Every finding on record at Whittier Hospital Medical CTR D/P SNF

Based on observation, interview and record review, the facility failed to ensure proper food storage and infection control practices were implemented in accordance with the facility's Policy and Procedure (P&P) titled Standards for storing food and supplies, and Infection Control - Food and Nutrition Services by failing to: 1. Ensure thermometers were kept inside refrigerators 1 and 2. 2. Ensure a pitcher of pre-made iced tea was not left in the refrigerator beyond safe use by date of 6/8/2026. 3. Ensure Dishwasher (DW) 2 used the correct test strip to test for the quaternary ammonium (QUAT-a quaternary ammonium, a type of sanitizing solution used to sanitize food contact surfaces) sanitizer. 4. Ensure dishwashing machine temperature was checked for PM shift on 6/8/2026 and ensure the dishwashing machine thermometer is working appropriately. The deficient practice had the potential to place the facility's residents at risk to consume expired, spoiled and contaminated food and increased the risk for the facility's residents to develop food-borne illnesses (any sickness caused by eating or drinking food contaminated with harmful germs or toxic chemicals). 1. During a concurrent kitchen tour and interview on 6/9/2026 at 9:40 AM with the Director of Food and Nutrition Services (DFN), there was no thermometer visible in refrigerators 1 and 2. The DFN stated there should be thermometers inside the refrigerators because that was what the kitchen staff use to ensure the temperatures inside the refrigerators matches the external gauges and document them in the temperature logs. The DFN stated, by checking the temperature and maintaining the temperature logs, they can ensure that the refrigerators are working appropriately. During an interview on 6/9/2026 at 9:42 AM with the Dietary Supervisor (DS), the DS stated, they just replaced old refrigerators and forgot to put the thermometers back inside the refrigerators. 2. During a concurrent observation and interview on 6/9/2026 at 9:44 AM with the DFN in the kitchen, a pitcher labeled Iced tea only and labeled with a prepared date of 6/4/2026 and use by date of 6/8/2026 was observed in refrigerator 2. The DFN stated, today is 6/9/2026, and the pitcher should have been discarded on 6/8/2026. During an interview on 6/10/2026 at 11:05 AM with the DFN, the DFN stated, if expired food or drink was left in the refrigerator, there was a potential risk that the service staff could serve the expired food or drink to all of the residents in the facility. 3. During a concurrent kitchen tour and interview on 6/9/2026 at 10:23 AM with the DFN, there are two sink areas. The DFN stated, there is one three-compartment sink area where they clean and sanitize cooking pots and pans manually (by hands) and another separate area where they clean and sanitize the residents' dishes and utensils using the dishwasher. During a concurrent observation and interview on 6/9/2026 at 10:38 AM with Dishwasher 2 (DW2) and the Director of Food and Nutrition (DFN) in the threecompartment sink area, DW 2 demonstrated how he normally tested the pink chemical sanitizing solution in one of the sink compartments. DW2 removed a paper test strip from a bottle labeled Ecolab Chlorine Test Strip and dipped it into the sanitizing solution. The test strip did not change color. DW2 stated that the strip was supposed to turn purple as soon as it was dipped into the solution. During the same concurrent observation and interview, the DFN observed the testing bottle and stated that the testing bottle expired in 2019. The DFN added, the testing strip that DW 2 used is not the correct testing strip to use. The DFN stated they are currently out of the correct testing strips. During an interview on 6/9/2026 at 10:47 AM with the DFN, the DFN stated, if the sanitizing solution is tested with the wrong testing strips, the facility cannot ensure that the solution is within the expected range. The DFN stated if the solution is not within the expected range, there could be potential for food contamination and the risk of food-born illnesses. 