Every finding on record at Southwest Medical Center SNF

Based on observation, interview, and record review, the facility failed to provide eight consecutive hours of Registered Nurse (RN) staff daily for the residents of the facility.Findings included:- The 08/05/25 Facility Assessment, documentation included: Staff/Personnel required, which stated Skilled Nursing Unit bases staffing on the resident population and their needs for care and support. A good faith effort and approach is made to ensure sufficient, qualified staff is available to meet the needs of the residents at any given time. The staffing plan in place can be adjusted based on changes in the resident census. The nurse to resident ratio is six residents to one RN and one Certified Nurse Aide. An additional Licensed Practical Nurse (LPN) may be utilized if the resident number increases. Staff are scheduled 12 hours shifts per day. Review of the Nursing schedule for 10/01/25 - 12/31/25, revealed a lack of scheduled RN coverage for the following dates:Thursday, 11/13/25.Sunday, 11/20/25.Saturday, 12/20/25. On 04/22/26 at 01:33 PM, Administrative Nurse E confirmed the lack of scheduled RN coverage as noted above. He stated the facility lacked auditable or verifiable evidence of him working as the RN on duty for eight consecutive hours and confirmed he was not listed or identified as the RN on the schedule or staff postings for RN coverage for the weekend days.On 04/22/26 at 02:00 PM, Administrative Nurse D reported she expected the Skilled Nursing Unit to have a scheduled RN for the required eight consecutive hours of registered nurse staff daily for the residents of the facility.On 04/24/26 at 12:15 PM, Administrative Nurse E confirmed the lack of scheduled RN coverage on Thursday 11/13/25, he reported he was off that day and the house coordinator for the hospital would have covered. Administrative Nurse E reported the house coordinator is not on the Skilled Nursing Unit for eight consecutive hours The facility's policy Provision of Care, Treatment, and Services dated 05/2025 documented how the department is staffed to meet patient needs. The minimal staffing required is RN coverage for 12 hours a day 7 days a week, and on any shift, there will be either an RN or LPN. The average staffing pattern on the unit is based on the average daily census and patient acuity.

Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 11 with a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer. The facility further failed to ensure adequate hand hygiene before medication administration for R11 and R2. Findings included:1. On 04/21/26 at 08:53 AM, Licensed Nurse (LN) G sanitized her hands and applied gloves, LN G did not apply any other personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) and entered R11's room with his medications in their blister packs. LN G placed the medications on the counter under the computer in his room. LN G then assisted R11 to sit up in his bed, as he had laid flat in the bed diagonally. LN G applied the gait belt on R11 and assisted him to the side of the bed, they worked together to scoot him up towards the head of the bed. LN G then assessed R11 and covered him up. LN G used the controllers to elevate R11's head of bed. LN G then walked back over to the computer and scanned R11's identification bracelet and scanned the medications, she opened each packet and dropped the pills into the medication cup. She continued to wear the same gloves that she wore when she provided hands on care. LN G then took one pill out of the medicine cup with her gloved hand and administered that pill directly to R11's mouth. LN G took another pill from the medicine cup with her gloved hand and placed that pill directly into R11's mouth. The remainder of the medications were administered from the medicine cup.2. On 04/21/26 at 09:40 AM, LN G sanitized her hands and applied gloves and gown as she entered R2's room. LN G prepared R2's medications with the same gloved hands that she used to touch the computer keyboard, she opened the blister packets administered the medications and then applied a topical (on the surface of the body) medication patch to R4's left hip. On 04/21/26 at 02:52 PM, LN G reported R11 was not on EBP as his Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) had been removed days ago. LN G confirmed R11 had a Stage 2 pressure ulcer on his buttock. LN G reported that he only needed EBP when he had a Foley. LN G reported that she had not realized that she had worn gloves to provide hands on care to R11 before she prepared his medications. Additionally, she reported that she did not think touching objects in the resident's rooms with gloved hands and preparing and administering medications in the resident's room was a concern. On 04/22/26 at 10:14 AM, Administrative Nurse I (Infection Preventionist) revealed she expected staff to wear appropriate PPE when providing direct care for residents on EBP. Additionally, she expected the staff to use clean gloves when administering medications and to remove gloves after hands-on care, perform hand hygiene, and apply new gloves. The facility's policy Medication Administration dated 08/23, documented to maintain clean technique throughout medication administration.The facility's policy Enhanced Barrier Precautions dated 04/25, documented that upon admission to the skilled nursing unit, the admitting nurse will complete the Enhanced Barrier Precautions Screening section. If any of the questions are answered yes, an order for Enhanced Barrier Precautions (EBP) must be placed.Examples of high-contact resident care activities requiring gown and glove use for EBP included dressing, transferring, and wound care: any skin opening requiring a dressing.

