's FS, the FS indicated, Resident 6 was admitted on [DATE], with diagnoses of diabetes, pleural effusion, COPD, and CHF. A review of Resident 6's Order, dated February 23, 2026, indicated Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indications: Indwelling Foley Catheter every shift. 3b. A review of Resident 23's FS, the FS indicated, Resident 23 was admitted on [DATE], with diagnoses of DM, osteomyelitis to right foot and ankle, and MRSA. A review of Resident 23's Order, dated February 16, 2026, indicated Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indications: wounds, infection and/or MDRO status every shift. 3c. A review of Resident 77's FS, the FS indicated, Resident 77 was admitted on [DATE], with diagnosis of DM. A review of Resident 77's Order, dated March 1, 2026, indicated Enhanced Barrier Precautions D/T wound every shift. During an interview on March 2, 2026, at 10:29 AM, with LVN 2, LVN 2 stated the facility staff is able to determine which residents are on EBP based on the purple dot next to the resident's name and the EBP poster. LVN 2 confirmed Resident 6 and Resident 77 in room [ROOM NUMBER] were on EBP. During a concurrent observation and interview on March 2, 2026, at 10:52 AM, with CNA 1, in front of room [ROOM NUMBER] and 4, there was no observable PPE cart. CNA 1 verified and confirmed the missing of PPE cart. CNA 1 stated that PPE cart should be readily available in front of resident's room with EBP. CNA 1 further stated, Resident 23 who is on EBP, residing in room [ROOM NUMBER]. 3d. A review of Resident 36's FS, the FS indicated Resident 36 was admitted on [DATE], with diagnoses of HLD, HTN, and COPD. A review of Resident 36's Order, dated February 16, 2026, indicated Enhanced Barrier Precautions D/T RLE [Right lower extremity- right leg] surgical site every shift . 3e. A review of Resident 51's FS, the FS indicated Resident 51 was admitted on [DATE], with diagnoses of muscle weakness, HTN, and COPD. A review of Resident 51's Order, dated February 17, 2026, indicated Enhanced Barrier Precautions D/T wound to the coccyx [the small bone at the bottom of the spine] every shift. During a concurrent observation and interview on March 2, 2026, at 10:53 AM, with CNA 1 in front of Rooms 6, there were no PPE carts present or PPE signage indicating Resident's 36 and 51 were on EBP. CNA 1 confirmed and verified there were no PPE carts or PPE signage. 3f. During a review of Resident 11's FS, the FS indicated, Resident 11 was admitted to the facility on [DATE], with the diagnosis of arthritis (a condition in which inflammation, pain and swelling of one or more joints) due to other bacteria, left elbow. During a review of Resident 11's Order, dated February 6, 2026, the Order indicated, Resident 11 is on EBP precaution for implanted (inside the body) IV access and wounds. 3g. During a review of Resident 31's FS, the FS indicated Resident 31 was admitted to the facility on [DATE], with diagnosis of unspecified open wound of vagina and vulva. During a review of Resident 31's Order, dated February 24, 2026, the Order indicated, Resident 31 is on EBP precaution for implanted IV access, wound and indwelling foley catheter. 3h. During a review of Resident 44's FS, the FS indicated Resident 44 was admitted to the facility on [DATE], with diagnosis of cellulitis (serious skin infection) of left lower limb. During a review of Resident 44's Order, dated February 17, 2026, the Orders indicated, Resident 44 is on EBP for wounds. During an interview on March 2, 2026, at 10:40 AM, with treatment nurse (TN- a person who takes care of wounds and dressing), TN verified and acknowledged that there is no PPE cart and EBP precaution poster in front of room [ROOM NUMBER] for Resident 11 and 44, and room [ROOM NUMBER] for Resident 31. TN stated, that the residents in both rooms are on EBP precaution and it is expected for the staff to wear PPE while in direct contact with the residents. During an interview on March 2, 2026, at 10:48 AM, with Minimum data set (the detailed assessment for residents) nurse (MDS), MDS stated, it is important to have the EBP precaution poster and PPE cart in front of all EBP precaution room as the staff will be reminded to wear the PPE. MDS further stated that the precautions are updated, and posters and PPE cart should be placed as soon as the orders are prescribed by the physician. During a follow-up interview on March 5, 2026, at 1:41 PM, the DSD/IP stated, it is important to have a PPE cart readily accessible to the staff outside of the room, for the staff to gown up (properly put on isolation gown) when needed and the poster should be clearly visible to ensure the staff know when to gown up. During a concurrent interview and record review on March 5, 2026, at 2:18 PM, with the DON and Admin, the facility's P&P titled, IPCP Standard and Transmission- Based Precautions, dated February 2026, was reviewed. The P&P Indicated, .Implementation: .i. post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (E.G [for example] gown and gloves). ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. b. Make PPE, including gowns and gloves, available immediately outside of the resident room. The DON stated that the policy was not followed and should have been because the cart and poster are a reminder for staff and there should be PPE available during urgent needs. 4. During a review of Resident 11's FS, the FS indicated Resident 11 was admitted to the facility on [DATE], with diagnosis of arthritis due to other bacteria, left elbow. During a concurrent observation and interview on March 2, 2026, at 9:40 AM, with RN 1, in Resident 11's room, cefazolin (medication to treat infection) 2 gram (G—unit of dosing medication) IV was observed hanging by Resident 11's bed. RN 1 verified and confirmed, the IV tubing did not have any label attached. RN 1 stated, it is within the facility's policy to place a label with date, time, and initial of the person who prepared and administered the medication. RN 1 further stated, it is important to have the label as an indication when IV tubing needs to be changed. RN 1 added, IV tubing should be changed every 24 hours to prevent risk of infection. During a review of Resident 11's Order, dated February 6, 2026, the Order indicated, cefazolin 2 G IV was ordered to be given every eight hours for cellulitis for six weeks until March 15, 2026. During an interview on March 5, 2026, at 1:30 PM, with the DSD/IP, the DSD/IP stated, the staff are educated to complete and label IV tubing prior to administering IV medications according to the policy. The DSD/IP further stated, it is hard to say when the tubing hung and needs to be changed with no label, and it is a concern for the infection control. During a concurrent interview and record review on March 5, 2026, at 2:35 PM, with the DON, the facility's P&P titled, Intermittent Administration of medication, undated, was reviewed. The P&P indicated, . I V tubing 1. All IV tubing must be dated and timed when hung. The DON acknowledged that the policy was not followed as the IV tubing had no labels. 5. During a review of Resident 31's FS, the FS indicated, Resident 31 was admitted to the facility on [DATE], with diagnosis of unspecified open wound of vagina and vulva. During a concurrent observation and interview on March 2, 2026, at 10:35 AM, in Resident 31's room, with LVN 2 and RN 1, Resident 31's foley tubing was touching the floor. LVN 2 acknowledged and stated that it is not acceptable for Resident 31's foley tubing to touch the floor. RN 1 further stated, it is concern for infection control. During a review of Resident 31's Order, dated February 24, 2026, the Order indicated, foley catheter is ordered to Resident 31 for the open wound on vulva. During an interview on March 5, 2026, at 1:40 PM, with the DSD/IP, the DSD/IP stated, the foley bag is expected to be placed inside a dignity bag (closed bag in which the urinary bag is placed) and hung below the bladder level, and foley tubing is expected not to touch the floor as it is an infection control concern. During a concurrent interview and record review on March 5, 2026, with the DON, the facility's P&P titled, Indwelling catheter, dated February 2026, was reviewed. The P&P indicated, .Position the drainage bag below the level of the of the resident's bladder and without resting on the floor. Ensure tubing allows for unobstructed drainage of urine. The DON stated that the policy was not followed. The DON further stated it is a high risk for infection. 6a. During a review of Resident 11's FS, the FS indicated Resident 11 was admitted to the facility on [DATE], with diagnosis of arthritis due to other bacteria, left elbow. During a review of Resident 11's Order, dated February 6, 2026, the Order indicated, cefazolin 2 G IV was ordered to be given every eight hours for cellulitis for six weeks until March 15, 2026. During medication administration observation for Resident 11 on March 4, 2026, at 7:45 AM, RN 1 was observed walking in the room with cefazolin 2 G IV bag. RN 1 connected a new IV tubing of cefazoline to Resident 11's PICC line. RN 1 started the IV infusion. RN 1 exited the room. 6b. During a review of Resident 31's FS, the FS indicated Resident 31 was admitted to the facility on [DATE], with diagnosis of unspecified open wound of vagina and vulva. During a review of Resident 31's Order, dated February 23,2026, the Order indicated, vancomycin (a medicine used to treat infection) 750 milligrams (mg-a unit of measurement) IV was ordered to be given every 12 hours. A follow-up medication administration observation for Resident 31 on March 4, 2026, at 8:15 AM, RN 1 was observed walking in the room with vancomycin 750 mg IV bag. RN 1 connected a new IV tubing of vancomycin to Resident 31's PICC line. RN 1 started the IV infusion. RN 1 exited the room. A follow-up interview on March 4, 2026, at 8:30 AM, with RN 1, RN 1 stated, it is expected to clean the injection connector with alcohol swab before giving IV medication. RN 1 further stated, it is infection control issue. RN 1 acknowledged that she did not clean PICC injector connector prior to access and administered medication to Resident 11 and 31. During a concurrent interview and record review on March 5, 2026, with the DON, the facility's P&P titled, Intermittent administration of medications, [undated], was reviewed. The P&P indicator, . Policies and guidelines: .6. Injection caps/connectors will be prepared with an alcohol swab prior to each injection. The DON stated, staff are educated to clean the connector with alcohol swab. The DON further stated it has a high chance for infection.

Based on observation, interview, and record review, the facility failed to ensure a medication was stored in accordance to the facility's policy and procedure (P&P) for Storage of medication and Disposal of medication, for one of one medication storage room when one bottle of 30 milliliter (ml-a unit of dosing medication) acetylcysteine (medication that can be used to clear airways) was found inside the refrigerator with an expiration date of February 28, 2026 (four days expired), and readily available for use. This failure had the potential to cause adverse health outcomes from administering expired medication which could negatively affect the vulnerable residents' health and safety.Findings: During a concurrent observation and interview on [DATE], at 5:30 AM, with Minimum Data Set (a detail assessment of the resident) nurse (MDS), the facility medication storage room was observed and found one bottle of 30 ml acetylcysteine. MDS verified and stated that the pharmacy indicated on the medication label that the medication would expire 96 hours or four days after opening. MDS further stated that this acetylcysteine bottle was delivered and opened on February 24, 2026, and expired on February 28, 2026 (four days expired), and it is expected to be discarded. During an interview on [DATE], at 1:40 PM, with the Director of staff development /Infection preventionist (DSD/IP), the DSD/IP stated that the expired medication should be discarded and should not be available in the patient care area. During a concurrent interview and record review on [DATE], with the Director of Nursing (DON), the facility's P&P titled, Storage of medication, dated 2023, and Disposal of medication, dated 2023, were reviewed. The P&P of Storage of medication indicated, .13. Outdated, contaminated, re deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures of medication disposal (section on disposal of medications, syringes and needles), and reordered from the pharmacy (C-section on ordering and receiving medications), if a current order exist. The P&P of Disposal of medication indicated, Policy 1. Discontinued medications and/our medications left in the care center after a residence discharge, which do not qualify to return to the pharmacy, are identified and removed from current medication supply in a timely manner for disposition. The DON acknowledged that the policies were not followed. The DON stated that she is not aware that the expired medication is still inside the refrigerator. The DON further stated that the facility failed to discard expired medication.

