Every finding on record at The Canyons Post-Acute

Based on interview and record review, the facility failed to follow its policy and procedures regarding activities of daily living (ADL) for one of three sampled residents (Resident 1) when Resident 1 did not receive a shower or bath on her scheduled shower day.This failure had the potential for Resident 1 to have body odor, greasy hair, and skin deterioration, which increases the risk of rashes and serious infections, especially for residents who are bedbound.Findings: During a review of Resident 1's admission record (contains demographic and medical information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (a life-threatening condition where the lungs cannot pass enough oxygen into the blood or remove enough carbon dioxide from it), morbid obesity (extremely high amount of excess body fat), and muscle weakness (muscle lack the force to move normally). During a review of Resident 1's Minimum Data Set (MDS- federally mandated clinical assessment tool) under Section C (Cognitive Patterns), dated June 9, 2026, it indicated Resident 1's Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline) score was 11, which indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1''s MDS, under Section GG (Functional Abilities -focuses on a resident's functional abilities and goals, specifically assessing self-care and mobility performance to capture the level of assistance needed), dated June 9, 2026, it indicated Resident 1 required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for showering and bathing. During an interview with Resident 1, on July 29, 2026, at 2:40 PM, Resident 1 stated she did not receive a shower or bed bath on her scheduled shower day, which was Monday, July 13, 2026, because her Certified Nursing Assistant (CNA) informed her that there was no hot water available that day.During an interview on July 29, 2026, at 2:29 PM, with the Maintenance Supervisor (Supervisor), the Supervisor stated that he did not receive any reports regarding hot water issue on July 13, 2026. During a concurrent interview and record review, on July 29, 2026, at 2:40 PM, with the Unit Manager (Manager), the Unit Manager reviewed Resident 1's bathing record for the month of July 2026, which indicated Resident 1 did not receive a shower on July 13, 2026. The Manager stated residents were given showers regularly, at least twice a week, according to their shower schedule. The Manager further stated the facility had no issues with hot water. During a telephone interview on August 3, 2026, at 10:29 AM, CNA confirmed she did not provide Resident 1 a shower when she was assigned to her on July 13, 2026. During a concurrent telephone interview and record review with the Manager, on August 5, 2026, at 11:06 AM, the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised March 2018 was reviewed. The P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The Manager stated this was not followed.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for maintenance service when a sink faucet in room [ROOM NUMBER] was unattached to the sink and without accessible to hot water. This failure resulted in residents and staff to perform handwashing in room [ROOM NUMBER] and had the potential for increased risk of infection for patients and staff. Findings: During an observation on June 15, 2026, at 10:30 AM, in room [ROOM NUMBER] , the sink faucet was observed to not be fully secured to the sink. A further observation revealed the sink was without hot water. During an interview on June 15, 2026, at 10:33 AM, with Housekeeping Manager (HM), the HM stated, the sink faucet is not supposed to be unattached to the sink and there should be access to hot water. The HM further stated she was unaware of the issue in room [ROOM NUMBER] During an interview on June 15, 2026, at 10:54 AM, with Maintenance Director ([NAME]), [NAME] stated, the sink faucet should be attached to the sink and there should be access to hot water. The [NAME] further stated, the staff were expected to document maintenance issues in the maintenance logs, but did not. During a review of Maintenance Repair Log, dated June 2026, the Maintenance Repair Log did not indicate a note describing the faucet not fully secured to the sink and without accessible hot water in room [ROOM NUMBER]. During a concurrent interview and record review on June 15, 2026, at 11:25 AM, with the [NAME], the facility's policy and procedure (P&P) titled, Maintenance service, dated December 2009, was reviewed. The P&P indicated, .2. Functions of maintenance personnel include but are not limited to: d. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. The [NAME] stated he was unaware of the problem, and it is important for the faucet to work properly for staff and residents so they can have water access. The [NAME] stated the hot water was not working because it had been turned off. The [NAME] further stated, the P&P was not followed by staff. During a concurrent interview and record review on June 17, 2026, at 12:35 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Maintenance service, dated December 2009 was reviewed. The P&P indicated, .2. Functions of maintenance personnel include but are not limited to: d. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. The DON confirmed the policy was not followed. The DON further stated, it is important for plumbing fixtures to be in good working order, so staff, residents, and visitors have access to water and can wash their hands.

Based on observation, interview, and record review, the facility failed to ensure nursing staff implemented appropriate interventions for one (1) of 29 sampled residents (Resident 17) when, nursing staff did not document the restraint (an item used to stop a patient from removing medical equipment or hurting themselves) repositioning every two hours or initiate a restraint care plan as indicated in the facility's policy and procedure (P&P). This failure had the potential to result in resident care needs not being met, inappropriate use of restraints, and failure to identify complications associated with the use of restraints which could jeopardize the health and safety for for Resident 17 Findings:During a review of Resident 17's admission Record (contains demographic and medical information), the admission Record indicated Resident 17 was admitted to the facility on [DATE], with diagnoses that included anoxic brain damage (Brain injury caused when the brain gets no oxygen for too long, killing brain cells), generalized muscle weakness (condition where muscles lose strength and can't move as well as they normally should), and gastrostomy (surgical procedure creating a small opening through the belly into the stomach for feeding or drainage). During an observation on June 15, 2026, at 8:34 AM, in Resident 17's room, Resident 17 was lying in bed, with bilateral (both sides) hand mitten restraints (soft, padded glove designed to prevent a patient from grasping, picking at medical devices or wounds, while still allowing arm movement). During a concurrent observation and interview on June 15, 2026, at 3:28 PM, with Licensed Vocational Nurse 1 (LVN 1), Resident 17 had bilateral hand mitten restraints. LVN 1 confirmed Resident 17 had bilateral hand mitten restraints in place. LVN 1 stated, she was unsure if there was an active order for restraints for Resident 17. During a review of Patient 17's Order Summary, (document that shows all active orders) dated June 3, 2026, the Order Summary indicated, [Brand name] Padded easy view protective mitt [mitten] x [times] 2. During an interview on June 16, 2026, at 4:25 PM, with LVN 2, LVN 2 stated that when residents are placed on restraints, the nursing staff are required to initiate the restraint care plan. LVN 2 stated, this process involved assessing the resident, and documenting the resident repositioning every two hours while the restraints remains in place. LVN 2 stated, the care plan is important to ensure restraints are removed when they are no longer required and guide the nursing staff in plan of care. LVN 2 added, the importance of assessing and documenting on a resident with restraints every two hours is to monitor the skin integrity and to identify any change in condition. During an interview on June 16, 2026, at 4:36 PM, with the Director of Nursing (DON), the DON stated the nursing staff was expected to initiate a restraint care plan and document the resident's restraint assessment and repositioning. During a concurrent interview and record review on June 16, 2026, at 4:38 PM, with the DON, the facility's P&P titled, Use of Restraints, dated April 2017 was reviewed. The P&P indicated, . examples of devices that are/may be considered physical restrains include . hand mitts.12. The following safety guidelines shall be implemented and documented while a resident is in restraints. d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. E. Restrained residents must be repositioned at least every two (2) hours on all shifts. 19. Documentation regarding the use of restraints shall include.f. observation, range of motion and repositioning flow sheets.17. Care plans for resident in restraints will reflect interventions that address not only the immediate medical symptom (s), but the underlying problems that may be causing the symptom(s)18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restrains use. The DON stated the policy was not followed as she was unable to provide documentation for a restraint care plan or assessment and repositioning of restraints every two hours. The DON further stated, it was important for the nursing staff to document the care plan, reposition and assessment to prevent skin breakdown.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- federal requirement ensuring that anyone with a serious mental illness, intellectual disability, or a related condition isn't placed in a nursing home without proper assessment and support) was completed for one (1) of 29 residents (Resident 14) when the facility did not complete a required PASRR level 1 screening (a quick check to spot potential mental illness or intellectual disability when someone is about to enter a nursing home) after Resident 14 remained in the facility for more than 30 days under exempted hospital discharge status (EHDS- allows an individual to enter a nursing facility without full PASRR, if a physician certifies before discharge that the resident is likely to need less than 30 days of skilled nursing care). This failure had the potential to delay the identification of mental health needs, the determination of whether a PASRR Level II evaluation (detailed follow-up when the Level I screening flags a concern that involves professionals assessing the individual's mental health, support needs, and whether a nursing home is the most suitable option) was necessary, and the development of appropriate placement and care plans for Resident 14Findings: During a review of Resident 14's admission Record (a document with resident demographics, brief medical history, and emergency contacts), the admission Record indicated, Resident 14 was admitted on [DATE] with diagnoses that included diabetes (DM- High blood sugar), chronic obstructive pulmonary disease (COPD-a long term lung condition that makes it hard to breathe because the airways are damaged and narrowed), and major depressive disorder (MDD- a serious mood disorder marked by persistent feelings of sadness or loss of interest, significantly impairing daily life through thoughts, emotions, behaviors, and physical health). During a concurrent interview and record review on June 16, 2026, at 2:11 PM, with the Minimum Data Set Coordinator (MDSC), Resident 14's PASRR Level I screening dated September 28, 2025, and Notice of Exempted Hospital Discharge dated October 27, 2025, were reviewed. The PASRR Level I screening indicated, .18. does the individual meet the criteria for an exempted hospital discharge? The answer was marked .yes.resolution: exempted hospital discharge. During a review of the Notice of Exempted Hospital Discharge, the Notice of Exempted Hospital Discharge indicated, .Your Level I Screening indicates that a Level II Mental Health Evaluation is not required.Reason: Exempted Hospital Discharge.if the individual remains int he NF [Nursing facility] longer than 30 days, the facility must resubmit a new Level 1 screening as a resident review on the 31s day. The MDSC stated, the facility is responsible for submitting a new PASRR level 1 if the residents remains in the facility for longer than 30 days. The MDSC stated for Resident 14 it was missing and was not completed until June 16, 2026. During an interview on June 17, 2026, at 1:21 PM, with the Administrator (Admin), the Admin stated, the MDSC is responsible for completing the PASRR. The Admin, further stated the facility did not have a policy and procedure (P&P) outlining the steps to follow when a resident remains in the facility longer than 30 days under an EHDS. During an interview on June 18, 2026, at 11:45 AM, with the Director of Nursing (DON), the DON stated the expectation for the PASRR Level I is to be reviewed, and corrected as needed to ensure residents receive the services they require.

Based on interview and record review, the facility failed to ensure appropriate catheter care was provided and documented for one (1) of 29 sampled residents (Resident 8) with an indwelling urinary catheter (foley- a tube inserted into the bladder to continuously drain urine) when staff did not document routine cleansing of the foley catheter as required by the facility's policy and procedure (P&P). This failure had the potential to increase the risk for catheter-associated urinary tract infection (CAUTI- a urinary tract infection caused by or associated with urinary catheter), skin irritation, and other catheter-related complications for Resident 8.Findings: During a review of Resident 8's admission Record (contains demographic and medical information), the admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included kidney transplant (received a donated kidney to replace a failed kidney), neuromuscular dysfunction of bladder (loss of normal bladder control cause by nerve or muscle dysfunction), generalized muscle weakness (condition where muscles lose strength and can't move as well as they normally should), and gastrostomy (surgical procedure creating a small opening through the belly into the stomach for feeding or drainage) status. During a review of resident 8's Order Summary dated June 13, 2026, through June 18, 2026, the Order Summary indicated, Catheter: Indwelling foley catheter.for neurogenic bladder [loss of bladder control caused by nerve damage]: check placement and patency Q (every) daily. During a review of the Care Plan dated June 18, 2026, the Care Plan indicated, Focus: Resident has indwelling foley catheter for dx [diagnosis]: neurogenic bladder .interventions: foley catheter care with soap and water every shift date. During an interview on June 18, 2026, at 2:56 PM, with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, the treatment nurse is typically in charge of cleaning and documenting the foley care provided. CNA 1 stated that the CNAs will clean the catheter when it has feces over it with soap and water. CNA 1 stated it is important to clean the catheter to avoid infections. During an interview on June 18, 2026, at 2:57 PM, with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated, both the CNA's and LVN's will clean the catheter. LVN 3 stated it is important to clean the catheter and document to prevent infections and to ensure someone is completing the task. During an interview on June 18, 2026, at 3:05 PM, with the Treatment Nurse (TN), the TN stated, sometimes the TN will have an order to clean the foley catheter. The TN added that if she does have an order, she will ensure it is completed her end. During an interview on June 18, 2026, at 3:13 PM, with the Infection Preventionist (IP), the IP stated the expectation is for the nursing staff to clean the foley catheter with soap and water every shift. The IP added it is important for it to be completed and documented to prevent CAUTI's. The IP stated Resident 8 did not have an order to have the catheter cleaned but should have. During a concurrent interview and record review on June 18, 2026, at 3:15 PM, with the Director of Nursing (DON), the Nursing Notes dated June 12, 2026, through June 18, 2026, and Treatment Administration Record (TAR-a record of non medication treatments provided to a resident) dated June 2026 were reviewed. The Nursing Notes and TAR did not indicate the nursing staff was cleaning the catheter. The DON stated there was no documentation the foley catheter was being cleaned by the nursing staff. The DON added the expectation is the nursing staff to clean and documented the foley catheter care. During a follow-up concurrent interview and record review on June 18, 2026, at 3:16 PM with the DON, the facility's P&P titled, Catheter Care, Urinary dated August 2022 was reviewed. The P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.perineal care 1. Use soap and water.for routine daily hygiene. 15. Use a clean washcloth with warm water and soap (or clean bathing wipe to cleanse and rinse the catheter from insertion site to approximately four inches outward. Documentation.the following information should be recorded in the resident's medical record.1. The date and time that catheter care was given. 2. The name and title of the individual giving the catheter care. 3. All assessment data obtained when giving catheter care.7. How the resident tolerated the procedure. The DON stated she was unable to provide documentation of the staff cleaning the foley and the policy was not followed and should have been. The DON added that it is important for the nursing staff to follow the policy to prevent the residents from getting an infection.