4. During a review of the facility's record titled Dishwasher machine Temperature Log for June 2026, the log indicated there was no temperature check for PM on 6/8/2026. During a concurrent observation and interview on 6/9/2026 at 9:50 AM with Dishwasher (DW) 1 and the Maintenance Manager (MM), DW 1 demonstrated her usual method for checking the dishwasher's operating temperature. After running a wash cycle, DW 1 reported that the dishwasher thermometers showed a Wash temperature of 165 F and a Rinse temperature of 180 F. The MM stated that DW 1 had misread the gauges and clarified that the dishwasher thermometers indicated the actual temperatures were 135 F for Wash and 152 F for Rinse. The MM further stated that these temperatures were below the acceptable ranges of 150-165 F for Wash and 160-190 F for Rinse. The MM added that he would request maintenance service for the dishwasher machine from the supply company. During an interview on 6/9/2026 at 9:55 AM with DW 1, DW 1 stated, the temperatures had been below the accepted range for a while, and it usually took a few wash cycles for about more than 30 minutes to increase the temperatures to the accepted range. During an interview on 6/9/2026 at 10:20 AM with the Maintenance Manager (MM) and the Director of Nutrition and Food Services (DFN), the MM stated that the dishwasher machine should always be functioning properly. The DFN stated that she expected DW 1 to notify DFN immediately when DW 1 first noticed that the machine was taking more than 30 minutes to reach the acceptable temperature range. The DFN further stated that the dishwasher must operate correctly to ensure proper sanitization of residents' dishes and utensils, preventing contamination and foodborne illness. During a concurrent interview and record review on 6/10/2026 at 11:10 AM with the DFN, the facility's Dishwasher machine Temperature Log for June 2026, was reviewed. The DFN stated that the log is used to make sure the temperature of the dishwasher was at the accepted temperature to ensure sanitation for all washing cycles (wash, rinse and final rinse) before washing the dishes after each mealtime. The DFN stated that the cook was new, and he forgot to check the temperature before washing the dinner dishes. The DFN stated that the dishwasher machine temperatures need to be checked to make sure it is working appropriately and ensure all dishes and utensils are clean for residents' use. During a review of the facility's policy and procedures (P&P) titled, Standards for storing food and supplies, reviewed 3/2021, the P&P indicated: All leftover items are covered, labeled and dated. Prepared leftover items are used within 48-72 hours unless frozen for later use. Reliable thermometers are kept in visible areas in all refrigerators, freezers and dry rooms. Temperature logs are maintained. During a review of the facility's P&P titled Infection Control - Food and Nutrition Services, reviewed 5/2024, the P&P indicated: a) all utensils and equipment are cleaned and sanitized with diluted Ecolab Oasis 146 Multi-Quat Sanitizer daily. Sanitizer concentration should be between 150-400 PPM. Strips are used to determine the proper sanitation range of the sanitizer; b) Food and Nutrition Services will ensure proper maintenance and operation of equipment. Any necessary repairs are requested of Maintenance for follow up.

Based on interview and record review, the facility failed to report to the physician irregularities (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) and to address the use of Sertraline (an antidepressant medicine used to treat depression [a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities] and other mental health conditions) on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of five residents (Resident 21) in accordance with the facility policy. These deficient practices had the potential to place Resident 21 at risk for significant adverse effects (also known as side effects - undesired, unwanted, or dangerous effects that a drug may have, such as nausea and sleep problem) from the use of unnecessary antipsychotic drugs, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. During a review of Resident 21's admission Record (AR), the AR indicated that Resident 21 was admitted to the facility on [DATE] with diagnosis that included depression. During a review of Resident 21's [NAME] Data Set (MDS, a resident assessment tool), dated 4/26/2026, the MDS stated, Resident 21's cognition (ability to think, remember, and reason) is intact and Resident 21 was dependent (helper does all of the effort, resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to compete the activity) in eating, toileting hygiene and personal hygiene. The MDS indicated Resident 21 is taking high-risk drug class (a group of medications with a heightened potential to cause significant