Every finding on record at Providence Holy Cross Med Ctr D/P SNF

Based on observation, interview, and record review, the facility failed to ensure to store, prepare, and serve food in accordance with professional standards of practice for food service safety by failing to: 1. Dispose green bell peppers pre-cut on its discard date (date out). 2. Dispose burger patties on its discard date. 3. Dispose chopped green onions discard date. 4. Label diced carrots with date in (when a product was prepared, opened, or received) and date out (discard date). 5. Cover and label with date in and date out three (3) cups of water in the Sub-Acute (for residents needing services that are more intensive than those typically received in skilled nursing facilities [SNF] but less intensive than acute care) pantry freezer. These deficient practices had the potential to cause food-borne illnesses (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in six of 46 medically compromised residents who received food from the kitchen. Findings: During a concurrent observation and interview on 3/23/2026 at 8:12 a.m., with Food and Nutrition Dietary Supervisor (FNDS) 1, inside the kitchen, observed the following: - vegetable precut of green bell peppers with good thru 3/20/2026; - chopped green onion with date out 3/21/2026; - diced carrots with no label of date it was date in and date out; - burger patties date in 3/18/2026 and date out 3/22/2026. FNDS 1 stated these should have been disposed of. FNDS 1 stated good thru and date out is the discard date. The FNDS 1 stated the diced carrots should have a label of date in and date out it is their policy for food safety. During a concurrent observation and interview on 3/23/2026 at 8:39 a.m., with FNDS 1, inside the Sub-Acute pantry, observed 3 cups of water in the freezer uncovered and no label of date in and date out. FNDS 1 stated in the freezer there are three cups of water in a disposable cup and should have a cover/lid and labeled with a date. FNDS 1 stated it should be covered to prevent contaminants from going in, anything can go inside the water and date to know how long it has been stored. FNDS 1 stated he will dispose of the 3 cups. During an interview on 3/27/2026 at 10:18 a.m., with the Director of Food and Nutrition Services (DFNS), the DFNS stated the date out would be the expiration date and beyond that should be discarded. The DFNS stated the items are labeled with a date in when it was thawed, opened, or prepared. The DFNS stated this is to provide safe food to their residents and not serve foods that has spoiled beyond the expiration date. The DFNS stated their facility follows a tighter schedule of 3 days shelf-life and they have to follow what their policy says. The DFNS stated that when the policy is not followed the residents can become more ill depending on their illness and their immune system, they can develop an intestinal issue and can be severe. During a review of the facility's policy and procedure (P&P) titled, Food and Supply Storage, revised 1/2025, the P&P indicated that All food, non-food items and supplies used in food preparation shall be stored in a manner as to prevent contamination to maintain the safety and wholesomeness of the food and human consumption. Most, but not all, products contain expiration date:. Foods past the use-by, sell-by, best-by:, or enjoy by date should be discarded. Cover, label, and date unused portions and open packages. Products are good through the close of business on the date noted on the label.

Based on observation, interview, and record review, the facility failed to ensure that each resident received care and services for the provision of parenteral fluids (formulated liquids that are injected into a vein) consistent with professional standards of practice for two of two sampled residents (Residents 50 and 2) by failing to: 1.a. Label Resident 50's Dextrose 5 percent (% - one part in every hundred) in Normal Saline (D5 NS, a sterile intravenous [IV - through the vein] solution used to replenish fluids, calories, and electrolytes) and document the administration per facility policy and procedures (P&P). 1.b. Label Resident 50's peripheral intravenous site with a date when it was inserted. 1.c. Ensure Resident 50's peripheral IV flush port (serves as an access to deliver saline or other medications to the vein) was covered with a disinfected cap (an alcohol containing caps that twist onto IV access points for disinfection and protection) 2.a. Label Resident 2's peripheral intravenous (IV - through the vein) site with a date when it was inserted. 2.b. Ensure Resident 2's peripheral IV flush port was covered with a disinfected cap. These deficient practices had the potential to result in parenteral fluids not being administered per physician's orders, mismanagement of resident's needs for fluid intake, and infections such as phlebitis (inflammation of a vein). Findings: 1. During a review of the facility's census (lists typically contain resident names, locations (unit/room), and the dates of admission), the facility's census indicated the facility originally admitted Resident 50 on 3/2/2026 and readmitted on [DATE]. During a review of Resident 50's History and Physical (H&P), dated 3/13/2026, the H&P indicated the resident had diagnoses including chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), percutaneous endoscopic gastrostomy (PEG, GT - a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) placement, and sepsis (a life-threatening blood infection). During a review of Resident 50's Minimum Data Set (MDS – a resident assessment tool), dated 3/4/2026, the MDS indicated the resident was rarely/never able to make himself understood and rarely/never able to understand others. The MDS indicated Resident 50 was dependent on staff for oral and personal hygiene, toileting, bathing, dressing, and mobility. During a review of Resident 50' s physician orders, the physician orders indicated an order for D5 NS continuous IV infusion at a rate of 75 milliliters (mL, a unit of measurement) per hour (mL/hr.), dated 3/22/2026. During a review of Resident 50's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the MAR indicated the last documented administration of D5 NS was on 3/22/2026 at 2:12 p.m. During a review of Resident 50's care plan (CP) titled, Altered Urinary Elimination ., with start date of 3/24/2026, the CP indicated interventions that included to give fluids as ordered. During a concurrent observation and interview on 3/23/2026 at 9:39 a.m., observed Resident 50 lying in bed with Family Member (FM) 1 at bedside. FM 1 stated Resident 50 required IV fluids because the resident was not tolerating the enteral feeding (EF - also known as tube feeding [TF], a method of supplying nutrients directly into the stomach) and the TF was not being administered. Observed an IV pump (device used to administer IV medication) administering fluids from an unlabeled bag of D5 NS to Resident 50 at a rate of 75 mL/hr. Observed approximately 300 mL out of 1000 mL remained in the bag. During a concurrent observation and interview on 3/23/2026 at 10:47 a.m., at Resident 50's bedside with Registered Nurse (RN) 6, RN 6 stated D5 NS is considered a medication, and the D5 NS bag should be labeled with the resident's name, date, and flow rate of administration as part of the medication administration process. RN 6 stated it was important to label medication and fluids to ensure the correct fluids were administered to the correct person at the correct time and at the correct rate. RN 6 stated Resident 50's D5 NS fluid bag was not labeled, but it should have been. During an interview on 3/25/2026 at 8 a.m. with RN 1, RN 1 stated the facility process for labeling and administering D5 NS fluids from the facility stock is the bag of fluids is labeled for safe medication administration. RN 1 stated during the medication administration the LN checks the label against the physician's order to ensure the resident gets exactly what the physician ordered. RN 1 stated when the D5 NS was not labeled there was the potential to result in a medication error leading to resident harm. During a concurrent interview and record review on 3/27/2026 at 7 a.m. with the Clinical Educator (CE), the CE reviewed Resident 50's physician orders and MAR for 3/2026. The CE stated on 2/23/2026 Resident 50 was administered D5 NS via IV and there was no documented evidence that the LN who started the administration documented in the MAR. The CE stated she was not sure who administered the D5 NS to Resident 50, when the D5 NS began being administered, or how much D5 NS Resident 50 received because there was no documentation and the fluids were not labeled. During an interview on 3/27/2026 at 8:33 a.m. with RN 5, RN 5 stated she (RN 5) cared for Resident 50 on 2/23/2026. RN 5 stated she did not start the administration of Resident 50's D5 NS on 2/23/2026 because the fluids were already being administered when she arrived. RN 5 stated Resident 50's D5 NS was not labeled, and she was not sure who started the administration of the unlabeled bag. During a concurrent interview and record review on 3/26/2026 at 4 p.m. with RN 1, RN 1 reviewed the facility P&P for medication administration. RN 1 stated the facility P&P was not followed when Resident 50's D5 NS was not labeled or documented as administered on 3/23/2026 potentially resulting in a medication error. During a review of the facility provided P&P titled, Medication Administration and Monitoring (Sub Acute), effective date 3/2025, the P&P indicated, The Registered Nurses and Licensed Vocational Nurses are responsible for the accurate administration and documentation of medications. The purpose of this policy is to safely and accurately administer medications to residents by those authorized to do so as defined by their scope of practice. E. Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. MAR represents the official and real-time document for active medication orders .Always observe the seven-rights of medication administration: 1. the right drug 2. the right patient 3. the right time 4. the right dose of the drug 5. the right route 6. the right reason (indication) 7. the right documentation Medications are administered exactly as ordered. All medications are appropriately labeled. 5. Documentation and EMAR: A. Documentation is required for all medications administered . 8. Documentation is completed by the healthcare providers, who administer the medications . E. IV solutions are documented every time a new bag is hung and at every rate change. The nurse must select the appropriate action when documenting IV infusion. Examples of action include: 1. New Bag 2. Rate/Dose change 3. Rate/Dose verify 4. Restarted 5. Stopped . 2. During a review of the facility's census, the facility's census indicated the facility originally admitted Resident 2 on 10/29/2024 and readmitted on [DATE]. During a review of Resident 2's H&P, dated 1/7/2026, the H&P indicated the resident with diagnoses including gunshot wound on abdomen, multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident had no speech, rarely/never makes self understood, rarely/never had the ability to understand others, and had severely impaired (never/rarely made decisions) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. During a review of Resident 2' s Active Orders (AO), dated 1/25/2026, the AO indicated an order to insert one peripheral IV one time with process instructions May use venipuncture analgesia per facility protocol. Flush line per standard of care. During a review of Resident 2's CP titled, Adult Inpatient Plan of Care, start date 12/17/2025, the CP indicated the resident with goals of absence of hospital-acquired illness or injury with interventions to prevent infection including identify potential sources of infection early to prevent or mitigate progression of infection (e.g., wound, lines, devices) and evaluate ongoing need for invasive devices; remove promptly when no longer indicated. During an observation on 3/23/2026 at 9:52 a.m., at Resident 2's bedside, Resident 2 with peripheral IV on left forearm wrapped with gauze dressing. During a concurrent observation and interview on 3/23/2026 at 11:10 a.m., at Resident 2's bedside with RN 5, RN 5 stated Resident 2 has a left forearm peripheral IV with no label of date of insertion and the peripheral flush port with no green disinfecting cap. RN 5 stated it should have a date of insertion , so they know when it needs to be changed and the flush port covered with a green disinfecting cap. During an interview on 3/27/2026 at 11:03 a.m. with the CE, the CE stated that once the peripheral IV line is inserted the licensed nurse labels the dressing with a date of when it was inserted. The CE stated this provides visible information that helps with the nursing assessments and following their protocol of IV dressing changes. The CE stated when IV dressing does not have a date of insertion this could place the resident at risk of infection and complication. The CE stated for peripheral IV they use of Curos caps (disinfecting caps) and they leave the cap to prevent any foreign bodies or bacterial build-up in the PIV line. The CE stated when this is not done the resident is at risk for infection. During a review of the facility's P&P titled, Comprehensive Vascular Access Management, last revised and approved on 5/2023, the P&P indicated M. Passive Disinfection Cap – A cap containing a disinfectant agent (isopropyl alcohol) that is placed on the access point in between intermittent infusions or medication administration to reduce intraluminal microbial contamination and minimize surface contamination. N. Peripheral Intravenous Catheter (PIV) – Short intravenous catheter inserted in a peripheral vein. Length of catheter ranges from 3 to 6 cm. PERIPHERAL AND MIDLINE MAINTENANCE. 5. The dressing will be labeled, indicating the date of insertion. 9. Place a passive disinfection cap, when available by ministry, to all access ports or needless connector in between intermittent infusions or medication administration. If the disinfection cap is removed, the used cap is discarded and is not reattached to the needleless connector

Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding [TF], a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications by failing to ensure the head of the bed (HOB) was elevated to greater than 30 degrees (a unit of angle measurement) per facility policy and procedures (P&P) for two of two sampled residents (Resident 7 and 39) reviewed for TF. This deficient practice placed Residents 7 and 39 at increased risk for complications of aspiration (when food or liquid enters the airway and lungs instead of the stomach) including aspiration pneumonia (an infection/inflammation in the lungs). Findings: a. During a review of Resident 7's History and Physical (H&P), dated 10/27/2025, the H&P indicated the resident was most recently admitted to the facility on [DATE] with diagnoses that included status epilepticus (a seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] lasting longer than 5 minutes) chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), tracheotomy (opening surgically created through the front of the neck and into the trachea [windpipe]), percutaneous endoscopic gastrostomy (PEG, GT - a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) placement, and aspiration pneumonia. The H&P indicated the resident ate nothing by mouth. During a review of Resident 7's Minimum Data Set (MDS-a resident assessment tool), dated 1/30/2026, the MDS indicated the resident was originally admitted to the facility on [DATE]. The MDS further indicated the resident rarely / never had the ability to make herself understood or understand others. The MDS indicated the resident was dependent on staff for oral and personal hygiene, toileting, bathing, dressing, and mobility. During a review of Resident 7's Physician's Orders, the physician's orders indicated the following: - Implement aspiration precautions per department protocol, dated 10/26/2025. - Continuous TF with TF Formula (TFF) 1 at a rate of 70 milliliters (mL, a unit of measurement) per hour (mL/hr.), until discontinued, dated 11/3/2025. During a review of Resident 7's Care Plan (CP) titled, Enteral Nutrition,, started 10/27/2026, the CP indicated a goal that the resident would be free from aspiration signs and symptoms with interventions that included to elevate the HOB to a semi recumbent position (a therapeutic, reclined posture where a resident lies on their back with the head of the bed elevated between 30 degrees [ degrees ] and 45 degrees ) During an observation on 3/23/2026 at 10:22 a.m., inside Resident 7's room, observed the resident lying in bed with the TF pump (device that delivers TF) turned on and administering the TF. Observed the digital angle display screen on the bed indicated 26 degrees . Observed no staff were present in the room. During a concurrent observation and interview on 3/23/2026 at 10:37 a.m., with RN 6, observed RN 6 entered Resident 7's room. RN 6 stated when a resident is being administered TF, the HOB should be elevated to 30 degrees to prevent aspiration potentially leading to pneumonia. RN 6 stated all staff members are responsible for ensuring the HOB is at 30 degrees and there is a screen on the bed that indicates the degree of the angle. RN 6 stated the screen on Resident 7's bed indicated the HOB was elevated to 26 degrees . RN 6 stated Resident 7's HOB needed to be elevated more, and it was not. During a concurrent interview and record review on 3/26/2026 at 4 p.m. with RN 1, RN 1 reviewed the facility policy and procedures (P&P) regarding TF. RN 1 stated residents on continuous TF should not be lying flat because the TF may go into their lungs resulting in complications like aspiration pneumonia. RN 1 stated the facility P&P indicates residents on TF should have the HOB elevated to 30 degrees. RN 1 stated the P&P was not followed when Resident 7's HOB was elevated to 26 degrees. b. During a review of Resident 39's H&P, dated 7/26/2025, the H&P indicated that the resident was admitted on [DATE] with diagnoses including sepsis (a life-threatening blood infection), ventilator (a medical device to help support or replace breathing) associated pneumonia (an infection/inflammation in the lungs), and percutaneous endoscopic gastrostomy status (a feeding tube placed directly into the stomach through the abdominal wall to provide long-term nutrition). During a review of Resident 39's MDS, dated [DATE], the MDS indicated that the facility originally admitted the resident on 11/22/2022 and readmitted the resident on 7/30/2025. The MDS indicated the resident was comatose (of, resembling, or affected with coma), dependent with rolling left and right while on the bed and has a feeding tube while a resident of this facility. During a review of Resident 39's physician order, dated 7/30/2025, the physician order indicated aspiration precautions to implement precautions per department/hospital protocol. During an observation on 3/23/2026 at 9:43 a.m., inside Resident 39's room, observed Resident 39 lying in bed with the TF pump turned on and administering TF. Observed the digital angle display screen on the bed indicated 26 degrees. Observed no staff were present in the room. During a concurrent observation and interview on 3/23/2026 at 10:17 a.m., with Certified Nursing Assistant (CNA) 1, inside Resident 39's room, CNA 1 stated Resident 39's digital bed angle indicated at 26 degrees. CNA 1 stated he does not know how long Resident 39 had been lying at 26 degrees bed angle. CNA 1 stated he will adjust it to 30 degrees. CNA 1 stated it should be 30 degrees or more. During a concurrent interview and record review on 3/27/2026 at 9:36 a.m., with the MDS Coordinator (MDSC), reviewed Resident 39's Care Plans (CP), the MDSC stated there was no care plan developed for aspiration precautions. The MDSC stated it should have been added when Resident 39 was readmitted on [DATE]. The MDSC stated the goal of aspiration precautions care plan is to prevent the resident from developing respiratory infections such as pneumonia related to TF and lying prone at risk for aspiration. The MDSC stated the interventions would include head of bed elevated at least 30 degrees to prevent aspiration. During a review of the facility provided P&P titled, Enteral Feeding, last revised 6/2023, the P&P indicated, The purpose of this policy is to. 1. Provide nourishment to patients who are unable to meet their nutritional needs orally. Enteral formula administration and handling guidelines are found in Lippincott procedures for nursing to follow for tube feeding administration. During a review of the facility provided Procedure titled, Enteral tube feeding, continuous, gastrostomy and jejunostomy, last revised 12/15/2025, the Procedure indicated, Procedure for . Pump Use. Implementation. Position the patient with the head of the bed elevated to at least 30 degrees or seated upright in a chair, unless contraindicated, to prevent aspiration.

Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards and adequate supervision and assistance to prevent falls and injury for one of two sampled residents (Resident 7) reviewed during the Accidents care area by failing to ensure the bed was maintained in the lowest position while the resident was left unattended. This deficient practice had the potential to result in falls leading to injury. Findings: During a review of Resident 7's History and Physical (H&P), dated 10/27/2025, the H&P indicated the resident was most recently admitted to the facility on [DATE] with diagnoses that included status epilepticus (a seizure disorder [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] lasting longer than five [5] minutes) chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), tracheotomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and percutaneous endoscopic gastrostomy (PEG, GT - a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) placement. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2026, the MDS indicated the resident was originally admitted to the facility on [DATE]. The MDS further indicated the resident rarely / never had the ability to make herself understood or understand others. The MDS indicated the resident was dependent on staff for oral and personal hygiene, toileting, bathing, dressing, and mobility. During a review of Resident 7's Physician's Orders, dated 10/26/2025, the physician's orders indicated the following: - Implement fall precautions per department protocol. During a review of Resident 7's Fall Risk Assessment, dated 3/23/2026, the Fall Risk Assessment indicated Resident 7 was a high risk for falls. During a review of Resident 7's Care Plan (CP) titled, Fall injury Risk, started 10/28/2026, the CP indicated a goal that the resident would be free of falls and fall related injuries with interventions that included to develop a fall prevention program, considering resident-centered interventions and to identify and address resident's barriers. During a review of Resident 7's Care Plan (CP) titled, Seizure, Active Management (adult), started 10/27/2026, the CP indicated a goal that the resident would have an absence of seizure and seizure related injury with interventions that included to maintain seizure precautions such as the bed in the low position. During an observation on 3/23/2026 at 10:22 a.m., inside Resident 7's room, observed the resident lying in bed. Observed the bed was elevated to the high position. Observed a flashing amber light projecting a bed symbol onto the floor. During a concurrent observation and interview on 3/23/2026 at 10:37 a.m., with Registered Nurse (RN) 6, RN 6 stated Resident 7's bed was flashing an amber light onto the ground, but she did not know why. RN 6 stated she would have to check why the light was flashing. Observed RN 6 exit Resident 7's room with the bed left in the high position. During a concurrent observation and interview on 3/23/2026 at 11:07 a.m. with RN 6, observed RN 6 return to Resident 7's room. Observed Resident 7's bed remain in the high position. RN 6 stated Resident 7's bed looked high. RN 6 stated most residents should not have the bed in the high position. Observed RN 6 lowered Resident 7's bed. Observed when the bed was lowered to the lowest position the amber flashing light turned to solid green. RN 6 stated Resident 7's flashing amber bed light indicated the bed was elevated. RN 6 stated Resident 7 was a high risk for falls and the bed should have been lowered to the lowest position, but it was not. RN 6 stated when Resident 7 was left unattended with the bed in the high position there was the potential for a gravity fall resulting in broken bones or worse. During a concurrent interview and record review on 3/24/2026 at 2:52 a.m. with the Director of Nursing (DON) and the Clinical Educator (CE), the manufacturer's instructions for Bed 1 was reviewed. The CE stated when Bed 1 flashed an amber light with a bed symbol it indicated the bed was not in the low position. The CE stated the light flashes to get staff attention to lower the bed. The DON stated Resident 7's has a history of seizures and the bed should always be in the lowest position to prevent falls from a higher position that can potentially worsen the severity of injuries. During a concurrent interview and record review on 3/26/2026 at 4 p.m. with RN 1, the facility's policy and procedures (P&P) regarding fall prevention was reviewed. RN 1 stated the facility P&P regarding fall prevention indicates to implement interventions to prevent falls. RN 1 stated the P&P was not followed when Resident 7 was left unattended with the bed in the high position potentially resulting in the resident having a seizure and falling from the bed leading to injuries. During a review of the facility's provided P&P titled, Fall Risk Prevention (Sub Acute), last revised 12/2025, the P&P indicated, In keeping with the mission and values . it is the policy . to provide excellent patient/resident care and follow the principles to reduce the incidence of preventable falls and the risk of patient injury from a fall. Implement the following resident specific fall prevention strategies based on the resident's fall risk score . Bed in low position.

Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to ensure: 1. Drugs were labeled in accordance with currently accepted professional principles to facilitate consideration of precautions and safe administration of medications by failing to ensure intravenous (IV, administered within a vein) piperacillin-tazobactam (an antibiotic [medication used to treat bacterial infections)] was labeled with the flow rate (the speed at which IV fluids or medications are delivered to a resident) for one of three sampled residents (Resident 7) reviewed under the urinary tract infection (UTI- an infection in the bladder/urinary tract) care area. This deficient practice had the potential to result in medication administration infused at the wrong rate resulting in adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) including worsening UTI. 2. Humulin R (insulin regular - a short-acting human insulin used to control high blood sugar) was discarded when it was past its 31-day storage in one of three medication cart (Med Cart 1) for Resident 5 reviewed under Medication Storage and Labeling task. This deficient practice had the potential to result in the medication to be administered to the resident possibly resulting in ineffective blood sugar control. Findings: a. During a review of Resident 7's History and Physical (H&P), dated 10/27/2025, the H&P indicated the resident was most recently admitted to the facility on [DATE] with diagnoses that included status epilepticus (seizure disorder [a sudden, uncontrolled electrical disturbance in the brain which can cause jerking, blank stares, and loss of consciousness] lasting longer than 5 minutes) chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), tracheotomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and percutaneous endoscopic gastrostomy (PEG, GT - a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) placement. During a review of Resident 7's Minimum Data Set (MDS-a resident assessment tool), dated 1/30/2026, the MDS indicated the resident was originally admitted to the facility on [DATE]. The MDS further indicated Resident 7 rarely / never had the ability to make herself understood or understand others. The MDS indicated Resident 7 was dependent on staff for oral and personal hygiene, toileting, bathing, dressing, and mobility. During a review of Resident 7's Care Plan (CP) titled, Infection, started 10/23/2026, the CP indicated on 3/22/2026 the resident had a fever of 101.1 degrees (a unit of measurement). The CP indicated a goal that Resident 7 would have an absence of signs and symptoms of infection with interventions that included to administer ordered antimicrobial (antibiotic) therapy promptly. During a review of Resident 7's Physician's Orders, the physician's orders indicated the following: - Piperacillin-tazobactam 4.5 grams (g, a unit of measurement) in 50 milliliters (mL, a unit of liquid measurement) sodium chloride 0.9 percent (a sterile solution in which medication is mixed), give 4.5 g intravenously (IV -fluids or medications given directly into the blood stream) at a flow rate of 100 mL per hour (mL/hr.), one time bolus (a single, relatively large dose of a drug administered over a short period to quickly achieve therapeutic levels) over thirty minutes followed in four hours by maintenance dosing for urinary tract infection (UTI), dated 3/23/2026 at 7:13 a.m. During a review of Resident 7's Medication form for piperacillin-tazobactam, dated 3/25/2026, the Medication form indicated administration details that on 3/23/2026 at 8:16 a.m. Registered Nurse (RN) 6 administered the first dose of piperacillin-tazobactam taken from the emergency kit (E-kit – a secure, portable container that stores specific medications that are used to treat patients in emergencies) followed by the maintenance dose on 3/23/2026 at 5 p.m. During an observation on 3/23/2026 at 10:22 a.m., inside Resident 7's room, observed the resident lying in bed with an IV pump (device used to administer IV medication) running at 21.3 mL/hr. Observed attached to the pump an IV bag with a hand-written label that indicated Zosyn ™ (brand name for piperacillin-tazobactam) 4.5 g and a start date and time of 3/23/2026 at 8:14 a.m. Observed approximately half of the medication solution remained in the IV bag. Observed the IV bag did not indicate the flow rate. During a concurrent observation and interview on 3/23/2026 at 10:37 a.m., with RN 6, RN 6 stated Resident 7 had and infection and she (RN 6) received an order to administer Zosyn™. RN 6 stated she removed the first dose of Zosyn™ from the E-kit, mixed the medication with the solution, labeled the IV bag, set up the IV pump to administer the medication at a rate of 21.3 mL/hr, and began the medication administration at 8:14 a.m. RN 6 stated all medications need to be labeled per the physician's order with the resident's name, medication, dosage, route, and date and time of administration. RN 6 stated the flow rate for IV medication is part of the physician's order and should be indicated on the label as well, but it was not. RN 6 stated it was important to label the medication with the flow rate to ensure the medication is administered per the physicians ordered rate. RN 6 stated when medication is not administered at the ordered rate it could cause adverse effects for the resident like fluid overload (too much fluid in the body causing swelling). During an interview on 3/25/2026 at 7:50 a.m. with the Director of Nursing (DON), the DON stated medication pulled from the E-kit is labeled by the licensed nurse (LN) to complete the five rights of medication administration (fundamental nursing principle designed to prevent medication errors that includes ensuring the correct person receives the right medication in the proper amount, method, and schedule). The DON stated when medication is administered the LN compares the physician's order with the medication label. During an interview on 3/25/2026 at 8 a.m. with RN 1, RN 1 stated the facility process for labeling and administering medication from the E-kit is the LN refers to the physician's order or contacts the pharmacy to determine the flow rate. RN 1 stated the flow rate should be indicated on the medication label to ensure that the medication is administered per the physician's orders. RN 1 stated when the label does not indicate the flow rate there is the potential that the LN would not check the flow rate during the medication administration process resulting in the wrong rate of administration potentially leading to resident harm. During a concurrent interview and record review on 3/26/2026 at 4 p.m. with RN 1, RN 1 reviewed the facility policy and procedures (P&P) regarding medication administration and labeling. RN 1 stated the P&P indicates medications are to be labeled and administered per the physician's orders. RN 1 stated the P&P was not followed when RN 6 did not label Resident 7's Zosyn™ per the physician's orders with the flow rate. During a review of the facility provided P&P titled, Admixing Medications, last revised 1/2025, the P&P indicated, A. The appropriate diluent is to be used when admixing medications. B. Admixed IV solutions must have a completed medication added label attached. IV. Procedure: A. Verify physician order. L. Label IV solution container with medication added label, to include the following: . 5. Route and rate . 6. Directions for administration. During a review of the facility provided P&P titled, Medication Administration and Monitoring (Sub Acute), effective date 3/2025, the P&P indicated, The Registered Nurses and Licensed Vocational Nurses are responsible for the accurate administration and documentation of medications. The purpose of this policy is to safely and accurately administer medications to residents by those authorized to do so as defined by their scope of practice. D. All medication orders are reviewed by a pharmacist prior to administration to a resident unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication; or in urgent situations, when the resulting delay would harm the resident, including situations in which the resident experiences a sudden change in clinical status. E. Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. Medications are administered exactly as ordered. All medications are appropriately labeled. b. During a review of Resident 5's H&P, dated 9/8/2025, the H&P indicated the facility admitted the resident on 9/7/2025 with diagnoses including acute (a sudden, severe worsening) on chronic respiratory failure after trauma, cervical spine fracture (commonly known as broken neck), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and motor vehicle accident. During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident has unclear speech, adequate hearing, makes self understood, and had the ability to understand others. The MDS indicated the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated Resident 5 received insulin since admission. During a review of Resident 5's physician order, dated 9/7/2025, the physician order indicated insulin regular (Humulin R) injection vial zero (0) to 12 units, subcutaneous (delivers medication into the fatty tissue layer between the skin and muscle), to administer per correctional scale with associated diagnosis diabetes. During a concurrent observation and interview on 3/24/2026 at 3:58 p.m., with Registered Nurse (RN) 4, observed in Med Cart 1 stored Resident 5's one (1) Humulin R vial with filled date 2/3/2026, opened date 2/14/2026, and expiration date 3/17/2026. RN 4 stated this should have been discarded on 3/17/2026 and should not been in use. During an interview on 3/27/2026 at 11:04 a.m., with the Clinical Educator (CE), the CE stated they follow the pharmacy guidelines and their facility's pharmacy policy for insulin. The CE stated the storage lifetime is indicative of the medication's effectiveness. The CE stated that when insulin is past its storage lifetime it should be discarded because when administered it can affect the effectiveness in blood sugar control which can vary depending on each resident's body's reaction can be hypoglycemia or hyperglycemia. During a review of the Manufacturer's Prescribing Information (MPI), revised 6/2023, the MPI indicated that when stored at room temperature, Humulin R can only be used for a total of 31 days including both not in-use (opened) and in-use (opened) storage time. During a concurrent interview and record review on 3/27/2026 at 11:12 a.m., with the Director of Post Acute Care Services (DPACS), reviewed the facility's P&P titled, Insulin Storage, last reviewed 1/2025, the P&P indicated that Humulin R stored opened for 31 days. The DPACS stated insulin regular Humulin R should only be stored for 31 days per their pharmacy policy. The DPACS stated it should be removed from the medication cart and discarded after 31 days.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure Licensed Vocational Nurse (LVN) 1 disinfected the computer mouse (a small, handheld device used to control a computer) after if fell on the floor and prior to use during the Medication Administration Task for two of four sampled residents (Residents 19 and 24). This deficient practice had the potential to spread communicable diseases and infections among staff and residents. Findings: a. During a review of the facility's census (lists typically contain resident names, locations (unit/room), and the dates of admission), the facility's census indicated the facility originally admitted Resident 24 on 12/16/2022 and readmitted on [DATE]. During a review of Resident 24's History and Physical (H&P), dated 12/10/2025, the H&P indicated the resident had diagnoses including acute respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and percutaneous endoscopic gastrostomy (PEG, GT - a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) placement. During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated 1/29/2026, the MDS indicated the resident was rarely/never able to make herself understood and rarely/never able to understand others. The MDS indicated the resident was dependent on staff for oral and personal hygiene, toileting, bathing, dressing, and mobility. During a review of Resident 24's care plan (CP) titled, Adult.Plan of Care . start date 3/4/2026, the CP indicated a goal that the resident would have the absence of illness or injury with interventions including to prevent infection by identifying sources of infection early to prevent infection. b. During a review of the facility's census, the facility's census indicated the facility originally admitted Resident 19 on 3/9/2023 and readmitted on [DATE]. During a review of Resident 19's H&P, dated 12/10/2025, the H&P indicated the resident had diagnoses including communicating hydrocephalus (a type of brain injury), tracheostomy, pneumonia (a respiratory infection) and PEG placement. During a review of Resident 19's MDS dated [DATE], the MDS indicated the resident was in a persistent vegetative state (a person is awake but shows no signs of awareness) / no discernible consciousness (awareness of internal and external existence). During a review of Resident 19's CP titled, Infection, start date 9/23/2025, the CP indicated a goal that the resident would have the absence of infection signs and symptoms including interventions to prevent infection to promote early source control to prevent spread of infection. During a medication administration observation on 3/25/2026 at 8:28 a.m. with LVN 1 at Station One medication cart, observed LVN 1 prepare Resident 24's medications in the hallway outside Resident 24's room. Observed during the preparation of the medications LVN 1 referred to the resident's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) in the computer located on the workstation on wheels (WOW). Observed LVN 1 used a computer mouse attached by a long wire to scroll between physician's orders while simultaneously removing each medication from the bubble packs (package that contains multiple sealed compartments with medication). Observed the computer mouse dropped on the floor in the hallway two times during the medication preparation. Observed LVN 1 used hand sanitizer to clean his hands after placing the mouse from the floor onto the WOW but did not disinfect the computer mouse. Observed LVN1 returned to using the mouse and removing the medications from the bubble packs and placing the medication in individual clear plastic cups, crushed the medications, then entered Resident 24's room and administered the medication from the cups by GT. LVN 1 then exited Resident 24's room and began to prepare medications for Resident 19. LVN 1 did not disinfect the computer mouse. During a medication administration observation on 3/25/2026 at 9:15 a.m. with LVN 1 at Station One medication cart, observed LVN 1 prepare Resident 19's medications in the hallway outside Resident 19's room. Observed during the preparation of the medications LVN 1 referred to the resident's MAR in the computer located on the WOW. Observed LVN 1 used the computer mouse to scroll between physician's orders while simultaneously removing each medication from the bubble packs. Observed the computer mouse dropped on the floor in the hallway one time during the medication preparation. Observed LVN 1 used hand sanitizer to clean his hands after placing the mouse from the floor onto the WOW but did not disinfect the computer mouse. Observed LVN1 returned to using the mouse and removing the medications from the bubble packs and placing the medication in individual clear plastic cups, crushed the medications, then entered Resident 19's room and administered the medication from the cups by GT. LVN 1 then exited Resident 19's room. During a follow-up interview on 3/25/2026 at 9:39 a.m. with LVN 1, immediately following Resident 19's medication administration observation, LVN 1 stated the computer mouse dropped on the floor three times during Resident 24 and 19's medication administration. LVN 1 stated he performed hand hygiene but did not disinfect the computer mouse and then continued using the mouse while pulling the medications from the bubble packs. LVN 1 stated he (LVN 1) should have disinfected the computer mouse, but he did not. LVN 1 stated when the computer mouse was not disinfected there was the potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and transferring germs from the floor to the WOW and the residents' medications. During an interview on 3/25/2026 at 8 a.m. with Registered Nurse (RN) 1, RN 1 reviewed the facility's policy and procedures (P&P) regarding medication administration and infection control. RN 1 stated LVN 1 should have disinfected the computer mouse during the medication preparation because there was potential for cross contamination. RN 1 stated the facility P&Ps were not followed. During a review of the facility provided P&P titled, Medication Administration and Monitoring (Sub Acute), effective date 3/2025, the P&P indicated, The purpose of this policy is to safely . administer medications to residents by those authorized to do so as defined by their scope of practice. G. eMAR represents the official and real-time document for active medication orders and should be reviewed to identify medications. H. Perform hand hygiene thoroughly before preparing or measuring medications. During a review of the facility provided P&P titled, Cleaning and Disinfection of Moveable Medical Equipment, last revised 12/2024, the P&P indicated, all moveable medical equipment should be routinely cleaned and disinfected. The purpose of this clinical standard is to establish responsibility and frequency for cleaning and disinfecting moveable medical equipment and to prevent transmission of organisms.

Based on interview and record review, the facility failed to screen for, offer, and administer the pneumonia vaccine (medication used to prevent serious lung infections caused by streptococcus pneumoniae [types of bacteria]) for one of five sampled residents (Resident 5) reviewed during the Infection Control task. This deficient practice had the potential to result in serious respiratory infection from pneumonia in Resident 5. Findings: During a review of the facility's census (lists typically contain resident names, locations (unit/room), and the dates of admission), the facility's census indicated the facility admitted Resident 5 on 9/7/2025. During a review of Resident 5's History and Physical (H&P), dated 9/8/2025, the H&P indicated the resident had diagnoses including chronic (long-term) respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), asthma (a chronic condition that affects the airways in the lungs) and gastrostomy tube (GT - a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) placement. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 12/15/2025, the MDS indicated the resident was able to make himself understood and able to understand others. The MDS further indicated the resident was dependent on staff for personal hygiene, toileting, bathing, dressing, and mobility. During a review of Resident 5's care plan (CP) titled, Infection, start date of 10/2/2025, the CP indicated a goal that the resident would have the absence of infection signs and symptoms. During a review of Resident 5's facility provided immunization record titled, California State Registry, dated 3/18/2026, the immunization record indicated Resident 5 had received four doses of the pneumococcal 7-valent conjugate vaccine (PCV7 vaccine - a vaccine used to prevent infections caused by seven common serotypes [strain] of the bacterium streptococcus pneumoniae ) at the following date and times: 12/26/2003, 4/2/2004, 6/19/2004, and 12/26/2006. During a concurrent interview and record review on 3/26/2026 at 9:38 a.m. with the Infection Preventionist (IP), the IP reviewed Resident 5's California Immunization Record Report (CAIR2 - a secure, confidential, statewide immunization system for California residents) undated, and the Centers for Disease Control and Prevention (CDC) document titled, Pneumococcal Vaccine Timing for Adults, dated 3/2025 . The IP stated there are various pneumonia vaccines used to prevent or minimize respiratory complications from pneumonia. The IP stated at admission and annually she (IP) questions the resident or family member and uses CAIR2 to screen for and offer vaccines. The IP stated there is a CDC tool to determine if a resident qualifies to receive any further doses of the pneumonia vaccines. The IP stated Resident 5 received 4 doses of PCV7 between 2003 to 2006. The IP stated CAIR2 indicated Resident 5's pneumonia vaccination was complete, so she did not screen to see if Resident 5 qualified for any further pneumonia vaccines. The IP then reviewed the CDC tool and stated Resident 5 qualified for and should have received the PCV15 (vaccine that protects against 15 strains of Streptococcus pneumoniae bacteria), PCV20 (vaccine that protects against 20 strains of Streptococcus pneumoniae bacteria), or the PCV21 (vaccine that protects against 21 strains of Streptococcus pneumoniae bacteria) pneumonia vaccine but he did not receive any further doses. The IP stated she should have further screened Resident 5 using the CDC tool but did not. During a concurrent interview and record review on 3/26/2026 at 4 p.m. with Registered Nurse (RN) 1, RN 1 reviewed the facility policy and procedure (P&P) regarding vaccination. RN 1 stated vaccinations are important to prevent residents from getting critically ill from pneumonia. RN 1 stated the facility process is to screen for and offer vaccinations at admission and as needed, get consent, educate on the risk and benefits, and administer vaccinations with a physician's order. RN 1 stated when Resident 5 qualified for and did not receive further doses of the pneumonia vaccine, the facility P&P was not followed. During a review of the facility provided CDC document titled, Pneumococcal Vaccine Timing for Adults, dated 3/2025, the Pneumococcal Vaccine Timing for Adults document indicated age [AGE] to 49 with certain underlying medical conditions or other risk factors** who have not previously received a PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown: one [1] dose PCV15 or 1 dose PCV20 or 1 dose PCV 21. previously received only PCV7: follow recommendations above. Underlying medical conditions or other risk factors include. chronic . lung disease. During a review of the facility provided P&P titled, Vaccines (. Pneumococcal) - (Sub-Acute), last reviewed 3/2025, the P&P indicated, it is the policy . to reduce the potential for transmitting and/or contracting influenza and/or pneumonia among Sub-Acute residents. PURPOSE. To ensure that . pneumococcal vaccines are offered and administered to each resident of the Sub-Acute Unit. E. Center for Disease Control and Prevention Guidelines are followed for administration of . pneumonia vaccine. 3. Pneumococcal disease A. Before offering the pneumococcal immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization. B. Offer each resident a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized. C. Resident or resident's legal representative has the opportunity to refuse immunization; and D. Indicate in resident's medical record, includes documentation indicating, minimum, of the following: a. Provide resident or resident's legal representative education regarding benefits and potential side effects of pneumococcal immunization; and b. Resident either received a pneumococcal immunization or did not receive pneumococcal immunization due to medical contraindication or refusal and reason for the refusal. c. Exception: as an alternative, based on an assessment and practitioner recommendation, second pneumococcal immunization given after 5 years following first pneumococcal immunization, unless medically contraindicated or resident or resident's legal representative refuses second immunization. 4. Administration of Vaccine A. Obtain vaccines from the provider pharmacy. C. Vaccines administered to residents WITH consent, or legal representative, received education on the benefits and potential side effects, by a Licensed Nurse according to manufacturer's directions.