Based on observation, interview and record review, the facility failed to ensure adequate nutritional interventions and monitoring for 2 (two) of 29 sampled residents (Resident 17 and 104) when: 1. For Resident 17, the facility failed to communicate Registered Dietitian's recommendations to the physician after the Resident 17 experienced weight loss, including recommendations for weekly weights and modification of the tube feeding regimen, resulting in no updated medical orders. 2. For Resident 104, the facility failed to ensure weekly weights were obtained as ordered by the physician. These failures resulted in delayed identification and treatment of nutritional concerns, contributed to continued weight loss, inadequate nutritional intake, and decline in overall health status for Residents 17 and 104. Findings: 1. During a review of Resident 17's admission Record (contains demographic and medical information), the admission Record indicated Resident 17 was admitted to the facility on [DATE], with diagnoses that included anoxic brain damage (Brain injury caused when the brain gets no oxygen for too long, killing brain cells), generalized muscle weakness (condition where muscles lose strength and can't move as well as they normally should), and with a gastrostomy (surgical procedure creating a small opening through the belly into the stomach for feeding or drainage). During an observation on June 15, 2026, at 8:35 AM, in Resident 17's room, Resident 17 sitting upright, and receiving [name of tube feeding] 1.2 cal [calories- units of energy provided by good and drinks] at 65 milliliters (ml-unit of measurement)/ hour (hr). A review of Resident 17's Section C [cognitive (the ability to understand) pattern] of the Minimum Data Set (MDS- A detailed checklist nursing facilities use to determine a resident's ability of moving around, memory, and medical problems) indicated, .C1000 cognitive skills for daily decision making. severely impaired. A review of Resident 17's Weights Summary dated May 4, 2026, through June 4, 2026, were reviewed as follows: May 4, 2026: 141.2 pounds (lbs. unit of measurement) June 4, 2026: 130.9 lbs. (loss of 10.3 lbs., -7.3% in one month) During an interview on June 17, 2026, at 8:35 AM, with the Registered Dietician (RD), the RD stated residents with significant weight loss are the ones who have lost 2% or more in one week, 5% or more in one month, 7.5% or more in three months, and 10% or more in six months. The RD further stated these residents are followed by the dietician on a weekly basis until the weight is stable. The RD stated if during her assessment an intervention is required, she documents recommendation on the Nutritional Recommendations by Registered Dietician provides a copy of the recommendations to each nursing station and emails it to the Director of Nurse (DON), the Administrator (admin), and medical records. The RD stated the registered nurse (RN) was expected to get the Nutritional Recommendation by Registered Dietician and call the doctor (MD) to get the orders changed or the rationale for denying the recommendation. During a concurrent interview and record review on June 17, 2026, at 8:38 AM, with the RD, Resident 17's Nutrition/Dietary Note dated June 8, 2026, and Order Summary (document that shows all active orders) dated May 29, 2026, through June 17, 2026, were reviewed. The Nutrition/Dietary Note indicated, .Res [resident] will benefit from gradual wt [weight] gain r/t [related to] BMI [Body mass Index- estimates whether a person's weight is healthy, less than 18.5 is underweight, 18.5-24.9 normal, 25-29.9 overweight, 30+ is overweight] of 18.8.significant wt [weight] loss x3 and x1 month . Possible wt [weight] loss d/t [due to] on TF [tube feeding] and wounds. RD will rec [recommend] to switch feeding to [name of tube feeding 1.5] to run at 55 ml/hr x 20 hrs (.1650 kcal.) to provide additional kcals and promote gradual wt gain.plan: switch to [name of tube feeding 1.5] to run at 55 ml/hr x 20 hrs (.1650 kcal).ADD on weekly weights x4 weeks. The Order Summary indicated, Enteral feed. [name of tube feeding 1.2] at. 65 ml [milliliter-unit of measurement] / hr [hour] x [times] 20 hrs.via PEG to provide a total of. 1560 kcal [kilocalorie- energy in food] . monitor every shift. The RD verified and confirmed that her recommendations were not implemented as an order, and Resident 17 had a significant weight loss. The RD stated, she currently had Resident 17 as part of her monthly assessment but should have been following Resident 17 on a weekly basis to prevent further weight loss. During an interview on June 18, 2026, at 8:08 AM with Registered Nurse 1 (RN 1), RN 1 stated the RN of the shift was responsible for checking the Nutritional Recommendations by Registered Dietician located in the nursing station and calling the MD to get new orders. RN 1 stated the orders should be reflected within 24 hours of the RD's recommendations. RN 1 stated when orders are not updated per RD's recommendations a nurse's note with the documentation of the discussion with the MD is placed in the resident's record. RN 1 stated it is important to notify the physician of the RD's recommendation to prevent further weight loss. During a follow up interview on June 18, 2026, at 9:16 AM with the RD, the RD stated the reason for changing the tube feeding for Resident 17 was to increase the caloric intake for Resident 17. The RD further stated the difference in calories between the tube feeding Resident 17 has been receiving and the tube feeding that was recommended on June 8, 2026, is approximately 90 calories per day (In 9 days it is approximately 810 calories). During a concurrent interview and record review on June 18, 2026, at 8:55 AM with Director of Nurses (DON), Resident 17's Nutritional Recommendations by Registered Dietician dated June 8, 2026, and Care plan dated June 8, 2026, were reviewed. The Nutritional Recommendations by Registered Dietician indicated, switch to [name of tube feeding 1.5] to run at 55 ml/hr x 20 hrs (.1650 kcal) .ADD on weekly weights x4 weeks. The DON stated the orders were implemented on June 17, 2026 (9 days after the recommendation was given). The Care plan indicated, Focus.Resident is at nutritional risk.goal.:GTF [Gastrostomy feeding] [name of tube feeding 1.5] The DON stated there were no nursing notes or documentation of the MD being notified of the RD recommendations and there should have been. The DON stated it is important to follow the care plan to know the residents' nutritional needs and ensure the facility is providing it. During a follow-up concurrent interview and record review on June 18, 2026, at 9:00 AM with the DON, the facility's policy and procedures (P&P) titled, Weight Assessment and Intervention, dated March 2022 and Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol dated September 2017 were reviewed. The Weight Assessment and Intervention P&P indicated, Resident weights are monitored for undesirable weight loss.the threshold for significant unplanned and undesired weight loss will be based on the following criteria.a. 1 month- 5% weight loss is significant; greater than 5% is severe.undesirable weight change is evaluated by the treatment team.care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist and the resident's legal surrogate. Individualized care plans shall address to the extent possible. b. goals and benchmarks for improvements, and c. time frames and parameters for monitoring and reassessment . The Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol P&P indicated, .4.the staff will report to the physician significant.loses or any abrupt or persistent change.the physician will review for.weight loss before ordering interventions.the physician with the help of the multidisciplinary team, will identify conditions.that may be causing.weight loss. the staff and physician will identify pertinent interventions based on identified causes and overall resident condition.10. The physician will authorize appropriate interventions, as indicated.1. The physician and staff will monitor nutritional status, an individual's response to interventions. The DON stated the P&Ps were not followed as the recommendations were never escalated to the physician. The DON stated that it is important to follow the P&P to prevent continued weight loss. 2. During a review of Resident 104's admission Record (contains demographic and clinical data), the admission Record indicated Resident 104 was admitted to the facility on [DATE], with diagnoses which included acute ischemic heart disease (heart isn't getting enough blood and oxygen due to blood vessels that feed it are blocked or narrowed), depression (health condition that affects mood, energy, sleep, appetite, and daily functioning), and epilepsy (brain condition that causes repeated seizures due to sudden bursts of abnormal electrical activity in the brain). During a review of Resident 104's Order Summary Report (written instructions from a doctor or authorized provider that tell the staff exactly what care a patient needs), dated April 9, 2026, the Order Summary Report stated Weight monitoring weekly X 4 weeks then monthly if stable every day shift every 31 day(s). During a review of Resident 104's Weights and Vitals Summary (weight trends and basic health measurements that show how the body is working) dated December 5, 2025, through June 3, 2026, were reviewed as follows: December 5, 2025, Current weight: 128.4 Lbs. [pounds- unit of measurement] January 1, 2026, Current weight: 125.2 Lbs. February 5, 2026, Current weight: 120.6 Lbs. March 18, 2026, Current weight: 115.6 Lbs. April 2, 2026, Current weight :112.5 Lbs. May 4, 2026, Current weight:113.1 Lbs. June 3, 2026, Current weight 108.4 Lbs. During a concurrent interview and record review on June 18, 2026, at 8:30 AM, with the Director of Nursing (DON), Resident 104's Weights and Vitals Summary, were reviewed. The Weights and Vitals Summary did not have documented evidence indicating weights for Resident 104 have been monitored weekly from April 9, 2026, to June 18, 2026. The DON stated, weights should be documented in the electronic medical record in the Weights and Vitals Summary section. During a concurrent interview and record review on June 18, 2026, at 2:20 PM, with the DON, the facility's policy and procedure (P&P) titled, Unplanned Weight Loss- Clinical Protocol, dated September 2012 was reviewed. The P&P indicated, .The physician and staff will monitor nutritional status, weight variance, an individual's response to interventions, and possible complications of such interventions. The DON acknowledged the policy was not followed. During a concurrent interview and record review on June 18, 2026, at 2:23 PM with the DON, the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated March 2022 was reviewed. The P&P indicated, .Residents are weighed upon admission and at intervals established by the interdisciplinary team. The DON acknowledged the policy was not followed and further stated it's important to monitor weights for residents and provide appropriate interventions for weight loss if necessary.

Based on observation, interview, and record review, the facility failed to ensure one (1) of 29 sampled residents (Resident 29) received enteral feeding (method of delivering liquid nutrition directly into the gastrointestinal tract using a tube placed into the stomach or small intestine) as ordered by the the physician when the ordered daily total of 918 mL (milliliter-unit of measurement ) was not administered. This failure had the potential to result in malnutrition, weight loss, and electrolyte imbalance for Resident 29.Findings: During a review of Resident 29's admission Record (contains demographic and medical information), the admission Record indicated Resident 29 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a temporary or permanent brain dysfunction caused by a chemical imbalance, illness, or organ failure elsewhere in the body, rather than a direct head injury), injury of left foot, and major depressive disorder (severe health condition where a persistent wave of sadness or emotional emptiness interferes with a person's ability to live his/her life). During a review of Resident 29's Order Summary Report, order dated September 21, 2025, the Order Summary Report indicated Patient 29 had an order to receive Enteral Feed Order every shift Enteral Feeding: [Brand name] Formula 1.2 to run at 51 mL/hr. (hour) x 18 hrs. (hours) or until dose is completed via GT [gastronomy tube] to provide total of 918 mL/day: 1102 kcal [a unit of energy measurement used in nutrition] Start: 2 pm. During an observation on June 15, 2026, at 9:38 AM, in Resident 29's room, Resident 29 was lying in bed and receiving enteral feedings. The enteral feed bottle [Brand name] formula was observed to be infusing and labeled with the date June 14, 2026, start time 1400 (2:00 PM). The formula in the bottle was measured below 1200 mL line. During a concurrent observation and interview on June 15, 2026, at 3:45 PM, with Licensed Vocational Nurse 5 (LVN 5) in Resident 29's room, LVN 5 verified the observed amount left in the enteral feeding bottle. LVN 5 stated Resident 29 received approximately 670 mL of formula over the period of one day, one hour, and 45 minutes (from June 14, 2026, at 2 PM to June 15, 2026, at 3:45 PM). LVN 5 further stated Resident 29 did not receive the ordered amount of 918 mL/day of enteral feeding formula. During a concurrent interview and record review on June 17, 2026, at 12:38 PM, with Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Enteral Nutrition, dated November 2018 was reviewed. The P&P indicated, Policy Interpretation and Implementation.11. The nurse confirms that the orders of enteral nutrition are complete. Complete orders include . e. volume and rate of administration. The DON stated the P&P was not followed. The DON further stated it is important to follow the physician's enteral feeding order to help meet Resident 29's nutritional needs.

Based on observation, interview, and record review, the facility failed to maintain effective infection control practices for one (1) of 29 sampled residents (Resident 60) when a humidifier bottle (a device that adds moisture to the air) attached to a tracheostomy (trach- a small tube placed into a surgically created opening in the neck to help a person breathe) oxygen delivery system was observed resting on the floor while in use. This failure resulted in improper handling and positioning of respiratory equipment, which had the potential to introduce germs (tiny organism that can cause an infection) into the humidification system and directly into Resident 60 airway (the breathing passage that carries air from nose and mouth to your lungs), increasing the risk for infections for Resident 60.Findings: During a review of Resident 60's admission Record (contains demographic and medical information), the admission Record indicated, Resident 60 was admitted to the facility on [DATE], with diagnoses which included respiratory failure with tracheostomy status (a serious breathing problem where the body cannot get enough oxygen in or remove carbon dioxide out needing a trach to assist them with breathing). A review of Resident 60's Order Summary dated January 29, 2026, through June 18, 2026, the order Summary indicated, Change humidifier.setup weekly on Tuesdays and as needed.tracheotomy mask (collar) at 2 liters [units of measurement] /minute every shift. During a concurrent observation and interview on June 15, 2026, at 11:35 AM with the Respiratory Therapist (RT 1) in Resident 60's room, the humidifier attached to the tracheostomy oxygen delivery system was observed resting on the floor while in use. RT 1 stated that the humidifier should never be on the floor because it can cause bacteria (tiny organism that can cause an infection). During a concurrent observation and interview on June 16, 2026, at 9:01 AM with the Licensed Vocational Nurse 2 (LVN 2) in Resident 60's room, the humidifier attached to the tracheostomy oxygen delivery system was observed resting on the floor while in use. LVN 2 stated that she was unsure why the humidifier was on the floor, but it should not be. LVN 2 stated, the humidifier should not be on the floor for infection control (prevent the spread of germs/bacteria). During an interview on June 17, 2026, at 2:00 PM with the Infection Preventionist (IP), the IP stated there was no reason for a humidifier to be on the floor. The IP further stated added it was important to keep off the floor because it could harbor bacteria. During an interview on June 18, 2026, at 11:30 AM with the Respiratory Therapist Lead (RTL), the RTL stated the expectation for the oxygen setup including the humidifier, was that everything was properly placed, secured and not touching the floor. RTL stated, it was important to keep the humidifier off the floor for infection control. During a concurrent interview and record review on June 18, 2026, at 11:41 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration via Artificial Airway dated June 2026, was reviewed. The P&P indicated .8.4 oxygen administration through an artificial airway shall be performed in a manner that promoted resident safety, comfort, infection prevention and maintenance of airway patency. The DON stated, the nursing staff and RTs are expected to ensure the oxygen equipment was set appropriately and the humidifier should not be on the floor. The DON stated, it was important to follow the P&P to prevent infections.

Based on observation, interview, and record review, the facility failed to adequately maintain its equipment when:#1. Three (3) of three exhaust fans (removes moisture and odors) in the shower rooms were not operational. This failure had the potential to pose a risk of mold (type of fungus that grows on damp organic matter, appearing as fuzzy, colorful patches and spreading via airborne spores) growth which may compromise the health and well-being of the 124 residents. #2. A faucet in one (1) of five (5) residents' (Resident 1) room was continuously leaking, which is creating a continuous noise disturbance. This failure resulted in disruption for Resident 1, particularly impacting on her ability to fall asleep during the night.Findings: #1. During a concurrent observation and interview, on May 7, 2026, at 2:50 PM, with the Maintenance Supervisor (Supervisor), shower rooms [ROOM NUMBER] were inspected. It was noted that the exhaust fans in the three shower rooms were not operational. The Supervisor acknowledged the findings. #2. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses that included acute respiratory failure ( is a condition where respiratory fails to maintain adequate blood supply of oxygen) with hypoxia (condition where body tissue do not receive enough oxygen), asthma (chronic condition that causes inflammation, swelling, and narrowing of the airway), and aphonia (total loss of voice). During an interview with Resident 1, on May 7, 2026, at 2:31 PM, she stated the faucet in her room has been leaking for about two months now, which has disrupted her sleep at night due to its noise disturbance. She also stated she had been informing the staff about this problem but all they told her was they had placed it on the maintenance list. During a concurrent observation and interview with the Supervisor, on May 7, 2026, at 2:55 PM, in Resident 1's room, it was noted that the faucet near Resident 1's bed was continuously leaking and creating a noise disturbance. The Supervisor acknowledged the finding. During a concurrent interview and record review, on May 7, 2026, at 3:19 PM, with the Assistant Director of Nursing (ADON), the ADON reviewed and acknowledged the facility's policy and procedure (P&P) titled, Maintenance Service, dated December 2009, which indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. The ADON stated the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure proper oral care (refers to the maintenance of a healthy mouth, which includes not only teeth, but the lips, gums, and supporting tissues) was provided for one of three sampled residents (Resident 1) when Resident 1 was found to have larvae (baby form of insects) inside his mouth.This failure could worsen Resident 1's oral health, particularly as he is being treated for periodontitis (bacterial infection that destroys the gums, ligaments, and bone supporting teeth caused by poor oral health and untreated gingivitis)Findings:A review of Resident 1's admission Record (a document containing clinical and demographic data) indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) affecting left non-dominant side following cerebral infarction (stroke), encephalopathy (a syndrome caused by changed in mental status such as confusion, memory loss, personality changes, or decreased consciousness), and dysphagia (difficulty swallowing).During a review of Resident 1's Minimum Data Set (MDS - a standardized clinical assessment tool), under Section GG (Functional Abilities - focuses on a resident's functional abilities and goals, specifically assessing self-care and mobility performance to capture the level of assistance needed), dated April 17, 2026, the MDS Section GG indicated, Resident 1 was dependent (Helper does ALL of the effort. Residents do none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) with oral hygiene (The ability to use suitable items to clean teeth).A review of Resident 1's Treatment Sheet, dated April 17, 2026, indicated Resident 1 received a comprehensive oral evaluation from a dentist, which revealed a clinical finding of generalized bone loss and periodontitis.During a review of Resident 1's nurses' notes, documented by Registered Nurse (RN), dated April 27, 2026, it indicated Called to room by CN [charge nurse] to assess resident [Resident 1] with larvae found inside mouth.During a telephone interview on April 29, 2026, at 11:55 AM, with Licensed Vocational Nurse (LVN), LVN stated Resident 1's daughter visited and reported to her that she noticed something inside Resident 1's mouth. LVN stated It looked like a small white spot moving, resembling white larvae. LVN further stated there was moderate amount of it, but they were able to remove it by using peridex (prescription antimicrobial oral rinse) and yankeur (suction tip is a rigid, curved oral suctioning tool used to remove fluids, blood, and secretions from the mouth and pharynx). During a concurrent interview and record review on April 29, 2026, at 12:40 PM, with the Assistant Director of Nursing (ADON), the ADON reviewed and acknowledged the facility's policy and procedures (P&P) titled, Activities of Daily Living (ADL), Supporting, dated March 2018, which indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . and stated it was not followed.

