Every finding on record at West Anaheim Medical Center D/P SNF

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure a blender container was dried thoroughly. * The facility failed to ensure the food preparation equipment was properly cleaned. * The facility failed to ensure proper labeling and dating of opened food items in the refrigerator. * The facility failed to ensure a dry food was stored properly. * The facility failed to ensure the proper storage of the employees' personal food in the kitchen was observed by the staff. * The facility failed to ensure the use of hair restraints was implemented by the facility staff who entered the kitchen. * The facility failed to ensure the cooking utensils were in good condition. * The facility failed to ensure the sanitary condition of the ice machine was maintained in the kitchen. * The facility failed to ensure the Dietary Aide performed hand hygiene after wearing a disposable gloves in the kitchen and before donning a new disposable gloves. * The facility failed to ensure the kitchen floor was free from debris and dirt. These failures had the potential to cause foodborne illnesses in a medically vulnerable residents population who consumes food prepared from the kitchen.Findings: Review of the facility's CMS-802 document titled Matrix for Providers showed two residents who resided in the facility consumed food prepared in the kitchen. 1. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. Review of the facility's P&P titled Cleaning Procedures dated 6/19/25, showed the food processor or blender must be cleaned to and allow to air dry. On 3/24/26 at 0810 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the FSS. The following was observed:- Two heavy-duty blenders stored with the lids on and visible water inside the blenders. The FSS acknowledged the above findings and stated the blenders would be washed again. 2. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled Dish and Utensil Procedure dated 3/3/20, showed any dish, tray, or utensil with debris should not be used. Send back to the dish room to be properly washed and sanitized. On 3/24/26 at 0810 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the FSS. There was one blender stored with food particles on the base of the machine. The FSS acknowledged the above findings and stated the blender machine would be cleaned again. 3. a. Review of the facility's P&P titled Labeling and Dating dated 3/21/24, showed opened products can be stored in original containers if the container can be closed properly. All products must clearly be labeled with the date when the product was opened. Opened products that cannot be stored in their original containers must be transferred to a plastic re-usable container and covered. Appropriate coverings include plastic wrap, foil, or tight-fitting lids, the products should be clearly labeled and dated. The items stocked in the resident refrigerators are labeled with the date the items expired. During the initial kitchen tour on 3/24/26 at 0810 hours, the following was observed in the walk-in refrigerator- sliced carrots opened in a plastic bag with no label and no date. - a rice bin with no label and no date. The FSS stated all the food items in the refrigerator and in the kitchen should have been covered, labeled, and dated. b. On 3/25/26 at 0816 hours, an inspection of the resident refrigerator and concurrent interview was conducted with MDS Coordinator. A container of ice cream sherbet with an expiration date of 12/2/25, was observed inside the freezer. The MDS Coordinator verified and removed the expired food item. 4. Review of the facility's P&P titled Personal Hygiene/ Employee Health dated 6/19/25, showed personal belongings are kept out of the kitchen. Lockers or desk drawers are used for personal belongings. On 3/24/26 at 0810 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the FSS. An unlabeled disposable food container was observed inside the walk-in refrigerator. The FSS verified and acknowledged the food was belonged to the kitchen staff. The FSS removed the kitchen staff's personal food from the walk-in refrigerator and threw it away in the garbage. 5. According to the USDA Food Code 2022, Section 2-402.11 Effectiveness (A), Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils. Review of the facility's P&P titled Personal Hygiene/ Employee Health dated 6/19/25, showed hair nets or caps and/ or beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. On 3/25/26 at 0840 hours, the Maintenance Manager was observed inside the kitchen with uncovered facial hair, as he checked the ice machine. The FSD verified the Maintenance Manager should wear a facial hair covering when inside the kitchen. 6. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils:(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations.(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 3/24/26 at 0810 hours, during the initial tour of the kitchen, a concurrent observation and interview with the FSS was conducted. Two white cutting boards with heavily marred with black discoloration were observed. The FSS verified the above findings. The FSS stated the above kitchen equipment would need to be replaced. 7. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. On 3/25/26 at 0840 hours, an inspection of the kitchen ice machine and concurrent interview with the Maintenance Manager was conducted. The ice machine front cover was removed by the maintenance Manager and observed with dried water scale, whitish to dark color around the motor and on the base of the ice machine. The Maintenance Manager verified the inside of the ice machine was dirty. The Maintenance Manager stated and verified the ice machine had a work order on 3/9/26, by a private company. The Maintenance Manager was able to show the work order. 8. Review of the facility's P&P titled Handwashing dated 3/16/23, showed all food services employees shall keep their hands and exposed areas of their arms clean thoroughly wash their hands after touching or handling soiled equipment and utensils, or objects that are unclean such as door handles, garbage can lids, and before putting on a clean pair of gloves to work with food. On 3/25/26 at 1130 hours, during the tray line observation, the Kitchen Aid was observed wearing disposable gloves while preparing for the tray line. The Kitchen Aid was observed picking up a trash from the floor wearing the disposable gloves, then he was observed removing the disposable gloves and donned new disposable gloves; however, the Kitchen Aid did not perform hand hygiene prior to donning the new disposable gloves. The FSS verified and acknowledged the Kitchen Aid should have washed his hands before donning on new disposable gloves. 9. Review of the facility's P&P titled Floor Cleaning dated 6/15/23, showed the floors in the food and nutrition department should be cleaned daily to maintain the kitchen sanitation standards. On 3/24/26 at 0810 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the FSS. The floor drainage with dirt near the drainage area in the kitchen was observed. The FSS verified and acknowledged the findings. On 3/26/26 at 1348 hours, an interview was conducted with the FSD. The FSD was informed of the above findings in the kitchen. The FSD verified and acknowledged the findings. On 3/26/2026 at 1415 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of the GT were provided for four of six final sampled residents (Residents 3, 4, 8, and 12) reviewed for tube feedings. * The facility failed to ensure Resident 3 and 4's HOB were elevated above 35 degrees while the enteral feeding formula was infusing, as per the physician's orders. * The facility failed to ensure Resident 12's enteral feeding formula was labeled with the correct feeding rate. * The facility failed to ensure LVN 1 mixed the crushed medication with water prior to the administration of the medication via GT for Resident 8. These failures posed the risk of complications related to use of the GT for Residents 3, 4, 8, and 12.Findings: Review of facility's P&P titled Enteral Feeding, Administration Of dated 10/28/25, showed for the pump or infusion controller method, to elevate the head of the bed at a 30-to-45-degree angle, except during direct resident care. 1. On 3/24/26 at 0824 hours, Resident 12 was observed in bed with the HOB elevated and the GT feeding of [NAME] Farms (enteral feeding formula) running at 35 ml/hr via the GT. The feeding rate on Resident 12's enteral feeding formula bag was labeled 5A. Medical record review for Resident 12 was initiated on 3/24/26. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's Active Order Sets showed a physician's order dated 1/22/26, to administer tube feeding with [NAME] Farms 1.4 via GT at 35 ml/hr continuously for 24 hours daily. May use Compleat Peptide (enteral feeding formula) 1.5 at 35 ml/hr continuously as an alternate if out of [NAME] Farms. On 3/24/26 at 0841 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 reviewed Resident 12's physician's orders and stated Resident 12 was currently receiving [NAME] Farms 1.4 at 35 ml/hr continuously for 24 hours. LVN 2 stated when hanging the enteral feeding formula, the licensed nurse should label the enteral feeding formula bag with the resident's name, the date and time when the formula was hung, and the ordered formula and rate to be administered. LVN 2 verified the above findings and stated the ordered rate was not labeled correctly on the enteral feeding formula bag. On 3/26/26 at 1030 hours, an interview was conducted with the DON. The DON stated the enteral feeding formulas should be labeled with the resident's name, the time, date, and order rate. The DON further stated the rate on the enteral feeding formula should match the ordered rate. On 3/26/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. On 3/24/26 at 0830 hours, during the initial tour of the facility, Resident 3 was observed lying in bed with the GT feeding of Jevity 1.2 running at 50 ml/hr. The indicator at Resident 3's foot of the bed showed the HOB was 26 degrees. On 3/24/26 at 0834 hours, an observation and concurrent interview was conducted with RN 1. RN 1 was observed entering Resident 3's room to turn off the GT feeding. RN 1 stated when the enteral feeding was infusing, the HOB should be above 30 degrees to prevent aspiration (inhalation of food, liquid or foreign objects into the airways). RN 1 verified the indicator at the foot of Resident 3's bed showed 26 degrees. RN 1 stated there was another indicator under the resident's head of the bed to show the angle. Concurrent observation was conducted of the indicator under Resident 3's head of bed and RN 1 verified the indicator showed the angle was less than 30 degrees. Medical record review for Resident 3 was initiated on 3/24/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 12/30/25, showed Resident 3 was GT dependent. Review of Resident 3's Physician's Orders for March 2026 showed a physician's order dated 5/6/25, to elevate Resident 3's the head of the bed 35 degrees at all times for aspiration precautions. On 3/25/26 at 1105 hours and 3/26/26 at 0820 hours, Resident 3 was observed lying in bed with the HOB at 30 degrees. On 3/26/26 at 0832 hours, an interview and concurrent observation was conducted with CNA 3. CNA 3 stated Resident 3 had a GT and received GT feedings. CNA 3 stated when the GT feeding was infusing, the HOB should be at 30 degrees. CNA 3 verified the indicator at Resident 3's foot of the bed showed