Based on interview and record review, the facility failed to ensure medical records were maintained in accordance with professional standards that were complete and accurately documented when the facility failed to ensure Resident 20's Certified Nursing Assistant (CNA) documentation every two hours when Resident 20 was repositioned. This deficient practice had the potential for incomplete and inaccurate medical documentation. Findings: During a review of Resident 20's History and Physical (H&P), dated 1/28/2026, the H&P indicated that the facility admitted the resident on 1/27/2026 with diagnoses including chronic hypoxemic respiratory failure (a long-term condition where the lungs cannot adequately transfer oxygen into the blood, resulting in consistently low blood oxygen levels), ventilator (a medical device to help support or replace breathing) dependent, and chronic neurological encephalopathy (a long-lasting, often progressive brain disease where damaged brain cells cause permanent impairment in thinking, memory, behavior, and movement). During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool), dated 2/3/2026, the MDS indicated the resident was comatose (of or in a state of deep unconsciousness for a prolonged or indefinite period), dependent on activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility, and at risk of developing pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 20's Care Plan (CP) titled, Wound, added 1/27/2026, the CP indicated the resident with goals of optimal wound healing with interventions including reposition every 2 hours and as needed. During a concurrent interview and record review on 3/27/2026 at 6:39 a.m., with CNA 3, reviewed Resident 20's Flowsheet Data, dated 3/19/2026 to 3/20/2026, CNA 3 stated he starts his shift at 7 p.m. and documented the following: - 3/19/2026 at 8:05 p.m. resident lying supine - 3/19/2026 at 9:30 p.m. resident lying supine, CNA 3 stated he did not reposition resident because he did not look comfortable, so he left the resident lying supine. - 3/19/2026 at 2:30 a.m. resident lying supine, CNA 3 stated he provided bath to the resident. - 3/19/2026 at 3:00 a.m. resident lying right-side lying. - 3/19/2026 at 5:20 a.m. resident lying supine. CNA 3 stated he missed 3/20/2026 at 12 a.m. documentation. CNA 3 stated Resident 20 was left side lying but he missed it. CNA 3 stated he was supposed to chart every 2 hours to make sure that they are turning and repositioning the resident and what care he provided to the resident. CNA 3 stated if it was not documented then it did not happen. CNA 3 stated Resident 20 needs to be repositioned every 2 hours because resident is totally dependent on bed mobility and is unable to turn himself. During an interview on 3/27/2026 at 10:04 a.m., with the Clinical Educator (CE), the CE stated CNAs document what care they provided such as incontinence care throughout their shift, repositioning every 2 hours, vital signs every shift in the quickchart (electronic health record). The CE stated turning/repositioning the resident every 2 hours is documented around 8-10-12-2-4-6 within that timeframe that their policy is being followed. The CE stated that when repositioning every 2 hours is not documented pressure injuries can occur and possible respiratory complications from stagnation and may missed catching it because that is supposed to be rounded on (regular checks on the resident). During a review of the facility's policy and procedure (P&P) titled, Documentation, Clinical (Sub Acute), last approved 3/2025, the P&P indicated that the purpose of this P&P is To ensure all information pertinent to each resident's individual care are accurately and effectively communicated. The P&P indicated procedures/general instructions included 1. All clinical documentation reflects a systematic, interdisciplinary approach to resident care. Care is based on outcomes/goals listed in the care plan. 3. Clinical documentation includes, but is not limited to the following:. B. Care and treatment of resident.

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of three sampled residents (Resident 7) reviewed under the urinary tract infection (UTI - an infection in the bladder/urinary tract) care area by failing to ensure intravenous (IV - administered within a vein) piperacillin-tazobactam (also known as Zosyn, an antibiotic [medication used to treat bacterial infections]) was administered per the physician's ordered flow rate (the speed at which IV fluids or medications are delivered to a resident) and time schedule. This deficient practice resulted in medication infused at the wrong flow rate and late administration time potentially resulting in adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) including worsening UTI. Cross-reference F761. Findings: During a review of Resident 7's History and Physical (H&P), dated 10/27/2025, the H&P indicated the resident was most recently admitted to the facility on [DATE] with diagnoses that included status epilepticus (seizure disorder [a sudden, uncontrolled electrical disturbance in the brain which can cause jerking, blank stares, and loss of consciousness] lasting longer than five [5] minutes) chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), tracheotomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and percutaneous endoscopic gastrostomy (PEG, GT - a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) placement. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2026, the MDS indicated the resident was originally admitted to the facility on [DATE]. The MDS further indicated the resident rarely / never had the ability to make herself understood or understand others. The MDS indicated the resident was dependent on staff for oral and personal hygiene, toileting, bathing, dressing, and mobility. During a review of Resident 7's Care Plan (CP) titled, Infection, started 10/23/2026, the CP indicated on 3/22/2026 the resident had a fever of 101.1 degrees (a unit of measurement). The CP indicated a goal that the resident would have an absence of signs and symptoms of infection with interventions that included to administer ordered antimicrobial (antibiotic) therapy promptly. During a review of Resident 7's Physician's Orders, dated 3/23/2026 and timed at 7:13 a.m., the physician's orders indicated the following: - Piperacillin-tazobactam 4.5 grams (g - a unit of measurement) in 50 milliliters (mL - a unit of liquid measurement) sodium chloride 0.9 percent (a sterile solution in which medication is mixed), give 4.5 g intravenously (IV -fluids or medications given directly into the blood stream) at a flow rate of 100 mL per hour (mL/hr.), one time bolus (a single, relatively large dose of a drug administered over a short period to quickly achieve therapeutic levels) over thirty minutes followed in four hours by maintenance dosing for urinary tract infection (UTI). During a review of Resident 7's Medication form for piperacillin-tazobactam, dated 3/25/2026, the Medication form indicated administration details that on 3/23/2026 at 8:16 a.m., Registered Nurse (RN) 6 administered the first dose of piperacillin-tazobactam taken from the emergency kit (E-kit - a secure, portable container that stores specific medications that are used to treat residents in emergencies) followed by the maintenance dose on 3/23/2026 at 5 p.m. During an observation on 3/23/2026 at 10:22 a.m., inside Resident 7's room, observed the resident lying in bed with an IV pump (device used to administer IV medication) running at 21.3 mL/hr. Observed attached to the pump an IV bag with a hand-written label that indicated Zosyn4.5 g and a start date and time of 3/23/2026 at 8:14 a.m. Observed approximately half of the medication solution remained in the IV bag. Observed the IV bag did not indicate the flow rate. During an interview on 3/23/2026 at 10:37 a.m. with RN 6, RN 6 stated Resident 7 had and infection and she (RN 6) received an order to administer Zosyn RN 6 stated she removed the first dose of Zosyn from the E-kit, mixed the medication with the solution, labeled the IV bag, set up the IV pump to administer the medication at a rate of 21.3 mL/hr, and began the medication administration at 8:14 a.m. RN 6 stated all medications need to be labeled per the physician's order with the resident's name, medication, dosage, route, and date and time of administration. RN 6 stated the flow rate for IV medication is part of the physician's order and should be indicated on the label as well, but it was not. RN 6 stated it was important to label the medication with the flow rate to ensure the medication is administered per the physicians ordered rate. RN 6 stated when medication is not administered at the ordered rate it could cause adverse effects for the resident. RN 6 stated Resident 7's Zosyn flow rate of 21.3 mL/hr was determined from the pre-programmed settings she selected from the IV pump. RN 6 stated the flow rate should be determined by the physician's order and not the IV pump settings to ensure the medication is administered at the rate determined by the physician. During an interview on 3/25/2026 at 7:50 a.m. with the Director of Nursing (DON), the DON stated medication pulled from the E-kit is labeled by the licensed nurse (LN) to complete the five rights of medication administration (fundamental nursing principle designed to prevent medication errors that includes ensuring the correct person receives the right medication in the proper amount, method, and schedule). The DON stated when medication is administered the LN compares the physician's order with the medication label. The DON stated the rate of flow is indicated in the order and the first dose of Zosyn was to be given as a bolus over half an hour. During an interview on 3/25/2026 at 8 a.m. with RN 1, RN 1 stated the facility process for labeling and administering medication from the E-kit is the LN refers to the physician's order or contacts the pharmacy to determine the flow rate. RN 1 stated the LN does not rely on the IV pump's preprogrammed settings to determine the flow rate. RN 1 stated the flow rate should be indicated on the medication label to ensure that the medication is administered per the physician's orders. RN 1 stated when the label does not indicate the flow rate there is the potential that the LN would not check the flow rate during the medication administration process resulting in the wrong rate of administration potentially leading to resident harm. During a follow-up concurrent interview and record review on 3/25/2026 at 10:59 a.m. with RN 1, Resident 7's Medication form for piperacillin-tazobactam, dated 3/25/2026, and surveyor provided photo, dated 3/23/2026 at 10:32 a.m., were reviewed. RN 1 stated Resident 7's physician ordered an initial bolus dose of Zosyn to be given over half an hour at approximately 8 a.m., followed by the maintenance dose four hours later at approximately 12 p.m. RN 1 stated on 3/23/2026, RN 6 administered Resident 7's initial dose of Zosyn at 8:13 a.m. at the wrong flow rate. RN 1 stated Resident 7 received Zosyn over four hours instead of a half an hour. RN 1 stated because of this, the second dose of Zosyn was not administered until 5 p.m. on 3/23/2026. RN 1 stated the second dose of Zosyn was administered four hours late. RN 1 stated it was considered a medication error when RN 6 did not administer Zosyn per the physician's orders when the flow rate and timing of the medication was wrong. During a follow-up interview on 3/25/2026 at 11:14 a.m. with RN 6, RN 6 stated on 3/23/2026 at around 8 a.m. she (RN 6) set Resident 7's IV pump to the wrong flow rate to administer Zosyn over four hours instead of per the physician's order of half an hour. RN 6 stated Resident 7's second dose of Zosyn was administered late. RN 6 stated it was a medication error that resulted in a delay of treatment, potentially resulting in the resident not receiving the medication quickly enough leading to a worsening of the resident's infection. During a concurrent interview and record review on 3/26/2026 at 4 p.m. with RN 1, RN 1 reviewed the facility's policy and procedures (P&P) regarding medication administration and labeling. RN 1 stated the P&P indicates medications are to be labeled and administered per the physician's orders. RN 1 stated the P&P was not followed when RN 6 did not label and administer Resident 7's Zosyn per the physician's orders resulting in a significant medication error that was reported and led to a delay in the resident's treatment for a UTI. During a review of the facility provided P&P titled, Admixing Medications, last revised 1/2025, the P&P indicated, A. The appropriate diluent is to be used when admixing medications. B. Admixed IV solutions must have a completed medication added label attached. IV. Procedure: A. Verify physician order. L. Label IV solution container with medication added label, to include the following: . 5. Route and rate . 6. Directions for administration. During a review of the facility provided P&P titled, Medication Administration and Monitoring (Sub Acute), effective date 3/2025, the P&P indicated, The Registered Nurses and Licensed Vocational Nurses are responsible for the accurate administration and documentation of medications. The purpose of this policy is to safely and accurately administer medications to residents by those authorized to do so as defined by their scope of practice. D. All medication orders are reviewed by a pharmacist prior to administration to a resident unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication; or in urgent situations, when the resulting delay would harm the resident, including situations in which the resident experiences a sudden change in clinical status. E. Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. Medications are administered exactly as ordered. All medications are appropriately labeled. During a review of the facility provided P&P titled, Medication Error Reporting, last revised 6/2025, the P&P indicated, DEFINITIONS: A. Medication error/event: any preventable event (actual/potential) that may cause or lead to inappropriate medication use and/or patient harm while the medication is in control of the healthcare professional, patient, or consumer. 1. Medication errors can occur within any of the following steps in the medication management process: . h. Administration.

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one of one sampled resident (Resident 2) reviewed for respiratory care by failing to ensure Resident 2's bubble humidifier, dated 3/12/2026, was changed every three days per facility policy and procedure (P&P). This deficient practice placed Resident 2 at risk for acquiring respiratory infections. Findings: During a review of Resident 2's History and Physical (H&P), dated 1/7/2026, the H&P indicated that the facility admitted the resident on 12/16/2025 resident with diagnoses including gunshot wound on abdomen, multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2026, the MDS indicated the resident had no speech, rarely/never makes self understood, rarely/never had the ability to understand others, and had severely impaired (never/rarely made decisions) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated that oxygen therapy (a treatment that provides extra oxygen to breathe in) was performed while a resident of the facility. During a review of Resident 2's Care Plan (CP) titled, Mechanical Ventilation Invasive (Adult), dated 12/17/2025, the CP indicated the resident with goals of optimal device function with interventions which included facilitate regular mechanical ventilator and proper humidification equipment checks to ensure proper function. Provide humidification. regularly replace closed suction equipment, perform ongoing device and stoma care to prevent infection. During a concurrent observation and interview on 3/23/2026 at 11:10 a.m., with Registered Nurse (RN) 5, inside Resident 2's room, RN 5 stated Resident 2 receives oxygen therapy, and the bubble humidifier was dated 3/12/2026. RN 5 stated the bubble humidifier is changed every 3 days or sooner if it is less than 25 per hundred (%). RN 5 stated she will change it. During a concurrent interview and record review on 3/27/2026 at 7:01 a.m., with Respiratory Therapist (RT) 1, reviewed Resident 2's respiratory daily charting, RT 1 stated oxygen tubing and bubble humidifier is changed every Wednesdays. Reviewed Resident 2's respiratory daily documentation from 3/17/2026 to 3/27/2026, RT 1 stated there was no documentation oxygen tubing and bubble humidifier was last changed. During an interview on 3/27/2026 at 10 a.m., with the Clinical Educator (CE), the CE stated oxygen therapy equipment is scheduled to be changed to avoid complications and place the resident at risk for respiratory illness such as pneumonia. During a review of the facility's P&P titled, Supply Change & Equipment Check Schedule, last approved 10/6/2025, the P&P indicated that the Bubble Humidifier is changed during the day when water level is at 25% or every 3 days.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for aspiration precautions for one of two sampled residents (Resident 39) reviewed for tube feeding (TF - a method of supplying nutrients directly into the stomach). This deficient practice had the potential to place Resident 39 at risk for respiratory infections such as pneumonia (an infection/inflammation in the lungs). Cross-reference F693. Findings: During a review of Resident 39's History and Physical (H&P), dated 7/26/2025, the H&P indicated that the resident was admitted on [DATE] with diagnoses including sepsis (a life-threatening blood infection), ventilator (a medical device to help support or replace breathing) associated pneumonia, and percutaneous endoscopic gastrostomy status (a feeding tube placed directly into the stomach through the abdominal wall to provide long-term nutrition). During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 2/26/2026, the MDS indicated that the facility originally admitted the resident on 11/22/2022 and readmitted the resident on 7/30/2025. The MDS indicated Resident 39 was comatose (of, resembling, or affected with coma), dependent with rolling left and right while on the bed and has a feeding tube while a resident of this facility. During a review of Resident 39's physician order, dated 7/30/2025, the physician order indicated aspiration precautions to implement precautions per department/hospital protocol. During an observation on 3/23/2026 at 9:43 a.m., inside Resident 39's room, observed Resident 39 lying in bed with the TF pump turned on and administering TF. Observed the digital angle display screen on the bed indicated 26 degrees. Observed no staff were present in the room. During a concurrent observation and interview on 3/23/2026 at 10:17 a.m., with Certified Nursing Assistant (CNA) 1, inside Resident 39's room, CNA 1 stated Resident 39's digital bed angle indicated at 26 degrees. CNA 1 stated he did not know how long Resident 39 had been lying at 26 degrees bed angle. CNA 1 stated he will adjust it to 30 degrees. CNA 1 stated it should be 30 degrees or more. During a concurrent interview and record review on 3/27/2026 at 9:36 a.m., with the MDS Coordinator (MDSC), reviewed Resident 39's Care Plans (CP), the MDSC stated there was no care plan developed for aspiration precautions. The MDSC stated it should have been added when Resident 39 was readmitted on [DATE]. The MDSC stated the goal of aspiration precautions care plan is to prevent the resident from developing respiratory infections such as pneumonia related to TF and lying prone at risk for aspiration. The MDSC stated the interventions would include head of bed elevated at least 30 degrees to prevent aspiration. During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding, last revised 6/2023, the P&P indicated, The purpose of this policy is to. 1. Provide nourishment to patients who are unable to meet their nutritional needs orally. Enteral formula administration and handling guidelines are found in Lippincott procedures for nursing to follow for tube feeding administration. During a review of the facility's P&P titled, Enteral tube feeding, continuous, gastrostomy and jejunostomy, last revised 12/15/2025, the Procedure indicated, Procedure for . Pump Use. Implementation. Position the patient with the head of the bed elevated to at least 30 degrees or seated upright in a chair, unless contraindicated, to prevent aspiration. During a review of the facility's P&P titled, Standards of Sub Acute, last revised and approved 10/2025, the P&P indicated the purpose of this P&P is To conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident in the Sub-Acute Unit. Procedures/General Instructions - Sub-Acute Unit Assessment:. 7. MDS, Care Area Assessment (CAA) and care plan will be completed within 14 days and amended within 21 days of admission.

Based on observation, interview, and record review, the facility failed to post the daily staffing posting that contained the total number of staff and actual hours worked per shift information for 7 p.m. to 7 a.m. night shift for four (4) of 4 days reviewed for Sufficient and Competent Staffing Task. This deficient practice had the potential to keep residents and visitors unaware of total number of staff and the actual hours worked by staff in the facility. Findings: During an observation on 3/23/2026 at 7:46 a.m., observed posting titled, STAFFING FOR TODAY on top of the nursing station countertop, dated 3/20/2026, the posting indicated a census of 46 but did not indicate the total number of staff for the night shift and did not indicate the actual worked hours by the Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs) per shift. During a concurrent interview and record review on 3/23/2026 at 2:41 p.m. with RN 2, the facility's Staffing for Today posting, dated 3/18/2026, 3/19/2026, and 3/20/2026, were reviewed. RN 2 stated she could not find postings for 3/21/2026 and 3/22/2026. RN 2 stated the posting did not have information for the night shift because they do not have a secretary at night. RN 2 stated they have a secretary in the morning that is responsible for completing the staffing for today for day shift, 7 a.m. to 7 p.m. shift. During an interview on 3/23/2026 at 2:53 p.m. with Administrative Assistant (ADTA) 1, ADTA 1 stated that part of her duties is to fill out the staffing for today for the day shift and for the night shift the charge nurse for the night shift fills it out. ADTA 1 stated in the posting she fills out the census, the date, and the number of staff on duty for day shift. ADTA 1 stated that is all she fills out on the form. During a concurrent interview and record review on 3/26/2026 at 7:26 a.m. with RN 3, the facility's Staffing for Today posting, dated 3/18/2026, 3/19/2026, 3/20/2026, and 3/23/2026, were reviewed. RN 3 stated they use this form Staffing for Today to post their staffing information. RN 3 stated they have always used this form in the station since she started. RN 3 stated the secretary usually fills it out and pre-fills it out for the night shift. RN 3 stated they, charge nurses for night shift, have not filled out this form. RN 3 stated the purpose of this form is to show their staffing information and if they are meeting the staffing regulations and if they meet the standards with the number of nurses per shift. RN 3 stated this is to ensure safe and adequate staffing for their residents and families and administration are aware of their staffing. RN 3 stated it would seem that nobody is working or not know how many are working on that shift. RN 3 stated when the staffing posting information is not completed per shift then they are not informing the public about their staffing information. During an interview on 3/27/2026 at 11:48 a.m. with the Director of Post Acute Care Services (DPACS), the DPACS stated the staffing posting information are inputted by the night shift charge nurse. The DPACS stated they do not have a policy for staffing posting information, but they follow the Centers for Medicare and Medicaid Services (CMS - federal agency within the Department of Health and Human Services that manages government health coverage programs regulation for staffing posting).