Based on observation, interview, and record review, the facility failed to ensure two rooms(room [ROOM NUMBER] and 2) accommodate no more than four residents per room when room [ROOM NUMBER] and 2 had 5 beds in each room. This failure had the potential to place residents housed in room [ROOM NUMBER] and 2 at risk of decreased privacy, increased infection transmission, and limiting the ability of staff to provide safe and individualized care. Findings: During an interview on March 2, 2026, at 8:10 AM, with the Director of Nursing (DON) and the Administrator (Admin), the Admin stated, the facility had two rooms (rooms [ROOM NUMBERS]) that were approved for a waiver to have more than four residents in each room. During an observation on March 2, 2026, at 9:09 AM, in room [ROOM NUMBER], there were currently four residents in the room. The room was free of clutter, with no concerns with the beds, bedside table, and the room was wheelchair accessible. During observation on March 2, 2026, at 9:31 AM, in room [ROOM NUMBER], there were currently four residents in the room. The room was free of clutter, with no concerns with the beds, bedside table, and the room was wheelchair accessible. During a concurrent environmental tour observation and interview on March 3, 2026, at 11:23 AM, with the Maintenance Director (DOM), the residents' room [ROOM NUMBER] and 2 measurements of livable space were noted as follows: -room [ROOM NUMBER] (5 beds) measured: 638.45 Sq Ft [Square feet- unit of measurement] (127.69 Sq. Ft. per residents)-room [ROOM NUMBER] (5 beds) measured: 644.08 Sq Ft. (128.81 Sq. Ft. per residents) The DOM confirmed the measurements and verified that there were currently five beds in room [ROOM NUMBER] and 2. During an interview on March 5, 2026, at 7:39 AM, with Certified Nurse Assistant (CNA 2), CNA 2 stated that room [ROOM NUMBER] and 2 are wheelchair accessible and have sufficient space to provide care to all the residents. CNA 2 stated there are no safety hazards due to the number of beds in the room. During an interview on March 5, 2026, at 2:12 PM, with the Admin and DON, the Admin stated there have been no issues with care in relation to the rooms having more than four residents. The rooms were not crowded and did not impose any safety hazards on the residents. There were no complaints about space or room issues from the residents occupying these rooms. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There were food crumbs, [NAME], and trash under the stove. 2. A tray lined with parchment paper stored condiments (oil, vinegar, soy sauce) had spills. 3. Seven food packages and fruit were found opened and undated inside the kitchen's walk-in refrigerator, freezer, and tray condiments area. 4. One bottle of drink was found inside the walk-in refrigerator which belonged to staff. These failures had the potential to cause foodborne illnesses (any illness resulting from eating contaminated/spoiled foods) to 50 medically compromised residents who receive food served by the kitchen. Findings: 1. During an initial observation tour of the kitchen and interview with Dietary Aide (DA), on November 18, 2024, at 8:05 AM, food crumbs, black grime, and trash were found on the floor under the kitchen stove. The DA stated areas in the kitchen should be kept clean and free of crumbs, trash, and dirt. He further stated the kitchen floor and under the stove area should be swept up and mopped out after breakfast trays were distributed out from the kitchen. An interview and record review with Dietary Services Supervisor (DSS) on November 21, 2024, at 9:38 AM, the DSS reviewed and confirmed the facility's undated policy and procedure (P&P), titled, General Cleaning of Food & Nutrition Services Department, indicated, Floors, floor mats .must be scheduled for routine cleaning and maintained in good condition .1. Floors must be mopped at least once per day .2. Sweep the floor .use a dustpan to remove and dispose of debris as it accumulates .7. Mop the floor .use a scraper to remove stubborn stains. During a phone interview with the Registered Dietitian (RD), on November 21, 2024, at 2:57 PM, RD stated kitchen floors and under kitchen tables should always be kept clean. The RD acknowledged the floor area under the stove should be swept up regularly as recorded on the daily cleaning log-in sheet. A review of the Foof and Drug Administration (FDA) Federal Food Code 2022, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicated The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 2. During an initial observation tour of the kitchen and interview with the DA, on November 18, 2024, at 8:15 AM, a tray lined with parchment paper which stored condiments (oil, vinegar, soy sauce) had spills. The DA stated the condiments area should be kept clean and free of crumbs, stains, and spills for it may produce bacteria. The DA confirmed kitchen staff were not able to do the regular cleaning. A concurrent interview and record review with the DSS on November 21, 2024, at 9:38 AM, the DSS reviewed and confirmed the facility's undated policy and procedure (P&P), titled, Sanitation, indicated, .There shall be adequate equipment for cleaning and disposal of waste and general storage .11. All utensils, counters, shelves, and equipment shall be kept clean. During a phone interview with the RD, on November 21, 2024, at 2:57 PM, the RD acknowledged tray liners should be removed and cleaned underneath and stored areas should always be kept clean. A review of the FDA Federal Food Code 2022, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 3. During an initial observation tour of the kitchen and interview with DA, on November 18, 2024, at 8:25 AM, the DA inspected the kitchen stored condiments area, walk-in refrigerator, and freezer, and found the following food items: I. One gallon of vegetable cooking oil, opened, half empty, found in the walk-in refrigerator undated. II. One gallon of milk, opened, more than half empty found in the walk-in refrigerator undated. III. One gallon of soy sauce, opened, half empty, found in the walk-in refrigerator undated. IV. One gallon of honey mustard, opened, more than half empty, found in the walk-in refrigerator undated. V. One gallon of Worcestershire sauce, opened, half empty, found in the walk-in refrigerator undated. VI. Half of a watermelon was found inside the walk-in refrigerator undated. VII. One pack of hotdog buns opened with no delivery received date found in the freezer. During a concurrent interview and record review with the DSS on November 21, 2024, at 9:38 AM, the DSS reviewed and confirmed the facility's undated policy and procedure (P&P), titled, Labeling and dating of Foods, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for food safety .Food delivered to facility needs to be marked with a delivery or received date .The individual opening or preparing a food shall be responsible for date marking at the time of processing and/or storage . During a phone interview with the RD, on November 21, 2024, at 2:57 PM, the RD stated the opened and undated food packages should be thrown away for they did not know when it was opened. The RD further stated the expectation was the dietary staff should follow infection control precautions for food safety. A review of the FDA Federal Food Code 2022, 3-101.11 titled Safe, Unadulterated, and Honestly Presented .Labeling-General, indicated, .Sources of packaged food must be labeled in accordance with law. Proper labeling of foods allows consumers to make informed decisions about what they eat. Many consumers, as a result of an existing medical condition, may be sensitive to specific foods or food ingredients . 4. During an initial observation tour of the kitchen and interview with DA, on November 18, 2024, at 8:55 AM, an open bottle of tea drink found inside the kitchen walk-in refrigerator. The DA stated it belonged to staff, and it should not be kept in the refrigerator. A concurrent interview and record review with the DSS on November 21, 2024, at 9:38 AM, DSS reviewed and confirmed the facility's undated policy and procedure (P&P), titled, Employee Meals, indicated, Food brought by employees from outside the facility should not be kept in the facility's refrigerator in the kitchen .Food may be kept in a refrigerator supplied for the employees in the employee lounge. During a phone interview with the RD, on November 21, 2024, at 2:58 PM, the RD stated, staff food and beverage should not be kept inside the kitchen walk-in refrigerator. RD acknowledged it was not appropriate to keep staff food inside kitchen refrigerators.

Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. A Certified Nurse Assistant (CNA) 1 did not wear appropriate PPE (Personal Protective Equipment - which includes gowns and gloves) during direct care contact with Resident 297 who was on Enhanced Barrier Precaution (EBP - an infection control intervention that involves wearing gown and gloves during high-contact resident care activities). 2. Visitor (V) 1 did not wear appropriate PPE during direct contact with a Resident who was on EBP. 3. V 2 and V 3 did not wear appropriate PPE while inside a resident room on Contact Precautions (CP - an infection control intervention that involves wearing gown and gloves to be avoid direct contact with the patient and indirect contact with the surfaces and objects in the room). 4. Contract Phlebotomist (CPH) 1 and CPH 2 did not complete hand hygiene and did not wear appropriate PPE when completing a blood draw on a resident on EBP. 5. A Registered Nurse Supervisor (RNS) 1 did not wear the required PPE while flushing the Peripherally Inserted Central Catheter (PICC) line (a thin, soft tube that is inserted into a vein in the arm, leg or neck for long-term IV antibiotics, nutrition, medications, and blood draws) of a resident (Resident 28) on EBP. 6. A Licensed Vocational Nurse (LVN) 1, failed to disinfect (clean something, especially by using a chemical substance that kills all germs and bacteria) the blood pressure (BP) cuff (a device to check blood pressure) before and after resident use during medication pass for Resident 298. These failures had the potential for cross contamination and spread of infection which can adversely affect the health and well being of 54 medically compromised residents, staff, and visitors. Findings: 1. During an initial tour observation, on November 18, 2024, at 8:26 AM, in Resident 297's room, CNA 1 was observed lifting the gown of Resident 297, and noted Resident 297 had a clean and dry dressing on the right lower chest area. Resident 297 was observed with a Left Ventricular Assist Device (LVAD - a device implanted in the chest that helps to pump blood from the lower chambers of the heart to the rest of the body) connected to the machine on the bedside. CNA 1 was not wearing a gloves and gown. During an interview with CNA 1, on November 18, 2024, at 8:39 AM, CNA 1 confirmed Resident 297 was on EBP, and staff should wear gloves and gown during close contact with residents on EBP to protect from cross contamination. CNA 1 acknowledged the use of appropriate PPE was missed during direct contact with Resident 297. During an interview with Licensed Vocational Nurse (LVN) 1, on November 18, 2024, at 8:49 AM, LVN 1 stated the importance of wearing gloves and gown during direct care contact with residents on EBP was to minimize the contact of infection. During an interview with the Infection Preventionist (IP), on November 19, 2024, at 8:46 AM, the IP confirmed Resident 297 was on EBP due to an incision site on the chest area for an LVAD connecting to Resident 297's heart. The IP stated it was very important for staff to wear gloves and gown during direct care contact with any residents on EBP, and to prevent staff and residents from infection. A review of Resident 297's Order Summary Report (a document with list of physician's orders), dated November 21, 2024, showed a physician's order dated on November 18, 2024, for ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: LVAD every shift. A review of facility's policy and procedure (P&P) titled, IPCP (Infection Prevention and Control Plan) Standard and Transmission-Based Precautions, revised March 2024, indicated, Policy. It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions .3. Enhanced Barrier Precautions (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities . 48431 2. During an observation on November 20, 2024, at 2:30 PM, in a resident room on EBP, V 1 touched the resident's gown, foot cradle, beddings, and blanket while not wearing gloves or a gown. During an interview on November 20, 2024, at 2:31 PM, V 1 stated they were aware gloves, and a gown should be worn while in the room but forgot. During an interview on November 20, 2024, at 2:39 PM, TN 1 stated staff and visitors should wear PPE for a resident on EBP to prevent the resident from getting any bacteria or an infection. During an interview on November 21, 2024, at 2:10 PM, the IP stated she recommended visitors to wear gowns, gloves, and other PPE to prevent the introduction of any bacteria or infection from the outside. During an interview on November 21, 2024, at 2:19PM with the Director of Nursing (DON), the DON confirmed family and visitors should wear PPE if they are touching or providing care to the resident on EBP. 3. During a concurrent observation and interview on November 18, 2024, at 9:39 AM, V 2 and V 3 were seen in the resident room without any PPE and resident was on contact precautions. TN 2 was in the room passing medications, and stated the resident was on contact precautions. TN 2 stated visitors must wear PPE while in the room, but the Facility did not reinforce visitors to wear PPE. During an interview on November 20, 2024, at 2:35 PM, the DON stated visitors needed to wear PPE when visiting a resident room on CP. The DON stated TN 2 should have educated the family members to put on PPE and reinforced the CP policy. During a concurrent interview and facility policy and procedure review on November 22, 2024, at 9:35 AM, the IP stated visitors should be wearing PPE when in a resident room is on contact precautions. The IP stated failure to wear PPE would violate the Facility's Infection Control policy. Review of the facility policy and procedures titled, IPCP Standard and Transmission-Based Precautions revised March 2024, indicated, Contact precautions/isolation are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment. b. i. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. ii. [NAME] PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens . The IP confirmed the above findings. 4. During a concurrent interview and observation on November 19, 2024, at 8:34 AM, CPH 1 and CPH 2 entered a resident room who was on EBP, and did not perform hand hygiene (practice of cleaning your hands). CPH 1 and CPH 2 put gloves on and performed the blood draw without putting on any other PPE. CPH 1 and CPH 2 proceeded with hand hygiene when exiting the room. CPH 1 stated the Facility informed him a gown was only worn in an EBP room when collecting a resident's urine sample. During a concurrent observation and interview on November 19, 2024, at 8:45 AM with RNS 1, RNS 1 confirmed the resident's room, which CPH 1 and CPH 2 entered, was on EBP. RNS 1 stated CPH 1 and CPH 2 should have worn appropriate PPE while performing a blood draw on a resident who was on EBP. During an interview on November 19, 2024, at 12:03 PM, with the DON, the DON stated CPH 1 and CPH 2 should have worn a gown and performed hand hygiene prior to entry of the resident's room. The DON stated when a resident is on EBP, the proper PPEs must be worn. During a concurrent interview and facility policy and procedure review on November 20, 2024, at 2:40 PM, the DON verified CPH 1 and CPH 2 violated the Facility's Infection Control Policy. Review of the facility policy and procedure titled, IPCP Standard and Transmission-Based Precautions revised March 2024, indicated, Enhanced Barrier Protection (EBP) used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities . The DON confirmed the above findings. 48985 5. During a concurrent observation and interview with RNS 1, on November 18, 2024, at 11:41 AM, RNS 1 was not wearing gown (a type of PPE clothing that is worn or used to provide protection against hazardous substances and/or environments) while flushing Resident 28's PICC. RNS 1 confirmed Resident 28 was on EBP, and proper PPE such as gown and gloves were required during high contact resident care activities. During an interview with the IP on November 19, 2024, at 8:52 AM, the IP stated all residents on EBP required staff to wear PPE during high contact resident care activities to prevent the spread of infection between the residents, staff, and visitors. A review of facility's policy and procedure titled, IPCP Standard and Transmission Based Precautions revision date March 2024, indicated, 3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities .PPE: The use of gown and gloves for high-contact resident care activities is indicated .for nursing home residents with .indwelling medical device include, but are not limited to central lines, peripherally inserted central catheter (PICC) lines . 6. During a concurrent medication administration observation and interview with LVN 1, on November 20, 2024, at 8:20 AM, LVN 1 checked Resident 298's blood pressure without disinfecting the BP cuff (a device to check blood pressure) before and after use. LVN 1 acknowledged the BP cuff should be disinfected before and after resident use. During an interview with the DON on November 20, 2024, at 9:47 AM, the DON stated the BP cuff should be disinfected between resident use to prevent spread of infection. A review of facility's policy and procedure titled, Infection Control Cleaning, Disinfection, and Sterilization undated, indicated, It is the policy of this facility to provide supplies and equipment that are adequately cleaned, disinfected, or sterilized .supplies and equipment will be cleaned before and after use .

