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

Based on interview and record review, the facility failed to report an injury of unknown origin (the source of the injury was not witnessed by any person and the source of the injury could not be explained by the resident and the injury is suspicious because of its extent, location, the number of injuries at a time, or the number of injuries over time) to the California Department of Public Health (CDPH), Adult Protective Services (APS, the county agency responsible for investigating reports of abuse, neglect, or exploitation of elders and dependent adults), and the Ombudsman (an impartial advocate who investigates and helps resolve complaints between patients and healthcare organizations) within 24 hours for one of three sampled residents (Resident 1) in accordance with state law and the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting.This deficient practice resulted in the delay of regulatory oversight and investigation of suspected abuse, resulting in the continued risk of harm to current and future residents. Findings: During a review of Resident 1's face sheet (FS, summary document summarizing a patient's essential information, acting as the cover sheet for their medical record), dated 6/22/2026 , the FS indicated that Resident 1 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure with dependence of a ventilator (a long-term inability of the lungs to adequately exchange oxygen and carbon dioxide that often requires ongoing oxygen therapy or support of a breathing machine).During a review of Resident 1's History & Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/15/2025, the H&P indicated Resident 1 was admitted due to chronic respiratory failure, tracheostomy (a surgical procedure creating an opening in the neck into the trachea to facilitate breathing, bypassing the mouth and nose to breathe), epilepsy (a brain condition causing seizures), cerebral palsy (a group of conditions that affect movement, balance and posture), sepsis (a life-threatening reaction to an infection that causes your immune system harming healthy tissues and organs), and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The H&P also indicated that Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 2/7/2026, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to think, remember, and reason) for daily decision making and was dependent (helper does all of the effort, resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) on staff for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on and removing footwear, personal hygiene, and rolling left and right. The MDS also indicated Resident 1's ability to move from sitting to lying and lying to sitting at the side of bed, sit-to-stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, and walk ten feet were not assessed as Resident 1 did not perform this activity prior to the current illness, exacerbation, or injury.During a review of Resident 1's Reportable Incidents Note, dated 6/20/2026, the Note indicated that Resident 1's primary Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) noticed that Resident 1's left leg from the hip to below the knee was swollen. The Note further indicated Resident 1 showed no signs of facial grimacing but noticeable tensing, with an increased heart rate; the charge Registered Nurse (RN) was notified along with the Medical Doctor (MD) who gave orders for an X-ray.During a review of Resident 1's Report Details, dated 6/21/2026, the Report Details indicated Resident 1's x-ray showed Resident 1 had a comminuted fracture (a type of bone break where the bone is shattered into three or more pieces) of the mid femur (thigh bone) and a nondisplaced fracture (a bone break where the bone cracks or snaps without shifting out of alignment) of the superior left acetabulum (the upper portion of the left hip socket).During an interview on 7/1/2026 at 11:40 a.m. with the Interim Acting Director Of Nursing (IDON), the IDON stated that according to Resident 1's Reportable Incidents Note, Resident 1's swollen leg was discovered by the CNA and LVN on 6/20/2026, MD was notified and Resident 1 was transferred to an outside hospital after X-ray confirmed a broken fracture of the left leg. The IDON also stated the facility conducted an in-house investigation into the fracture and determined the fracture was related to severe contractures. The IDON confirmed that the injury was not reported by the facility to any agency. The IDON further stated that a consequence of not reporting this incident to CDPH could be that if it was abuse, it could continue.During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 6/2021, the P&P indicated, Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) Hours of reporting the event or as required by federal and state regulations.During a review of the facility's policy and procedure (P&P) titled, Abuse, Elder and Dependent Adult dated 11/2024, the P&P indicated, Reports of an elder or dependent adult abuse are to be made immediately or as soon as possible by telephone and follow up written reports on a SOC form 341, and must be sent within two (2) working days. When an incident of abuse or neglect is alleged or suspected to have occurred in a long-term care facility, the report is made to the Long- Term Care Ombudsman Program and to the local law enforcement agency. The Department of Health is also to be notified.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurses accurately documented during each shift on 12/4/25 and 12/22/2025 as per facility's policy and procedures for one of three sampled residents (Resident 1) investigated under quality of care. This deficient practice resulted in Resident 1's medical record containing inaccurate documentation of patient assessment, which had the potential to affect Resident 1's provision of care. During a review of Resident 1's admission Record, dated 9/13/2024, the admission Record indicated Resident 1 had a medical diagnosis of Chronic Respiratory Failure (a serious condition that develops when the lungs cannot get enough oxygen into the blood), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), with tracheostomy (a surgical procedure creating an opening in the neck into the windpipe to provide a direct airway for breathing, often using a tube, used for blockages, long-term ventilation, or secretion clearance) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) in place. During an observation and interview on 12/23/25 at 12:20 p.m. with Certified Nurse Assistant 2 (CNA 2), in Resident 1's room, Resident 1 was observed awake resting in her bed and appeared confused. Resident 1 refused to be interviewed. Resident 1 requested Certified Nurse Assistant 2 (CNA 2) to close the window curtains as the sun was bothering her. CNA 2 was observed closing the window curtains as per Resident 1's request. CNA 2 stated Resident 1 had fluctuating capacity to understand. During an interview on 12/23/2025 at 12:29 p.m. with Licensed Vocational Nurse (LVN) 1, the LVN 1 stated the daily narrative charting for Resident 1 was to be completed only during the night shift (7 p.m.-7 a.m.) by the assigned LVN as per facility document titled, Daily Narrative Charting Schedule, which indicated Resident 1's room to have the daily narrative charting completed during night shift 7pm-7 am. LVN 1 verified there was no narrative charting for Resident 1 on 12/4/25 and 12/22/25 for night shift and day shift completed by the assigned LVNs. LVN 1 stated that a daily narrative charting was important to keep an accurate record of the resident assessments. During an interview on 12/23/2025 at 12:44 p.m. with LVN 2, LVN 2 stated there was a daily narrative charting schedule titled, Daily Narrative Charting Schedule, which indicated the list of room numbers assigned to the LVNs in day shift (7 a.m.-7 p.m.) and the list of room numbers assigned to the LVNs in night shift (7p.m.-7 a.m.). LVN 2 stated that it was important to document a daily narrative charting to have a record of what happens to the patient, their status, if there were any changes or no changes and to communicate with the Registered Nurse and other nurses. During an interview on 12/23/2025 at 1:57 p.m. with the Charge Nurse (CN), the CN verified Resident 1 was missing narrative charting for the dates of 12/4/25 and 12/22/25. CN stated a daily narrative charting was important during each shift to have an accurate documentation record for the residents. During a review of the facility's policy and procedure (P&P) titled, Charting, reviewed on 1/28/2025, the P&P indicated, Charting is a concise legal record of the patient's stay in the hospital. Purpose: to keep a detailed record of the patient's progress and care including admission, medication, treatment and discharge.During each shift, documentation should include, but not be limited: 1. Patient assessment with specific references to the problems and potential problems. 2. Status of IV lines, N/G tube, chest tubes, indwelling catheter and any other line/tubes that may be present.