Based on observation, interview and record review the facility failed to ensure 24 of 24 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13,Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, and Resident 24) who were on mechanical ventilators (a life-support machine that helps or takes over breathing for people who can't breathe sufficiently on their own, delivering oxygen) was free of contaminants (any physical or chemical substances) when the facility returned the oxygen gas line system back on for service and not had a certified medical gas verifier conduct testing to ensure oxygen is safe, pure and free of contaminants. This deficient practice of not verifying the oxygen from the medical gas line were free of contaminants prior to returning back on for service had the potential to cause serious harm and infection especially to the lungs (major organ for body's air exchange), or death to 24 residents who were on mechanical ventilators and were reliant (dependent) on the oxygen supplied by the gas line system. On 12/12/2025 an unannounced onsite visit was conducted by the Department regarding a report received from the facility indicating on 12/09/202 at 10:02 AM, the oxygen alarm was activated in the Subacute Unit (specialized in-patient care setting) (DP/SNF-distinct part /Skilled Nursing Facility - specialized area of the hospital for rehabilitation and transitional care), and an air and gas technician confirmed the oxygen line feeding the Subacute Unit was broken. The census of the unit was with 24 residents dependent on the mechanical ventilators. A review of the Resident 1 Facesheet (a summary of patient data), undated, indicated that the resident was admitted to skilled nursing facility (SNF 1, a licensed clinical care setting that provides 24-hour medical support and rehabilitation services to residents who require more intensive care than what can be delivered at home do not need acute hospitalization) on 11/03/2025, with the admitting diagnosis of respiratory failure (a serious condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide, leading to low oxygen and/or high carbon dioxide in the blood. A review of Resident 1 History and Physical, dated 11/04/2025, the record indicated that resident is a [AGE] years old year old female with history of polysubstance abuse presented to the hospital with cardiac arrest on 10/09/2025. Resident with percutaneous endoscopic gastrostomy (PEG, a feeding tube placed directly through the skin and abdominal wall into the stomach, used for long-term nutrition and hydration) and tracheostomy (trach, a surgically created opening in the neck into the windpipe to help someone breathe, allowing air directly to the lungs).A review of Resident 1 medical order, dated 11/07/2025, indicated that Resident 1 be placed on continuous mechanical ventilation (a life-support machine that helps or takes over breathing for people who can't breathe sufficiently on their own, delivering oxygen) with the following setting - Cycle: Pressure (The breath is terminated when the inspiratory flow falls to a set percentage, usually 25% of the peak flow, which is typical for pressure support ventilation; Mode: Pressure Support Ventilation (PSV, This is a resident-triggered, The patient controls their own respiratory rate and duration of inspiration); Pressure Support (PS, is the amount of pressure assistance the ventilator provides during each resident-initiated inspiration. A setting of 10 is a common starting point for weaning and helps overcome the resistance of the endotracheal tube and circuit, allowing the resident's respiratory muscles to do some work) Level 10; Titrate Fraction of inspired oxygen (FiO2, means the percentage of oxygen delivered to the patient should be adjusted by the healthcare team to keep the patient's blood oxygen at a certain level): Yes, to maintain peripheral oxygen saturation (SpO2, the percentage of oxygen in a resident's blood) above 92%; Positive End-Expiratory Pressure (PEEP, This is a constant baseline positive pressure maintained in the lungs during the entire breathing cycle, including exhalation):5. A review of Resident 2 Facesheet, undated, indicated that the resident was admitted SNF 1 on 12/06/2024, with the admitting diagnosis of chronic respiratory failure (CRF, a long-term condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide).A review of Resident 2 History and Physical, dated 12/10/2025, the record indicated that resident is a [AGE] year old female who was admitted at Hospital (Hospital 1) in September of 2022 for respiratory failure, was intubated and had a tracheostomy procedure. She was transferred to SNF1 for long term management. A review of Resident 2 medical order dated 12/06/2024, indicated that Resident 2 be placed on continuous mechanical ventilation with the following setting - Cycle: Volume Cycle (VC, The ventilator delivers a set volume with each breath, not a set Mode: Assist-Control (AC, means every breath, whether triggered by the resident or the machine, receives the full set volume and support, ensuring consistent ventilation).; Tidal Volume (VT, Each breath delivers a certain amount of air in milliliters[mL] into the lungs): 450 ml; Respiratory Rate (RR, The machine will deliver a certain number of breaths per minute (if the patient doesn't breathe faster): 14; Titrate FiO2: Yes, to maintain SpO2: > 92%; PEEP:5. A review of Resident 3 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 12/05/2025, with the admitting diagnosis of respiratory failure. A review of Resident 3 History and Physical, dated 10/04/2025, the record indicated that Resident is a [AGE] year-old with a history of middle cerebral artery (MCA, a stroke damages the left side of the brain, causing right-sided weakness/ paralysis, facial droop, and significant language issues). She was admitted to SNF 1 on 10/24/25 for ongoing management. A review of Resident 3 medical order dated 12/05/2025, indicated that Resident 3 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: SIMV; VT (ml): 450; PS.: 8; RR: 8; Titrate FiO2: Yes; Initial FiO2: 45; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 4 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 10/26 /202x, with the admitting diagnosis of respiratory failure. A review of Resident 4 History and Physical, dated 10/27/2025, the record indicated that Resident is a [AGE] years old female past medical history significant anoxic brain injury (ABI, occurs when the brain gets no oxygen, causing brain cells to die, leading to potentially permanent damage. Resident was recently admitted to Hospital 2 from 10/16- 10/26/2025 for severe anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood) and aspiration pneumonia (a lung infection from inhaling foreign substances like food, liquid, or vomit, causing inflammation and bacterial growth). She was discharged back to SNF1 for ongoing care on 10/26/2025. A review of Resident 4 medical order dated 10/26/2025, indicated that Resident 4 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT (ml): 450; RR: 16; Titrate FiO2: Yes; Initial FiO2: 40; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5.A review of Resident 5 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 02/07/2024, with the admitting diagnosis of Traumatic Brain Injury (TBI, damage to the brain caused by an external physical force, leading to temporary or permanent functional/ psychosocial impairments affecting thinking, feeling, moving, and communicating).A review of Resident 5 History and Physical, dated 07/14/2025, the record indicated that Resident is a [AGE] year-old who was involved in a motor vehicle accident on 12/2017 sustaining severe traumatic brain injury, with chief complaint of respiratory failure with status post (s/p, after an intervention) trach and is vent dependent. She was transferred to SNF1 0n 1/2018. In the last year, she remains unresponsive, vent dependent and total care with Activities of Daily Living (ADL, refers to basic self-care tasks like eating, bathing, dressing, using the toilet, and moving around, crucial for assessing health and independence, especially for the elderly or disabled). A review of Resident 5 medical order dated 10/15/2025, indicated that Resident 5 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: AC; VT (ml): 500; RR: 14; Titrate FiO2: Yes; Initial FiO2: 40; Titrate FiO2 to maintain SpO2 greater than 92%. A review of Resident 6 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 07/05/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 6 History and Physical, dated 07/07/2025, the record indicated that resident is a 50 -year-old male with chief complaint of respiratory failure. He has a past medical history of spontaneous Intracerebral Hemorrhage (ICH, bleeding inside the brain), tracheostomy and PEG tube. He has been a patient of SNF1 since 12/03/2019. A review of Resident 6 medical order dated 08/04/2025, indicated that Resident 6 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: SIMV; VT (ml): 520; PS: 8; RR: 8; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 7 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 05/15/2025, with the admitting diagnosis of Cardiac Arrest (when heart stops beating or beats so fast that it stops pumping blood). A review of Resident 7 History and Physical, dated 05/16/2025, the record indicated that Resident is a 59-years-old male who was admitted to Hospital 2 on 4/27/25. His hospitalization was complicated by progressing hypoxic ischemic brain injury (insufficient blood flow to the brain) and ongoing respiratory failure requiring tracheostomy. His condition stabilized and was deemed appropriate for discharge to subacute. He was transferred to SNF 1 on 5/15/2025 for ongoing management of multiple chronic conditions. A review of Resident 7 medical order dated 09/24/2025, indicated that Resident 7 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: AC; VT (ml): 500; RR: 14; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 8 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 03/05/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 8 History and Physical, dated 03/07/2025, the record indicated that Resident is a [AGE] year-old male with past medical history subarachnoid hemorrhage (bleeding in the area between brain and the thin tissues that cover and protect), respiratory failure, tracheostomy and PEG placement who resides in SNF1 for long term care. A review of Resident 8 medical order dated 06/09/2025, indicated that Resident 8 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT (ml): 500; RR: 12; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 9 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 11/04/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 9 History and Physical, dated 11/05/2025, the record indicated that Resident is a 49-years-old male with past medical history significant for motor vehicular accident (MVA) in 2011, quadriplegic (paralysis of all 4 limbs) and chronic respiratory failure status post tracheostomy. A review of Resident 9 medical order dated 11/4/2025, indicated that Resident 9 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: SIMV; VT (ml): 500; PS: 10; RR: 18; Titrate FiO2: Yes; Initial FiO2: 40; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 10 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 07/29 /2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 10 History and Physical, dated 07/30/2025, the record indicated that Resident is a [AGE] year-old female with a past medical history of chronic respiratory failure, trach to vent dependent. Resident was transferred to Hospital 2 emergency department on 7/28/25 for gastrostomy tube (feeding tube) replacement and returned to SNF 1 on 7/29/25. A review of Resident 10 medical order dated 07/29/2025, indicated that Resident 10 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT (ml): 500; RR: 20; Titrate FiO2: Yes; Initial FiO2: 50; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 11 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 12/20/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 11 History and Physical, dated 12/28/2025, the record indicated that Resident is a 86-years-old man with a past medical history of MCA stroke in August 2024. Resident is ventilator-dependent respiratory failure. On 12/16/2024, patient was admitted and treated for aspiration pneumonia. He was discharged back to SNF1 on 12/20/24 for continued care. A review of Resident 11 medical order dated 12/02/2025, indicated that Resident 11 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: SIMV; VT {ml): 500; PS: 14; RR: 14; Titrate FiO2: Yes; PEEP: 5. A review of Resident 12 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 11/18/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 12 History and Physical, dated 11/19/2025, the record indicated that Resident is a [AGE] year-old with past medical history of severe Degenerative Joint Disease (DJD, a condition where joint cartilage breaks down, leading to pain, stiffness, swelling, and reduced mobility) of the spine (vertebral column), compression fracture (a crack or break in a bone) of the spine at multiple levels, pneumonia (lung infection) complicated by chronic respiratory failure status post trach. She has been a long-term resident at SNF 1 since 2020. A review of Resident 12 medical order dated 11/18/2025, indicated that Resident 12 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Pressure; Mode: PCV; I-Pressure: 27; RR: 14; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 13 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 10/17/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 13 History and Physical, dated 10/20/2025, the record indicated that Resident is a [AGE] year-old female with a past medical history of Amyotrophic Lateral Sclerosis (ALS, a progressive neurological disease that destroys nerve cells of controlling voluntary muscles, leading to weakness and muscle wasting resulting to eventual inability to walk, talk, swallow, or breathe, causing paralysis and death) with functional quadriplegia, chronic respiratory failure status post tracheostomy insertion and ventilatory dependence. She resides in SNF 1. A review of Resident 13 medical order dated 10/17/2025, indicated that Resident 13 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: AC; VT (ml): 450; RR: 14; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 14 medical order, dated 09/10/2025, indicated Resident 14 be placed on mechanical ventilation. A review of Resident 14 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 09/07/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 14 History and Physical, dated 09/08/2025, the record indicated that Resident is 21-years-old male with past medical history of Motor Vehicular Accident (06/12/2025) with a cervical spine injury (CSI, affects the neck's vertebrae or spinal cord, ranging from fractures to dislocations, causing paralysis), and chronic respiratory failure. Resident has had a prolonged hospital stay including a tracheostomy and gastrostomy tube placement. He had been off the ventilator, but he came back and needed the ventilator placement. A review of Resident 14 medical order dated 09/10/2025, indicated that Resident 14 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC;VT (ml): 450; RR: 14; Titrate FiO2: Yes; Initial FiO2: 35; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 15 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 07/20/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 15 History and Physical, dated 08/01/2025, the record indicated that Resident is a 28-years-old male with history anoxic brain injury, PEG dependence, and chronic respiratory failure with tracheostomy dependence. The Resident is admitted to SNF 1 on 7/30/25 for ongoing care and management of multiple chronic conditions. A review of Resident 15 medical order dated 09/08/2025, indicated that Resident x be placed on continuous mechanical ventilation with the following setting Mechanical ventilation : Adult; Cycle: Volume; Mode: SIMV; VT (ml): 500; PS: 8; RR: 8; Titrate FiO2: Yes; Initial FiO2: 30; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 16 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 12/11/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 16 History and Physical, dated 12/05/2025, the record indicated that Resident chief complaint is Respiratory Failure, with past medical history of tracheostomy and PEG placement and has been a resident of SNF 1 since 08/21/2024. A review of Resident 16 medical order dated 05/28/2025, indicated that Resident 16 be placed on continuous mechanical ventilation with the following setting Mechanical ventilation : Adult; Cycle: Volume; Mode: SIMV; VT (ml): 500; PS: 10; RR: 10; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 17 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 05/28/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 17 History and Physical, dated 07/07/2025, the record indicated that Resident is a [AGE] year-old male with a history aortic valve replacement (a heart surgery to replaced damage aortic valve), pneumonia, cardiac arrest, anoxic brain injury, chronic respiratory failure, status-post tracheostomy and PEG placement, A review of Resident 17 medical order dated 10/31/2025, indicated that Resident 17 be placed on continuous mechanical ventilation with the following setting -Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT (ml): 450; RR: 12; PEEP: 5.A review of Resident 18 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 11/20/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 18 History and Physical, dated 09/10/2025, the record indicated that Resident is a 62-years-old male with past medical history of stroke (happens when blood flow to the brain is cut off, causing brain cells to die from lack of oxygen) status post hemicraniotomy (a life-saving emergency brain surgery where a large piece of the skull is removed to relieve dangerous pressure from severe brain swelling caused by stroke), chronic respiratory failure status post tracheostomy, ventilator dependent, and PEG tube placement. She has been residing at PHC subacute since 11/2019. A review of Resident 18 medical order dated 11/20/2025, indicated that Resident 18 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT {ml): 550; RR: 14; Titrate FiO2: Yes; Initial FiO2: 40; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 19 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 02/21/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 19 History and Physical, dated 02/21/2024, the record indicated that Resident is a very [AGE] year-old male with a past medical history of traumatic brain injury, history of chronic respiratory failure status post tracheostomy and vent dependence and G-tube placement who resides at SNF1. A review of Resident 19 medical order dated 04/20/2025, indicated that Resident 19 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: AC; A review of Resident 20 Facesheet, undated, indicated that the resident was admitted to SNF 1 on xx/xx/202x, with the admitting diagnosis of Respiratory Failure. A review of Resident 20 History and Physical, dated 10/13/2025 the record indicated that Resident is a [AGE] year-old female with past medical history thalamic infarct (a stroke damaging the thalamus, a brain region crucial for sensory, motor, and consciousness relays), and left parietal meningioma(a slow-growing, benign tumor developing from the brain coverings on the left side) was recently admitted at Hospital 2 from 5/6-5/25/2023 status post fall. Patient was in respiratory distress requiring intubation (a medical procedure where a tube is inserted into the windpipe through the mouth or nose to maintain an open airway, allowing for ventilation and oxygen administration) on 5/14/2025, status post trach on 5/20/2025, status post PEG on 5/21/2025. She was transferred to SNF 1 for continuity of care. A review of Resident 20 medical order dated 10/02/2025, indicated that Resident 20 be placed on continuous mechanical ventilation with the following setting - A review of Resident 21 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 10/17/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 21 History and Physical, dated 10/13/2025, the record indicated that Resident is a [AGE] year-old male with past medical history significant for gunshot wound to the head with a complicated history of multiple surgeries with unchanged neurologic status for years, chronic tracheostomy, ventilator dependence, and chronic G-tube dependence. A review of Resident 21 medical order dated 08/08/2025, indicated that Resident 21 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: SIMV; VT (ml): 500; PS: 10; RR: 10; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 22 medical order, dated 07/11/2024, indicated Resident 22 be placed on mechanical ventilation. A review of Resident 22 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 03/02/2022, with the admitting diagnosis of Respiratory Failure. A review of Resident 22 History and Physical, dated 03/14/2025, the record indicated that Resident is a [AGE] year-old man who suffered from hemorrhagic cerebrovascular accident (CVA, happens when a blood vessel in the brain ruptures, spilling blood and causing pressure and damage to brain tissue) years ago with right hemiparesis (weakness on one side of the body), chronic respiratory failure status post tracheostomy, status post G-tube placement, who is a resident at SNF 1 since early 2017.A review of Resident 22 medical order dated 07/11/2024, indicated that Resident x be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT (ml): 600; RR: 16; Titrate FiO2: Yes; Initial FiO2: 35; Titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 23 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 12/01/2021, with the admitting diagnosis of Respiratory Failure. A review of Resident 23 History and Physical, dated 01/03/2025, the record indicated that Resident is a 54-years-old male with past medical history of prolonged cardiopulmonary arrest (the sudden, unexpected loss of heart function, breathing, and consciousness) back in May 2019 complicated by anoxic brain injury(ABI, happens when the brain is completely deprived of oxygen, leading to rapid death of brain cells causing severe damage or loss of consciousness), chronic respiratory failure and ventilator dependence requiring tracheostomy, status post G-tube placement, who has been residing at SNF 1 in vegetative state and who remains on the ventilator via tracheostomy. A review of Resident 23 medical order dated 09/12/2025, indicated that Resident 23 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Pressure; Mode: PCV; I-Pressure to maintain VT of (ml): 500; RR: 14; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 24 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 02/14/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 24 History and Physical, dated 02/21/2025, the record indicated that Resident is a [AGE] years old male with past medical history of traumatic brain injury status post craniotomy in 2016, status post PEG insertion, chronic respiratory failure status post tracheostomy and is vent dependent. A review of Resident 24 medical order dated 12/14/2024, indicated that Resident x be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Pressure; Mode: PCV; I-Pressure: 32; RR: 12; Titrate FiO2: Yes; Initial FiO2: 40; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5 (Order 1686940168) On 12/12/2025 at 12:34 PM, during an Interview with Facility Director (FD1), the FD1 stated the leaking medical air pipe had been repaired, and the medical gas line was turned back on to the Subacute from the main tank. On 12/12/2025 at 1:35 PM, during interview with the Regional Compliance Officer (RCO), RCO stated the facility had not opened a project or received approval for the repair. The RCO stated a medical gas verifier needed to complete the medical gas verification process. The RCO stated concerns about the safety, purity, and functionality of the medical gas system. On 12/12/2025 at 2:45 PM during a concurrent observation and interview with the FD1, the main line valve at the nursing station was open, and 24 residents who were mechanical ventilation in the Subacute Unit were receiving oxygen from the main tank. During an interview on 12/12/2025 at 4:15 PM, with the Facilities Director (FD1), FD1 stated that low oxygen alarm was triggered on 12/9/2025 at 10:02 AM, the alarm may be due to a possible leak of the oxygen pipe system. The location of the leak was identified on 12/11/2025 around 4:00 PM, by a nurse who was walking outside the facility and directed him to the location . The facilities had a contract service come out, and the repair of the leak was completed on 12/12/2025 12:30 pm. After the repairs, the portable oxygen tank was disconnected, and patients were placed back on to the in- wall oxygen gas line. The facility did not conduct oxygen quality testing after repair. Facility has no available quality report to confirm the safety, purity, and integrity of the medical gas system after repair. Last oxygen gas quality testing was done on 10/31/2025 and is done once a year. FD1 added that he deemed it safe to return the oxygen gas line back on and that there was no certified medical gas verifier called to conduct oxygen gas line quality inspection, testing and verification after repair. On 12/12/2025 at 5:55pm, during an interview with FD1, the FD1 stated, he is not certified as a medical gas verifier but is have one in electrical engineering and another in biomedical engineering. and that he's been working since 1991 when asked how they are qualified. FD1 added that NFPA 99 (the Health Care Facilities Code, sets minimum safety criteria for healthcare environments, focusing on preventing hazards like fire, explosion, and electrical failures for patients, staff, and visitors, using a risk-based approach that categorizes systems of medical gases, electrical, and plumbing by their potential impact on patient safety) is a health care facilities code that facility adheres to and to his understanding, oxygen gas line quality inspection, testing and verification from a certified medical gas verified is required for new construction only, not for its repair. A review of the NFPA 99 (the Health Care Facilities Code, sets minimum safety criteria for healthcare environments, focusing on preventing hazards like fire, explosion, and electrical failures for patients, staff, and visitors, using a risk-based approach that categorizes systems of medical gases, electrical, and plumbing by their potential impact on patient safety) requires that after any repair or modification to a medical gas piping system, the affected section undergoes thorough leak testing, purging, and functional testing by a certified third-party verifier before being returned to service, ensuring no leaks, cross-connections, or contamination, with detailed documentation kept for at least five years to confirm safety and code compliance for patient use.