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly and securely when: 1. The Intravenous cart (IV cart - mobile cart that carries and stores medications, supplies, and equipment for administering medications through a vein) was left unlocked with key hanging from the cart lock. 2. The IV and medication carts were left unlocked and not under direct observation by authorized staff. 3. Three expired topical (applied to skin) medications were found inside the treatment cart. These had the potential to allow unauthorized access to medications and supplies which could cause undetected misuse, diversion (distribution, abuse, or use of drugs for purposes not intended by the prescriber), and unsafe use of medications intended for 54 residents. Findings: 1. During an initial tour observation on November 18, 2024, at 11:54 AM, in the facility hallway in front of rooms [ROOM NUMBERS], the IV cart was observed unlocked and unattended. The cart lock was not pushed in, and the key was hanging from the lock. During a concurrent observation and interview with the Treatment Nurse (TN) 1, on November 18, 2024, at 11:55 AM, TN 1 acknowledged these findings and stated the cart should be kept locked when unattended. During an interview with the Registered Nurse Supervisor (RNS) 1, on November 18, 2024, at 12:33 PM, RNS 1 stated it was not acceptable to leave the IV cart unlocked and key unattended. RNS 1 also stated the expectations were for the RNS to always keep key with them and the IV cart locked when not in use. RNS 1 stated these were important to ensure only authorized individuals have access to the contents of the IV cart. During an interview with the Director of Nursing (DON), on November 18, 2024, at 12:53 PM, the DON stated her expectations were for the IV cart to be locked when out of staff's sight and key be kept by the RNS on duty. The DON also stated these were important to ensure safety by preventing unauthorized individuals having access to the IV cart. A review of the facility's Registered Nurse's Job Description, dated 12/17/21, indicated, Our expectation is that you will perform your job in a manner consistent with our Core Values .ACCOUNTABILITY .OWNERSHIP .ESSENTIAL DUTIES AND RESPONSIBILITIES .Implement and maintain established policies, procedures, objectives, quality assurance, safety . A review of the facility's policy and procedure (P&P) titled, IV. MEDICATION STORAGE IN THE FACILITY undated, indicated, STORAGE OF MEDICATIONS Policy: Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure: .Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, medication carts, and medication supplies are locked or attended by persons with authorized access. 41707 2. During medication pass observation with RNS 1, on November 20, 2024, at 9:20 AM, RNS 1 went inside Resident 347's room to administer the IV medication to Resident 347. RNS 1 did not lock the IV cart located in front of Resident 347's room. There were staff and residents observed passing by the unlocked IV cart. During an interview with RNS 1, on November 20, 2024, at 9:28 AM, RNS 1 stated the importance of locking the IV cart at all times was to prevent unauthorized access of medications from residents, staff, and visitors. During an interview with the DON, on November 20, 2024, at 9:47 AM, the DON confirmed medication carts should always be locked when out of sight for safety purposes. During a medication pass observation with Licensed Vocational Nurse (LVN) 1, on November 20, 2024, at 11:22 AM, LVN 1 went inside Resident 7's room to administer insulin injection (a hormone that removes excess sugar from the blood given artificially via medication) to Resident 7. LVN 1 did not lock the medication cart located in front of Resident 7's room. There were staff and residents observed passing by the unlocked medication cart. During an interview with LVN 1, on November 20, 2024, at 11:35 AM, LVN 1 stated the importance of locking the medication cart when out of sight was to prevent residents from accessing the medications. A review of facility's undated policy and procedure titled, Policy and Procedures for Med (medication) Pass, indicated IV. MEDICATION STORAGE IN THE FACILITY STORAGE OF MEDICATIONS .Procedure: .Medication rooms, medication carts, and medication supplies are locked or attended by persons with authorized access. 3. During medication storage observation in the facility Treatment Cart, with TN 1, on November 20, 2024, at 2:50 PM, the following outdated topical medications were noted: a. Aspercreme Lidocaine Pain Relief Spray (a topical spray works to temporarily reduce minor pain) - expired date June 2024. b. Antiseptic Skin Cleanser (helps to prevent skin infections) - expired date September 2024. c. Hydrogen Peroxide (used on skin to prevent infection of minor cuts, scrapes, and burns) with opened date of April 1, 2023. During an interview with TN 1, on November 20, 2024, at 2:53 PM, TN 1 stated any expired skin medications should be discarded and not given to residents to prevent cross contamination. TN 1 also stated skin medication that was opened for over a year should also be discarded. During an interview with the DON, on November 21, 2024, at 9:39 AM, the DON stated expired medications should be disposed and should not be in the treatment cart to prevent from giving to residents. A review of facility's undated policy and procedure titled, Policy and Procedures for Med (medication) Pass, indicated IV. MEDICATION STORAGE IN THE FACILITY STORAGE OF MEDICATIONS . Procedure: .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.

Based on interview and record review, the facility failed to ensure timely completion of the Comprehensive Admission Minimum Data Set (MDS - a federally mandated resident assessment tool) assessments for one of 17 sampled residents (Resident 350). This deficient practice had the potential to delay the care planning process to meet Resident 350's comprehensive and individualized care needs. Findings: During an initial screening observation on November 18, 2024, at 11:42 AM, inside resident's room, Resident 350 was lying on her bed, awake, and covered with blanket. Resident 350 was observed with scattered purplish brown discolorations on both forearms. A review of Resident 350's Admission Record (document which contains demographic and medical information) indicated she was admitted to the facility on [DATE]. During a concurrent interview and record review with the MDS Nurse (MDSN) on November 20, 2024, at 9:48 AM, the MDSN reviewed Resident 350's Comprehensive Admission MDS Assessment with an Assessment Reference Date (ARD) of November 8, 2024, and stated it was not completed yet. MDSN also stated the Comprehensive Admission MDS Assessment should have been completed within 14 days of admission and was now six days overdue. MDSN stated in this situation, the facility did not follow its policy and procedure on Resident Assessment and the RAI (Resident Assessment Instrument- comprehensive assessment and care planning process used by nursing home) guidelines. MDSN also stated it was important the Comprehensive Admission Assessment be completed in a timely manner to identify care areas that need to be addressed in the care plan. During a concurrent interview and record review with the Director of Nursing (DON), on November 20, 2024, at 10:06 AM, the DON reviewed Resident 350's Comprehensive Admission MDS Assessment and acknowledged that it was not completed timely. The DON stated she missed signing the assessment on November 14, 2024. The DON stated the facility's policy and procedure, and RAI guidelines were not followed. A review of Resident 350's Comprehensive Admission MDS Assessment, with an ARD of November 8, 2024, indicated Section Z0500B. Date RN Assessment Coordinator signed assessment as complete 11-20-2024 (6 days overdue). A review of the facility's policy and procedure titled, Resident Assessment and Associated Processes, dated 1, 2022, indicated, POLICY: It is the policy of this facility that resident's will be assessed, and the findings documented in their clinical health record. Procedure . 3. Comprehensive Assessment will be conducted within 14 days of admission .8. A Registered Nurse will electronically sign and certify that the assessment is completed . The Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, indicated, Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred .01. Admission Assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed on the end of day 14, counting the date of admission to the nursing home as day 1 .The MDS completion date (item Z0500B) must be no later than day 14 .