Based on observation, interview, and record review, the facility failed to provide a written baseline care plan to Resident (R) 1, R2, 11, and R4. Findings include:- On 04/20/26 at 09:51 AM, R1 reported she had not received a copy of a baseline care plan. She reported that she has not attended a care plan meeting or any discharge planning since she admitted . R1's Electronic Medical Record (EMR) lacked documentation that a written baseline care plan was given or reviewed by R1 or a family member since she admitted on [DATE]. On interview on 04/20/26 at 10:24 AM, R2 reported she was never provided a written copy of the care plan while she had been a resident in this facility.R2's EMR lacked documentation that a written baseline care plan was given or reviewed to R2 or a family member since she admitted on [DATE]. On 04/20/26 at 10:28 AM, R11 reported he was uncertain about a baseline care plan and reported he did not receive any paperwork about a care plan.R11's EMR lacked documentation that a written baseline care plan was given or reviewed to R11 or a family member since he admitted on [DATE]. On 04/22/26 at 11:07 AM R4 reported neither she nor her family member received a copy of care plan. R4's EMR lacked documentation that a written baseline care plan was given or reviewed to R4 or a family member since she admitted on [DATE]. On 04/21/26 at 02:52 PM, Licensed Nurse (LN) G reported the charge nurse would start the baseline care plan in the EMR the day the resident was admitted . LN G revealed they would not review or give a written copy of the baseline care plan to the resident or resident's family. On 04/21/26 at 03:30 PM Administrative Nurse F reported that the baseline care plan was completed in the EMR and started on the first day of the admission by the nurse as it was a basic skilled care plan and it would be developed to a personalized care plan. Administrative Nurse F revealed that the facility did not give a copy of the baseline care plan to the resident or resident's family. Administrative Nurse F reported there was no area in the EMR in the teaching section to document that the care plan was reviewed. On 04/22/26 at 02:00 PM, Administrative Nurse D reported the baseline care plan was completed after the initial assessments were completed and reported that the baseline care plan should be documented when reviewed with the resident or family member. The facility's policy Care Plans dated 07/2011, lacked documentation regarding a baseline care plan.

Based on observation, interview, and record review, the facility failed to store and label biologicals adequately when staff failed to date an insulin (medications used to treat high blood glucose levels) pen when opened. Findings included:- On 04/21/26 at 09:50 AM, observation of the Resident (R) 1's Lantus (long-acting insulin) pen revealed the pen lacked an open date or the discard date. On 04/21/26 at 09:51 AM, Licensed Nurse (LN) G reported that all insulin pens should be labeled with an opened date and a discard date.On 04/22/26 at 01:15 PM, Administrative Nurse E reported he expected all insulin pens to be labeled with the date it was opened and a discard date. The facility's policy Medication Administration, dated 08/23, documented insulin vials may be kept at room temperature in the patient's medication drawer. Date the vial when it is opened. Insulin is outdated 28 days after being opened.

Based on interviews and record review, the facility failed to ensure Resident (R) 1 received the opportunity to participate in the care planning process when staff failed to invite R1, or their responsible party to care plan meetings. Findings included:- R1's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and displaced intertrochanteric fracture of right femur (broken bone outside the hip joint). R1's admission Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. R1's MDS documented R1 required moderate assistance with activities of daily living (ADLs) and touching assistance with bed mobility and transfers. R1's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 04/14/26, documented R1 had a left arm sling, right hip fracture, and falls.R1's Care Plan, dated 04/01/26, documented R1 planned to return to care of her husband once she reached her therapy goals and she is safe to go home.R1's Progress Note, dated 04/14/26 at 02:29 PM, documented a care team meeting held with the following staff present: Administrative Nurse E, Administrative Nurse F, Administrative Nurse H, and Consultant Staff HH (Physical Therapy Aide). R1 had a goal of 150 feet and had ambulated 40 feet twice using the hemi-walker. R1 lived with her husband. Discharge plan to home with home health next week Monday or Tuesday. On 04/20/26 at 09:51 AM, R1 reported she had not been invited or attended a care plan meeting about her care or a discharge plan since she admitted at the beginning of the month. On 04/21/26 at 09:30 AM, R1 completed ambulation in the hallway with Consultant Staff HH using a hemi-walker, she wore a gait belt, and her gait was slow and steady. R1 ambulated approximately 75 feet each way with a brief rest period. On 04/21/26 at 03:30 PM, Administrative Nurse F reported that the care plan meeting would consist of Administrative Nurse E, Administrative Nurse H, Consultant Staff HH, and herself. Administrative Nurse F reported that if a resident wanted to attend a care planning meeting they could, and it would be documented if they did attend in the progress notes. Administrative Nurse F reported it would not be documented if the resident or family member was invited if they refused to attend. On 04/22/26 at 02:00 PM, Administrative Nurse D revealed she expected the staff to invite R1 and or the responsible party to a care plan meeting. The facility's policy Interdisciplinary Care Team, dated 06/2011, documented upon admission to the Skilled Nursing Unit the resident and/or family will receive a letter inviting them to the next Interdisciplinary care meeting to discuss comments/concerns regarding the residents' plan of care. The facility's policy Care Plans, dated 07/2011, documented immediately following admission, the resident will be visited by the nurse responsible for developing the Initial nursing care plan. Resident centered interdisciplinary conferences will be held weekly to ensure continuity of the interdisciplinary plan of care and subsequent changes in the care provided by the team members. Goals will be revised as needed.