Based on interview and record review, the facility failed to fully develop and implement an antibiotic (antimicrobial, medicine that inhibits the growth of or destroys microorganisms) stewardship program (ASP- a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics as a part of its overall Infection Prevention and Control Program (IPCP) for one of six sampled residents (Resident 3) reviewed under Infection Control facility task by: a. Failing to establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria for initiating antibiotic treatment b. Failing to identify Resident 3's use of levofloxacin (antibiotic) indicated for urinary tract infection (UTI- an infection in the bladder/urinary tract). These deficient practices had the potential to result in increased risk of inappropriate antibiotic use, potentially leading to adverse outcomes (complications arising from an intervention or condition) such as antibiotic resistance (the acquired ability of bacterial pathogens to withstand the effects of antimicrobial agents, reducing treatment efficacy) to Resident 3. Cross-reference F881 Findings: During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/17/2025 with diagnoses including acute hypoxic respirator (a condition where the lungs cannot get enough oxygen into the blood) and hyperlipidemia (abnormally high fat). During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident's initial start date at the facility on 10/29/2024. The MDS indicated the resident had adequate hearing and unclear speech. The MDS indicated the resident made self understood and sometimes understood others. The MDS indicated the resident was dependent on staff with toileting, oral hygiene, shower/bathing self, lower body dressing, and personal hygiene. The MDS indicated the resident was taking antibiotics. During a review of Resident 3's physician order, dated 3/4/2025, the physician order indicated levofloxacin (Levaquin) tablet 500 milligrams (mg-a unit of measurement) per gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for UTI, daily, end date 3/10/2025. During a concurrent interview and review on 3/27/2025 at 10:41 a.m. with the Infection Preventionist (IP), Resident 3's physician order, nursing progress notes, and registered nurses' plan of care, antibiotic tracking sheet (a document or tool used to monitor and record prescribed antibiotics and usage patterns [how often, how much, and what reason it's prescribed]), and Loeb's minimum criteria (evidence-based national standard criteria for initiating antibiotic treatment designed to reduce inappropriate prescribing by outlining minimum clinical signs and symptoms suggesting an infection) for initiating antibiotic therapy were reviewed. The Plan of Care indicated, on 3/1/2025 at 11:25 a.m., Resident 3 was noted with increased heart rate and had a temperature of 101.1 degrees Fahrenheit (F - a unit of measurement). The IP stated she uses the antibiotic tracking sheet and the Loeb's minimum criteria for initiating antibiotic therapy as a guide that she uses to monitor and review new or changes in antibiotic orders and uses Loeb's criteria, but this is not indicated in their policy. The IP stated they do not have a standard protocol in using the Loeb's criteria that shows which residents have met or have not met the criteria. The IP stated when Loeb's criteria is used for Resident 3's use of levofloxacin for UTI without urinary catheter, the resident would not have met the criteria because the resident only have increased heart and fever as signs and symptoms of infection. The IP stated the Loeb's minimum criteria for UTI includes either one of the following criteria: acute dysuria (discomfort or pain when urinating) or temperature greater than 100 F, and one or more of the following new or worsening symptoms: urgency, suprapubic pain (pain above pelvic bone), urinary incontinence, frequency, gross hematuria (visible blood in the urine), and costovertebral angle tenderness (pain in the upper back near the ribs). During a concurrent interview and record review on 3/27/2025 at 10:50 a.m. with the IP, the facility's P&P titled, Antimicrobial Stewardship (AMS) Program, last reviewed and approved on 3/10/2025, was reviewed. The IP stated the P&P did not indicate the protocol on the use of antibiotic tracking sheet and the use of Loeb's criteria to assess the residents for any infection. The IP stated she should have mentioned to the Manager of Infection Prevention (MIP) about the use of antibiotic tracking sheet and the use of Loeb's minimum criteria in initiating antibiotic therapy when they reviewed their P&Ps. During an interview on 3/27/2025 at 1:57 p.m. with the IP, the IP stated when the resident does not meet the Loeb's minimum criteria, she would notify the resident's physician that the resident did not meet the criteria to initiate the antibiotic then document on the resident's chart what she did and what the physician's response was. During a concurrent interview and record review on 3/27/2025 at 2:12 p.m. with Registered Nurse (RN) 2, Resident 3's nursing progress notes, plan of care, and physician orders were reviewed. RN 2 stated he was covering for the IP when Resident 3 had the order for levofloxacin for UTI. RN 2 stated he notified the primary nurse about the resident's laboratory results that were ordered, and he (RN 2) does not use any standardized criteria when reviewing antibiotics. During an interview on 3/27/2025 at 3:17 p.m. with the MIP, the MIP stated she was not aware of the Centers of Medicare and Medicaid Services (CMS- a federal agency that administers major healthcare programs) of the regulation antibiotic stewardship regulation requirements to be implemented. The MIP stated they have an ASP which they collaborate with the antimicrobial stewardship pharmacist. The MIP stated they purpose of the ASP is to administer antibiotics in the least amount of duration, and to make sure the antibiotic ordered had the appropriate frequency and dose to prevent multidrug resistance organisms. During a review of the facility's P&P titled, Antimicrobial Stewardship (AMS) Program, last reviewed and approved on 3/10/2025, the P&P indicated it is the facility's policy to implement a comprehensive AMS program to evaluate judicious use of antimicrobials. The P&P indicated the purpose of the P&P is to optimize antibiotic therapy to improve clinical outcomes while minimizing unintended consequences of antimicrobial use, such as drug toxicity (drug causing harm) and emergence of resistance. During a review of the facility P&P titled, Department Policy Guidelines, last reviewed and approved on 3/10/2025, the P&P indicated the policy's purpose was to provide guidelines for the creation and/or review of policies, and to outline the approval process. Departmental policies and procedures are created, approved, maintained and archived in a consistent and timely manner, following a standardized approval and maintenance process. The ''Policy Owner is the Director/Manager of each department, as they are responsible for the creation, review, revision, removal, and/or archive of their department's policies. The Policy Owner is responsible for updating policy. All clinical content is to be reviewed and revised by licensed caregivers and/or department Directors/Managers. Ensure policy content and formatting accuracy. Check that policy content is correct and applies to the department/unit's current practices. Ensure the policy is within scope of practice, and in accordance with Nurse Practice Act. Confirm that the policy contains the most current and evidence-based information. All departments are required to review their departmental policies according to the following timelines, and as needed for regulatory purposes. It is the responsibility of the department manager to ensure that appropriate documentation is maintained for any Standardized Procedures used in their department/area.

Based on observation, interview and record review, the facility failed to ensure three of five sampled residents (Resident 24, Resident 38, and Resident 40) investigated under the respiratory care area oxygen (type of gas our body needs in order to function) therapy equipment was maintained, and standard infection control practices were followed by failing to ensure: 1. Resident 24 and Resident 38's oxygen tubing did not touch the floor. 2. Resident 40's humidification bottle was labeled and changed per the facility established schedule. 3. Resident 38's Yankauer suction tool (long plastic tool used to remove secretions [thick or thin sticky fluids from the mouth and throat]) was labeled with the date when it was opened. These deficient practices had the potential for Resident 24, Resident 38, and Resident 40 to develop complications such as infection. Findings: 1a. During a review of Resident 24's Face Sheet (Admission Record), the Face Sheet indicated the facility originally admitted the resident on 7/16/2020, and readmitted the resident on 3/31/2022, with diagnoses including acute respiratory failure (a condition where the respiratory system is unable to function properly, which can lead to a failure of gas exchange), traumatic brain injury (TBl - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 24's History and Physical (H&P), dated 11/11/2024, the H&P indicated the resident is unable to make medical decisions. During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated 1/28/2025, the MDS indicated Resident 24 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 24 had tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] in the front of the neck) and was on continuous oxygen therapy (a treatment that supplies oxygen at higher levels than normal room air). During a review of Resident 24's physician's orders, dated 12/30/2024, the Order Summary Report indicated an order of may suction resident for increase secretion three times a day (TID) as needed. During an observation, on 3/24/2025, at 9:16 a.m., inside Resident 24's room, Resident 24 laid in bed with the resident's tracheostomy connected to oxygen at two (2) liters per minute (liters/min - a unit of measurement) via tracheostomy mask with the oxygen tubing touching the floor. During a concurrent observation and interview, on 3/24/2025, at 9:40 a.m., with the Infection Preventionist (IP), inside Resident 24's room, the IP confirmed and stated Resident 24's oxygen tubing was touching the floor. The IP stated oxygen tubing is not supposed to be touching the floor. The IP stated the tubing is supposed to be changed to a shorter one if the tubing is too long to prevent the tubing from touching the floor. The IP stated Resident 24's oxygen tubing should not be touching the floor as the floor is dirty and contaminated and can place the resident at risk for acquiring an infection. During a review of the facility's policy and procedure (P&P) titled, Standards of Care (Sub Acute), last reviewed on 3/10/2025, the P&P indicated the licensed nurse will carry out safety procedures for proper infection control practices, isolation techniques, use of restraints and side rails and care of the environment should be followed as indicated. 1b. During a review of Resident 38's Face Sheet, the Face Sheet indicated the facility admitted Resident 38 on 11/25/2024 with a diagnosis including respiratory failure (lungs are not working well causing difficult breathing). During a review of Resident 38's, dated 11/26/2024, the H&P indicated Resident 38 had a medical history of tracheostomy, cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain), hypertension (HTN - high blood pressure), and urinary bladder (stores urine) neurogenic (brain, spinal cord, and/or nervous system) dysfunction (not working properly). During a review of Residents 38's MDS, dated [DATE], the MDS indicated Resident 38 had severe cognitive impairment and required assistance of two-person physical assist for ADLs. The MDS indicated Resident 38 received oxygen therapy, suctioning, and tracheostomy care. During a review of Resident 38's Care Plan (CP) titled, Device-Related Complication Risk (Artificial Airway), initiated on 8/29/2024, the CP interventions included: Provide oral (mouth) care regularly, evaluate need for suctioning to minimize risk of airway obstruction (blockage), and apply O2 (oxygen)/ventilation (moving air in and out of lungs). During a concurrent observation and interview, on 3/24/2025, at 1:45 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 38's room, the oxygen tubing from Resident 38's tracheostomy site at the neck to the oxygen humidifier (adds moisture to oxygen) on the wall, coiled on the floor. LVN 1 stated the oxygen tubing should not touched the floor because the floor was contaminated (dirty). During an interview, on 3/27/2025, at 8:38 a.m., with Registered Nurse (RN) 4, RN 4 stated it was important to keep oxygen tubing off the floor for infection control. RN 4 stated we need to prevent tubing from being on the floor because the resident could get an infection such as ventilator (breathing machine) associated pneumonia ([NAME] - lung infection from using the ventilator through a tube inside the mouth and throat, or through a tracheostomy). During a review of the facility's P&P titled, Standards of Care - Sub Acute, dated 3/2024, the P&P indicated, Licensed nurse will carry out safety procedures as outlined in the P&P for proper infection control practices, isolation techniques, use of restraints and side rails, and care of the resident's environment should be followed as indicated. 44244 2. During a review of Resident 40's H&P, dated 9/27/2024, the H&P indicated the facility originally admitted the resident on 9/26/2024 with diagnoses including squamous cell carcinoma (a type of cancer) of the neck, chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues), tracheotomy, and ventilator dependence. During a review of Resident 40's MDS, dated [DATE], the MDS indicated the facility originally admitted the resident on 9/26/2024 and most recently admitted on [DATE]. The MDS further indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident used a mechanical ventilator and received oxygen therapy. During a review of Resident 40's Order Report, dated 3/26/2025, the Order Report indicated a physician's order for humidified O2 via T-piece (a device use to help tracheostomy breathing) during waking hours as tolerated with supervision and family on bedside (start at 60 minutes, increase duration daily if possible). Place back on ventilator support if in distress. Titrate (adjust) O2 to maintain 92 percent (%, a measurement), add humidifier, dated 11/15/2024. During a review of Resident 40's CP on presence of an artificial airway, initiated 9/27/2024, the CP indicated to provide humidification. During an observation, on 3/24/2025, at 10:30 a.m., inside Resident 40's room, supplemental oxygen via oxygen tubing and a humidifier bottle connected to Resident 40. Resident 40's oxygen humidifier bottle did not indicate the date it was last changed. During a concurrent observation and interview, on 3/24/2025, at 10:35 a.m., with RN 8, RN 8 entered Resident 40's room, turned on the light, and stated humidification bottles are changed by the night shift and should be labeled with the date the bottle was changed. RN 8 stated Resident 40's humidification bottle was not labeled, and RN 8 did not know when the bottle was last changed. During a concurrent observation, interview, and record review, on 3/24/2025, at 10:40 a.m., with Respiratory Therapist (RT) 1, the Subacute Supply Change and Equipment Check Schedule was reviewed. RT 1 confirmed and stated oxygen humidification bottles are changed every three days and the bottles are labeled with the date the bottle was last changed. RT 1 assessed Resident 40's oxygen humidification bottle and stated the bottle did not indicate the date it was last changed. RT 1 stated there was no documentation indicating Resident 40's humification bottle was changed within the last three days. RT 1 stated if Resident 40's humidification bottle was not labeled with the date, then RT 1 did not know when the bottle was last changed. During an interview, on 3/27/2025, at 8:35 a.m., with the Nurse Manager (NM), the NM stated oxygen humidification bottles are changed every three days and must be labeled with the date last changed. The NM stated it was important to label with the date to communicate when the bottles were last changed and to identify when the bottle needs to be changed next. The NM stated when Resident 40's oxygen humidification bottle did not indicate the date it was last changed, there was a risk the bottle was used for an extended amount of time causing an infection control issue. The NM stated Resident 40 is connected to a ventilator system and when the humidification bottle was not changed, there was a potential for the resident to develop a respiratory infection. The NM stated the facility policy and procedures regarding infection control were not followed. During a review of the facility provided, Subacute Supply Change and Equipment Check Schedule, last reviewed 4/2024, the Subacute Supply Change and Equipment Check Schedule indicated the RT is responsible for ventilator patients. The bubble humidifier (humidification bottle) is changed by the day shift when the water level is 25 % or every three days. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions and Transmission-Based Precautions, last reviewed 3/10/2025, the P&P indicated standard precautions is the primary practice used for the prevention of the spread of disease and infections. Standard precautions are used in the care of all patients regardless of their diagnosis or presumed infection status. All caregivers including clinical and non-clinical caregivers are expected to follow appropriate precautions. Ensure single use items are discarded properly. 50516 3. During a concurrent observation and interview on 3/24/2025 at 1:45 p.m., with LVN 1, in Resident 38's room, Resident 38's Yankauer suction tool was opened and had yellow secretions inside. LVN 1 stated the Yankauer did not have a date of when it was opened or needed to be changed. LVN 1 stated I don't know when it was opened. LVN 1 stated the Yankauer should be changed every day and as needed and should be dated when it was opened or needed to be changed. During an interview on 3/27/2025 at 8:38 a.m., with Registered Nurse (RN) 4, RN 4 stated if oxygen equipment was not changed on the right date or time, it could cause an infection for the resident. During a review of the facility's policy and procedure (P&P) titled, Standards of Care - Sub Acute, dated 3/2024, the P&P indicated, licensed nurse will carry out safety procedures as outlined in the P&P for proper infection control practices, isolation techniques, use of restraints and side rails, and care of the resident's environment should be followed as indicated. During a review of the facility's procedure titled Subacute (more specialized care than a general skilled nursing facility) Supply Change and Equipment Check Schedule, undated, the procedure indicated to change the Yankauer weekly and PRN (as needed) when soiled (caking [dried or hardened substance] present).

