Every finding on record at South Coast Global Medical Center D/P SNF

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of four residents (Residents 8, 12, 14, and 25) reviewed for accidents remained free from accident hazards. * The facility failed to ensure both side rails were padded for Resident 8, as per the physician's order and as care planned for Resident 8, due to the risk of injury from their seizure disorder. * The facility failed to ensure Resident 12's bilateral side rails were used as per the physician's order and failed to ensure Resident 12's bed was in the lowest position to prevent/minimize any injuries in the event Resident 12 had a seizure episode. Additionally, the facility failed to ensure two staff members assisted in the transfer of Resident 12 from the shower gurney back to the bed as per the facility's P&P. * Resident 14 had a diagnosis of seizure disorder with a history of seizures at the facility. Resident 14 had a physician's order for padded side rails. The facility failed to implement the physician's order which placed the resident at risk for injuries. * Resident 25 was totally dependent on the staff for transfer to and from his bed to a chair. A CNA independently transferred Resident 25 from a Geri-chair to his bed using a Hoyer lift. These failures had the potential to place the residents at risk for serious injuries.Findings: Review of the facility's P&P titled Transfer Policy dated 9/2025 showed the purpose of the transfer policy is to ensure the resident environment remains as free from accident hazards as possible, and each resident receives adequate supervision and provides supervision and assistive devices to prevent avoidable accidents. Procedure for the mechanical lift requires two-person assistance for transferring when using the mechanical lift with residents that are non-ventilator dependent. 1. Medical record review for Resident 25 was initiated on 1/5/26. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Care Plan titled At Risk for Falls due to quadriplegia dated 11/2025 showed to transfer Resident 25 via Hoyer lift with two-person assistance. Review of Resident 25's MDS dated [DATE], showed Resident 25 was totally dependent on the staff for transfer to and from his bed to a chair, with two or more staff required for Resident 25 to complete the activity. Review of Resident 25's Physician Order Report showed a physician's order dated 12/23/25, for the use of a Hoyer lift, with two-person assistance when Resident 25 needed to be transferred. On 1/7/26 at 1609 hours, an observation and concurrent interview for Resident 25 was conducted with CNA 5. CNA 5 was observed independently transferring Resident 25 from a Geri-chair to his bed, using a Hoyer lift. Resident 25 was observed suspended in the air lying on the Hoyer lift sling, in between the Geri-chair and his bed. CNA 5 stated the staff informed her Resident 25 had returned from activities and needed to be transferred from his Geri-chair into his bed. CNA 5 was asked if she was aware of Resident 25's medical condition and his abilities specific to the level of assistance required to safely transfer Resident 25 to bed. CNA 5 stated she worked for the registry and did know the resident's name, medical condition, or level of assistance he required. CNA 5 was asked if she had received a report from facility staff specific to Resident 25's needs, to which CNA 5 replied no. CNA 5 was asked if she could independently transfer Resident 25 from a Geri-chair to his bed safely, utilizing the Hoyer lift. CNA 5 stated no, the process required two staff members to safely transfer Resident 25. CNA 5 was then asked if she requested another staff member's assistance to safely transfer Resident 25, to which CNA 5 replied, she had not. On 1/7/26 at 1624 hours, an interview was conducted with the DON. The DON was informed of CNA 5 having independently transferred Resident 25 from a Geri-chair to his bed using the Hoyer lift. The DON stated this type of transfer required two staff members to ensure Resident 25's safety. Cross reference F695, example #1. 2. Medical record review for Resident 14 was initiated on 1/5/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Physician Order Report showed an order dated 2/5/25, for padded side rails times two when in bed for safety due to seizure disorder. Review of Resident 14's H&P examination dated 6/22/25, showed Resident 14 had no capacity to understand and make decisions. Review of Resident 14's Event Note dated 12/30/25, showed Resident 14 had a forty second seizure-like episode with shaking and eyes rolling upward. Resident was 14 placed on seizure precautions. On 1/6/26 at 0830 hours, an observation for Resident 14 was conducted. Resident 14 was observed lying in bed. Resident 14's bed was observed with an elevated side rail attached to the right side of the bed. The right side of Resident 14's body was observed adjacent to the side rail. The side rail was observed without padding. On 1/6/26 at 0931 hours, an observation and concurrent interview for Resident 14 was conducted with RN 1. Resident 14 was observed lying in bed. Resident 14's bed was observed with an elevated side rail attached to the right side of the bed. The right side of Resident 14's body was observed adjacent to the side rail. The side rail was observed without padding. RN 1 verified the findings and stated the side rail should be padded in accordance with the physician's order to prevent injury in the event of a seizure. 3. Medical record review for Resident 12 was initiated on 1/5/26. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 9/22/25, showed Resident 12 had no capacity to understand and make medical decisions. Resident 12 had diagnoses including quadriplegia and seizure disorder. a. On 1/5/26 at 1000 hours, Resident 12 was observed lying in bed with the bilateral side rails elevated. There were no staff in the room providing care or repositioning Resident 12. Review of Resident 12's care plan for risk for injury during seizures dated 9/22/22, showed interventions included low bed as ordered. Review of Resident 12's Physician Order Report for January 2026 showed the following physician's orders dated 4/21/25: - for the low bed and no side rails, and - may use the side rails (two) only when providing care and turning the resident. On 1/5/26 at 1600 hours, Resident 12 was observed lying in bed. The bilateral side rails were observed elevated and a staff was not in the room providing care to Resident 12. On 1/6/26 at 0856 hours, CNA 2 was observed exiting Resident 12's room. Resident 12 was observed lying in bed with the bilateral side rails elevated. No other staff members were in Resident 12's room. On 1/6/26 at 0934 hours, Resident 12 was observed lying in bed and the bilateral side rails were elevated. There were no staff in Resident 12's room. On 1/6/26 at 1015 and 1250 hours, Resident 12 was observed lying in bed. The bilateral side rails were elevated and Resident 12's bed was not in the lowest position. On 1/6/26 at 1307 hours, an interview and concurrent observation for Resident 12 was conducted with CNA 2. CNA 2 stated Resident 12 was totally dependent on the staff for activities of daily living care. CNA 2 stated he was not sure about the use of the side rails. CNA 2 verified the bilateral side rails were elevated and not only specific to repositioning and care. CNA 2 also verified Resident 12's bed was not in the lowest position and stated the bed should have been in the lowest position to prevent Resident 12 from sustaining any injuries if he fell out. On 1/6/26 at 1356 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 3. LVN 3 stated Resident 12 was totally dependent on staff for his care. LVN 3 stated Resident 12 had the diagnosis of seizure disorder and the interventions included providing visuals every shift to check for episodes of seizure, ensuring the bed was in the lowest position to minimize any injuries in the event Resident 12 had a seizure and fell out of bed. LVN 3 further stated Resident 12's bed should be in the lowest position at all times. LVN 3 stated the side rails should only be used when providing care to Resident 12 and the side rails should not be always elevated due to the potential for injury if Resident 12 had any episodes of seizures. On 1/8/26 at 1255 hours, Resident 12 was observed lying in bed. Resident 12's bed was raised and not in the lowest position. There were no staff in the room. On 1/8/26 at 1300 hours, an interview and concurrent observation for Resident 12 was conducted with the DSD. The DSD verified the above findings and stated Resident 12's bed should be in the lowest position. b. On 1/6/26 at 0831 hours, CNA 2 was observed wheeling the shower gurney into Resident 12's room. Resident 12 was lying on the shower gurney. CNA 2 transferred Resident 12 from the shower gurney back to Resident 12's bed by himself. No other staff was present in the room. On 1/6/26 at 0840 hours, an interview was conducted with CNA 2. CNA 2 stated for the transfer of the residents from the shower gurney to the resident's bed, there should be two people to provide assistance. CNA 2 verified he transferred Resident 12 from the shower gurney to the resident's bed by himself. On 1/8/26 at 1005 hours, an interview was conducted with the DSD. The DSD stated for the transfer of the residents to and from the shower gurney, there should be two people to provide assistance with the transfer to prevent any injuries or falls from occurring. On 1/12/26 at 1451 hours, an interview was conducted with the DON. The DON stated for the residents with a physician's order for the low bed to ensure the safety of the residents, the bed should always be in the lowest position, except when the staff were providing care to the resident. The DON further stated the side rails should be used as per the physician's orders. On 1/12/26 at 1630 hours, an interview was conducted with the CNO, DON, DSD, and IP. The CNO, DON, DSD, and IP were informed and acknowledged the above findings. 4. Medical record review for Resident 8 was initiated on 1/8/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's care plan for risk for injury during seizures dated 1/13/23, showed interventions included padded siderails when up in bed. Review of Resident 8's Physician Order Report showed a physician's order dated 10/24/24, for low bed with bilateral padded side rails for safety due to seizure disorder. On 1/5/26 at 1442 and 1530 hours, Resident 8 was observed in bed with the rails partially padded, leaving half of the upper rail exposed. Resident 8's upper body, including the head, was not protected due to the exposed upper rail. On 1/6/26 at 0817, 1020, 1320, and 1520 hours, Resident 8 was observed in bed with the rails partially padded, leaving half of the upper rail exposed. Resident 8's upper body, including the head, was not protected due to the exposed upper rail. On 1/7/26 at 0852 and 1015 hours, Resident 8 was observed in bed with the rails partially padded, leaving half of the upper rail exposed. Resident 8's upper body, including the head, was not protected due to the exposed upper rail. On 1/7/26 at 1020 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 8 had history of seizures. CNA 2 verified Resident 8's side rails were not fully padded and the exposed railing on both sides was closest to the resident's head. CNA 2 stated Resident 8 could have an injury if they were to have a seizure. On 1/8/26 at 0845 hours, an interview and concurrent medical record review for Resident 8 was conducted with RN 2. RN 2 acknowledged Resident 8's bed rails were partially padded. RN 2 stated the entire side rails should be padded because if the resident were to have a seizure, the resident could have an injury. RN 2 verified Resident 8 had a physician's order and care plan for padding both side rails. On 1/12/26 at 1620 hours, an interview was conducted with the CNO/Interim CEO. The CNO/Interim CEO was shown a picture of the padded side rails for Resident 8. The CNO/Interim CEO acknowledged both side rails were exposed and not padded per Resident 8's physician's order and care plan, which could cause harm to the resident.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory services for four of four sampled residents (Residents 7, 10, 12, and 25) reviewed for respiratory care. * The facility failed to ensure Resident 7's ventilator circuit set-up and in-line suction catheter changes were done as per the physician's orders. * The facility failed to ensure Resident 10's ventilator high-pressure alarm was set within a safe parameter. * The facility failed to ensure Resident 12 's oxygen flowmeter was set to the appropriate liter flow to match the aerosol mist setting as per the physician's order. In addition, the facility failed to ensure the flowmeter was in working condition. * The facility failed to provide Resident 25 continuous oxygen therapy during the transfer from a Geri-chair to his bed using a Hoyer lift. These failures had the potential to result in negative health outcomes for the residents.Findings: Review of the facility's P&P titled Oxygen Therapy dated 4/2024 showed it is the policy of the facility that oxygen therapy is administered as ordered by the physician. 1. Medical record review for Resident 25 was initiated on 1/5/26. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Physician Order Report showed a physician's order dated 11/11/25, for aerosol mist to tracheostomy via T-piece or trach mask at 60% FI02. Review of Resident 25's care plan titled Tracheostomy revised on 11/2025 showed a care plan problem to address Resident 25's altered respiratory status due to tracheostomy secondary to a diagnosis of chronic respiratory failure and traumatic brain injury. The care plan goals included maintaining adequate ventilation as evidenced by patent airway and normal oxygen saturations. The care plan approaches included aerosol mist to trach via T-piece or trach mask with FI02 of 60%, and titration of FI02 to maintain oxygen saturation greater than 92%. On 1/7/26 at 1609 hours, an observation and concurrent interview was conducted with CNA 5. CNA 5 was observed independently transferring Resident 25 from a Geri-chair to his bed using a Hoyer lift. Resident 25 was observed suspended in the air lying on the Hoyer lift sling in between the Geri-chair and his bed. Resident 25 was observed with a tracheostomy; however, Resident 25 was not receiving supplemental oxygen. CNA 5 was asked if she was aware of Resident 25's medical condition and specifically if Resident 25 required continuous oxygen therapy. CNA 5 stated she did not know anything about the oxygen or the equipment and did not know whether Resident 25 required continuous oxygen therapy. CNA 5 stated she worked for the registry and she was not familiar with Resident 25. A bedside oxygen flow meter and venturi device were observed attached to the wall adjacent to Resident 25's bed. The venturi device was set at a rate of 60% FI02. A bottle of sterile water was attached to the venturi device and corrugated breathing tubing was observed attached to the sterile water bottle. However, the distal end of the corrugated breathing tubing was not attached to Resident 25's tracheostomy piece. CNA 5 was asked if she had observed Resident 25's corrugated breathing tubing disconnect from Resident 25's tracheostomy piece. CNA 5 stated she noticed Resident 25's oxygen tubing (corrugated breathing tubing) was disconnected from Resident 25 when she transferred Resident 25 from his Geri-chair onto the Hoyer lift, which occurred approximately two minutes ago. CNA 5 was asked if the corrugated breathing tubing should be connected to Resident 25's tracheostomy piece, to which CNA 5 replied, I don't know. CNA 5 was then asked if she should have notified the licensed nurse when Resident 25's corrugated breathing tubing was disconnected from his tracheostomy piece. CNA 5 replied she would not leave Resident 25 disconnected from oxygen for over five minutes. RN 5 was notified about Resident 25. RN 5 then entered the room and attached Resident 25's corrugated breathing tubing to Resident 25's tracheostomy piece. RN 5 then obtained Resident 25's oxygen saturation which was measured at 93% (while receiving FIO2 of 60 percent). On 1/7/26 at 1616 hours, a follow up interview was conducted with RN 5. RN 5 stated Resident 25 had a physician's order for aerosol mist to trach via T-piece or tracheostomy mask at 60% FI02. RN 5 stated Resident 25 required continuous oxygen therapy as a result of a brain injury and chronic respiratory failure. RN 5 stated Resident 25 was dependent on oxygen therapy and should not be without continuous oxygen therapy at any time. RN 5 stated CNA 5 should not have performed a transfer of Resident 25 from the Geri-chair to the bed independently. RN 5 stated this placed Resident 25 at risk for injury from falls and resulted in Resident 25 having been disconnected from his continuous oxygen therapy, which could result in negative health outcomes including desaturation, lack of oxygen to the brain, cardiac injury, respiratory distress, or death. 