Based on observation, interview, and record review, the facility failed to adequately monitor two of 17 sampled residents (Residents 350 and 297) for adverse consequences of anticoagulant (used to prevent or treat blood clots) medication therapy. This failure had the potential to result in unidentified care concerns, inconsistent care coordination, and delay of treatment which could adversely affect the health and safety of these residents. Findings: 1. During an initial tour observation on November 18, 2024, at 11:42 AM, inside resident's room, Resident 350 was lying on her bed, awake, and covered with a blanket. Resident 350 was observed with scattered purplish brown discolorations on both forearms. Resident 350 was unable to explain how she got those skin discolorations. A review of Resident 350's Admission Record (document which contains demographic and medical information) indicated Resident 350 was admitted to the facility on [DATE] with diagnoses of unspecified atrial fibrillation (irregular and rapid heart rate) and thrombocytopenia (condition where there is a low platelet [blood cell that helps blood to clot] count causing bleeding). A review of Resident 350's Order Summary Report (a document with a list of physician's orders), indicated, Resident 350 was taking the following anticoagulant medication: Apixaban Oral Tablet 2.5 mg [milligram- unit of measure for weight]. Give 1 tablet by mouth two times a day related to UNSPECIFIED ATRIAL FIBRILLATION. A review of Resident 350's Care Plan (individualized outline of specific care, interventions, and goals for a patient), indicated, Focus: Anticoagulant therapy (APIXABAN) r/t [related to] atrial fibrillation dated November 18, 2024 .Goal: Will be free from discomfort or adverse reactions related to anticoagulant use .Interventions/Tasks: .Monitor/document/report to MD [Medical Doctor] PRN [as needed] s/sx [signs and symptoms] of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, .bruising, bleeding . During an interview with the Treatment Nurse (TN) 2, on November 20, 2024, at 11:20 AM, the TN 2 stated residents on anticoagulant therapy were monitored for signs and symptoms of bleeding. TN 2 also stated the monitoring was documented in the MAR (Medication Administration Record- summary report of medicines/interventions received by an individual). During a concurrent interview and record review with the Registered Nurse Supervisor (RNS) 1 on November 20, 2024, at 11:38 AM, RNS 1 reviewed Resident 350's Order Summary Report and MAR for the month of November 2024. RNS 1 stated there was no order to monitor for anticoagulant side effects and there was no documented evidence in the MAR that the monitoring was done by staff. RNS 1 also stated Resident 350 required anticoagulant therapy monitoring the day the apixaban order was placed, and monitoring the resident for any complications related to the use of medication was important. During an interview with the Director of Nursing (DON), on November 20, 2024, at 11:44 AM, the DON stated Resident 350 should have an order to monitor for anticoagulant therapy side effects. The DON also stated staff should have obtained the order to monitor for the use of the anticoagulant medication from the doctor on the day Resident 350 started using the medication, and should continue during the duration of medication use. The DON further stated her expectation was for staff to monitor the resident for anticoagulant complications every shift and document it in the MAR. A review of the facility's Licensed Nurse's Job Description, dated December 17, 2021, indicated ESSENTIAL DUTIES AND RESPONSIBILITIES .Examine the resident and his/her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical, emotional, or mental problems .Implement and maintain established policies, procedures, objectives, safety .Chart nurses' notes in professional and appropriate manner that is timely, accurately, and thoroughly reflects the care provided to the resident, as well as the resident's response to the care . 41707 2. During an initial tour observation, in Resident 297's room, on November 18, 2024, at 8:26 AM, Resident 297 was observed lying in bed and noted multiple purplish skin discoloration on Resident 297's bilateral arms and right hand. During an interview with Resident 297, on November 18, 2024, at 8:49 AM, Resident 297 stated that a medication named Coumadin (a brand name of anticoagulant medication) made Resident 297's skin bruised easily. A review of Resident 297's Admission Record indicated Resident 297 was admitted to the facility on [DATE]. A review of Resident 297's Order Summary Report, showed a physician's order dated November 17, 2024, for Warfarin Sodium [a generic name of anticoagulant medication] Oral Tablet 1 MG Give 0.5 tablet by mouth one time a day for A-FIB [Atrial Fibrillation]. No monitoring of complications was ordered and implemented to reflect Resident 297's anticoagulant therapy. A review of Resident 297's Care Plan, indicated, Focus Anticoagulant Therapy (WARFARIN) r/t: Atrial Fibrillation At risk for side effects from medication dated November 18, 2024 .Interventions/Tasks Monitor and report s&sx of thromboembolism [blood clot that blocks the flow of blood through the veins] .Monitor/document/report to MD PRN s/sx of anticoagulant complications . During an interview and concurrent record review with RNS 2, on November 21, 2024, at 9:26 AM, RNS 2 verified Resident 297 was on an anticoagulant therapy. RNS 2 also verified Resident 297's care plan reflected monitoring and documenting anticoagulant complications should be implemented. RNS 2 stated that Resident 297 was high risk for bleeding, and the nurses should monitor signs and symptoms of bleeding every shift. During an interview with the DON, on November 21, 2024, at 9:39 AM, the DON acknowledged there was no monitoring of complications on anticoagulant therapy for Resident 297. The DON stated the importance of monitoring was to check for adverse reactions and complications. A review of the facility's undated policy and procedure titled, Section: Quality of Care; Subject: Anticoagulation Therapy indicated, POLICY: It is the policy of this facility to ensure that anticoagulation therapy is provided to residents who require such services, consistent with the professional standards of practice .Signs and Symptoms of Bleeding: Licensed nursing staff will monitor all residents on anticoagulant recognizing signs and symptoms of bleeding, including, but is not limited to, bruising, gum bleeding, dark stools, and hematuria and document in the medical record.

Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (g-tube - a tube inserted through the wall of the abdomen directly into the stomach that can be used to give food and medication to a person) was flushed before and after medication administration as ordered by the physician for one of one observed resident (Resident 12) with g-tube during medication administration observation. This deficient practice posed a risk of not maintaining patency (open or unobstructed) of Resident 12's g-tube which could lead to ungiven medications, hydration, and nutritional feedings to meet Resident 12's needs. Findings: During medication pass observation and concurrent interview with Licensed Vocational Nurse (LVN) 2, on November 20, 2024, at 11:02 AM, in Resident 12's room, LVN 2 did not flush the g-tube with water before administering the medications to Resident 12. LVN 2 proceeded to administer the medications and flushed the g-tube with 15 milliliter (ml - unit of measurement) of water after administering all medications to Resident 12. LVN 2 stated Resident 12 did not have an order to flush the g-tube with water before medication administration. During an interview and concurrent record review with LVN 2, on November 20, 2024, at 11:09 AM, the Electronic Medication Administration Record (E-MAR - an electronic system to record medication administration documentation) indicated Resident 12 had an order to flush the g-tube with 30 ml of water before and after medication administration. LVN 2 verified the order and acknowledged flushing of the g-tube was missed before medication administration, and an inaccurate amount of water was flushed after medication administration. LVN 2 stated it was important to flush the g-tube per physician's order with an accurate amount of water to prevent clogging the g-tube and to provide hydration. During an interview with the Director of Nursing (DON), on November 20, 2024, at 11:12 AM, the DON confirmed the importance of flushing the g-tube before and after medication administration was to maintain the g-tube's patency. A review of Resident 12's Admission Record (document which contains demographic and medical information), indicated Resident 12 was admitted to the facility on [DATE]. A review of Resident 12's Order Summary Report (a document with list of physician's orders), dated November 20, 2024, showed a physician's order dated on October 22, 2024, for Enteral Feed [a way of delivering nutrition directly to the stomach] Order every shift FLUSH TUBE WITH 30-50cc [cubic centimeter - unit of volume equivalent to milliliter] PRE [before] AND POST [after] MEDICATION ADMINISTRATION VIA TUBE. A review of the facility's policy and procedure titled, ENTERAL TUBE MEDICATION ADMINISTRATION PROCEDURES, undated, indicated, Policy: Oral medication (s) are administered through an enteral tube in a safe and accurate manner .Procedure .Flush the tube with 30 mL of water prior to medication administration .Flush the tube with 30 mL of water or as directed .

Based on observation, interview and record review, the facility failed to develop a baseline care plan that addressed Left Ventricular Assist Device (LVAD - a device implanted in the chest that helps to pump blood from the lower chambers of the heart to the rest of the body) for one of 17 sampled residents (Resident 297). This deficient practice had the potential for not receiving necessary care and treatment related to resident's medical, physical, mental, and psychosocial needs. Findings: During an initial tour observation, in Resident 297's room, on November 18, 2024, at 8:26 AM, Resident 297 was lying in bed, awake, and verbally responsive. Resident 297 was noted with an LVAD connected to the machine on the bedside. During an interview with Resident 297, on November 18, 2024, at 8:49 AM, Resident 297 stated that LVAD was a battery-operated machine with a tubing connected to resident's heart to help pump the blood to the rest of the body. Resident 297 also stated that it was very important to check the battery and setting of the machine in able for the machine to work properly A review of Resident 297's Admission Record (contains a summary of basic information about the resident), indicated Resident 297 was admitted to the facility on [DATE]. A review of Resident's 297 Skilled Nursing Facility H&P [History and Physical] dated November 18, 2024, indicated a past medical history of LVAD. A review of Resident 297's Care Plan (individualized outline of specific care, interventions, and goals for a patient), on November 20, 2024, at 2:48 PM, noted no care plan was developed to reflect Resident 297's LVAD related to its cardiovascular (heart and the blood vessels) functions and risks. During an interview and concurrent record review with Registered Nurse Supervisor (RNS) 2, on November 21, 2024, at 9:07 AM, RNS 2 verified there was no baseline care plan developed for Resident 297's LVAD. RNS 2 stated Resident 297 should have a baseline care plan addressing the LVAD to monitor the risks of malfunction and to determine what interventions to implement if any problem would arise related to Resident 297's cardiovascular condition. During an interview with the Director of Nursing (DON), on November 21, 2024, at 9:39 AM, the DON confirmed and verified Resident 297's LVAD should have a baseline care plan as it was a very important device connected to Resident 297's cardiovascular system to monitor if the device was working properly. A review of the facility's policy and procedure titled, Care Planning undated, indicated, POLICY: It is the policy of the this facility that the interdisciplinary team (IDT) shall develop and implement a comprehensive person-centered care plan or each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. PROCEDURES: 1. A baseline care plan shall be developed within 48 hours of admission .

Based on observation, interview, and record review, the facility failed to ensure the Comprehensive Admission Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment was accurately completed per Resident Assessment Instrument (RAI- comprehensive assessment and care planning process used by nursing home) guidelines for one of 17 sampled residents (Resident 351) when: 1. Resident 351's hearing abilities and limitations was not accurately coded. 2. Resident 351's antiplatelet medication (medication to prevent blood clot) was not coded. These deficient practices had the potential for Resident 351 not to receive the necessary care, treatment, and/or services to attain his highest practicable level of functioning. Findings: 1. During a concurrent observation and interview with Resident 351, on November 20, 2024, at 2:54 PM, inside the resident's room, Resident 351 was leaning forward toward the Surveyor and stated he had hearing difficulties for three years now and used hearing aids. Resident 351 also stated both ears were affected, but more pronounced in his left ear. During an interview with Resident 351's Family Member (FM), on November 20, 2024, at 3:00 PM, inside resident's room, the FM stated Resident 351 had hearing difficulties for a while now. FM stated someone had to move closer or speak louder for Resident 351 to hear better. FM also stated the resident had a scheduled audiology (hearing) appointment on November 22, 2024. A review of Resident 351's Admission Record (document which contains demographic and medical information) indicated Resident 351 was admitted to the facility on [DATE]. A review of Resident 351's History and Physical dated September 12, 2024, indicated Resident 351 had the capacity to understand and make decisions. A review of Resident 351's Activity-Admission Evaluation dated September 10, 2024, indicated, Hearing G. Communication & [and] Cognition .2. Moderate Difficulty (speaker has to increase volume and speak distinctly) .G.1 Hearing Aid or other appliance used .1. Yes . A review of Resident 351's LN [Licensed Nurse]- Initial Admission Record dated September 9, 2024, indicated .3. EENT [Eyes, Ears, Nose and Throat] .D. Ability to hear .1. Minimal Difficulty [Difficulty in some environments, when person speaks softly, or setting is noisy] . A review of Resident 351's Order Summary Report (a document with a list of physician's orders), dated September 9, 2024, indicated, Audiology eval (evaluation) and treat PRN [as needed] . A Physician's Order dated November 21, 2024, indicated HEARING AIDE CHECK AT 1:00 PM . During a review of Resident 351's Comprehensive Admission MDS Assessment with an ARD (Assessment Reference Date) of September 16, 2024, indicated, Section B. Hearing Speech, and Vision .B0200. Hearing Ability was coded 0 [Adequate] - no difficulty in normal conversation, social interaction, listening to TV . During an interview with the MDS Nurse (MDSN), on November 21, 2024, at 10:07 AM, the MDSN stated that the coding decision to determine resident's hearing abilities was based on interview with the resident, family, and interdisciplinary assessments. MDSN also stated Section B of the MDS was based on RAI guidelines. During a concurrent interview and record review with the MDSN on November 21, 2024, at 10:17 AM, MDSN reviewed Resident 351's Comprehensive Admission MDS Assessment Section B0200 and stated it was incorrectly coded. MDSN also reviewed CMS' RAI Version 3.0 Manual and stated the guidelines for coding resident's hearing status were not followed. The Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, indicated B0200: Hearing .Steps for Assessment .2. Interview the resident and ask about hearing function in different situations .3. Observe the resident during your verbal interactions and when they interact with others throughout the day .5. Review the medical record. 6. Consult the resident's family, caregivers, direct care staff, activities personnel, and speech, or hearing specialists . 2. During an initial tour observation on November 18, 2024, at 12:07 PM, inside dining area, Resident 351 was observed sitting on his wheelchair while waiting for lunch meal to be served. Resident 351 had scattered reddish-purple discolorations on both forearms. A review of Resident 351's Admission Record indicated Resident 351 was admitted to the facility on [DATE]. A review of Resident 351's Order Summary Report dated September 9, 2024, indicated, Resident 351 was taking the following antiplatelet medication: Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for CVA [Cerebrovascular Accident- a disease that occurs when blood flow to the brain is suddenly cut off] prophylaxis [prevention] . During a review of Resident 351's comprehensive admission MDS assessment with an ARD (Assessment Reference Date) of September 16, 2024, indicated, Section N0415I box was left blank (indicating the resident did not receive any antiplatelet medication during the 7-day look-back period [observation period]). A review of Resident 351's Medication Administration Record (MAR- summary report of medicines/interventions received by an individual)) for September 1-30, 2024, revealed Resident 351 received Aspirin daily during the Comprehensive Admission MDS assessment's look-back period (September 10-16, 2024). During an interview with the MDSN, on November 21, 2024, at 10:22 AM, the MDSN stated the resident's MAR was used in coding Section N0415. MDSN also stated Section N0415 items were marked x in column 1 if the resident received these medications during the 7-day look-back period. During a subsequent interview and record review with the MDSN on November 21, 2024, at 10:24 AM, MDSN reviewed Resident 351's Comprehensive Admission MDS assessment Section N0415 and stated the Comprehensive Admission MDS assessment was not coded correctly because item N0415I was left blank. MDSN also reviewed CMS's RAI Version 3.0 Manual and stated she did not follow the guidelines for coding resident's medication use. During an interview with the Director of Nursing (DON), on November 21, 2024, at 10:39 AM, the DON stated that her expectation was for the staff to accurately complete the MDS assessment and follow the RAI guidelines in coding. The DON also stated these were important in the development of resident's plan of care. A review of the facility's Minimum Data Set's (MDS Coordinator) Job Description, dated December 17, 2021, indicated POSITION SUMMARY: To conduct and coordinate the development and completion of the Resident Assessment Instrument (RAI), that is, the Minimum Dat Set (MDS), and Care Plan with State and Federal requirements .ESSENTIAL DUTIES AND RESPONSIBILITIES .Monitors overall the documentation in the medical record to validate that it supports MDS coding . The Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, indicated N0415: High-Risk Drug Classes: Use and Indication .N0415I. Antiplatelet: Check if an antiplatelet medication (e.g., [example] aspirin .) was taken by the resident at any time during the 7-day observation period . A review of the facility's policy and procedure (P&P) titled, Resident Assessment and Associated Processes, dated January 2022, indicated, POLICY: It is the policy of this facility that resident's will be assessed, and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident .Procedure: A Comprehensive Assessment will be made of the resident's needs, strength, goals, life history and preferences, using the RAI (Resident Assessment Instrument) .