Based on observation, interview, and record review, the facility failed to adequately assess Resident (R) 11's present-on -admission pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) at the time of admission and failed to ensure wound treatment orders were obtained and treatments provided.Findings included:- R11's Electronic Medical Record (EMR) revealed diagnoses of weakness, frailty, and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid).R11's EMR revealed no admission [NAME] Data Set (MDS) was completed since R11 admitted on [DATE].R11's Base Line Care Plan, dated 04/17/26, instructed staff to keep skin dry and intact, avoid pressure on skin, and avoid shearing/friction. Collaborate with Dietitian for R11's dietary needs.R11's Physician Orders instructed staff to apply lanolin ointment (moisturize and protect dry, scaly, or cracked skin) one application topically as need for skin irritation, date ordered 04/17/26. R11's Physician Orders lacked documentation for a treatment for the Stage 2 pressure ulcer. R11's Braden Scale (is a standardized, evidence-based tool used to assess a patient's risk of developing pressure injuries), dated 04/17/26, documented a score of 19, which indicated R11 was at low risk. R11's admission Physical Assessment, dated 04/17/26 at 05:33 PM, documented R11 admitted with a Stage 2 pressure ulcer on his sacrum (large triangular bone/area between the two hip bones). The documentation lacked assessment and measurement. R11's Hospitalist History and Physical, dated 04/18/26, documented a pressure ulcer of the sacral region, Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open). R11's Nursing Shift Assessment, reviewed from 04/17/26 through 04/19/26, documented R11 had a Stage 2 pressure injury on sacrum, provider aware, and sacral adhesive foam. R11's Nursing Shift Assessment, dated 04/20/26 at 06:00 PM, documented R11 had a Stage 2 pressure injury on right buttock, lanolin ointment applied and a foam dressing. R11's Hospitalist Visit, dated 04/21/26 at 12:04 PM, lacked documentation of pressure ulcer. R11's Nursing Shift Assessment dated 04/21/26 at 04:10 PM, documented R11 had a Stage 2 pressure injury on right buttock, measured 1 centimeter (cm) x 0.8 cm wound base beefy red. On 04/20/26 at 02:33 PM, R11 was seated in his chair with his feet up and eyes closed no issues noted.On 04/21/26 at 08:10 AM, R11 was seated up on the side of the bed eating breakfast he had a family member visiting. R11 reported that he slept well and had no concerns. On 04/20/26 03:38 PM, Licensed Nurse (LN) G reported R11 did not have an order in the physician orders for his wound on his right inner buttocks. LN G reported R11's wound should have been measured and documented on when he admitted on [DATE], she also reported an order should have been obtained from the provider. LN G reported the admitting nurse would take a picture of a wound. She reported R11 did not have a picture completed of his pressure ulcer. LN G reported that there were standing orders but could not locate the standing orders for R11's provider and reported that she did observe R11's wound but he refused to have her place a new foam dressing on the area, and she was unable to measure the wound this morning but stated it was approximately 1 cm in length.On 04/22/26 at 08:30 AM, Administrative Nurse E entered R11's room with a high-performance foam dressing and assisted LN G to complete wound care for R11. LN G removed a 7cm x 7cm pink sacral shaped foam dressing off his sacrum that did not cover the open area on right inner buttock. LN G reported that the dressing was not applied the correct way as it did not cover the open area on right inner buttock. Observed a small amount of serosanguinous drainage on his brief, the open area on the right inner buttock was not measured by the nurse or any pictures were taken, the approximate size was 1.5 cm x 1 cm the wound bed was red, and the peri wound was macerated and blanchable. LN G completed wound care and applied the high-performance foam dressing to the open area on the right inner buttock. No open wound was observed on R11's sacrum.On 04/21/26 at 03:30 PM, Administrative Nurse F reported all the nurses would complete wound care and should document in the EMR the skin concerns should be measured and assessed, and an order should be obtained. Administrative Nurse F reported there were no standing orders for wound care, the provider would just leave that up to the nurse, and generally the nurse would use the lanolin ointment. Administrative Nurse F expected the nurse to complete a weekly note which included measurements and picture of the wound uploaded in the EMR. The facility's policy Skin Assessment (includes Braden Scale)/Wound Prevention/Wound Protocols, dated 11/2023, documented a wound assessment intervention would be documented on by the nurse who first observed any skin impairment, in collaboration with any member of the health care team. Wound treatment would be according to the stage/type of wound. Continuing assessments would be made by nurse and documented daily and with each dressing change. The Physician would be notified when wound therapy was indicated.

Based on record review and interviews, the facility failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers/discharges for Resident (R) 10 and R3.Findings included:- R10's Electronic Medical Record (EMR) documented R10 discharged home on [DATE]. R3's EMR documented R3 discharged home on [DATE].The facility was unable to provide evidence that the facility notified the LTCO of the residents' transfer/discharge from the facility.On 04/22/26 at 01:00 PM, Administrative Nurse E reported that the facility did not notify the LTCO when a resident was transferred/discharged . The facility did not provide an Ombudsman Notification policy.

Based on observation, interview and record review, the facility failed to electronically submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) related to weekend staffing.Findings included - The PBJ Staffing Date Report revealed No RN Hours triggered four or more days within the quarter with no RN Hours. Additionally, the facility failed to have Licensed Nursing Coverage 24 hours/day for four or more days within the quarter for the following timeframes:Fiscal Year (FY) 2026, Quarter 1 2026 (October 1 - December 31). FY Quarter 3 2025 (April 1 - June 30). Review of the Nursing schedule for 04/01/25 - 06/30/25 and 10/01/25- 12/31/25 revealed the facility had 24 hours/day of Licensed Nursing Coverage when the Skilled Nursing Unit was open. On 04/22/26 at 01:33PM, Administrative Nurse D and Administrative Nurse E confirmed the inaccuracies of the PBJ data for the quarters identified above and reported that neither of them had looked at the PBJ reports prior to today and were unsure why the PBJ reports were submitted inaccurately.On 04/22/26 at 02:00 PM Administrative Nurse D stated she expected the PBJ reports to be submitted accurately. The facility's policy Staffing Data Submission Payroll Based Journal, dated 07/2024, documented Section 6106 of the Affordable Care Act (ACA) required facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. The data, when combined with census information, can then be used to report on the level of staff in each nursing home, as well as employee turnover and tenure, which can impact on the quality of care delivered. CMS has developed a system for facilities to submit staffing information - Payroll Based Journal (PBJ). This system allows staffing information to be collected on a regular and more frequent basis than previously collected. It is auditable to ensure accuracy. All long-term care facilities have access to this system at no cost.