2. Review of the facility's P&P titled Continuous Mechanical Ventilation revised 10/2018 showed the RT assigned to the management of mechanical ventilation in the sub-acute unit will be responsible for checking for the proper function of equipment, proper settings, and resident parameters per shift. T he P&P further showed to maintain the high-pressure alarm setting 15 to 20 cm of water pressure above the resident's peak airway pressure. Medical record review for Resident 10 was initiated on 1/5/26. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Physician Order Report showed a physician's order dated 7/4/25, for Mechanical Ventilator Settings: Tidal Volume = 450, Assist Control = 18, FI02 = 35%, and PEEP = 5. Review of Resident 10's Resident Care Plan titled Tracheostomy revised 12/20/25, showed Resident 10 had altered respiratory status due to tracheostomy, secondary to a diagnosis of chronic respiratory failure. On 1/5/26 at 1050 hours, an observation was conducted of Resident 10. Resident 10 was observed lying in bed connected to a mechanical ventilator. The average peak airway pressure on the ventilator was 28 to 30 and the high-pressure alarm was observed set at 60 cm. On 1/5/26 at 1059 hours, a follow-up observation and concurrent interview was conducted with RT 2. Resident 10 was observed lying in bed connected to a mechanical ventilator. T he average peak airway pressure on the ventilator was 28 to 30 and the high-pressure alarm was observed set at 60 cm. RT 2 verified the findings and stated in accordance with the facility's P&P, the high-pressure alarm should have been set at 15 to 20 cm of water pressure above Resident 10's peak air way pressure. RT 2 then set the high-pressure alarm to 50. RT 2 stated Resident 10 would need to be assessed when the ventilator alarmed and the high-pressure alarm alerted staff for possible bronchospasm, the need for possible tracheal suctioning due to increased secretions, ventilator tube kinking, coughing, or airway obstruction. 3. Medical record review for Resident 12 was initiated on 1/5/26. Resident 12 was admitted to the facility on [DATE], with diagnoses including respiratory failure. Review of Resident 12's Physician Order Report showed a physician's order dated 5/21/24, to provide the aerosol mist to the trach via the T-piece or trach mask at FI02 50%. Review of Resident 12's H&P examination dated 9/22/25, showed Resident 12 had no capacity to understand and make medical decisions. Resident 12 had respiratory failure with a tracheostomy. On 1/7/26 at 0922 and 1600 hours, Resident 12 was observed lying in bed connected to a cool aerosol adapter via the T-piece. Resident 12's cool aerosol adapter was connected to the oxygen wall unit and was set at 50% FI02/10 LPM. Resident 12's T-piece was connected to an oxygen wall unit and the oxygen flowmeter was set at eight LPM. On 1/7/26 at 1614 hours, an interview, medical record review and concurrent observation of Resident 12 was conducted with RN 4. RN 4 stated Resident 12 had a physician's order to administer oxygen via the T- bar at 50% FI02. RN 4 stated the oxygen setting was checked every shift. RN 4 verified Resident 12's oxygen flowmeter was set at eight LPM and the cool aerosol adapter was set at 50% FI02/10 LPM. RN 4 stated the oxygen flowmeter should be set at 10 LPM as per the physician's order. RN 4 was observed adjusting the knob on the oxygen flowmeter, however the oxygen gauge was not observed to go above eight LPM. RN 4 stated she could not set the oxygen flowmeter to 10 LPM and needed to get another oxygen flowmeter. On 1/8/26 at 1330 hours, an interview was conducted with the DON. The DON stated the RNs were responsible for ensuring the oxygen was administered to the residents as ordered by the physician. On 1/12/26 at 1630 hours, an interview was conducted with the CNO, DON, DSD, and IP. The CNO, DON, DSD, and IP were informed and acknowledged the above findings. 4. Medical record review for Resident 7 was initiated on 1/7/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Physician Order Report showed the following physician orders: - dated 4/18/22, change the in-line suction of the tracheostomy every Monday, Wednesday, and Friday; and - dated 5/31/23, change the ventilator circuit set up every two weeks and as needed if visibly soiled or malfunctioning. On 1/7/26 at 1348 hours, an interview and concurrent medical record review was conducted with RT 1. RT 1 stated the in-line suction catheter of the tracheostomy was changed every Monday, Wednesday, and Friday. RT 1 stated the changing of the ventilator circuit set-up was every month. RT 1 stated they were not aware of Resident 7's order for changing the ventilator circuit set up for every two weeks and as needed if visibly soiled or malfunctioning. RT 1 verified there was no documentation to show that the ventilator circuit set-up was changed every two weeks. RT 1 verified documentation showed the in-line suction catheter was changed every Monday, Wednesday, and Friday was done for the following dates: 12/5, 12/8, 12/12, 12/15, 12/17, 12/19, 12/24, 12/26, 12/29, and 12/31/25;1/2 and 1/5/26. RT 1 stated they were unsure when the in-line suction catheter or the ventilator circuit set-up was last changed. On 1/8/26 at 1442 hours, an interview and concurrent medical record review was conducted with the Cardiovascular-Pulmonary Manager. The Cardiovascular-Pulmonary Manager verified there was no documentation to show the ventilator circuit set-up was changed per physician's order and documentation for the in-line suction catheter was not always done. The Cardiovascular-Pulmonary Manager stated they were clinicians and it was important to document the care provided. The Cardiovascular-Pulmonary Manager stated an in-service was initiated immediately once the issue was brought to their attention.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program from August 2025 through December 2025. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria). The facility failed to include these residents in the facility's infection control surveillance program. The facility failed to ensure the Surveillance Data Collection Form was complete and accurate to determine whether the resident's infection met the McGeer's criteria for true infection. * The facility failed to ensure the residents' clean linen cart was covered and failed to ensure the clean linen cart did not contain the residents' towels lying on top of the cart. These failures have the potential risk for not identifying, managing, containing, and controlling the transmission of communicable disease within the facility.Findings: 1. Review of the facility's P&P titled Infection Control and Surveillance revised 9/2025 showed it is the policy of the facility to closely monitor all residents who exhibit signs and symptoms of infection. The infection control program will: - develop prevention, surveillance, and control measures to protect residents and personnel from hospital-acquired infections. - perform surveillance activities to monitor and investigate causes of infections and manner of spread in order to prevent infections in the facility. - analyze clusters of infections, changes in prevalent organisms, and any increase in the rate of infection in a timely manner. When a resident exhibits signs and symptoms of suspected infection, the charge nurse will record the resident's name on the initial Infection Surveillance Form, follow routine procedures for notifying the attending physician and family. The ICP (Infection Control Preventionist) will gather further data for infection tracking and reporting and provide consultation and education as needed. Complete Infection Control Reports will be presented at quarterly Quality Improvement and Medical Staff meeting and will be available to all staff for review upon request. Review of the facility's monthly Infection Prevention and Control Surveillance Logs from July 2025 through December 2025, showed the following infection surveillance data for HAIs, CAIs, and residents who did not meet McGeer's Criteria (DNMC): - July 2025: a total of 23 infections, including 13 HAIs, three CAIs, and six DNMCs. - August 2025: a total of 17 infections, including nine HAIs, and eight DNMCs. - September 2025: a total of nine infections, including four HAIs, and three DNMCs. - October 2025: a total of 18 infections, including 10 HAIs, two CAIs, and six DNMCs. - November 2025: a total of 18 infections, including eight HAIs, one CAI, and nine DNMCs. - December 2025: a total of 22 infections, including 14 HAIs, one CAI, and five DNMCs. Further review of the facility's monthly Infection Control Surveillance Logs from July 2025 through December 2025 showed all the residents determined to have either an HAI, CAI, or DNMC were also prescribed the antimicrobial medications. There was no documented evidence the residents who exhibited signs and symptoms of infection but were not prescribed antimicrobial medications were included in the monthly surveillance logs. On 1/12/26 at 1102 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated he was responsible for the infection control and surveillance of infections in the Sub-Acute unit. The IP stated the purpose of infection surveillance in the facility was to utilize the data collected to track and trend the resident infections, to guide interventions, and to prevent the transmission of organisms and the spread of infections in the facility. The IP stated when the resident exhibited signs and/or symptoms of an infection, or any change of condition, the charge nurse would conduct an assessment and inform the physician. The IP stated following the results of any ordered laboratory or diagnostics tests, the licensed nurse would inform the physician and the antimicrobial therapy would be prescribed. The IP stated once the antimicrobial therapy was prescribed, the IP would complete the McGeer's criteria form to determine if the resident had a true infection. The IP was asked when a resident at the facility exhibited signs and/or symptoms of infection and was not prescribed the antimicrobial medication, if the facility initiated the McGeer's criteria form for those residents and included those residents in the facility's infection surveillance program (from July 2025 to December 2025). The IP stated the McGeer's criteria form was only initiated for the residents with signs and/or symptoms of infection and were prescribed the antimicrobial medications. The IP stated the residents who were prescribed the antimicrobial therapy would be included in the infection surveillance and be included on the monthly Infection Surveillance Log. The IP was asked how many residents in the facility had infections (met McGeer's criteria) and were not prescribed the antimicrobial medications (from July 2025 through December 2025). The IP stated he did not know as the facility did not complete the McGeer's criteria form for the residents who exhibited signs and/or symptoms of infections and were not prescribed the antimicrobial medications. Review of the McGeer's criteria form for Residents 11, 19, 22, 26, and 31 was conducted with the IP. The residents' McGeer's criteria form showed the following documentation: * For Resident 26, the report showed the following: - the antibiotic treatment prescribed for Resident 26 was Merrem 1 gm three times a day and Zyvox 600 mg two times a day for blood stream infection, to start on 8/27/25. - Yes was selected in the section on the form to indicate whether the infection met the NHSN criteria for a true infection. - further review of the form showed blood cultures 1 and 2 were collected and showed no growth. * For Resident 31, the report showed the following: - the antibiotic treatment prescribed for Resident 34 was cefepime 1 gm two times a day and vancomycin 750 mg for one dose and 1 gm three times a day for pneumonia, to start on 8/27/25. - No was selected in the section on the form to indicate whether the infection met McGeer's criteria for a true infection. - further review of the form showed the documentation on 8/27/25, the chest x-ray showed small left pleural effusion, increased sputum production and temperature 100.8 degrees F. (all three criteria for pneumonia were met, however, the infection was marked as DNMC). * For Resident 19, the report showed the following: - the antibiotic treatment prescribed for Resident 19 was Merrem 1 gm three times a day for pneumonia, from 9/23/25 to 10/3/25. - Yes was selected in the section on the form indicate whether the infection met McGeer's criteria for a true infection. - further review of the form showed the documentation on 9/21/25, the chest x-ray showed unremarkable chest. * For Resident 22, the report showed the following: - the antibiotic treatment prescribed for Resident 22 was Zosyn 3.375 gm four times a day for seven days from 9/26 to 10/3/2025. - NO was selected in the section on the form to indicate whether the infection met the NHSN criteria for a true infection. However, review of the Surveillance Log for September 2025 failed to show the selection of DNMC for the infection on the log. * For Resident 11, the report showed the following: - indications: elevated WBC, low BP, increase sputum production - the antibiotic treatment prescribed for Resident 11 was Fortaz 1 gm three times a day for seven days from 12/18 to 12/25/25, for bronchitis. - YES was selected in the section on the form to indicate whether the infection met the McGeer's criteria for a true infection. - Under the section for McGeer's criteria for bronchitis showed for the lower respiratory tract, all three criteria must be present. For criteria 2- at least two respiratory sub criteria must be present; however, only one was documented (increased sputum). The IP reviewed the medical records and McGeer's criteria form for Residents 11, 19, 22, 26, and 31 and verified the McGeer's criteria forms were inaccurate. The IP stated the McGeer's criteria form and the determination of a true infection should be accurate to effectively conduct surveillance and track the prevalence of infections in the facility. On 1/12/26 at 1630 hours, an interview was conducted with the CNO, DON, DSD, and IP. The CNO, DON, DSD, and IP were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Linen Handling revised 12/2009 showed proper linen handling techniques will be used to protect against the transmission of organisms from one location to another. On 1/5/26 at 1002 hours, an observation and concurrent interview was conducted with LVN 6. The clean linen cart was observed with residents' gowns and bed linens inside of the cart. The clean linen cart cover was hanging on the side of the cart and not covering the clean linen. On top of the clean linen cart a plastic bin was observed with a razor and towels inside. Underneath the plastic bin were two towels. LVN 6 verified the findings. LVN 6 stated neither clean towels nor used towels should be stored on top of the cart for infection control. Additionally, LVN 6 stated the clean linen cart cover should be in place to cover the clean linens stored inside of the cart, to ensure the linens remain clean for infection control.