Based on observation, interview, and record review the facility failed to revise a plan of care for three of three sampled residents (Residents 4, 15 and 22), as indicated in the facility's policy and procedure titled Care Planning by failing to:a. Revise Resident 4's care plan following an unintended and significant 35 lbs. weight loss.b. Revise Resident 15's care plan who had Pneumonia on 11/25/2025.c. Revise Resident 22's care plan who had a weight loss in 10/2025 and 11/2025. These deficient practices had the potential for Residents 4, 15 and 22 to not receive appropriate care treatment and/or services specific to their individual needs. Findings: a. During a review of Resident 4's admission Record (AR), the AR indicated Resident 1 was admitted to the facility 10/21/25 with diagnoses including chronic respiratory failure (lungs cannot adequately oxygenate {supply with oxygen} the blood or remove enough carbon dioxide), chronic obstructive pulmonary disease (lung condition causing breathing difficulties) and heart failure (heart muscle isn't pumping blood effectively). During a review of Resident 4's History & Physical (H&P) dated 10/22/25, the H&P indicated Resident 4 did not have the capacity to make medical decisions. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 11/3/25, the MDS indicated Resident 4's cognition (ability to think and process information) was severely impaired and Resident 4 was dependent for activities of daily of living (ADLs). During a review of Resident 4's Weekly Weights (WW), the WW indicated Resident 4 weighed 229 lbs. on 10/23/25 lbs., 205 lbs. on 11/4/25, and 194 lbs. on 12/8/25. During a record review of Resident 4's Weight Loss Comprehensive Care Plan (WLCP) initiated on 11/9/25, the WLCP indicated Resident 1 had a 24 lbs. weight loss. Resident 4's WLCP did not indicate the WLCP was revised following Resident 4's additional 11 lbs. weight loss on 12/8/25. During a concurrent interview and record review with Licensed Vocational Nurse 2 (LVN 2) of Resident 4's WLCP on 12/16/25 at 3:48 p.m., LVN 2 stated Resident 4's WLCP was updated on 11/9/25 to obtain Resident 4's weekly weights. LVN 2 stated there were no further revisions or updates of Resident 4's WLCP after Resident 4's weight loss on 12/8/25. LVN 2 stated licensed staff were supposed to update/revise the resident's care plan to determine if the care was effective or if licensed staff needed to inform the physician (MD) or the Registered Dietitian (RD) of the current condition of the resident. LVN 2 stated revising the care plan was important to identify if care was effective. During an interview on 12/18/25, at 2:25 p.m., with the Infection Preventionist (IPN), the IPN stated it was important to revise the resident's care plan because that was the primary care plan for the resident so that staff would know what to do, what to implement, plan and how to evaluate and provide proper care. b. During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was admitted to the facility on [DATE], with diagnoses including encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support), dysphagia (difficulty swallowing), and quadriplegia (paralysis from the neck down, including legs, and arms). During a review of Resident 15's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/12/2025, the MDS indicated Resident 15 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 15 was dependent (helper does all of the effort) on staff for eating, oral hygiene, toileting, showering/bathing self, upper/lower body dressing, and personal hygiene. During a review of Resident 15's Radiology Report (RR) result date 11/25/2025, the RR indicated Resident 15 had bilateral multifocal (multiple spots in both lungs) pneumonia with a right-sided effusion (buildup of fluid). During a review of Resident 15's Order Summary Report (OSR) dated 11/26/2025, the OSR indicated for licensed staff to administer Azithromycin (antibiotic medication that destroys microorganisms) Oral Tablet 500 milligrams (mg, unit of measurement) one time a day for pneumonia (an infection/inflammation in the lungs) for five days. During a review of Resident 15's Care Plan (CP) for pneumonia initiated on 8/13/2025, the CP did not indicate Resident 15 had pneumonia on 11/25/2025. During an interview and concurrent record review on 12/19/2025 at 3:17 pm with the Licensed Vocational Nurse 2 (LVN 2) of Resident 15's medical records (PointClickCare - PCC, a cloud-based software), LVN 2 stated Resident 15 had pneumonia on 11/25/2025 and the CP for pneumonia initiated on 8/13/2025 was not revised. LVN 2 stated Resident 15's CP for pneumonia needed to be revised to determine if nursing interventions were effective or not. LVN 2 stated it was the Registered Nurse Supervisor who should revise and update the resident's CP. c. During a review of Resident 22's AR, the AR indicated Resident 22 was admitted to the facility on [DATE], with diagnoses including encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing). During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22 had severely impaired cognition. The MDS indicated Resident 22 was dependent on staff for eating, oral hygiene, toileting, showering/bathing self, upper/lower body dressing, and personal hygiene. During a review of Resident 22's CP for weight loss, revised on 2/11/2025, the CP did not indicate Resident 22 had a weight loss in 10/2025 and 11/2025. During a review of Resident 22's Monthly Weight Record (MWR), the MWR indicated Resident 22 weighed 188 pounds (lbs.- unit of measurement) in 10/2025 and 181 lbs. in 11/2025. During an interview and concurrent record review on 12/16/2025 at 2:56 pm, with LVN 2 of Resident 22's PCC, LVN 2 stated Resident 22 had a weight loss of six lbs. in 10/2025 and seven lbs. in 11/2025 and Resident 22's CP for weight loss that was revised on 2/11/2025 was not revised to reflect the weight loss in 10/2025 and 11/2025. LVN 2 stated Resident 22's CP for weight loss needed to be revised to determine if nursing interventions were effective or not on how to manage Resident 22's weight loss. During an interview on 12/18/2025 at 10:46 am, with the facility's Director of Nursing (DON), the DON stated resident's CP should have been revised if there was a change of condition such as recurrent Pneumonia for Resident 15 and weight loss for Resident 22 to determine if nursing interventions provided were effective or not. During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, reviewed 1/13/2025, the P&P indicated care plans shall be reviewed quarterly and revised PRN (as needed).

Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by failing to label and discard expired food items stored in one of one resident's refrigerator located inside the supply room at the nurse's station.The facility staff did not label food items with resident's name and current date.The facility staff did not remove expired food items from the resident's refrigerator.These deficient practices had the potential to result in foodborne illness (illness caused by consuming contaminated food or beverages) for the residents.Findings: During initial observation of the resident's refrigerator inside the supply room on 12/16/2025 at 12:11 PM, one box of pastries did not have a resident's name, room number or an expiration date, two blueberry yogurts did not have a resident's name or room number, six Ensure Drinks ( nutritional supplement designed as meal replacement or dietary supplement) did not have a resident's name or room number, five assorted flavored gelatin cups inside a white plastic bag was dated 12/08/2025 with Resident 1's name, and one soda bottle dated 10/29 also for Resident 1. During an interview with License Vocational Nurse (LVN 4) on 12/16/2025 at 12:17 PM, LVN 4 stated there were only three residents that their family would leave food for. LVN 4 stated staff would place the food inside the resident's refrigerator. LVN 4 stated all food items inside the resident's refrigerator should include the resident's name, the date when the food item was received and when the item would expire. LVN 4 stated, if a resident ate a food item that has expired/spoiled, the resident could get sick. LVN 4 stated expired food items should be thrown away. LVN 4 stated staff were not supposed to mix expired foods with non-expired foods because expired food could be given to the residents and cause them to get sick. LVN 4 stated, in order to prevent having expired food inside the resident's refrigerator, the food items should be labeled with the resident's name or room number and the open and expired date or use by date. During an interview with the Director of Nursing (DON) on 12/18/2025 at 11:00 AM, the DON stated resident's family and friends could bring food for the residents but the food needed to have the residents name, date received, date of expiration, and if expired the food should be removed from the refrigerator. The DON stated the Dietary Staff and Registered Nurse Supervisor (RNS) should check every shift to ensure there were no expired food inside the resident's refrigerator and if there was, then it should be thrown out. During an interview with the Infection Prevention Nurse (IPN) on 12/18/2025 at 12:02 PM, the IPN stated, if the resident's family brought food, it should be placed inside the resident's refrigerator and labeled with the resident's room number and date of expiration. The IPN stated, if a food item did not have an expiration date, it was not safe to give the food to a resident because it could make them sick and cause stomach problems like nausea, vomiting and/or diarrhea (lose bowel movement). The IPN stated once a food item was placed inside the resident's refrigerator, it was considered to be expired after 72 hours and must be discarded. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition where the lungs gradually become unable to get enough oxygen into the blood), sepsis due to streptococcus pneumonia (a life-threatening condition where the body's extreme response to a bacterial infection damages tissues and organs), major depressive disorder (mood disorder causing persistent sadness, hopelessness, and loss of interest in activities) and paraplegia (paralysis of the legs and lower body). During a review of Resident 1's Order Summary Report (OSR) dated 9/14/2024, the OSR indicated, Regular diet. Pureed (thick liquid suspension) texture, Regular/Thin consistency, puree/thin liquid, 3 meals a day, .1:1 feeder (dedicated caregiver needed to assist with eating) with full aspiration (food enters the airway by accident) precautions. During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 9/16/2025, the MDS indicated Resident 1 had intact cognitive skills (ability to process thoughts) and was dependent (helper does all of the effort to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of the facility's P&P titled, Food: Safe Handling for Foods from Visitors, dated 1/2021, the P&P indicated, Patients will be assisted in properly storing and safely consuming food brought into the hospital for patients by visitors. When food items are intended for consumption, the hospital staff responsible will: Label foods with the patient's name and the current date. During a review of the facility's P&P titled, Use and Storage of Food Brought by Family/Visitors, reviewed 4/23/25, the P&P indicated, It is the right of the residents of this facility to have food brought in by family or other visitors, however the food must be handled in a way to ensure the safety of the resident. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. If not consumed within 3 days, food will be thrown away by the facility staff.

Based on observation, interview, and record review, the facility failed to promote one of one sampled resident (Resident 15) with respect, privacy and dignity in accordance to facility's Policy and Procedure(P&P) titled Promoting/Maintaining Resident Dignity/Quality of Life. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline and lowered self-esteem and self-worth. Findings: During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was admitted to the facility on [DATE], with diagnoses that included encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing), history of urinary tract infection (infection that affects part of the urinary tract) and quadriplegia (paralysis from the neck down, including legs, and arms). During a review of Resident 15's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/12/2025, the MDS indicated Resident 15 had intact cognition (process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 15 was dependent (helper does all of the effort) on staff for eating, oral hygiene, toileting, showering/bathing self, upper/lower body dressing, and personal hygiene. During an observation on 12/16/2025 at 9:20 am with Registered Nurse 1 (RN 1), in Resident 15's room, Resident 15 was awake, lying in bed. RN 1 pulled up Resident 15's gown, checked Resident 15's foley catheter tubing attachment and did not ask permission from Resident 15. Resident 15 stated Oh, wait wait, you did not ask permission. No! During an interview on 12/16/2025 9:22 AM with RN 1, RN 1 stated, RN1 should have asked permission from Resident 15 and explained the procedure to Resident 1. RN 1 stated Resident 15 had the right to refuse care and treatment. During an interview on 12/18/2025 at 10:41 am with the facility's Director of Nursing (DON), the DON stated staff needed to introduce themselves and explain the procedure before touching the resident. The DON stated staff needed to ask consent from the resident to provide privacy and respect. The DON stated residents have the right to refuse and know the care provided to them. During a review of the facility's P&P titled, Promoting/Maintaining Resident Dignity/Quality of Life dated 1/28/2025, the P&P indicated to explain care or procedures to the resident before initiating the activity.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 28)'s discharge destination was coded accurately in the Minimum Data Set (MDS - a federally mandated resident assessment tool). Resident 28 was discharged to a general acute care hospital but was coded as being discharged to Skilled Nursing Facility (SNF - an inpatient rehabilitation and medical treatment center staffed with medical professionals). This deficient practice resulted in inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Resident 28 not receiving interventions to address specific care concerns. Findings: During a review of Resident 28's admission Record (AR), the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that included dependence on respiratory ventilator (machine that helps a person breathe), dependence on supplemental oxygen, and encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for medication/nutritional support). During a review of Resident 28's Physician's Order (PO) dated 11/13/2025, the PO indicated for facility staff to call 911 (phone number used to contact emergency services in the event of a medical emergency) due to resident's fever not relieved by Tylenol (medicine that relieves mild to moderate pain and reduces fever) and cooling measures. During a review of Resident 28's Progress Notes (PN) dated 11/13/2025 at 6:09 am, the PN indicated Resident 28 was transferred to an acute hospital at 6:20 am. During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 28 was discharged to a nursing home/SNF (long term care facility). During a concurrent interview and record review of Resident 28's MDS with MDS Coordinator (MDSC) on 12/17/2025 at 11:39 am, the MDSC stated Resident 28's MDS was coded as discharged to a SNF. The MDSC stated Resident 28 was discharged to an acute care hospital on [DATE] and not to a SNF. The MDSC stated Resident 28's MDS assessment needed to be coded as discharged to an acute hospital. The MDSC stated Resident 28's MDS assessment needed to be coded accurately to provide accurate information to CMS. During an interview with the facility's Director of Nursing (DON) on 12/18/2025 at 10:38 am, the DON stated, MDS assessment needed to be coded accurately to ensure the facility was not sending wrong information to CMS. During a review of the facility's Policy and Procedure (P&P) titled, Minimum Data Set 3.0 Assessment Completion, Transmission and Validation, dated 1/14/2025, the P&P indicated, To develop and modify the resident's plan of care based on the resident's status. The Resident Assessment Instrument (RAI) Coordinator will schedule all OBRA (Omnibus Budget Reconciliation Act) ARD's daily, monthly and as needed. Addendums to the schedule will be provided by the RAI Coordinator to the IDT as needed as it relates to Discharge Assessments and SCSA's (Significant Change in Status Assessments).