the HOB was at 30 degrees and the GT feeding was infusing at 50 ml/hr. 3. On 3/24/26 at 1421 hours, Resident 4 was observed lying in bed receiving Jevity 1.2 (enteral feeding formula) infusing at 45 ml/hr and water flush at 70 ml/hr via the GT. Resident 4's HOB was observed at 30 degrees. Medical record review for Resident 4 was initiated on 3/24/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 11/29/25, showed Resident 4 had the presence of a GT. Review of Resident 4's Physician's Orders for March 2026 showed a physician's order dated 12/30/23, to elevate Resident 4's head of the bed 35 degrees at all times for aspiration precautions. On 3/26/26 at 0835 hours, Resident 4 was observed lying in bed, with the water flush infusing at 70 ml/hr. The indicator under Resident 4's head of bed showed the HOB was less than 30 degrees. On 3/26/26 at 0840 hours, an interview and concurrent observation was conducted with CNA 4. CNA 4 stated Resident 4 had a GT and when the GT feeding was infusing, the HOB should be 30 degrees of more to prevent aspiration. CNA 4 verified the indicator at the foot of Resident 4's bed showed 30 degrees. On 3/26/26 at 1018 hours, an interview and concurrent medical record review for Residents 3 and 4 was conducted with the DON. The DON stated for the residents with the GT feeding infusing, the HOB should be at 30 to 35 degrees. The DON further stated, the facility staff entering the residents' rooms should check to ensure the HOB was appropriately elevated when the GT feeding was infusing. The DON reviewed Resident 3 and 4's medical records and verified the physician's orders showed to elevate the HOB at 35 degrees at all times, for aspiration precautions. On 3/26/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. Review of the facility's P&P titled Medication Administration Through a Feeding Tube dated 10/28/25, showed medications will be administered via the feeding tube by an RN or LVN, as per the physician's orders. To crush the pills, tablets, or empty the contents of the capsules into separate containers and mix with water. To mix with a minimum of five to 10 ml of water for each medication, rinse the medication cup if residue is present. To check e-MAR to confirm medications administered. Medical record review for Resident 8 was initiated on 3/25/26. Resident 8 was admitted to the facility on [DATE]. On 3/25/26 at 0508 hours, a medication administration observation for Resident 8 was conducted with LVN 1. LVN 1 prepared and crushed Resident 8's baclofen (muscle relaxant) 10 mg medication and placed it into the plastic medication cup. After checking for GT placement and gastric residual, LVN 1 was observed pouring 10 ml of water into the syringe. LVN 1 then poured the crushed medication into the syringe. LVN 1 was then observed adding 10 ml of water into the syringe. LVN 1 added another 10 ml of water to the syringe and swirled the mixture in the syringe. LVN 1 was not observed adding water to the medication cup and mixing the contents prior to pouring the medication into the syringe. On 3/25/26 at 0526 hours, an interview was conducted with LVN 1. LVN 1 was asked about the facility's process for the administration of medications via the GT. LVN 1 stated her process was to flush the GT with water, then added the crushed medication into the syringe (not mixed with water), and then added the water to the syringe. LVN 1 verified she did not add water to the crushed medication and thoroughly mixed the medication prior to adding the medication to the syringe. LVN 1 stated when she added the water to the syringe, she swirled the water with the crushed meds to mix it. On 3/26/26 at 1035 hours, an interview was conducted with the DON. The DON stated the medications administered via the GT should be crushed, placed in the medication cup, and dissolved with water prior to pouring into the syringe to prevent clogging of the GT. On 3/26/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation and interview, the facility failed to store the drugs and biologicals in a safe manner for one of two medication carts (Medication Cart A) and one of 12 final sampled residents (Resident 3). * The facility failed to discard the bottle of sterile water at Resident 3's bedside. * Two sterile alginate wound dressings (highly absorbent wound dressing) with antimicrobial silver (potent antimicrobial agent), and one sterile Puracol (Collagen) Plus wound dressing were observed opened and stored inside Medication Cart A. These failures had a potential to negatively impact residents' physiological well-being by exposing the residents to contaminated dressings and irrigation fluids.Findings: 1. On 3/24/26 at 0830 hours, during the initial tour of the facility, a bottle of sterile water was observed at Resident 3's bedside table. The bottle of sterile water was observed opened and labeled with the date 3/20/26. The label showed: sterile, single-dose container; to discard the unused portion. On 3/24/26 at 0850 hours, an interview and concurrent observation was conducted with LVN 2. LVN 2 stated the sterile water was used to flush Resident 3's Foley catheter (flexible, indwelling tube inserted through the urethra into the bladder to drain urine) as needed. LVN 2 stated when opened, the sterile water should be labeled with the opened date. LVN 2 verified the above findings. On 3/24/26 at 1535 hours, a follow-up interview was conducted with LVN 2. LVN 2 stated the bottle of sterile water should be discarded 24 hours after opening. 2. On 3/25/26 at 0812 hours, a concurrent inspection of Medication Cart A and interview was conducted with the DON. The following was observed:- Two opened- sterile alginate wound dressings with antimicrobial silver; and- One opened- sterile Puracol (Collagen) Plus wound dressing.The DON verified the above findings and stated the sterile dressings should not be opened until ready for use due to infection control purposes. On 3/26/26 at 1035 hours, an interview was conducted with the DON. The DON stated the dressings should be opened prior to the wound treatments and the remaining unused sterile dressings should be discarded after each use to prevent transmission of microorganisms or infections to the wound bed. The DON stated the bottles of sterile water used for the irrigation of the indwelling urinary foley catheter, should be discarded after 24 hours of opening. On 3/26/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for four of seven final sampled residents (Residents 2, 3, 12, and 15) reviewed for respiratory care. * The facility failed to ensure Yankauer suction tubing was changed as per the physician order for Resident 2. * The facility failed to ensure the Yankauer suction tips were changed as per the physician's order and care plan for Residents 3 and 12. * The facility failed to ensure the manufacturer's recommendation for cleaning and disinfecting of the ventilator machines was followed for Resident 15. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.Findings: 1. Review of the [NAME]-C1 Ventilator Operator's Manual dated 4/20/20, under the cleaning, disinfection, and sterilization section showed to clean the device parts by washing in warm water and soap or an appropriate mild detergent solution. Rinse parts thoroughly with clean, warm water, and air dry. Medical record review for Resident 15 was initiated on 3/24/26. Resident 15 was admitted to the facility on [DATE]. On 3/24/26 at 0943 hours, an observation was conducted for Resident 15. Resident 15 was observed asleep in bed. Resident 15 was observed with the tracheostomy connected to the ventilator machine and oxygen supply from the concentrator machine. Review of Resident 15's Physician's Order dated 9/15/25, showed an order for the ventilator setting as follows: Mode: VC/AC; Rate: 18; Total Volume: 350; PEEP: 5; Fi02: 30; and titrate Fi02 to keep Sp02 94%. Further review of Residents 15's physician's order, failed to show the physician's order to clean and disinfect the ventilator machine per manufacturer's recommendation was obtained. Further review of Resident 15's medical record failed to show documented evidence of the cleaning and disinfecting of the ventilator machine. Review of Resident 15's respiratory flowsheet for respiratory treatment showed the breathing treatment, respiratory care, and assessment. However, there was no documentation for the cleaning and disinfecting of the ventilator machine per the manufacturer's manual was documented. On 3/25/26 at 0623 hours, an interview and concurrent medical record review for Resident 15 was conducted with RT 3. RT 3 verified Resident 15's physician's order for the respiratory treatment and ventilator machine setting. RT 3 was asked who was responsible for cleaning the resident's ventilator machine. RT 3 was uncertain who was responsible for cleaning the ventilator machine. RT 3 acknowledged the cleaning of the ventilator machine was a must. On 3/25/26 at 0923 hours, an interview and concurrent medical record review for Resident 15 was conducted with RT 4. RT 4 stated the facility did not have a specific regular cleaning and disinfecting of the ventilator machines, only as needed. RT 4 was asked if the facility had a P&P on cleaning the ventilator machine, RT 4 stated no. The ventilator machine manual was provided and reviewed with RT 4. RT 4 verified the manual showed the regular cleaning for the ventilator machine. RT 4 stated and verified the facility cleaned the ventilator machine with the bleach wipes as needed and the facility did not follow the manual for the cleaning and disinfecting of the ventilator machine. On 3/26/26 at 1402 hours, an interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON was informed and verified the above findings. Cross Reference to F0657, example # 3. 2. On 3/24/26 at 0824 hours, Resident 12 was observed lying in bed receiving oxygen via the trach-bar at 28% FIO2. A Yankauer suction tip was observed opened and stored inside the original packaging on top of Resident 12's bedside drawer. The Yankauer packaging was not observed labeled with the opened date. Medical record review for Resident 12 was initiated on 3/24/26. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's plan of care showed a care plan problem dated 1/20/26, addressing Resident 12's risk for respiratory distress. The interventions included to change the Yankauer suction every 24 hours and as needed. Review of Resident 12's Active Order Sets showed the following physician's orders dated 1/21/26: - to suction every two hours and as needed. - to change the Yankauer suction daily and as needed. 