The facility reported a census of four residents. Based on interview and record review, the facility failed to ensure five of five Certified Nurse Aides (CNAs) reviewed had the required in-service education which included the abuse, neglect and exploitation (ANE) and one CNA which also lacked dementia management training. This deficient practice placed the residents at risk for inadequate care. Findings included: - Review of five staff personnel files/in-service training records revealed all five CNA staff, (CNA H, CNA I, CNA J, CNA K and CNA L) lacked abuse, neglect and exploitation (ANE) training as required. Additionally, CNA J lacked training related to the care of residents with dementia (a progressive mental disorder characterized by failing memory, confusion) as required. On 06/11/24 at 02:33 PM, Administrative Staff M confirmed the above information and revealed that she was unaware of the regulatory requirement for required continuing education topics. On 06/13/24 at 11:23 AM, Administrative Nurse B confirmed the training records for CNA H, CNA I, CNA J, CNA K and CNA L lacked ANE training as required and that CNA J lacked training related to the care of residents with dementia as required. The facility's Employee Annual Education policy, dated 05/2024 documented that the education department required an ongoing annual in-service that included the topic of ANE, but lacked documentation related to the care of persons with dementia as required. The facility failed to ensure five of five CNAs reviewed had the required in-service education which included the abuse, neglect and exploitation and one CNA which also lacked dementia management training. This deficient practice placed the residents at risk for inadequate care.

The facility reported a census of four residents. Based on observation, interview, and record review the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 59 dates between 01/01/23 and 12/31/23. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 3 2023 (April 1-June 31) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 04/05, Wednesday (WE), On 04/08, Saturday (SA), On 04/12, WE, On 04/22, SA, On 04/28, Friday (FR), On 04/29, SA, On 05/06, SA, On 05/13, SA, On 05/29, Monday (MO), On 06/15, Thursday (TH), Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 4 2023 (July 1-September 30) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 07/13, TH, On 07/15, SA, On 08/01, Tuesday (TU), On 08/20, SU, On 08/22, TU, On 08/23, WE, On 08/25, FR, On 08/29, TU, On 08/30, WE, On 09/02, SA, On 09/03, SU, On 09/04, MO, On 09/07, TH, On 09/11, MO, On 09/12, TU, On 09/15, FR, On 09/16, SA, On 09/17, SU, On 09/20, WE, On 09/21, TH, On 09/24, SU, On 09/26, TU, On 09/29, FR, On 09/30, SA, Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 1 2024 (October 1-December 31) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 10/01, SU, On 10/10, TU, On 10/20, FR, On 10/23, MO, On 11/07, TU, On 11/10, FR, On 11/20, MO, On 12/16, SA, On 12/17, SU, On 12/25, MO, Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 2 2023 (January 1-March 31) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 01/01, MO, On 01/14, SU, On 02/05, MO, On 02/06, TU, On 02/10, SA, On 02/11, SU, On 02/12, MO, On 02/14, WE, On 02/15, TH, On 02/19, MO, On 02/20, TU, On 02/24, SA, On 02/25, SU, On 02/29, TH, On 03/03, SU, On 06/11/24 at 02:00 PM, Administrative Nurse C provided information which revealed the facility had the required 24-hour nurse staff on the days mentioned. The facility lacked a policy for the accurate completion of the PBJ reports. The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to licensed nursing staffing information when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 59 dates between 01/01/23 and 12/31/23.

The facility reported a census of four residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. Findings included: - Initial tour of the kitchen facilities on 06/10/24 at 02:00 PM with Dietary Manager F, revealed that the outside dumpster area contained eight double-lidded dumpsters and that four of the eight dumpster lids were in the open position. On 06/10/24 at 02:10 PM, Dietary Manager F stated that the dumpsters were shared between the facility and the attached hospital and that the lids remaining open was an on-going problem and stated that the attached hospital's environmental services staff routinely left the lids open on the trash dumpsters. Additionally stated that the lids to the dumpsters were to be closed at all times. On 06/10/24 at 05:30 PM, observation of two of the eight dumpsters had lids stowed in the open position. On 06/11/24 at 07:20 AM, observation of one of the eight dumpsters had lids stowed in the open position. The facility failed to provide a policy related to garbage and refuse handling and disposal as requested on 06/10/24. The facility failed to provide sanitary garbage and refuse containers that were maintained with lids closed or otherwise covered. This deficient practice had the potential to lead to harborage and feeding of pest animals.

The facility reported a census of four residents. Based on observation, interview, and record review, the facility failed to serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne illness. This deficient practice had the potential to negatively affect all residents in the facility. Findings included: - During observation of the noon meal service in the kitchen on 06/11/24 at 11:35 AM, Dietary Staff G removed a thermometer probe from the sheath in her sleeve pocket and placed the tip of the thermometer into a steak product without sanitizing the thermometer probe. On 06/11/24 at 11:35 AM, Dietary Staff G stated that the thermometer had been sanitized that morning and that the thermometer was stowed in a sheath in her sleeve pocket. On 06/11/24 at 11:36 AM, Dietary Staff G inspected the sheath of the thermometer probe in her sleeve pocket under the direction of Dietary Manager F and surveyor and revealed that the sheath was not fully enclosed and had a pre-manufactured hole in the end. Dietary Staff G stated that she should have sanitized the thermometer before obtaining a temperature measurement of the foods. On 06/11/24 at 11:37 AM, Dietary Manager F stated that all thermometers should be sanitized with commercially available sanitizer solution or isopropyl alcohol wipe before each temperature measurement. The facility's Diet, Menu, and Tray Service policy, dated 2022, documented temperatures of foods are taken at the beginning of tray service to ensure proper serving temperatures using a stem thermometer sanitized with alcohol. The facility failed to serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne illness. This deficient practice had the potential to negatively affect all residents in the facility.