Based on observation, interview, and record review, the facility failed to report a change of condition (COC) for symptoms of a urinary tract infection (UTI) to the physician (MD) for one of three sampled residents (Resident 4) with foley catheter (a flexible tube that passes through the urethra and inserted into the bladder to drain urine). Resident 4's foley catheter tubing had cloudy, white urine sediments (bacteria and white blood cells are shed into the urine). This failure had the potential to result in delay of care and treatment of urinary tract infection (UTI) and unmanaged UTI pain.Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 1 was admitted to the facility 10/21/25 with diagnoses including chronic respiratory failure (lungs cannot adequately oxygenate {supply with oxygen} the blood or remove enough carbon dioxide), chronic obstructive pulmonary disease (lung condition causing breathing difficulties) and heart failure (heart muscle isn't pumping blood effectively). During a review of Resident 4's History & Physical (H&P) dated 10/22/25, the H&P indicated Resident 4 did not have the capacity to make medical decisions. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 11/3/25, the MDS indicated Resident 4's cognition (ability to think and process information) was severely impaired and Resident 4 was dependent on activities of daily of living (ADLs). The MDS indicated Resident 4 had an indwelling catheter (foley catheter). During a review of Resident 4's Order Summary Report (OSR) dated 10/22/25, the OSR indicated to monitor foley catheter for hematuria (blood in urine), sediments, foul smelling urine, and color of urine. During a concurrent observation and interview on 12/16/25, at 4:20 p.m., with Licensed Vocational Nurse 2 (LVN 2), white cloudiness was observed in the tubing of Resident 4's indwelling foley catheter. LVN 2 stated the white cloudiness observed in Resident 4's foley catheter tubing could be urine sediments. LVN 2 stated urine sediments could be a sign of infection. LVN 2 stated the tube should be flushed or changed and the physician (MD) notified. LVN 2 stated LVN 2 observed the sediments in the foley catheter tubing this morning but LVN 2 did not report it to the MD as of this interview. LVN 2 stated it was important to report a resident's COC to the MD because the MD would know what interventions to implement to prevent the situation from getting worse. During an interview on 12/17/25 at 9:03 a.m., with the facility's Infection Preventionist (IPN), the IPN stated Resident 4 had a foley catheter due to (d/t) a history of (h/o) Stage 3 pressure ulcer (bedsore involving full-thickness skin loss). The IPN stated nursing staff should have reported the cloudiness observed in Resident 4's foley catheter tubing. The IPN stated the licensed nurse should have flushed or changed the foley catheter tubing. During a subsequent interview with LVN 2 on 12/17/25 at 10:00 a.m., LVN 2 stated LVN 2 observed the cloudiness in Resident 4's Foley tubing around 10:00 a.m. on 12/16/2025. LVN 2 stated LVN 2 did not notify the physician because LVN 2 was all over the place and was asked to complete other tasks. LVN 2 stated the steps LVN 2 should have taken when cloudiness was observed in the foley catheter tubing included notifying the MD, completing a Situation, Background, Assessment, Recommendation (SBAR), initiating a care plan, determining if there was a need for continuing the foley catheter and flushing the foley catheter tubing and changing the bag as needed. During a review of the facility's Policy and Procedure (P&P) titled, Change of Condition- SBAR- ADLs, dated January 2025, the P&P indicated it was the policy of the facility that any changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. The P&P further indicated the facility may use the SBAR process to assess and evaluate the resident's change of condition.

Based on observation, interview, and record review, the facility failed to ensure the Registered Dietitian's (RD) recommendation for one of one sampled resident (Resident 22) to start weekly weights on 11/5/2025 was implemented/carried out and communicated to the physician. This deficient practice had the potential to result in adverse consequences for Resident 22. Findings: During a review of Resident 22's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE], with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for medication/nutritional support), encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing) and anemia (decrease in the total amount of red blood cells in the blood). During a review of Resident 22's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/25/2025, the MDS indicated Resident 22 had severely impaired cognition (mental action or process of acquiring knowledge) for daily decision making. The MDS indicated Resident 22 was dependent (helper does all of the effort) on staff for eating, oral hygiene, toileting, showering/bathing self, upper/lower body dressing, and personal hygiene. During a review of Resident 22's Care Plan (CP) for weight loss revised on 2/11/2025, the CP indicated Resident 22 was at risk for weight loss secondary to chronic medical condition. The CP indicated for nursing staff to monitor Resident 22's weight as ordered, RD consult to adjust diet as needed and to weigh Resident 22 every week as ordered. During a review of Resident 22's Monthly Nutritional Review (MNR) dated 11/5/2025, the MNR indicated weighing Resident 22 weekly to monitor changes. During an observation on 12/16/2025 at 9:13 am while inside Resident 22's room, Resident 2 was asleep lying in bed. During a concurrent record review of the facility's Monthly Nutritional Review dated 11/5/2025 and interview on 12/16/2025 at 2:25 pm with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the RD recommended to monitor Resident 22's weight every week for the month of November 2025. LVN 2 stated there was no clinical documentation that weekly weights were done for Resident 22. LVN 2 stated Resident 22's primary physician was not notified regarding the RD's recommendation. LVN 2 stated weekly weights needed to be monitored to determine if Resident 22 was losing or gaining weight. LVN 2 stated the RD recommendation needed to be communicated to Resident 22's primary physician to prevent significant weight problems on Resident 22. During a concurrent record review of the facility's Monthly Nutritional Review dated 11/5/2025 and interview on 12/17/2025 at 2:03 pm with the facility's RD, the RD stated Resident 22 had a total weight loss of 13 pounds (lbs.) in two months and the RD's recommendation to monitor Resident 22's weekly weight for November 2025 was not carried out nor communicated to the primary physician. The RD stated the RD expected from the staff to follow through the RD's recommendation every month and to notify the primary physician to monitor the resident's weight. During an interview on 12/18/2025 at 10:46 am with the facility's Director of Nursing (DON), the DON stated, RD recommendation for Resident 22 was not followed and the primary physician was not notified with the RD's recommendation to monitor Resident 22's weight weekly for November 2025. The DON stated Resident 22's nutritional needs would not be met and could lead to weight loss or gain if the RD's recommendation was not acted upon. During a review of the facility's Policy and Procedure (P&P) titled, Medical Nutrition Therapy: Nutrition Screening, Assessment and Care Planning dated 1/2021 the P&P indicated, the Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional's recommendations for changes in the nutrition plan of care will be communicated to the licensed nursing team and dining Services Director via the summary recommendation sheet.