Based on observation, interview, medical record review, and P&P review, the facility failed to provide RNA services per the physician's order for one of 14 final sampled residents (Resident 3). * Resident 3 did not receive RNA services per the physician's order. This failure had the potential for Resident 3's upper body contractures and range of motion (ROM) to worsen.Findings: Medical record review for Resident 3 was initiated on 1/9/26. Resident 3 was admitted to the facility on [DATE]. On 1/6/26 at 0813 hours, Resident 3 was observed with a contracture to the right hand. Review of Resident 3's care plan for actual functional limitation in range of motion dated 6/22/22, showed interventions including RNA to perform range of motion exercises as ordered by the physician. Review of Resident 3's Physician Order Report showed the following physician orders:- dated 12/3/25, RNA to provide range of motion to both upper extremities daily five times a week for 30 days; and- dated 12/18/25, RNA to provide range of motion to both lower extremities daily five times a week for 30 days. Review of the RNA schedule for December 2025 showed there was one RNA scheduled for the month and no RNA scheduled on the following dates: 12/1, 12/3, 12/5, 12/8, 12/10, 12/12, 12/14, 12/17, 12/19, 12/22, 12/24, 12/26, and 12/31/25. Review of the RNA schedule for January 2026 showed there was one RNA scheduled for the month and no RNA scheduled on the following dates: 1/2, 1/5, and 1/7/26. On 1/9/26 at 0844 hours, an interview and concurrent medical record review was conducted with RNA 1. RNA 1 stated documentation of services are done after providing care. Review of Resident 3's medical record failed to show the resident received RNA services on 12/1, 12/3 to 12/4, 12/9 to 12/11, 12/16 to 12/19, 12/24 to12/25, and12/31/25; and 1/2, 1/5, and 1/7/26. RNA 1 verified Resident 3 did not receive RNA services per physician's order on those dates. RNA 1 stated they were not always able to provide the services to Resident 3 since there was the only RNA providing services to all the residents on the floor. RNA 1 stated there should be two RNAs scheduled, but typically there's one RNA scheduled or no RNA's scheduled. On 1/9/26 at 1047 hours, an interview was conducted with the DSD. The DSD stated there were two RNA's to be scheduled Monday through Friday. The DSD verified there was only one RNA scheduled on some days, sometimes none, and therefore Resident 3 did not receive the RNA services per the physician's order. The DSD stated only RNAs are allowed to provide RNA services since it requires training, clearance for competency, and certification. On 1/9/26 at 1502 hours, the DON was made aware of the above findings and verified Resident 3 was not always given RNA services per physician's orders.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented for three of 14 final sampled residents (Residents 14, 22 and 8). * The facility failed to ensure Resident 8's side rails were padded in accordance with the resident's plan of care. * The facility failed to ensure Resident 14's side rails were padded and the bilateral heel protectors were applied in accordance with the resident's plan of care. * The facility failed to ensure Resident 22's bilateral heel protectors were applied while in bed in accordance with the resident's plan of care. These failures placed the residents at risk for injuries and not being provided with the appropriate, consistent, and individualized care.Findings: 1. Medical record review for Resident 14 was initiated on 1/5/26. Resident 14 was admitted to the facility on [DATE]. a. Review of Resident 14's Physician Order Report showed a physician's order dated 2/5/25, for padded side rails times two when in bed for safety due to seizure disorder. Review of Resident 14's Resident Care Plan titled Side Rail revised 11/2025 showed Resident 14 was at risk for injury due to use of side rails related to seizure activity and poor safety awareness. The Approach Plan included to apply padded side rails when Resident 14 was in bed for safety related to a diagnosis of seizure disorder and as order by the physician. Review of Resident 14's Event Note dated 12/30/25, showed Resident 14 had a forty second seizure like episode with shaking and eyes rolling upward. Resident 14 was placed on seizure precautions. On 1/6/26 at 0830 hours, an observation was conducted of Resident 14. Resident 14 was observed lying in bed. Resident 14's bed was observed with an elevated side rail attached to the right side of the bed. The right side of Resident 14's body was observed adjacent to the side rail. The side rail was observed without padding. On 1/6/26 at 0931 hours, a follow-up observation and concurrent interview was conducted with RN 1. Resident 14 was observed lying in bed. Resident 14's bed was observed with an elevated side rail attached to the right side of the bed. The right side of Resident 14's body was observed adjacent to the side rail. The side rail was observed without padding. RN 1 verified the findings and stated the side rail should be padded in accordance with Resident 14's care plan. b. Review of Resident 14's Physician Order Report showed a physician's order dated 8/30/22, to apply bilateral heel protectors while Resident 14 was in bed. Review of Resident 14's Resident Care Plan titled Skin Integrity dated 11/2025 showed Resident 14 was at risk for the development of skin breakdown due to fragile skin, incontinence, and dependence on staff for ADLs and bed mobility. The Approach Plan included the application of the bilateral heel protectors while in bed. On 1/6/26 at 0830 hours, an observation was conducted of Resident 14. Resident 14 was observed lying in his bed. Resident 14's heels were observed resting directly on the mattress. Resident 14 had no heel protectors. On 1/6/26 at 0931 hours, a follow-up observation and concurrent interview was conducted with RN 1. Resident 14 was observed lying in his bed. Resident 14's heel protectors were not applied and the resident's heels were observed resting directly on the mattress. RN 1 verified the findings. RN 1 stated Resident 14's heel protectors should have been applied while Resident 14 was in bed to prevent pressure injuries, in accordance with Resident 14's care plan. 2. Medical record review for Resident 22 was initiated on 1/5/26. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Physician Order Report showed a physician's order dated 7/16/25, to apply bilateral heel protectors while Resident 22 is in bed. Review of Resident 22's Resident Care Plan titled Actual Skin Breakdown dated 11/3/25, showed Resident 22 had a left ankle redness. The Approach Plan included to provide Resident 22 with the treatment as ordered. On 1/5/26 at 1035 hours, an observation was conducted of Resident 22. Resident 22 was observed lying on his bed. Resident 22's heels were observed resting directly on the mattress. Resident 22 had no bilateral heel protectors. On 1/5/26 at 1140 hours, a follow-up observation and concurrent interview was conducted with CNA 4. Resident 22 was observed lying on his bed. Resident 22's heel protectors were not applied and the resident's heels were observed resting directly on the mattress. CNA 4 verified the findings and stated Resident 22's heel protectors should always be applied while Resident 22 was in bed in accordance with Resident 22's care plan. 3. Review of the facility's P&P titled Care Planning revised on 8/2010 showed the purpose of care planning is to assure a coordinated and comprehensive written plan is developed based on the resident assessment and on the individual needs of the resident. Medical record review for Resident 8 was initiated on 1/8/26. Resident 8 was admitted on [DATE]. Review of Resident 8's plan of care dated 1/13/23, showed a care plan problem addressing the resident's risk for injury during seizures; and risk for seizure activity related to diagnosis of seizure disorder. Interventions in the care plan included padding both side rails. On 1/5 at 1442 and 1530 hours; 1/6 at 0817, 1020, 1320, and 1520 hours; and 1/7/26 at 0852 and 1015 hours, concurrent observation was conducted for Resident 8. During the observations, Resident 8's side rails were padded partially, leaving half of the upper rail exposed. Resident 8's upper body including the head was not protected due to the exposed upper rail. On 1/7/26 at 1020 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 8 had a history of seizures. CNA 2 stated the purpose of both padded side rails was to prevent Resident 8 from injury. CNA 2 verified Resident 8's side rails were not fully padded, the exposed railing on both sides was closest to the head, and Resident 8 could have an injury if the resident were to have a seizure. On 1/8/26 at 0845 hours, an interview and concurrent medical record review for Resident 8 was conducted with RN 2. RN 2 acknowledged Resident 8's bed rails were partially padded. RN 2 stated the entire side rails should be padded, and if a resident were to have a seizure the resident could have an injury. RN 2 verified Resident 8 had a care plan for padding on both side rails. On 1/12/26 at 1620 hours, an interview was conducted with the CNO/Interim CEO. The CNO/Interim CEO was shown a picture of the padded side rails for Resident 8. The CNO/Interim CEO acknowledged both side rails were exposed and not padded per Resident 8's care plan which could cause harm to the resident. Cross reference to F689, example #4.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident (Resident 5) reviewed for IV care. * The facility failed to ensure Resident 5's peripheral IV dressing on the left lower extremity was labeled with the date and initials and a care plan was developed for the use and maintenance of Resident 5's peripheral IV. In addition, the facility failed to ensure the insertion and/or removal of the peripheral IV and daily assessment of the peripheral IV site were documented. These failures had the potential to delay the identification of catheter related complications for Resident 5.Findings: Review of the facility's P&P titled Intravenous Therapy reviewed 9/2023 under the section for Therapy, General Guidelines - IV Initiation and Maintenance showed to:- initiate an IV using the aseptic technique,- cover the IV site with a transparent occlusive dressing, to flush the IV site every 12 hours and after each use with two milliliters of normal saline, and- change the IV site every 96 hours (unless ordered otherwise by the physician). Further review of the facility's P&P, under the section for Documentation on the Nursing Flowsheet showed to document:- all IV attempts and when an IV was started or changed, and- all IV sites, to document daily, the site, type/gauge, assessment, and insertion date. On 1/5/26 at 1543 hours, Resident 5 was observed lying in bed with a peripheral IV in Resident 5's left lower leg. The peripheral IV's transparent dressing was observed undated. Medical record review for Resident 5 was initiated on 1/5/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P dated 10/13/25, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's plan of care failed to show a care plan problem was developed to address the use and maintenance of Resident 5's left lower extremity peripheral IV. Review of Resident 5's medical record failed to show any documentation of the insertion and assessment of Resident 5's peripheral IV site in the left lower extremity. On 1/5/26 at 1548 hours, an interview and concurrent observation of Resident 5 was conducted with LVN 2. LVN 2 verified Resident 5's peripheral IV dressing was not labeled with the date and the licensed nurse's initials. When asked about Resident 5's peripheral IV, LVN 2 stated she did not know when Resident 5's left lower leg peripheral IV line was placed. On 1/5/26 at 1625 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 1. RN 1 stated Resident 5's left lower leg peripheral IV was started on 1/3/26, when the physician initially wanted Resident 5 on an antibiotics for leukocytosis. RN 1 stated Resident 5's physician decided to wait for the culture and sensitivity results before prescribing the antibiotics. RN 1 further stated Resident 5's peripheral IV was kept because it was hard to start a peripheral IV on Resident 5. On 1/7/26 at 0924 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 3. RN 3 stated for the residents with peripheral IVs, the peripheral IV dressings should be labeled with the date and the initials of the RN who applied the dressing. RN 3 stated on every shift, the RN was responsible for the assessment of the peripheral IV, to assess the site for patency, any signs and symptoms of infection, phlebitis and infiltration into surrounding soft tissue. RN 3 stated for the residents with a peripheral IV, there should be a care plan developed for the use and monitoring of the peripheral IV. RN 3 reviewed Resident 5's medical record and verified the above findings. RN 3 verified there was no documentation of when Resident 5's left lower leg peripheral IV was initiated, there were no documentation of the assessment of the peripheral IV every shift by the registered nurse and there was no care plan developed for Resident 5's peripheral IV. On 1/12/26 at 1541 hours, an interview was conducted with the DON. The DON stated after the insertion of the peripheral IV, the licensed nurse should document the location and assessment of the IV site in the resident's medical record. The DON stated the peripheral IV site should be assessed for signs and symptoms of infection, infiltration, or swelling and documented every shift, and as needed. On 1/12/26 at 1630 hours, an interview was conducted with the CNO, DON, DSD, and IP. The CNO, DON, DSD, and IP were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 18) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 18's orthostatic BP was monitored for the use of the Seroquel (antipsychotic medication). * The facility failed to ensure Resident 18's nonpharmacological interventions and its effectiveness were documented for the documented observed behaviors related to the use of the Zoloft (antidepressant medication). These failures had the potential for Resident 18 to experience potential harm from the adverse consequences from the use of the Seroquel medication and prevented the facility from accurately monitoring the effectiveness of the behavioral interventions in an effort to discontinue the use of the Zoloft medication.Findings: Review of the facility's P&P titled Medication, Psychotropic/Chemical Restraint reviewed 9/2025 showed Nursing and Social Services document in their progress notes the interventions and resident' s response to treatment. Record and incorporate into the plan of care any non-drug interventions for the specific mood or behavior problem. Use the Psychotherapeutic Drug Summary Sheet to document the ongoing summary of behavior data, PRN doses, adverse reactions, and observations along with dosage changes and the rationale for changes. Medical record review for Resident 18 was initiated on 1/5/26. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's MDS assessment dated [DATE], showed Resident 18 had severe cognitive impairment and had diagnoses including psychotic disorder and depression. a. Review of Resident 18's Clinical Summary Report dated 11/25/25, showed a physician's order to administer Seroquel 150 mg via GT every 12 hours for psychosis manifested by striking out to staff. Review of Resident 18's care plan for the Seroquel medication dated 6/5/25, showed the interventions included observing the resident closely for significant side effects and report to the physician. Postural hypotension was listed under side effects. Review of Resident 5's Routine Psychotropic Medication forms for the Seroquel medication for 12/2025 and 1/2026 showed the licensed nurse's documentation on monitoring Resident 18 for adverse side effects related to using the Seroquel medication. The forms showed from 12/1 to 12/31/25 and from 1/1 to 1/6/26, the licensed nurses documented zero 0 adverse reactions were observed, every shift. Review of Resident 18's medical record failed to show the documentation of the monitoring for the orthostatic hypotension for Resident 18's use of the Seroquel medication. On 1/7/26 at 1336 hours, an interview and concurrent medical record review for Resident 18 was conducted with LVN 7. LVN 7 stated Resident 18 was taking the Seroquel medication for the behavior of striking out to the staff. LVN 7 stated every shift the licensed nurse monitored Resident 18 for the potential side effects related to the use of the Seroquel medication. LVN 7 stated postural hypotension was a potential side effect related to the Seroquel medication. When asked how postural hypotension was monitored, LVN7 stated the blood pressure reading should be obtained in different positions and compared, to determine if there was drop in the blood pressure related to the position change. When asked, LVN 7 stated Resident 18 was able to get into the sitting position from the lying position and should be monitored for orthostatic hypotension. When asked how postural hypotension was being monitored for Resident 18, LVN 7 stated Resident 18's vital signs, including his blood pressure reading, were obtained every shift, however, Resident 18's blood pressure reading was not monitored in the different positions and the blood pressure readings were not compared to monitor for orthostatic hypotension. LVN 7 reviewed Resident 18's medical record and stated she was unable to find the blood pressure monitoring for orthostatic hypotension for the use of the Seroquel medication. b. Review of Resident 18's Clinical Summary Report dated 11/25/25, showed a physician's orders to administer Zoloft (antidepressant) 50 mg via GT daily for depression manifested by self-isolation. Review of Resident 18's Routine Psychotropic Medication form for Zoloft 50 mg for 11/2025 showed on 11/17/25, the licensed nurse documented two observed behaviors during the 0700 to 1900 shift. Further review of the Routine Psychotropic Medication Record failed to show the documentation for the nonpharmacological interventions implemented and its effectiveness for the above observed behaviors. Review of Resident 18's Routine Psychotropic Medication form for Zoloft 50 mg for 12/2025 showed the licensed nurse documented on 12/2/25, one observed behavior during the 0700 to 1900 shift. Further review of the Routine Psychotropic Medication Record failed to show the documentation for the nonpharmacological intervention implemented and its effectiveness for the above observed behavior. On 1/7/26 at 1336 hours, an interview was conducted with LVN 7. LVN 7 stated Resident 18 was administered the Zoloft 50 mg medication daily for depression. LVN 7 stated for the use of the Zoloft medication, Resident 18 was monitored every shift for the observed behaviors of self-isolation. LVN 7 stated if the manifested behavior was observed, the nonpharmacological interventions should be implemented and its effectiveness documented on the back of the Routine Psychotropic Medication form for Zoloft. On 1/7/26 at 1434 hours, an interview and concurrent medical record review for Resident 18 was conducted with the DON. The DON stated for the residents who were administered the psychotropic medications, the manifested behavior related to the use of the medication was monitored every shift by the licensed nurse. The DON stated if the behavior was observed, the licensed nurse should assess the resident for pain, incontinence, need for position changes, and implement the nonpharmacological interventions and document its effectiveness on the Routine Psychotropic Medication flowsheet. The DON reviewed Resident 18's Routine Psychotropic Medication flowsheet for Zoloft for 11/2025 and 12/2025 and verified the above findings. The DON stated the nonpharmacological interventions should be implemented and documented for each observed behavior and its effectiveness documented. The DON stated the licensed nurses were also responsible for monitoring the residents prescribed the antipsychotic medications for side effects and adverse reactions. The DON stated the potential side effects of antipsychotic medications included tardive dyskinesia, increased heart rate, or orthostatic hypotension. When asked how orthostatic hypotension should be monitored, the DON stated the resident's BP reading should be obtained in two different positions and compared. The DON further stated for the residents who were able to tolerate the lying and sitting position, the BP readings for each position should be obtained and compared. When asked how orthostatic hypotension was being monitored for Resident 18, the DON stated the facility was not checking for orthostatic hypotension for the resident. On 1/12/26 at 1630 hours, an interview was conducted with the CNO, DON, DSD, and IP. The CNO, DON, DSD, and IP were informed and acknowledged the above findings.