3. On 3/24/26 at 0830 hours, Resident 3 was observed lying in bed receiving oxygen via the mechanical ventilator machine. An opened Yankauer suction tip was observed opened and stored inside the original packaging, kept inside a clear bag. The opened Yankauer was not observed labeled with the opened date. Medical record review for Resident 3 was initiated on 3/24/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's plan of care showed a care plan problem dated 5/6/25, addressing Resident 3's risk for respiratory distress. The interventions included to change the Yankauer suction every 24 hours and as needed. Review of Resident 3's Active Order Sets for March 2026 showed the following physician's orders dated 5/7/25: - to suction every two hours and as needed. - to change the Yankauer suction daily and as needed. On 3/24/26 at 0904 hours, an observation at Resident 3 and 12's bedside and concurrent interview was conducted with RT 1. RT 1 stated the Yankauer suction tip was used for oral suctioning and should be labeled with the date when it was opened. RT 1 stated the Yankauer suction tip should be changed every shift for infection control purposes. RT 1 verified the above findings. When asked, RT 1 was unable to state when the Yankauer suction tips were first opened. RT 1 was observed discarding the Yanker suction tips for Residents 3 and 12. On 3/26/25 at 1018 hours, an interview and concurrent medical record review for Residents 3 and 12 was conducted with the DON. The DON stated the Yankauer suction tip was used for oral care and suctioning for the residents. The DON stated the Yankauer suction tips should be changed every 24 hours and when opened, the Yankauer suction tips should be labelled with the resident's name and the opened date. The DON further stated the date labeled was used as a reference for the staff to determine when the Yankauer suction tip was last changed. The DON reviewed Resident 3 and 12's medical records and verified the physicians' orders and care plans showed to change the Yankauer suction every 24 hours. On 3/26/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. Medical record review for Resident 2 was initiated on 3/24/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Active Order Sets showed the following physician's orders: - dated 7/14/25, for oxygen therapy via trach collar (T bar) to maintain oxygen saturation at 94%. - dated 7/14/25, to suction every two hours and as needed. - dated 7/14/25, to change the Yankauer suction device every 24 hours and as needed. On 3/24/26 at 0916 hours, Resident 2 was observed lying in his bed receiving oxygen via T-bar. An opened Yankauer suction device was observed in the original packaging (opened) on the left side of the resident's bed. The label on the packaging of the suction device showed 3/22/26. On 3/24/26 at 0926 hours, an observation and concurrent interview was conducted with RT 1. RT 1 stated the Yankauer suction tubing should be changed every 24 hours as per the facility's practice. RT 1 verified the above observation and stated the Yankauer suction tubing should have been changed after 24 hours, once opened. RT 1 was observed discarding the Yankauer suction tubing. On 3/27/26 at 0953 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to ensure LVN 1 donned the appropriate PPE during the medication administration observation for Resident 8 via the GT; additionally, LVN 1 failed to disinfect the stethoscope after use and prior to exiting Resident 8's room. * The facility failed to ensure RN 2 removed the gloves, performed hand-hygiene, and donned new gloves in between the administration of eye ointment medication for both eyes. These failures had the potential for the spread of infection to the residents, staff, and visitors in the facility.Findings: 1. Review of the facility's P&P titled Guidelines for Enhanced Barrier Precautions dated 4/2025 showed Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in long-term care facilities. It involved gown and glove use during high contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition which include residents with wounds or indwelling devices. Enhanced Barrier Precautions are indicated for residents with any of the following: wounds and/or indwelling devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Gown and gloves are the minimum level PPE required when performing high-contact activities. On 3/25/26 at 0508 hours, a medication administration observation for Resident 8 was conducted with LVN 1. Resident 8 was on enhanced barrier precautions. LVN 1 prepared and administered Resident 8's baclofen (muscle relaxant) 10 mg medication. During the medication administration, LVN 1 was observed reaching across Resident 8 from the right side of the bed to expose Resident 8's GT from under his gown. After using the stethoscope to check for GT placement, LVN 1 was observed administering the baclofen medication to Resident 8. LVN 1 was not observed wearing a gown during the medication administration observation. On 3/25/26 at 0520 hours, an interview was conducted with LVN 1. LVN 1 verified she did not don the gown during the medication administration via the GT for Resident 8. LVN 1 was then observed donning a gown to perform oral care for Resident 8. On 3/25/26 at 0530 hours, an observation was conducted of LVN 1. LVN 1 was observed removing the gown, gloves, and performing hand hygiene prior to exiting Resident 8's room. LVN 1 was observed with the stethoscope (previously used on Resident 8, to check for the GT placement) around her neck. LVN 1 was not observed disinfecting the stethoscope prior to exiting Resident 8's room. LVN 1 was observed pushing the portable computer from outside of Resident 8's room to the nursing station. LVN 1 was interviewed and LVN 1 stated the stethoscope should be disinfected after each use and prior to exiting the resident's room. LVN 1 verified she did not disinfect her stethoscope after use and prior to exiting Resident 8's room. On 3/25/26 at 0615 hours, an interview was conducted with IP 2. IP 2 stated the stethoscope should be disinfected before and after each use, in between residents, and before exiting the resident's room to prevent the transmission of microorganisms. On 3/26/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Review of the facility's P&P titled Administration of Eye Drops or Ointments dated 10/2025 showed the eye medications were administered as ordered by the physician and in accordance with the professional standards of practice to lubricate the eye or treat certain eye conditions. For eye ointment: to squeeze a ribbon of ointment on the edge of the conjunctival sac from the inner to outer canthus. Hands are washed or use alcohol gel before and after instilling the medication(s) to one eye and donning and doffing gloves. On 3/25/26 at 0532 hours, a medication administration observation for Resident 13 was conducted with RN 2. During the medication administration observation, RN 2 was observed using the same tissue paper to wipe Resident 13's right and left eyes. RN 2 removed her gloves, performed hand hygiene, and donned a new pair of gloves. RN 2 was then observed administering the ophthalmic ointment to Resident 13's right eye and massaging the ointment under Resident 13's right eyelid. RN 2 then applied the ointment to Resident 13's left eye and massaged the ointment over Resident 13's eyelid. RN 2 was not observed doffing the gloves, performing hand-hygiene, and donning new gloves in between the application of the eye ointment to each eye. On 3/25/26 at 0606 hours, an interview was conducted with RN 2. RN 2 was asked about the protocol for the administration of the eye medications when the physician's order was to administer for both eyes. RN 2 stated eye care should first be performed by wiping each eye with a tissue paper. RN 2 stated the gloves should be changed, and hand-hygiene performed. RN 2 stated after donning new gloves, to apply the eye medication and change gloves in between eyes. RN 2 verified she did not change gloves in between the application of the eye ointment to both eyes. On 3/25/26 at 0615 hours, an interview was conducted with IP 2. IP 2 stated for the administration of eye medication to both eyes, the licensed nurse should remove the gloves, perform hand-hygiene, and don new gloves between each eye to prevent any contamination between eyes. On 3/26/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P, the facility failed to ensure the comprehensive plans of care were revised to reflect the residents' current care needs and interventions for three of 12 final sampled residents (Residents 3, 4, and 15) reviewed for care plans. * The facility failed to ensure Resident 3 and 4's care plans were revised to reflect the physician's order for aspiration precautions, to elevate the head of the bed to 35 degrees at all times. * The facility failed to ensure Resident 15's care plan for the use of the mechanical ventilator machine was revised to include the cleaning of the machine. These failures posed the risk of not providing the residents with individualized and person-centered care.Findings: Review of the facility's P&P titled Care Planning dated 10/28/25, showed a comprehensive care plan must be developed within 14 days and completed no later than seven days after a comprehensive assessment had been completed. Resident care planning included participation from all involved health care disciplines at the resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until the resident's discharge. 1. On 3/24/26 at 0830 hours, during an observation, Resident 3 was lying in bed and connected to a mechanical ventilator machine. Resident 3 was observed receiving Jevity 1.2 (enteral feeding formula) at 50 ml/hr via the GT. The display at the foot of Resident 3's bed showed the head of the bed was 26 degrees. Medical record review for Resident 3 was initiated on 3/24/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Physician's Orders showed an order dated 5/6/25, to elevate Resident 3's the head of the bed 35 degrees at all times for aspiration precautions. Review of Resident 3's plan of care showed the following care plan problems dated 5/6/25: - risk for respiratory distress with interventions including to position Resident 3 for optimal lung expansion greater than 30 degrees, and to keep the head of bed greater than 30 degrees; and - altered nutrition, on GT feeding with interventions including to elevate the head of the bed at 30 to 45 degrees during and one hour after feeding. Review of Resident 3's H&P examination dated 12/30/25, showed Resident 3 was GT and ventilator dependent. 2. On 3/24/26 at 1421 hours, during an observation, Resident 4 was lying in bed and connected to a mechanical ventilator. Resident 4 was observed receiving Jevity 1.2 (enteral feeding formula) infusing at 45 ml/hr and water at 70 ml/hr via the GT. Resident 4's HOB was observed at 30 degrees. Medical record review for Resident 4 was initiated on 3/24/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Physician's Orders showed an order dated 12/30/23, to elevate Resident 4's head of the bed 35 degrees at all times for aspiration precautions. Review of Resident 4's plan of care showed the following care plan problems dated 4/17/25: - risk for respiratory distress with interventions including to position Resident 4 for optimal lung expansion: with the HOB elevated above 30 degrees; - altered nutrition, on GT feeding with interventions including to elevate the head of the bed at 30 to 45 degrees during and one hour after feeding; and - high risk for aspiration related to the diagnosis of dysphagia (trouble swallowing), with interventions including to maintain the head of bed at 30 to 45 degrees at all times unless contraindicated. Review of Resident 4's H&P examination dated 11/29/25, showed Resident 4 had ventilator-dependent respiratory failure and the presence of a GT. On 3/26/26 at 1018 hours, an interview and concurrent medical record review for Residents 3 and 4 was conducted with the DON. The DON stated the HOB should be at 30 to 35 degrees. The DON stated the MDS nurse or the QA nurse were responsible for reviewing the resident's care plans and should revise the care plans to meet the resident's needs. The DON reviewed Resident 3 and 4's medical records and verified the above findings. The DON stated the care plan interventions should have been revised to reflect the physician's order. On 3/26/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 15 was initiated on 3/24/26. Resident 15 was admitted to the facility on [DATE]. On 3/24/26 at 0943 hours, during an observation, Resident 15 was in bed asleep. Resident 15 had a tracheostomy connected to a ventilator machine and with oxygen supply from concentrator machine. Review of Resident 15's care plan for respiratory distress related to ventilator dependency dated 8/11/25, showed interventions for ventilator management. However, the care plan interventions failed to include the cleaning and disinfecting of the ventilator machine per manufacturer's manual were included. On 3/26/26 at 1328 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 3. RN 3 stated the care plan was formulated and updated by the licensed staff including the nurses, PT and dietician. RN 3 was asked if there was a care plan for the resident use of the ventilator. RN 3 verified the care was formulated for the use of the ventilator machine. RN 3 verified the care plan was not included in the intervention for the cleaning and disinfecting of the ventilator machine per manufacturer's recommendation. On 3/26/2026 at 1402 hours, an interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON was informed and verified the above findings. Cross Reference to F0695, example # 1.