Based on observation, interview and record review, one of one License Vocational Nurse (LVN 3) did not flush Resident 23's Gastrostomy Tube (GT- a feeding tube placed directly into the stomach through the abdominal wall, used to deliver nutrition, fluids, and medicine) with water before and after giving medication, to prevent the GT from clogging, to ensure the medication passes, and ensure patency of the GT for future use. This deficient practice had the potential to result in negative consequences for Resident 23.Findings: During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (a condition when the lungs cannot get enough oxygen into the blood), encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing), dysphagia (difficulty swallowing food or liquids) and encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for medication/nutritional support). During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/27/2025, the MDS indicated Resident 23 has severely impaired cognition (mental action or process of acquiring knowledge). The MDS indicated Resident 23 was dependent (helper does all of the effort) to staff for oral hygiene, toileting hygiene, shower, upper/lower body dressing, and personal hygiene. During a review of Resident 23's Order Summary Report (OSR) dated 4/17/2025, the OSR indicated Resident 23 was placed on nothing by mouth (NPO) diet and was on enteral feeding (delivering specially formulated liquid nutrition directly into the stomach through the GT). The order indicated licensed staff may give additional 30 milliliters (ml- unit of measurement) of water during medication pass. During a medication administration observation with LVN 3 for Resident 23 on 12/18/2025 at 9:06 AM, LVN 3 administered the morning medications to Resident 23 via GT without flushing the GT with water before and after each medication. During the same medication observation, LVN 3 did not flush Resident 23's GT with water after all medications had been administered. During an interview with LVN 3 on 12/18/2025 at 9:07 AM, LVN 3 stated LVN 3 did not know if Resident 23 was on fluid restriction and that was the reason why LVN 3 did not flush Resident 23's GT with water during medication administration and once the medication administration was completed. During a concurrent interview with LVN 3 on 12/18/2025 at 9:12 AM, LVN 3 stated after giving all of Resident 23's medications, LVN 3 should have given an additional 30 ml. of water to ensure the medications went into the gastric area and did not stay in the GT. LVN 3 stated if there was not enough water flush after medication administration, the medication would stay in the GT and the GT would get clogged. LVN 3 stated LVN 3 did not flush Resident 23's GT with water in between medications because LVN 3 thought it was too much water for Resident 23. During an interview with the facility's Director of Nursing (DON) on 12/18/2025 at 10:21 AM, the DON stated when the licensed nurse administered medications through the GT, the medications were supposed to be flushed with water after each individual medication was given. The DON stated, the licensed nurse needed to flush the GT with no more than 15 to 20 ml of water before administering the medication, then flush the GT again with 5 to10 ml of water. The DON stated that each medication needed to be given one at a time and the licensed nurse should flush the GT with water. The DON stated the licensed nurse should flush the GT with about 30 ml of additional water to ensure the GT was not clogged and that the medications did not stay in the GT. During an interview with the facility's Infection Prevention Nurse (IPN) on 12/18/2025 at 2:29 PM, the IPN stated licensed nurses were aware that when administering multiple medications through the GT, the licensed nurse should flush the GT with water before and after each medication. The IPN stated licensed staff had to flush the GT in between medication with at least 5 ml. water and even if the medication was mixed with water and had been diluted (weakened by addition of water), the medication still needed to be flushed with water after administration. The IPN stated, if the medication was in a syrup consistency/form, it was not considered as a flushed medication and there should be at least 5m.l of water flushed after administration. The IPN stated if this procedure was not done, it was considered to be a medication administration error. During the same interview with the IPN on 12/18/2025 at 2:32 PM, the IPN stated, the license nurse should flush the GT with 30-60 ml water before and after giving any medication to prevent clogging the GT, to ensure the medicine passed through the GT and to keep the GT clear/patent for future use. The IPN stated, flushing the GT with water in between each separate medication was very important to ensure the intended results of the medications were achieved. During a review of the facility's Policy and Procedure (P&P) titled Medication Administration (Nasogastric, Gastric and Jejunostomy) dated 1/14/2025, the P&P indicated, Flush the tube with approximately 30 ml. of water before and after medication administration. Rinse medication cup and administer rinsing to assure complete dose. Flush in between medication administration 5ml to 10ml of water.

Based on interview and record review, the facility failed to act upon the pharmacist's Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) recommendation for one of five sampled residents (Resident 1) to specify the behavior manifestation to be monitored for Resident 1's routine Xanax (a medication used for the short-term treatment of anxiety disorders and panic disorders) 0.5 milligrams (mg- unit of measurement) QHS (every night at bedtime) for anxiety, ordered on 9/13/2025, for the months of October and November 2025. This deficient practice had the potential for Resident 1 to receive unnecessary medications and result in undesirable or non-therapeutic effect of the medication to the resident. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition where the lungs gradually become unable to get enough oxygen into the blood), sepsis due to streptococcus pneumonia (a life-threatening condition where the body's extreme response to a bacterial infection damages tissues and organs), major depressive disorder (mood disorder causing persistent sadness, hopelessness, and loss of interest in activities) and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease). During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 9/16/2025, the MDS indicated Resident 1 had intact cognitive skills (ability to process thoughts) and was dependent (helper does all of the effort to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 1's Order Summary Report (OSR) dated 10/10/2025, the OSR indicated for licensed staff to give Xanax Oral Tablet 0.25 mg by mouth at bedtime for anxiety. During a review of the MRR for the months of October and November 2025, dated 10/24/25 through 10/24/25 and 11/23/2025 through 11/23/2025, the MRR indicated a note written by the pharmacy consultant to the physician regarding Resident 1 as follows: Please specify the behavior manifestation to be monitored for patient's routine Xanax 0.5mg q HS for anxiety ordered on 9/13/25. Monitor this behavior every shift on the Medication Administration Record (MAR- form used to document and tract medications given to residents) and add in the Xanax order. During an interview with the facility's Director of Nursing (DON) on 12/18/2025 at 10:31 AM, the DON stated Resident 1's medications should be verified by the doctor for specific indication to monitor the behaviors as to why the resident was getting Xanax. The DON stated the monitoring for target behavior for all psychotropic medication (medication used to treat mental health conditions) should be done by the primary nurse, and the resident should be monitored every shift. During the same interview with the DON on 12/18/2025 at 10:42 AM, the DON stated licensed staff needed to monitor Resident 1 to determine if Xanax was effective or not. The DON stated the pharmacist's recommendation was important to acknowledge and for the licensed staff to notify the physician of the pharmacist's recommendation. The DON stated it should not take three months to act upon the pharmacist's recommendation for Resident 1. The DON stated, if the physician has not reviewed the pharmacist's recommendations, it can be emailed or faxed over to the physician. The DON stated the House Supervisor or the Infection Prevention Nurse (IPN) were responsible for calling the physician about the pharmacist's recommendations. The DON stated the purpose of the pharmacist's monthly recommendation was to point out the necessity of the medications and to check for unnecessary medication for the residents (in general). During a review of the facility's Policy and Procedure (P&P) titled Medication Regimen Review dated June 2021, the P&P indicated, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.

Based on observation, interview, and record review, Licensed Vocational Nurse 5 (LVN 5) failed to ensure medications were kept secure by failing to lock one of one medication cart (MedCart) that was left unattended and outside of LVN 5's view while providing medication to Resident 3. This deficient practice had the potential for the residents' medications to be accessible to others not authorized to have access to drugs (medications) and biologicals (drugs derived from natural sources) and increased the risk for loss and medication diversion (illegally redirecting prescription medications from intended patient for personal use). Findings: During medication pass observation on 12/18/2025 at 8:25 AM with LVN 5 in the hallway outside Resident 3's room, LVN 5 left the MedCart in the hallway unlocked. During an interview with LVN 5 on 12/18/2025 at 8:38 AM, LVN 5 stated, I did not lock my MedCart when I went inside the resident's room (Resident 3) to give medications. I should have locked the MedCart and not left it unlocked for safety. During an interview with LVN 3 on 12/18/2025 at 9:26 AM, LVN 3 stated, We (licensed staff) must lock the MedCart for safety and we don't want anyone passing by get access to patients' medications. Locking the MedCart was also to keep patient confidentiality. It was very important to have the MedCart locked if the license nurse walked away. During an interview with the facility's Director of Nursing (DON) on 12/18/2025 at 10:21 AM, the DON stated the MedCart needed to be locked if it was outside of licensed nurse's view. Per the DON, when a nurse is administering medication the medication cart is supposed to be locked if the nurse walks away to prevent people from taking medication, it's for safety. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition where the lungs gradually become unable to get enough oxygen into the blood) and sepsis due to staphylococcus (a life-threatening condition where the body's extreme response to a bacterial infection damages tissues and organs). During a review of Resident 3's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 10/13/2025, the MDS indicated Resident 3 had severely impaired cognitive skills (ability to process thoughts) and was dependent (helper does all of the effort to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. During a review of the facility's Policy and Procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for one of five sampled residents (Resident 24) by failing to wear proper personal protective equipment (PPE, equipment that protects people from injury or illness in hazardous environments) while providing care to Resident 24 who was placed on Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents who are colonized or infected with an multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics] and those at a higher risk of developing a MDRO, such as, residents with wounds or indwelling medical devices). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for Resident 24 and staff that could result in a widespread infection in the facility.Findings: During a review of Resident 24's admission Record (AR), the AR indicated Resident 24 was admitted to the facility on [DATE], with diagnoses that included encounter for attention to gastrostomy (GT, creation of an artificial external opening into the stomach for nutritional support) and encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing). During a review of Resident 24's Order Summary Report (OSR) dated 4/16/2025, the OSR indicated to place Resident 24 on EBP due to presence of tracheostomy. During a review of Resident 24's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/27/2025, the MDS indicated Resident 24 had severely impaired cognition (mental action or process of acquiring knowledge). The MDS indicated Resident 24 was dependent (helper does all of the effort) on staff for eating, oral hygiene, toileting, showering/bathing self, upper/lower body dressing, and personal hygiene. During a review of Resident 24's undated Care Plan (CP) titled Enhanced Barrier Precautions, the CP indicated Resident 24 had a tracheostomy and gastrostomy. The CP indicated for nursing staff to observe infection prevention and control at all times such as frequent handwashing and the use of proper PPE as necessary. During an observation on 12/16/2025 at 9:33 am, Resident 24 was awake lying in bed in Resident 24's room. During a concurrent observation and interview on 12/16/2025 at 9:34 am, Resident 24 was lying in bed. Registered Nurse 1 (RN 1) did not wear gown and clothes while touching Resident 24's bed and bedding while assessing Resident 24 GT site. RN 1 stated RN 1 did not wear a protective gown while doing assessment with Resident 24. During an interview on 12/16/2025 at 1:43 pm with the Infection Preventionist Nurse (IPN, a healthcare professional who specializes in preventing the spread of infections in healthcare settings), the IPN stated staff needed to wear gown, gloves and mask before touching Resident 24 who was on EBP to avoid the spread of infection from staff to other residents. The IPN stated staff needed to wear appropriate PPE because residents (in general) were susceptible to infection and to prevent cross contamination (the process by which bacteria or other microorganisms are transferred from one substance or object to another). During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 1/14/2025, the P&P indicated, Refer for the use of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices. Initiation of EBP - wounds and/or indwelling medical devices (central lines, hemodialysis, urinary catheters, feeding tubes, tracheostomy/ventilator tubes even if the resident is not known to be infected or colonized with a MDRO.

Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 days after a change of condition for one of one sampled resident (Resident 4). This deficient practice placed Resident 4 at risk for delayed implementation of clinical interventions.Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 1 was admitted to the facility 10/21/25 with diagnoses including chronic respiratory failure (lungs cannot adequately oxygenate {supply with oxygen} the blood or remove enough carbon dioxide), chronic obstructive pulmonary disease (lung condition causing breathing difficulties) and heart failure (heart muscle isn't pumping blood effectively). During a review of Resident 4's History & Physical (H&P) dated 10/22/25, the H&P indicated Resident 4 did not have the capacity to make medical decisions. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 11/3/25, the MDS indicated Resident 4's cognition (ability to think and process information) was severely impaired and Resident 4 was dependent for activities of daily of living (ADLs). During a review of Resident 4's Order Summary Report (OSR) dated 11/9/25, the OSR indicated weekly weights for four weeks due to (d/t) 24 pounds (lbs.) weight loss. The OSR dated 10/22/25 indicated weekly weight x four (for four times) for gain/loss of 5 lbs. During a review of Resident 4's Weekly Weights (WW), the WW indicated Resident 4 weighed 229 lbs. on 10/23/25 lbs., 205 lbs. on 11/4/25, and 194 lbs. on 12/8/25. During a concurrent interview and record review of Resident 4's clinical record on 12/16/25 at 3:41 p.m., with Licensed Vocational Nurse 2 (LVN 2), there was no Situation, Background, Assessment, Recommendation (SBAR) completed and LVN 2 stated there should be an SBAR completed for Resident 4. LVN 2 stated there should be an SBAR for every change of condition on a resident. LVN 2 stated a resident must have an SBAR, so staff will be aware of the condition of the resident and what interventions needed to be done. During the same record review, there was no change of condition comprehensive assessment MDS completed indicating Resident 4's 24 lbs. weight loss on 11/4/2025 and additional 11 lbs. weight loss on 12/8/25. During an interview, on 12/18/25, at 2:25 p.m., with the Infection Preventionist (IPN), the IPN stated it was important to complete a change of condition assessment as the primary plan of care for the resident so that staff would know what to do, what to implement, plan and how to evaluate and provide necessary care. During a record review of the facility's Policy and Procedure (P&P), titled, Change of Condition-SBAR- ADLs, dated January 2025, the P&P indicated it is the policy of the facility that any changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. The P&P further indicated the facility may use the SBAR process to assess and evaluate the resident's change of condition.

Based on observation, interview, and record review, the facility failed to: a. Ensure the oxygen cannula (tubing used to deliver oxygen) was connected to the tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person breathe) with a T-Bar (a T shaped device) for one of one sampled resident (Resident 4). b. Follow the physician's order for tracheostomy care for one of one sampled resident (Resident 16) These deficient practices placed Residents 4 and 16 at risk for complications of shortness of breath and infection. Findings: a. During a review of Resident 4's Face Sheet (FS), the FS indicated the facility admitted Resident 4 on 3/26/2024 with diagnoses that included encounter for attention to tracheostomy and pneumonia (an infection/inflammation in the lungs). During a review of Resident 4's Physician Order (PO) dated 3/26/2024, the PO indicated an order for licensed staff to apply continuous oxygen at two (2) liters per minute (L/min) via T-bar with humidifier. During a review of Resident 4's Care Plan (CP) for Gas Exchange initiated on 3/26/2024, the CP indicated Resident 4 was at risk for impaired gas exchange related to respiratory failure (a condition when the lungs cannot get enough oxygen into the blood). The care plan interventions included for staff to administer oxygen as ordered. During a review of Resident 4's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/13/2024, the MDS indicated Resident 4 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 4 was dependent (helper does all of the effort) with eating, oral hygiene and toileting hygiene. During an observation on 10/15/2024 at 12:18 pm, with Registered Nurse Supervisor 1 (RN 1), Resident 4 was awake, lying in bed. Resident 4's oxygen tubing was observed not connected to the tracheostomy T- bar. The RN 1 stated Resident 4's oxygen tubing needed to be connected to the T-bar for Resident 4 to receive the desired oxygen needed as ordered. During an interview on 10/18/2024 at 8:59 am with the facility's Assistant Director of Nursing (ADON), the ADON stated oxygen tubing needed to be connected to the T-bar to ensure the desired oxygen needed by Resident 4 was administered as ordered. During a record review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, reviewed on 1/13/2024, the P&P indicated, oxygen therapy is administered as ordered by the physician. The P&P indicated to connect cannula or Tracheostomy piece to humidifier outlet via its connecting tube or corrugated tubing. 40037 b. During a review of Resident 16's FS, the FS indicated Resident 16 was readmitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide ) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a review of Resident 16's Physician Order (PO) dated 9/8/2024, the PO indicated an order for tracheostomy care with 10 percent (%) strength hydrogen peroxide ( H2O2- a chemical compound, a colorless liquid often used as a bleaching agent, antiseptic, and oxidizer) plus normal saline pat dry and apply drain sponge every shift, by Respiratory Therapist (RT- a healthcare professional who treats patients with breathing problems or lung disorders), During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16 had unclear speech, rarely/never understood others and made self-understood. Resident 16 was dependent (helper does all of the effort) for personal hygiene and showering/bathing self. During an observation on 10/15/2024 at 10:20 am, in Resident 16's room, Resident 16 was lying in bed. Resident 16 had tracheostomy and the resident's breathing was supported by a ventilator (a machine that helps a person breathe or breathe for a person). During an interview on 10/16/2024 at 12:51 pm, Respiratory Therapist 1 (RT 1) stated, RT 1 used only NS to provide tracheostomy care for Resident 16. RT 1 stated, RT 1 did not use H2O2 plus NS to clean Resident 16's tracheostomy. RT 1 stated, RT 1 was not aware that the physician ordered H2O2 and NS for Resident 16's tracheostomy care. RT 1 stated, RT 1 should check and follow Resident 16's physician's order to use H2O2 to clean Resident 16's tracheostomy. RT 1 stated, H2O2 prevent tracheostomy infection from bacteria accumulating around the surgical opening. RT 1 stated, if the resident's tracheostomy site got infected, the resident could get sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury) and result in hospitalization . During an interview on 10/16/2024 at 1:18 pm, Respiratory Therapy Supervisor (RTS) stated, RT 1 should check the physician's order first before providing tracheostomy care to Resident 16. RTS stated, H2O2 was used for cleaning to prevent infection. RTS stated, if the resident's tracheostomy was not cleaned properly, the resident could get infected. During a review of the facility's Policy and Procedure (P&P) titled Tracheostomy Stoma (surgical opening) Care, reviewed 1/13/2024, the P&P indicated Clean stoma with hydrogen peroxide and normal saline by wiping gauze from center of stoma outwards and then discard.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for two of three sampled residents (Residents 2 and 123 ). These failures had the potential for complications related to tube feedings for Residents 2 and 123. Findings: a. During a review of Resident 123's Face Sheet (FS), the FS indicated Resident 123 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that occurs when the lungs could not exchange enough oxygen and carbon dioxide in the body), dependence on ventilator (a medical device to help support or replace breathing) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach) malfunction. During a review of Resident 123's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/22/2024, the MDS indicated Resident 123 had severely impaired cognition (ability to understand) and dependent (helper did all of the effort, resident did none of the effort to complete the activity) with eating, oral/toileting hygiene, and personal hygiene. The MDS indicated Resident 123 required feeding tube for nutrition. During a review of Resident 123's Physician's Orders (PO), dated 9/5/2024, the PO indicated Resident 123 had an order for gastrostomy care with half strength hydrogen peroxide (H2O2) and normal saline (NS, a saltwater solution), pat dry and apply drain sponge every shift. During a review of Resident 123's Care Plan (CP) titled Resident Care Plan for Impaired Skin Integrity dated 9/7/2024, the CP indicated Resident 123 had an impaired skin integrity to the gastrostomy site. The CP indicated to provide good skin care, to keep the affected area clean and dry and to do treatment as ordered. During a review of Resident 123's Treatment Administration Record (TAR), the TAR indicated gastrostomy care was done on 10/14/2024 and 10/15/2024. During a concurrent observation and interview on 10/15/2024 at 10:58 am with licensed vocational nurse (LVN) 1 inside Resident 123's room, Resident 123 had a GT site with dislodged drain sponge dressing. LVN 1 stated the gastrostomy dressing was not clean and the GT site was red and dirty around the stoma. LVN 1 stated Resident 123's GT site should be kept clean and covered with drain sponge dressing to prevent skin irritation and infection. b. During a review of Resident 2's FS, the FS indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, dependence on ventilator, and gastrostomy. During a review of Resident 2's PO dated 7/14/2024, the PO indicated Resident 2 had an order for gastrostomy care with half strength H2O2 and NS, pat dry and apply drain sponge every shift. During a review of Resident 2's untitled CP dated 7/14/2024, the CP indicated Resident 2 had an enteral tube for feeding/hydration and/or medication. The CP indicated to keep the affected area clean and dry at all times, perform enteral tube care every shift and as needed when soiled, moist, or falls off and apply a drain sponge around the tube, secure with tape, date and initial dressing. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognition and dependent with eating, oral/ toileting hygiene, shower, upper and lower body dressing and personal hygiene. The MDS indicated Resident 2 required feeding tube for nutrition. During a review of Resident 2's TAR, dated 10/15/2024, the TAR indicated gastrostomy care was done on 10/14/2024 and 10/15/2024. During a concurrent observation and interview on 10/15/2024 at 11:02 am with LVN 1 inside Resident 2's room, Resident 2 had a GT site with no drain sponge dressing in place and the GT site was not clean. LVN 1 stated Resident 2's GT site should be kept clean and covered with drain sponge dressing to prevent skin irritation and infection. During an interview on 10/17/2024 at 11:59 am with the Assistant Director of Nursing (ADON), the ADON stated GT site should be kept clean as ordered and covered with drain sponge dressing to absorb moist and leaking around the stoma and to prevent skin irritation and infection of the resident. During a review of the facility's Policy and Procedure (P&P) titled, Gastrostomy and PEG Tube Care Of and Changing, dated 1/12/2024, the P&P indicated Apply a 4 x 4 split gauze pad around the tube, and secure with paper tape. Change gauze, render skin care at bedtime or more often when soiled or moist (or per physician order).