Based on observation, interview, and record review, the facility failed to maintain infection control practices for one of four sampled residents (Resident 1), who was on contact precaution isolation (measures applied when caring for patients with infections known or suspected to spread via touch or contact with contaminated item), when a Certified Nurse Assistant (CNA) failed to wear gloves while picking up the call light of Resident 1 from the floor.This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to Resident 1, other residents, and staff in the facility.Findings: During a review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a long-term condition where the lungs cannot properly move oxygen into the blood or remove carbon dioxide), and Klebsiella Pneumoniae (a type of bacterium that can cause severe, hard-to-treat infections if it spreads to lungs or blood). During a review of Resident 1's physician's order, dated June 1, 2023, it indicated an isolation order for .Contact Precautions every shift for CRAB (Carbapenem-Resistant Acinetobacter Baumannii- a high-priority drug-resistant bacteria causing severe health care associated infection like pneumonia and blood stream infections), KPC (Klebsiella pneumoniae carbapenemase - an enzyme produced by some CRAB that breaks down last-resort antibiotics) infection, wear gown and gloves before entering room/caring for patient. Follow proper PPE donning and doffing procedures. Perform hand hygiene before putting on gloves and after removing them. During concurrent observation and interview on March 5, 2026, at 10:45 AM, with CNA 1, in Resident 1's room, the door signage indicated Resident 1 was placed on isolation for contact precautions. CNA 1 was observed picking up Resident 1's call light from the floor without wearing gloves. CNA 1 stated she forgot to wear gloves. She further stated that she is aware of the importance of wearing gloves to protect both herself and Resident 1. During an interview on March 5, 2026, at 12:39 PM, with the Assistant Director of Nursing (ADON), the ADON stated that it was unacceptable for CNA 1 to attend to Resident 1 without wearing gloves. She further stated that all staff are required to follow the established isolation protocols. During interview on March 5, 2026, at 12:44 PM, with the Director of Staff Development (DSD), the DSD stated that it was unacceptable for CNA 1 not to wear groves in a contact isolation room, as this poses a risk of cross-contamination (the unintentional transfer of harmful microorganisms like bacteria, virus). A review of the facility Policy and Procedure (P&P) titled, Isolation - Categories of Transmission-Based Precautions, dated October 2018, indicated, .4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). b. Gloves will be removed and hand hygiene performed before leaving the room. c. Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of four sampled residents (Residents 1 and 2), when Resident 1's call light was located on the floor, and Resident 2's call light was wrapped around the bed rail. In both instances, the call lights were out of reach of Resident 1 and Resident 2.These failures had the potential to delay Residents 1 and 2's ability to request assistance when needed, increasing the risk of unmet care needs, and possible injury.Findings: A review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a long-term condition where the lungs cannot properly move oxygen into the blood or remove carbon dioxide), and Klebsiella Pneumoniae (a type of bacterium that can cause severe, hard-to-treat infections if it spreads to lungs or blood).During a concurrent observation and interview on March 5, 2026, at 10:45 AM, with a Certified Nursing Assistant (CNA 1), in Resident 1's room, Resident 1 was lying in bed, CNA 1 searched for Resident 1's call light and found it on the floor. CNA 1 stated the call light should be within the resident's reach. A review of Resident 2's face sheet indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting right dominant side, tracheostomy status (a surgically created opening in the neck to assist with breathing).During a concurrent observation and interview on March 5, 2026, at 11:13 AM, with the Assistant Director of Nursing (ADON), in Resident 2's room, Resident 2 was lying in bed, ADON searched for Resident 2's call light and found it wrapped around the bed rail, which was not within Resident 2's reach. ADON stated the staff must have neglected to place it within reach after attending Resident 2, which is deemed unacceptable. A review of the facility's undated Policy and Procedures (P&P) titled, Answering the Call Light, undated, indicated, . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, the facility failed to ensure their Bed-Holds (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) and Returns policy and procedure was implemented for one of four sampled residents (Resident 1) when Resident 1's responsible party (Resident 1's daughter) was not provided any verbal or written information regarding Resident 1's right to exercise the bed hold provision (legal requirement, often lasting 7 days, that allows nursing home or skilled nursing facility (SNF) residents to reserve their specific bed while temporarily hospitalized ) when he was transferred to the general acute care hospital (GACH) on January 4, 2026.This failure resulted in Resident 1 and Resident 1's representative not being able to exercise their right for the bed hold provision.Findings:A review of Resident's 1 admission Record (a document containing clinical and demographic information data) indicated Resident 1 was initially admitted to the facility on [DATE], with a diagnoses which included anxiety disorder (excessive and persistent fear, worry and apprehension), hematuria (presence of blood in the urine), and psychosis (mental state where a person loses touch with reality). Further review indicated Resident 1's responsible party was Resident 1's daughter.During a review of Resident 1's nurses' notes, dated January 4, 2026, it indicated At approximately 0445 (4:45 AM), CNA (Sitter) informed RN (Registered Nurse) and LVN (Licensed Vocational Nurse) that the resident had removed his catheter from his penis, CN (Charge Nurse) and RN came to the room to find resident still lying in bed, with blood coming from the penis profusely. RN asked the resident what happened and stated that he purposely pulled out his catheter because he wanted to be sent out. Sitter witnessed resident pull out his catheter . MD (Medical Doctor) notified. LVN called [Name of Ambulance Company], came around 0500 (5 AM). Patient left the facility at 0505AM (5:05 AM) accompanied by the [Name of Ambulance Company] personnel.During a review of Resident 1's Bed Hold Policy and Notification, it indicated Resident 1's daughter was notified via phone by the facility regarding Resident 1's right to hold a bed for 7 days on January 4, 2026, but Resident 1's daughter declined to exercise it. The form did not indicate what time the call occurred, and who the facility representative was. During a telephone interview on January 22, 2026, at 5:05 PM, with the Registered Nurse Supervisor (Supervisor), Supervisor stated she did not call Resident 1's daughter to notify her about Resident 1's bed hold.During a telephone interview on January 26, 2026, at 4:21 PM, with Licensed Vocational Nurse (LVN), LVN stated she called Resident 1's daughter and informed her about Resident 1's transfer to the GACH on January 4, 2026, but did not inform her about the bed hold.During a telephone interview with Resident 1's daughter on January 26, 2026, at 7:33 AM, Resident 1's daughter stated she still hasn't received any call or mail from the facility regarding Resident 1's exercise to the bed hold provision since Resident 1 was transferred to the GACH on January 4, 2026. (17 days ago)During a concurrent interview and record review on January 29, 2026, at 11:38 AM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, dated March 2022 was reviewed. The P&P indicated, .1. All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: a. well in advance of any transfer (e.g., in the admission packet); and b. at the time of transfer (or, if the transfer was an emergency, within 24 bours). The DON stated the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure that call light was within reach for two of four sample residents (Resident 1 and 2) reviewed, when Resident 1's call light was observed wrapped around the left bed rail with the cord hanging down towards the floor, while the bedside table was placed against the left bed rail, obstructing access to the call light. Resident 2's call light was observed clipped to the top portion of the bed with the cord oriented away from Resident 2, placing it out of Resident 2's reach.This failure had the potential to delay Resident 1 and 2's ability to request assistance when needed, increasing the risk of unmet care needs, and exacerbating the confusion of Resident 1 and 2, leading to possible Injury.During a review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease stage 3B (moderate to severe kidney function loss), repeated falls. During a review of Resident 2's face sheet (contains demographic and medical information) indicated Resident 2 was originally admitted to the facility on [DATE], with diagnoses that included nondisplaced bimalleolar fracture (a broken ankle where both the inner and outer ankle bones are fractured but remain in their corrected alignment and position) of right lower leg, repeated falls. During a concurrent observation and interview on December 2, 2025, at 11:02 AM, with Resident 1, in resident 1's room, Resident 1 mentioned that he is unaware of the location of the call light and cannot recall the last time he experienced a fall within the facility. It was observed that the resident's call light was wrapped around the left bed rail, with the cord hanging down towards the floor, and the bedside table was placed against the left bed rail, obstructing access to the call light. During observation on December 2, 2025, at 11:03 AM, Resident 2, who shares a room with Resident 1, was found asleep in bed. It was observed that the call light designated for Resident 2 was attached to the upper section of the bed, with the cord oriented away from Resident 2, placing it out of Resident 2's reach. During a concurrent observation and interview on December 2, 2025, at 11:05 AM, in Resident 1 and 2's room with the Certified Nursing Assistant (CNA 1), CNA 1 reported that both Resident 1 and Resident 2 are capable of moving their hands to access the call light; however, when the CNA requested Resident 1 to reach for the call light, Resident 1 was unable to do so. Subsequently, the CNA roused Resident 2 and asked Resident 2 to reach for the call light, but Resident 2 also could not reach it. When inquired about the policy concerning the call light, the CNA indicated that the policy specifies that the call light should be within reach. During an interview on December 2, 2025, at 11:33AM with License Vocational Nurse (LVN 1), LVN 1 stated, the call light must be within reach. During a concurrent record review and interview on December 2, 2025, at 11:50 AM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). During this meeting, both DON and ADON reviewed the photograph depicting the placement of the call light for Residents 1 and 2. They confirmed that the call light was situated beyond the reach of both residents, which is unacceptable. The DON stated that it is the responsibility of the staff to ensure that the call light remains accessible after they have attended to the residents or participated in any activities. In this case, the established policy is not being followed. The DON further pointed out that resident confusion does not excuse the failure to keep the call light within reach. A concurrent interview and record review were conducted with both the DON and ADON. The call light policy was reviewed, which specifies, '5. When the resident is in bed or confined to a chair, ensure the call light is within easy reach of the resident.' Both DON and ADON affirmed that this is indeed their policy.

Based on observation, interview, and record review, the facility failed to ensure that respiratory therapists were available for 41 residents when there was no respiratory therapist on duty for approximately seven (7) hours during the night shift of October 12, 2025.This failure had the potential to place clinically compromised residents' health and safety at risk by not having a respiratory therapist available to provide appropriate care when necessary.Findings:During an interview on 10/14/2025, at 3:00 PM, with one of the residents (Resident 1), Resident 1 stated, two nights ago, there was no RT (Respiratory Therapist) at all. The nurses do not know how to operate the machine; I just stayed off the machine. I was suctioned before the RT left.During an interview on 10/14/2025, at 3:50 PM, with Respiratory Therapist (RT 1), RT 1 stated, I came early Monday [10/13/2025] at 5:00 AM, I clocked in before 5:00 AM, there was no RT on duty. RT 1 indicated that the scheduled RT called off, and another RT, who lacks work permit, did not report to work. To address the situation, an RT from the day shift extended his hours and remained on duty until 10:00 PM that shift.During an interview on 10/15/2025, at 12:44 PM, with Respiratory Therapist (RT 2), RT 2 stated, .They could not find anybody and there was no RT on the floor, I left at 10:00 PM, there was no RT when I left. There was two scheduled, [Name of two RTS], they called off.During an interview on 10/28/2025, at 12:40 PM, with Registered Nurse (RN ), RN stated, There was no RT, the young lady [Name of staff], is not a registered therapist, there was no cover, the scheduled RT called off. RN confirmed she was working on the floor that night.During record review of respiratory therapist time sheet dated October 12, 2025, the timesheet indicated Respiratory Therapist (RT 3) did not work on the night shift on October 12, 2025. Also, the timesheet showed that RT 2 clocked out at 10:10 PM on October 12, 2025, and RT 1, clocked in at 4:55 AM on October 13, 2025. The timesheet illustrates that between 10:10 PM on October 12, 2025, and 4:55 AM on October 13, 2025, there was no respiratory therapist on duty at the facility.During a concurrent interview and record review on 11/04/2025, at 3:38 PM, with the Director of Nursing (DON) the facility policy and procedure (P&P) titled, Staffing, was reviewed dated, October 2017. The P&P indicated, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. When the DON was asked if they facility followed this policy she stated, No.

Based on interview, and record review, the facility failed to ensure appropriate dialysis (the process of removing excess water and cleaning the blood) treatment was acquired for one of three residents (Resident 1) for 2 days.This failure resulted in a clinically compromised resident Resident 1 not receiving dialysis as ordered by the physician and was sent out to acute hospital for treatment and placing health and safety at risk. Findings:During review of Residents 1's admission Record (general demographics information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which include End Stage Renal Disease (kidneys have severe damage) dependent on Renal Dialysis, acute respiratory failure (fluid prevents lungs filling with air), hypertension (high blood pressure).During a record review on October 23, 2025, at 11:30AM, Resident 1's medical records, reviewed and verified the following:1. History and Physical dated October 22, 2025: Patient is not able to make own decisions.2. Order: June 04, 2025, 18:48: Dialysis Care Center, Dialysis IV access Right chest IJ one time a day every Monday, Tuesday, Wednesday, Thursday, Friday for Dialysis.3. admission Summary Note October 21, 2025, 1548: Dialysis resident and dialysis on Mondays, Wednesdays, and Fridays. Hemodialysis port at right upper chest.4. Order October 21, 2025: Dialysis Care center Dialysis IV Access right chest IJ every shift for Monday, Wednesday and Friday.Start 10/24/25. (Resident 1 was readmitted [DATE], missed dialysis October 22, 2025, and October 24, 2025)5. Spectrum Dialysis: Consent to home hemodialysis treatment dated/signed by resident son 10.22.25.During an interview on October 23, 2025, at 11:20 AM, with the Assistant Director of Nursing (ADON), ADON stated, our admissions, consent needs to be done first before the resident gets here for Dialysis. Prior to residents being transferred back from the acute hospital, so for the residents at [acute hospital], there are labs to be drawn up and family consents before admitting the resident back. The dialysis does have an office here in our facility.During an interview on October 23, 2025, at 12:36 PM, with the admission Coordinator Marketing Director (ACMD), ACMD stated, I submitted to [dialysis company] the documents for this resident. I was not made aware that [dialysis company] had discharged (D/C) him off their dialysis schedule. He was D/C completely from the facility, he was at acute over 30 days, there was no bed hold. It should have been my responsibility to get consent from family for his Dialysis. The Dialysis coordinator told me we need to be all paperwork because he was no longer in their system. I did not know we had to do all the paperwork over again. He should have been a new admission. It was my responsibility to follow up and I dropped the ball; I take full responsibility.During an interview on October 23, 2025, at 12:40 PM, with the Director of Nursing (DON), DON stated, It is a third-party Dialysis, they usually get the consents. I do understand that he is our responsibility, and it should have been our responsibility to make sure the authorization and documents were done. He missed Wednesday because we still did not have consent from the son, we called the doctor he ordered labs and Friday we sent him out because we did not have consent.During a review of the facility's policy and procedure titled, Change in a Resident Condition or Status revised on May 2017, the policy and procedure indicated, Our facility shall promptly notify the resident his or her attending physician and representative of changes in the resident medical/ mental condition and or statusDuring a review of the facility's policy and procedure titled, Hemodialysis Access Care revised on September 2010, the policy and procedure indicated, Hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of these devices.