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests for one of 12 final sampled residents (Resident 5). * The facility failed to provide documentation Resident 5 had received meaningful activities as per the care plan. This failure had the potential to affect the resident's psychosocial well-being.Findings; Review of the facility P&P titled Activity Plan dated 6/2025 showed an activity plan will be developed and implemented for each resident and shall be integrated with the individual interdisciplinary resident care plan . The purpose of the activity plan is to assist the activity personnel and the rest of the unit staff in providing for each resident those activities that will provide the highest quality of life that is possible for the resident. On 3/24/26 at 0921 and 1443 hours, on 3/25/26 at 0835 hours, and on 3/26/26 at 1010 hours, Resident 5 was observed lying awake in bed, connected to mechanical ventilation, with eyes open and staring at the ceiling. The television was off, no music was heard, and the resident was not observed participating in any activities. On 3/26/26 at 1010 hours, an observation of Resident 5 and concurrent interview was conducted with LVN 4. LVN 4 verified Resident 5 was not engaged in any activity. LVN 4 stated Resident 5 was alert and oriented to person place and time and sometimes used the Tobii device for communication. On 3/26/26 at 1012 hours, an observation of Resident 5 and concurrent interview was conducted with CNA 3. CNA 3 stated Resident 5 was alert and oriented and enjoyed watching Netflix on her Tobii device. CNA 3 verified Resident 5 was not engaged in any activity. CNA 3 reported that a family member typically turned Netflix on for Resident 5 on her Tobii device and that she did not know how to operate Netflix on the resident's Tobii device. When asked whether the activity department assisted with turning on the television or accessing Netflix on the Tobii device, CNA 3 stated activity staff sometimes turned on the television for Resident 5. When asked CNA 3 what other activities were being provided to Resident 5 she stated she did not know. Medical record review for Resident 5 was initiated on 3/24/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Activity assessment dated [DATE], showed the resident was bedbound, nonverbal, and required encouragement to engage in socialization. Further review of the staff assessment of daily activity preferences showed the resident participated in preferred activities, such as watching Korean movies. Review of Resident 5's MDS assessment dated [DATE], showed Resident 5 had no memory problem and had modified independence (some difficulty in new situation only) for cognitive skills for daily decision making. Further review of the MDS assessment showed Resident 5 had impairment on both upper and lower extremities and was dependent on the staff for her activity of daily living. Review of Resident 5's Care Plan dated 2/25/26, showed a problem related to altered activity participation due to a communication deficit. The care plan indicated that Resident 5 was nonverbal and used a Tobii device for communication. The goal included for the resident to engage in independent leisure activities at least once daily and accept activity contact visits twice weekly. Interventions included providing and encouraging participation in preferred activities such as music, watching television or movies, and sensory stimulation. Review of Resident 5's Activity Progress Notes for March 2026, showed the Activity was provided on 3/1, 3/2, 3/3, 3/4, 3/9, 3/11, 3/12, 3/13, 3/14, 3/15, 3/16, 3/18, 3/21, 3/23, 3/24, and 3/25/26. Further review of the activity notes did not show if the activity was provided to Resident 5 on 3/5, 3/6, 3/7, 3/8, 3/10, 3/17, 3/19, 3/20, and 3/22/26. On 3/26/26 at 1012 hours, an interview and concurrent medical record review for Resident 5 was conducted with the Activity Director. The Activity Director confirmed the above findings and stated there was no documented evidence indicating whether activities were provided on 3/5, 3/6, 3/7, 3/8, 3/10, 3/17, 3/19, 3/20, and 3/22/26. The Activity Director stated preferred activities should be offered daily as identified in the resident's care plan and verified Resident 5 enjoyed watching Korean movies. The Activity Director further confirmed activities for Resident 5 should have been offered and documented daily, and if the resident refused, the refusal should also have been documented. On 3/27/26 at 0953 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of 12 final sampled residents (Resident 11). * The facility failed to ensure Resident 11's POLST was complete and accurate, and discussed in the facility IDT meeting, when Resident 11 did not have a responsible party. This failure had the potential to result in care being provided that did not reflect the resident's treatment preferences, leading to unwanted interventions, delays in appropriate care, and compromising the resident's overall health and well being.Findings: Review of the facility's P&P titled POLST ( Physician Orders for Life Sustaining Treatment) dated [DATE], showed the POLST is a physician's order form that converts the wishes of the resident/legal representative regarding life-sustaining treatment and resuscitation for the resident. It is designed to be a statewide mechanism for resident/legal representative to communicate his or her wishes about a range of life sustaining and resuscitative measures regarding the resident. Further review of the P&P showed the POLST form:Can be revised or revoked by resident/legal representative with a decision making at any time;Is legally sufficient and recognized as a physician order;Is recognized and honored across treatment setting. On [DATE] at 1034 hours, Resident 11 was observed lying in bed and connected to a mechanical ventilation (life-support therapy that helps a person breathe or breathes for them) via her tracheostomy tube (curve plastic tube inserted into a surgically created opening in the neck to provide a direct airway, remove secretions, or deliver oxygen). Medical record review for Resident 11 was initiated on [DATE]. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's acute care hospital physician's progress notes dated [DATE], showed no family or next of kin was found and on [DATE], the resident had been made DNR by two physicians. Review of Resident 11's POLST dated [DATE], showed under Section A, Cardiopulmonary Resuscitation (CPR), Do Not Attempt Resuscitation/DNR (Allow Natural Death) was selected. Section B indicated a preference for comfort focused treatment, with the primary goal of maximizing comfort, including the use of medication by any route as needed, oxygen, suctioning, and manual airway clearing. Under Additional Orders, the POLST specified no invasive or non invasive mechanical ventilation. Further review of the document showed the POLST was signed by the physician, and the signature section for the resident or legally recognized decisionmaker indicated no known family contacts, IDT responsible. Review of Resident 11's IDT/Care Plan Conference dated [DATE], showed under the POLST section, Do Not Resuscitate was selected; however, the documentation did not indicate whether the resident's preferences for no invasive or non invasive mechanical ventilation or comfort focused treatment were discussed by the IDT. Review of Resident 11's Active Order Sets showed a physician's order dated [DATE], for mechanical ventilation with the following settings: Volume Control/Assist Control (VC/AC) [ventilator is set to deliver a specific volume each breath, regardless of the amount of pressure required to deliver the volume], respiratory rate of 16 breaths per minute, tidal volume (volume of air inhaled or exhaled during normal, resting breath) of 450 ml, PEEP [Positive End-Expiratory Pressure- mechanical ventilation setting that maintains airway pressure above atmospheric levels at the end of expiration, preventing alveolar (air sacs) collapse] of 5 cmH O, and oxygen titrated to maintain an SpO (oxygen saturation) of 94%. On [DATE] at 0902 hours, an interview and concurrent medical record review for Resident 11 was conducted with the MDS/DSD. The MDS/DSD verified Resident 11's POLST showing DNR, comfort focused treatment - primary goal of maximizing comfort, no invasive or non-invasive mechanical ventilation, no defibrillation (an emergency, life-saving treatment for cardiac arrest or life-threatening heart rhythms), no chest compression, no ACLS (drugs). The MDS/DSD stated Resident 11 had no responsible party, so the facility IDT team members and representatives from the Council of Aging were making treatment decisions for the resident. When asked if the facility IDT and representative from Council of Aging discussed the resident's POLST, including the choice for comfort focused treatment - primary goal of maximizing comfort, no invasive or non-invasive mechanical ventilation, the MDS/DSD was not able to show documentation. On [DATE] at 0953 hours, an interview and concurrent medical record review for Resident 11 was conducted with the DON. The DON verified Resident 11's POLST indicated DNR, comfort focused treatment as the primary goal, and directives for no invasive or non invasive mechanical ventilation. The DON verified Resident 11 was currently receiving mechanical ventilation, which was inconsistent with the POLST instructions. The DON stated Resident 11 was admitted from the acute care hospital with a DNR order; however, she was unable to provide documentation to show the choice for comfort focused treatment and the additional directives including no invasive or non invasive mechanical ventilation were reviewed or discussed during with the facility IDT team and the representative from the Council on Aging. The DON stated the facility should have arranged an IDT meeting to review Resident 11's POLST and the associated treatment preferences. The DON also verified there was no documented evidence to show the physician was contacted to clarify the resident's POLST. The DON acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medications when two of four licensed nurses were observed to have made errors. * LVN 5 failed to follow the administration instructions to dissolve the GlycoLax (laxative) for Resident 21. * During the medication administration observation, LVN 6 failed to administer the Pro-Stat (liquid protein supplement) medication to Resident 6. These failures had the potential to negatively affect the residents' health conditions and posed the risk of possible complications or delay in interventions. Findings: Review of the facility's P&P titled Medication Administration revised 3/2025 showed all dosing frequencies for inpatients will be administered at fixed times approved by nursing and the medical staff. The pharmacy information system would be programmed to include standard medication frequency abbreviations and administration times. Prior to administration, the practitioner will verify the prescriber's order against the medication being administered. To review the medication administration record (MAR) for any special considerations that would influence the administration of medications including but not limited to, clinical parameters, NPO status. Medications at odd hours, one time only medications, or medications that must be given with food. The pharmacy will dispense medications in ready to use form whenever possible. If dispensing the product in ready to use form is not possible, the healthcare professional administering the medication may appropriately manipulate the dosage form prior to administration. 