Based on interview and record review the facility failed to provide information on Advance Directive (AD- a process of communication between individuals and their healthcare agents for future healthcare decisions when individuals are no longer able to make their own healthcare decisions) for three of three sampled residents (Residents 6,14, and 20) in accordance with the facility's policy on Advance Directives. These failures had the potential for facility staff to provide medical treatment against the residents' will. Findings: a. During a review of Resident 20's Face sheet (FS), the FS indicated the facility initially admitted Resident 20 on 8/23/2024 and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) and encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing). During a review of Resident 20's Minimum Data Set Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/27/2024, the MDS indicated, Resident 20 had severe cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 20 was dependent (helper did all of the effort, resident did none of the effort to complete the activity) with oral hygiene, toileting hygiene, shower/bathing self, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent interview and record review of Resident 20's medical records (chart) on 10/15/2024 at 11 am with the facility's Assistant Director of Nursing (ADON), the ADON stated she could not find the Advance Directive Acknowledgement Form in Resident 20's chart. The ADON stated, there was no clinical documentation that AD was discussed and identified if Resident 20 had previous AD completed prior to admission. The ADON stated, the form needed to be in the resident's chart for accessibility to determine Resident 20's wants and wishes. 40438 b. During a review of Resident 6's FS, the FS indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure and dependence on ventilator (a medical device to help support or replace breathing) During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had severely impaired cognition. The MDS indicated Resident 6 was dependent with eating, oral, toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a concurrent interview and record review on 10/15/2024 at 11:40 am with the Assistant Director of Nursing 2 (ADON 2), Resident 6's Physician Orders for Life-Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life) dated 11/29/2023 and Advance Directive Acknowledgment of Receipt were reviewed. Resident 6's POLST indicated, Resident 6 did not have an AD. ADON 2 stated there were no documented evidence that the resident and/or responsible party was provided with information on how to formulate an AD and discussed the resident's rights to make decisions regarding care in the facility. ADON 2 stated all residents should have an AD acknowledgement receipt upon admission, for the staff to determine how to provide care to the resident while in the facility. 40037 c. During a review of Resident 14's FS, the FS indicated Resident 14 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had no speech, rarely/never understood others and made self-understood. The MDS indicated Resident 14 was dependent with personal hygiene and shower/bathing self. During a review of Resident 14's medical record, there was no AD in the resident's medical record and there was no acknowledgement provided. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, reviewed on 1/18/2024, the P&P indicated, upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive. The P&P indicated all advance directive document copies will be obtained and located (identify the same section of the resident's medical record that would be readily retrievable by any facility staff.)

Based on observation, interview, and record review, the facility failed to follow it's policy and procedure on storing, preparing, distributing and serving food in accordance with professional standards for food service safety, proper sanitation and food handling practices by failing to ensure: 1. Thawed meat was stored on the top shelf in one of one refrigerator. 2. Stored food items were labeled and dated when it was first opened, in one of three kitchen freezers. These deficient practices had the potential risk for food borne illnesses (infections caused by ingesting contaminated food or beverages). Findings: 1. During an initial tour of the kitchen on 10/15/2024 at 9:34 am, together with Dietary Aid 1 (DA 1), one bag of uncooked meat and one bag of uncooked sausage being thawed were placed on the top shelf of the refrigerator. There were16 pieces of uncovered sliced bread placed on a tray on the second shelf immediately below the uncooked meat and sausage being thawed. The DA 1 stated, thawed meat should not be placed or thawed on top of the bread because blood from the thawed meat and sausage might drip on the bread. 2. During an initial tour of the kitchen on 10/15/2024 at 9:36 am, together with DA 1, one two-pound (lbs.- unit of measurement) bag of whole corn kernel, 20 lbs. of penne pasta and one gallon of liquid marinade did not have a label or date of when it was first opened. DA 1 stated all open food items should be labeled and dated once used and re stored. During an interview on 10/16/2024 at 9:49 am with Dietary Supervisor (DS), the DS stated, bread should not be stored below a raw meat for it could cross contaminate (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). The DS stated, all food items needed to have a label with date open to keep track of how long the food item was opened. During an interview on 10/16/2024 at 12:19 pm with the Kitchen District Manager (KDM), the KDM stated uncooked meat could not be mixed with ready to eat food. The KDM stated, bread should not be thawed together with uncooked meat in the refrigerator due to the risk of cross contamination. During a review of the facility's Policy and Procedure (P&P) titled, Food Preparation, dated 1/2021, the P&P indicated thawing in the refrigerator, in a drip-proof container, an in a manner that prevents cross-contamination. During a review of the facility's P&P titled, Food Storage: Cold Foods, dated 1/2021, the P&P indicated all foods will be stored wrapped or on covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. During a review of the facility's P&P titled, Food Storage: Dry Goods, dated on 1/2021, the P&P indicated storage areas will be neat, arranged for easy identification and date marked as appropriate.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for two of two sampled residents (Residents 2 and 123) by failing to ensure the residents' call lights were within reach and appropriate to the resident's physical ability. These deficient practices had the potential for Residents 2 and 123 not to receive necessary care or received delayed services to meet their needs. Findings: a. During a review of Resident 123's Face Sheet (FS), the FS indicated Resident 123 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that occurs when the lungs could not exchange enough oxygen and carbon dioxide in the body) and dependence on ventilator (a medical device to help support or replace breathing). During a review of Resident 123's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/22/2024, the MDS indicated Resident 123 had severely impaired cognition (ability to understand). The MDS indicated Resident 123 was dependent (helper did all of the effort, resident did none of the effort to complete the activity) with eating, oral, toileting hygiene, and personal hygiene. During a review of Resident 123's untitled Care Plan (CP) dated 9/5/2024, the CP indicated Resident 123 needed assistance with activities of daily living (ADLs). The CP indicated an approach plan to ensure the call light was within reach of the resident at all times. During a concurrent observation and interview on 10/15/2024 at 11:04 am with Certified Nurse Assistant 1 (CNA 1) inside Resident 123's room, CNA 1 stated, Resident 123's call light was hanging on the wall. CNA 1 stated the resident's call light should be placed closed to the resident's strong arm or hand so the resident could call in case of emergency. b. During a review of Resident 2's FS, the FS indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure and dependence on ventilator. During a review of Resident 2's untitled CP dated 7/14/2024, the CP indicated Resident 2 needed assistance with ADLs. The CP indicated an approach plan to ensure the call light was within reach of the resident at all times. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had an intact cognition. The MDS indicated Resident 2 was dependent with eating, oral, toileting hygiene, shower, upper and body dressing, and personal hygiene. During a concurrent observation and interview on 10/15/2024 at 11:08 am with Licensed Vocational Nurse 2 (LVN 2) inside Resident 2's room, LVN 2 stated, Resident 2's call light was hanging on the wall. LVN 2 stated the resident's call light should be placed on the resident's strong arm or hand so the resident could call for help and staff could address their needs timely. During an interview on 10/17/2024 at 12:04 pm with Assistant Director of Nursing 1 (ADON 1), ADON 1 stated Residents 2 and 123 had a touch sensitive call light because of the residents' medical condition. ADON 1 stated, the resident's call light should be placed on the resident's strong extremity so the resident could call whenever they needed help and staff would attend to their needs timely and immediately. During a review of the facility's Policy and Procedure (P&P) titled, Call Light, reviewed 1/18/2024, the P&P indicated, The patient's call light is always to be placed within his easy reach.