Based on observation and interview, the facility failed to maintain a homelike environment for four of 14 final sampled residents (Residents 5, 12, 14, and 25). * Resident 5 resided in Room C. The emergency outlet on the wall behind Resident 5's head of bed was observed in disrepair with chipped paint, wall debris and an opening above the red wall plate and the wall. * Resident 12 resided in Room A. The wall at the foot of Resident 12's bed was observed in disrepair with chipped paint and unpainted areas. * Residents 14 and 25 resided in Room B. The walls behind the residents' beds were observed in disrepair, as evidenced by scratches, chipped drywall, and peeled paint. These failures had the potential to negatively impact the residents' quality of life. Findings: 1. On 1/5/26 at 1006 hours, Resident 5 was observed lying in his bed in Room C. The emergency outlet on the wall behind Resident 5's head of the bed was exposed with an opening (or not sealed), chipped paint and wall debris above the wall plate. 2. On 1/6/26 at 0856 hours, Resident 12 was observed lying in bed in Room A. The wall at the foot of Resident 12's bed had chipped paint and unpainted areas. On 1/6/26 at 1605 hours, an observation of Rooms A and C and concurrent interview was conducted with the DON. The DON verified the above findings and stated the resident rooms needed to be in good repair and the facility should ensure a homelike and presentable environment for the residents. On 1/12/26 at 1630 hours, an interview was conducted with the CNO, DON, DSD, and IP. The CNO, DON, DSD, and IP were informed and acknowledged the above findings. 3. On 1/6/26 at 1600 hours, an observation and concurrent interview was conducted with the DON. Residents 14 and 25 resided in Room B. The walls behind the residents' beds were observed in disrepair, as evidenced by scratches, chipped drywall, and peeled paint. The DON verified the findings and stated the residents' room should be presentable and homelike. The DON stated the walls needed to be repaired.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below five percent. The facility's medication error rate was 7.69% * Resident 8 had a physician's order for amlodipine 5 mg daily via GT for hypertension (high BP). The order showed to hold the medication if Resident 8's SBP was less than 100 mmHg. However, the licensed nurse held the medication when Resident 8's SBP was not less than 100 mmHg. This failure to administer the antihypertensive medication in accordance with the physician's order had the potential to result in negative health outcomes. * Resident 8 had a physician's order for liquid potassium chloride 10 mEq daily via GT for hypokalemia. The licensed nurse failed to dilute the potassium chloride prior to administering the medication, in accordance with the label affixed to the medication. This failure to dilute liquid potassium chloride had the potential to cause severe stomach irritation and inhibit proper absorption. Findings: Review of the facility's P&P titled Medication Administration revised 10/2023 showed the medications given to the residents will be safely administered. Medication preparation included obtaining a unit dose (of medication) from the resident medication cassette or pharmacy and verifying for accuracy. Medication preparation included having checked and documented necessary vital signs before administering medications. Medical record review for Resident 8 was initiated on 1/5/26. Resident 8 was admitted to the facility on [DATE]. On 1/12/26 at 0823 hours, a medication administration observation for Resident 8, interview, and concurrent medical record review was conducted with LVN 9. LVN 9 prepared and administered Resident 8's morning medications. LVN 9 obtained 7.5 ml (equal to 10 mEq) of liquid potassium chloride from a bulk bottle. LVN 9 then administered the 7.5 ml of liquid potassium chloride to Resident 8. LVN 9 stated Resident 8's BP was obtained at 0800 hours, and was measured at 100/75 mmHg. LVN 9 stated she held Resident 8's morning dose of amlodipine 5 mg via GT for hypertension, due to Resident 8's systolic blood pressure of 100 mmHg. a. Review of Resident 8's Clinical Summary Report showed a physician's order dated 4/8/25, for amlodipine 5 mg daily via GT for hypertension. Hold medication for SBP less than 100 mmHg. Review of Resident 8's Vitals Flow Sheet (undated) showed Resident 8's BP was measured at 100/75 mmHg on 1/12/26 at 0807 hours. LVN 9 verified Resident 8's order for amlodipine 5 mgs daily via GT for hypertension was to be held if Resident 8's SBP was less than 100 mmHg. LVN 9 verified Resident 8's SBP was not measured as less than 100 mmHg this morning. LVN 9 stated she made an error having held the medication. LVN 9 stated she would return to Resident 8's room and administer the medication in accordance with the physician's order. b. Review of Resident 8's Clinical Summary Report showed a physician's order dated 3/25/24, for potassium chloride 10 mEq daily via GT for hypokalemia. Review of Resident 8's bulk bottle of potassium chloride liquid label showed to administer 7.5 ml (10 mEq) of potassium chloride once daily. The bottle was labeled HIGH ALERT, dilute prior to administration. LVN 9 verified the label attached to Resident 8's bulk bottle of potassium chloride liquid, showed to administer 7.5 ml (10 mEq) of potassium chloride once daily. LVN 9 verified Resident 8's bulk potassium chloride liquid bottle was labeled HIGH ALERT, dilute prior to administration. LVN 9 verified she failed to dilute the 7.5 ml (10 mEq) of liquid potassium chloride she administered to Resident 8.

Based on observation, interview, and facility P&P review, the facility failed to ensure two of four medication carts were clean. * Medication Carts A and B were observed with unclean containers. The unclean containers contained lancets, alcohol pads, insulin syringes, and a pill splitter. This failure to maintain the medication carts in a sanitary condition posed the risk for negative residents health outcomes.Findings: Review of the facility's P&P titled Infection Control Program and Surveillance dated 9/2025 showed the facility has developed and maintains an Infection Control Program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections. 1. On 1/8/26 at 1245 hours, an inspection of Medication Cart A was conducted with LVN 5. The top drawer of Medication Cart A contained two plastic containers. The two plastic containers contained alcohol pads, lancets, and insulin syringes. The bottom of the containers were observed with brownish/blackish stains and an unknown brownish/blackish substance. LVN 5 verified the findings. LVN 5 stated the containers needed to be cleaned for infection control as the alcohol pads, lancets, and insulin syringes were items used to provide resident care. 2. On 1/8/26 at 1250 hours, an inspection of Medication Cart B was conducted with LVN 8. The top drawer of Medication Cart B contained two plastic containers. The two plastic containers contained alcohol pads, lancets, insulin syringes, and a pill splitter. The bottom of the containers were observed with brownish/blackish stains and an unknown brownish/blackish substance. LVN 8 verified the findings. LVN 8 stated the containers needed to be cleaned for infection control.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling of food in the freezer. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the kitchen utensils were air-dried. * The facility failed to ensure the item in the kitchen was discarded after the use-by date. * The facility failed to ensure proper sanitary condition of the ice machine. These failures had the potential for exposure to food-borne illnesses for a medically vulnerable population.Findings: 1. According to FDA Food Code 2022, Section 3-501.17, Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking (undated), showed date marking requirements apply to containers of processed food that have been opened and to food prepared, if held for more than 24 hours, by marking the date or day the original container is opened with a procedure to discard the food on or before the last date by which the food must be consumed. On 1/5/26 at 0819 hours, an initial tour of the kitchen was conducted with RD 1 and the Dietary Assistant. There was an opened bag of chocolate covered pastries stored inside of the walk-in freezer. The bag was not labeled with an open date. RD 1 verified the findings. The Dietary Assistant stated the bag of frozen pastries was a personal food item from the dietary staff and should not have been stored inside the freezer. 2. According to FDA Food Code 2022, 4-602.13, Non-Food Contact Surfaces (undated) showed the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. On 1/5/26 at 0819 hours, an initial tour of the kitchen was conducted with RD 1. The following was observed:- one bin containing clean kitchen utensils had debris and multiple white particles at the bottom of the bin; and- one bin containing clean kitchen utensils had greyish colored debris and a pepper packet at the bottom of the bin. RD 1 verified the above findings and stated the bins storing the clean kitchen utensils should be clean. 3. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics (undated) showed for materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 1/5/26 at 0819 hours, an initial tour of the kitchen was conducted with RD 1. The following was observed:- two blue-handled scoopers had discolored and chipped handles; - three black-handled and one grey-handled portion servers had melted handles; and- two spatulas were discolored, cracked, and chipped. RD 1 verified the above findings. 4. According to the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required (undated) showed items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. Review of the facility's P&P titled Dish Machine Procedures revised 6/2023 showed to allow the flatware to air dry. On 1/5/26 at 0819 hours, during the initial tour of the kitchen with RD 1, two grey handled scoopers were observed stored wet inside a bin with multiple clean kitchen utensils. RD 1 verified the above findings. 5. Review of the facility's P&P titled Food Storage reviewed 6/2023 showed food supplies shall be continuously checked for freshness and expiration date. Any expired food items shall be discarded immediately and the manager/supervisor shall be notified. On 1/5/26 at hours, an initial tour of the kitchen was conducted with RD 1. The following was observed:- one bin labeled lentil had a use by date of 12/30/25; and- one bin labeled jasmine rice was not labeled with the use-by date. RD 1 verified the above findings and stated the bins should be labeled with the use-by date to determine when the items should be discarded, and should be discarded timely. 6. Review of the facility's P&P titled Ice Machine Maintenance reviewed 8/2023 showed ice machines shall be scheduled for regular maintenance at intervals not exceeding semi-annual. Ice machines shall be visually inspected monthly for cleanliness and proper operation. Review of the Hoshizaki Model DCM-300AH Cubelet Icemaker/Dispenser Instruction Manual issued 3/25/20, showed under Cleaning and Sanitizing Instructions, the icemaker must be cleaned and sanitized at least twice a year. More frequent cleaning and sanitizing may be required in some conditions. On 1/8/26 at 1410 hours, an interview was conducted with RD 2. RD 2 stated for the residents in the Sub-Acute unit who had an order for ice chips, the ice chips were obtained from the ice machine located in the cafeteria. On 1/8/26 at 1415 hours, an inspection of the Hoshizaki ice machine located in the cafeteria and a concurrent interview was conducted with RD 2 and the Director of the Facility. The ice machine cover was removed to reveal inner compartment. The inner shoot was observed with blackish-brown colored build-up surrounding the exit spout of the ice compartment. RD 2 verified the findings and stated ice should be served clean. A paper towel was used to wipe the build- up and the paper towel was observed with blackish- brown colored substance on the paper towel. The Director of the Facility verified the finding and was asked to describe what it was. The Director of the Facility stated it was dark, black-brown build-up. a. Medical record review for Resident 18 was initiated on 1/5/26. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's Active Order Requisition dated 1/8/26, showed a physician's order dated 1/6/26, for ice chips only. To give one to three ounces of ice chips daily for oral gratification. On 1/8/26 at 1524 hours, an interview was conducted with LVN 4. LVN 4 stated Resident 18 had GT feeding, however, the resident could have ice chips when he requested. LVN 4 stated she obtained the ice from the ice machine in the cafeteria. b. Medical record review for Resident 23 was initiated on 1/8/26. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's Physician Order Report for January 2026 showed a physician's order dated 10/21/25, for Resident 23 to be NPO (nothing by mouth) except for ice chips for oral gratifications. On 1/8/26 at 1527 hours, an interview was conducted with LVN 5. LVN 5 stated the ice chips were provided to Resident 23 twice a day. On 1/12/26 at 1510 hours, an interview was conducted with the DON and RD 2. The DON and RD 2 were informed and acknowledged the above findings.