The facility reported a census of four residents with four residents sampled. Based on interview and record review, the facility failed to provide requested vaccination to one of the residents. Resident (R) 6 requested the pneumococcal vaccine (vaccine designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]). Findings included: - Review of the Electronic Health Record (EHR) on 06/11/24 for (R)6 lacked documentation of any pneumococcal vaccine administered. A consent for pneumococcal vaccine was located in R6's paper chart, which R6 signed to receive a pneumococcal vaccine on an undated form. Review of EHR on 06/11/24 revealed an Immunization assessment dated [DATE] at 12:44 PM, documented yes, that indicated the physician to be informed before discharge of patient's indication for the pneumococcal vaccine. On 06/11/24 at 10:05 AM, Administrative Nurse C stated that R6 did not receive the requested pneumococcal vaccine prior to discharge. Administrative Nurse C stated, it slipped through the cracks. On 06/11/24 at 01:00 PM, Administrative Nurse O stated that R6 did not have a history of having the pneumococcal vaccine in the system and indicated he was eligible for the vaccine on admission. Administrative Nurse O expected that resident who consents for the pneumococcal vaccine, should have one administered prior to discharge. The facility lacked a policy on pneumococcal vaccine. The facility failed to provide requested vaccination to one of the residents, R6 who requested the pneumococcal vaccine.

The facility reported a census of four residents. The sample included four residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to hand hygiene by lack of hand hygiene during R7's peripherally inserted central catheter (PICC-a form of access directly into the bloodstream via a vein that can be used for a prolonged period of time) to prevent the spread of infection. Findings included: - On 06/11/24 at 10:38 AM, Licensed Nurse (LN) N stood at R7's door with gloves on her hands, handled a wound vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) and the bag for the wound vac. LN N proceeded to place wound vac and bag down on a counter, and applied a personal protective gown to herself and left the gloves on her hands. LN N then explained to R7 that she was there to remove his peripherally inserted central catheter (PICC-a form of access directly into the bloodstream via a vein that can be used for a prolonged period of time). LN N removed the dressing from the PICC line site, removed gloves, then applied new sterile gloves. LN N lacked hand hygiene prior to removal of the dressing and in between glove changes during the procedure. On 06/11/24 at 10:50 AM, Administrative Nurse C revealed that hand hygiene should be completed prior to any care being delivered. Also stated that LN N should have removed her gloves after handling the wound vac and should have completed hand hygiene and applied new gloves before PICC dressing removal. Administrative Nurse C stated that LN N should have completed hand hygiene when gloves were removed, before applying a new the sterile gloves. On 06/11/24 at 10:55 AM, Administrative Nurse O revealed she expected staff to perform hand hygiene prior to care and agreed that LN N should have removed her gloves after handling the wound vac as any equipment is considered contaminated. Administrative Nurse O stated that hand hygiene should be completed when gloves are removed during care and before applying a new pair of gloves. On 06/11/24 at 01:55 PM, LN N stated that she generally does wash her hands and thought the wound vac was clean and agreed she should have removed her gloves and washed her hands prior to the PICC dressing removal and stated she should have washed her hands after removing the gloves before applying the sterile gloves. Review of the policy PICC Line Care dated 05/2022 documented: To establish guidelines for RN's (Registered Nurses) working with a PICC line that provided for patient safety, infection prevention and standards of care. Discontinuations of PICC directions for staff included: Wash hands, put on non-sterile gloves. The facility failed to maintain an effective infection control program related to hand hygiene by lack of hand hygiene during R7's peripherally inserted central catheter (PICC-a form of access directly into the bloodstream via a vein that can be used for a prolonged period of time) to prevent the spread of infection.

The facility reported a census of four residents with four residents sampled. Based on interview and record review, the facility failed to accurately complete a comprehensive assessment on the Minimum Data Set, for resident (R)7 within the time frame of 14 calendar days. Findings included: - Resident (R)7's Electronic Health Record (EHR) revealed a diagnosis of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), diabetic left foot ulcer (is a skin sore that often occurs on the feet, toes, or legs in people with diabetes) and pain. The EHR lacked an Admission Minimum Data Set (MDS). R7 was admitted on [DATE]. Review of the 05/26/24 five day MDS, documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. No depression, no behaviors. R7 was independent with ADL's (activities of daily living such as walking, grooming, toileting, dressing and eating). On 06/10/24 the Care Plan dated 05/22/24 documented: R7 had impaired skin integrity instructed staff to keep skin dry, avoid pressure and friction. Review of Physician Orders on 06/10/24 documented: Wound- Vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) management, change every 72 hours, ordered on 05/20/24. Review of the Progress Notes from 05/20/24 to 06/10/24 revealed the following: On 05/20/24 at 02:30 PM, R7 admitted (to the facility) and was alert and oriented. R7 has debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) and wash out of left foot on 05/14/24. On 06/10/24 at 04:00 PM, Administrative Nurse C stated R7 would not have an admission MDS completed. Stated he would have to look at the timeframe R7 had been here. On 06/11/24 at 08:25 AM, Administrative Nurse C stated that the admission MDS was not completed as patient was a private insurance. Administrative Nurse C agreed that a five day MDS was the only MDS completed and stated that patients do not stay longer than two weeks. On 06/11/24 at 08:56 AM, Licensed Nurse (LN) N revealed that she was not aware that R7 required a MDS because of PDPM (Patient Driven Payment Model. It's a case-mix classification model implemented by the Centers for Medicare & Medicaid Services (CMS) for Medicare-covered nursing home care. The PDPM focuses on patient diagnoses and characteristics rather than the specific services provided to them). LN N stated that she knows to complete an MDS on day eight for days one through seven. LN N agreed R7 had been a resident in the facility for 22 days on 06/11/24. LN N stated there was no alert in EHR when a MDS is needed to be completed. Review of the Assessment and Reassessment policy dated 12/2023 documented: The goal of the patient assessment is to determine what kind of care, treatment and services are required to meet the patients' needs. The MDS coordinator will complete an admission MDS no later than day 14 of admission. The facility failed to complete a timely comprehensive admission assessment on the MDS and an analysis of findings on R5. This practice had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs.