Based on interview and record review, the facility failed to follow their policy in providing Activities of Daily Living (ADLS) when showers/bed bath were not provide as scheduled for 17 of 25 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,13,14,15,16, and 17).This failure had the potential to result in skin irritation, odor, and decreased quality of life for the residents.Findings:During a concurrent interview and record review of the Shower Schedule Station 2 with the Certified Nursing Assistant (CNA 2), on July 9, 2025, at 2:36 PM, CNA 2 stated they have residents who complained about not receiving showers on Saturdays. Review of the Shower Schedule Station 2 document indicated the following schedule for Wednesday's and Saturday's:a. Hallway 1, AM shift: 201B, 202B, 207B, 208B, 209A, 210Ab. Hallway 2, AM shift: 215A, 216A, 220B, 222A, 225Cc. Hallway 3, AM shift: 227B, 228B, 233A, 236Ad. Hallway 1, PM shift: 203A, 209B, 211C, 212Ae. Hallway 2, PM shift: 215B, 214A, 218Bf. Hallway 3, PM shift:228A, 230B, 236BDuring a review of the electronic medical record for Activities of Daily Living (ADLs) Bathing with the DON, on July 9, 2025, at 4:09PM, there was no documentation indicating that showers/bed baths were provided for the following residents on subacute (higher level of care and patient assistance) unit: a. Resident 1, No documentation for June 07, 14, 21 and 28, 2025. July 05, 2025b. Resident 2, No documentation for June 07, 14, 21, and 28, 2025.c. Resident 3, No documentation for June 07, 14, 21, and 28, 2025.d. Resident 4, No documentation for June 07, 21, 25 and 28, 2025.e. Resident 5, No documentation for June 11, 14, 21, and 25, 2025.f. Resident 6, No documentation for June 14, 21, and 28, 2025.g. Resident 7, No documentation for June 21, and 28, 2025.h. Resident 8, No documentation for June 14, 2025.i. Resident 9, No documentation for June 14 and 28, 2025.j. Resident 10, No documentation for June 14, 21, and 28, 2025.k. Resident 11, No documentation for June 21 and 28, 2025.l. Resident 12, No documentation for June 14 and 21, 2025.m. Resident 13, No documentation for June 07 and 21, 2025.n. Resident 14, No documentation for June 07, 14, 21, and 28, 2025.o. Resident 15, No documentation for June 14 and 28, 2025.p. Resident 16, No documentation for June 14, 21, and 28, 2025.q. Resident 17, No documentation for July 05, 2025. During an interview and record review on July 09, 2025, at 11:59 AM, with the License Vocational Nurse (LVN1), the shower binder was reviewed. LVN 1 stated there were only two shower refusals documented. LVN 1 further stated the Director of Staff Development (DSD) is responsible for checking the shower binder.During an interview and record review on July 09, 2025, at 12:41 PM, with the CNA 1, CNA 1 stated, We give resident showers and back to bed so treatments can get done. It's not my responsibility to make sure the team is completing the showers or reviewing the shower binder. CNA1 stated, on June 21, 2025, there should have been a total of nine (9) showers in AM and six (6) in PM. CNA 1 further stated the shower sheets should be in the shower binder; however, it was not, I only see 2 shower sheets.All subacute residents are dependent on staff for showers.During an interview and record review on July 09, 2025, at 3:04 PM, with the Registered Nurse (RN), the RN stated the CNAs gives baths, besides the shower team. RN 1 stated the CNA has to complete a shower form and they should document in electronic record. RN 1 further stated, There is no proof of it because it was not documented.During an interview and record review of the Shower Binder Station 2, on July 09, 2025, at 3:54 PM, with the DSD, DSD stated the shower binder is reviewed to make sure it is completed and filled by licensed staff. The DSD stated showers should be documented in shower binder and in electronic records. The DSD further stated CNAs should be reporting to charge nurse or Registered Nurse if the residents did not receive a shower, I did not receive report about this.During an interview and record review of the Shower Binder Station 2, on July 09, 2025, at 4:02 PM, with the Assistant Director of Nursing (ADON), ADON stated, the charge nurse and RN are supposed to check and follow up after the CNAs; the CNAs report to them about refusals. The nurse signs when the resident refused. ADON agreed, the staff should provide showers and document it as scheduled.During an interview and record review of the Shower Binder Station 2, on July 09, 2025, at 4:09 PM, with the Director of Nursing (DON), DON stated she was not aware of the shower binder audit. The DON further stated CNAs know when they have a shower team and when they do not. The DON agreed, the staff should provide showers and document it as scheduled.During a review of the facility's policy and procedure titled, Activities of Daily Living ADL, supporting revised March 2018, the policy and procedure indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.(3) refuses care and treatment to restore or maintain functional abilities and (a) the resident and or representative has been informed of the risk and benefits of the proposed care or treatment.(c) the refusal and information are documented in the residents clinical record.2. Appropriate care and services will be provided for residents who are unable to carry out ALDs independently, with the consent of the resident and accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming and oral care).

Based on observation, interview, and record review, the facility failed to ensure the Certified Nursing Assistant (CNA) performed hand hygiene after doffing (removing) Personal Protective Equipment (PPE) upon leaving the isolation (to keep patients with contagious diseases separate from others) room for two of 25 (Resident 18 and 19).This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to other residents and staff in the facility.Findings:During a concurrent observation and interview on July 08, 2025, at 1:54 PM, with the Certified Nursing Assistant (CNA 3), CNA 3 was observed to enter the isolation room for Resident 18 wearing gloves and isolation gown. CNA 3 exited the room and doffed (removed) her (PPE). CNA 3 did not perform hand hygiene after doffing her PPE. CNA 3 stated she did not touch the resident or anything in the room, that is why she did not do hand hygiene.During a review of Resident 18's clinical record, the isolation list indicated Resident 18 was placed on contact precautions on July 08, 2025, due to MDRO-Multidrug Resistant Organism (a type of bacteria that has become resistant to several antibiotics that are normally used to treat infections).During a review of Resident 19's clinical record, the isolation list indicated Resident 19 was placed on contact precautions on on May 17, 2023, due to MDRO-Multidrug Resistant Organism.During an interview with the Director of Nursing (DON), DON agreed that CNA 3 should have performed hand hygiene.During a review of the Centers for Disease Control (CDC) guidelines titled Clinical Safety: Hand Hygiene for Healthcare Workers, dated February 27, 2024, the CDC recommendations included Know when to clean your hands:.(bullet 6) Immediately after glove removal, to reduce the potential spread of deadly germs to patients including those resistant to antibiotics.During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene revised August 2015, the policy and procedure indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 8.Hand hygiene is the final step after removing and disposing of personal protective equipment.

Based on observation, interview, and record review, the facility failed to perform timely maintenance on the ventilators (a breathing machine or breathing device that helps a resident breath when they cannot do it on their own) for two (2) of five (5) sampled residents (Residents 1 & 2). This failure has the potential to cause malfunctions of the ventilators, which may place the health of clinically compromised Residents 1 and 2 at risk. Findings: During an observation on 5/22/2025, at 12:43 p.m. in the Subacute Unit, with the respiratory therapist (RT 1) and the Assistant Director of Nursing (ADON), it was noted that the two ventilators currently in use for Resident 1 and Resident 2 were overdue for service maintenance. The maintenance sticker observed for both ventilators indicated the following: a. For Resident 1 - preventative maintenance was due on June 17, 2023. b. For Resident 2 - preventative maintenance was due on September 20, 2024. The ADON and RT 1 acknowledged that preventive maintenance for both ventilators is already past due. During a concurrent interview and review of the policy and procedure (P&P) titled Maintenance Service, on 5/22/2025, at 1:31 p.m. with the ADON, the ADON was inquired about the procedures for scheduling maintenance on ventilators. ADON stated respiratory therapist informs her when maintenance is required for a ventilator, and she will then contact the outside company for scheduling. A continued review of the policy and procedure titled Maintenance Service, dated December 2009, with the ADON, the P&P indicated .Providing routinely scheduled maintenance service of equipment according manufacturer ' s guidelines or other facility needs that may become necessary or appropriate . When the ADON was asked if this policy was being followed, the ADON replied, No. During a concurrent interview and record review on 5/22/2025, at 1:49 p.m. with the Respiratory Therapist (RT 2), RT 2 stated the RT in charge of the department is responsible to inform the ADON and Director of Nursing (DON) about any ventilator that requires servicing or are nearing their service due date. The ADON or DON will then contact an outside company to arrange for the servicing of those ventilators. The P&P titled Maintenance Service, dated December 2009, was also reviewed with RT 2. RT 2 was asked if this policy was being followed, RT 2 replied, No. During a concurrent interview and review of the (P&P) titled Maintenance Service on 5/22/2025, at 2:02 p.m. with the Administrator (ADM), the administrator explained respiratory therapists typically check the ventilators and coordinate maintenance with the ADON for those due for service. The ADON is responsible for notifying the outside company that services the ventilators. The P&P titled Maintenance Service, dated December 2009, was reviewed with the Administrator. The P&P indicated .Providing routinely scheduled maintenance service of equipment according manufacturer ' s guidelines or other facility needs that may become necessary or appropriate . The Administrator agreed the policy was not followed and further stated There is room for improvement.