Based on interview and medical record review, the facility failed to ensure the medical record for one of 14 final sampled residents (Resident 5) was accurate. * The facility failed to ensure Resident 5's POLST was complete. This failure had the potential for the resident's care needs not being met as the medical information was inaccurate.Findings: Medical record review for Resident 5 was initiated on 1/5/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Advance Directive Acknowledgement dated 10/24/22, showed Resident 5's responsible party selected yes to formulating an advance directive. Review of Resident 5's POLST dated 10/24/22, showed Resident 5' responsible party signed on the POLST on 10/24/22. Further review of the POLST showed under section D, showed the information regarding the advance directive was left blank. Review of Resident 5's H&P examination dated 10/13/25, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's MDS assessment dated [DATE], showed under section S9040H, Resident 5 was coded for no advance directive. Review of Resident 5's medical record failed to show the documentation the discrepancy regarding Resident 5's advance directive was clarified. On 1/7/26 at 0854 hours, an interview and concurrent medical record review for Resident 5 was conducted with the Social Service Worker. The Social Service Worker stated Resident 5 had no advance directive. The Social Service Worker reviewed Resident 5's medical records and verified the above findings. The Social Service Worker stated the POLST should be complete and accurate. The Social Service Worker stated she spoke with Resident 5's responsible party and verified Resident 5 had no advance directive and Resident 5's responsible party selected yes in error. The Social Service Worker was unable to find documentation to show if she clarified it with Resident 5's responsible party. On 1/12/26 at 1630 hours, an interview was conducted with the CNO, DON, DSD, and IP. The CNO, DON, DSD, and IP were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure care was provided in a manner which promoted dignity and respect for two of 14 final sampled residents (Residents 5 and 6). * The facility failed to ensure Resident 5 and 6's urinary output drainage bags were stored inside of the privacy bag. This failure had the potential to compromise Resident 5 and 6's rights to be treated with respect and dignity.Findings: Review of the facility's P&P titled Dignity Bags Utilization reviewed 9/2025 showed each resident who utilized a urinary catheter with an attached drainage bag would be provided with a dignity bag. 1. Medical record review for Resident 5 was initiated on 1/5/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 10/13/25, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's Physician Order Report for January 2026 showed a physician's order dated 7/15/25, for suprapubic catheter sized 8.5 French to gravity drainage due to urinary stricture. On 1/5/26 at 1010 and 1543 hours, Resident 5 was observed lying in bed and the urinary drainage bag was hanging on Resident 5's left side rail. The urinary drainage bag had yellow colored output. The urinary drainage bag was not inside a privacy bag. On 1/5/26 at 1548 hours, an observation of Resident 5 and concurrent interview was conducted with LVN 2. LVN 2 stated Resident 5 had a suprapubic catheter and the urinary drainage bag should have been stored inside of a privacy bag to provide the resident with privacy and dignity. LVN 2 verified the above findings. On 1/12/26 at 1451 hours, an interview was conducted with the DON. The DON stated for the residents with the urinary drainage bags, the urinary drainage bags should be placed inside of the privacy bag to provide the residents with dignity. On 1/12/26 at 1630 hours, an interview was conducted with the CNO, DON, DSD, and IP. The CNO, DON, DSD, and IP were informed and acknowledged the above findings. 2. Medical record review for Resident 6 was initiated on 1/5/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Physician Order Report showed an order dated 4/15/22, for a suprapubic catheter to gravity drainage for urinary retention. On 1/5/26 at 1543 hours, an observation of Resident 6 and concurrent interview was conducted with LVN 6. Resident 6 was lying in his bed. Resident 6's urinary drainage bag was hanging from Resident 6's bed. Resident 6's urinary drainage bag was full of urine and without a privacy cover in place. LVN 6 verified the findings and stated Resident 6's urinary drainage bag should have been covered with a privacy cover to ensure Resident 6's dignity.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries, for three of five sampled residents (Residents 5, 14, and 22) reviewed for pressure ulcers. * The facility failed to ensure the bilateral heel protectors were applied while Residents 5, 14, and 22 were in bed as per the physician's orders. These failures had the potential for the residents to develop pressure injuries.Findings: Review of the facility's P&P titled Skin Care Management reviewed 9/2025 showed all the residents would have a skin risk assessment completed upon admission utilizing the Braden Scale and direct observation. This assessment would create a baseline for further skin and/or wound care and minimize and/or prevent any further deterioration of tissue. Under the section, Reassessment and Documentation showed to employ prevention techniques, pressure reduction mattress, heel protectors, and turning of the residents every two hours. 1. Medical record review for Resident 14 was initiated on 1/5/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Physician's Order Report showed a physician's order dated 8/30/22, to apply bilateral heel protectors while Resident 14 was in bed. Review of Resident 14's H&P examination dated 6/22/25, showed Resident 14 had no capacity to understand and make decisions. Review of Resident 14's Resident Care Plan titled Skin Integrity dated 11/2025 showed Resident 14 was at risk for the development of skin breakdown due to fragile skin, incontinence, and dependence on staff for ADL care and bed mobility. The plan of care included the application of bilateral heel protectors while in bed. On 1/6/26 at 0830 hours, an observation of Resident 14 was conducted. Resident 14 was observed lying in his bed. Resident 14's heels were observed resting directly on the mattress. Resident 14's heel protectors were not applied. On 1/6/26 at 0931 hours, an observation and concurrent interview for Resident 14 was conducted with RN 1. Resident 14 was observed lying in bed. Resident 14's heels were observed resting directly on the mattress. Resident 14's heel protectors were not applied. RN 1 verified the findings. RN 1 stated Resident 14's heel protectors should have been applied while Resident 14 was in bed to prevent pressure injuries. Cross reference F656 #1a. 2. Medical record review for Resident 22 was initiated on 1/5/26. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Physician's Order Report showed a physician's order dated 7/16/25, to apply bilateral heel protectors while Resident 22 is in bed. Review of Resident 22's Resident Care Plan titled Actual Skin Breakdown dated 11/3/25, showed Resident 22 had left ankle redness. The plan of care included to provide Resident 22 with treatment as ordered. Review of Resident 22's Physician's Order Report showed a physician's order dated 12/29/25, for left ankle wound treatment. The order showed to cleanse Resident 22's left ankle wound with normal saline, pat dry, apply Santyl (prescription medication used to remove dead or damaged tissue from chronic skin ulcers and severe burns) ointment, cover with dry dressing daily and as needed if soiled or dislodged for 21 days. On 1/5/26 at 1035 hours, an observation for Resident 22 was conducted. Resident 22 was observed lying in bed. Resident 22's heels were observed resting directly on the mattress. Resident 22's heel protectors were not applied. On 1/5/26 at 1140 hours, an observation and concurrent interview for Resident 22 was conducted with CNA 4. Resident 22 was observed lying in bed. Resident 22's heels were observed resting directly on the mattress. Resident 22's heel protectors were not applied. CNA 4 verified the findings. CNA 4 stated Resident 22's heel protectors should always be applied while Resident 22 was in bed, in accordance with the physician's order. Cross reference F656 #2. 3. Medical record review for Resident 5 was initiated on 1/5/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 10/13/25, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's Plan of Care showed a care plan problem dated 10/13/22, addressing Resident 5's risk for the development of skin breakdown. The interventions included to offload (suspension of the heel in the air by placing pillows under the lower leg so as not to place pressure on the Achilles tendon and the heel to prevent or heal ulcers, wounds, and other conditions) the heels when in the bed or chair, and to apply the bilateral heel protectors while in bed. Review of Resident 5's MDS assessment dated [DATE], showed Resident 5 was fully dependent on staff for rolling from left and right and Resident 5 required was at risk of developing pressure ulcers/injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore). Review of Resident 5's Physician's Order Report for January 2026 showed a physician's order dated 10/13/22, to apply the bilateral heel protectors while Resident 5 was in bed. On 1/5/26 at 1548 hours, Resident 5 was observed lying in bed. Resident 5 was not observed wearing the bilateral heel protectors and Resident 5's bilateral heels were observed directly on top of the mattress. On 1/7/26 at 0935 hours, Resident 5 was observed lying in bed. Resident 5's bilateral lower extremities were observed contracted and Resident 5 was not observed wearing the bilateral heel protectors. On 1/7/26 at 1130 hours, an interview and concurrent observation for Resident 5 was conducted with RN 3. Resident 5 was observed lying in bed and was not observed wearing the bilateral heel protectors. Resident 5 was observed with both heels on top of the mattress. RN 3 verified the above findings. RN 3 stated Resident 5 was at risk for developing pressure injuries and Resident 5 had a physician's order to apply the bilateral heels while in bed. RN 3 further stated Resident 5 should have the bilateral heel protectors when in bed. On 1/7/26 at 1504 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 5 was contracted in the upper and lower extremities. When asked about Resident 5's bilateral heel protectors, CNA 3 stated Resident 5's bilateral heel protectors were not applied in the morning because Resident 5's heel protectors were soiled and were being washed. CNA 3 stated Resident 5's bilateral heels should have been offloaded with the pillows until the heel protectors were available. On 1/12/2026 at 1451 hours, an interview was conducted with the DON. The DON stated for the residents at risk for developing skin breakdown, including pressure injuries, the bilateral heel protectors should be applied as per the physician's orders. On 1/12/26 at 1630 hours, an interview was conducted with the CNO, DON, DSD, and IP. The CNO, DON, DSD, and IP were informed and acknowledged the above findings.

Based on interview and medical record review, the facility failed to ensure the MDS assessment was completed accurately for one of 14 final sampled residents (Resident 18). * The facility failed to ensure the section for Resident 18's gradual dose reduction (GDR) was coded correctly in the resident's quarterly MDS assessment. This failure had the potential risk of the resident not receiving the individualized plan of care based on the resident's specific needs.Findings: Medical record review for Resident 18 was initiated on 1/5/26. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's MDS assessment dated [DATE], showed Resident 18 had a diagnosis of psychotic disorder and Resident 18 was taking the antipsychotic medication. Under the section for Medications showed Resident 18 received the antipsychotic medication on a routine basis since admission to the facility. Further review of the MDS showed a GDR had not been attempted, and a GDR had been documented by the physician as clinically contraindicated on 9/30/25. Review of Resident 18's Progress Notes dated 9/30/25, showed a physician's progress note titled GDR Meeting. The physician's note showed the documentation Resident 18 was due for GDR, to decrease the Seroquel (antipsychotic medication) medication to 100 mg BID. Further review of Resident 18's Physician's Progress Notes failed to show the documentation by the physician, the GDR was clinically contraindicated. Review of Resident 18's Clinical Summary Report dated 11/25/25, showed an active physician's order to administer Seroquel 150 mg via GT every 12 hours for psychosis as manifested by striking out to staff. On 1/7/26 at 1447 hours, an interview and concurrent medical record review for Resident 18 was conducted with the MDS Coordinator. When asked about the physician's documentation showing the GDR for the Seroquel medication was contraindicated, the MDS Coordinator was unable to find the documentation. The MDS Coordinator verified Resident 18's MDS was coded inaccurately. On 1/12/26 at 1630 hours, an interview was conducted with the CNO, DON, DSD, and IP. The CNO, DON, DSD, and IP were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was revised for one of 14 final sampled residents (Resident 7). * The facility failed to ensure Resident 7's comprehensive care plan was revised to reflect a physician's order for changing the ventilator circuit-set up every two weeks and as needed if visibly soiled or malfunctioning. This failure posed the resident at risk for not being provided with the appropriate, consistent, and individualized care.Findings: Medical record review for Resident 7 was initiated on 1/7/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's plan of care showed a care plan dated 4/18/22, for potential alteration in gas exchange related to ineffective airway clearance and risk for infection related to long term trach tube status and colonization. The approach plan included to change the ventilator circuit set-up as needed when visibly soiled or malfunctioning. Review of Resident 7's Physician Order Report showed a physician's order dated 5/31/23, to change the vent circuit set up every two weeks and as needed if visibly soiled or malfunctioning. On 1/7/26 at 1348 hours, an interview and concurrent medical record review was conducted with RT 1. RT 1 verified the current physician's order for changing the vent circuit set up was every two weeks and as needed if visibly soiled or malfunctioning. On 1/12/25 at 1521 hours, an interview was conducted with the DON. The DON was made aware of the above findings. The DON stated the importance of revising the care plan was to ensure the goals were being met, interventions were being implemented, and monitoring the interventions for the purpose of needing to change them if not meeting the goal.

Based on observation, interview, and facility P&P review, the facility failed to ensure the residents' PHI was kept confidential for 27 residents. All 27 residents' PHI was displayed on a computer screen and left unattended by the staff member. This failure had the potential to violate the residents' rights to PHI privacy. Findings: Review of the facility's P&P titled Confidentiality of Medical Records revised 8/2023 showed all the information contained within the medical record belongs to the resident and will be kept confidential. Access will be restricted to the authorized users. The records will be viewed by the facility staff member only on a need to know basis. On 1/21/25 at 0914 hours, an ongoing observation was conducted in Hallway 1. A computer was observed with the computer screen displaying the names, dates of birth, and ages of all residents currently residing in the facility. The computer was observed unattended without a staff member nearby and multiple staff members were observed walking pass the computer. On 1/21/25 at 0919 hours, an interview and concurrent observation was conducted with the IP. The IP verified the above findings. The IP stated when the computer was not in use or left unattended, the computer screen should be locked to prevent the exposure of the resident protected information. On 1/23/25 at 1648 hours, an interview was conducted with the Director of Sub-Acute Unit. The Director of Sub-Acute Unit stated the staff were expected to ensure and protect the confidentiality of each of the resident's medical records. The Director of Sub-Acute Unit further stated the computer screens should be covered and signed out when the staff left the computer unattended. The Director of Sub-Acute Unit was informed and acknowledged the above findings.

Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. Include a plan to maximize recruitment and retention of direct care staff; and 4. Include a contingency plan for staffing needs. This failure placed the residents at risk for unmet care needs if their assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and includes the active involvement of direct care staff in developing the Facility Assessment. Also includes the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs for the events not to activate the facility's emergency plan. Review of the Facility assessment dated [DATE], did not show the direct care staff member, direct care representatives, residents, residents' representatives, and residents' family members were actively involved in developing the FA; the resources necessary to care for the residents including weekends; and a plan to maximize recruitment and retention of the direct care staff, or include a contingency plan for the staffing needs. On 1/23/25 at 1602 hours, an interview and concurrent facility document review of the Facility Assessment was conducted with the DON/Interim CNO and the Director of Sub-Acute Unit. The DON/Interim CNO and the Director of Sub-Acute Unit verified the Facility Assessment was dated 1/2/25, and was based on the 10/4/16 CMS regulations. The DON/Interim CNO and the Director of the Sub-Acute Unit verified there were no direct care staff, direct care representatives, residents, resident representatives, and family members actively involved in developing the Facility Assessment. The DON/Interim CNO and the Director of Sub-Acute Unit further verified there were no resources necessary to care for the residents including weekends, and a plan to maximize recruitment and retention of the direct care staff, or include a contingency plan for the staffing needs. The DON/Interim CNO and the Director of Sub-Acute Unit verified and acknowledged the Facility Assessment was not updated based on the latest update from CMS.