Based on observation, interview, and record review, the facility failed to ensure two rooms (rooms [ROOM NUMBERS]) accommodate no more than four residents per room when rooms [ROOM NUMBERS] had 5 beds in each room. This failure had the potential for the residents housed in rooms [ROOM NUMBERS] to not have the ability to move about freely if the five beds limited their personal space. Findings: During a concurrent interview and record review with the Administrator (ADM), on November 18, 2024, at 8:47 AM, the ADM reviewed the Entrance Conference Checklist, and stated the facility had room waivers for rooms [ROOM NUMBERS], with five beds each. During an environmental tour with the Maintenance Supervisor (MS), on November 21, 2024, at 2:09 PM, resident room [ROOM NUMBER] had five beds each. The residents' room measurements of livable space were noted as follows: i. room [ROOM NUMBER] (5 beds) measured: 643.97 sq. ft. [square feet] (128.80 sq. ft. per resident) During an environmental tour with the MS, on November 21, 2024, at 2:14 PM, resident room [ROOM NUMBER] had five beds each. The residents' room measurements of livable space were noted as follows: i. room [ROOM NUMBER] (5 beds) measured: 636.39 sq. ft. [square feet] (127.28 sq. ft. per resident) During a follow up interview with the ADM, on November 21, 2024, at 2:23 PM, the ADM confirmed the measurements for two of the 23 residents' rooms and two of these did not meet the accommodation requirement per each room. Acknowledged that any room with more than four beds needs a waiver. The rooms were not crowded and did not impose any safety hazards to the residents. There were no complaints of space or room issues from the residents occupying these rooms. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents for one of three sampled residents (Resident1). When Resident 1 fell out of bed. This failure contributed to Resident 1 sustaining multiple discoloration to left eye, left forearm and left knee. Findings: During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: cardiac arrest (unexpected loss of heart function), pneumonia (infection in lungs), type 2 diabetes (body has trouble controlling blood sugar), hypertension (high blood pressure). During a concurrent interview and record review of Resident 1 ' s Medical Record with the Director of Nursing (DON) reviewed and verified the following: 1. Acute hospital transfer documents dated August 15, 2024: Poor safety awareness .Rehab Potential and Diagnosis: Tremors, falls/alarms, life vest, treatment diagnosis for Physical Therapy: decrease independence with functional mobility. 2. Fall Risk assessment dated [DATE]=3 (low risk) 3. Change Of Condition (COC) Fall dated September 06, 2024. 4. COC for Bruises September 06, 2024. Re-eval Fall Risk Assessment September 06, 2024=13 (high risk). 5. Careplan- At risk for falls related to impaired mobility muscle weakness, impaired safety awareness, impulsiveness initiated September 04, 2024 .Will be free of serious injury do to fall through the review date .September 06, 2024 Resident was found sitting on the floor at foot of bed .bed alarm while in bed initiated September 10, 2024, floor mats initiated September 08, 2024, room assignment close to nurse station initiated September 06, 2024 .Skull, left knee and left forearm Xray on September 08, 2024. During an interview on September 24, 2024, with Resident 2 (R2) R2 states, Resident 1 had bruising all along the side of leg and arm, all along the left side, I heard he fell in another room. There were no mats on the floor when he was moved to this room, the sister was the one that told them to place the mats on the floor after he fell .he was in and out of clarity. I would use call light at night, and they would take a long time, he wound take off his oxygen .he needed more hands on and supervision because of his clarity. When I see that he needed a nurse, I would call them, and push the call light. The bruising was bad, I was not in the other room when he fell , but in this room, he was really bruised up, and like I said the sister was the one telling them to place the floor mats. During concurrent interview and record review on September 24, 2024, with the Director of Nursing (DON) of medical records, skin assessments, DON states, Resident 1 fell [DATE].2024, I think they found this resident at foot of bed family and doctor notified. Doctor came September 06, 2024, at 4PM for to H&P at this point he had bruising to eyelid, he wrote for Xray, but I don ' t know what happened. The bruising to eyelid was small. We moved him closer to nurse station, the floor mats were started September 08, 2024, our immediate intervention was to move closer to nursing station. He was sent out due to low oxygen and chest pain. During a review of the facility ' s policy and procedure titled, Fall Management System revised [no date], the policy and procedure indicated, This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assisted devices and functional programs as appropriate to prevent accidents.

Based on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. The stainless-steel wall backsplash, behind the stove and the steam table, had food splash and white-water splash. 2. There were food crumbs and trash under the stove. The food preparation area drawer was lined with paper and had crumbs underneath. The front drawer had black grime. A tray lined with foil stored condiments (oil, vinegar, soy sauce) had crumbs and spills. A metal pan with clean serving spoons, lined with parchment paper, had crumbs underneath. There were trash and food crumbs under the handwashing sink and condiment shelf. 3. The stainless-steel shelves, storing clean pots and pans, were lined with grip liner and had crumbs underneath. The shelf above the drink dispenser had black grime and dust. 4. The microwave had yellow buildup on the sides. The can opener blade have residue and the base had food spills. 5. In the walk in refrigerator, there were spilled red and white liquid on the floor, under the shelf. In the dry storage, the floor in 3 of the 4 corners had food crumbs, trash, dry noodles, chocolate chips, cobwebs, and dead bugs. 6. The resident food fridge, was overpacked. The temperature was not maintained at 41 degrees Fahrenheit (unit of measurement) from April 1, 2023 to April 4, 2023. Most of the food items were not labeled and dated. 7. Three half egg sandwiches were left over night at Resident 26's bed side table. These failures had the potential to expose 52 highly susceptible residents who received food from the kitchen to foodborne illness (illness caused by ingestion of contaminated food or beverages) due to cross- contamination (the transfer of harmful substances or disease- causing microorganisms to food). Findings: 1. During a concurrent observation and interview, with the Dietetics Service Supervisor (DSS) on April 4, 2023, at 8:30 AM, in the kitchen, the stainless-steel wall backsplash, behind the stove and the steam table, had food splash and white-water splash. The DSS stated areas should be kept clean and free of stains after each meal preparation. During an interview, with the Registered Dietitian (RD), on April 6, 2023, at 12:41 PM, the RD stated the stainless-steel wall behind the stove and the steam table should be kept clean and she expects the staff to wipe it down after each meal. During a record review of facility's policy titled Sanitation, dated 2018, it indicated The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stove, which will be cleaned by the maintenance staff. A review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. 2. During a concurrent observation and interview, with the DSS on April 4, 2023, at 8:40 AM, there were food crumbs and trash under the stove. The food preparation area drawer was lined with paper and had crumbs underneath. The front drawer had black grime. A tray lined with foil stored condiments (oil, vinegar, soy sauce) had crumbs and spills. A metal pan with clean serving spoons, lined with parchment paper, had crumbs underneath. There were trash and food crumbs under the handwashing sink and condiment shelf. The DSS stated areas should be kept clean and free of crumbs, grime, dirt, stain and spills. He stated they were not able to do the regular cleaning. During an interview with the RD, on April 6, 2023, at 12:41 PM, the RD stated under the stove, cook preparation area drawer, metal pans with serving spoons, and the floor under the handwashing sink and condiment shelf should be kept clean. The RD further stated utensils should be removed out of the drawer, and bins and liners should be removed and cleaned underneath. She also stated under the stove should be swept up regularly. A review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicated The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 3. During a concurrent observation and interview, with the DSS, on April 4, 2023, at 8:40 AM, in the kitchen, the stainless-steel shelves, storing clean pots and pans, were lined with grip liner and had crumbs underneath. The shelf above the drink dispenser had black grime and dust. The DSS stated the area should be kept clean and free of stains after each meal preparation. During an interview with the RD, on April 6, 2023, at 12:41 PM, the RD stated, her expectation was for the stainless-steel shelves storing clean pots and pans, and the shelf above the drink dispenser to be cleaned and maintained weekly and as needed. A review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 4. During a concurrent observation and interview, with the DSS, on April 4, 2023, at 8:45 AM, in the kitchen, the microwave had yellow buildup on the sides. The can opener blade have residue and the base had food spills. The DSS stated they will get a new microwave to replace a new one and the can opener should be kept clean after use. During an interview with the RD, on April 6, 2023, at 12:41 PM, the RD stated, the microwave and the can opener should be kept clean after each use. During a record review of facility's P&P titled Sanitation, dated 2018, it indicated The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stove, which will be cleaned by the maintenance staff. A review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-601.11, indicates The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 5. During a concurrent observation and interview, with the DSS, on April 4, 2023, at 8:50 AM, in the kitchen, inside the walk in refrigerator, there were spilled red and white liquid on the floor, under the shelf. In the dry storage, the floor in 3 of the 4 corners had food crumbs, trash, dry noodles, chocolate chips, cobwebs, and dead bugs. The DSS stated that the floor and corner areas should be kept clean and free of spills, food crumbs and trash. During an interview with the RD, on April 6, 2023, at 12:41 PM, the RD stated, the floor under shelf of walk-in refrigerator and dry storage floors and back corners should be kept clean and should be swept up and mopped out regularly. A review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 6. During a concurrent observation and interview, with the DSS, on April 4, 2023, at 8:55 AM, in the kitchen, the resident food fridge, was overpacked. Most of the food items were not labeled and dated. The DSS reviewed the resident food fridge temperature log, which indicated the temperature was not maintained at 41 degrees Fahrenheit from April 1, 2023 to April 4, 2023. The DSS acknowledged the resident food fridge was not monitored and checked. He stated it was the nursing department who maintains the fridge. He further stated when the temperature was not at 41 degrees Fahrenheit or below, it should be reported immediately to Maintenance and the food should be discarded. During a review of the facility document titled Refrigerator Temperature, dated 2023, it indicated the temperature of the resident food refrigerator was above 41 degrees Fahrenheit on the following dates: i. April 1 was 52 degrees Fahrenheit ii. April 2 was 44 degrees Fahrenheit iii. April 3 was 50 degrees Fahrenheit iv. April 4 was 48 degrees Fahrenheit During an interview with the RD, on April 6, 2023, at 12:41 PM, the RD stated, the resident refrigerator in the staff lounge should be checked everyday, and the foods should be labeled and dated. He further stated the foods that are outdated should be thrown away. The RD stated if the refrigerator was not within temperature below 41 Fahrenheit, staff should notify DSS and Maintenance immediately. During a review of the facility's undated policy and procedure titled Policy for food brought from outside, it indicated 7. Perishable foods must be stored in re-sealable containers in the refrigerator. Container will be labeled with the resident's name, receiving date and use by date (3 days). 8. The nursing staff will be responsible for discarding perishable foods on or before the use by date. 15. The refrigerator will be cleaned by the housekeeping staff weekly and the microwave on a daily basis. 17. The nursing staff is responsible to monitor and record the refrigerator temperature twice a day. Refrigerator temperature standards are less than or equal to 41 degrees Fahrenheit. During a review of the FDA Federal Food Code, dated 2022, 3-501.16, it indicated Time/Temperature control for safety food shall be maintained: (2) At 5 C (41 F) or less. And Maintaining TCS (time/temperature control for safety foods) foods under the cold temperature control requirements prescribed in this code will limit the growth of pathogens that may be present in or on the food and may help prevent foodborne illness. 44841 7. During a concurrent observation and interview, with a License Vocational Nurse (LVN 3), on April 4, 2023, at 10:15 AM, in Resident 26's room, there were three half egg sandwiches on Resident 26's bedside table. LVN 3 inspected the sandwiches and stated the three half egg sandwiches had a label with a date April 3, 2023. she further stated it was from the day before. LVN 3 stated it should have been not left overnight. During an interview, on April 6, 2023, at 2:00PM, with the Director of Staff Development (DSD), the DSD stated the practice was for staff to come back and check if the resident consumed the food and discard them accordingly. The DSD further stated it should have not been left at the bedside overnight. A review of facility's undated policy and procedure titled Infection Prevention-Foodborne Illness, indicated, Intent: . It is the policy of the facility to procure, store, prepare, distribute, and serve food under sanitary conditions following proper sanitation and food handling practices to prevent the outbreak of foodborne illness in accordance with State and Federal Regulations . Procedures: . 11. Food left out at room temperature for more than two (2) hours will be discarded .