Based on observation, interview and record review the facility failed to follow its Activities of Daily Living ADLs policy and procedure for 3 of 3 sampled Residents (Resident ' s 1,2 and 3) when: Resident ' s 1, 2 and 3 were left soiled and wet on observation April 30, 2025. This failure had the potential to cause (Resident 1,2, and 3) health and safety to be at risk for skin breakdown when their care needs were not met. Findings: 1. During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: encephalopathy (brain disease altering function, causes: infection tumor or stroke), respiratory failure, tracheostomy status (trach tube assisting with breathing). Hypertension (high blood pressure). During a concurrent observation and interview on April 30, 2025, at 11:30AM, with License Vocational Nurse (LVN1) at bedside assisting during observation. Resident 1 brief is completely drenching wet, linen sheet wet, gown wet. LVN1 states, the Certified Nursing Assistant (CNA) is at lunch right now, he last changed, around 8AM he had Bowel Movement. I agree he is completely soiled wet, he should not be like this, the CNA is at lunch. During an interview on April 30, 2025, at 12:52 PM with the Certified Nursing Assistant (CNA1), CNA1 states, I check on the residents every 1-2 hours. I don ' t know when Resident 1 was last changed, he is not my patient, I was told to clean him up. His brief was really wet. He should not have been left to much time. We know our patients, which one we have to check on frequently and change frequently. I have 12 residents ' assign; I am able to care for all the residents. During a concurrent observation and interview on April 30, 2025, with Director of Nursing (DON), DON viewed the condition I found Resident 1, and informed Resident 2 is also completely soiled wet, briefs soiled wet. DON confirms the status of both residents, and calls for staff to clean both residents up now. 2. During review of Residents 2 ' s Admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses to include: metabolic encephalopathy (brain disease caused by body chemical process), chronic respiratory failure, type 2 diabetes (condition affecting how body processes sugar), hypertension (high blood pressure), cerebral infarction (stroke, blood clot in brain). During a concurrent observation and interview on April 30, 2025, at 11:39AM, with License Vocational Nurse (LVN1) at bedside assisting during observation. Resident 2 brief drenched wet; gown wet. LVN1 confirms observation, same and Resident 1, can agree this resident should not be left soiled like this. 3. During review of Residents 3s Admission Record (general demographics), the document indicated Resident 3 was admitted to the facility on [DATE], with diagnoses to include: cerebral infarction (stroke, blood clot in brain), acute respiratory failure, type 2 diabetes (condition affecting how body processes sugar). During a concurrent observation and interview on April 30, 2025, at 12:36PM, with CAN 2, CAN 2 states, Resident 1 and 2, I changed around 8:30-9:00AM. I checked on both at 10:30AM, got repositioned. Both are heavy wetter ' s, void a lot. I change as they void. They were both dry then I went to lunch. He got cleaned up by the CNA. Observation of Resident 3 with CNA2 at bedside, noted brief wet, moderate amount. CNA 2 states, I will change him now. During an interview on April 30, 2025, with the DON, DON states, The residents has to be dry and repositioned. The residents should not have been left soiled. The charge nurse should be checking on the residents. In Subacute there is a shower team to help the staff in AM and PM shifts, so the CNAs are not showering their residents. There is enough staff to care for the residents. During a review of the facility ' s policy and procedure titled, Activities of Daily Living (ADLs), Supportingrevised [March 2018], the policy and procedure indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for one of three residents (Resident 1), when the Registered Nurses failed to perform a comprehensive nursing assessment (a detailed physical examination of the patient's entire body, to gather information about the patient's status) on Resident 1 upon his initial admission to the facility on [DATE], and his readmission from the hospital on [DATE],after Resident 1 was sent out due to being unresponsive. This failure resulted in Registered Nurse 6 (RN 6) being unaware of Resident 1's paracentesis drainage tube (a catheter to remove fluid from the abdominal cavity) and connecting the enteral feeding formula (liquid food designed to provide nutrition directly into the stomach) to the paracentesis drainage tube, instead of the gastrostomy tube feeding (G-tube, a tube inserted through the abdominal wall that brings nutrition directly to the stomach). The administration of the enteral feeding formula into the peritoneal cavity (space within the abdomen that contains the intestines, the stomach and the liver) caused Resident 1 to experience unnecessary abdominal pain from the retained enteral feeding formula into the peritoneal cavity Resident 1 was transferred to a general acute care hospital (GACH) in the intensive care unit (ICU), where he died . Findings: During a review of Resident 1's Admission Record (contains demographic information), the Admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included, cardiac arrest (when a person's heart stop pumping blood around the body), end stage renal disease (condition in which kidneys can no longer function adequately to meet the body needs) with hemodialysis (a treatment to filter wastes and water from the blood), liver cirrhosis (condition in which liver is permanently damaged), diabetes mellitus type 2 (a condition in which pancreas can't produce enough insulin), tracheostomy status (a surgically created hole in the front of the neck and into the windpipe, to allow to insert a tube to keep it open for breathing) and gastrostomy status (a surgically that creates an opening in the stomach through the abdomen, allowing for a tube to be inserted and used for feeding). During a review of Resident 1's document [NAME], Facility: [name of the facility] . History and Physical (H&P-information about a patient's health status and to establish diagnosis), for Resident 1, dated [DATE], the H&P indicated Resident 1 had diagnoses which included, tracheostomy dependence, ventilator dependence (a machine that pumps air into the lungs when a patient is unable to breathe independently), dependence on renal dialysis (a treatment to filter wastes and water from the blood), paracentesis with peritoneal drain placement (peritoneal drainage tube) and gastrostomy tube dependent. During a concurrent interview and record review on [DATE], at 9:15 AM, with the Director of Nursing (DON), Resident 1's Admit/Readmit Screener V.2 (screener assessment - a basic health assessment), effective [DATE], at 2:01 AM, was reviewed. The Admit/Readmit Screener V.2 indicated, Resident 1 had a PEG-TUBE (PEG - percutaneous endoscopic gastrostomy tube inserted surgically through the abdomen into the stomach), received nutrition via tube feeding and received oxygen via tracheostomy. The Admit/Readmit Screener V.2, did not include Resident 1 had a paracentesis drainage tube and it was signed by License Vocational Nurse 7 (LVN 7). The DON was not able to provide documented evidence of a Registered Nurse conducted Resident 1's comprehensive assessment upon admission on [DATE], and readmission from the hospital, on [DATE]. The DON stated, LVN 7 completed the screener assessment, not a comprehensive assessment. During a review of Resident 1's nursing Progress Notes . Type: Alert Note, dated [DATE], at 2:26 AM, the Progress Notes indicated, @ [at] 0145 [1:45 AM] Family at bedside stated pt [patient] having difficulty breathing. RT [respiratory therapist] notified and performed interventions. Pt [Resident 1] observed unresponsive to verbal and tactile stimuli. Respirations observed, pulses palpable. Patient bagged at 100 % FiO2 [fraction of inspired oxygen - the percentage of oxygen in the air a person is breathing] via ambu-bag [ a bag valve mask used to force air into the lungs of a person who cannot breathe] and regained consciousness . @ 0210 [ 2:10 AM] RT responded to mechanical ventilator alarm. Pt unable to respond appropriately. Pt was removed from ventilator and bagged again by RT. Rapid response called. Pt noted having 3 episodes of vomiting. RT suctioned copious amount of chunky secretions from tracheostomy tube and suspected patient may have aspirated. RN supervisor called 911 to send patient to ER for further evaluation . The Progress Notes . Type: Alert Note, was signed by Registered Nurse 2 (RN 2). During a review of Resident 1's nursing Progress Notes . Type: Admission Summary, dated [DATE] at 2:00 PM, the Progress Notes indicated, Resident returned from [name of the GACH] ER [emergency room ] via gurney and [Name of ambulance ] transport, without incident or injury, no new orders noted at this time from ER visit, resting in bed, no s/s [signs or symptoms] of distress to note, patient's wife at bedside, charge nurse aware, call light within reach, cooling measures implemented, all needs met by staff, will continue to monitor, bed in lowest position. The Progress Notes . Type: Admission Summary, was signed by the Subacute Manager/LVN (SM). During a review of Resident 1's nursing Progress Notes . Type: Transfer to Hospital Summary, dated [DATE], at 10:06 PM, the Progress Notes indicated, Wife asked CN [charge nurse] to connect drainage bag to paracentesis tube. When assessing the pt [patient] CN noted that the LTAD [Long Term Abdominal Drain] did not have the proper connection to connect the drain. CN noted that the tube appeared to have thick viscus cream/tan colored liquid in it. Informed RN supervisor to assess the resident. After assessment RN called NP [Nurse Practitioner] at 2045 [8:45 PM] and informed him of the situation. NP gave order to send patient out for further evaluation . The Progress Notes . Type: Transfer to Hospital Summary, was signed by Licensed Vocational Nurse 5 (LVN 5). During an interview on [DATE], at 9:55 AM, with the DON, the DON stated, she received a call from Registered Nurse 2 (RN 2) on [DATE], at approximately 10:00 PM, informing her that Resident 1's wife reported her husband complained of abdominal pain. The DON stated, RN 2 noticed the enteral feeding formula was infusing through Resident 1's paracentesis drainage tube. The DON further stated Resident 1 was transferred to GACH on [DATE], at 1:45 AM due to difficulty breathing and returned to the facility at 2:00 PM, on the same day. The DON stated, it was Registered Nurse 6 (RN 6)'s responsibility to assess Resident 1 upon his return from GACH and connect the enteral feeding formula to the G-tube, but she did not. During an interview on [DATE], at 11:35 AM, with Registered Nurse 2 (RN 2), RN 2 stated, on [DATE], at approximately 8:20 PM, Resident 1's wife reported her husband was having abdominal pain. The RN 2 stated, she assessed Resident 1 and observed the enteral feeding formula was infusing through the paracentesis drainage tube, which was on the floor. RN 2 further stated, she removed the feeding from the paracentesis drainage tube and called the physician. During an interview on [DATE], at 3:00 PM, with Registered Nurse 1 (RN 1), RN 1 stated, she saw Resident 1 in his room, on [DATE], at 3:30 PM, when she [RN 1] was doing rounds. RN 1 stated, she did not conduct a comprehensive nursing assessment to Resident 1. RN 1 further stated she should have performed it to Resident 1, after he [Resident 1] returned from the hospital. During a follow up interview on [DATE], at 3:20 PM, with the DON, the DON stated, when residents are admitted or readmitted from GACH, the license vocational nurse who admits the residents, perform Admit/Readmit Screener (a basic health assessment), not a comprehensive nursing assessment. The DON further stated, Registered Nurses are expected to complete a comprehensive nursing assessment within 24 hours of admission. During an interview and record review on [DATE], at 4:23 PM, with the Subacute Manager (SM), Resident 1's medical records were reviewed. The SM was not able to find documented evidence that demonstrate a comprehensive nursing assessment was performed to Resident 1. The SM stated, there was no documented evidence to indicate a comprehensive nursing assessment was conducted for Resident 1 upon his admission on [DATE], and readmission on [DATE]. During a concurrent interview and record review on [DATE], at 9:15 PM, with the DON, the DON reviewed Resident 1's medical records and was unable to find documented evidence that a comprehensive nursing assessment was performed for Resident 1 after his admission on [DATE], and his re-admission on [DATE]. During a concurrent interview and record review on [DATE], at 9:48 PM, with the DON, the facility's policy and procedure (P&P), titled, Admission Evaluation/Assessment & Follow Up: Role of Nurse, revised [DATE], was reviewed. The P&P indicated, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission or readmission for the purpose of managing the resident, initiating the care plan and completing the required assessment instruments . The DON stated, the P&P did not indicate the staff responsible to perform the assessment. During an interview on [DATE], at 9:58 PM with Registered Nurse 3 (RN 3), RN 3 stated it is the responsibility of the Registered Nurses to perform a comprehensive nursing assessment to the residents upon an admission or readmission to the facility. The RN 3 further stated the registered nurses would have 24 hours to complete a comprehensive nursing assessment and would need to endorse to the next shift if unable to complete a comprehensive assessment during admission. The RN 3 stated, the admission assessment must be documented in the residents' medical records. During a record review of the Registered Nurse job description, undated, the job description indicated, .4. Collect resident pre-admission and/or admission information and assist Director of Nursing Service to determine appropriate level of care . 19. Assess resident upon admission/readmission, change of condition, resident equipment, and supply needs, and make recommendations to the DON. An Immediate jeopardy (IJ- a situation in which an entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death ) was called on [DATE], at 10:15 PM under CFR 483.12(a)(1) Freedom from abuse, neglect, and exploitation. It was determined that due to the Registered Nurses lack of awareness, they failed to perform a comprehensive assessment to meet the needs of Resident 1, upon admission, on [DATE], and on readmission on [DATE], and resulted in Resident 1 being transferred out to GACH, in the intensive care unit (ICU). The IJ was called in the presence of Administrator and DON. A corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested. The Administrator provided CAP on [DATE], at 7:17 PM, the CAP was reviewed and approved on [DATE], at 11:35 AM, and included the following: 1) In-Service was conducted by the DON and Assistant director of Nursing (ADON), on [DATE], and completed on [DATE], regarding new admissions and readmissions to be assessed by RN upon admission/arrival to include head to toe assessment as soon as practically possible or within the first 2 hours from the time of admissions to assess stability of the resident, with documented evidence of full assessment by the end of the shift and according to the regulatory standards. 2) In-Service was conducted by the DON and ADON, on [DATE], and completed on [DATE], regarding Licensed staff including RNs will be educated by DON or Designee on the assessment process to ensure compliance prior to starting shifts. Ongoing training will be provided via verbal education and skills-check to existing and new staff, as needed and upon orientation, respectively, to ensure compliance. Onboarding Licensed staff and staff who are away will also be oriented of the proper procedures, with documented evidence accordingly, prior to beginning shift/ floor duties. 3) In-Service was conducted by the DON and ADON on [DATE], and completed on [DATE], regarding the policy and procedures of Admission Evaluation / Assessment & Follow-up: Role of Nurse. During a record review of three (3) residents (Resident 4, 5 and 6) admitted on [DATE], the comprehensive nursing assessment was performed by a Registered Nurse, within two (2) hours of admission. The acceptable CAP was verified with the facility through observations, interviews, and record review. The IJ was removed on [DATE], at 8:00 PM, in the presence of the Administrator and DON. During a record review of the hospital H&P, dated [DATE], the H&P indicated Resident 1 .presents w [with]/ 1d [one day] severe, constant, diffuse abdominal pain after received tube feeds though the peritoneal drain instead of his PEG tube [Percutaneous endoscopic gastrostomy - a feeding tube inserted through the skin and the stomach wall directly to the stomach]. MICU [Medical Intensive Care Unit] consulted d/t [due to] septic shock [when an infection causes dangerously low blood pressure and organ failure] ,d+[DATE] [secondary to] peritonitis [inflammation of the peritoneum, the thin tissue lining in the abdominal wall that covers the abdominal organs] in a trach [tracheostomy] dependent patient. During a record review of the hospital discharge summary, dated [DATE], the discharge summary indicated, . Continue on abx [antibiotic] and bedside washout ( a procedure that involved washing the peritoneal cavity with a saltwater solution) performed by surgery team . family opting for non-surgical management given patient's overall clinical status at this time. Patient's family opting for comfort-focused care given grave prognosis [a prediction about the course of a disease]. He [Resident 1] passed surrounding by family.

Based on observation, interviews, and record review, the facility failed to ensure licensed nurses were provided training to demonstrate competencies with paracentesis drainage tube (a catheter to remove fluid from the abdominal cavity) and gastrostomy tube feeding (G-tube, a tube inserted through the abdominal wall that brings nutrition directly to the stomach), for one of three residents (Resident 1) when Registered Nurse 6 (RN 6) connected and infused the enteral feeding formula (liquid food designed to provide nutrition directly into the stomach) to the paracentesis drainage tube, instead of the gastrostomy tube feeding, on [DATE]. This failure resulted in Resident 1 to experience unnecessary abdominal pain, retained enteral feeding formula into the peritoneal cavity (space within the abdomen that is lined by the peritoneum, a thin, smooth membrane) and Resident 1 was transferred to a general acute care hospital (GACH) in the intensive care unit (ICU), where he died . Findings: During a review of Resident 1's Admission Record (contains demographic information), the Admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included, cardiac arrest (when a person's heart stop pumping blood around the body), end stage renal disease (condition in which kidneys can no longer function adequately to meet the body needs) with hemodialysis (a treatment to filter wastes and water from the blood), liver cirrhosis (condition in which liver is permanently damaged), diabetes mellitus type 2 (a condition in which pancreas cannot 't produce enough insulin- a hormone that lowers the glucose in the blood), tracheostomy status (an artificial opening into the windpipe, that allows to insert a tube into the trachea, allowing a person to breathe) and gastrostomy status (a surgically created opening into the abdominal wall through which liquid nutrition and medication can be administered into the stomach). During a review of Resident 1's document titled, Facility: [name of the facility] . History and Physical (H&P-information about a patient's health status and to establish diagnosis), for Resident 1, dated [DATE], the H&P indicated Resident 1 had diagnoses which included, tracheostomy dependence, ventilator dependence (a machine that pumps air into the lungs when a patient is unable to breath independently), dependence on renal dialysis (a treatment to filter wastes and water from the blood), paracentesis with peritoneal drain placement (peritoneal drainage tube) and gastrostomy tube dependent. During a review of Resident 1's nursing Progress Notes . Type: Transfer to Hospital Summary, dated [DATE], at 10:06 PM, the Progress Notes indicated, Wife asked CN [charge nurse] to connect drainage bag to paracentesis tube. When assessing the pt [patient] CN noted that the LTAD [Long Term Abdominal Drain] did not have the proper connection to connect the drain. CN noted that the tube appeared to have thick viscus cream/tan colored liquid in it. Informed RN supervisor to assess the resident. After assessment RN called NP [Nurse Practitioner] at 2045 [8:45 PM] and informed him of the situation. NP gave order to send patient out for further evaluation . The Progress Notes . Type: Transfer to Hospital Summary, was signed by Licensed Vocational Nurse 5 (LVN 5). During an interview on [DATE], at 9:20 AM, with License Vocational Nurse 1 (LVN 1). LVN 1 stated training and education was done regarding drainage tube in general, but not specifically on how to manage paracentesis drainage tube. During an interview and record review on [DATE], at 9:55 AM, with the Director of Nursing (DON), the DON stated Registered Nurse (RN 6) reported to her she [RN 6] hung Resident 1's enteral feeding and was unaware of the paracentesis drainage tube. The DON further stated, she contacted Resident 1's wife for a follow-up and was informed Resident 1 was in ICU and 200 mL (mL - milliliters, unit of measurement) of fluid was removed from the peritoneal cavity. During an interview on [DATE], at 10:37 AM, with License Vocational Nurse 2 (LVN2), LVN 2 stated he received education on how to check residual and placement of a gastrostomy tube feeding but could not differentiate between a gastrostomy tube feeding and a paracentesis drainage tube. During an interview on [DATE], at 11:03 AM, with Registered Nurse 1 (RN 1), RN 1 stated she received training for gastrotomy tube feeding, but was not familiar with the management of paracentesis drainage tube. During an interview on [DATE], at 11:35 AM, with Registered Nurse 2 (RN 2), RN 2 stated, on [DATE], at approximately 8:20 PM, Resident 1's wife reported her husband was having abdominal pain. The RN 2 stated, she assessed Resident 1 and observed the enteral feeding formula was infusing through the paracentesis drainage tube, which was on the floor. RN 2 further stated, she removed the feeding from the paracentesis drainage tube and called the physician. RN 2 stated she did not receive training or education for management of paracentesis drainage tube. During a concurrent interview and record review on [DATE], at 2:45 PM, with the DON, the facility's policy and procedure (P&P), titled, Managing Draining Tube, revised [DATE], was reviewed. The P&P indicated, Purpose . To Ensure safe Monitoring of drainage tubes such as JP [Jackson Pratt - a thin flexible tube with a bulb at the end that drains fluid away from a wound] Drains, Nephrostomy [a tube that lets urine drain from the kidney through an opening in the skin on the back], Urostomy [an opening in the abdomen that directs urine from the bladder], Paracentesis, G-Tube, etc. 1. All personnel responsible for monitoring drainage tubes will be trained, qualified and competent in his or her responsibilities . Preventing misconnection errors . 1. Assess all drainage tubes prior to treatment. 2. Regularly inspect tubing for proper and secure connections. The DON stated staff did not follow the policy. The DON further stated that education and training was conducted after the incident on [DATE]. The DON stated no training or education was done regarding paracentesis draining tube, prior to the incident. During a review of the facility's P&P titled, Competency of Nursing Staff, revised [DATE], the P&P indicated, 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 2. In addition, licensed nursed and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skills sets deemed necessary to care for the needs of the residents, as identified through resident assessments and described in the plans of care. An Immediate jeopardy (IJ- a situation in which an entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) was called on [DATE], at 10:15 PM under CFR 483.35(a)(3) Nursing Service. It was determined that nursing staff did not have competencies to take care Resident 1's paracentesis drainage tube and gastrostomy tube feeding. The IJ was called in the presence of Administrator and the DON. A corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested. The facility's Administrator provided CAP on [DATE], the CAP was reviewed and approved on [DATE], at 11:35 AM, included the following: 1) In-service initiated/conducted by Director of Nursing from [DATE], and completed on [DATE], on: a. Proper Infusion of G-Tubes and management of drainage tubes including, but not limited to paracentesis drainage tubes, b. Monitoring of the G-tube feeding by license staff per shift, to verify pump has been infused properly, c. Observe the status of the resident, and ensure resident's needs are met, d. As safety precaution 2 nurses will check to verify g-tube feedings for accuracy and compliance at the change of shift. e. Ongoing education and competency training to be provided to staff to verify competency of the licensed staff particularly as it relates to proper infusion and monitoring of G-tube feeding and managing paracentesis drainage tubes. f. Onboarding Licensed staff and staff who are away will also be oriented of the proper procedures, with documented evidence accordingly, prior to beginning shift/ floor duties. 2) In-service initiated/conducted by DON and Assistant Director of Nurses (ADON) from [DATE], and completed on [DATE], regarding identifying the different type of enteral feeding, enteral tube use and maintenance, tube occlusion: Prevention/Management, g-tube replacement, and patency. During an observation on [DATE], at 7:30 PM, during shift change (AM shift- PM shift). Incoming and outgoing staff, shift report at the bedside of each patient, verifying the gastrostomy tube feedings site, patency [flushing with water], the correct formula and feeding pump settings. The acceptable CAP was verified with the facility through interview and record review. The IJ was removed on [DATE], at 8:00 PM, in the presence of the Administrator and DON. During a record review of the hospital H&P, dated [DATE], the H&P indicated Resident 1 .presents w [with]/ 1d [one day] severe, constant, diffuse abdominal pain after received tube feeds though the peritoneal drain instead of his PEG tube [Percutaneous endoscopic gastrostomy - a feeding tube inserted through the skin and the stomach wall directly to the stomach]. MICU [Medical Intensive Care Unit] consulted d/t [due to] septic shock [when an infection causes dangerously low blood pressure and organ failure] ,d+[DATE] [secondary to] peritonitis [inflammation of the peritoneum, the thin tissue lining in the abdominal wall that covers the abdominal organs] in a trach [tracheostomy] dependent patient. During a record review of the hospital discharge summary, dated [DATE], the discharge summary indicated, . Continue on abx [antibiotic] and bedside washout ( a procedure that involved washing the peritoneal cavity with a saltwater solution) performed by surgery team . family opting for non-surgical management given patient's overall clinical status at this time. Patient's family opting for comfort-focused care given grave prognosis [a prediction about the course of a disease]. He [Resident 1] passed surrounding by family.