Based on interview, medical record review, and facility P&P review, the facility failed to notify three of three residents (two final sampled residents, Residents 2 and 27 and one nonsampled, Resident 17) reviewed for hospitalization of their rights to a bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care facility in writing. This failure had the potential for the residents and/or their representatives to be unaware of their rights to request a bed hold upon transfer. Findings: Review of the facility's P&P titled Bed Hold revised 7/2005 showed the residents will be informed upon admission of their right to have a bed hold in the event the resident must be transferred to an acute facility or during therapeutic leave. Under the Additional Policy Statements section, showed any resident to be transferred to an acute care facility or to go on a therapeutic leave will be offered a bed hold, which may be executed by the resident or representative. The P&P aslo showed to complete the Bed Hold Notification Form and give copy to the resident/family. 1. Medical record review for Resident 27 was initiated on 1/21/25. Resident 27 was admitted to the facility on [DATE]. Review of Resident 27's H&P examination dated 10/21/24, showed Resident 27 had anoxic encephalopathy (a condition that occurs when the brain is deprived of oxygen). Review of Resident 27's Resident Transfer or discharge date d 1/22/25, showed Resident 27 was transferred to the acute care hospital. Review of Resident 27's Bed Hold Notification form failed to show documented evidence Resident 27's representative was provided a copy of the form when the resident was transferred to the acute care hospital on 1/22/25. On 1/23/25 at 1359 hours, an interview and concurrent medical record review was conducted with the Social Service Staff. The Social Service Staff acknowledged the bed hold notification was not given or mailed to Resident 27's responsible party. The Social Service Staff stated she called Resident 27's family member but she did not mail the bed hold notification because Resident 27's family member did not request for it. 2. Medical record review for Resident 17 was initiated on 1/21/25. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's H&P examination dated 12/5/24, showed Resident 17 had anoxic encephalopathy (a condition that occurs when the brain is deprived of oxygen). Review of Resident 17's Resident Transfer or discharge date d 1/16/25, showed Resident 17 was transferred to the acute care hospital. Review of Resident 17's Bed Hold Notification form failed to show documented evidence Resident 17's representative was provided a copy of the form when the resident was transferred to the acute care hospital on 1/16/25. On 1/23/25 at 1440 hours, an interview and concurrent medical record review was conducted with the Social Service Staff. The Social Service Staff verified the bed hold notification was not given or mailed to Resident 17's responsible party. The Social Service Staff stated she did not mail the bed hold notification because Resident 17's family member did not request for it. The Social Service Staff stated she would give a copy of the bed hold notification when the resident's representative was in the facility and give a copy upon request if the resident's representative was not in the facility. On 1/23/25 at 1725 hours, an interview was conducted with the Director of Sub-Acute Unit. The Director of Sub-Acute Unit was informed and acknowledged the above findings. 44175 2. Medical record review for Resident 2 was initiated on 1/21/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2 's H&P examination dated 8/30/24, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Physician's Order dated 11/21/24, showed an order to transfer Resident 2 to the acute care unit and to provide bed hold for seven days. Review of Resident 2's Event Note showed following: - On 11/21/24 1703 hours, showed Resident Representative 1 was informed and agreed of the transfer and bed hold for seven days. - On 11/21/24 at 1905 hours, showed on 11/21/24 at 1800 hours, Resident 2 was transferred to the acute care unit of the facility. Review of Resident 2's Bed Hold Notification dated 11/21/24, showed Resident 2 was transferred out of the unit on 11/21/24, and Resident Representative 1 was notified of the bed hold by telephone. Under the section In Person and Date Mailed of the Bed Hold Notification form did not show any entry. Further review of the Bed Hold Notification showed the facility will hold a bed for seven days without charge, after the seven days are completed, the bed may be filled by another resident or a new admission. If Resident 2 is covered by Medicare or privately funded, then his/her benefit do not routinely make payments for bed hold if desired the facility will maintain a bed hold at a private daily rate for the period of the bed hold. Further review of Resident 2's medical record did not show if Resident 2 and/or their representative were provided with the written information regarding the facility's bed-hold policy. On 1/23/25 at 1048 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 3. RN 3 was not able to show if Resident 2 and/or their representative was provided with the written information regarding the facility's bed-hold policy when Resident 2 was transferred to the acute care unit on 11/21/24. On 1/23/25 at 1447 hours, the Director of Sub-Acute Unit was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for seven of 13 final sample residents (Residents 2, 6, 8, 18, 26, 27, and 28). * The facility failed to ensure Resident 18's Trach Bar (T-Bar) aerosol tubing set-up was labeled with the date. * The facility failed to ensure Resident 26's yanker was labeled with the opened date and changed per the facility's P&P; and failed to ensure the T-Bar aerosol set-up was labeled with the date. * The facility failed to ensure Resident 28's T-Bar aerosol tubing set-up was labeled with the date; failed to ensure the sterile water connected to the oxygen flowmeter was labeled with the opened date; and failed to ensure the yanker was changed per the facility's P&P. * The facility failed to ensure the suction canister (a container used in medical settings to collect and store bodily fluids, secretions, and other waste removed from a patient's body) and suction tubing was changed as per the facility's P&P for Residents 2 and 8. In addition, facility failed to ensure opened yankauer (a medical device used to remove fluids and debris from the body, such as mouth airway) tube was labeled for Residents 2 and 8. * The facility failed to ensure tracheostomy {an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs} site was clean to sight for Resident 8 * The facility failed to ensure Resident 6 was placed on the ventilator machine alarms were not set for high pressure alarms. In addition, the ventilator machine alarms were not check every shift per physician's order and the care plans for respiratory status was not included in the interventions for monitoring of the mechanical ventilator and settings. These failures had the potential to result in poor health outcomes to the resident and posed the risk of delayed intervention in the event of an emergency. * The facility failed to ensure Resident 27's set up bag was changed weekly. These failures had the potential for these residents to not receive the appropriate respiratory care and may negatively affect the residents' medical conditions. Findings: Review of the facility's P&P titled Oxygen Therapy reviewed 7/2024 showed to connect the humidifier to the outlet of the flowmeter and to label the humidifier with the date. Review of the facility's P&P titled Changing Disposable Equipment reviewed 7/2024 showed the purpose was to provide a schedule of when disposable equipment should be changed to minimize the risk of hospital acquired infections. The table would be followed as to the frequency and the responsible team member for changing the disposable equipment. Review of the table showed the following equipment and the frequency to be changed: - Aerosol tubing- inline Suction Catheter- weekly, - Aerosol water- weekly and as needed when empty, - Suction Canister Inner Liners and tubing- weekly or sooner if three-fourths (3/4) full, - Yanker- daily or as needed. Review of the facility's P&P titled Changing Disposable Equipment dated 7/2024 showed suction canister inner liners and tubing will be changed weekly or sooner if 3/4th full, yankauer needed to be changed daily or PRN (as needed). 1. On 1/21/25 at 0902 hours, Resident 18 was observed lying in bed with the Trach-Bar (T-Bar) connected to the aerosol set-up and receiving an oxygen therapy at 28 percent (%) FiO2 with the flowmeter set at five liters per minute. The aerosol set-up connected to the flowmeter was observed undated. Medical record review for Resident 18 was initiated on 1/21/25. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 18's Patient Orders dated 1/22/25, showed the following physician's order: - dated 5/17/23, to administer aerosol mist to the trach via T-piece or trach mask at 28% FiO2, - dated 5/17/23, to change the aerosol set-up weekly on Mondays. Review of Resident 18's MDS dated [DATE], showed Resident 18 had severely impaired cognitive skills and required an oxygen therapy, suctioning, and tracheostomy (breathing tube inserted through the neck into the airway to maintain an open airway) care. Review of Resident 18's plan of care showed a care plan problem dated 9/18/20, addressing Resident 18's altered respiratory status due to the tracheostomy, secondary to the diagnosis of chronic respiratory failure. The intervention showed to change the aerosol set-up every Monday. Review of Resident 18's Respiratory Care Orders Flowsheet for January 2025 failed to show documentation the aerosol set-up was changed weekly on Mondays. On 1/22/25 at 1111 hours, an interview was conducted with LVN 6. LVN 6 stated for the residents receiving the oxygen therapy via the T-Bar aerosol, the licensed nurses were responsible for the respiratory care and services, including the suctioning and changing of the aerosol set-up and tubing. LVN 6 stated the changing of the aerosol set-up was done every Mondays, Wednesdays, and Fridays. LVN 6 further stated, when changing the T- Bar aerosol setup, the licensed nurse should label the aerosol set up/tubing with the date it was changed, to ensure the staff knew when it was last changed. On 1/22/25 at 1127 hours, an interview and concurrent observation was conducted with LVN 6. Resident 18's aerosol set-up and tubing were observed undated. LVN 6 verified this finding. LVN 6 was asked when Resident 18's aerosol set-up was last changed and LVN 6 stated she did not know. 2. On 1/21/25 at 0847 hours, Resident 26 was observed sleeping in bed, Resident 26 was observed with the T-Bar connected to the aerosol set-up and receiving oxygen therapy at 28% FiO2 with the flowmeter set at five liters per minute. Medical record review for Resident 26 was initiated on 1/21/25. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's Patient Orders dated 1/22/25, showed a physician's order dated 10/16/24, to administer the oxygen therapy via cool aerosol at 28 % oxygen. Review of Resident 26's MDS dated [DATE], showed Resident 26 had severely impaired cognition, and Resident 26 required the oxygen therapy, suctioning, and tracheostomy care. Review of Resident 26's plan of care showed a care plan problem, dated 10/15/24 addressing Resident 26's altered respiratory status due to the tracheostomy, secondary to the diagnosis of respiratory failure. The intervention showed to change the aerosol set-up every Monday. Review of Resident 26's Respiratory Care Orders Flowsheet for January 2025 failed to show documentation the aerosol set-up was changed weekly on Mondays. On 1/22/25 at 1111 hours, an interview was conducted with LVN 6. LVN 6 stated for the residents receiving oxygen therapy via the T-Bar aerosol, the licensed nurses were responsible for the respiratory care and services, including the suctioning and changing of the aerosol set-up and tubing. LVN 6 stated the changing of the aerosol set-up was done every Mondays, Wednesdays, and Fridays. LVN 6 further stated, when changing the T- Bar aerosol setup, the licensed nurse should label the aerosol set up/tubing with the date it was changed, to ensure the staff knew when it was last changed. On 1/22/25 at 1116 hours, an interview and concurrent observation was conducted with LVN 6. Resident 26's aerosol set up was observed undated, and the yanker was observed opened and undated. LVN 6 verified the findings. LVN 6 was asked when Resident 26's aerosol set-up was last changed. LVN 6 stated she did not know. LVN 6 also stated she did not know when the yanker was opened. 3. On 1/21/25 at 0852 hours, Resident 28 was observed lying in bed. Resident 28 was observed with the T-Bar connected to the aerosol set up and receiving oxygen therapy at 28 % FiO2 with the flowmeter set at six liters per minute. The bottle of sterile water connecter to the oxygen flowmeter was observed undated. Medical record review for Resident 28 was initiated on 1/21/25. Resident 28 was admitted to the facility on [DATE] with a diagnosis of respiratory failure. Review of Resident 28's Patient Orders dated 1/22/25, showed the physician's order dated 12/2/24, to administer the oxygen therapy via the cool aerosol at 28 % oxygen and to maintain the oxygen saturation at 92%. Review of Resident 28's MDS dated [DATE], showed Resident 28 was in a persistent vegetative state or had no discernible consciousness, and required oxygen therapy, suctioning, and tracheostomy care. Review of Resident 28's plan of care showed a care plan problem dated 12/2/24, addressing Resident 28's altered respiratory status due to the tracheostomy, secondary to the diagnosis of respiratory failure. The intervention showed to change the aerosol set-up every Monday. Review of Resident 28's Respiratory Care Orders Flowsheet for January 2025 failed to show documentation the aerosol set-up was changed weekly on Mondays. On 1/22/25 at 0805 hours, Resident 28 was observed receiving oxygen therapy via the T-Bar at FiO2 28% with the oxygen flowmeter set at five liters per minute. The sterile water connected to the oxygen flowmeter was observed undated with one-third of the contents remaining in the bottle. The yanker was observed opened and dated 1/20/25. On 1/22/25 at 1111 hours, an interview and concurrent observation was conducted with LVN 6. LVN 6 stated for the residents receiving oxygen therapy via the T-Bar aerosol, the licensed nurses were responsible for the respiratory care and services, including the suctioning and changing of the aerosol set-up and tubing. LVN 6 verified the above findings. LVN 6 was asked when the aerosol set-up/tubing was last changed. LVN 6 stated the changing of the aerosol set-up was done every Mondays, Wednesdays and Fridays. LVN 6 stated the last change for the aerosol set up should have been on Monday. LVN 6 further stated, when changing the T- Bar aerosol setup the licensed nurse should label the aerosol set-up/tubing with the date it was changed to ensure the staff knew when it was last changed. On 1/23/25 at 1648 hours, an interview was conducted with the Director of Sub-Acute Unit. The Director of Sub-Acute Unit stated for the residents receiving oxygen therapy via the T-Bar, the licensed nurses were responsible for the respiratory care, suctioning, and changing of the aerosol set-up. The Director of Sub-Acute Unit stated the sterile water used for the oxygen therapy should be dated when opened, and the yanker should be dated when opened and changed per the facility's P&P. The Director of Subacute Unit stated the aerosol set up should be changed every week and as needed, the tubing should be dated so staff were informed of when it was last changed, and the nurse should document the change of the aerosol set up in the flowsheet. On 1/23/25 at 1702 hours, the Director of Sub-Acute Unit was informed and acknowledged the above findings. 44175 4a. On 1/21/24 at 0845 hours, Resident 8 was observed in bed with a tracheostomy tube (breathing tube inserted through the neck into the airway to maintain an open airway) in place and connected to a mechanical ventilator (a machine that takes over the work of breathing when a person is not able to breathe enough on their own). A suction canister attached to the wall was observed connected to the resident's ventilator tubing with a suction tubing. The suction tubing and canister was observed labeled 1/12/24, and the suction canister was observed 1/3 full with greenish liquid. The yankauer tube was observed at the left side of Resident 8's bed, with brownish stain and inside an opened original package with no label. On 1/21/25 at 0855 hours, an observation and concurrent interview was conducted with RT 1. RT 1 verified the above observation. RT 1 stated the facility staff member changed the suction tubing and canister every week and as needed. RT 1 verified the suction tubing and canister were not changed for the last nine days for Resident 8. RT 1 stated the yankauer tubing should be changed every shift and should have been labeled when it was opened. Medical record review for Resident 8 was conducted on 1/21/25. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Patient Orders showed following physician orders dated: - 12/20/23, for mechanical ventilation with the ventilation settings. -11/16/23, for tracheostomy care change trach dressing every shift and PRN when soiled. b. On 1/21/24 at 0845 hours, Resident 8 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The tracheostomy tube was observed with dry brownish stain. On 1/21/25 at 0855 hours, an observation and concurrent interview was conducted with RT 1. RT 1 verified the above observation and stated the tracheostomy site for Resident 8 needed to be cleaned and the tracheostomy dressing needed to be changed. On 1/23/24 at 0841 hours, the Director of Sub-Acute Unit was informed and acknowledged the above findings. 5. On 1/21/25 at 0935 hours, Resident 2 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. A suction canister attached to the wall was observed connected to the resident's ventilator tubing with a suction tubing. The suction tubing and canister was observed labeled 1/12/24, and the suction canister was observed 3/4 full with greenish liquid. The yankauer tube was observed inside an opened original plastic package with no label, at the left side of Resident 2's bed. On 1/21/25 at 0945 hours, an observation and concurrent interview was conducted with RT 2. RT 2 verified the above observation. RT 2 verified the suction tubing and canister were not changed for the last nine days for Resident 2. RT 2 stated the yankauer tube should have been labeled when it was opened. Medical record review for Resident 2 was initiated on 1/21/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Patient Orders dated 11/27/24, showed an order for mechanical ventilation with the ventilation settings. 39670 6. Review of the facility's P&P titled Ventilator Alarm Setting Guidelines Troubleshooting and Corrective Action reviewed date 4/2020 showed the ventilator-dependent residents should have a safe environment by creating awareness of ventilator alarms and take corrective action when an alarm present itself. Alarms will be set appropriately for each resident needs. Team members will respond immediately to all ventilator alarms and the ventialtor alarm settings should be documented in the resident's medical record. On 1/21/25 at 0911 hours, and 1/22/25 at 0812 hours, Resident 6 was observed in bed with tracheostomy tube in place and connected to a mechanical ventilator. Resident 6's ventilator was observed set to tidal volume of 500 ml, breath rate of 10, High pressure Inspiration to 70. The mechanical ventilator machine had the red flashing light showing HIGH PRESSURE. There was no audible sound of the mechanical ventilator alarm was heard in the room or in the hallway. Medical record review for Resident 6 was initiated on 1/21/25. Resident 6 was admitted to the facility on [DATE] with a diagnosis of respiratory failure. Review of Resident 6's Physician's Order dated 5/31/23, to set Resident 6's ventilator to Assist control mode, rate of 10, tidal volume of 500 ml, and PEEP of 5. Another physician's order showed special instructions to check the high/low pressure ventilator alarms every shift. Review of Resident 6's Respiratory Flowsheets dated 1/15/25 to /1/22/25, showed Resident 6's ventilator machine settings and respiratory care were documented. However, there was no documented evidence the ventilator alarms were checked every shift per the physician's order. Review of Resident 6's plan of care showed a care plan problem dated 4/18/22, addressing the respiratory status of the resident. However, there was no interventions included for the mechanical ventilator monitoring of the alarms and settings per the physician's order. On 1/22/25 at 0855 hours, an observation and concurrent interview was conducted with the IP. The IP was asked at Resident 6's bedside about the vetilator machine flashing of red light High Pressure. The IP stated the ventilator machine flashing was from the old alarm that has not been cleared and when not cleared it will come. The IP stated the RT was responsible for the resident's respiratory care including the ventilator machines. The IP verified there was no alarm sounds heard from the ventialtor machine and in the hallway monitor. On 1/22/25 at 0859 hours, an observation and concurrent interview was conducted with RT 4. RT 4 was asked at the resident room bedside. The ventilator machine was observed flashingHigh Pressure. RT 4 was asked why was the ventilator machine flashing a high pressure, RT 4 stated when the resident cough and the ventilator machine detect high pressure, then it will flash the high pressure indication there was something going on with the resident. When asked why was there was no sounding alarm when the ventilator machine was showing a high pressure alarm, RT 4 stated the machine will go back to original setting when the resident had stop coughing. RT 4 was asked what was the purpose of the machine alarm, RT 4 stated to alert staff member to check on the resident's respiratory status. RT 4 was asked what other monitoring alarm will sound off when the ventilator machine detected an alarm, RT 4 stated there was a monitor on the hallway that will show an alarm and sounding off when the ventilator machine has alarm. When asked why there was no sounding alarm heard in the hallway when the ventilator machine had a high pressure alarm on, the RT was unable to explain. On 1/22/25 at 0915 hours, an observation and concurrent interview was conducted with RT 5. RT 5 was asked at the resident room and asked about the ventilator machine of the resident. RT 5 stated when the high or low pressure alarm would come off, the machine will sound off an alarm in the machine and in the hallway monitoring. RT 5 verified there was no sounding alarm for the monitor in the hallway and on the ventilator machine went off for a high pressure alarm. RT 5 was unable to explain why was the machine did not sounding off the alarm. Review of the Operator's Manual LTV 1200, 1150 Ventilator, Under Ventilator Alarms, showed when an alarm occurs, a flashing alarm message appears in the display window, an audible alarm sounds, and any associated control displays flash. Warning alert, showed for Audible Alarms: Failure to immediately identify and correct audible alarm situations may result in serious patient injury. On 1/22/25 at 1428 hours, an interview and concureent medical record review was conducted with RTs 4 and 5. RT 4 verified the physician's order for respiratory therapy. RT 4 was asked about the physician's order for checking of the high/low pressure ventilator alarms every shift. RT 4 was unable to provide a documentation the ventilator machine was checked for the alarm sound. RT 5 verified there was no documentation the ventilator machine sound alarm was checked every shift, and added they just enter the parameters on the machine and did not checked if the alarm sound of the machine was working or not. RT 5 was asked about the plan of care for the respiratory problem of the resident. RT 5 was able to show the care plan for respiratory failure, however, when asked if the interventions were included to check the alarm sounds of the ventilator machine, RT 5 verified there was no interventions included on checking the alarm sound of the vent machine. On 1/23/25 at 1133 hours, an interview and concurrent medical reord review for Resident 6 was conducted with the Director of Sub-Acute Unit. The Director of the Sub-Acute Unit stated she expected the residents machines were working properly including the sounding of the alarm to alert the staff member if the resident had any problem. The Director of the Sub-Acute Unit was informed and verified the above findings. 49644 * The facility failed to ensure Resident 27's set up bag was changed weekly. 7. During the initial facility tour on 1/21/25 at 0854 hours, Resident 27's was observed lying in bed with eyes closed. A set up bag with nebulizer inside was observed hanging on the oxygen flowmeter and dated 1/12/25. Medical record review for Resident 27 was initiated on 1/21/25. Resident 27 was admitted to the facility on [DATE]. Review of Resident 27's physician's order dated 1/24/25, showed a physician's order dated 10/19/24, to administer albuterol + ipratropium (treat symptoms of lung diseases) 2.5 mg-0.5 mg/3 ml inhalation, 3 ml nebulizer every six hours. On 1/21/25 at 0925 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified Resident 27's set-up bag for the nebulizer was dated 1/12/25, and should have been changed on 1/19/25. LVN 4 stated the respiratory therapist should have changed the nebulizer and the set-up bag every week. On 1/23/25 at 1144 hours, an interview was conducted with RT 3. RT 3 stated the night shift RT change the nebulizer on Sunday nights and as needed. RT 3 stated they changed the nebulizer and set up bag at the same time. On 1/23/25 at 1725 hours, an interview was conducted with the Director of Sub-Acute Unit. The Director of Sub-Acute Unit was informed and acknowledged the above findings.

Based on observation, interview and review of the clinical record and the facility's documents, the facility failed to maintain a complete infection control program, follow infection control guidelines per their P&P, use PPE (gowns, gloves and masks) appropriately and prevent the spread of infections by inappropriately isolating (a process of separating residents with infections from other residents) and cohorting (placing residents with the same type of infections in the same room while in isolation) the residents. These have the potential to cause or spread infections to all residents within the facility. Seventy five percent of the facility's residents (28 of 36 residents) were in contact isolation (use of gowns, gloves and masks to prevent the transmission of infectious agents that are spread by direct or indirect contact with the resident or the resident's contaminated environment by staff or visitors) for a prolonged time frame due to a history of a MDRO (infections that are resistant to some antibiotics and/or over use of antibiotics) infection. The residents were in contact isolation for greater than five years. Once a resident was found to have an MDRO infection, the facility kept the resident in contact isolation until discharge or death, even if the MDRO infection was from a previous hospitalization . The facility was following a study from the CDC dated 2006, as their justification for the residents' prolonged isolation. The facility did not follow the recommendations of the study completely. Residents were not screened to determine if these MDRO infections were active (if the infection is still active), colonized (the bacteria lives on the resident but the infection is not active), or had resolved (the bacteria/infection is no longer present) as recommended by the study. In addition, the facility did not address the psychosocial impact on the residents as shown in the CDC study. If a resident developed a MDRO infection, the resident is placed in contact isolation and is cohorted with other residents who had a history of [REDACTED]. The lack of screening and the exposure to multiple new MDRO infections has placed residents who could be infection free with other residents with serious infections. This may also expose residents to new MDRO infections, increasing their risk of contracting a new serious infection. Two of 10 sampled residents (Residents 1 and 7) were found to have a history of a MDRO infection which had resolved. These residents remained in contact isolation without clinical justification. Resident 7 had MRSA (a MDRO) infection in her left eye identified on 12/27/12, and was placed on contact isolation. The resident was retested on [DATE], and found to be clear of this infection and had no history of any other MDRO infections. Due to the facility's P&P of not removing the resident from contact isolation once a [DIAGNOSES REDACTED]. She was cohorted with a roommate who had three MDRO infections and another roommate who had four MDRO infections. Some of the roommates' infections were different from Resident 7's previous infections and had occurred while Resident 7 had been cohorted with her roommates. The Infection Control RN stated Resident 7 was not moved out of the infected room due to the facility's policy. Resident 1 was placed on contact isolation since admission on 4/24/13, and cohorted with two roommates who both had been diagnosed as having multiple MDRO infections. There was no clinical documentation to show Resident 1 had an active infection that required contact isolation. This practice places Residents 1 and 7 in jeopardy of contracting new MDRO infections from her other roommates who had multiple active MDRO infections. The Infection Control RN was not mapping (showing the room location of the infections) the infections within the facility. This has the potential for the facility to not recognize an outbreak of active infections, a contaminated room, or if staff members are spreading infections to other residents. The infection control surveillance was not accurate. The Infection Control RN did not recognize a positive laboratory culture of greater than 100,000 colony forming units of bacteria as an infection. The RN stated the residents did not meet the complete criteria of an infection by displaying or verbalizing symptoms such as pain or difficulty urinating. Most residents within the facility are ventilator dependent (a machine used to breath for the resident) and cannot speak. The Infection Control RN did not modify the infection control criteria. The facility had a 75% rate of MDRO infections, but was not monitoring for inappropriate antibiotic usage. The PPE used for the residents in contact isolation was located inside the residents' rooms rather than in the hallway. Staff members and visitors must enter the room approximately five feet before being able to access the PPE. Staff members and visitors were not consistently using PPE. A respiratory therapist was observed suctioning a resident in contact isolation without a gown on. A staff member did not wash her hands when changing gloves during wound care for a resident in contact isolation. In addition, the residents' family members were not required to use PPE on the patio for residents in contact isolation. Staff members were observed using paper gowns while providing bed baths. When paper gown become wet, they can contaminate staff members clothing and cause infections to be spread to other residents during care. Staff were observed taking resident equipment such as portable blood pressure machines and scales out of an isolation room and using them on multiple residents without cleaning or disinfecting. The temperature inside the washer, being used to wash the resident's personal clothing, was not being monitored correctly. The Immediate Jeopardy was identified on 6/12/13 at 0900 hours, regarding the facility's failures to: a) provide appropriate isolation and cohorting techniques which increased the potential residents with no infections to be cohorted with residents with active and different infections. b) protect Resident 7 from potentially serious infections by cohorting her with a resident with three MDRO infections and a second resident with four MDRO infections. Resident 7 has no MDRO infections to justify her continued contact isolation with other residents who have had active infections while cohorted with her. c) protect Resident 1 from potentially serious infections by cohorting him with two other residents with seven MDRO infections when the resident was cultured and found to no longer have MDRO infections. d) recognize long-term contact isolation and cohorting of residents with MDRO infections which might lead to residents cross contaminating their roommates and increasing the risk of new or reoccurring infections of these residents. The facility's Administrator, DON and CNO were notified of the Immediate Jeopardy on 6/12/13 at 0900 hours. An acceptable written plan of action was provided on 6/12/13 at 1630 hours, which included the following measures: * All 28 residents in contact isolation were screened for active infections to determine if contact isolation was still necessary. Of the 28 residents, 25 were cleared for the need to continue the prolonged contact isolation. * The PPE was removed from the inside resident's rooms and placed in the hallways. Plastic gowns were added to the PPE for use while providing bed baths. * The facility changed and/or revised their infection control P&P to include standard precautions or enhanced standard precautions (using PPE based on the risk of exposure) for their isolation protocol. In addition, the criteria to determine if the resident had an infection was updated. * The infection control surveillance was changed to include mapping and criteria to determine the unnecessary use of antibiotics. The pharmacy revised their P&P to address the use of unnecessary antibiotics as well. * All staff members were inserviced about the new infection control P&P and its updates. The Immediate Jeopardy was abated on 6/14/13 at 1500 hours, prior to the exit of the survey. Findings: 1. Review of the facility's P&P titled Definitions of Infection for Surveillance dated 3/11, shows colonization of infections means the presence of micro-organisms on skin, mucus membranes, in open wounds or in excretions or secretions, but are not causing adverse clinical signs or symptoms, are not infectious. The Infection control designee evaluates each suspected facility's acquired infection utilizing the definitions of infections. Review of the facility's P&P titled Infection Surveillance Line Listing revised 6/10, shows the surveillance form is maintained in a binder at the subacute nursing station and the data is to be filled in at the time of discovery of an infection. The Infection Control Practitioner will evaluate the Line Listing. The Line Listing will be used as one of the monitoring tools to identify any trends or patterns of nosocomial infections. Review of the facility's three page table titled MDRO Mapping dated 6/3/13, shows 11 of 16 resident rooms have contact isolation precautions in place. Each resident entry shows multiple MDROs and multiple dates the organisms were identified with multiple sources. The range of dates the organisms were shown to be identified included 4/30/09 through 5/23/13. Documentation to show on a monthly basis, the facility had mapped newly identified infections by location, and the source was not found. Review of the Line Listing for positive cultures showed 36 of 36 residents with infections. 