Based on interview and record review, the facility failed to ensure residents are free of any significant medication errors for two of two sampled residents (Residents 35 and 42) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin and heparin (an anticoagulant) administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross Reference F658 Findings: a. During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a major type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain, hypertension (HTN - also known as high blood pressure), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 35's History and Physical (H&P) dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck and was non-verbal (not speaking). During a review of Resident 35's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/28/2025, the MDS indicated Resident 35 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 35 received anticoagulant. During a review of Resident 35's physician's order, the physician's order dated 1/8/2025 indicated heparin sodium injection (porcine) solution 5000 units per milliliter (units/ml - a unit of measurement) 5000 units subcutaneously every 12 hours for DVT (deep vein thrombosis - a blood clot that forms in one or more of the deep veins in the body, usually in the legs causing leg pain or swelling) prophylaxis. During a review of Resident 35's care plan (CP) on thrombolytic therapy (the use of medications to dissolve blood clots) last revised on 3/2/2025 with a target date of 5/28/2025, the CP indicated to frequently monitor peripheral perfusion to address complications early as one of the interventions to prevent and manage risk of bleeding. During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 35's physician's order, subcutaneous administration sites for heparin from 1/8/2025 to 3/25/2025, and the MDS with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 35 received heparin, had a physician's order for heparin, and were administered as follows: Heparin 5000 units/ml injection 5000 units: - 1/20/2025 5:51 a.m. left upper quadrant - LUQ - 1/20/2025 5:03 p.m. LUQ - 3/2/2025 6:22 p.m. LUQ - 3/3/2025 5:14 a.m. LUQ - 3/7/2024 6:58 a.m. right upper quadrant - RUQ - 3/7/2025 5:39 a.m. RUQ - 3/23/2025 5:15 a.m. LUQ - 3/23/2025 17:32 LUQ The MDSN stated administration sites for insulin and anticoagulants such as heparin should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for the heparin were not rotated. The MDSN stated Resident 35's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin. The MDSN stated not rotating the administration sites for the insulin is not following the standards of practice and manufacturer's guideline and can be considered a medication error which may lead to an adverse reaction to the medicine. During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with Registered Nurse (RN) 8, RN 8 stated the location of administration sites for Resident 35's heparin were not rotated. RN 8 stated the nurses are supposed to rotate heparin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 35's administration sites for heparin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the medication. RN 8 stated not rotating the administration sites for the heparin is not following the standards of practice and manufacturer's guideline and can be considered a medication error. During a review of the facility-provided manufacturer's guideline for heparin sodium injection solution, dated 1/2022, the manufacturer's guideline indicated to use a different site for each injection. The manufacturer's guideline further indicated injection site irritation is one of the most common adverse reactions for the use of heparin. During a review of the facility's policy and procedure (P&P) titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following: - Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. - Injection sites for subcutaneous and intramuscular administration must be rotated. During a review of the facility's P&P titled, Medication Error Reporting, last reviewed on 3/10/2025, the P&P indicated a medication event/error is defines as any preventable event (actual/potential) that may cause or lead to inappropriate medication use and/or patient harm while medication is in the control of health care professional, patient or consumer. Medication errors can occur within any of the following steps in the medication management process including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. b. During a review of Resident 42's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 9/4/2024 and readmitted in the facility on 12/20/2024 with diagnoses including history of stroke (loss of blood flow to a part of the brain), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck, and ventilator-dependent respiratory failure (condition when a patient's lungs cannot breath on their own and required a machine to help breathe). During a review of Resident 42's History and Physical (H&P) dated 12/22/2024, the H&P indicated Resident 42 was awake and alert but did not indicate the resident's capacity to understand and make decisions. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was able to make his needs known and able to understand others. The MDS further indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 42 received insulin. During a review of Resident 42's physician's order, the physician's order dated 2/24/2025 indicated insulin glargine-yfgn (a long-acting insulin) injection vial eight (8) units (a unit of measurement) at bedtime for diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 42's care plan (CP) on hyperglycemia last revised on 3/2/2025 with a target date of 7/31/2025, the CP indicated to provide pharmacologic therapy (drug or medication therapy) to maintain blood sugar levels within targeted range. During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 42's physician's order, subcutaneous administration sites for insulin glargine from 2/24/2025 to 3/25/2025, and the MDS with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 42 had a physician's order for insulin glargine, and were administered as follows: Insulin glargine-yfgn injection 8 units: - 3/12/2024 5:35 p.m. left lower quadrant - LLQ - 3/13/2025 5:34 p.m. LLQ - 3/17/2025 5:27 p.m. left upper arm - LUA - 3/18/2025 5:51 p.m. LUA The MDSN stated administration sites for insulin and anticoagulants should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for Resident 42's insulin glargine were not rotated. The MDSN stated Resident 42's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin. The MDSN stated not rotating the administration sites for the insulin is not following the standards of practice and manufacturer's guideline and can be considered a medication error. During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with Registered Nurse (RN) 8, RN 8 stated the location of administration sites for Resident 42's insulin glargine were not rotated. RN 8 stated the nurses are supposed to rotate insulin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 42's administration sites for insulin glargine should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. RN 8 stated not rotating the administration sites for the insulin is not following the standards of practice and manufacturer's guideline and can be considered a medication error. During a review of the facility-provided manufacturer's guideline for insulin glargine (rDNA origin) 100 units per milliliter (units/ml - a unit of measurement) three (3) ml pen dated 8/26/2022, the manufacturer's guideline indicated to change (rotate) the injection site for each injection and to inject under the skin of the stomach area, buttocks, upper legs or upper arms. During a review of the facility's P&P titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following: - Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. - Injection sites for subcutaneous and intramuscular administration must be rotated. During a review of the facility's P&P titled, Medication Error Reporting, last reviewed on 3/10/2025, the P&P indicated a medication event/error is defines as any preventable event (actual/potential) that may cause or lead to inappropriate medication use and/or patient harm while medication is in the control of health care professional, patient or consumer. Medication errors can occur within any of the following steps in the medication management process including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure towels were stored in clean towel bins, sanitation buckets, or dirty towel bins when not in use. 2. Ensure food items in the walk-in Refrigerators #2 and #5 were labeled according to facility policy. 3. Ensure the personal property of staff was not stored in the kitchen area next to an uncovered serrated knife and food items. 4. Ensure Refrigerator #10 and the Subacute Resident Refrigerator/Freezer temperatures were maintained per facility policy and procedure. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (the process by which bacteria, microorganisms, or chemicals are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 10 of 45 medically compromised residents who received food and ice from the kitchen. Findings: a. During an Initial Kitchen Tour, on [DATE], at 8 a.m., with the Interim Director of Hospitality Services (IDHS) and Food Service Attendant 1 (FSA 1), the IDHS stated the facility uses white towels to sanitize the kitchen. The IDHS stated all towels should only be stored in clean towel bins prior to use, red sanitizer buckets when in use, or dirty towel bins after use. The IDHS stated no towels should be left out in the tray line area to prevent cross contamination from one surface to another while staff is performing tasks in the kitchen. Observed the following in the tray line area: 1. A white towel placed on the top of FSA 1's black rolling cart. The IDHS stated the towel was used and should not be on the cart. FSA 1 stated at approximately 6:30 a.m., FSA 1 used the towel and placed the dirty towel on the cart. FSA 1 stated she should not have placed the dirty towel on the cart. FSA 1 stated dirty towels should not be left on carts because the towel could be soiled with bacteria that could potentially contaminate the tray line area. FSA 1 stated there was no reason why she left the towel on the cart and stated she should not have. 2. Two white towels placed on an unattended black rolling cart. The IDHS stated she did not know if the towels were used. The IDHS stated the towels should not be placed on the unattended cart. The IDHS removed the towels and placed them in the dirty towel bin. The IDHS stated the towels could be dirty and cause cross contamination resulting in foodborne illness in residents. During a concurrent interview and record review, on [DATE], at 1:35 p.m., with the Clinical Nutrition Manager (CNM), the facility provided Health and Safety Code (HSC) regarding equipment, utensils, and linens was reviewed. The CNM stated the facility does not have a specific policy regarding the use of towels in the kitchen, but it is a standard of practice to never keep towels in the kitchen area unless they are in a sanitization bucket. The CNM reviewed the HSC and stated the kitchen staff did not follow the HSC when towels were left out in the kitchen. During a review of the facility provided HSC document titled, Article 5. Linens, dated effective [DATE], the HSC indicated wiping cloths that are used repeatedly are held in a sanitizing solution of an approved concentration. Working containers of sanitizing solutions for storage of in-use wiping cloths shall be used in a manner to prevent contamination of food, equipment, utensils, and linens. Soiled linens shall be kept in receptacles and transported to prevent contamination of food, clean equipment, and clean utensils. During a review of the facility policy and procedure (P&P) titled, Safety and Sanitation Standards, effective date [DATE], the P&P indicated safety and sanitation standards are followed to ensure the provision of safe food to the customers. Each employee is responsible for maintaining a clean and safe work area throughout their shift. b. During an Initial Kitchen Tour, on [DATE], at 8 a.m., with the IDHS and FSA 1, the IDHS stated staff have a locker to store their personal belongings and personal knives when not in use. The IDHS stated no personal items should be in the kitchen because there is a potential of cross contamination resulting in foodborne illness in residents. The top shelf of FSA 1's black rolling cart contained a box of substitute sugar packets, a box of seasoning packets, a cellphone, a wireless headphone case, and a serrated knife. The IDHS stated FSA 1 should have stored the cell phone and headphone case in FSA 1's locker. The IDHS stated FSA 1's knife should have been covered and securely stored in the designated storage area when not in use, but FSA 1 stored the uncovered knife on the cart next to FSA 1's personal items. FSA 1 stated the cell phone and headphone case belonged to her and personal items should not be stored in the kitchen. FSA 1 stated she uses the knife to cut fruit and the knife should not be stored uncovered and next to personal items because the phone and headphone case could contaminate the knife and other food items with bacteria. FSA 1 stated there was no reason why she stored the knife and personal items in the cart. During a concurrent interview and record review, on [DATE], at 1:35 p.m., the CNM reviewed the facility provided HSC regarding personal belongings. The CNM stated some kitchen staff bring personal knives to use in the facility kitchen and the knives should be stored properly when not in use. The CNM stated all cell phones and headphone cases should always be stored in the staff members locker and not in the kitchen or tray line area. The CNM stated the facility did not have a specific policy regarding personal items and uncovered knives in the kitchen, but it was a standard of practice based on the HSC. The CNM stated FSA 1 did not follow the facility practice when the knife, cell phone, and headphone case were stored on the cart in the tray line area. During a review of the facility provided HSC document titled, Article 4. Employee Storage Areas dated effective [DATE], the HSC indicated lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, and linens cannot occur. No personal effects are stored in any area used for the storage or preparation of food. A safety knife holder shall be provided to avoid loose storage of knives. During a review of the facility P&P titled, Dress Code, effective date [DATE], the P&P indicated the purpose of the P&P was to avoid contamination of food. As appropriate and available, a locker will be assigned for employee use. Cell phones are not permitted at workstations. During a review of the facility P&P titled, Safety and Sanitation Standards, effective date [DATE], the P&P indicated safety and sanitation standards are followed to ensure the provision of safe food to the customers. Each employee is responsible for maintaining a clean and safe work area throughout their shift. c. During an Initial Kitchen Tour, on [DATE], at 8 a.m., with the IDHS, observed the facility walk in refrigerators with the IDHS. The IDHS stated the facility labels food items that are stored in the refrigerators to facilitate the first in, first out method (rotation method used to minimize waste and ensure food safety by preventing spoilage) and to ensure expired food is discarded and not served to residents. The IDHS stated it was important to label and discard expired food because there is a potential that expired foods served to resident may cause foodborne illness. Observed the following: 1. In Refrigerator #5, two unopened, prepackaged egg salad sandwiches by Manufacture 1(Mfr. 1), labeled ,d+[DATE]. The IDHS stated the sandwiches expired on [DATE] and should not have been stored in the refrigerator available to be served to residents. The IDHS stated the staff should have discarded the expired sandwiches and they did not. The IDHS stated when the expired sandwiches were left in the refrigerator, there was a potential that the expired sandwiches could be served to residents causing illness. 2. In Refrigerator # 5, there was one unlabeled large pan of cooked meat that was partially uncovered with the contents exposed to air. The IDHS stated the pan contained leftover chicken breasts and was unlabeled. The IDHS stated she did not know when the pan was placed in the fridge because it was not labeled. The IDHS stated it was important to label leftovers with the item contents and date of expiration to ensure staff knows what the food is and to ensure expired food is not served to residents. 3. In Refrigerator #2, one opened container labeled sour cream. The IDHS stated the expiration date on the container was not legible. The IDHS stated the facility uses the expiration on the container to know when to discard the sour cream. The IDHS stated because the expiration date was not legible, she did not know if the sour cream was expired. The IDHS stated if an expiration date is not legible then the sour cream should be thrown out. During a concurrent interview and record review, on [DATE], at 1:35 p.m., the CNM reviewed the facility P&P regarding food storage labeling and leftovers. The CNM stated the kitchen floor stocking staff should discard any unlabeled, illegibly labeled, or expired foods from the refrigerators to ensure expired food that may be sour, rotted, or moldy is not served to residents. The CNM stated when expired food is served to residents it may affect the nutritional value of food and cause the residents to not feel well. During a review of the facility P&P titled, Label and Dating, effective date [DATE], the P&P indicated the Food and Nutrition Services shall ensure that foods are labeled, dated, and stored appropriately. The purpose of the P&P was to ensure proper storage and safety of the department's food supply. The following procedures and checks are done regularly to prevent any possible contamination or spoilage of food: i. Caregivers are to remove any expired item and ensure that foods are safely stored. ii. All food supplies shall be rotated on a first-in, first-out, basis. This will ensure the oldest product is used first. iii. The pull date, is the last date that an item can be used. The product will be pulled on the morning following its pull date, and disposed of. Items prepared on premises, will carry a pull date to ensure maximum freshness. Where items are pull-dated by the manufacture, items will be pulled accordingly. iv. Products will be dated via the following acceptable mechanisms. a) Label with the following information will be used to label and date foods for holding and storage: i) Item name ii) Use by date (pull date) iii) Employee signature v. All prepared items will receive a three day pull date. During a review of the facility P&P titled, Label and Dating, Attachment A; Pull Dates, effective date [DATE], the P&P attachment indicated the following pull dates: Product: sour cream has a pull date of the date on the container. Product: cooked chilled chicken has a pull date of three days. Product: Mfr. 1 Sandwiches have a pull date of two days. During a review of the facility P&P titled, Leftovers, effective date [DATE], the P&P indicated leftover food is given a three day pull date to ensure proper usage, storage, and safety of the department leftover's food. Food portions not utilized in the service of a meal will be refrigerated in a shallow covered container labeled and dated with a three day pull date. d.1. During an Initial Kitchen Tour, on [DATE], at 8 a.m., with the IDHS, observed the facility walk in refrigerators with the IDHS. The IDHS stated the facility maintains refrigerators at an acceptable temperature range of 32 to 41 degrees Fahrenheit ( F, a unit of measurement for temperature) to ensure the quality of the food and to prevent food borne illness in residents . The IDHS stated refrigerator # 10 is used during tray line and the thermometer indicated the refrigerator was 41 degrees. The IDHS reviewed Refrigerator #10's Temperature Log for ,d+[DATE] and noted the refrigerator was out of the acceptable temperature range for the p.m. shift (evening shift) on the following dates: - On [DATE], the temperature was 42 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 48 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 42 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 42 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 44 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 44 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 44 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 44 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 44 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 45 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 44 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 44 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 42 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 46 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 52 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 50 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 50 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 42 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 42 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 44 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 42 F, no corrective actions/comments are indicated. The IDHS further stated she did not know why Refrigerator #10 was out of the acceptable temperature range only on the p.m. shift. During a concurrent interview and record review, on [DATE], at 10:45 a.m., with the CNM, the facility provided Work Order email, dated [DATE], and Refrigerator #10's Temperature Log, for ,d+[DATE], were reviewed. The CNM noted Refrigerator #10 was out of the acceptable temperature range for the p.m. shift (evening shift) on the following dates: - On [DATE], the temperature was 44 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 42 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 42 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 44 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 42 F, no corrective actions/comments are indicated. The CNM further stated, on [DATE], at 6:43 p.m., the evening kitchen supervisor entered a work order indicating Refrigerator #10 was out of the temperature control limits and needed service. The CNM stated there was no follow up to the work order. The CNM stated the refrigerator was taking too long to reach acceptable temperature ranges after the evening tray line and should have been removed from the kitchen service, but it was not removed. The CNM stated a refrigerator should consistently provide an acceptable temperature range for food safety. The CNM stated the food safety temperature zone is below 41 degrees to prevent bacterial growth. The CNM stated when Refrigerator #10 was not maintained at a temperature between 32 to 41 F, it could have potentially resulted in bacterial growth causing food borne illnesses in residents. During a review of the facility P&P titled, Refrigerator/Freezer Temperature Logs, effective date [DATE], the P&P indicated all refrigerators and freezers must be monitored and the temperature documented to ensure the proper storage of food. The purpose of the policy was to ensure that food is safe and is being held n compliance with public health regulations. Temperatures will be checked daily in the main kitchen and patient units. All temperatures are documented on the appropriate temperature log with the recorder's initials. Acceptable temperature ranges are 32 to 41 F for refrigerators and below 0 F for freezers. When refrigerators and freezer temperatures are out of range, the following action step occur: a) Circle the out-of-range temperature in red ink b) Check the internal temperature of the food contained in the affected refrigerator and/or freezer, if the foods' temperature is out of the acceptable range, discard. c) Write an action plan on the temperature log, if more room is needed, turn the temperature log over and record the date and remainder of the action plan. d) Contact plant operations for repair as indicated e) Follow up to ensure the action plan has been completed. d.2. During a Subacute Kitchen Tour, on [DATE], at 9 a.m., with the Clinical Educator (CE), observed the subacute refrigerators with the CE. The CE stated the Subacute refrigerator was maintained and monitored by the facility kitchen staff. The CE stated the acceptable temperature range for the refrigerator was between 32 and 41 F. The CE reviewed the Subacute Refrigerator's Temperature Log for ,d+[DATE] and noted the refrigerator was out of the acceptable temperature range on the following dates: - On [DATE], the temperature was 20 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 24 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 25 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 28 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 25 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 25 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 25 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 25 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. - On [DATE], the temperature was 30 F, no corrective actions/comments are indicated. During a concurrent interview and record review, on [DATE], at 1:35 p.m., with the CNM, the CNM reviewed the Subacute Refrigerator's Temperature Log for ,d+[DATE]. The CNM stated the CNM was made aware the Subacute refrigerator was out of acceptable temperature range with no corrective actions indicated. The CNM stated the Subacute freezer log also indicated the freezer was out of the acceptable temperature range of below 0 F on the following dates: - On [DATE], the temperature was +10 F, no corrective actions/comments are indicated. - On [DATE], the temperature was +10 F, no corrective actions/comments are indicated. The CNM further stated the importance of reporting when the temperature is out of range is to ensure the refrigerator/freezer is checked and functioning properly. The CNM stated when the subacute refrigerator's temperature was too low it could have potentially resulted in quality issues like the liquids freezing. The CNM stated residents must be served the intended appropriate texture and consistency of foods. The CNM stated when the items do not remain frozen in the freezer, it may result in quality issues from foods defrosting and refreezing. During a review of the facility P&P titled, Refrigerator/Freezer Temperature Logs, effective date [DATE], the P&P indicated all refrigerators and freezers must be monitored and the temperature documented to ensure the proper storage of food. The purpose of the policy was to ensure that food is safe and is being held in compliance with public health regulations. Temperatures will be checked daily in the main kitchen and patient units. All temperatures are documented on the appropriate temperature log with the recorder's initials. Acceptable temperature ranges are 32 to 41 F for refrigerators and below 0 F for freezers. When refrigerators and freezer temperatures are out of range, the following action step occur: a) Circle the out-of-range temperature in red ink b) Check the internal temperature of the food contained in the affected refrigerator and/or freezer, if the foods' temperature is out of the acceptable range, discard. c) Write an action plan on the temperature log, if more room is needed, turn the temperature log over and record the date and remainder of the action plan. d) Contact plant operations for repair as indicated e) Follow up to ensure the action plan has been completed.

Based on observation, interview, and record review the facility failed to implement and maintain an infection control program by failing to ensure Registered Nurse (RN) 9, accompanied by the Nurse Practitioner (NP) and Medical Doctor (MD), implemented Contact Precautions (an infection control measure aimed to prevent spread of infection by direct or indirect contact by the use of personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments]) during rounding in the residents room for one of five sampled residents (Resident 39) reviewed under the Infection Control task area. This deficient practice had the potential to result in the spread of infectious microorganisms amongst staff, residents, and visitors. Findings: During a review of Resident 39's History and Physical (H&P), dated 3/27/2025, the H&P indicated the resident was readmitted to the facility on [DATE] with diagnoses that included prostate (a gland in the male reproductive system) cancer, chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and percutaneous endoscopic gastrostomy (PEG or GT - a tube placed directly into the stomach to give direct access for supplemental feeding, hydration or medicine) placement. During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 1/24/2025, the MDS indicated the resident was originally admitted to the facility on [DATE]. The MDS further indicated the resident sometimes had the ability to make self-understood and sometimes understood others. The MDS indicated the resident was dependent on staff for oral and personal hygiene, bathing, dressing, toileting, and mobility. During a review of Resident 39's Physician Orders, dated 11/18/2024, the Physician Orders indicated a physician's order for contact isolation for Carbapenem-resistant pseudomonas aeruginosa (CRPA - an infectious bacteria spread through contact with contaminated surfaces, healthcare workers, or equipment); multidrug-resistant pseudomonas aeruginosa (MDRA - infectious bacteria that are resistant to the effects of multiple types of antibiotics [medication used to treat bacteria]) During an observation, on 3/24/2025, at 10:55 a.m., Resident 39's entry to the room had a contact isolation sign posted. The sign indicated before entering the room, all staff and visitors must put on a gown and gloves. RN 9, Resident 39's NP and MD were inside Resident 39's room not wearing gowns. RN 9, the NP, and the MD exited the resident's room after speaking with Resident 39's family member. During an interview, on 3/24/2025, at 11 a.m., with RN 9 upon exiting Resident 39's room, RN 9 stated Resident 39 had a contact isolation sign at the entry to the room because the resident was on contact isolation. RN 9 stated gloves and a gown should be donned (put on) before entering the resident's room. RN 9 stated that RN 9, the NP, and the MD did not don gowns prior to entering or while inside the resident's room because they were not touching the resident. During an interview, on 3/27/2025, at 11:44 a.m., with the facility Infection Preventionist (IP), the IP stated Resident 39 was diagnosed with CRPA. The IP stated CRPA can be spread amongst staff, residents, and visitors by touching surfaces contaminated with secretions or when secretions unexpectedly exit a resident's mouth or tracheostomy tubing during a cough. The IP stated to prevent the spread of CRPA, anyone entering the resident's room must don a disposable gown to prevent contamination of the staff or visitor's clothing. The IP stated staff and visitors should don a gown even if they do not intend to touch the resident or any environmental surfaces. The IP stated the gown prevents any cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) from Resident 39 to any of the other residents that the NP, MD, or RN 7 visit during their rounds. During an interview, on 3/27/2025, at 8:35 a.m., with the Nurse Manager (NM), the NM stated facility residents are at increased risk of infection and wearing a gown prevents the spread of infection between residents. The NM stated when RN 9, the NP, and the MD did not don gowns while inside Resident 39's room, the facility policy and procedures regarding contact isolation were not followed. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions and Transmission-Based Precautions, last reviewed 3/10/2025, the P&P indicated standard precautions are the primary practice used for the prevention of the spread of disease and infections. Standard precautions are used in the care of all residents regardless of their diagnosis or presumed infection status. All caregivers including clinical and non-clinical caregivers are expected to follow appropriate precautions. Contact precautions are used in addition to standard precautions. Use contact precautions for residents known or suspected to be infected or colonized with epidemiologically important / significant microorganisms that can be transmitted, by direct / indirect contact. For the resident who appears to have a disease requiring contact precautions, it is important to institute the appropriate precautions immediately. The appropriate sign should be posted on the resident's door. In addition to standard precautions, wear a gown providing 360-degree coverage to protect skin and prevent soiling and / or contamination of clothing. [NAME] PPE when entering a resident's room based on the anticipated interaction with the resident and environment. Remove / doff PPE before leaving the resident's room. During a review of the facility's P&P titled, [Regional] Standard Precautions and Transmission-Based Precautions, Appendix A last reviewed 3/10/2025, the P&P indicated contact precautions are recommended in long term care facilities for carbapenem resistant organisms.