1. On 3/25/26 at 0825 hours, a medication administration observation for Resident 21 was conducted with LVN 5. LVN 5 prepared the following medications for Resident 21:- 30 milliliters of lactulose (laxative) 20 grams;- one tablet of famotidine (antacid) 20 mg;- one tablet of Vitamin D3 (supplement) 25 mcg;- one tablet of Thera multivitamin (supplement);- one tablet of aspirin (antiplatelet) 81 mg;- one capsule of cranberry (supplement) 465 mg;- 5 milliliters of valproic acid (mood stabilizer) 250 mg;- one tablet of simethicone (antacid) 80 mg;- one tablet of metformin (antidiabetic) 500 mg;- one capsule of tamsulosin (for benign prostatic hyperplasia) 0.4 mg;- two tablets of memantine (dementia medication) 5 mg;- one packet of GlycoLax (laxative) 17gm;- one drop of refresh plus (lubricant) 0.5% to each eye; and- one drop of azelastine (eye drop used to treat itching, redness, and swelling) 0.05% to the left eye. During the observation, LVN 5 was observed emptying the packet of GlycoLax powder into a cup. LVN 5 then added chocolate pudding and mixed the contents with a tongue depressor. LVN 5 was observed administering the above medications to Resident 21. Medical record review for Resident 21 was initiated on 3/25/26. Resident 21 was admitted to the facility on [DATE]. Review of Resident 21's Active Order Sets dated 3/26/26, showed the following physician's orders:- dated 12/24/23, may give oral medications with a small amount of thickened water.- dated 1/24/24, may crush medications and mix with pudding preferably chocolate pudding.- dated 3/24/26, to administer GlycoLax 17 grams by mouth two times daily. Review of Resident 21's MAR for 3/26/26, showed the administration instructions for the GlycoLax 17 grams powder showed to stir the powder in 120 to 240 ml (four to eight ounces) of water, juice, soda, coffee, or tea and administer. On 3/25/26 at 0922 hours, an interview and concurrent medical record review for Resident 21 was conducted with LVN 5. LVN 5 verified the administration instructions for the GlycoLax medication in the MAR and verified she did not mix the powder with water, as per the instructions, and instead mixed it with the chocolate pudding. 2. On 3/26/26 at 0900 hours, a medication administration observation for Resident 6 was conducted with LVN 6. LVN 6 prepared and administered Resident 6's medications via the GT, which included the following:- 10 ml of docusate sodium (stool softener) 100 mg;- 10 ml of levetiracetam (anticonvulsant)1000 mg;- one tablet of calcium carbonate (antacid) 500 mg;- one tablet of vitamin C (supplement) 500 mg;- one tablet of Vitamin D3 (supplement) 25 mcg-1000 units;- one capsule of Culturelle- lactobacillus GG (supplement) 10 billion CFUs; and- one tablet of metoprolol (antihypertensive) 25 mg. Medical record review for Resident 6 was initiated on 3/26/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Active Order Sets dated 3/26/26, showed a physician's order dated 4/9/25, to administer Pro-Stat (supplement) Sugar Free 30 ml daily via the GT. Review of Resident 6's MAR for 3/26/26, showed the Pro-Stat Sugar Free 30 ml medication was scheduled to be administered at 0900 hours. On 3/26/26 at 1003 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 6. LVN 6 reviewed Resident 6's MAR and verified the Pro-Stat medication was scheduled to be administered at 0900 hours. LVN 6 verified the medication was not administered during the medication administration observation. On 3/26/26 at 1035 hours, an interview was conducted with the DON. The DON stated the medications should be administered as per the physician's orders and should be administered within the ordered time, which was within an hour before and after the scheduled time. On 3/26/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings

Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the intravenous (IV) accesses for one of 12 final sampled residents (Resident 13) reviewed for IV care. * The facility failed to ensure a physician's orders were obtained for the IV fluid and peripheral IV access site rotation every 72 hours and as needed. This failure had the potential to delay the identification of intravenous complication of the resident.Findings: Medical record review for Resident 13 was initiated on 3/24/26. Resident 13 was admitted to the facility on [DATE]. On 3/24/26 at 0937 hours, Resident 13 was observed in bed with the normal saline (NS, sterile solution of 0.9 grams or salt per 100 ml of water) IV fluids infusing from the IV pump machine at 10 ml/hr, which was connected to Resident 13's right hand IV access with a transparent dressing dated 3/22/26. Reviewed Resident 13's physician's order dated 3/24/26, showed to administer cefepime (antibiotic medication) 2 grams IVPB every eight hours at 200 ml/hr for 30 minutes. Further review of Resident 13's medical record failed to show documented evidence a physician's order for the normal saline IV fluid and peripheral IV access site rotation every 72 hours and as needed were obtained. On 3/26/26 at 0831 hours, an observation and concurrent interview at Resident 13's beside was conducted with IP 2. IP 2 verified Resident 13 was on IV antibiotic and the resident had IV NS infusing at 10 ml/hr, which was connected to the resident's right hand IV access. IP 2 stated the RNs were responsible for the IV care and maintenance for the residents. On 3/26/26 at 1025 hours, an interview and concurrent medical record for Resident 13 was conducted with RN 3. RN 3 stated when the licensed nurses received an order for the IV antibiotic, she would inform the pharmacy about the order and start an IV access for the resident. RN 3 added, when the IV antibiotic was available she would then start an IV fluid, usually a NS 250 ml bag, via the IV pump machine. RN 3 stated she then would administer the IV antibiotic as ordered. RN 3 was asked about Resident 13's IV medication. RN 3 verified Resident 13's physician's order for the IV ATB for sepsis for seven days. RN 3 was asked for the physician's orders for the NS IV fluid and the care and maintenance of the IV access site. RN 3 reviewed the Resident 13's medical record and verified there were no physician's orders for the NS IV fluid and the care and maintenance of the IV access site obtained. On 3/26/2026 at 1416 hours, an interview and concurrent medical record review for Resident 13 was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff provided care and services to promote dignity and respect for one of 12 final sampled residents (Resident 13). * Resident 13's family member preferred Resident 13 not to be covered or to wear a shirt. The facility failed to ensure Resident 13's curtain was pulled to provide Resident 13 with dignity. These failures had the potential to negatively impact the resident's self-worth and well-being.Findings: Review of the facility's P&P titled Resident Privacy, Dignity, and Confidentiality revised 2/2024 showed the subacute facility will provide privacy for the residents, including but not limited to accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings with legal representative, family, and groups. Nursing staff will use curtains to provide full visual privacy and dignity during resident care, toileting, treatments, and issues of dignity and other requested times. This includes closing doors, removing residents from public view and providing clothing and draping residents to prevent unnecessary exposure of body parts. On 3/26/26 at 0810 hours, Resident 13 was observed lying in bed. Resident 13 was visibly seen with his upper body exposed and a blanket at the resident's waist from the doorway of Resident 13's room. On 3/26/26, from 0810 to 0816 hours, an ongoing observation was conducted of multiple staff members walking in the hallway passing Resident 13's room. On 3/26/26 at 0818 hours, an interview and concurrent observation was conducted with IP 2. IP 2 verified the above findings. IP 2 stated Resident 13's family member requested for the resident to be without a shirt. IP 2 stated the curtain should be pulled to provide Resident 13 with privacy and dignity when he did not have a shirt covering him. Medical record review for Resident 13 was conducted on 3/26/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's care plan for risk for alteration in comfort dated 11/4/25, showed per Resident 13's family member, Resident 13 liked to remain in a cooler temperature and not to be covered with blankets. The interventions showed to not cover the resident with a blanket and may cover his private area only. Review of Resident 13's Nursing Note dated 12/5/25, showed Resident 13 did not wear the gown per Resident 13's family member request due to excessive perspiration and tachycardia. Review of Resident 13's MDS assessment dated [DATE], showed Resident 13 had severely impaired cognitive skills for daily decision making. On 3/26/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive plan of care to reflect the individual care needs for one of five final sampled residents (Residents 16) reviewed for unnecessary medication. * The facility failed to develop a care plan for Resident 16's use of Xarelto (anticoagulant medication). This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.Findings: Review of facility's P&P titled Care Planning dated 10/28/25, showed a comprehensive care plan must be developed within 14 days and completed no later than seven days after a comprehensive assessment has been completed. Resident care planning includes participation from all involved health care disciplines at resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge. The comprehensive care plan will provide specific information to include resident strengths, goals, life history and preferences, discharge planning and will be completed upon the assessment completion. Medical record review for Resident 16 was initiated on 3/24/26. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Physician's Order showed an order dated 12/19/25, to administer Xarelto 10 mg via GT at bedtime for DVT prophylaxis. Review of Resident 16's comprehensive care plans failed to show documented evidence an individualized care plan was developed to address Resident 16's use of the Xarelto medication. On 3/26/26 at 1253 hours, an interview and concurrent medical record review for Resident 16 was conducted with RN 3. RN 3 verified Resident 16 had a physician's order for anticoagulant medication. RN 3 reviewed Resident 16's care plans and verified there was no care plan developed for the Xarelto medication. RN 3 stated the licensed nurse formulate a care plan once there was an new condition of the resident. On 3/26/2026 at 1419 hours, an interview and concurrent medical record review for Resident 16 was conducted with the DON. The DON was informed and verified the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 11) reviewed for nutritional status received the appropriate services needed to maintain acceptable parameters of the nutritional status. * The facility failed to ensure the physician was notified when Resident 11 had excessive weight changes of more than 5 (five) pounds in a week, and 20 pounds in a month. This failure had the potential to result in the lack of effectiveness of the nutritional interventions and increased the potential for further weight loss and/or nutritional decline.Findings: Review of the facility's P&P titled Weight Variance Monitoring dated 2/2024 showed it was the policy of the facility to provide weight variance monitoring based on good nursing practice and as indicated by resident need or physician order. Further review of the P&P showed excessive weight losses or gains will be more than 2 (two) lbs. per week or more than 8 (eight) lbs. in one month. The physicians will be notified of all excessive losses or gains. Medical record review for Resident 11 was initiated on 3/24/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's Recent Vitals showed the following:- on 1/6/26, a weight of 153 lbs.;- on 1/11/26, a weight of 146 lbs.; a weight loss of 7 lbs. from 1/6/26;- on 1/18/26, a weight of 145 lbs.;- on 1/25/26, a weight of 138 lbs.; a weight loss of 7 lbs. from 1/18/26;- on 2/1/26, a weight of 133 lbs.; weight loss of 5 lbs. from 1/25/26, and 20 lbs. from 1/6/26;- on 2/10/26, a weight of142 lbs.; weight gain of 9 lbs. from 2/1/26; and,- on 2/22/26, a weight of135.6 lbs.; weight loss of 7 lbs. from 2/10/26. Review of Resident 11's Care Plan showed the following:- dated 1/6/26, showed a care plan problem addressing the resident's altered nutrition, risk for weight loss and intolerance to tube feeding. The interventions included to monitor the weight as ordered and to notify the physician of any unplanned significant weight gain or losses.- dated 2/3/26, showed a care plan problem addressing the resident's 20 pound weight loss in 30 days. The goal showed the facility to minimize further significant weight loss/gain in the next 30 days. The intervention included notifying the physician of significant weight change.Review of Resident 11's physician's progress notes dated 1/13/26, showed Resident 11 was noted to have lost about 7 lbs. since admission and the RD to evaluate Resident 11. Further review of the physician's progress notes did not show if the above weight changes on 1/25, 2/1, 2/10, and 2/22/26 was relayed to the physician. Review of the facility's document titled Change of Condition log showed the following:- on 1/11/26, Resident 11 had unplanned wight loss of 7.3 lbs./week and- on 1/25/26, Resident 11 had unplanned weekly weight loss.The change of condition log showed the treatment and duration for above identified change in condition for Resident 11 was 72 hours. However, further review of the resident's medical record failed to show if the physician was notified and if Resident 11 was monitored for 72 hours for the above identified change in condition. Review of Resident 11's Nutrition and Hydration Risk assessment dated [DATE], showed Resident 11 was at high risk for malnutrition and dehydration. Review of Resident 11's Nutrition assessment dated [DATE], showed weight goals per the RD was 140-155 lbs. Review of Resident 11's Dietary Orders showed a physician's order dated 2/26/26, for Jevity 1.5 (type of enteral feeding formula) at 60 ml per hour (totaling 1200 ml/1800 kcal) to be administered via GT. On 3/26/26 at 0834 hours, an interview and concurrent medical record review for Resident 11 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated she was unable to locate the documentation showing the physician was notified of these weight changes on the dates they occurred. RN 1 verified although the physician documented the resident's 7 pound weight loss since admission on [DATE], there was no documented evidence to show the physician had been notified at the time the weight loss was first identified. RN 1 stated the physician should be notified as soon as possible when a resident experiences excessive weight changes. On 3/27/26 at 0953 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to administer the pneumococcal vaccines to two of five residents reviewed for vaccinations (final sampled residents, Residents 4 and 19). This failure had the potential to cause medical complications related to pneumococcal infections for the affected residents. Findings: Review of the facility's P&P titled Pneumococcal Vaccine, Administration and Guidelines dated 1/2024 showed under section procedure, all the patients will be assessed for prior vaccination history during admission, provide the resident or legal representative with the latest edition of the vaccine information statement developed by the CDC, administer the vaccine, and document in MAR. 1. Medical record review for Resident 4 was initiated on 1/6/25. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 4's Pneumococcal Vaccine dated 7/8/24, showed Resident 4's RP consented for the resident to receive the pneumococcal vaccine. However, there was no documented evidence the vaccine was administered to Resident 4. There was no documented evidence to explain why the pneumococcal vaccine was not administered to the resident after the consent was obtained on 7/8/24. 2. Medical record review for Resident 19 was initiated on 1/6/25. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Pneumococcal Vaccine dated 9/30/24, showed Resident 19's RP consented for the resident to receive the pneumococcal vaccine. However, there was no documented evidence the vaccine was administered to Resident 19. There was no documented evidence to explain why the pneumococcal vaccine was not administered to the resident after the consent was obtained on 9/30/24. On 1/8/25 at 1530 hours, a concurrent interview and medical record review was conducted with the IPs 1 and 2. IPs 1 and 2 were asked if Residents 4 and 19 were offered the pneumococcal vaccine. IPs 1 and 2 stated they had offered the vaccine and obtained consents but it was not administered to the residents. IPs 1 and 2 verified the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of GT for one of 12 final sampled residents (Residents 12) and one nonsampled resident (Resident 13). * The facility failed to ensure Resident 12's enteral feeding formula was labeled with the time as per the facility's P&P. * The facility failed to ensure RN 2 checked for gastric residual prior to the administration of the GT medication for Resident 13, as per the facility P&P. These failures posed the risk for complications related to the use of the GT for Residents 12 and 13. Findings: Review of the facility's P&P titled Enteral Feeding, Administration revised 2/2023 showed the pump bags, syringe and tubing are to be changed every 24 hours and properly labeled with the date, time, and nurse's initials. Review of the facility's P&P titled Medication Administration Through a Feeding Tube revised 2/2023 showed medications will be administered via the feeding tube by an RN or LVN, per the physician's orders. The P&P further showed to place the continuous tube feeding on hold and check the residual and tube placement per procedure. 1. Medical record review for Resident 12 was initiated on 1/6/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 8/2/24, showed Resident 12 was GT dependent. Review of Resident 12's Active Order Sets: Dietary Orders dated 1/8/25, showed a physician's order dated 5/28/24, to administer Glucerna 1.5 (enteral feeding formula) at the rate of 50 ml/hr for 20 hours per day. On 1/6/25 at 0959 hours, Resident 12 was observed lying in bed and the GT enteral feeding was observed infusing Glucerna 1.5 at 50 ml/hr. The Glucerna 1.5 enteral feeding formula bottle was observed labeled with the date and rate, however the time was not documented on the enteral feeding bottle. On 1/9/25 at 0853 hours, Resident 12 was observed lying in bed. The GT formula feeding was observed off. The Glucerna 1.5 enteral feeding formula was observed hanging on the feeding pump pole with 850 ml of enteral feeding formula remaining in the bottle. The enteral feeding formula bottle was labeled with Resident 12's name, room, the date, and the rate, however, a time was not observed on the label. On 1/9/25 at 0955 hours, a concurrent observation and interview was conducted with LVN 3. LVN 3 stated when starting a new enteral feeding formula bottle, the enteral feeding formula should be labeled with the resident's name and room number, the date, the time the formula was started, and the infusion rate. LVN 3 further stated the enteral feeding formulas should be discarded after 24 hours. When asked when Resident 12's current enteral feeding formula was started, LVN 3 verified the above findings and stated she did not know when the enteral feeding formula was started. On 1/9/25 at 1213 hours, an interview was conducted with the DON. The DON stated when administering the enteral feeding formulas, the licensed nurses were expected to label the enteral feeding formula with the resident's name, the date and time the enteral feeding formula was started and the rate. When asked about the purpose of the labeling of the time on the enteral formula, the DON stated the enteral feeding formulas should be labeled with the time to ensure the infusion of the enteral feeding formula did not exceed 24 hours. On 1/9/24 at 1444 hours, the DON was informed and acknowledged the above findings. 2. Medical record review for Resident 13 was initiated on 1/8/25. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Active Order Sets dated 1/8/25, showed the following physician's orders: - dated 9/20/19, to monitor the GT residual before feeding and as needed. If residual was greater than 500 ml, to hold the feeding for one hour, then reassess. - dated 12/3/24, to administer Glucerna 1.5 at the rate of 55 ml/hr for 20 hours per day via the GT. On 1/8/25 at 0825 hours, a medication administration observation was conducted with RN 2. RN 2 was observed placing her stethoscope on Resident 13's stomach and used a syringe to check Resident 13's GT placement. RN 2 was not observed checking Resident 13's gastric residual volume prior to the administration of Resident 13's medications and water flushes via the GT. On 1/8/25 at 0847 hours, an interview was conducted with RN 2. RN 2 verified she did not check for gastric residual for Resident 13 prior to the administration of medications via the GT during the medication administration observation. On 1/9/25 at 1213 hours, an interview was conducted with the DON. The DON stated for the medication administrations through the GT, the licensed nurses were expected to check the placement of the GT via auscultation and check for the gastric residual prior to the administration of the medications. On 1/9/24 at 1444 hours, the DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils were air dried prior to storage. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's untitled document dated 1/6/25, showed two of 22 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Food Preparation revised 1/2023 showed non-porous cutting boards in good condition are used and sanitized between uses. Color coded cutting boards for raw meat, poultry, fish, and prepared foods, fruits and vegetables and allergies are utilized to prevent cross contamination. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. During the initial kitchen tour on 1/6/25 at 0824 hours, a concurrent observation and interview was conducted with the Dietary Director. Eight cutting boards (four white, one yellow, two red, and one purple) were observed heavily marred, discolored, and fuzzy with deep groves. The Dietary Director acknowledged the findings and stated the cutting boards should have been tossed and replaced. 2. Review of the facility's P&P titled Dish and Ware Washing/ Care of Dishmachine revised 12/2022 showed towel drying dishes is not allowed. Air drying: as the racks of dishes come from the machine, they should be allowed to air dry. If the drying space is too small to allow dishes to air dry. Allow silver to air dry by letting it stand for a few minutes after washing. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 1/6/25 at 0824 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Director. The following items were wet with visible water, and stored inside the drawer for clean utensils: - Five slotted scoops with green handles - Three scoops with green handles - Three scoops with black handles - Three slotted scoops with black handles - One scoop with blue handle The Dietary Director acknowledged the above findings and stated all the scoops should have been air dried and not stored in the clean drawer wet. 3. Review of the facility's P&P titled Dish and Ware Washing/ Care of Dishmachine revised 12/2022 showed the sanitary dishes, cooking vessels and utensils are free from visible soil, stains, greasy film, cracks and chips, and bacteria. Review of the facility's P&P titled Food Preparation revised 1/2023 showed the cooking equipment is to be clean and in good working order. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 1/6/25 at 0824 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Director. The following was observed: - Three small mesh strainers with wooden handles were deformed and discolored - One large mesh strainer with a wooden handle was deformed and discolored - Two stainless steel potato mashers had an orange/brown discoloration - One stainless steel whisk with a cracked gray handle - One stainless steel whisk with a partially melted gray handle - Two green scoops used for food portioning were worn out with peeling handles - One cream scoop used for food portioning was worn out with a discolored and peeling handle - One red scoop used for food portioning was fuzzy with a discolored handle - One white basting brush was frayed, discolored, and worn out - Six rubber spatulas with red handles were cracked, chipped at the edges, and discolored - One stainless steel slotted spatula with a brown handle was deformed and bent at one of the edges - One stainless steel spatula with a brown handle was deformed, bent at the edges and had linear black discoloration which resembled a burn mark The Dietary Director acknowledged the above findings and stated all kitchenware should have been tossed and has not been used. 4. Review of the facility's P&P titled Dish and Ware Washing/ Care of Dishmachine revised 12/2022 showed the sanitary dishes, cooking vessels and utensils are free from visible soil, stains, greasy film, cracks and chips, and bacteria. Review of the facility's P&P titled Food Preparation revised 1/2023, showed cooking equipment is to be clean and in good working order. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 1/6/25 at 0824 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Director. The following was identified: - One scoop with a blue handle, three scoops with yellow handles and one scoop with a gray handle used for food portioning were dirty, had water marks and were dry, crusted food residue - One stainless steel blue spatula was fuzzy and dirty The Dietary Director acknowledged the above findings and stated all kitchenware should have been washed. 5. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. During the initial kitchen tour on 1/6/25 at 0824 hours, a concurrent observation and interview was conducted with the Food Service Supervisor. Black dirt, grease residue was observed on the kitchen stove hood. The Food Service Supervisor verified the findings and stated the janitor was supposed to clean the stove hood every other day. The Food Service Supervisor stated it was important to clean the stove hood for air circulation to prevent smoke and grease build up.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to prevent the development and transmission of diseases and infections. * RN 1 failed to disinfect the stethoscope after use on Resident 1 and prior to exiting the room. * RN 2 failed to disinfect the stethoscope after use on Resident 13 and prior to exiting the room. * CNA 1 failed to remove the gown and gloves and perform hand hygiene after touching Resident 1's surroundings and before touching Resident 10's environment. * Three linen cart covers were observed to be dirty, stained with black, white, and brown colors, and worn out. These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility. Findings: Review of the facility's P&P titled Patient Equipment Use Maintenance and Cleaning dated 6/27/21, showed all reusable instruments and equipment will be thoroughly cleaned and decontaminated prior to use on a patient. 1a. On 1/7/25 at 0828 hours, during the medication administration observation for Resident 1, RN 1 was observed using a stethoscope and syringe to check for the GT placement. After completing Resident 1's medication administration, RN 1 removed the gloves and gown, washed his hands, and exited Resident 1's room. RN 1 did not disinfect the stethoscope prior to exiting Resident 1's room. On 1/7/25 at 0844 hours, an interview was conducted with RN 1. RN 1 stated the stethoscope should be disinfected after use on each resident and prior to exiting the resident's room. RN 1 verified he did not disinfect his stethoscope after using the stethoscope to check Resident 1's GT placement, and prior to exiting Resident 1's room. RN 1 stated he should have disinfected his stethoscope to prevent the transmission of organisms between residents. 1b. On 1/8/25 at 0831 hours, during the medication administration observation for Resident 13, RN 2 was observed using a stethoscope and irrigation syringe to check for the GT placement for Resident 13. After completing Resident 13's medication administration, RN 2 removed the gloves, placed the stethoscope on her workstation cart, and removed the gown. RN 2 performed hand hygiene and exited Resident 13's room. RN 2 did not disinfect the stethoscope prior to exiting Resident 13's room. RN 2 moved the stethoscope from the top of the cart to the bottom compartment of her workstation cart. On 1/8/25 at 0845 hours, an interview was conducted with RN 2. RN 2 was asked about the facility protocol for disinfection of multi- use equipment's like the stethoscope. RN 2 stated the stethoscope should be disinfected before and after use on a resident and before exiting the resident's room. RN 2 verified she did not disinfect the stethoscope after using on Resident 13, and prior to exiting Resident 13's room. On 1/8/25 at 1515 hours, an interview was conducted with the IP 1. IP 1 stated all the resident rooms, except for one room was on EBP. When asked about the facility protocol for the disinfection of the multi-use equipment on residents, IP 1 stated the staff are expected to disinfect the equipment after each use and prior to exiting the resident's room to prevent the transmission of organisms to other surfaces and residents. On 1/9/25 at 1444 hours, the DON was informed and acknowledge the above findings. 2. Review of the facility document titled Enhanced Barrier Precautions (undated), showed everyone must clean their hands, including before entering and when leaving the room. The sign showed do not wear the same gown and gloves for the care of more than one person. Medical record review for Resident 10 was initiated on 1/6/25. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Active Order Sets: Care Order/Instructions showed a physician's order dated 8/26/24, Resident 10 may have one to one feeding assistance three times per day for seven days a week with weighted spoon and grip cup during meals, per resident request. May self-feed as tolerated. On 1/6/25 at 1145 hours, a concurrent observation and interview was conducted with CNA 1 in Resident 10's room. There was an EBP sign posted outside of Resident 1 and 10's room. CNA 1 was observed wearing gloves and placed Resident 10's lunch tray on Resident 10's bedside table. CNA 1 then was observed donning a gown and with the same pair of gloves, walked by Resident 1's bed and tucked Resident 1's blanket under. CNA 1 then pulled the privacy curtain between Resident 1 and Resident 10 and was observed grabbing Resident 10's bedside table to move the table towards Resident 10. CNA did not remove his gown or gloves after contact with Resident 1's environment and before coming in contact with Resident 10's environment. CNA 1 stated he was preparing to assist Resident 10 with his lunch. CNA 1 verified he did not change his gloves and gown between touching each resident's environment. CNA 1 stated the gloves and gowns should be used for one resident and should not be used again for a different resident. CNA 1 further stated he should have removed the gloves and gown and donned a new pair of gloves before touching Resident 10's environment. On 1/8/25 at 1515 hours, an interview was conducted with IP 1. IP 1 stated all the resident rooms in the unit, except for one room was on EBP. IP 1 stated when moving from one resident to another resident in the same room, staff were expected to remove the gown and gloves, perform hand hygiene, and don a new gown and gloves. IP 1 further stated, the same gown or glove may not be worn between residents and should be removed prior to assisting the next resident. On 1/9/25 at 1213 hours, an interview was conducted with the DON. The DON stated when the staff members were in the residents' rooms providing care to a resident, the staff members were expected to doff their gown and gloves and perform hand hygiene before moving on to the next resident in the same room. The DON further stated the staff member should not wear the same gown and/or gloves for a different resident to prevent the transmission of organisms and infections to the other residents. On 1/9/25 at 1444 hours, the DON was informed and acknowledge the above findings. 32179 3. On 1/6/25 at 0805 and 1105 hours, three linen cart covers located in the hallway in front of Room A were observed dirty, worn out and stained with black, white, and brown colors. On 1/6/24 at 1420 hours, an interview was conducted with the DSD/MDS Coordinator. The DSD/MDS Coordinator stated the covers should be clean and verified the findings.