Based on observation, interview, and record review, the facility failed to ensure all facility residents' records were safeguarded against unauthorized use and access, when two Licensed Vocational Nurses (LVN 1 and LVN 15) were observed using their own personal laptops to access resident health records in the facility. This failure had the likelihood to cause a breach of the residents' sensitive protected health information (PHI - any identifiers such as name, date of birth, social security number and medical record number and personal health records which include medical diagnoses, medications, and treatments). In addition, a Respiratory Therapist (RT 1) stated that he had used his personal laptop on one occasion and other RTs had used their personal laptops to access residents' personal health records when there were not laptops available and then took these laptops home with them. This failure had the potential to cause significant psychosocial harm to 120 out of 120 vulnerable residents, in addition to the significant potential harm related to their personal identity information being compromised by unauthorized individuals. Findings: During a concurrent observation and interview with LVN 1 on April 6, 2023, at 6:09 AM, outside of Resident 417's room, LVN 1 was observed reviewing the medication administration record (MAR) for Resident 417 on a pink [Name of computer/technology manufacturer] laptop with a pink-to-white gradient keyboard overlay. LVN 1 stated, the laptop was her own personal laptop because the facility did not provide the staff with the equipment and supplies the staff needed to perform their jobs. During a follow up interview on April 6, 2023, at 6:51 AM, with LVN 1, she stated, she had been using her own personal laptop for a year and a half because of connection problems with [Name of computer program being used by facility for electronic health records] on facility provided laptops but did not experience issues accessing [Name of computer program being used by facility for electronic health records] on her own personal laptop. LVN 1 further stated, she took her personal laptop home with her at the end of her shift and there were a few staff members employed by the facility who use their own personal laptops to access resident health records for documentation. LVN 1 further stated, it was possible to access [name of computer program used by the facility for electronic health records] from her home, as well as from personal cell phones. During a concurrent observation and interview on April 6, 2023, at 7:05 AM, with LVN 15, LVN 15 stated, she brought her personal laptop from home to the facility for work. She was observed using her personal laptop to access the electronic health record program used by the facility for residents' medical records and medication administration. LVN 15 pointed to the closed laptop that was placed beneath her personal laptop and stated the closed laptop belonged to the facility. During an interview on April 6, 2023, at 10:24 AM, with LVN 16, LVN 16 stated, the facility does not allow staff members to use their own personal laptops to access resident health records. During an interview on April 6, 2023, at 10:37 AM, with LVN 17, LVN 17 stated, all medication carts came equipped with a facility-provided laptop. LVN 17 further stated, if a facility laptop was broken, staff may request supplies from the business office. During an interview with RT 1 on April 6, 2023, at 10:41 RT 1 stated, he used his own personal laptop one time and staff occasionally used their own personal laptops because the facility runs out of laptops. RT 1 further stated, if the staff used their own personal laptops, the staff accessed the resident health records while at the facility and brought their personal laptops home with them at the end of their shift. During an interview on April 6, 2023, at 11:10 AM, with the Director of Nursing (DON), the DON stated, the facility provided all supplies including laptops and desktop computers at each nurse's station and there was enough equipment to accommodate the staff. The DON further stated it was the expectation that all staff abided by the Health Insurance Portability and Accountability Act of 1996 (HIPAA - federal law that protects patient health information from being disclosed without patient's consent) rules and regulations. During an interview on April 6, 2023, at 2:41 PM, with the Administrator (ADMIN), the ADMIN could not explain why the staff stated there were not enough laptops in the facility especially because there was a staff member's personal laptop placed on top of a facility-provided laptop on a medication cart. The ADMIN further stated, there could be a concern for a HIPAA violation and resident information being compromised, including, but not limited to, names, birthdates, and social security numbers. The ADMIN further stated the outcome of using a personal laptop to access resident health information was compromised resident information. During an interview on April 6, 2023, at 2:46 PM, with Resident 318, Resident 318 stated, if their medical information was compromised, she would be upset because identity theft is an issue. During an interview on April 6, 2023, at 2:53 PM, with Resident 265, Resident 265 stated, if their health information was compromised, he would be upset because it may affect their insurance and finances. Resident 265 further stated, people may use his personal information for their own benefit. During an interview on April 6, 2023, at 4:21 PM, with the facility's Information Technologist 1 (IT 1), IT 1 stated, he was responsible for providing computer hardware to the facility, and all issued facility laptops were [Name of computer/technology manufacturer] made and was not supplied with [Name of computer/technology manufacturer] computer products. During an interview on April 6, 2023, at 4:57 PM, with Resident 422, Resident 422 stated, if her health information was compromised, she would be angry. During an interview on April 6, 2023, at 5:13 PM, with Resident 417, Resident 417 stated, if his health information was compromised, he would be upset. During an interview on April 6, 2023, at 5:36 PM, with Resident 93, Resident 93 stated, if her medical records were compromised, it would bother her because she had experienced fraudulent activity in the past and it was a problem. During an interview on April 7, 2023, at 4:52 PM, with the Information Technologist 2 (IT 2), IT 2 stated, he worked for [Company Name - a cybersecurity and IT management company] and provided a service to the facility on [DATE], he was instructed by the facility to perform a factory reset on three laptops, because staff members were using their personal laptops to access resident health records. IT 2 described two of the laptops as [Computer brand not provided by facility] laptops and one laptop was a [Name of a different brand than the other personal laptops or what was used by the facility]. During a review of the resident record titled, Admission Record for Resident 318, undated, the record indicated, Resident 318 was admitted to the facility on [DATE], with a diagnosis of a complete traumatic amputation at knee level. The Admission Record also included sensitive personal information including the resident's date of birth, address, insurance information, and social security number. During a review of the resident record titled, Admission Record for Resident 265, undated, the record indicated, Resident 265 was admitted to the facility on [DATE], with a diagnosis of cellulitis (skin infection) to the right lower limb. The Admission Record also included sensitive personal information such as the resident's address, medical insurance number, and social security number. During a review of the resident record titled, Admission Record for Resident 422, undated, the record indicated, Resident 422 was admitted to the facility on [DATE], with a diagnosis of a compression fracture of lumbar vertebra (fracture in backbone), atrial fibrillation (irregular heart rhythm), and hyperlipidemia (high cholesterol). The Admission Record also included sensitive personal information including the resident's date of birth, home address, and social security number. During a review of the resident record titled, Admission Record for Resident 417, undated, the record indicated, Resident 417 was admitted to the facility on [DATE], with a diagnosis of sepsis (life threatening complication of an infection) and paraplegia (paralysis that affects the legs). The Admission Record also included sensitive personal information including the resident's home address, occupation, and social security number. During a review of the resident record titled, Admission Record for Resident 93, undated, the record indicated, Resident 93 was admitted to the facility on [DATE], with a diagnosis of sepsis and severe obesity (excessively overweight). The Admission Record also included sensitive personal information including the resident's home address, date of birth, insurance policy numbers, and social security number. During a concurrent interview and record review on April 13, 2023, at 9:42 AM, of the facility's policy and procedure (P&P) titled, HIPAA: Non-Disclosure of Resident of Facility Information dated March 26, 2021, with the ADMIN, the P&P indicated, All resident and facility information must be protected and may not be accessed, released, or used without proper authorization .2. Our facility will not condone the unauthorized use, access, or release of protected resident information as defined by current HIPAA rules and regulations . The ADMIN stated, when staff used their personal laptops to access resident health information, the facility was not in compliance with HIPAA rules and regulations and their policy was not followed. During a continued concurrent interview and record review on April 13, 2023, at 9:42 AM, of the facility's P&P titled, Confidentiality of Information of Personal Privacy dated, October 2017, with the ADMIN, the P&P indicated, Our facility will protect and safeguard resident confidentiality and personal privacy .1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . The ADMIN stated, staff were not supposed to access resident's health information on their personal laptops because only facility owned laptops are secured and safeguarded and personal laptops were not secured. On April 6, 2023, at 3:34 PM, an immediate jeopardy (IJ - a situation that placed the health and safety of residents at risk for serious injury, harm, impairment, or death) was called in the presence of the ADMIN and the DON, for the facility's failure to ensure all resident's personal health information was being kept secured and safeguarded against unauthorized use and access when three staff members (LVN 1, LVN 15, and RT 1) used their personal laptops to access resident health information for documentation and brought their laptops home. The ADMIN and the DON were verbally notified of the IJ situation. A Corrective Action Plan (CAP) was submitted by the facility and accepted which included: 1.On April 6, 2023, administration instructed all staff to remove any personal computers from the facility immediately to ensure that all resident's health information is kept secure via company computers/laptops. Employees were educated on HIPAA risks associated with using personal computers to access our EHR (electronic health record). Employees were made aware that personal laptops and/or computers are not to be brought into the facility effective immediately. 2.An audit was immediately completed to ensure all staff were using company computers. The building was found to be free of personal computers and/or laptops. 35 desktops and 40 laptops were identified as company devices in the facility, which ensures enough devices for all employees to utilize while working in the facility. At full census, the facility has a max of 17 staff on carts that will require use of a laptop versus use of a desktop on any given shift. This total number may fluctuate depending on in-house census. 3.Administrator/designee will audit all employee computers every shift to ensure company computers are being used. Auditing results will be brought to QAPI (Quality Assurance and Performance Improvement - program to improve quality of care delivered in nursing homes) Committee daily for two weeks, weekly for four weeks, and monthly thereafter for six months. 4.On April 6, 2023, all three owners of the laptops, LVN 1, LVN 15, and RT 1 were contacted. All three laptops have been confiscated. The owners of the laptops have agreed to having their cache cleared and hard drives wiped by the IT department. This action was completed by the IT department by 7:45 AM. After interviewing the three employees, they confirmed they had only used their laptops while connected to the guest Wi-Fi for the facility, RC-Guest which provided their laptops with our internal firewall. Their laptops were also password protected at all times. All other employees have denied using personal computers within the facility to access the EHR. Facility HIPAA policy was also updated to include an addendum prohibiting the use of a personal laptop on premises. The IJ was removed on April 7, 2023, at 6:05 PM, in the presence of the ADMIN and the DON after the CAP was verified as being implemented through observations, interviews, and record reviews.