Based on observation, interview, and record review, the facility failed to ensure the resident's indwelling catheter (foley catheter - thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) bag was covered and provided the resident privacy in accordance with the facility's policy on Urinary Catheter, Insertion and Care for one of one sampled resident (Resident 17). This deficient practice had the potential to result in psychosocial (mental and emotional well-being) decline and lowered self-esteem and self-worth for the resident. Findings: During a review of Resident 17's Face sheet (FS), the FS indicated the facility initially admitted Resident 17 on 12/10/2018 and readmitted on [DATE] with diagnoses that included bladder (stores urine) disorder and urinary tract infection (UTI- infection that affects any part of the urinary tract). During a review of Resident 17's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/17/2024, the MDS indicated Resident 17 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 17 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, shower/bathing self, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 17's Physicians Order (PO) dated 9/30/2024, the PO indicated for licensed staff to insert foley catheter French (a type of catheter) 16 (size of the catheter) for neurogenic bladder (impaired bladder function resulting from damage to the nerves that govern the urinary tract). During a review of Resident 17's Care Plan (CP) for foley catheter initiated on 9/30/2024, the CP indicated Resident 17 had a foley catheter for neurogenic bladder. The care plan interventions included for staff to ensure a dignity bag was in placed for Resident 17. During an observation on 10/15/2024 at 10:19 am, inside Resident 17's room, Resident 17 was awake, lying in bed with foley catheter bag hanging on the right side of the bed, uncovered and without a dignity bag (privacy bag). During a concurrent observation and interview on 10/15/2024 at 10:32 am with the facility's Assistant Director of Nursing (ADON), the ADON stated, foley catheter bag needed to be covered with a privacy bag to provide dignity to the resident. During an interview on 10/15/2024 at 10:51 am, Resident 17 stated I want my foley catheter bag inside the privacy bag. During a review of the facility's Policy and Procedure (P&P) titled, Urinary Catheter, Insertion and Care, revised 1/13/2024, the P&P indicated to place the drainage bag inside the dignity bag.

Based on interview and record review, the facility failed to notify the State Long Term Care Ombudsman (public advocate) of the Notice of Proposed Transfer and Discharge for one of three sampled resident's (Resident 22) transfer to the General Acute Hospital (GACH) on 8/8/2024 in accordance with facility's policy on Transfer and Discharge (Including Against Medical Advice [AMA].) This deficient practice had the potential to violate Resident 22's right to ensure for an appropriate discharge/transfer from the facility. Findings: During a review of Resident 22's Facesheet (FS), the FS indicated the facility admitted Resident 22 on 4/8/2024 with diagnoses that included encounter for attention to tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) and pneumonia (an infection/inflammation in the lungs). During a review of Resident 22's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 7/18/2024, the MDS indicated Resident 22 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 22 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, shower/bathing self, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 22's Physicians Order (PO) dated 8/8/2024, the PO indicated to discharge Resident 22 via 9-1-1 (emergency services) for fluctuating oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage). During a concurrent interview and record review of Resident 22's Medical Records (chart) on 10/17/2024 at 10:58 am with the facility's Medical Records staff (MR), MR stated there was no Notice of Proposed Transfer/Discharge Form completed. The MR stated, there was no clinical documentation that the Notice of Proposed Transfer/Discharge Form was completed, and the State Long Term Care Ombudsman was notified of Resident 22's transfer to GACH on 8/8/2024. During a concurrent interview and record review of Resident 22's chart on 10/17/2024 at 1:22 pm with the facility's Assistant Director of Nursing (ADON), the ADON stated Resident 22 was transferred to GACH via emergency care for fluctuating oxygen saturation on 8/8/2024. The ADON stated the family member and State Long Term Care Ombudsman needed to be notified upon resident's transfer to GACH. The ADON stated the purpose of the notice was to determine where the resident will be transferred. During a review of the facility's Policy and Procedure (P&P) titled Transfer and Discharge Including AMA, dated 7/24/2024, the P&P indicated for emergency transfers/discharges, provide transfer notice as soon as practicable to resident and representative. The P&P indicated, Social Services Director or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly visit.