Based on observation and interview, the facility failed to maintain a clean, safe, and homelike environment for four of 12 final sampled residents (Residents 4, 8, 9, and 19) and one nonsampled resident (Resident 13). * There was a brownish colored stain on Resident 19's wall. * There were brown and white stains on Residents 8 and 13's curtains. * There was a brown feeding formula, GT tube cap and multiple gauze pads on the floor between Residents 4 and 8's beds. * There were feeding stains on Resident 8's IV pump and two other feeding pumps. * There was brownish colored droplet stains on the wall behind Resident 9's head of bed. Additionally, there was dry and brown colored residue on Resident 9's enteral feeding pump device and vacuum regulator. These failures had the potential to negatively impact the residents' safety and quality of life. Findings: Review of the facility's P&P titled Safe and Homelike Environment dated 6/20/24, showed the housekeeping and maintenance services will maintain a good wroking, sanitary, orderly and comfortable environment. Each resident will be provided a safe, clean, comfortable and homelike enviroment, allowing resident to sue to bring momentos and personal beloingings to the extent possible. 1. On 1/6/25 at 0830 and 1035 hours, Resident 19's wall was observed stained with a brownish color. On 1/6/25 at 0230 hours, an interview was conducted with the DSD/MDS Coordinator. The DSD/MDS Coordinator acknowledged the staff should have cleaned the wall as soon as they saw there was splash from the enteral feeding. The DSD/ MDS verified the above findings. 2. On 1/6/25 at 0900 and 1100 hours, Resident 8's curtain was observed with brown and white stains. Additionally, there was a brown feeding formula, GT tube cap and multiple gauze pads on the floor between Residents 4 and 8's beds. There were feeding stains on Resident 8's IV pump and two other feeding pumps. On 1/6/25 at 0230 hours, an interview was conducted with the DSD/MDS Coordinator. The DSD/MDS Coordinator acknowledged Resident 8's curtain should have been replaced and the floor should have been cleaned daily. The DSD/MDS Coordinator stated if the nurse spilled the enteral feeding, they should have cleaned it right away. The DSD/MDS Coordinator further stated the staff should have kept the room environment and medical equipment clean. The DSD/MDS Coordinator verified these findings. 3. On 1/6/25 at 0820 and 1040 hours, Resident 13's curtains were observed with brown and white stains. On 1/6/25 at 0230 hours, an interview was conducted with the DSD/MDS Coordinator. The DSD/MDS Coordinator acknowledged Resident 13's curtain should have been replaced and kept clean. The DSD/MDS Coordinator verified the findings. 48882 4. On 1/8/25 at 0822 hours and 1/9/25 at 0818 hours, an observation was conducted in Resident 9's room. The wall behind Resident 9's bed and the vacuum regulator attached to the wall were observed with brownish colored droplet stains. Resident 9's enteral feeding pump device was also observed with dry light brownish colored residue. On 1/9/25 at 0900 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated the stain appeared to be from the enteral feeding formula. When asked who was responsible for the cleaning of the residents' walls and equipment, LVN 2 stated upon noticing the stains, the licensed nurses and/or therapists were responsible for informing the Environmental Services staff to clean. LVN 2 further stated the residents' walls and equipment should be kept clean to ensure a clean, homelike environment for the residents. On 1/9/25 at 0905 hours, an interview was conducted with the EVS Aide 1. EVS Aide 1 stated she was responsible for the cleaning of the resident rooms for the sub-acute unit at the facility. When asked how she was informed of the rooms that needed to be clean, EVS Aide 1 stated the staff would notify her of the rooms that needed to be cleaned. When asked if she had been informed the wall in Resident 9's room needed to be cleaned, EVS Aide 1 stated she was not aware. On 1/9/25 at 0937 hours, an interview was conducted with the DSD/MDS Coordinator. The DSD/MDS Coordinator stated the EVS staff were responsible for the cleaning of walls and equipment in the residents' rooms. On 1/9/25 at 1213 hours, an interview was conducted with the DON. The DON stated the residents' rooms and equipment should be cleaned of stains and wiped down. The DON further stated, all stains should be reported by the staff member when first observed to ensure the stains were cleaned. On 1/9/24 at 1444 hours, the DON was informed and acknowledged the above findings.

Based on observation and interview, the facility failed to ensure the medications were stored properly. * There were two ounces of Zinc Oxide paste (medicated cream, ointment or paste that treats or prevents skin irritation like cuts, burns or diaper rash) at Resident 14's bedside table. This failure had the potential for visitors to have access to medications. Findings: Review of the facility's P&P titled Control: Procurement, storage, and security of medications dated 9/2024 showed all medications, needle and syringes are stored in a loackable areas and are accessible only to personel duty authorized to dispense and/or administer medications. On 1/6/25 at 0830 and 1115 hours, Resident 14 was observed with two tubes of two ounces of Zinc Oxide paste at Resident 14's bedside table. On 1/6/25 at 1420 hours, a concurrent interview and medical record review was conducted with the DSD/MDS Coordinator. The DSD/ MDS Coordinator stated the Zinc Oxide paste should have been locked in the treatment cart. The The DSD/ MDS Coordinator verified these findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medical records for two of 12 final sampled residents (Residents 12 and 19) were accurate. * The facility failed to ensure Resident 12's weekly wound assessment for 12/19/24 was recorded in the medical record. Additionally, the wound treatments administered to the resident did not match the Wound Consultant Physician's orders, and there was no documentation of the clarifications made on the physician's orders. * The facility failed to ensure Resident 19's skin assessment for measuring pressure sores and non-pressure sores was documented upon readmission and on a weekly basis. These failures had the potential for Residents 12 and 19's care needs not being met as their medical information was inaccurate. Findings: Review of the facility's P&P titled Charting Guidelines revised 3/2024 showed to document the normal findings as well as abnormal findings as this shows that the resident was being assessed. When physician intervention is required, document the time the physician was contacted and the time he responded. When new orders are implemented, the chart needs to reflect the resident notification and response to the intervention. Under the section Documentation Requirements showed special focus: weekly document requirements for the assessment of pressure sore progress/skin conditions. Review of the facility's P&P titled Skin Integrity revised 6/2024 showed the patient's skin integrity from head to toe will be assessed upon admission and on each shift. Detailed assessment should be completed: i. Within 24 hours of admission and then weekly thereafter; ii. With a change in condition; upon discovery of a new wound; iii. Within 24 hours post-debridement, if possible. Further review of the facility's P&P showed to document the description of each resident's wound (in centimeters) to include the following: location, length, width, depth, and all aspects of general wound care. 1a. Medical record review for Resident 12 was initiated on 1/6/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's MDS dated [DATE], showed Resident 12 had severely impaired cognitive skills, and one Stage 4 pressure injury present upon admission or reentry. Review of Resident 12's plan of care showed a care plan problem dated 11/1/24, addressing Resident 12's risk for skin breakdown and/or pressure ulcer. The interventions showed to administer treatment as ordered and monitor the response, and weekly documentation to include the measurement of each area of skin breakdown (width, length, and depth). Review of the facility's document titled Pressure Ulcer Log- Subacute Unit for December 2024 showed the weekly wound assessment for Resident 12's sacral pressure injury for the following dates: 12/5, 12/12, and 12/26/24. The assessments included the size, depth, stage, and color of Resident 12's sacral wound. However, there was no documentation in the log for the weekly wound assessment for 12/19/24. Review of Resident 12's medical record failed to show documentation of the weekly wound assessment, including the size, depth, stage, and description for Resident 12's sacral pressure injury for 12/19/24. On 1/8/25 at 1329 hours, a concurrent interview and medical record review for Resident 12 was conducted with the DON. The DON verified the above finding. The DON stated for the residents with wounds, the wounds were measured weekly and documented in the facility's pressure ulcer log. The DON stated on 12/19/24, the measurements for Resident 12's sacral pressure injury was obtained with the Wound Consultant and the measurements were discussed during the daily communication meeting. The DON stated the nurse should have documented Resident 12's weekly wound assessment on 12/19/24, in the Pressure Ulcer Log. b. Review of Resident 12's Wound Physician Consultation Notes dated 12/12 and 12/19/24, showed the following additional orders: - for the sacral region Stage 3 Pressure Injury, to cleanse the wound with wound cleanser, to apply collagen with silver (collagen dressing with antimicrobial), to cover with foam dressing, daily and as needed. Review of Resident 12's Treatment Record for December 2024 showed the following treatments: - dated 12/5/24, for the opened sacral Stage 3, to cleanse with normal saline, pat dry, apply medihoney (medical grade honey intended for wound care) with calcium alginate with silver (antimicrobial dressing) and cover with foam dressing every shift and as needed if peeled off/soiled for 14 days, to reevaluate on 12/19/24. The treatment record showed the above treatment was administered from 12/6/24 to 12/18/24, during the 0700 to 1900 hours and the 1900 to 0700 hours shifts. - dated 12/19/24, for the reopened sacral Stage 3, to cleanse with normal saline, pat dry, apply medihoney with calcium alginate with silver and cover with foam dressing every shift and as needed if peeled off/soilage for 14 days, to reevaluate on 1/3/25. The treatment record showed the above treatment was administered from 12/19/24 to 12/25/24, for the 0700 to 1900 hours and the 1900 to 0700 hours shifts, and on 12/26/24 during the 0700 to 1900 hours shift. On 1/8/25 at 1103 hours, a concurrent interview and medical record review for Resident 12 was conducted with LVN 1. LVN 1 verified the above findings and stated the wound treatment administered did not match the Wound Consultant Physician's orders. LVN 1 stated she informed the physician that the facility needed to special order the collagen and the Wound Consultant had ordered to continue the previous treatment order until the collagen was available. When asked to show the documentation LVN 1 had clarified the order, LVN 1 stated she did not document in the resident's progress notes. When asked about the discrepancy in the wound cleansing agent and the frequency of the dressing changes, LVN 1 stated she had clarified the order with the physician. When asked to show the documentation she clarified the order, LVN 1 stated she did not document the order clarifications in Resident 12's medical record. On 1/9/25 at 1213 hours, a concurrent interview and medical record review for Resident 12 was conducted with the DON. The DON stated, if the nurse clarified a physician's order, the DON expected the nurse to document the order clarification in the resident's records. The DON verified the above findings and stated LVN 1 should have documented the order clarification to ensure the resident's medical record accurately reflected the care the resident was receiving. On 1/9/25 at 1444 hours, the DON was informed and acknowledge the above findings. 32179 2. Review of the facility's P&P titled Assessment Body dated 10/2023 showed the licensed nurse shall perform the weekly skin checks according to the weekly summary schedule. Body assessments will be completed upon admission of the resident by the licensed nurse. Observation will be documented. Medical record Review for Resident 19 was initiated on 1/6/25. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Skin Body Check Sheet dated 12/12/24, showed under the diagram section, superficial erythema on the right and left buttocks, and the mid spine was unable to be determined. There was no documentation of measurements of the erythema. On 1/8/25 at 1500 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 was asked about the readmission skin assessment for pressure sore measurements and description for 12/12 and 12/19/24. LVN 1 was unable to provide the documents for 12/12 and 12/19/24. LVN 1 stated she had been off for a week and was not aware if the assessments had been completed. LVN 1 stated the wound consultant made an assessment on 12/19/24, and verified it was not in the chart. LVN 1 stated the licensed nurses should have documented the weekly assessment and verified all of the above findings.