Based on interview and record review, the facility failed to provide care in accordance with professional standards for two of two sampled residents (Residents 35 and 42) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin for Resident 42, and heparin (an anticoagulant) for Resident 35. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a major type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain), hypertension (HTN - also known as high blood pressure), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 35's H&P dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy and was non-verbal (not speaking). During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 35 received anticoagulant. During a review of Resident 35's physician's order, the physician's order dated 1/8/2025 indicated heparin sodium injection (porcine) solution 5000 units per milliliter (units/ml - a unit of measurement) 5000 units subcutaneously every 12 hours for DVT (deep vein thrombosis - a blood clot that forms in one or more of the deep veins in the body, usually in the legs causing leg pain or swelling) prophylaxis. During a review of Resident 35's care plan (CP) on thrombolytic therapy (the use of medications to dissolve blood clots) last revised on 3/2/2025 with a target date of 5/28/2025, the CP indicated to frequently monitor peripheral perfusion to address complications early as one of the interventions to prevent and manage risk of bleeding. During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 35's physician's order, subcutaneous administration sites for heparin from 1/8/2025 to 3/25/2025, and the MDS with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 35 received heparin, had a physician's order for heparin, and were administered as follows: Heparin 5000 units/ml injection 5000 units: - 1/20/2025 5:51 a.m. left upper quadrant - LUQ - 1/20/2025 5:03 p.m. LUQ - 3/2/2025 6:22 p.m. LUQ - 3/3/2025 5:14 a.m. LUQ - 3/7/2024 6:58 a.m. right upper quadrant - RUQ - 3/7/2025 5:39 a.m. RUQ - 3/23/2025 5:15 a.m. LUQ - 3/23/2025 17:32 LUQ The MDSN stated administration sites for anticoagulants such as heparin should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for the heparin were not rotated. The MDSN stated Resident 35's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin. During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with Registered Nurse (RN) 8, RN 8 stated the location of administration sites for Resident 35's heparin were not rotated. RN 8 stated the nurses are supposed to rotate heparin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 35's administration sites for heparin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the medication. During a review of the facility-provided manufacturer's guideline for heparin sodium injection solution dated 1/2022, the manufacturer's guideline indicated to use a different site for each injection. The manufacturer's guideline further indicated injection site irritation is one of the most common adverse reactions for the use of heparin. During a review of the facility's P&P titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following: - Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. - Injection sites for subcutaneous and intramuscular administration must be rotated. b. During a review of Resident 42's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 9/4/2024 and readmitted in the facility on 12/20/2024 with diagnoses including history of stroke (loss of blood flow to a part of the brain), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck, and ventilator-dependent respiratory failure (condition when a patient's lungs cannot breath on their own and required a machine to help breathe). During a review of Resident 42's H&P dated 12/22/2024, the H&P indicated Resident 42 was awake and alert but did not indicate the resident's capacity to understand and make decisions. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was able to make his needs known and able to understand others. The MDS further indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 42 received insulin. During a review of Resident 42's physician's order, the physician's order dated 2/24/2025 indicated insulin glargine-yfgn (a long-acting insulin) injection vial eight (8) units (a unit of measurement) at bedtime for diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 42's CP on hyperglycemia last revised on 3/2/2025 with a target date of 7/31/2025, the CP indicated to provide pharmacologic therapy (drug or medication therapy) to maintain blood sugar levels within targeted range. During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 42's physician's order, subcutaneous administration sites for insulin glargine from 2/24/2025 to 3/25/2025, and the MDS with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 42 received heparin, had a physician's order for insulin glargine, and were administered as follows: Insulin glargine-yfgn injection 8 units: - 3/12/2024 5:35 p.m. left lower quadrant - LLQ - 3/13/2025 5:34 p.m. LLQ - 3/17/2025 5:27 p.m. left upper arm - LUA - 3/18/2025 5:51 p.m. LUA The MDSN stated administration sites for insulin should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for Resident 42's insulin glargine were not rotated. The MDSN stated Resident 42's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin. During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with RN 8, RN 8 stated the location of administration sites for Resident 42's insulin glargine was not rotated. RN 8 stated the nurses are supposed to rotate insulin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 42's administration sites for insulin glargine should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. During a review of the facility-provided manufacturer's guideline for insulin glargine (rDNA origin) 100 units/ml three (3) ml pen dated 8/26/2022, the manufacturer's guideline indicated to change (rotate) the injection site for each injection and to inject under the skin of the stomach area, buttocks, upper legs or upper arms. During a review of the facility's P&P titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following: - Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. - Injection sites for subcutaneous and intramuscular administration must be rotated.

Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received the appropriate care and services to prevent complications for three of three sampled residents (Resident 2, 35, and 41) reviewed under the tube feeding care area by failing to: 1. Change Resident 35's water flush bag according to the manufacturer's guideline. 2. Indicate the date for Resident 2's medication syringe replacement. 3. Ensure Resident 41 the accurate amount of tube feeding formula was delivered to the resident as ordered. These deficient practices had the potential to result in altered nutritional status, such as dehydration and malnutrition, and complications associated with enteral feeding, such as gastrointestinal (GI - relating to stomach and intestines) problems, such as abdominal pain and diarrhea, and for residents to experience unmet nutritional needs and place residents at risk for unintended weight loss. Findings: a. During a review of Resident 2's Face Sheet (Admission Record), the Face Sheet indicated the facility originally admitted the resident on 6/7/2022 and readmitted in the facility on 1/30/2025 with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems), and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). During a review of Resident 2's History and Physical (H&P), dated 2/2/2025, the H&P indicated Resident 2 was awake and oriented but did not indicate if the resident had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/18/2024, the MDS indicated Resident 2 had intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated Resident 2 had a feeding tube (a soft, flexible tube inserted into the stomach or small intestine to deliver nutrition and fluids when someone can't eat or drink normally). During a review of Resident 2's physician's order, dated 10/28/2024, the physician's order indicated cyclic tube feeding Tube Feeding Formula (TFF - a liquid nutrition delivered directly into the stomach or small intestine via a feeding tube) 4 at 70 milliliter (ml - a unit of measurement for volume) per (/) hour (hr - a unit of measurement for time) start feeding at 5 p.m. until 6 a.m. During an observation, on 3/24/2025, at 9:58 a.m., inside Resident 2's room, Resident 2's medication syringe affixed with a sticker did not indicate a date of when to change the syringe. During a concurrent observation and interview, on 3/24/2025, at 10:10 a.m., inside Resident 2's room, with Registered Nurse (RN) 8, RN 8 stated Resident 2's medication syringe sticker did not indicate the date of when it should be changed. RN 8 stated the medication syringes are supposed to be changed every day and label the sticker with the date it would be changed. RN 8 stated Resident 2's medication syringe should have been labeled with the date it would be changed to ensure the syringe is clean and not contaminated as it placed the resident at risk for acquiring infection from a contaminated medication syringe. During an interview, on 3/27/2025, at 5 p.m., with the Infection Preventionist (IP), the IP stated medication syringes are changed every day and should indicate in the sticker the date it would be replaced. The IP stated Resident 2's medication syringe should have been labeled with the date it would be replaced as it was an infection issue and placed the resident at risk for acquiring infection from a contaminated medication syringe. During a concurrent interview and record review, on 3/26/2025, at 4:30 p.m., with the Nurse Manager (NM), the facility provided procedure titled, Enteral Tube Feeding, continuous, Gastrostomy, and Jejunostomy, last revised on 11/18/2024, was reviewed and the NM stated the facility follows the procedure for any enteral feeding related issues. The NM stated the procedure did not specifically indicate labeling of the medication syringe. The NM stated per facility practice, medication syringes are supposed to be changed every day and should indicate the date it will be replaced so the staff would know if it was old or new. b. During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain), percutaneous endoscopic gastrostomy tube (PEG - a feeding tube inserted directly into the stomach allow a person to receive nutrition through the stomach) dependent, and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 35's H&P, dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had severely impaired cognition and required total assistance from staff with all ADLs. The MDS further indicated Resident 35 had a feeding tube. During a review of Resident 35's physician's order, dated 10/28/2024, the physician's order indicated continuous tube feeding renal Nepro (a therapeutic nutrition designed to meet the nutritional needs of people with kidney disease) at 35 ml/hr. During an observation, on 3/24/2025, at 11:07 a.m., inside Resident 35's room, Resident 35's water flush bag and label indicated a date of 3/23/2025 at 4 a.m. During a concurrent observation and interview, on 3/24/2025, at 11:27 a.m., inside Resident 35's room with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed and stated Resident 35's water flush bag indicated a date of 3/23/2025 at 4 a.m. LVN 1 stated water flush bags are changed by the nurse assigned to the resident as the water flush bags were only good for 24 hours. LVN 1 stated Resident 35's water flush bag had been hanging for more than 24 hours and should have been changed according to the manufacturer's guideline as it can already be contaminated, and Resident 35 can get infection. During a concurrent observation and interview, on 3/24/2025, at 11:50 a.m., inside Resident 35's room with RN 9, RN 9 stated Resident 35's water flush bag indicated a date and time of 3/23/2025, at 4 a.m., and it had already been more than 24 hours since the bag was last changed. RN 9 stated water flush bags are changed by the nurse assigned to the residents every 24 hours according to the manufacturer's guidelines. RN 9 stated Resident 35's water flush bag should have been changed as it can already be contaminated which placed the resident at risk for acquiring infection. During an interview, on 3/27/2025, at 5 p.m., with the IP, the IP stated water flush bags are supposed to be changed every 24 hours as indicated in the manufacturer's guideline. The IP stated Resident 35's water flush bag should have been changed as the bag can already be contaminated from being used for more than 24 hours and Resident 35 can get infection from the contaminated water flush bag. During a review of the facility provide manufacturer's guideline for the Water Flush Bag (WFB) 1, undated, the manufacturer's guideline indicated the device is intended for enteral feeding only and recommended to be replaced every 24 hours. During a review of the facility provided procedure titled Enteral Tube Feeding, continuous, Gastrostomy, and Jejunostomy, last revised 11/18/2024, the procedure indicated to change the administration set according to the manufacturer's instructions to prevent bacterial growth. 38552 c. During a review of Resident 41's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/11/2024 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe) and dementia (a progressive state of decline in mental abilities). During a review of Resident 41's MDS, dated [DATE], the MDS indicated the resident had no speech, hearing highly impaired, rarely/never makes self-understood, and rarely/never had the ability to understand others. The MDS indicated the resident had function limitation in range of motion (full movement of a joint) on both sides of upper and lower extremities. The MDS indicated the resident with feeding tube while a resident of the facility. During a review of Resident 41's physician order, dated 2/26/2025, the physician order indicated TFF 3; 70 ml/hr, continuous 22 hours daily, gastrostomy, free water amount 100 ml, free water frequency every six hours. During a review of Resident 41's Follow-Up Nutrition Assessment, dated 2/22/2025, the Follow-Up Nutrition Assessment indicated the dietitian recommendations to continue TFF 3 1.2 to 70 milliliters for 22 hours daily to slow down weight loss. During a review of Resident 41's Flowsheet, dated 3/24/2025 to 3/25/2025, the Flowsheet indicated the following tube feeding intake: - 3/24/2025 at 6 a.m., 794 ml - 3/24/2025 at 6 p.m., 770 ml - 3/25/2026 at 6 a.m., 776 ml. During a review of Resident 41's care plan focusing on enteral nutrition, dated 12/17/2024, the care plan indicated interventions including minimizing unnecessary disruptions to feeding and using enteral nutrition protocol to optimize delivery. During a concurrent observation and interview, on 3/25/2025, at 8:34 a.m., with RN 9, inside Resident 41's room, the tube feeding connected to Resident 41 indicated TFF 3 labeled with the date 3/25/2025, start time 2 a.m., and set at 70 ml/hr in a one-liter container. RN 9 stated about 750 ml of fluid was left in the TFF 3 container. RN 9 stated 146 ml of formula was administered. RN 9 stated the next shift clears the amount in the tube feeding machine when they start their shift. RN 9 stated the start date and time was when the new TFF 3 was started, 3/25/2025 at 2 p.m. RN 9 stated the total time from 2 a.m. to 8:30 a.m. is 6 hours and 30 minutes. RN 9 stated when the tube feeding formula rate is set to 70 ml/hr, there should be about 455 ml delivered and should have about 545 ml left in the bag. RN 9 stated they also account for pausing the tube feeding during ADLs or repositioning which takes about 10 to 15 minutes. During a concurrent interview and record review, on 3/25/2025, at 8:38 a.m., with RN 9, Resident 41's Flowsheet, dated between 3/24/2025 to 3/25/25, nursing notes, dated between 3/24/2025 to 3/25/2025, and physician orders were reviewed. RN 9 stated there was no documentation to account for the 205 ml difference left in the bag. RN 9 stated there should have been a documentation why TFF 3 still had that much formula left in the bag. RN 9 stated there were no new orders to hold Resident 41's tube feeding formula. During an interview, on 3/27/2025, at 5:42 p.m., with RN 7, RN 7 stated at the start of the primary nurse's shift they check the tube feeding machine regarding the timing, the rate, and clear the amount delivered and monitor how much the resident's intake is. RN 7 stated the primary nurse can set up the machine to deliver the amount of formula at a set time and once the time has been reached, the machine will alarm. RN 7 stated if there is discrepancy with the amount left in the formula bag the primary nurse should have documented the reason why it has that much left and should have notified the resident's physician and the resident's family about it. RN 7 stated they should have notified the physician because there is no order for bolus or to increase the rate to catch up to the amount the resident is supposed to receive. RN 7 stated they can hold it for a short amount of time when the staff is providing ADLs or repositioning the resident. RN 7 stated the importance of following the order is to ensure the resident receives the amount of nutrients and vitamins as ordered to keep the resident in a healthy condition. RN 7 stated when the set amount of tube feeding formula is not received by Resident 41, the resident could potentially lose weight and may not get enough vitamins, minerals, or calories which can lead to malnutrition. During a review of the facility's Reference (Ref) 1 titled, Enteral tube feeding, continuous, gastrostomy and jejunostomy, last reviewed and approved on 3/10/2025, the Ref 1 indicated implementation included the following: - Verify the practitioner's order including administration method, volume, rate, and type, volume, and frequency of water flushes. - Make sure the enteral formula container is labeled with the date and time that the formula was hung, administration route, rate, and duration. - Frequently monitor the gravity drip rate or enteral feeding pump infusion rate to ensure accurate delivery of the enteral formula. During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings, last reviewed and approved on 3/10/2025, the P&P indicated it is the purpose of this policy to provide nourishment to residents who are unable to meet their nutritional needs orally. The P&P indicated enteral formulas/supplements are ordered by the physician or dietitian when directed by the physician. The P&P indicated enteral formula administration and handling guidelines are found in the Ref 1 Procedures for nursing to follow tube feeding administration.