Based on interview and record review, the facility failed to ensure nursing staff provided adequate monitoring for one of three residents (Resident 451) reviewed for dialysis (process of removing excess water and toxins from the blood by using a machine and an artificial kidney), when Resident 451 was not monitored by the nursing staff after missing two dialysis treatments. This failure had the potential to compromise Resident 451 health due to missed dialysis treatments and increased the risk for complications such as fluid overload (too much fluid in the body). Findings: During a concurrent observation and interview, on April 4, 2023, at 10:30 AM, with Resident 451, Resident 451 was lying in bed, playing games in an electronic device. Resident 451 stated he missed a dialysis treatment last month, March 2023. During a review of Resident 451's Admission Record (clinical record with demographic information), it indicated, Resident 451 was initially admitted to the facility on [DATE], with diagnoses of type two diabetes mellitus (high blood sugar levels), end stage renal disease (when kidneys cease functioning) and dependence of renal dialysis. During a review of Resident 451's physician order, dated April 3, 2023, it indicated Resident 451 had an order for Dialysis type: Hemodialysis on Mon [Monday]-Wed [Wednesday]-Fri [Friday] (9:30 AM- 1:45 PM) . During an interview and record review, on April 6, 2023, at 1:13 PM, with the Director of Nursing (DON), the DON reviewed Resident 451's progress notes and acknowledged Resident 451 missed a dialysis treatment on March 27, 2023 and April 5, 2023. The DON was not able to find documented evidence to indicate Resident 451 was monitored for signs of complications after his missed dialysis treatments. The DON further stated when residents miss dialysis, it is the nurse's responsibility to monitor for signs of complications for 72 hours and to document it in the medical records. The facility was not able to provide policies and procedures regarding resident's missing dialysis treatments. During a review of a facility document titled License Vocational Nurse/License Practical Nurse Job Description, dated December 17, 2021, it indicated, . Examine the resident and his/her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical, emotional or mental problems . Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures and applicable state and federal regulations.

Based on observation, interviews and record review, the facility failed to follow the physician's order for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) care for one resident (Resident 12) reviewed for urinary catheter. This failure has the potential for Resident 12 to be at risk of Urinary Tract Infection (UTI- clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract), placing his health and safety to be jeopardized. Findings: During an observation in Resident 12's room, on April 4, 2023 at 9:00 AM, Resident 12 was lying in bed in a semi-upright position, watching television. Resident 12 had a catheter attached to a urinary bag. During a record review of Resident 12's Admission Record (record that contains pertinent information), it indicated Resident 12 was admitted to the facility on [DATE] with the diagnoses of hypertensive heart and chronic kidney disease with heart failure, (where high blood pressure damages the small blood vessels in your kidneys), urinary tract infection (an infection in any part of the urinary system), major depressive disorder (a mood disorder that causes feeling of sadness and loss of interest) and other obstructive and reflux uropathy (when urine can't flow through the ureter, bladder and flows backwards). During a record review of Resident 12's physician's order, May 27, 2021, it indicated Resident 12 had an order for licensed nurses to Clean catheter with soap and water every shift. During a concurrent interview and record review, with the Director of Nursing (DON), on April 6, 2023, at 1:30 PM, the DON reviewed Resident 12's Treatment Administration Record (TAR) for March 2023 and April 2023, which indicated the urinary catheter care was not provided to Resident 12 on the following shifts: i. March 4, 2023, on AM shift (7AM to 3 PM) ii. April 4, 2023, on PM shift (3 PM to 11 PM) iii. April 5, 2023, on PM shift (3 PM to 11 PM) The DON acknowledged Resident 12 did not receive urinary catheter care on those shifts. During a review of the facility's undated policy and procedure (P&P) titled, Catheter Care, Indwelling, the P&P indicated, . It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN [as needed] for soiling . PURPOSE: .To promote hygiene, comfort and decrease risk of infection for catheterized residents. During a review of the facility job description for a Licensed Vocational Nurse, dated December 17, 2021, it indicated, . Administer services within the applicable scope of nursing practice, which may include catheterization, . as appropriate and in accordance with applicable standards.

Based on observation, interview, and record review, the facility failed to ensure a safe environment was maintained for one of two residents (Resident 37) reviewed for accidents when there was no oxygen sign posted outside of Resident 37's room. This failure has the potential to increase the risk of injuries, which could threaten the welfare, health, and safety of Resident 37. Findings: During a review of Resident 37's medical record, the Admission Record (clinical records with demographic information) indicated Resident 37 was admitted to the facility on [DATE], with diagnoses which included pyothorax (presence of pus in the pleural cavity-space between lungs and chest), follicular lymphoma (cancer in the lymphatic system-organs that fight infections and other diseases) and emphysema (lung disease that makes difficult to breath). During a review of Resident 37's Physician's Order, dated March 29, 2023, it indicated PRN [as needed] OXYGEN AT 2-3 L [liters- unit of measurement]/ MIN [minute] VIA NASAL CANNULA/MASK TO KEEP OXYGEN SATURATION [Sat-level of absorption] ABOVE 90% . During a concurrent observation and interview, with a Licensed Vocational Nurse (LVN 2), in Resident 37's room, on April 4, 2023, at 12:33 PM, Resident 37 was sitting on his wheelchair with a portable oxygen tank (a tank that delivers oxygen) strapped at the back of the wheelchair. Resident 37 was receiving oxygen through a nasal cannula (tube used to deliver oxygen). There was no Oxygen in Use sign outside Resident 37's room. LVN 2 acknowledged the finding. During a follow up interview, with LVN 2, on April 4, 2023, at 12:47 PM, LVN 2 LVN 2 stated there should have been an Oxygen in Use sign outside Resident 37's room door. During an interview, with the Director of Nursing (DON), on April 5, 2023 at 12:05 PM, the DON stated Resident 37 was receiving oxygen and there must be a sign outside his room indicating he was on oxygen therapy.