Based on observation, interview, and record review, the facility failed to provide oversight and ensure that only Dialysis (a life sustaining procedure of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally) Registered Nurses were allowed to access residents' central venous catheters (CVC), (CVC- a plastic flexible tube that's located in the neck, upper chest, or groin. The CVC is connected to the bloodlines during dialysis, allowing for the transfer of blood to and from the body to the dialysis machine and back) during the provision of resident's dialysis care, according to professional standards of practices when: 1) Dialysis Caregiver 1 (DC 1) accessed (to initiate use) Resident 216's CVC 2) Dialysis Caregiver 2 (DC 2) accessed Resident 220's CVC 3) Dialysis Caregiver 3 (DC 3) accessed Resident 6's CVC These failures had the potential for resident harm and/or death, the risk of the residents acquiring blood borne infections (infection caused by direct contact with bodily fluid and blood), bleeding, and/or air embolism (a blood vessel blockage caused by one or more bubbles of air in the circulatory system) that can affect three (Residents 216, 220, and 6) out of ten vulnerable and immunocompromised ( patients with weak immunity ) residents who are receiving dialysis. Findings: 1. During an interview, on April 7, 2023, at 4:55 PM, with Dialysis Registered Nurse 1 (DRN 1), she stated, the dialysis caregivers employed by (name of the facility) Dialysis are part of the team providing dialysis service to the facility. DRN 1 further stated the dialysis caregivers were trained by the [name of dialysis company] Registered Nurse, to initiate and terminate hemodialysis ( process of filtering blood using a dialysis machine ) treatment through the CVC's, fistulas (an access for hemodialysis made by joining an artery and vein in your arm), and graft (an access made by using a piece of soft tube to join an artery and vein in your arm). DRN 1 stated the dialysis caregivers were allowed to push intravenous (IV, through the vein) medications like heparin (medication used to prevent blood clots) through the resident's CVC. She stated their dialysis caregivers were appointed by (name of the dialysis center) to provide hemodialysis to residents at this facility. She stated, the dialysis caregivers can provide this type of care and treatment as stipulated in the (name) dialysis policy. A review of the [name of dialysis company] RN Hemodialysis HHD Skills Checklist, for DRN 1, dated March 14, 2023, indicated, All procedures will be done per [name of dialysis company] Policies and Procedures and manufacturers guidelines. Verify demonstration of competency with return demonstration, along with date and preceptors initials .B) Assessment of the Central Venous Catheter (CVC) 1)Access preparation; (a) Gather all supplies and equipment needed (b) Follow good hand washing techniques (c) Follow standard precautions (d) Using aseptic technique (e) Prepare CVC for initiation (see appropriate checklist) . During an observation, on April 10, 2023, at 6:30 AM, Dialysis Caregiver ( DC 1) changed the CVC dressing, accessed the CVC and connected the blood lines (tube that connects the machine to the resident's CVC) to Resident 216's CVC. DC 1 did not put a mask on Resident 216. DC 1 did not perform hand hygiene in between seven glove changes. DC 1 had open sterile syringes (disposable and individually wrapped syringes) on top of a non-sterile blue pad. DC 1 did not clean the CVC exit site from the center to outward (from the clean open area to potentially infected area to prevent reinfection). A review of the [name of dialysis company] Care Givers HHD Skills Checklist, for DC 1, dated September 26, 2022, indicated, All procedures will be done per [name of dialysis company] Policies and Procedures and manufacturers guidelines. Verify demonstration of competency with return demonstration, along with date and preceptors initials .V) Initiating Dialysis A) Check M.D. orders B) Check care givers notes C) Verify dialysate flow D) Assessment E) Patient condition F) Vascular access G) Weight status H) Vitals signs I) Direction of blood flow J) Direction of needles K) Securing needles L) Connecting blood lines M) Administering bolus heparin N) Giving a saline bolus . There is no Assessment of the Central Venous Catheter, Initiation of Central Venous Catheter, and Termination of Central Venous Catheter noted on DC 1's Care Givers HHD Checklist. During a review of Resident 216's face sheet (a document that contains resident's basic demographic information) indicated Resident 216 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidneys can no longer function on their own), anemia ( deficiency of red blood cells), and encounter for attention to tracheostomy (a hole that surgeons make through the front of the neck and into the windpipes, a tracheostomy tube is placed into the hole to keep it open for breathing). During a phone interview with Resident 216's emergency contact, (Mother), on April 11, 2023, at 10:03 AM, she stated her son is getting hemodialysis through CVC at the facility. She did not designate a dialysis caregiver to provide hemodialysis care for her son. She further stated, (name of the dialysis facility) assigned their own dialysis caregiver to attend to all her son's dialysis needs. An interview and record review, with the Dialysis Registered Nurse 1 (DRN 1), on April 11, 2023, at 4:47 PM, she reviewed the facility's policy and procedure (P&P) titled, Patients with a Central Venous Catheter (CVC),dated December 1, 2020, which indicated, Purpose: To provide care to a resident with a Central Venous Catheter (CVC) .5. The SNF RN/ Caregiver and the resident must be masked during initiation or termination of treatment, during dressing changes, and reversing the bloodlines. DRN 1 stated that Resident 216 was not wearing a mask during the initiation of dialysis treatment, DC 1 did not follow infection control policy. 2. During an observation, on April 10, 2023, at 7:15 AM, DC 2 was accessing and connecting the blood lines (blood tubing that connects the dialysis machine to the resident's CVC ) to Resident 220's CVC. DC 2 placed 10 cc sterile syringes on top of the unsterile blue pad (plastic protective pad to prevent fluid leak), along with a pile of non-sterile gloves, tape, opened gauge, and alcohol pads. The tips of the sterile syringes were touching the non-sterile gloves and the unsterile blue pad. DC 2 did not perform hand hygiene before donning and/or doffing gloves. DC 2, kept the same blue pad that was laying across patient's lap during CVC access, folded it and placed it on the clear bag that was hanging on the machine, he stated, I'll save and use it for the end of the treatment. A review of the [name of dialysis company] Care Givers HHD Skills Checklist, for DC 2, dated December 9, 2022, indicated, All procedures will be done per [name of dialysis company] Policies and Procedures and manufacturers guidelines. Verify demonstration of competency with return demonstration, along with date and preceptors initials .V) Initiating Dialysis A) Check M.D. orders B) Check care givers notes C) Verify dialysate flow D) Assessment E) Patient condition F) Vascular access G) Weight status H) Vital signs I) Direction of blood flow J) Direction of needles K) Securing needles L) Connecting blood lines M) Administering bolus heparin N) Giving a saline bolus . There is no Assessment of the Central Venous Catheter, Initiation of Central Venous Catheter, and Termination of Central Venous Catheter noted on DC 2's Care Givers HHD Checklist. During a review of Resident 220's face sheet (a document that contains resident's basic demographic information) indicated Resident 220 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease, (kidneys can no longer function on their own), tracheostomy dependence (an opening surgically created through the neck into the trachea to allow air to fill the lungs) and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). 3. During an observation and interview on April 10, 2023, at 11:25 AM, with DC 3, she stated her role and title is dialysis caregiver, employed by (name) dialysis, and has been a dialysis caregiver at this skilled nursing facility for five years. DC 3 was observed to remove Resident 6's old CVC dressing, clean the CVC exit site (wound opening) and placed a sterile new CVC dressing. DC 3 connected the blood lines/blood tubing to initiate the dialysis through Resident 6's CVC. DC 3 stated, that it is their common practice from when she started working at the dialysis center, for the dialysis caregivers, to change the CVC dressings, access the CVCs', initiate and terminate hemodialysis through the central venous catheters. She stated, the Dialysis RN 1 stays in the room, watches her, assesses the patients, and presses the start button on the dialysis machine. A review of the [name of dialysis company] Care Givers HHD Skills Checklist, for DC 3, dated September 26, 2022, indicated, All procedures will be done per [name of dialysis company] Policies and Procedures and manufacturers guidelines. Verify demonstration of competency with return demonstration, along with date and preceptors initials .V) Initiating Dialysis A) Check M.D. orders B) Check care givers notes C) Verify dialysate flow D) Assessment E) Patient condition F) Vascular access G) Weight status H) Vital signs I) Direction of blood flow J) Direction of needles K) Securing needles L) Connecting blood lines M) Administering bolus heparin N) Giving a saline bolus . There is no Assessment of the Central Venous Catheter, Initiation of Central Venous Catheter, and Termination of Central Venous Catheter noted on DC 3's Care Givers HHD Checklist. During an observation and interview on April 10, 2023, at 3:40 PM, DC 3 pushed one syringe to CVC's red arterial port ( larger blood vessel supplying blood away from the heart) and another syringe to the blue venous port ( smaller blood vessel supplying blood to the heart). DC 3 stated, she pushed IV heparin (anticoagulant) in both ports of the CVC for heparin lock (used to keep IV catheters open and flowing freely). During a review of Resident 6's face sheet (a document that contains resident's basic demographic information) indicated Resident 6 was originally admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidneys can no longer function on their own), dependence on respirator ventilator status (using an apparatus designed to control air that is breathed through it to assist or control pulmonary ventilation) and anemia (deficiency of red blood cells). During a review of [name of dialysis facility] Dialysis Policy and Procedure dated October 7, 2008, the policy indicated, Subject: Patient Rights and Responsibilities .Quality of Health Care, the patient has the right to quality health care resulting from high professional standards. During a review of the facility's policy titled, End-Stage Renal Disease, Care of a Resident with, Revised September 2010, indicated, Policy Statement: Resident with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . A review of the facility's policy titled, Department: On-Site Hemodialysis Dept. Policy Description: Patients with a Central Venous Catheter (CVC), dated December 1, 2020, indicated Purpose: To provide care to a resident with a Central Venous Catheter (CVC) .Policy & Procedure. 1. All CVC procedures must be performed by a SNF Registered Nurse (RN) and/or Caregiver . A review of the facility's policy titled, On-site Hemodialysis Dept .Policy Description: Hemodialysis Access Site, dated December 29, 2020, indicated Purpose: Hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of these devices .Guidelines 1. Verify with state Nurse Practice Act regulations regarding scope of practice for licensed staff in the care of residents with hemodialysis access devices .Central Catheters: 1. Central catheters for hemodialysis are generally inserted in the neck, chest, or groin area. 2. This is not the preferred site for long-term placement. There is more risk of clotting and infection than with either fistulas or grafts .Care of Central Dialysis Catheters .4. Flushing, drawing blood or administering medications via central hemodialysis catheters require specialized training and/or certification of an RN or caregiver. Do not allow non-dialysis personnel to access the catheter . During a review of the facility's policy titled, On-site Hemodialysis Dept . Policy Description: Facility Registered Nurse, dated March 16, 2021, indicated Position summary: The Registered Nurse is responsible and accountable for providing optimal care and services to patients with end- stage renal disease, who are dependent upon chronic dialysis therapy for life .C. Patient Care Management and Responsibilities: .3. Provide useful oversight for dialysis care 4. Supervise and delegate care of patients 5. Daily Assessments to include initiating and terminating dialysis treatments 6. Must be available to Dialysis Caregiver at all times during patient hemodialysis treatments . During a review of the facility's policy titled, On-site Hemodialysis Dept . Policy Description: Hemodialysis Caregiver, dated March 16, 2021, indicated Purpose: To provide the job description, qualifications, and responsibilities of Hemodialysis Caregiver .Certified Hemodialysis Caregivers work under the direct supervision of the Registered Nurse. Caregivers will carry out standing dialysis treatment orders from the Physicians and or Nurse Practitioner .Qualifications: Demonstrate ability and competence as a Hemodialysis Caregiver .Demonstrates understanding of Hemodialysis, theory, methods and care of dialysis patients .Duties and Responsibilities: Assess the patient as to appearance, weight, blood pressure, temperature, pulse, and general wellbeing. Report any abnormal findings to the Registered Nurse, Nurse Practitioner, or Physicians .Maintains a clean, comfortable, safe environment for the patient .Administer Heparin per Physician's Order .Able to access hemodialysis catheters, fistulas and grafts. Catheter dressing changes with aseptic technique. Proper connect and disconnect of catheters .Adheres to and enforces all policy and procedures as they pertain to Infection Control and Safety . A review of the facility's policy titled, Department: On-Site Hemodialysis Dept, Policy Description: Initiation and Completion of Hemodialysis Treatment, dated February 21, 2021, indicated, Policy: Hemodialysis Personnel will remain with the resident from initiation of hemodialysis treatment, during hemodialysis treatment, ad at the completion of hemodialysis treatment. The Hemodialysis RN will start and stop the hemodialysis treatment following the Nephrologist's Orders. Initiation of Hemodialysis Treatment: The Hemodialysis RN will conduct a pre-assessment of the resident prior to hemodialysis treatment .Completion of Hemodialysis Treatment: Upon completion of hemodialysis treatment, the Hemodialysis Personnel will report to the Hemodialysis RN. The Hemodialysis RN will terminate the hemodialysis treatment and perform a post- assessment on the resident. According to the AFL 20-66.1 dated March 8, 2021, indicated, Subject: Updated Guidance for the Provision of Home Dialysis in a Skilled Nursing Facility .Home dialysis services in a SNF: Home hemodialysis or peritoneal dialysis services rendered in a SNF under a collaborative arrangement with an approved ESRD or CDC by trained and qualified personnel who have received training and competency verification from the dialysis facility. Dialysis services in SNF's can only be administered at the resident's bedside and must follow all federal and state laws . According to the Ref: QSO-18-24-ESRD revised March 22, 2023,indicated Qualification and Training .Home Dialysis Administration: Individuals who administer home dialysis treatments in the LTC facility may include the RN, LPN/LVN, certified nursing assistant (CNA), patient care technician (PCT), resident, or the resident's existing designated caregiver .If the dialysis facility will be training staff member(s) (that are employed by either the dialysis facility or nursing home) to perform the home dialysis, they must make sure any state limitations are considered when assigning individuals to administer dialysis treatments. The individuals who initiate, monitor, and discontinue home HD and PD treatments for nursing home residents must meet the practice requirements in the State in which they are employed. According to the Nephrology Nursing Journal, March- April 2021, Vol. 48, No. 2, dated June 17, 2021 indicated, The scope of practice and duties for RN's, LPNs/ LVNs, and PCTs and the rules under which they practice in the hemodialysis setting may be determined by state statutes, regulations, Nurse Practice Acts, Boards of Nursing (BON) advisory opinions or position statements, Medical Practice Acts, and end stage kidney disease (ESKD) facility licensing rules. The scope of practice and rules vary greatly from state to state .Table 1: The Authority for Certain Clinical Tasks Performed by Unlicensed Patient Care Technicians and LPNs/ LVNs- By State .in California .Can PCT Access Central Venous Catheter? No Can LPN/ LVN Access Central Venous Catheter? No . Immediate Jeopardy was called on: April 11, 2023 at 1:15 PM under F-Tag 698 , in the presence of Direct of Nursing (DON), and Administrator when the facility failed to provide oversight and ensure that only Dialysis Registered Nurses were allowed to access residents' central venous catheter during the provision of resident's dialysis care, according to professional standards of practices. Facility provided the following Corrective action plan: 1. [Name of dialysis agency] director was immediately notified on April 11, 2023 that dialysis caregivers are no longer permitted to access patient CVC's to initiate, terminate or administer medications through the CVC or AV fistula. 2. Only Qualified Dialysis Registered Nurses are permitted to access CVC, AV fistula, change dressings, administer medications, and initiate and terminate treatments for dialysis patients in the facility. Dialysis caregiver job description and scope of practice was updated on April 11, 2023 to reflect this change. Facility ESRD policy and facility contract with [Name of dialysis agency] were updated on April 12, 2023 to reflect this change. These changes will be effective the next scheduled dialysis date on April 13, 2023. 3. Facility administrator or designee will audit to ensure that only [Name of dialysis agency] Registered nurses initiate, terminate, administer medications, or complete dressing changes for dialysis patients. Auditing results will be brought to QAPI Committee weekly for 4 weeks and monthly thereafter for 6 months. The corrective action plan (CAP) was accepted and implementation was determined through observations, interviews and record reviews. IJ was removed on April 13, 2023 at 3:16 PM in the presence of the Administrator and DON.