The facility had a census of four residents. Based on interview and record review during the annual resurvey completed 09/25/19, the facility failed to hold a Quality Assessment and Assurance (QAA) meeting on at least a quarterly basis. Findings included: - Review of the QAA documentation revealed no sign-in sheets for quarterly QAA meetings for (YEAR). During an interview on 09/25/19 at 07:58 AM, Administrative Nurse A stated the facility did not hold any QAA meetings from the second quarter through the fourth quarter of (YEAR) and did not meet again until (MONTH) 2019. Review of the Quality Assessment Performance Improvement Plan for SNU dated 01/2018 revealed, The QAPI Committee meets on a quarterly basis. The facility failed to ensure QAA meetings were conducted on a quarterly basis.

The facility census totaled 4. The facility employed one housekeeper who cleaned all the rooms. Based on observation, interview and record review, the facility failed to provide a sanitary environment to prevent the spread of infection when housekeeping staff failed to utilize adequate wet times of chemicals for sanitization of resident's rooms. This deficient practice had the potential to affect all residents. Findings included: - Observation on 12/21/16 at 9:27 AM housekeeping staff B donned clean gloves before entering a resident room. At 9:30 AM staff B sprayed the sink and soap dispenser with Virex II 256 (a brand of disinfectant) and wiped immediately with a dry rag. At 9:31 AM staff B swabbed the toilet seat, toilet rim, bowl edge and inner bowl with a johnny mop and Foamy Q&A (a brand of disinfectant). At 9:32 AM staff B wiped the toilet seat, rim, and bowl with a dry rag. During an interview on 12/21/16 at 9:32 AM housekeeping staff B said he/she changed the johnny mop weekly or when it got really bad . At 9:38 AM housekeeping staff B said he/she sprayed with Virex II 256 and then dried Virex II 256 as long as the resident remained in the room. Staff B said he/she allowed the Virex II 256 to stay wet when the resident dismissed. Staff B said he/she did not know the wet time (time determined by the manufacturer where the product must stay wet in order to work as indicated) required for Virex II 256. During an interview on 12/21/16 at 10:50 AM housekeeping supervisor staff E said the wet time for Virex II 256 was 10 minutes for sanitization. Staff E said staff let Virex II 256 air dry after wiping with a slightly wet rag. Staff E said they used a Foamy Q&A for toilets and it had a wait time of 10 minutes for sanitization. Staff E said staff used the Foamy Q&A on the johnny mop on the toilet seat and then dried it with the Virex II 256 on a damp rag. Staff E said they used the same johnny mop on all toilets for a week and that is why they used the Virex II 256 to wipe the toilet seat after. Review of the Virex II 256 product label indicated under use as a one-step cleaner/disinfectant that the product should remain wet on surfaces for 10 minutes. Review of the Foamy Q&A product label indicated under five-minute disinfection action that the foam should remain wet on surfaces for 5 minutes. Review of the facility policy titled occupied patient room cleaning dated 9/94 directed staff to not dry disinfectant on the sink, counter, faucet, shower or toilet. The policy had a note under section E that revealed most disinfectants take 10 minutes to work properly. The facility failed to prevent the development and transmission of infection when staff failed to use chemicals according to the manufacturer's directions for disinfection of resident rooms. This deficient practice had the potential to affect all residents.

The facility reported a census of 4 residents. The facility had a skilled nursing unit with a nutrition room. Based on observation and interview, the facility failed to store food items under sanitary conditions which had the potential to affect all residents. Findings included: - During the initial environmental tour on 12/19/16 at 11:01 AM observation of the nutrition room revealed 9 cans of soup in a cabinet were expired. One can expired in 2014, 1 can expired in 2015 and 7 cans expired in August 2016. During an interview on 12/19/16 at 11:40 AM licensed nursing staff C stated he/she expected staff to monitor for expiration dates and remove any expired food items from the nourishment room. During an interview on 12/21/16 at 11:51 AM dietary staff D stated dietary staff stocked the skilled nursing unit nourishment room and removed any expired food items every Monday, Tuesday and Wednesday. Review of the Delivery of Floor Stock policy dated 8/20/15 revealed, Food and Nutrition employees shall rotate the floor stock items to insure freshness and quality of the stock. Any outdated stock shall be removed from the floor and returned to the department for pick up by the vendor or to be discarded. The facility failed to properly store food items under sanitary conditions.