Based on interview and record review, the facility failed to notify the physician of one of one sampled resident's (Resident 37) who continued to have blood in the urine (hematuria) with presence of clots. Resident 37, who had an indwelling urinary catheter (IUC, a hollow flexible tube inserted in the bladder [the organ that stores urine] to drain urine) and was on blood thinner medication, was having hematuria from 1/12/2024 at 11:40 a.m. to 1/15/2024 and the attending physician (Physician 1) was not informed. As a result, on 1/15/2024 at 9:11 p.m., Resident 37 required emergency transfer to General Acute Care Hospital 1 (GACH 1) where Resident 37 was found with elevated body temperature (fever) and abdominal distention (abnormally swollen outward) requiring removal of the IUC with significant hematuria draining immediately after its removal. Resident 37 required intermittent catheterization (draining urine by passing a catheter through the urethra [the tube between the bladder and the external part of the body, which allows urine to be eliminated from the bladder] into the bladder which is removed after the urine has been drained) obtaining 800 milliliters (ml, unit of measure) of dark red urine. Resident 37 was diagnosed with septic shock (a life-threatening widespread infection causing organ failure and dangerously low blood pressure), urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the bladder to the outside of the body] and infect the urinary tract), and pneumonia (an infection of one or both lungs caused by bacteria, viruses, or fungi). Cross reference F690. Findings: A review of Resident 37's Admission Record indicated the facility admitted Resident 37 on 12/27/2023 with diagnoses including ischemic stroke (when a blood clot, known as a thrombus, blocks or plugs an artery leading to the brain), paroxysmal atrial fibrillation (when a person has an irregular heartbeat in the upper chambers of the heart), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own). Resident 37 was dependent on a ventilator (a machine used to help a patient breathe). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/3/2024, indicated Resident 37 had severe cognitive impairment (involving conscious intellectual activity such as thinking, reasoning, or remembering). The MDS indicated Resident 37 was dependent on staff for all activities of daily living (ADLs, such as oral hygiene, toilet use, bathing, dressing, etc.). The MDS further indicated Resident 37 was admitted to the facility with an IUC. A review of Resident 37's Physician Order, dated 12/27/2023, indicated Apixaban (Eliquis, blood thinner [anticoagulant] used to treat and prevent blood clots and to prevent stroke) 5 milligram (mg - unit of measurement) tablet 5 mg twice daily for atrial fibrillation. A review of Resident 37's Physician Order, dated 12/28/2023. indicated to insert an IUC for acute urinary retention (inability to urinate) and/or obstruction (blockage). A review of Resident 37's Physician Order, dated 1/2/2024, indicated to hold (not to administer) Eliquis. A review of Resident 37's Physician Progress Note, dated 1/10/2024, indicated to start continuous bladder irrigation (CBI - is used to reduce the risk of clot formation and IUC patency by continuously irrigating the bladder via a three?way catheter [allows fluid to flow into and out of the bladder simultaneously]) due to Resident 37's IUC bag having blood-tinged urine; continue to hold Eliquis, and would re-evaluate on Friday (1/12/2024). A review of Resident 37's Physician Order, dated 1/10/2024, indicated CBI management as follows: - Run CBI at a rate to always keep pink or clearer. - Do not let CBI run out. - Do not let blood clots form in bladder or tubing. - Do not remove IUC without physician's order. - If new onset of heavy or uncontrolled blood in urine appears, notify the physician. A review of Resident 37's Nurse Progress Note, dated 1/11/2024 at 6:48 p.m., indicated urine had been clear since start of CBI, Physician 1 was informed and ordered to hold the CBI but if Resident 37 started having hematuria, continue with the CBI. A review of Resident 37's Physician Progress Note, dated 1/12/2024 timed at 2:31 p.m., indicated Resident 37's urine was clear, re-start Eliquis, and monitor for hematuria. A review of Resident 37's Intake and Output indicated the urine characteristics was described as red, light, and with clots or red/pink on 1/12/2024 at 11:40 a.m. and at 9:42 p.m.; on 1/13/2024 at 11 a.m.; on 1/14/2024 at 1:55 a.m., at 11:34 a.m., and at 10:10 p.m.; and on 1/15/2024 at 11:30 a.m. A review of Resident 37's Respiratory Therapist Progress Note, dated 1/15/2023 timed at 7:29 p.m., indicated Resident 37 was on the ventilator, hyperventilating (an abnormally rapid rate), respiratory rate in the high 50s (normal rate 12 to 16 breaths per minute), normal oxygen saturation (O2 Sat, normal above 92 %), and to monitor at bedside. A review of Resident 37's Respiratory Therapist Progress Note, dated 1/15/2023 timed at 7:50 p.m., indicated Resident 37 continued to hyperventilate with respiratory rate in the low 60s. A review of Resident 37's Nurses Progress Note, dated 1/15/2023 timed at 7:55 p.m., indicated Resident 37 appeared to have shortness of breath and the heart rate was 155 beats per minutes (bpm, normal range 60 to 100). Physician 1 was informed and ordered to transfer Resident 37 via paramedics (healthcare professionals trained to give emergency medical care to people who are injured or ill). A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 timed at 9 p.m. , described Resident 37's urine output was dark red with foul odor. A review of Resident 37's GACH 1 Emergency Department (ED ) Progress Noted, dated 1/15/2024 at 9:23 p.m., indicated a Computed Tomography (CT - an imaging test that helps healthcare providers detect diseases and injuries) scan of Resident 37 showed inflammation around the bladder which could represent urinary tract infection. A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 at 9:23 p.m., indicated Resident 37's body temperature was 103 degrees Fahrenheit ( F, normal range between 97 F and 99 F; the heart rate was 150 bpm, the respiratory rate was 41 breath per minute, and the blood pressure (is the pressure of circulating blood against the walls of blood vessels) was 158/114 millimeters of mercury (mmHg, unit of pressure; normal range 120/80 to 139/89 ). A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 timed at 11:49 p.m., indicated Resident 37 arrived hot to touch, abdomen distended and firm, IUC in place with drainage bag to gravity with 100 ml with tea-colored urine. At 9:45 p.m., IUC removed with significant hematuria (blood in urine) drainage from penis immediately after removal. Intermittent catheterization (draining urine by passing a catheter through the urethra into the bladder; the catheter is removed after the urine has been drained) removed 800 ml (the bladder can store up to 700 ml of urine in men) of dark red output, an IUC was inserted and drained 200 ml of dark sanguineous (with blood) urine. A review of Resident 37's GACH 1 record of the Pulmonary and Critical Care Consultation note, dated 1/16/2024 at 8 a.m. indicated Resident 37 was diagnosed with pneumonia, septic shock, abdominal distention, and hematuria. A review of Resident 37's GACH 1 History and Physical, dated 1/20/2024, included in the Infections Disease Assessment and Plan that Resident 37 had septic shock and UTI. During an interview on 4/14/2024 at 6:41 p.m., the Nurse Manager (NM) stated Resident 37 had hematuria from 1/12/2024 to 1/15/2024 and Physician 1 should have been notified because this was a change of condition. The NM stated Physician 1 needed to be notified as Resident 37 was back on Eliquis and continued bleeding. During an interview on 4/14/2024 at 7:51 p.m., Physician 1 stated licensed nurses did not inform him that Resident 37 continued to have hematuria for him to stop the Eliquis and transfer Resident 37 to a hospital sooner if the bleeding did not stop. A review of the current facility-provided policy and procedure (P&P) titled, Change of Condition, Notification (Sub Acute), last revised on 3/2024. indicated to ensure that the attending physician and responsible party are promptly notified upon significant change in the resident's condition. 1. Notify the resident's primary physician for the following conditions: B. Any sudden and/or marked adverse change in vital signs (are measurements of the body's most basic functions including body temperature, blood pressure, pulse and respiratory [breathing] rate), symptoms, or a significant divergence from the resident's established pattern of behavior. A review of the current facility-provided P&P titled, Indwelling Urinary Catheter Care and Management, last revised on 12/10/2023, indicated monitor intake and output, as ordered. Monitor for changes in urine output, including volume and color. Notify practitioner of abnormal findings.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 37), who had an indwelling urinary catheter (IUC, a hollow flexible tube inserted in the bladder [the organ that stores urine] to drain urine), was on blood thinner medication, and had recent hematuria (blood in the urine) with presence of clots, received care and services to prevent complications including continued hematuria, urinary retention (inability to urinate) and/or obstruction (blockage), urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the bladder to the outside of the body], and infect the urinary tract). As a result, on 1/15/2024 at 9:11 p.m., Resident 37 required emergency transfer to General Acute Care Hospital 1 (GACH 1) where Resident 37 was found with elevated body temperature (fever), abdominal distention (abnormally swollen outward) required removal of the IUC with significant hematuria draining immediately after its removal. Resident 37 required intermittent catheterization (draining urine by passing a catheter through the urethra into the bladder which is removed after the urine has been drained) obtaining 800 milliliters (ml, unit of measure) of dark red urine with foul odor. Resident 37 was diagnosed with septic shock (a life-threatening widespread infection causing organ failure and dangerously low blood pressure), UTI, and pneumonia (an infection of one or both lungs caused by bacteria, viruses, or fungi). Cross reference F580. Findings: A review of Resident 37's Admission Record indicated the facility admitted Resident 37 on 12/27/2023 with diagnoses including ischemic stroke (when a blood clot, known as a thrombus, blocks or plugs an artery leading to the brain), paroxysmal atrial fibrillation (when a person has an irregular heartbeat in the upper chambers of the heart), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own). Resident 37 was dependent on a ventilator (a machine used to help a patient breathe). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/3/2024, indicated Resident 37 had severe cognitive impairment (involving conscious intellectual activity such as thinking, reasoning, or remembering). The MDS indicated Resident 37 was dependent on staff for all activities of daily living (ADLs, such as oral hygiene, toilet use, bathing, dressing, etc.). The MDS further indicated Resident 37 was admitted to the facility with an IUC. A review of Resident 37's Physician Order, dated 12/27/2023, indicated Apixaban (Eliquis, blood thinner [anticoagulant] used to treat and prevent blood clots and to prevent stroke) 5 milligram (mg - unit of measurement) tablet 5 mg twice daily for atrial fibrillation. A review of Resident 37's Physician Order, dated 12/28/2023, indicated to insert an IUC for acute urinary retention (inability to urinate) and/or obstruction (blockage). A review of Resident 37's Physician Order, dated 1/2/2024, indicated to hold (not to administer) Eliquis. A review of Resident 37's Physician Progress Note, dated 1/10/2024, indicated to start continuous bladder irrigation (CBI - is used to reduce the risk of clot formation and IUC patency by continuously irrigating the bladder via a three?way catheter [allows fluid to flow into and out of the bladder simultaneously]) due to Resident 37's IUC bag having blood-tinged urine; continue to hold Eliquis, and would re-evaluate on Friday (1/12/2024). A review of Resident 37's Physician Order, dated 1/10/2024, indicated CBI management as follows: - Run CBI at a rate to always keep pink or clearer. - Do not let CBI run out. - Do not let blood clots form in bladder or tubing. - Do not remove IUC without physician's order. - If new onset of heavy or uncontrolled blood in urine appears, notify the physician. A review of Resident 37's Nurse Progress Note, dated 1/11/2024 at 6:48 p.m., indicated urine had been clear since start of CBI, Physician 1 was informed and ordered to hold the CBI but if Resident 37 started having hematuria, continue with the CBI. A review of Resident 37's Physician Progress Note, dated 1/12/2024 timed at 2:31 p.m., indicated Resident 37's urine was clear, re-start Eliquis, and monitor for hematuria. A review of Resident 37's Intake and Output indicated the urine characteristics was described as red, light, and with clots or red/pink on 1/12/2024 at 11:40 a.m. and at 9:42 p.m.; on 1/13/2024 at 11 a.m.; on 1/14/2024 at 1:55 a.m., at 11:34 a.m., and at 10:10 p.m.; and on 1/15/2024 at 11:30 a.m. A review of Resident 37's Respiratory Therapist Progress Note, dated 1/15/2023 timed at 7:29 p.m., indicated Resident 37 was on the ventilator, hyperventilating (an abnormally rapid rate), respiratory rate in the high 50s (normal rate 12 to 16 breaths per minute), normal oxygen saturation (O2 Sat, a test that measures the amount of oxygen being carried by red blood cells and the normal result is above 92 %), and to monitor at bedside. A review of Resident 37's Respiratory Therapist Progress Note, dated 1/15/2023 timed at 7:50 p.m., indicated Resident 37 continued to hyperventilate with respiratory rate in the low 60s. A review of Resident 37's Nurses Progress Note, dated 1/15/2023 timed at 7:55 p.m., indicated Resident 37 appeared to have shortness of breath and the heart rate was 155 beats per minute (bpm, normal range is 60 to 100). Physician 1 was informed and ordered to transfer Resident 37 via paramedics (healthcare professionals trained to give emergency medical care to people who are injured or ill). A review of Resident 37's GACH 1 Emergency Department (ED) Progress Notes, dated 1/15/2024 timed at 9 p.m., described Resident 37's urine output was dark red with foul odor. A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 at 9:23 p.m., indicated Resident 37's body temperature was 103 degrees Fahrenheit ( F, normal range between 97 F and 99 F; the heart rate was 150 bpm, the respiratory rate was 41 breath s per minute, and the blood pressure (is the pressure of circulating blood against the walls of blood vessels) was 158/114 millimeters of mercury (mmHg, unit of pressure; normal range is 120/80 to 139/89 ). A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 timed at 11:49 p.m., indicated Resident 37 arrived hot to touch, abdomen distended and firm, IUC in place with drainage bag to gravity with 100 ml with tea-colored urine. At 9:45 p.m. IUC removed with significant hematuria (blood in urine) drainage from penis immediately after removal. Intermittent catheterization (draining urine by passing a catheter through the urethra into the bladder; the catheter is removed after the urine has been drained) removed 800 ml (the bladder can store up to 700 ml of urine in men) of dark red output, an IUC was inserted and drained 200 ml of dark sanguineous (with blood) urine. A review of Resident 37's GACH 1 record of the Pulmonary and Critical Care Consultation note, dated 1/16/2024 at 8 a.m. indicated Resident 37 was diagnosed with pneumonia, septic shock, abdominal distention, and hematuria. A review of Resident 37's GACH 1 History and Physical, dated 1/20/2024, under Assessment and Plan indicated Resident 37 had septic shock and UTI. During an interview on 4/14/2024 at 6:41 p.m., the Nurse Manager (NM) stated Resident 37 had hematuria from 1/12/2024 to 1/15/2024 and Physician 1 should have been notified because this was a change of condition. The NM stated Physician 1 needed to be notified as Resident 37 was back on Eliquis and continued bleeding. During an interview on 4/14/2024 at 7:51 p.m., Physician 1 stated licensed nurses did not inform him that Resident 37 continued to have hematuria for him to stop the Eliquis and transfer Resident 37 to a hospital sooner if the bleeding did not stop. A review of the current facility-provided policy and procedure (P&P) titled, Change of Condition, Notification (Sub Acute), last revised on 3/2024. indicated to ensure that the attending physician and responsible party are promptly notified upon significant change in the resident's condition. 1. Notify the resident's primary physician for the following conditions: B. Any sudden and/or marked adverse change in vital signs (are measurements of the body's most basic functions including body temperature, blood pressure, pulse and respiratory [breathing] rate), symptoms, or a significant divergence from the resident's established pattern of behavior. A review of the current facility-provided P&P titled, Indwelling Urinary Catheter Care and Management, last revised on 12/10/2023, indicated monitor intake and output, as ordered. Monitor for changes in urine output, including volume and color. Notify practitioner of abnormal findings.

Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment for 40 of 40 residents, staff, and visitors by not maintaining the roof in good repair. This deficient practice resulted to roof leaks of rainwater from the ceilings at the Nursing Station, North Corridor, South Corridor, East Corridor, West Corridor, Main entrance lobby, Activity Room, and Resident Room 3146. The leaking roof had the potential to cause serious harm, injury, or death to residents, staff, and visitors. An Immediate Jeopardy (IJ, a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) was called on December 14, 2021, at 6:01 p.m. in the presence of the Sub Acute Nurse Manager, Sub Acute Charge Nurse, and Accreditation Coordinator and Quality Manager. On December 14, 2021, at 6:08 p.m., the Chief Executive Officer (CEO), Executive Director of Quality, and Risk Management were informed of the IJ via telephone. On December 20, 2021, the facility submitted a Plan of Action in response to the Immediate Jeopardy which included the following: 1. Facility to place temporary tarp roofing on leaking areas. 2. Facility's approval from Department of Health Care Access and Information (HCAI) to start reroofing project. 3. Facility submitted contractor and subcontractor information to start and complete the reroofing project, and timeline to complete the project. 4. Facility's monitoring process to ensure residents' safety were maintained during the reroofing project. After reviewing the placement of these elements, the Immediate Jeopardy was removed on December 20, 2021 at 6:32 p.m. in the presence of the CEO, Executive Director of Quality and Risk Management, and Director of Healthcare. Findings: On December 14, 2021, from 4:00 p.m. to 6:00 p.m., during a general observation tour of the Sub Acute building, in the presence of the Sub Acute Nurse Manager and Accreditation Coordinator and Quality Manager, the following were observed: 1. Rainwater leaking from the ceilings at the Nursing Station, North Corridor, South Corridor, East Corridor, West Corridor, Main entrance lobby, and Activity Room. 2. There was rainwater leaking from the sprinkler head and ceiling in Resident Room 3146, previously occupied by 2 residents bfore the leak had happened. No residents were present in the room during the time of the observation. There were wet towels on the floor absorbing the rainwater and trash cans collecting the rainwater. 3. There were multiple small white buckets, mop buckets, small black plastic trash cans, large plastic trash can with wheels, and large commercial trash carts filled with rainwater leaking from the ceiling at the Nursing Station, North Corridor, South Corridor, East Corridor, West Corridor, and Activity Room. 4. There were multiple wet towels brownish gold in color absorbing the rainwater on the floor at the Nursing Station, North Corridor, South Corridor, East Corridor, West Corridor, Main entrance lobby, and Activity Room. 5. There were plastic tarps attached to the ceilings to catch the rainwater and large commercial trash carts and large trash cans with wheels under the tarps collecting the rainwater at the Nursing Station, North Corridor, South Corridor, East Corridor, and West Corridor. 6. There was plastic material covering equipment to prevent water damage from the exposed ceiling in the Minimum Data Set (MDS) Coordinator Room. 7. There was exposed insulation material, sprinkler piping systems, heating and ventilation ducts, wiring, and loosely hanging debris in the ceiling areas above the Nursing Station, North Corridor, South Corridor, East Corridor, and West Corridor. 8. There was ceiling tile debris inside large commercial trash carts located in the South and East corridors. 9. There were water-stained ceiling tiles in the Main entrance lobby and Activity Room. 10. There was plastic covering the cubicle walls and desk counter area from water leaking from the ceiling at the Nursing Station. On December 14, 2021 at 4:10 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1), stated she observed water leaking in the corridors and at the Nursing Station when she arrived to work at 7:00 a.m., on December 14, 2021. LVN 1 also stated the building had problems for a couple of years of rainwater leaking from the ceiling due to rain. On December 14, 2021 at 4:15 p.m., during an interview, a Sub Acute Registered Nurse 1 (RN 1) stated the building had problems with rainwater leaking from the ceiling due to rain in past years. RN 1 also stated she was conducting rounds in resident rooms to monitor for any water leaks. RN 1 further stated there were no documented evidence of the rounds in resident rooms for water leaks. On December 14, 2021 at 4:30 p.m., during an interview, the Sub Acute Nurse Manager stated two residents s in Room 3146, Beds 1 and 2 of the South Wing were transferred to Room 3122 in the East Wing due to rainwater leaking from the ceiling in Room 3146. The Sub Acute Nurse Manager also stated historically rainwater leaks in other resident rooms in the South Wing other than in Resident Room 3146. The Sub Acute Nurse Manager further stated the building in general has a history of rainwater leaking from the ceiling in past years due to rain and that this the worse she has seen the rainwater leaking from the ceiling in the building. The Sub Acute Nurse Manager also stated nursing staff are conducting hourly rounds in resident rooms to look for any water leaks. The Sub Acute Nurse Manager further stated she could not provide any documented evidence that nursing staff was conducting hourly rounds in resident rooms to monitor for rainwater leaks. The Sub Acute Nurse Manager also stated the Activity Room was a designated room for visitation by family members and friends, but visits in the Activity Room has been discontinued due to rainwater leaking from the ceiling. On December 14, 2021 at 5:00 p.m., during an interview, the Facilities Manager (FM) stated the rainwater leaking in the building was due to a current natural gas line installation project that further damaged the roof allowing rainwater to enter multiple areas inside the building. The FM also stated the roof already needed repairs prior to natural gas line installation because rainwater has leaked in the building in the past. The FM stated the facility did not have a roofing contractor to repair or replace the roof. On December 14, 2021 at 5:15 p.m., during a phone interview, the Facilities Director (FD) stated the facility placed several plastic coverings over the damaged areas of the roof to temporary prevent rainwater leaking into the building. The FD also stated the facility has Environmental Services Department (EVS) staff to empty the rainwater collected in the buckets and trash bins and to remove water damaged ceiling tiles. The FD further stated the roof needs to be completely dry before any repairs on the roof begins and that the repairs may not start for another two weeks. The FD stated the facility does not have a roofing contractor or contract to repair and or replace the roof. The FD also stated the facility did not conduct a current roof assessment for the extent of the rainwater damage on the roof and inside the building after the rain event of December 14, 2021. On December 14, 2021 at 5:45 p.m., the Sub Acute Nurse Manager and Accreditation Coordinator and Quality Manager with nursing staff took action transferring residents from the South Wing to the East Wing residents rooms due to the ongoing concerns that more resident rooms in the South Wing will have rainwater leaks from the ceiling. On December 14, 2021, a review of the current census (list of residents in the facility) revealed the following resident room transfers: 1. Two residents in Room 3140 of the South Wing were transferred to Room 3126 of the East Wing. 2. One resident in Room 3142 of the South Wing was transferred to Room 3136 of the East Wing. 3. One resident in Room 3138 of the South Wing was transferred to Room 3128 of the East Wing. On December 14, 2021 at 6:30 p.m., during an interview with FM, he stated the facility will increase EVS staffing until 7:00 a.m., to ensure that all buckets, trash bins, and commercial trash carts are emptied of rainwater in a timely manner to prevent overflow of waste water onto the floors and into resident rooms and other areas while roof repair has not started yet. The FM also stated EVS staff will replace all wet towels and remove deteriorated water damaged ceiling tiles. On December 15, 2021 at 7:30 a.m., during a tour of the Sub Acute building, it was observed water was still leaking from the roof on the Nursing Station,North Corridor, South Corridor, East Corridor, West Corridor, and Activity Room. On December 15, 2021 at 8:20 a.m., during a tour of the roof top, a clear plastic material covering the damaged areas of the roof surface, accumulated water near the roof drains, and pooled water near an exhaust unit were observed with the FD. On December 15, 2021 at 8:30 a.m., during an interview, the FD stated that the multiple water leaks inside the building was due to rainwater protruding through the patch work from a current project involving mounting brackets for a natural gas line installation. The FD also stated the roof has been leaking rainwater for a couple or more years every time it rains, and the roof was due for replacement. The FD further stated the rain and additional damaged to the roof due to the natural gas line installation project made the leaking of rainwater in the building worse. The FD stated that a tenting company will visit today to evaluate for placing large tents over the entire Sub Acute roof for a short term solution. The FD also stated the facility did not have a roofing contractor or contract to repair and or replace the roof. On December 15, 2021, a document review titled, Sub Acute Roof Findings, revealed the facility was aware of the multiple roof issues and the need to replace the Sub Acute building roof for the past 3 years.