46917 Based on observation, interview, and record review, the facility failed to ensure a care plan (a summary of a resident's health conditions, specific care needs, and current treatments) were developed for two of two residents (Resident 9 and 46) reviewed for care planning when: 1. For Resident 9, a care plan was not developed for her behavior of removing her nasal cannula (a pronged device used to administer oxygen). This failure had the potential for Resident 9's oxygen needs not being met. 2. For Resident 46, a care plan was not developed when Resident 46 repeatedly refused weekly weights. This failure has the potential for Resident 46's weight changes not being identified and addressed which could place his health at risk. 3. For Resident 46, a care plan was not developed for his refusal of anti-coagulant medications (used to prevent blood clots). This failure had the potential for Resident 46 developing a deep vein thrombosis (blood clot forming in a deep, large vein) causing life threatening complications such as pulmonary embolism (a sudden blockage in a lung), heart attack, or ischemic stroke (blockage in the brain). Findings: 1. During an observation, on April 4, 2023, at 10:21 AM, outside the facility's gym, Resident 9 was sitting up in her wheelchair and was being wheeled by a staff member into the Activities room. Resident 9's nasal cannula was connected to a portable tank on the back of her wheelchair. During a concurrent observation and interview, on April 4, 2023, at 12:53 PM, in Resident 9's room, Resident 9 was not wearing her nasal cannula. A Certified Nursing Assistant (CNA 1) verified the finding, and stated Resident 9 likes to take it [nasal cannula] off and chew on it. During a concurrent observation and interview, on April 4, 2023, at 4:11 PM, in Resident 9's room, with the Director of Nursing (DON), Resident 9 was sitting in bed, without her nasal cannula. The DON verified the finding. During a review of Resident 9's clinical record titled, Admission Record (contains demographic and medical information), it indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (not enough oxygen in a person's blood), dysphagia (difficulty swallowing), and hyperglycemia (increased blood sugar levels). During a review of Resident 9's physician's order, it indicated Resident 9 had an order for .CONTINUOUS OXYGEN AT 1-2 L [liters- unit of measurement]/MIN [minute] and titrate [continuously measure and adjust the balance of] as needed VIA NASAL CANNULA/MASK [a device used to administer oxygen] TO KEEP OXYGEN SATURATION [amount of oxygen in blood] ABOVE 90% and CHECK O2 [oxygen] SATS [saturation] as needed for SOB [shortness of breath]. During a review of Resident 9's Care Plan (contains a plan of care for resident) for Altered respiratory status/difficulty breathing, dated February 17, 2023, it indicated .goal .will maintain normal breathing pattern as evidenced by normal respirations .interventions .provide oxygen as ordered: CONTINOUS OXYGEN AT 1-2 L/MIN and titrate as needed VIA NASAL CANNULA/MASK TO KEEP OXYGEN SATURATION ABOVE 90%. Further review indicated there was no interventions addressing Resident 9's behavior in removing the nasal cannula. During a concurrent interview and record review of facility's undated policy and procedure (P&P) titled Care Planning, with the DON, on April 5, 2023, at 9:46 AM, the DON reviewed the P&P, which indicated, . the interdisciplinary team (IDT) shall develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs . The DON stated the policy was not followed for Resident 9 when Resident 9's behavior in removing the nasal cannula was not identified and care planned. 47126 2. During a concurrent observation and interview, with Resident 46, on April 4, 2023, at 11:04 AM, Resident 46 was lying in bed, talking on his cellphone. Resident 46 stated, he was a vegan (a person who does not eat any food or food products that comes from animals) and the facility was not able to accommodate his dietary needs. Resident 46 stated he has not been weighed at the facility since his admission on March 10, 2023. During a review of Resident 46's Admission Record, it indicated Resident 46 was admitted to the facility on [DATE], with diagnoses which included history of falling and difficulty in walking. During a review of Resident 46's physician's order, dated March 10, 2023, it indicated, WEEKLY WEIGHTS X [times] 4 WEEKS, every day shift every 7 day(s) for 4 Weeks .End date 04/08/2023 (April 8, 2023). During an interview, on April 4, 2023, at 10:04 AM, with a Restorative Nursing Assistant (RNA 1), RNA 1 stated Resident 46 was weighed on admission March 10, 2023, and he refused all other weekly weights due to pain. RNA 1 stated she informed the supervising nurse and the DON regarding Resident 46's refusals to be weighed and they were aware of him refusing everything. During a concurrent interview and record review, on April 7, 2023, at 08:30 AM, with the DON, the DON reviewed Resident 46's Medication Administration Record (MAR-form that helps keep track of every dose administered to residents), for the month of March 2023, which indicated, Resident 46 refused Weekly Weights on March 18, 2023 and March 25, 2023. The DON reviewed Resident 46's clinical records and stated there was no care plan developed for Resident 46's refusal of weight monitoring. During a review of the facility's undated policy and procedure (P&P) titled, Nursing Administration: Care and Treatment - Comprehensive Person-Centered Care Planning, the P&P indicated, .5. The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternative means to address risk. 3. An observation of medication administration for Resident 46 by a Licensed Vocational Nurse (LVN 1) was conducted on April 6, 2023, at 5:54 A.M., in Resident 46's room. Resident 46 was lying in bed and refused all morning medications. LVN 1 stated Resident 46 repeatedly refuses medication. During a review of Resident 46's physician orders, dated March 10, 2023, it indicated Resident 46 had an order to receive Clopidogrel Bisulfate (a blood thinner) Tablet 75 MG (milligram - a unit of measurement) Give 1 tablet by mouth one time a day for DVT PROPHYLAXIS (prevention). During a concurrent interview and record review, on April 7, 2023, at 8:30 AM, with the DON, the DON reviewed Resident 46's MAR, for the month of March, 2023, which indicated, Resident 46 refused Clopidogrel Bisulfate tablet 13 times on the following dates: i. March 15, 2023 at 9 AM ii. March 16, 2023 at 9 AM iii. March 18, 2023 at 9 AM iv. March 20, 2023 at 9 AM v. March 22, 2023 at 9 AM vi. March 24, 2023 at 9 AM vii. March 25, 2023 at 9 AM viii. March 26, 2023 at 9 AM ix. March 27, 2023 at 9 AM x. March 28, 2023 at 9 AM xi. March 29, 2023 at 9 AM xii. March 30, 2023 at 9 AM xiii. March 31, 2023 at 9 AM The DON stated there was no care plan developed for Resident 46's repetitive medication refusal. The DON further stated Resident 46 was at risk for developing a blood clot due to being bed bound and refusing the blood thinner medication. During a review Resident 46's MAR, from April 1, 2023 through April 5, 2023,it indicated Resident 46 refused Clopidogrel Bisulfate tablet four times on the following dates: i. April 1, 2023 at 9 AM ii. April 2, 2023 at 9 AM iii. April 3, 2023 at 9 AM iv. April 5, 2023 at 9 AM During a review of the facility's undated policy and procedure (P&P) titled, Nursing Administration: Care and Treatment - Comprehensive Person-Centered Care Planning, the P&P indicated, .5. The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternative means to address risk.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were accurately completed to reflect the resident's status, care, and services in the skin conditions under Section M for two of three residents (Residents 299 and 350) reviewed for Resident Assessment. These failures had the potential to cause inaccuracy in identifying Resident 299's and 350's care and support needs. Findings: 1. During a review of Resident 299's Admission Record (a document that contains demographic and clinical data), it indicated Resident 299 was admitted to the facility on [DATE], with diagnoses which included hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and hypertension (when your blood pressure is higher than the recommended level). During a concurrent interview and record review, on April 6, 2023, at 1:21 PM, with the Minimum Data Set Nurse (MDS Nurse), the MDS Nurse reviewed Resident 299's clinical record which indicated, an initial admission record assessment and admission note was conducted for Resident 299 on March 16, 2023. Further review indicated Resident 299 did not have pressure injury/ulcer (an open wound on the skin caused by a long period of constant pressure) upon admission. The MDS Nurse was not able to find documented evidence that Resident 299 had a pressure injury upon admission. During further record review and interview, with MDS Nurse, on April 6, 2023, at 1:30 PM, the MDS Nurse reviewed Resident 299's MDS Admission Assessment (a comprehensive assessment for a resident that must be completed within 14 days after admission), dated March 23, 2023, under Section M titled Skin Conditions, which indicated Resident 299 had an Unhealed Pressure Ulcer/injuries category stage 3 [sore that involved skin loss throughout the entire thickness of the skin], and it was present on admission. The MDS Nurse further stated, it was coded in error. 2. During a review of Resident 350's Admission Record, it indicated Resident 350 was initially admitted to the facility on [DATE], with diagnoses which included hyperlipidemia, major depressive disorder and hypertension. During a concurrent interview and record review, on April 6, 2023, at 1:40 PM, with the MDS Nurse, the MDS Nurse reviewed Resident 350's clinical record which indicated a skin pressure weekly assessment was conducted for Resident 350 on February 7, 2023. The assessment indicated .Pressure ulcer review .Present on admission [marked] No .Onset date 2/6/23. The MDS Nurse was not able to find documented evidence that Resident 350 had pressure injury upon admission. During further record review and interview, with the MDS Nurse, on April 6, 2023, at 1:55 PM, the MDS Nurse reviewed Resident 350's MDS Admission Assessment, dated February 9, 2023, on section M titled Skin Conditions, which indicated, Resident 350 had an Unhealed Pressure Ulcer/injuries category unstageable - deep tissue injury [sore as 'purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue], and it was present on admission. The MDS Nurse further stated, it was coded in error. During a concurrent interview and record review, with the MDS Nurse, on April 7, 2023, at 10:30 AM, the MDS Nurse reviewed the RAI manual, revised October 2019, which indicated .The RAI process .require that (1) the assessment accurately reflects the resident's status .It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound.Steps for Assessment 1. Review the medical record, including skin care flow sheets or other skin tracking forms. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review . Steps 3: Determine Present on Admission For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement. 1. Review the medical record for the history of the ulcer/injury admitted to the facility without a pressure ulcer/injury. During the stay .develops . pressure ulcer. This is a facility acquired pressure ulcer and was not present on admission. The MDS Nurse stated that the facility did not follow the RAI manual.

46917 Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal their need for assistance from facility staff) was not within reach for two of four residents (Residents 9 and 20) reviewed for call light. This failure had the potential to place Residents 9 and 20 at risk of harm, as residents would be unable to call for help, or alert staff in the event of an incident. Findings: 1. During a review of Resident 9's clinical record titled, Admission Record (contains demographic and medical information), it indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (not enough oxygen in a person's blood), dysphagia (difficulty swallowing), and hyperglycemia (increased blood sugar levels). During a concurrent observation and interview on April 6, 2023, at 1:32 PM, with the Physical Therapist (PT 1), in Resident 9's room, Resident 9's was lying in bed. Resident 9's call light was on the on the floor, at right side of the bed. Its button was touching the floor. It was not within Resident 9's reach. The PT 1 verified Resident 9's call light was on the floor. 2. During a review of Resident 20's Admission Record, it indicated Resident 20 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side (complete paralysis [loss of function] and partial weakness following a stroke), repeated falls (more than two falls in a six-month period), and major depressive disorder (persistent feeling of sadness and loss of interest). During an observation, on April 7, 2023, at 8:44 AM, in Resident 20's room, Resident 20 was sleeping in bed. Resident 20's call light was hanging on the urinal (used to collect urine) holder on the right side of bed, and the red button of the call light was touching the floor. The call light was not within Resident 20's reach. During a follow up observation and interview, on April 7, 2023, at 8:48 AM, Resident 20 attempted to reach his call light and stated that he could not reach it [call light]. During a concurrent observation and interview, on April 7, 2023, at 8:52 AM, in Resident's 20 room, with the Minimum Data Set Nurse (MDS Nurse) verified the call light was not easily accessible to Resident 20. During a review of the facility's undated policy and procedure (P&P) titled, Call Light, the P&P indicated, . place the call device within resident's reach.

Based on observations, interviews, and record reviews, the facility failed to ensure that resident rooms had direct access to an exit corridor when four of four Resident rooms (rooms 15, 17, 19 and 21) in the red zone (rooms with confirmed COVID -19 a contagious virus) had been drilled shut. This had the potential to result in three residents (Resident 1, Resident 2 and Resident 3) who were dependent on staff, being trapped in their rooms in the event of a fire, causing severe [CONDITION(S)], permanent disability or even death. Findings: During an observation on September 16, 2021, at 9:20 AM, four Resident rooms, (Room 15, Room 17, Room 19 and Room 21) were noted to have doors that had been drilled closed with a screw. The Maintenance Director (MD 1) was observed coming from Room 19 with a drill in his hand. During an interview on September 16, 2021, at 10:50 AM, with the Maintenance Director (MD 1) he stated that he had screwed the doors closed. During an observation and concurrent interview on September 16, 2021, at 11:20 AM with a certified nursing assistant (CNA 2), she was asked to look at the doors and confirm that they have been drilled shut with a large screw. CNA 2 stated, yes there are large screws preventing the doors from being opened. When asked if she was able to open the door, she pulled on the door and stated she could not open the door. During an observation and concurrent interview on September 16, 2021, at 11:25 AM, with the Infection Preventionist Nurse (IP), inside the facility hallway, when asked if she was able to open the doors of rooms 15, 17, 19 and 21. She attempted to open the door and stated that maintenance must have secured the door from the other side with plastic. During an observation on September 16, 2021, at 11:28 AM, a radiology technician (X-ray Tech 1- a person who takes X-rays) was seen outside room 17 and attempted to open the door. She was observed to be pushing hard on the door which would not open. During an interview and concurrent observation on September 16, 2021, at 11:35 AM, with the IP the doors to rooms 15, 17, 19 and 21 were observed from the inside, she was asked to look at the screws in the doors and asked if the doors should be drilled that way. She stated that the doors should be able to be opened if needed and should not be drilled closed. When asked to confirm that the doors cannot be opened, she stated that she was unable to open the doors. An Immediate Jeopardy (IJ -a situation that has threatened or is likely to threaten the health and safety of a resident) called on September 15, 2021, at 12:43 PM, under CFR §483.90(e)(1)(iii) Have direct access to an exit corridor: when rooms 15, 17, 19 and 21 were found to be screwed shut and preventing access to the hallway corridor. This placed patients at risk for severe injury and death in the event of a fire. The IJ was verbally presented in the presence of Director of Nursing (DON), Infection Preventionist (IP), and Director of Staff Development (DSD). The facility's Administrator provided a Corrective Action plan which consisted of the following steps to address the screwed doors: 1. Removal of screws from doors. Administrator met with Maintenance Dept and maintenance assistant immediately removed the screw from all four doors. Maintenance assistance also removed plastic from all four doors. Ensured everyone in the department were aware doors not to be opened from hallway unless emergency, and entrance and exit of COVID unit from outside. 2. Inservice Provided for AM and PM Nursing Department - Ensured everyone in the department were made that doors not to be opened from hallway unless emergency and be left closed but unsealed with no obstruction of the doors in case of emergencies. 3. Inservice Provided for AM CNAs - Ensured both CNAs were made aware of the importance of maintaining egress of doors free of obstruction and left closed but unsealed with no obstruction of the doors in case of emergencies. 4. Inservice Provided for Housekeeping and Laundry Department - Ensured both department staff were made aware of importance of maintain egress of doors free of obstruction. Ensured everyone in departments were aware that the doors not to be opened from hallways unless emergency. 5. Inservice Provided for Therapy Department - Ensured department were made aware of maintaining egress of doors free of obstruction. Ensured everyone in department were made aware doors not to be opened from hallway unless emergency, and entrance and exit of COVID unit from outside. 6. Inservice Provided for Dietary Department - Ensured department was made aware of importance of maintaining egress of doors free of obstruction. Ensured everyone in department were made aware doors are not to be opened from hallway unless emergency, and entrance and exit of COVID unit from outside. 7. Inservice Provided for Administration - Ensured administration were made aware of importance of maintaining egress of doors free of obstruction. Ensured administration were made aware doors are not to be opened from hallways unless emergency, and entrance and exit of COVID unit from outside. The IJ was lifted on September 16, 2021 at 1:58 PM, in the presence of IP, DSD, DON, MRD (Medical Record Director) and Administrator, after an acceptable Corrected Action Plan (CAP) was provided and verified to be implemented by observation, interviews and record reviews.