The facility census totaled 4 residents all receiving meals prepared for the main kitchen for the facility and connected hospital. Based on observation, interview and record review the facility failed to store foods in a sanitary manner by the failure to mark and date open food items in refrigerators and freezers located in the kitchen. Findings included: - During initial tour of the kitchen on 7/7/15 at 7:00 a.m. obvervation of a refrigerator located in the main kitchen area revealed a bag of brocolli, a bag of carrots, a bag of grapes, a container with 12 boiled eggs, a container containing a pre-mixed salad and cooked chicken in a container. All the food items were open and undated. The food was removed by dietary staff. Observation of a freezer in the main kitchen area revealed a bag of chicken strips, a bag of regular chicken patties, and spicy chicken patties. All food items were open and undated. Observation of a walk-in refrigerator in a back hall revealed a bag of grated cheese that was open and undated. Observation of the back hall freezer revealed an opened, undated ag of broccoli and an open box of pastries open to air that were not dated or covered. During an interview on 7/7/15 at 7:30 a.m. dietary staff E reported he/she did not know food had to be dated after opening and placing it back into the refrigerator or freezer. During an interview on 7/7/15 at 7:40 a.m. dietary manager D reported all staff should know about covering and dating food items prior to returning to the refrigerator or freezer. During an interview on 7/8/15 at 11:20 a.m. dietary supervisor C reported there were signs on every refrigerator and freezer to remind staff to date all opened food. A policy for stored foods was requested on 7/9/15 with no food storage policy received. The facility failed to store food in a sanitary manner by the failure to mark and date open food items prior to returning to the refrigerator or freezer. This had the potential to affect all 4 residents served meals from the main kitchen.

The facility census totaled 4 with 8 in the sample. Based on observation, interview and record review the facility failed to develop temporary care plan sufficient to meet the needs of newly admitted residents with urinary tract infections, catheter care and administration of IV(intravenous) antibiotics or for the BBW (black box warnings) for 2 of 8 sampled residents. (#46, #7) Findings included: - Review of resident #46 ' s signed physician orders [REDACTED]. No MDS (minimum data set) due related to admission date of [DATE]. Review of the initial care plan with a date of 7/2/15 revealed: No interventions related to the use of IV (intravenous) antibiotics ([MEDICATION NAME] and aztreonam). The care plan further failed to identify BBW (black box warnings) for [MEDICATION NAME] and [MEDICATION NAME] for the specific severe adverse reactions to these medications. Review of the physician orders [REDACTED]. [MEDICATION NAME] 2 gm(gram) in 100ml(milliliters) sodium chloride IV every 8 hours for treatment of [REDACTED].>[MEDICATION NAME] tab(tablet) 750 mg (milligrams) 1 tablet by mouth daily for pneumonia Observation on 7/7/15 at 12:10 p.m. revealed the resident sat in an electric wheelchair at the dining table. The resident was smiling and interacting with other residents and family. The resident had an occasional moist cough and covered his/her mouth with a tissue. Observation on 7/8/15 at 9:38 a.m. revealed licensed nurse H began administration of the IV medication ([MEDICATION NAME] 2 grams in 100 milliliters sodium chloride). The resident had no complaints regarding the medication. During an interview on 7/8/15 at 4:00 p.m., direct care staff G reported the resident was getting medication through the IV. Staff G was not sure what medications the resident was receiving but seemed a little stronger a little stringer than what?. The staff did not know about the BBW but had seen something about them on some care plans but did not know if the resident had BBW on his/her care plan. During an interview on 7/8/15 at 10:30 a.m. licensed nurse H reported the residents on the unit are very short term. The resident medications are dispensed from the hospital and had special warnings or BBW (Black Box Warnings, and what those are). Those warnings are carried over to the care plan as the orders are entered into the computer system. Nurse H was not aware that the antibiotics with BBW were not included on the care plan since the resident ' s other medications such as Tylenol, [MEDICATION NAME] and [MEDICATION NAME] had BBW on the care plan. During an interview on 7/9/15 at 10:00 a.m. administrative, staff A reported that the nurses initiated the resident's care plan with the physician orders [REDACTED]. Administrative staff A then reviewed a copy of the care plan for resident #46 and confirmed not all the medications with BBW were addressed on the care plan. The facility failed to develop a temporary care plan to include all medications with a BBW and the potentially severe adverse reactions for those medications. - Review of resident #7's signed History and Physical dated 2/3/15 revealed the resident had a significant history of Polio (a [MEDICAL CONDITION] disease that can affect nerves and can lead to partial or full paralysis) diagnosed at age 15 with gradual decline in strength leading to tetraplegia (also known as [MEDICAL CONDITION], is paralysis caused by illness or injury to a human that results in the partial or total loss of use of all their limbs and torso) for the last 5 years requiring indwelling an indwelling catheter and frequent UTI's(Urinary Tract Infections). At the time of admission on 2/2/15 the resident had a multidrug resistant Pseudomonas aeruginosa (an infectious organism that was resistant to most other antibiotics to treat it) urinary tract infection and needed to continue using an indwelling catheter. Review of the 5 day MDS (minimum data set) dated 2/5/15 revealed the resident had cognitive impairment and was unable to complete the BIMS (brief interview for mental status). The resident had impaired long and short term memory and severely impaired decision making ability. The resident was total dependence on two staff for transfers and toileting. The resident had a Foley catheter and was always incontinent of bowel. The assessment identified a UTI (urinary tract infection) in the last 30 days. The resident had a feeding tube and received all nutrition through the tube. Medications included an anticoagulant, IV (intravenous) antibiotic and a diuretic taken 7 of the 7 days during the look-back period. The care plan dated 2/4/15 lacked documentation regarding the indwelling catheter or catheter care, the administration of IV medications and IV care. During an interview on 7/7/15 at 3:30 p.m. direct care staff I reported not remembering the resident. The residents came and went to fast to remember all of the residents. When asked about care plans and how he/she knew how to care for each resident the aide showed a cardex used in end of shift report that listed basic care of the resident. The aide reported that if he/she had to do anything extra such as catheter care those cares had to be looked up on the facility intranet so he/she could see the facility policy. Staff I acknowledged the policy did not tell him/her how to care for a specific resident but just the care of a normal catheter. During an interview on 7/8/15 at 4:00 p.m., licensed nurse H reported he/she worked the SNU (skilled nursing unit) and also worked at the hospital and really did not remember back to last February and anything specific about any given resident. During an interview on 7/9/15 at 9:45 a.m. licensed nurse B reported he/she did the MDS but the floor nurses developed the care plan when a resident admitted to the unit. During an interview on 7/9/15 at 10:00 a.m., Administrative staff A reported that the nurses initiate the care plan with the physician orders [REDACTED]. He/she then reviewed a copy of the resident's care plan and confirmed the issues did not appear to be on the care plan. He/she reported the aides knew how to care for the resident from monthly in services covering different topics each month. If a resident required special procedures like monitoring the resident for specific things and completing catheter care by the care guide on the aides computers. Staff A brought up a computer screen the aides documented on including vital signs, meal intake, fluid intake and output and catheter care. There were no further interventions listed as to how the aides were to do tasks and the aides had to look on the facility intranet for the policies for the care the resident required. A policy on initial care plans was requested on 7/9/15 however facility staff did not provide a policy for temporary care plans. The policy provided was about comprehensive care plan development with no mention of the temporary care plan. The facility failed to develop a temporary care plan to include catheter care for resident #7.