Based on interview and record review, the facility failed to ensure one (1) out of three (3) sampled residents (Resident 1) was supervised by the facility's staff member at all times, to prevent accidents during a family member's visit, in accordance with the facility's policy and procedure. Resident 1 was left unsupervised by staff in the activity room with a family member and fell on the floor from her (Resident 1) wheelchair, after leaning forward to take a photo, on 3/24/22. This deficient practice resulted in Resident 1 falling out of the resident's wheelchair and on to the floor during family visitation. Resident 1 sustained a laceration (cut) on her left arm and a non-displaced hairline fracture (one in which the bone cracks or breaks but retains its proper alignment) in the lateral (from the side) segment of the left 10th rib (bones surrounding the lungs). Findings: A review of Resident 1's Face Sheet (document which contains personal information of the resident) indicated that Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical (H&P), dated 12/1/21, the H&P indicated, Resident 1 was admitted with [CONDITION(S)] exacerbation (worsening of a breathing condition), ventilatory-dependent [CONDITION(S)] (a medical condition wherein a person's lungs are dependent on a medical equipment to perform breathing functions), status-post [CONDITION(S)] (a procedure of creating an opening through the front of the neck into the windpipe), hypertension (elevated blood pressure), and anxiety (a feeling of worry, nervousness, or unease). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/1/21, indicated Resident 1 was able to make herself understood and was able to understand others. Resident 1 required total dependence with 2-person physical assist with bed mobility, transfer, and dressing. Resident 1 required 2-persons physical assist when transferring to or from bed to wheelchair. Resident 1 has posture control while sitting on the wheelchair. During an interview on 4/7/22, at 11:10 a.m., the Director of Nursing (DON) stated Resident 1 had a visit with her (Resident 1) mother in the facility's activity room, on 3/24/22. During the visit, Resident 1 repositioned herself (Resident 1) in her (Resident 1) wheelchair and leaned forward to take a photo, Resident 1 fell on to the floor. DON stated the incident (Resident 1's fall) was unwitnessed. DON said, Resident 1's mother reported to a facility staff who was outside the activity room. DON stated, Resident 1 sustained a laceration (cut) on her left arm from the fall. DON stated, Resident 1 complained of left upper abdominal (stomach area) pain on 3/25/22 and an X-ray (a photographic/digital image of the body's internal composition) revealed a hairline fracture on the 10th rib. During an interview on 4/22/22, at 11:57 a.m., Director of Nursing (DON) stated, the Restorative Nursing Assistant (RNA, a person with special training in restorative care which entails helping to attain and implementing strategies to increase strength capacity) left the activity room during visitation to assist a certified nursing assistant with providing bath to another resident. DON stated, this was against protocol as one staff must always monitor visitation to ensure safety practices including infection control and social distancing. RNA was responsible in supervising Resident 1 while Resident 1 was in a wheelchair in the activity room with the visitor. During an interview on 5/2/22, at 10:45 a.m., with nurse manager (NM), NM stated, RNA was aware of the facility's visitation guideline that staff must remain with residents to ensure safety. NM stated, upon interview with RNA, RNA said he (RNA) left the room during visitation because She's (Resident 1) alert. NM said, upon counseling, RNA stated, I accept. It's my fault. A review of Resident 1's Fall Risk Assessment, dated 11/27/21, revised on 2/28/22, the Fall Risk Assessment indicated, Resident 1 scored 10 and 14, which placed her (Resident 1) at high risk for fall due to her (Resident 1) ambulation (ability to walk) status, gait (walk) balance, and number of medications. A review of Resident 1's Risk for Fall (Care Plan), dated 11/27/21, the Care Plan indicated, Resident 1 was At risk for fall, injuries r/t B&B (bowel and bladder) incontinence, unsteady gait, chronic/acute condition makes unstable. The Care Plan indicated, Approach Plan, Assess resident for propensity of falls. A review of Resident 1's Physician's Orders, dated 3/24/22, indicated, Left lower arm laceration. Cleanse with NS (normal saline, solution used for cleaning wounds), pat dry, paint with [MEDICATION(S)] (antiseptic liquid solution) and cover with foam dressing q (every) shift times (x) 14 days. Resident 1 to be monitored for 72 hours (hrs.) neuro check (neurological check, assessment of reflexes to determine impairment after a fall (S/P Fall). A review of Resident 1's Nursing Progress Notes, dated 3/24/22, indicated, Resident 1 was found on the floor sitting during visitation. Body check done to left lower arm noted with laceration/cut, slight bleeding. A review of Resident 1's Nursing Progress Notes, dated 3/25/22, indicated, Resident 1 felt a little pain on the left side under her (Resident 1)'s breast. A review of Resident 1's Physician's Orders, dated 3/25/22, indicated, an order for stat (immediate) X-ray (a photographic/digital image of the body's internal composition) of the left (L) rib (S/P Fall). A review of Resident 1's Radiology Report, dated 3/25/22, indicated, Nondisplaced hairline fracture in the lateral segment of the left 10th rib. A review of the facility's policy and procedure (P&P) titled, Visitation Policy During COVID-19 Pandemic, revised 3/15/21, indicated, Visitation will be supervised at all times by a staff member.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in a sanitary manner to ensure food safety and prevent the potential for food borne illness for 5 residents who consumed meals prepared by the facility. The facility failed to store eggs, meat, and tuna according to industry standards.The cumulative effects of these system failures presented a situation where potential for a high harm (food borne illness) was likely to occur in the very near future if immediate action was not taken. To effectively reduce the occurrence of food-borne risk factors, food service operators develop and implement food safety management systems to prevent, eliminate or reduce the occurrence of food-borne illness risk factors. The US Food and Drug Administration (FDA) Food Code identifies a preventative rather than a reactive approach to food safety through a continuous system of monitoring and verification. Control measures essential to food safety, such as proper cooking, cooling, and refrigeration. For example, raw eggs that are broken should be used for immediate service. Approximately a dozen unpasteurized eggs were pre-cracked (raw shell eggs that were manually cracked) and pooled (raw unpasteurized eggs that have been cracked and combined together) in a container kept in the refrigerator. According to the American Egg Board, the practice of pooling unpasteurized eggs posed an increased risk of serving eggs possibly contaminated with salmonella enteritis and an increased risk of infection. Additionally, defrosting meat was found stored above to ready to eat foods, posing a cross-contamination (the contamination or potential contamination of food by contact with potentially hazardous foods or substances) risk. A jar of tuna salad had an expiration date of approximately three weeks after it was prepared, which had the possibility to spoil due to the extended expiration date. On January 11, 2011 at 2:20 p.m., the facility's administrator (Staff C), director of nurses (Staff D), clinical nurse manager (Staff E), and the dietary supervisor (Staff B) were notified of the Immediate Jeopardy situation to protect the facility's highly susceptible residents from the high potential for food borne illness. On January 11, 2011 at 5:10 p.m., the facility submitted an acceptable Immediate Plan of Correction which included the following: discarding tuna salad, pooled eggs, rearranging thawing meat inside a refrigerator to prevent cross-contamination, and revising the facility's policy and procedure on "Dietary Food Service Receiving and Handling" (after the IJ was declared). In-services on safe food handling were provided to the kitchen staff by Staff B. On January 11, 2011 at 5:15 p.m., Staff B, Staff C, and Staff D were notified the Immediate Jeopardy was abated. In addition to the Immediate Jeopardy situation, the facility also failed to follow the facility's standard regarding labeling and dating of foods, personal items were found in the kitchen area, chemicals were found in the kitchen area, the floor and counter tops were dirty, and chipped paint was found near clean dishes. Findings: 1. On January 11, 2011, between 9:15 a.m. and 11:30 a.m., during an initial tour and observation of the facility's kitchen accompanied by a food services worker (Staff A), the following was observed: a. In the refrigerator across from the stove was inspected and a tray of approximately a dozen unpasteurized eggs that were pre-cracked and pooled in a container were kept in the refrigerator. The tray was found on the bottom shelf without a date. On January 11, 2011, Staff B was interviewed at 9:50 a.m. Staff B stated the eggs are cracked a day before they are to be used. Staff B stated the eggs in the tray were cracked a day before and were to be used for breakfast on January 12, 2010. Staff B stated that he saw nothing wrong with the pooling of eggs in a tray. On January 11, 2011 at 11:15 a.m., Staff A stated that it was common practice to crack the eggs a day before there were to be cooked. Staff A stated the kitchen served eggs daily and the eggs were cracked a day before they were cooked. b. In the refrigerator across from there food preparation table, defrosting meat was observed in a tray directly over ready to drink individual cups of juice. Raw uncooked bacon was in a tray directly over an ill covered bin of ready to eat sliced zucchini. A pan of defrosting fajita meat was adjacent to a pan of cooked steam rice. In the same refrigerator, a personal cup of liquid which belonged to Staff B, was found on the shelf. On January 11, 2011 at 9:55 a.m., Staff B observed the refrigerator and the thawing meats. When interviewed at 9:56 p.m., Staff B stated he did not see anything wrong with the location of the defrosting meats in relation to ready to eat foods. On January 11, 2011 at approximately 11:20 a.m., in an interview with Staff B, he stated he did not have a policy and procedure on safe food handling of eggs or the safe thawing of raw meat. The kitchen's rear refrigerator was inspected and a plastic jar of tuna salad was found. The jar was labeled "January 30, 2011." On January 11, 2011 at approximately 9:30 a.m., Staff A stated the tuna salad was made on January 8, 2011 and they are told by the director of dietary services that tuna salad had an expiration date of thirty (30) days after the tuna salad was made. c. On January 11, 2011 at approximately 2 p.m., the tuna salad remained in the refrigerator and the tray pooled eggs remained where they were first observed; however, they had been dated as January 12, 2011. d. On January 11, 2011, a container of meatloaf was found in the freezer labeled "use by December 30, 2010." At approximately 9:34 a.m., an interview was conducted with Staff A. Staff A stated the meatloaf was going to be cooked and served on January 19, 2010 (approximately nineteen (19) days after the "use by date"). On January 11, 2011, at approximately 9:45 a.m., an interview was conducted with the director of dietary services (Staff B). Staff B stated the dates on the food products are the "use by date" and the meat loaf was to be cooked and served on January 19, 2010. Staff B stated the meatloaf was expired and tuna salad was good for fourteen (14) days after it was prepared. On January 11, 2010 at 2:20 p.m., the survey team declared a state of Immediate Jeopardy (IJ) due to unsafe dietary practices resulting in high potential for food-borne illness. The facility's practice of egg pooling; thawing of raw meats over and adjacent to ready to eat foods; the use of tuna salad after the manufacturer's recommended expiration date; and the lack of the kitchen's staff knowledge of safe food handling resulted in a high potential for food-borne illness to the residents and jeopardized their health and well-being. The facility's administrator (Staff C), director of nurses (Staff D), clinical nurse manager (Staff E), and the dietary supervisor (Staff B) were informed of the IJ. According to the United States Department of Agriculture: Food Safety and Inspection Service's Basics for Handling Food Safely, to prevent food-borne illnesses tuna salad should be stored in a refrigerator for 3 to 5 days (http://www.fsis.usda.gov/factsheets/basics_for_handling_food_safely/index.asp). According to the 2009 "Food Code" published by the Food and Drug Administration showed to crack only raw eggs that will be used for immediate service. According to the American Egg Board, eggs should be used immediately after cracking and facilities should avoid pooling of eggs to prevent food-borne illnesses (http://www.aeb.org/foodservice-professionals/egg-safety). On January 11, 2011 at 5:05 p.m., Staff C stated policies were created and revised to reflect proper food handling of raw eggs, raw meats, and tuna salad. On January 11, 2011 a review of the facility's policy and procedure titled "Dietary Food Service Receiving and Handling" revised on January 11, 2011 (after the IJ was declared), stipulated that raw eggs were never to be cracked before the time and day they were to be used. The "Dietary Food Service Receiving and Handling" policy indicated that tuna salad would be labeled with a 3 day expiration date from the date it was prepared. The policy stipulated that raw meat would be separated from prepared foods and raw meats would be placed on the bottom shelf and prepared foods on the top shelf to prevent cross-contamination. On January 11, 2011 at 5:10 p.m., the facility submitted an acceptable Immediate Plan of Correction which included the following: the discarding tuna salad and pooled eggs, rearranging thawing meat inside the refrigerator to prevent cross-contamination, and revising the facility's policy and procedure on "Dietary Food Service Receiving and Handling" (after the IJ was declared). In-services on safe food handling were provided to the kitchen staff by Staff B. On January 11, 2011 at approximately 5:13 p.m., during the kitchen inspection, the tuna salad was discarded, the pooled eggs were discarded, and the thawing meat was rearranged to prevent cross-contamination. The IJ was abated on January 11, 2011 at 5:15 p.m. in the presence of Staff B, Staff C, and Staff D. 2. On January 11, 2011, between 9:15 a.m. and 11:30 a.m. during the intial tour of the kitchen, the following was observed: a. Various seasoning shakers were observed on a rack open and not dated with the open date. On January 11, 2011 at approximately 9:17 a.m. during an interview, Staff A stated she was not sure whether the seasoning should have been dated with the open date. b. A box of allergy medication and a bottle of [MEDICATION NAME] medication was observed on the food sink counter top. c. An electric pencil sharpener was found on the food preparation table. Pencil shavings were observed on the counter top approximately 1 foot from where food was prepared. Pencil shavings were observed directly on a rack of clean knives and potato peelers. d. An open bottle of soy sauce was observed without an open date label on the bottle. On January 11, 2011 at approximately 9:20 a.m., an interview was conducted with Staff A regarding the open bottle of soy sauce. Staff A stated she was not sure how long the bottle had been open. e. Under a food preparation sink, a can of enamel spray paint was observed next to a basket of onions. f. The kitchen's floor was generally dirty with debris and food particles. At approximately 9:22 a.m., Staff A stated the floors were cleaned once a week. g. During an interview on January 11, 2011 at approximately 9:50 a.m., Staff B was observed without a hair net while in the kitchen area. A review of the facility's policy and procedure titled, "Dietary Food Service: Dietary Service/Cafeteria/Tray Line Personnel" dated May 16, 2004 stipulated that personal belongings were never to be placed in the kitchen or in any food preparation area. A review of the facility's policy and procedure titled "Dietary Cleaning and Sanitation" dated January 11, 2007 stipulated that all staff were required to wear hair nets. The policy indicated that all eating and service areas were to be maintained clean at all times. h. On January 13, 2010, during a tray line observation at 11:25 a.m., there was peeling paint and a chipped wall adjacent to where clean plates and covers were stored. The peeling paint posed a potential danger of contamination of the clean plates from the chipped wall.