Based on observation, interview, and record review, the facility failed to ensure the ice and water machine, used for resident consumption of ice and drinking water in the facility, was maintained in a clean and sanitary manner, and free from visible contamination indicative of foreign growth matter, for 46 out of 46 residents in the facility. This failure resulted in the residents being exposed to unsanitary and contaminated water and ice used for resident consumption, risking the likelihood of severe health consequences due to foodborne illness upon these vulnerable residents in the facility. Findings: During an interview on July 14, 2021, at 12:57 PM, with the Maintenance Director (Maintenance), the Maintenance stated the facility had only one ice machine. During a concurrent observation and interview on July 14, 2021, at 1:15 PM, with the Maintenance and the Administrator (Admin), within the employee breakroom area, the facility's ice and water machine was observed and surveyed. The following was observed within the ice and water machine's internal components: -Black-colored foreign matter was observed within the ice formation grate (part of the ice and water machine that is circulated with flowing water to form ice cubes) and was able to be removed with applied friction using a toothbrush, indicating the foreign matter was capable of becoming loose and contaminating the product ice and water. -Dark-colored foreign matter was observed along the many surfaces of the ice and water machine's internal components, including within the water-containment tray, which contained the source water for the machine. The Maintenance acknowledged and confirmed the toothbrush was able to remove black-colored foreign matter from the ice formation grate. The Maintenance further stated the following: -The foreign growth matter could indicate bacterial and mold growth inside the ice machine. -Gunk was visible within the machine's water tray, underneath the ice formation grate. -The facility's ice and water machine was not clean, nor acceptable for resident use in the facility. During a concurrent observation and interview on July 14, 2021, at 1:20 PM, with the Maintenance and the Admin, within the employee breakroom area, the facility's ice and water machine continued to be observed and surveyed. Surveyor completed a white paper towel test (taking a clean, white paper towel, and wiping the internal food safe surfaces of the ice machine that are expected to be clean, to verify if contaminants are able to be removed), and brown and orange matter was able to be removed from within the product ice containment bin ceiling surface. Both the Maintenance and the Admin observed the brown and orange matter on the white paper towel, removed from the ice product bin ceiling surface, and acknowledged it was not acceptable. The Maintenance further stated he just recently cleaned the ice and water machine but did not document the recent cleanings. The Maintenance and Admin further stated the ice and water machine was not acceptable for use in the facility, due to the current state and condition of the machine. The Admin failed to provide a response when asked if the ice and water machine was clean to use for resident consumption. During an interview on July 14, 2021, at 2:13 PM, with the Admin, the Admin stated all of the ice and drinking water for resident consumption in the facility was provided from the contaminated ice and water machine that was earlier observed and surveyed in the facility. The Admin further stated the ice and water machine will be replaced, and no longer used in the facility. The Admin further stated all ice and water pitchers were removed from the residents. During an interview on July 15, 2021, at 9:19 AM, with the Dietary Director (DD), the DD stated when he checked on the contaminated ice and water machine, he never took the machine apart to look inside the machine, to verify the machine's internal components were clean and sanitary. During an interview on July 15, 2021, at 9:26 AM, with the DD, the DD stated and confirmed that the contaminated ice and water machine, found to have foreign growth matter, was the only machine of its kind in the facility, and it was used for all resident dietary needs in the facility. During an interview on July 15, 2021, at 10:20 AM, with the Registered Dietician Consultant (RDC), the RDC stated and confirmed she inspected the facility's ice and water machine every month, and she would document these inspections on monthly reports. During an interview on July 15, 2021, at 11:47 AM, with the RDC and the Nutrition Consultant Surveyor, the RDC stated the following: -The RDC stated she had been working with the facility since December 2020, and since starting her monthly rounds at the facility, she had some concerns with the cleanliness of the facility's ice and water machine, as documented in her monthly reports. The RDC further stated she would always notify the Admin regarding these concerns, and the Admin would have been aware of these concerns. -The RDC stated she would not open the ice and water machine to observe and verify the condition of the machine's internal components, and she would only observe and verify what was easily accessible upon the machine. The RDC further stated she documented that the facility's ice and water machine needed more attention towards cleanliness. -The RDC further stated she would only complete the white paper towel test within the final ice cube chute, and not within the actual product ice containment bin. -The RDC further stated as a Consultant, she would advise for the facility to follow the manufacturer guidelines in regard to cleaning the ice and water machine, and more often as needed. -The RDC further stated, based upon her expertise and the professional standards of practice for her specialty, no foreign matter or growth should exist within these ice and water machines used for resident consumption needs. During a concurrent interview and record review, on July 15, 2021, at 12:00 PM, with the RDC and the Nutrition Consultant Surveyor, the RDC's monthly reports titled, Dietary Services - Kitchen Sanitation / Food Storage, dated December 1, 2020 through June 28, 2021, were reviewed. The RDC reviewed her monthly reports and stated the following: -For her report completed for February 2021, she reviewed her documentation and stated her notes included cleanliness of the facility's ice and water machine was a concern, and how she discussed these concerns with the facility. -For her report completed for March 29, 2021, she reviewed her documentation and stated her notes included cleanliness of the facility's ice and water machine was a concern, and the machine did not pass the white paper towel test. -For her report completed for May 10, 2021, she reviewed her documentation and stated her notes included her communication with the Admin in regards to the cleaning logs for the ice and water machine needing to be completed properly and the manufacturer guidelines needing to be followed. The RDC further stated she was never able to verify if the facility was completing and maintaining cleaning logs for their ice and water machine, and she would communicate this requirement to the Admin and to the DD, with the Admin stating to her that this was getting taken care of. The RDC further stated again the documentation in regard to the facility cleaning the ice and water machine was not available for her review, and she had never seen the available cleaning logs from the facility, in regard to their ice and water machine. The RDC further stated she would expect that the person responsible for cleaning the facility's ice and water machine was aware of how to take the machine apart to adequately clean the machine, and verify the cleaning was effective. During an interview on July 15, 2021, at 12:20 PM, with the RDC, the RDC stated typical contaminants that will grow and spread within an inadequately cleaned ice and water machine include bacteria and mold. During an interview on July 15, 2021, at 3:43 PM, with Licensed Vocational Nurses 1 & 2 (LVN 1) & (LVN 2), LVN 1 & LVN 2 both stated and confirmed that the water dispensed out of the facility's ice and water machine, including the machine that was found to be contaminated with foreign growth matter, was used for resident consumption needs, as well as for resident medication administration, including for the residents with feeding tubes (a tube surgically placed through a person's abdomen, to artificially provide nutrition and/or medication directly into the digestive system). During a review of RDC's monthly reports titled, Dietary Services - Kitchen Sanitation / Food Storage, dated December 1, 2020 through June 28, 2021, the documentation indicated the following: -For the monthly report dated February 26, 2021 through March 1, 2021, the document indicated, Per manufactures guidelines needs cleaning - does not appear appropriate. DSS to discuss (with) maintenance in regard to the deficient report item Ice machine clean and scoop clean; stored separately. -For the monthly report dated March 29, 2021, the document indicated, Discussed (with) DSS (Dietary Services Supervisor) and Administrator - guidelines for cleaning ice machine in regards to the deficient report items Cleaning documented routinely for ice machines in use & Sanitizing documented per Mfr. for ice machines in use. -For the monthly report dated May 10, 2021, the document indicated, Discussed (with) Maintenance and Administrator in regard to deficient report items Cleaning documented routinely for ice machines in use & Sanitizing documented per Mfr. (Manufacturer) for ice machines in use. During a review of the [Name of Facility] Progress Notes for Residents 36, 44, 19, 24, & 37, dated July 14, 2021, the progress notes for these residents included, Assessed Resident at bedside in regards to GI (Gastrointestinal) Distress such as N/V (Nausea/Vomiting), Diarrhea, or Stomach Cramping D/T (due to) possible mold contamination of ice/ water machine . These assessments indicated the residents were exposed to the ice and water product from the facility's contaminated ice and water machine. During a review of the [Name of Facility] Progress Notes *New* for Residents 31, 4, & 32, dated July 14, 2021, the progress notes for these residents included, Assessed Resident at bedside for GI Distress such as N/V, Diarrhea, or Stomach cramping D/T possible mold contamination of ice/water machine . These assessments indicated the residents were exposed to the ice and water product from the facility's contaminated ice and water machine. During a review of the physician orders for Residents 31, 36, 4, 44, 19, 32, 24, & 37, dated July 14, 2021, the physician orders for these residents included, .Monitor for GI Distress: (0) No Symptoms, (1) Nausea, (2) Vomiting, (3) Stomach Cramping, (4) Diarrhea, (5) Fever ever shift for 3 Days Notify MD (Medical Doctor) is having any symptoms . During a review of the care plans for Residents 31, 36, 4, 44, 19, 32, 24, & 37, dated July 14, 2021, the care plans for these residents included, At risk for Transient GI Upset such as: Stomach cramping, Nausea, Vomiting, Diarrhea due to water ingestion from possible exposure to moldy ice machine . On July 14, 2021, at 4:55 PM, an Immediate Jeopardy (IJ - a situation that had threatened or was likely to threaten the health and safety of a patient) situation was called in the presence of the Administrator (Admin) and the Director of Nursing (DON), for noncompliance towards the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. The noncompliance regarded the facility's failure to ensure the ice and water machine, used for resident consumption of ice and drinking water in the facility, was maintained in a clean and sanitary manner, and free from visible contamination indicative of foreign growth matter. The Admin and the DON were verbally notified of the IJ situation. On July 15, 2021, at 8:55 AM, an acceptable corrective action plan (CAP) was provided by the facility, which included: [Name of Facility Letterhead] This document will serve as a credible allegation of our intent to correct the deficient practice identified. Preparation and/or execution of this CAP do not constitute admission or agreement, by the provider, of the truth of facts alleged or conclusions set forth on the Statement of Deficiencies. This CAP prepared and/or executed solely because it is required by the provisions of Health and Safety Code Section 1280 and 42 C.F.R. 405.1907 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? All residents are potentially affected by the deficient practice were assessed for GI symptoms from the ice machine mold contamination such as nausea, diarrhea, stomach cramping, fever and vomiting and no residents were affected. Maintenance director assisted by Dietary supervisor immediately removed ice machine with its connective tubing from the designated area. Upon identification of the alleged deficient practice, Restorative Nurse Assistant and Infection Prevention (IP) Nurse pulled all water pitchers from each resident rooms. Assigned staff purchased multiple bags of ice from outside source as well as bottled water. Residents were immediately provided with new water pitchers with store bought bottled water and ice. Administrator purchased new ice machine and will immediately have it installed in addition to newly filtered water system in the designated area. All residents will be monitored for the next 72 hours for any sign and symptoms of GI distress. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? All residents are potentially affected by the alleged deficient practice as this has the potential to affect resident overall health condition. C. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur? Cleaning and the sanitation of the machine will be done by the maintenance director according to the manufacture recommendation, or minimum one time per month. Infection control nurse will monitor cleaning and sanitation of the machine on a monthly basis. Ice machine cleaning log will be kept in the designated area next to the ice machine. Administrator or Director of Nursing will ensure all above items are implemented. D. How the facility plans to monitor its performance to make sure that solutions are sustained? RD will conduct monthly inspection on the ice machine cleanliness. RD and Infection control nurse (IP) findings will be communicated to the Director of Nursing. Director of Nursing will monitor monthly for compliance. Director of Nursing will report findings identified to the QAA (refers to Quality Assurance) Committee during the monthly Quality Assurance Performance Improvement for the purpose of process improvement or changes to the plan to ensure substantial compliance with this plan of correction. Staff will be in serviced and trained today on how to operate and maintain the new machine. The IJ was abated on July 15, 2021, at 4:24 PM, in the presence of the DON, after onsite observation, interview, and record review verified the facility's implementation of the corrective action plan.