35 of the 36 residents were identified to have multiple entries with multiple organisms identified. a. On 6/3/13 at 1425 hours, an interview and review of the facility's infection control program were conducted with the Infection Control RN. The Infection Control RN identified herself as being responsible for the facility's infection control program. When asked to describe the program, the Infection Control RN stated she refers to McGeer's criteria (a set of specific definitions to identify true infections in long-term nursing facilities) for identification of an infection and the CDC's 2006 study as a reference for transmission based precautions. She stated upon admission , a laboratory testing is performed to identify a MDRO infection by obtaining panel of specimens including urine, sputum (mucus coughed up), tracheostomy (a surgical procedure to create an opening through the neck into the windpipe) site, nares (nostrils), gastric tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) site, rectal swap and any open wounds. The Infection Control RN stated this screening is performed for each resident even if they do not have any signs or symptoms of an active infection present. She stated if the results of the testing shows a MDRO infection is identified, the resident is placed on contact isolation precautions. The Infection Control RN stated once the need for contact isolation precautions are determined, the resident remains in contact isolation for the remainder of their stay in the facility. The Infection control RN stated the nursing staff complete the surveillance form which is kept in a binder at the nursing station, and she is notified if there is a positive culture result. She stated she reviews the information and determines if an actual infection has been identified based on McGeer's criteria. She stated she adds the information on the Line Listing which is a cumulative list of the resident's infections. She stated the Line Listing for positive cultures includes all of the May, 2013 data. She stated she does not do the Line Listing by the month. The facility does a lot of routine cultures; however, she is not tracking antibiotics usage when the infection does not meet the McGeer's criteria. She stated she defines a community acquired infection as any actual infections in which the symptoms are present by the third day after admission. She verified she does not track community acquired infections. The Infection Control RN verified she does not do monthly mapping for infections. She stated she uses the MDRO Mapping form and the Line Listings to evaluate if trends are identified. She stated the infection control rates and any trends are presented to the Infection Control Committee quarterly. She stated she has not identified any trends for the first quarter of 2013. The Infection Control RN stated she counts up the HAI and reports it quarterly to the Infection Control Committee. She stated she has not completed her evaluation of April and May, 2013 because the facility transitioned to the electronic medical record during this time. Review of the 2013 infection control rates showed the infection control rate for 2012 was 0.63. Review of the infection control rate for the first quarter 2013 showed a rate of 0.77. The Infection Control RN was unable to explain why the low rate of infections with 28 of 36 residents with contact isolation precautions in place. b. On 6/7/13 at 0925 hours, an interview was conducted with the Infection Control RN. When asked how the facility has identified if an organism is colonized, she stated she does not test for colonization. She stated once the MDRO is identified it is considered to be present, and there is not a need for further testing. The surveyor requested copies of the February, 2013 surveillance forms. On 6/7/13 at 1125 hours, an interview and review of the February, 2013 surveillance forms were conducted with the Infection Control RN. Review of the surveillance forms for February, 2013 showed eight residents were treated with antibiotics during the month. Two surveillance forms were randomly selected. Review of the surveillance form dated 2/22/13, showed Resident J had a positive urine culture obtained from an indwelling urinary catheter with greater than 100,000 colony forming units of bacteria present and a positive sputum culture. The documentation also showed Resident J was treated with [MEDICATION NAME] (antibiotic medication) 875 mg twice a day for 14 days. Review of the surveillance form dated 2/20/13, showed Resident K had a positive urine culture obtained from an indwelling urinary catheter with greater than 100,000 colony forming units of bacteria present. The documentation showed Resident K was treated [MEDICATION NAME](antibiotic medication) 500 mg every 12 hours for 7 days for UTI. The Infection Control RN stated she does not track residents who are treated with antibiotics. The Infection Control RN verified the findings and stated the residents did not complain of symptoms, so they did not meet the criteria for an infection and are not included in the calculation for the monthly rate. When asked, since many of the residents do not speak, how she has determined if they have symptoms, the Infection Control RN stated this is a problem. On 6/13/13 at 0950 hours, an interview and review of the infection control surveillance documentation were conducted with the Infection Control RN, the Pharmacy Director, the Pharmacy Consultant, the Director of Clinical Process Improvement and the DSD. Review of the infection control rates for November, 2012, December, 2012 and February, 2013 showed a rate of zero. The Infection Control RN also verified the infection control rates for November, 2012, December, 2012 and February, 2013 were zero. Further review of the surveillance documentation shows: * November, 2012: 8 residents were administered antibiotics (15 antibiotics ordered) *December, 2012: 11 residents were administered antibiotics (15 antibiotics ordered) * February, 2013: 8 residents were administered antibiotics (9 antibiotics ordered). The DSD verified the findings. The Infection Control RN stated she does not track the use of antibiotics. When asked if the pharmacy tracks the use of antibiotics, the Pharmacy Consultant stated he only checks to see if the organism on the culture is sensitive to the antibiotics ordered and calls the physician if needed. 2.a. Clinical record review for Resident 7 was initiated on 6/6/13. Review of the physician orders [REDACTED]. Resident 7 had remained in contact isolation since 12/27/12. Review of the laboratory report dated 12/27/12, showed Resident 7 had an MRSA infection (a MDRO) of the left eye. Resident 7 was moved into a new room and placed in contact isolation. Further review of the laboratory reports showed on 1/12/13, the left eye was recultured and found to be clear of any further infections. Review of nonsampled Resident H's clinical record, Resident 7's roommate, showed Resident H had an ESBL infection from E. coli (an organism) of a wound on 2/15/13, a MRSA infection of the nares on 2/15/13, and an ESBL infection from E. coli of the urine on 4/4/13. Review of Resident 4, Resident 7's other roommate, showed Resident 4 has an ESBL infection from E. coli of the urine on 7/30/10, a MDRO infection of the urine on 2/18/11, a MRSA infection of the nares on 11/4/12, an ESBL infection from [DIAGNOSES REDACTED] (an organism) of the GT site and wound on 5/22/13, and a MRSA infection of the nares on 5/24/13. An interview with the Infection Control RN was initiated on 6/3/13 at 1415 hours. The Infection Control RN was asked about the policy of prolonged contact isolation and the need for Resident 7 to remain in contact isolation even though she was cleared of infections. The Infection Control RN stated once a resident is found to have a MDRO infection, due to the possibility of the infection returning, the resident is never taken out of contact isolation. The Infection Control RN was asked if the resident is routinely screened after a MDRO infection has been treated to determine if the infection has cleared, if the resident is colonized, or if the infection remains. The RN stated no. 2.b. On 6/3/13 at 0810 hours, tour rounds were conducted with the DSD. The DSD reported Resident 1 had respiratory failure and was on contact precautions. The DSD did not know if Resident 1 was currently being treated for [REDACTED]. On 6/6/13, clinical record review was initiated. Resident 1 was admitted to the facility on [DATE]. Review of the Acute Care Fax Referral dated 4/22/13, showed the resident needed isolation precautions for Acinetobacter in the sputum. Review of the physician's orders [REDACTED]. Review of the sputum culture dated 4/25/13, showed normal respiratory flora. Documentation to show Resident 1 had an active infection on admission was not found in the clinical record. On 6/14/13 at 1350 hours, an interview and concurrent clinical record review were conducted with the DSD. The DSD verified the finding. The DSD stated contact isolation precautions was not indicated for Resident 1, and Resident 1 should not have been placed in a room with Residents M and N who both have been diagnosed as having multiple MDRO infections. 3. Clinical record review for Resident 3 was initiated on 6/3/13. Review of the physician's orders [REDACTED]. According to the facility's P&P titled Methicillin Resistant Staphylococcus Precautions dated 11/10, hand hygiene must be performed after removal of gloves. According to 2007 CDC guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, healthcare workers wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. An observation of wound care for Resident 3 was initiated on 6/5/13 at 1500 hours. The PT washed her hands prior to beginning the dressing change and put on gloves. Throughout the dressing change the PT removed her gloves three times and put on new gloves, but did not wash her hands. An interview with the PT was initiated after the dressing change was completed on 6/5/13. The PT was asked why she did not wash her hands. The PT stated she would have washed her hands after she changed her gloves if her hands were wet or soiled. 4. An observation on 6/3/13 at 0730 hours, showed RT 1 was suctioning Resident J. The RT had gloves and a mask on but not gown. Record review of Resident J showed the resident had been in contact isolation since 4/30/09, for four MDRO infections. The 2007 CDC guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings showed to wear a gown, that is appropriate to the task, is to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. 5. On 6/3/13 at 0710 hours, the facility's initial tour was conducted with LVN 4. A green sign was observed on the wall outside room [ROOM NUMBER] showing "Contact Precautions." The sign showed to wear gloves upon entering the room and to wear a gown if you anticipate your clothes coming in contact with the patient and blood/bodily fluids of environmental surfaces. LVN 4 was observed entering the room without wearing gloves. LVN 4 was observed donning a gown, and gloves from a rack on the wall next to the residents' closet. Three residents were occupying the room. LVN 4 verified gowns, gloves and masks are donned inside the room, not upon entering the room. Six of eight rooms (18 of 22 residents in one hallway) were on contact precautions. 6. On 6/3/13 at 0730 hours, CNA 1 was observed entering room [ROOM NUMBER]. A green sign showing "Contact Precautions" was in place and observed on the wall next to the door. CNA 1 was observed placing a disposable blood pressure cuff on the side rail of the resident in bed A and then unplugging a portable blood pressure machine from the wall opposite the residents' beds. She was observed removing the blood pressure machine from the room without disinfecting the machine or washing her hands. CNA 1 did not wear a gown or gloves. CNA 1 verified the findings and stated she should have been using PPE when in the room and washed her hands. When asked about the facility's policy for disinfecting resident care equipment for residents on contact isolation precautions, she stated she should have wiped down the blood pressure machine with a disinfectant prior to removing it from the room. 7. On 6/3/13 at 1040 hours, a CNA was observed transferring Resident L from her room to the shower room on a stretcher. Resident L was on contact isolation precautions. The CNA was observed in the room without wearing a gown or gloves. The CNA was observed covering Resident L's feet with a blanket before leaving the room and did not wash her hands. 8. On 6/3/13 at 1040 hours, Housekeeper 1 was observed entering room [ROOM NUMBER] and removing the soiled linen bag from the hamper inside the room and placing the soiled linen bag in his cart located in the hallway. Housekeeper 1 was observed wearing gloves but not gown. Housekeeper 1 verified he was picking up the soiled linen from the room. Housekeeper 1 stated he is aware contact precautions are in place for room [ROOM NUMBER]. He stated he wears gloves and washes his hands; however, does not wear a gown when picking up soiled linen. 9. An observation and interview were initiated on 6/4/13 at 0855 hours. A mechanical scale was observed in Room A, a room with three residents, all residents are in contact isolation. The scale was used by CNA 3. The scale was observed being moved out of the room without being cleaned. The CNA stated the scale should have been cleaned prior to removing it from the isolation room. The 2007 CDC guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings showed to handle used patient-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments and ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed and that single-use items are properly discarded. 10. An observation on 6/3/13 at 1000 hours, showed CNA 2 performed a bed bath for nonsampled Resident I. Resident I had been in contact isolation since 4/30/09. The CNA was wearing a paper gown. An interview with CNA 2 was initiated on 6/3/13 at 1500 hours. The CNA stated she used the paper gown because it was the only type available in the resident's room. The 2003 CDC guidelines for Environmental Infection Control in Healthcare Facilities showed gowns are protective barriers against the transfer of microorganisms, particulates and fluids to minimize strikethrough and the potential for personnel contamination. Microorganisms can be transferred through barrier materials by wicking of fluids and/or pressure or leaning on a flooded area of the product. 11. An observation of the Activity Room on 6/4/13 at 1030 hours, showed a washer, dryer and water heater in the north west corner of the room. The water heater had a temperature gauge on top of the heater. According to the facility's P&P Laundry Management dated 6/12, laundry water temperature should be maintained at 160 degrees F. Let the machine fill with water and check the temperature of the water inside the machine. An interview with the Activities Director was initiated on 6/4/13 at 1100 hours. The Director stated she checks the temperature daily from the gauge and records it on a log. The Director stated she does not have a thermometer available to check the temperature inside the washer.