The facility reported a census of 3 residents with 7 sampled for review (including 4 closed records). Two of the four closed records were reviewed for nutritional concerns. Based on record review and interview, the facility failed to ensure 1 of the 2 residents sampled for nutritional concerns maintained acceptable parameters of nutritional status. Resident #12 experienced a severe weight loss of 6.9% in one month and the facility failed to implement appropriate interventions to address the weight loss and prevent additional losses. Findings included: - Record review revealed resident #12's admission to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The clinical record also included a pre-admission physician's orders [REDACTED].#12 while on the skilled unit. The graphic record of weights contained an admission weight of 149.9 lbs (pounds) on 5/10/11. The 5/11/11 Registered dietician assessment recorded the resident's weight of 149.9 pounds on 5/10/11 and recommended a regular diet and to provide milk with each meal if tolerated. "Patient stated he/she does not like milk but will eat ice cream and sometimes yogurt." The dietician further documented that the dietician would follow intake (percent of food eaten), weight and labs weekly throughout the resident's stay. Resident #12's 5/23/11 Admission MDS (minimum data set) identified the resident with moderate cognitive impairment, required set up with no help for meals, no problems with dental or swallowing and no nutritional approaches. The 5/27/11 CAAS (care area assessment summary) triggered for nutrition. Comments on the CAAS stated, " Will not care plan. Resident is eating well at this time, needs nutrition for bone healing, losing weight is not a focus at this time." Although the CAA noted resident #12 did not have a problem with weight loss, the clinical record included no evidence staff weighed the resident in the time period between admission on 5/10/11 and the date staff completed the CAA on 5/27/11, a time period of 17 days. The current care plan included a 5/17/11 dietary intervention to offer high calorie foods or a calcium supplement secondary to resident #12's [DIAGNOSES REDACTED].#12 wanted to take a calcium supplement he/she had at home, and therefore staff did not start the supplement until the spouse brought it to the facility on [DATE]. According to Nurse B, resident #12 never received a high calorie diet, and he/she remained on a regular diet throughout the entire stay at the facility. According to the graphic record of weights, staff weighed resident #12 one time after addmission to the facility, and that weight occurred on on 6/10/11, one month after admission to the facility. At that time, resident #12 weighed 139.5 lbs, a weight loss of 10.4 lbs (6.9%) in the one month since admission. The registered dietician reassessment notes for 5/24/11 and 6/7/11 did not include any assessments or comments related to weight loss because the clinical record included no additional weights for the dietician to review. The registered dietician wrote an additional note on 6/14/11, after staff weighed resident #12 on 6/10/11 and noted a weight loss of 10.4 lbs in one month. The 6/14/11 note did not mention the weight loss and did not include suggested interventions to address the weight loss and prevent additional losses. On each of the dietary notes, the registered dietician reported resident #12, "eats meals well." The dietary intake recorded for 5/10/11 thru 6/20/11, the resident's dismissal date, revealed the percent of meal intake for resident #12 to be between 25% to 100%. The record lacked further nurse or physicians documentation related to the resident's weight and significant weight loss in the time period between 5/10/11 and 6/10/11. According to nursing documentation, staff discharged resident #12 on 6/20/11. During an interview on 8/10/11 at 3:12 p.m. licensed nursing staff B stated that the facility does not weigh the residents more than monthly and is aware that is a problem. On 8/10/11 at 3:40 p.m. registered dietician K stated that she felt that residents need to be weighed more often to better monitor the residents' weights. On 8/11/11 at 4:30 p.m., licensed nurse B reported the facility did not implement interventions to address resident #12's weight loss after staff identified the 6.9% loss on 6/10/11. In summary, the facility failed to have a system in place to monitor weights and implement interventions to maintain acceptable parameters of nutritional status for resident #12 who had a severe weight loss of 10.4 pounds (6.9%) in one month.