Based on observation, interview, and record review, the facility failed to ensure their infection control program was followed when: 1. Three dialysis caregivers (Caregiver 1, 2 and 3) from [Name of dialysis center] accessed the Central Venous Catheter (CVC, a flexible thin tube that is inserted to the vein to the large artery of the heart used for hemodialysis, (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys no longer work, a life sustaining procedure) and practiced poor infection control for two of three (Residents 216, and 220) of 3 hemodialysis sampled residents. This deficient practice had the potential to promote development and spread of communicable diseases and infections to Resident 216 and Resident 220, who are vulnerable and immunocompromised (when one's immune system's defenses are low, affecting its ability to fight off infections and diseases) residents who are receiving hemodialysis. 2. One Licensed Vocational Nurse (LVN 1) entered a transmission-based precaution room (a separate room that keep residents with certain medical conditions or infections separate from other people while they receive medical care) with contact precautions (require anyone entering the room to wear gown and gloves) without a gown for one of three residents (Resident 30). This failure had the potential to cause cross-contamination of infectious pathogens (bacteria and microorganisms transferred unintentionally from one object to another) within the facility 3. One Licensed Vocational Nurse (LVN 1) did not clean and disinfect a glucometer (medical device used to measure glucose in the blood) for two of three residents (Resident 416 and Resident 417) and stated she cleaned and disinfected the glucometer only after an isolation room and at the end of her shift. This failure had the potential to result in blood-borne infections (viruses that are carried in the blood). 4. The Certified Nursing Assistant (CNA 1) entered the contact isolation room for Resident 30 without hand hygiene or personal protective equipment (PPE specialized clothing or equipment worn to protect against infectious materials) and exited the room without hand hygiene. This failure had the potential to cause cross-contamination of infectious pathogens from one resident (Resident 30) to others in the facility. 5. The Housekeeping Aide (HA 1) collected trash from one room room [ROOM NUMBER] to another room room [ROOM NUMBER] without observing hand hygiene, then walked along the hallway wearing the same used gloves going to another room. This had the potential to spread contaminants present from the contents of the trash bins into the surrounding areas of the facility. 6. Two trash bins in two resident rooms (Rooms 218 and isolation room [ROOM NUMBER] a room on contact isolation (precaution used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) were overflowing with used Personal Protective Equipment (PPE), causing the trash bin lid to remain open. This had the potential to spread infectious organisms from contaminated used PPE. 7. Four sharps containers (used for safe disposal of used needles and syringes) in Rooms 122, 218, 221, and 234, were observed filled past the fill line indicator (a line marker indicating the container needs to be replaced). This had the potential risk for infections related to needlestick injuries (injuries caused by punctures from needles used in medical procedures). These deficient infection control practices had the potential to result in the cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect), of infectious pathogens that increased the risk for blood-borne infections (viruses that are carried in the blood) towards all 120 vulnerable residents in the facility, including 10 residents on hemodialysis with eight residents on artificial airways using tracheostomy ventilation (an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe). Findings: 1. During an observation on April 10, 2023 at 6:30 AM, a Dialysis Caregiver 1 (DC 1) repeatedly failed to follow infection control practices, when DC 1 changed the CVC dressing, accessed the CVC and connected the CVC blood lines (plastic tubes that connects resident's to the hemodialysis machine) to Resident 216's CVC. Resident 216 was not wearing a mask. DC 1 did not perform hand hygiene in between seven glove changes, and placed 10 opened sterile syringes on top of a non-sterile blue chux (a pad made of paper with a waterproof backing), and did not clean the exit site of Central Venous Catheter from the center towards the outside (an infection control techniques that requires to disinfect an open skin area from the least contaminated to the most contaminated skin area). During a review of Resident 216's face sheet (a document that contains resident's basic demographic information) indicated Resident 216 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidneys can no longer function on their own), anemia ( deficiency of red blood cells), and encounter for attention to tracheostomy (a hole that surgeons make through the front of the neck and into the windpipes, a tracheostomy tube is placed into the hole to keep it open for breathing). During a concurrent observation and interview on April 10, 2023, at 7:15 AM, DC 2 was accessing and connecting the blood lines to Resident 220's CVC, without following infection control guidelines. He placed 10 cc sterile syringes on top of the non-sterile blue chuck/pad, along with a pile of non-sterile gloves, tape, opened gauge, and alcohol pads. Tips of the sterile syringes were touching the non-sterile gloves and non-sterile chuck/pad. DC 2 did not perform hand hygiene before donning (Putting on) and/or doffing (removing) gloves. DC 2, kept the same blue chuck/pad that was laying across Resident 220's lap during CVC access, folded it and placed it on the clear bag that was hanging on the machine, he stated, I'll save and use it for the end of the treatment. During a review of Resident 220's face sheet (a document that contains resident's basic demographic information) indicated Resident 220 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease,(kidneys can no longer function on their own), tracheostomy dependence (an opening surgically created through the neck into the trachea to allow air to fill the lungs) and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). During a concurrent interview and record review with the Dialysis Registered Nurse 1 (DRN 1) on April 11, 2023, at 4:47 PM. The DRN 1 reviewed the facility's policy and procedure (P&P) titled, Patients with a Central Venous Catheter (CVC), effective date December 1, 2020, which indicated, Purpose: To provide care to a resident with a Central Venous Catheter (CVC) .5. The SNF RN/ Caregiver and the resident must be masked during initiation or termination of treatment, during dressing changes, and reversing the bloodlines. DRN 1 stated that Resident 216 wasn't wearing a mask during the initiation of treatment, the policy wasn't followed. During a concurrent interview and record review with the Dialysis Registered Nurse 1 (DRN 1) on April 11, 2023, at 4:47 PM. The DRN 1 reviewed the facility's policy and procedure (P&P) titled, Dressings, Dry-Clean, effective date February 27, 2020, which indicated, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings .Steps in the Procedure: 1 .Establish a clean field .5. Wash and dry your hands thoroughly .6. Put on clean gloves .remove soiled dressing .7. Pull glove over dressing and discard .8. Wash and dry your hands thoroughly .15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated are (usually from the center outward) .17. Apply the ordered dressing .18. Discard disposable items into the designated container .19. Remove disposable gloves and discard .wash and dry hands thoroughly . DRN 1 stated that DCs 1 and 2 didn't follow the policy. A request to provide a copy of the facility's policy and procedure indicating sterile technique to be observed while initiating, terminating, and administering intravenous medication (in to the vein) through CVC, was made, but the facility was not able to provide. 2. During a concurrent observation, interview, and record review, on April 6, 2023, at 5:44 AM, with LVN 1, outside of Resident 30's room, Resident 30 was lying in her bed, and called out for LVN 1's assistance because she could not find her television remote. Outside of Resident 30's door was a facility sign titled, Contact Precautions, dated May 30, 2019, which indicated when entering and leaving the room, everyone must clean hands and put on a gown and gloves at the door. LVN 1 told Resident 30 she would help her find her television remote. LVN 1 put on a pair of gloves, entered the room, picked up the remote on the resident's bedside table, and handed the remote to the resident. LVN 1 then removed her gloves, exited the room, and cleansed her hands with hand sanitizer. LVN 1 stated, the standard practice when entering an isolation room would be to wear a gown and gloves, but if there was no physical contact, then only wearing gloves was permissible. LVN 1 further stated, if a person enters an isolation room and touches something, the person should wear a gown and gloves. During an interview, on April 6, 2023, at 10:33 AM, with the Director of Nursing (DON), she stated, it was expected that any person who entered an isolation room, use all personal protective equipment (PPE-gowns, gloves, may include face mask or face shield) for the specific isolation organism. The DON further stated no one should have entered an isolation room without a gown because of the risk of infection transmission in the environment. During an interview on April 7, 2023, at 11:52 PM, with the Infection Preventionist Nurse (IP),the IP stated, if a person passed through the doorway into a contact isolation room, he/she must have their PPE on, which included a gown and gloves. The IP further stated, the risk of isolation precautions not being followed would be to potentially spread infections to those who entered the room without the correct PPE, their families, and everyone that person came in contact with. During an interview, on April 10, 2023, at 8:57 AM, with LVN 6 regarding isolation procedure, LVN 6 stated, if at any point a person went into an isolation room, they must have been, fully dressed in a gown and gloves. During an interview, on April 10, 2023, at 9:07 AM, with LVN 4, LVN 4 stated, after having exited an isolation room and all PPE was removed, sometimes the residents would ask staff to come back into the room for assistance. LVN 4 stated, when that happens, it was still expected that staff put on a gown and gloves before they entered the isolation room. During a review of Resident 30's medical record, the Admission Record, (contains admission and demographic information), dated April 7, 2023, the Admission Record indicated, Resident 30 was admitted on [DATE], with a diagnosis of enterocolitis (inflammation affecting the large and small intestine) due to clostridium difficile (bacterium that causes diarrhea and colitis) and osteomyelitis (inflammation of bone tissue caused by an infection). During a record review of Resident 30's Order Summary Report, dated April 7, 2023, the Order Summary Report indicated, there was an order from a physician for the resident to be placed on Isolation for Contact Precautions with a diagnosis of Carbapenem-resistant Enterobacterales (CRE-a large order of different types of bacteria that commonly causes infections in healthcare settings) from March 16, 2023, until May 21, 2023. During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment, dated on October 2018, the P&P indicated, .PPE required for transmission-based precautions is maintained outside and inside the resident's room. During a review of the facility document titled, CDC Guideline for Isolation Precautions: Appendix A indicated, A Transmission-Based Precautions category was assigned if there was a strong evidence for person-to-person transmission via droplet, contact, or airborne routes in healthcare or non-healthcare settings and/or if patient factors increased the risk of transmission. 3. During an observation and interview with LVN 1, on April 6, 2023, at 6:03 AM, inside Resident 417 and Resident 416's shared room, she had a tray with two medication cups with medications, labeled with the resident's room number, a glucometer (medical device used to monitor glucose in the blood), two lancets (sharp needle used to obtain blood for testing glucose), and two opened alcohol wipes. She placed the tray on Resident 417's bedside table and proceeded to check Resident 417's blood sugar. After LVN 1 administered Resident 417's medications, she picked up the tray and glucometer and placed them on Resident 416's bedside table and proceeded to check Resident 416's blood sugar. After LVN 1 checked Resident 416's blood sugar, she exited the room and placed the glucometer on her medication cart without cleaning or disinfecting the device. During an interview with LVN 1, on April 6, 2023, at 6:18 AM, when asked how often the glucometer was cleaned, LVN 1 stated, she cleaned the glucometer after the device was used in an isolation room and at the end of her shift. LVN 1 stated, she had to check seven more residents' glucose readings that morning. When asked to clarify if she would continue checking all seven residents' glucose without cleaning and disinfecting the glucometer, LVN 1 asked the surveyor to wait while she browsed the Internet on her personal cell phone. LVN 1 stated, she changed her answer, and that the glucometer should be cleaned after each resident use. During a concurrent observation and interview with LVN 1, on April 6, 2023, at 6:20 AM, LVN 1 proceeded to move her medication cart to the next room. When asked if LVN 1 will clean the glucometer before going into the next room, LVN 1 stated, Right. It's a force of habit, and cleaned the glucometer with a bleach wipe. During an interview, on April 6, 2023, at 11:10 AM, with the Director of Nursing (DON), the DON stated, the glucometer should be cleaned and disinfected with bleach wipes after each use. During an interview, on April 7, 2023, at 11:41 AM, with LVN 8, LVN 8 stated, glucometers should be cleaned before use and between patient use with a [Name of cleaning and disinfecting wipe manufacturer] wipe and air dried for five minutes. During an interview, on April 7, 2023, at 11:52 AM, with the Infection Preventionist Nurse (IP), the IP stated, it was the expectation that staff cleaned the glucometer before and after every use and the risk associated with not cleaning the glucometer would be a potential for blood infections including HIV (human immunodeficiency virus - a virus that attacks the body's immune system) and hepatitis (inflammation of the liver). The IP further stated staff were also at risk when the glucometer was not cleaned and disinfected because staff usually first touch the glucometer without gloves. During a concurrent interview and record review of the [Name of cleaning and disinfecting wipe manufacturer] bleach wipes label, on April 13, 2023, at 11:05 AM, with LVN 14, LVN 14 stated, she cleaned the glucometer after each patient use with [Name of cleaning and disinfecting wipe manufacturer] bleach wipes. The [Name of cleaning and disinfecting wipe manufacturer] bleach wipes label, undated, indicated, the wipes were intended for use in healthcare settings and was EPA (environmental protection agency - developed and enforced environmental regulations) registered. The [Name of cleaning and disinfecting wipe manufacturer] wipes indicated, when used, the treated surface should remain visibly wet for three minutes and air dried. During a review of Resident 417's History and Physical (H&P), dated March 17, 2023, the H&P indicated, Resident 417 was admitted after being hospitalized with a diagnosis of severe sepsis (organ damage as a result of severe infection), urinary tract infection, and a sacral pressure ulcer (wound formed as a result of pressure over the sacral {area between lower back and tailbone} region). During a review of Resident 416's H&P, dated March 27, 2023, the H&P indicated, Resident 416 was admitted after being hospitalized with a diagnosis of bacteremia (bacteria in the bloodstream), osteomyelitis (inflammation of the bone caused by an infection) of the second toe, septic arthritis (infection that spreads to the joint fluids and tissues) to the left knee, and Covid-19 infection (highly contagious respiratory disease). During a concurrent interview and review of the facility's policy and procedure (P&P) titled, Blood Sampling - Capillary (Finger Sticks), on April 13, 2023, at 9:37 AM, with the DON, the P&P indicated, .1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use . The DON stated, the P&P was not followed when the glucometer was cleaned and disinfected only after an isolation room and at the end of the shift. During a review of the [Name of glucometer device manufacturer} manual titled, User Instruction Manual, the manual indicated, Healthcare professionals should wear gloves when cleaning the [Name of glucometer]. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. The manual further indicated, Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. 4. During an observation, on April 4, 2023, at 12:05 PM, CNA 1 entered the contact isolation room [ROOM NUMBER] without performing hand hygiene or wearing PPE and exited the room without performing hand hygiene. During a subsequent interview, with CNA 1, on April 18, 2023, at 12:10 PM, CNA 1 stated, she was told she doesn't have to wear PPE if she is not providing the direct patient care. CNA 1 also stated, she only put a pillow under the resident's head and did not touch the resident. CNA 1 further stated she will wash her hands at the nursing station. During an interview, with the Infection Preventionist Nurse (IP), on April 7, 2023, at 2:54 PM, the IP nurse stated, staff should don (put on) PPE when entering the contact isolation room and doff (take off) the PPE when exiting the contact isolation room. The IP nurse also stated, staff performs hand hygiene before exiting the room. The IP nurse further stated, all staff should follow the isolation signs posted outside the resident's room. During a concurrent interview and record review, with the Director of Nursing (DON), on April 13, 2023, at 9:36 AM, of facility's policy and procedure (P&P) titled, Isolation-Notice of Transmission-Based precautions, revised August 2019, indicated . Policy interpretation and Implementation .2 . b. contact precautions: (1) A notice at the doorway instructing visitors to report to the nurses' station before entering the room. (2). A sign indicating contact precautions on the door to the resident's room . The DON stated, CNA 1 should have worn PPE and should have performed hand hygiene before exiting the room. The DON also stated, CNA 1 did not follow the policy. 5. During an observation, on April 6, 2023, at 5:55 AM, HA1 was coming out from room [ROOM NUMBER] after collecting the trash. HA 1 was wearing gloves she used for collecting trash when she stepped out of the room [ROOM NUMBER], then went into room [ROOM NUMBER] wearing the same gloves. HA 1 collected the trash from room [ROOM NUMBER] then stepped out and walked along the hallway towards the back of the facility to dispose of the collected trash. During an interview, with HA 1, on April 6, 2023, at 6:05 AM, HA 1 stated she does not usually walk along the hallways with used gloves on, HA 1 further stated she went from one room to another without removing the used gloves and should have washed her hands after. During a concurrent interview and record review, with the Director of Nursing (DON), on April 11, 2023, at 4:49 PM, the DON reviewed the facility's policy and procedure (P&P) titled, Personal Protective Equipment- Using Gloves, revised September 2019, which indicated, .Objectives 1. To prevent the spread of infection .3. To protect hands from potentially infectious material .Removing gloves .4. Discard the glove into the designated waste receptacle inside the room .6. Wash hands. The DON stated HA 1 should have removed her gloves before leaving room [ROOM NUMBER], washed her hands before entering room [ROOM NUMBER], removed the gloves before leaving room [ROOM NUMBER] then washed hands before walking along the hallway. The DON stated HA 1 did not follow their policy. 6. During an observation, on April 6, 2023, at 5:44 AM, the garbage containers for rooms [ROOM NUMBERS] were overflowing, causing the top lid not to close. It was further observed that room [ROOM NUMBER] was placed on contact isolation. During a concurrent interview and record review, LVN 9, on April 6, 2023, at 6:23 AM, LVN 9 reviewed the facility's Isolation list 04/05/23 (April 5, 2023), which indicated room [ROOM NUMBER] was placed on isolation due to Carbapenem-resistant Acinetobacter Baumannii (CRAB- a bacteria resistant to nearly all antibiotics and difficult to remove from the environment). LVN 9 further stated the trash bins should not be overflowing and with the lids closed to prevent contact with contaminated PPE and prevent risk of spreading an infectious organism inside the facility. During a concurrent interview and record review, with the Director of Nursing (DON), on April 11, 2023, at 4:49 PM, of the facility's policy and procedure (P&P) titled, Garbage and Refuse (matter thrown away) Disposal, revised October 2017, which indicated, .Policy Interpretation and Implementation .2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in use. 3. Housekeeping personnel will empty garbage and refuse containers daily and as needed taking care not to contaminate other areas while cleaning . The DON stated the trash bins should not be overflowing so the lids can close properly. The DON further stated this had the potential to expose residents and staff to infectious organisms that may be present in those used PPE. 7. During a tour of the facility, on April 6, 2023, between 6:30 AM and 6:51 AM, the following observations and interviews indicated: a. Sharps container for room [ROOM NUMBER] was full. LVN 10 stated the container needs to be replaced when full. b. Sharps container for room [ROOM NUMBER] was full. LVN 11 stated it should not be in that condition and should be replaced when full. c. Sharps container in room [ROOM NUMBER] and 221 was full. LVN 12 stated it shouldn't be full all the way to the top. During an interview, with the Infection Preventionist (IP) on April 7, 2023, at 10:12 AM, the IP stated the sharps containers should be replaced when it is three quarters (an amount equal to three of the four equal parts which make up something; equal to 75 percent) full. During a concurrent interview and record review with the DON, on April 11, 2023, at 4:49 PM, of the facility's P&P, titled, Sharps Disposal, revised January 2012, indicated, .The facility shall discard contaminated sharps into designated containers .Policy Interpretation and Implementation .3 .c. Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container . The DON stated they did not follow their policy. These observations and interviews of deficient infection control practices lead the survey team, to call an Immediate Jeopardy, (a clearly identifiable situation that can cause severe harm or likelihood for serious harm and the immediate need for it to be corrected to avoid further, or future serious harm to the residents) on April 10, 2023, at 5:05 PM, in the presence of Direct of Nursing (DON), Administrator, and Assistant Direct of Nursing (ADON). Facility provided the following written Corrective action plan: 1. On April 10, 2023, in-service was completed by housekeeping staff regarding the importance of ensuring trash cans in isolation rooms are not overfilled. Trash bins were immediately emptied for all the isolation rooms and any other rooms as needed. Trash bins will be emptied every 2 hours with an emphasis on isolation rooms. 2. On April 10, 2023, and in-service was completed with all staff on schedule regarding appropriate PPE for isolation rooms, and hand hygiene practices. An audit was completed on all isolation rooms to observed staff were: 3. On 4/10/23, an in-service was completed with all staff on schedule regarding appropriate PPE for isolation rooms, and hand hygiene practices. All non-scheduled staff will be in-serviced upon return to the facility. Housekeeping staff were immediately in-serviced on the importance of hand hygiene and changing gloves between the room. 4. LVN1 was terminated from the facility upon the identification of not disinfecting the glucometer between residents and not following infection control policies and procedures. All nurses were in-serviced on April 6, 2023 and April 10, 2023 on properly disinfecting glucometers before, after, and in-between use to prevent cross contamination. 5. Central supply and nursing staff were educated on not overfilling sharps containers and changing them when necessary. Over-filled sharps containers were immediately emptied upon notification. 6. Effective April 10, 2023, dialysis caregivers are no longer able to manipulate any dialysis central venous catheter except for the Dialysis Registered Nurse. On April 11, 2023, an in-service was given to the Dialysis RN by the ADON on sterile technique. The survey team verified through observations, interviews, and record reviews the Corrective Action Plan (CAP, interventions to remove the IJ) had been implemented, and the IJ was removed on April 12, 2023 at 11:18 AM, in the presence of the Administrator and DON