patient harm, severe side effects, or death if misused, miscalculated, or administered in error) for antidepressant. During a review of Resident 21's Order Summary Report (OSR), the OSR indicated that on 12/11/2025 the physician ordered staff to administer 125 mg (milligram, unit of weight) or 6.5 ml (milliliter, unit of volume) of Sertraline HCL solution (20 mg/ml) by mouth every night at 9 PM for a diagnosis of depression. The OSR did not indicate the specific behaviors or symptoms exhibited by Resident 21 that were associated with the diagnosis of depression, and there was no order directing staff to monitor for any specific behavior associated with the condition. During a review of Resident 21's Medication Regimen Review (MRR), dated 1/6/2026, 2/5/2026, 3/9/2026, 4/2/2026, 5/2/2026, and 6/4/2026, the MRR did not indicate any irregularities identified or reported to the physician and DON for Resident 21's use of Sertraline. The MRRs also indicated that there was no documented rationale supporting the continued use of Sertraline for Resident 21. During an observation on 6/9/2026 at 12:05 PM in Resident 21's room, Resident 21 was lying in bed watching his iPad. During a concurrent interview and record review on 6/11/2026 at 12:47 PM with the facility's Pharmacist (PHARM 1), Resident 21's MRR dated 1/6/2026, 2/5/2026, 3/9/2026, 4/2/2026, 5/2/2026, 6/4/2026, were reviewed. PHARM 1 stated that when completing monthly MRR, they rely solely on the attending physician's progress notes and the psychiatrist's notes. PHARM 1 that that the facility's pharmacy consultants only considered information from nursing staff if there are significant changes observed in the resident. PHARM 1 stated, the pharmacists were responsible to review the medications, and the physician was responsible to complete the rationale on whether to continue the medication or not. During a concurrent interview and record review on 6/11/2026 at 1:24 PM with the facility's Case Manager (CM), Resident 21's electronic health record and physical chart related to the use of Sertraline since admission on [DATE], was reviewed. The CM stated that the last time Resident 21 was seen by the psychologist was on 9/20/2026. The CM stated that she could not find any documentation from the attending physician and the psychiatrist that justified the continuous use of Resident 21's Sertraline. During a concurrent interview and record review on 6/11/2026 at 2:52 PM with the Chief Nursing Officer (CNO), Resident 21's MRR dated 1/6/2026, 2/5/2026, 3/9/2026, 4/2/2026, 5/2/2026, 6/4/2026, were reviewed. The CNO confirmed that the pharmacist did not identify the lack of specific behavior monitoring for Resident 21's use of Sertraline in the monthly written reports to the facility. The CNO stated, the behavior should be specific to Resident 21 because each resident will manifest depression differently. The CNO stated, there should be documented rationale to justify the continued use of Resident 21's prescribed Sertraline. The CNO confirmed that not having specific behavior monitoring and justification for the continued use of Sertraline will lead to inaccurate monitoring, inability to measure the effectiveness of psychotropic medications, potentially causing unnecessary use and more harm than benefit to Resident 21. During a review of the facility's policy and procedures (P&P) titled, Psychotropic Medication Use in Pediatric Subacute, dated 6/2024, the P&P indicated the use of psychotropic medications for a specific behavior or manifestation of disordered thought process is to be identified in the patient's health record by the physician. The P&P indicated a physician's order is to be written for each specific psychotropic drug indicating the behavior for which the drug is being used. A new physician's order is required to continue the medication and must specify the number of days and rational for use. The P&P indicated the care plan of each patient will identify the specific behavior disorder, with type of psychotropic medication and common side effects to observe for and to document the effectiveness of the psychotropic medication and any adverse reaction or side effect will be noted in the nursing note and in the Behavioral/Intervention Flow Sheet each time the drug is given. Nursing will tabulate behaviors during the weekly summary report. The P&P indicated a summary of all the all the medications given and behaviors observed, the effectiveness of the drug will be noted weekly in the Weekly Summary.

Based on observation, interview, and record review, the facility did not provide privacy for one of one sampled resident (Resident 1) reviewed for dignity when Resident 1's nephrostomy bag (a clear bag thatcollects your pee (urine) from your kidney) was exposed. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline, resident's individuality, self-esteem, and self-worth. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including urinary tract infection (an infection in any part of your urinary system) and epileptical spasm (a rare but severe type of seizure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/05/2026, the MDS indicated Resident 1's cognition (ability to understand and make decisions) could not be assessed. The MDS indicated Resident 1 was dependent (helper does all) with eating, oral hygiene, toileting, shower, upper and lower body dressing. During an observation on 6/09/2026 at 10:29 AM in Resident 1's shared room (4 residents observed in the room), Resident 1 was observed lying in bed with privacy curtains pulled back leaving Resident 1 exposed to the other residents in the room. Resident 1's nephrotomy bag was observed hung on the right side of the bed without a dignity bag (a discreet, fabric or vinyl sleeve used to conceal the clear urine collection bag). During a concurrent observation and interview on 6/09/2026 at 10:31 AM in Resident 1' room with Registered Nurse Clinical Manager (RNCM), RNCM stated Resident 1's nephrostomy bag did not have a dignity bag leaving it exposed to the other residents and visitors in the room since Resident 1's privacy curtain was pulled back, leaving Resident 1 exposed to passersby. were pulled open as well. During an interview on 6/11/2026 at 12:42 PM with Chief Nursing officer (CNO), CNO stated the facility had purchased dignity bags to over Residents foley catheter (a thin, flexible, sterile tube inserted into the bladder to drain urine) and nephrostomy bags. CNO stated dignity bags should be placed over the urine drainage bag to protect the resident's dignity. CNO stated the facility had not developed a policy for placing a dignity bag over the urine drainage bag, but the use of a dignity bag was facility practice and should be implemented by all of the staff to ensure the residents privacy.

Based on observation, interview, and record review, the facility failed to ensure one of ten dishwashers were competent in their duties when Dishwasher 2 (DW 2) did not know the proper sanitizer test strip to use for the quaternary ammonium (QUAT-a quaternary ammonium, a type of sanitizing solution used to sanitize food contact surfaces) sanitizer and when DW 2 did not know the procedure for testing strength of the quaternary ammonium sanitizer. This deficient practice had the potential to result in unsafe and unsanitary food production and could affect residents who were served food from the facility kitchen. During a concurrent kitchen tour and interview on 6/9/2026 at 10:23 AM with the Director of Food and Nutrition Services (DFN), two sink areas were observed. The DFN stated, there is one three-compartment sink area where they clean and sanitize cooking pots and pans manually (by hands) and another separate area where they clean and sanitize the residents' dishes and utensils using the dishwasher. During a concurrent observation and interview on 6/9/2026 at 10:38 AM with Dishwasher 2 (DW) 2 and the DFN in the three-compartment sink area, DW2 demonstrated how he normally tested the pink chemical sanitizing solution in one of the sink compartments. DW 2 removed a paper test strip from a bottle labeled Ecolab Chlorine Test Strip and dipped the test strip into the sanitizing solution. The test strip did not change color. DW 2 stated that the strip was supposed to turn purple as soon as it was dipped into the solution. DW 2 also stated that he did not know how long he was supposed to keep the test strip in the solution. DW 2 stated, he could not remember the last time he received in-service training on testing the sanitizing solution. During the same concurrent observation and interview, the DFN observed the testing bottle and stated that the testing bottle already expired in 2019. The DFN stated, the testing strip that DW 2 used is not the correct testing strip to use. The DFN stated they are currently out of the correct testing strips, which is the QUAT sanitizer testing strips. The DFN stated, DW 2 is required to be competent in checking the sanitizing solution to make sure the sanitizing solution remains in the critical 150-400 parts per million (PPM-unit of concentration measurement) range because if the solution is too weak, it fails to kill pathogens, risking foodborne illness. During a concurrent interview and record review on 6/9/2026 at 11:05 AM with the DFN, the DFN stated that there was no skill check in place for verifying QUAT sanitizing solution. The DFN stated that she would provide in-service training to all staff on the proper procedure for checking QUAT sanitizing solution. During an interview on 6/9/2026 at 10:47 AM with the DFN, the DFN stated, if the sanitizing solution is tested with the wrong testing strips, the facility cannot ensure that the solution is within the expected range. The DFN stated if the solution is not within the expected range, there could be potential for food contamination and the risk of food-born illnesses (any sickness caused by eating or drinking food contaminated with harmful germs or toxic chemicals). During a review of the facility's policy and procedures (P&P) titled Dishwasher Job Description, dated 8/2018, the P&P indicated the dishwasher is responsible in cleaning and sanitizing of equipment, dishes, utensils, and physical environment of the department. Clean and sanitize utensils, cups, plates, pots, pans, and trays by hand and/or machine. During a review of the facility's P&P titled Infection Control - Food and Nutrition Services, reviewed 5/2024, the P&P indicated: All utensils and equipment are cleaned and sanitized with diluted Ecolab Oasis 146 Multi-Quat Sanitizer daily. Sanitizer concentration should be between 150-400 PPM. Strips are used to determine the proper sanitization range of the sanitizer.

Based on interview and record review, the facility's failed to meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, and ensure the required committee members (Thedirector of nursing (DON), The Medical Director or his/her designee, The Infection Preventionist (IP), and at least three other staff, one of whom must be the facility's administrator, owner, board member) were inregular attendance of the facilities quality assessment and assurance (QAA) meetings. This deficient practice had the potential to affect all of the facilities 22 residents residing in the facility. Findings: During an interview on 6/11/2026 at 12:45 PM with Chief Nursing Officer (CNO), CNO stated she was covering for the facilities DON since the DON was on leave since May 2026. CNO stated the facilities last QAA meeting had been held in May but she was unable to attend due to scheduling conflicts. During a concurrent interview and record review on 6/11/2026 at 12:45 PM with CNO of the facility's QAA meeting attendance sign in sheets were reviewed. The sign in sheets indicated the following: 1.QAA meeting sign-in sheet dated 7/10/2025 did not indicate facilities DON or covering DON, Infection Preventionist (IP), or facility administrator or board member were in attendance. 2. QAA meeting sign in sheet 12/18/2026 did not indicate facilities DON or covering DON, Infection Preventionist (IP), or facility administrator or board member were in attendance 3. QAA meeting sign in sheet 5/07/2026 did not indicate facilities Infection Preventionist (IP), or facility administrator or board member were in attendance. During an interview and record review on 6/11/2026 at 12:50 PM with CNO stated she was the one who attended the facilities QAA meetings acting as the board member/administrator, but had been unable to attend the meetings that were held on 710/2025,12/18/2025 and 5/07/2025 due to scheduling conflicts. CNO stated she was aware QAPI committee meetings had to occur quarterly, but due to scheduling conflicts the facility was unable to schedule them on time that was why they were held past the indicated regulatory time of quarterly. CNO stated the facility must have the required members meet on time to ensure appropriate coordination and evaluation of facilities QAPI program, and to ensure implementation of QAPI meetings per the federal regulations. During a review of the facility's Policy and Procedure (P&P) titled Performance Improvement Plans, revised 2/2026, the P&P indicated the purpose was to serve as a framework to describe all performance improvement activities within the organization that foster safety and quality of care, treatment, and services. The P&P indicated methods used to gauge the organization through collection data and analysis that lead to prioritized improvement activities. The P&P authority and responsibility of the governing body was ultimately responsible and accountable for oversight and priority setting for the safety and quality of care, treatment, and services provided.

Based on interview and record review, the facility failed to review the infection prevention and control program (IPCP) annually in accordance with the facility's policies and procedures (P&P) titled, Pediatric Subacute Infection Prevention Program 2024-2025. The deficient practice had a potential for the IPCP to fail in ensuring quality and compliance with recommended guidelines and practices. During an interview on 6/10/2026 at 1:25 PM with the Infection Prevention Nurse (IPN), the IPN stated, the facility's infection control policies and procedures are reviewed every three (3) years. The IPN stated she could not remember the last time she reviewed the facility's infection prevention and control program (IPCP). During concurrent interview and record review on 6/11/2026 at 3:15 PM with the Chief Nursing Officer (CNO), the facility's Pediatric Subacute Infection Prevention Program 2024-2025, undated, was reviewed. The IPCP indicated the program was developed for the year 2024-2025. The CNO stated they are using an outdated IPCP, and the IPCP should be reviewed and revised in 2025 to be used for the period of 2025-2026. The CNO stated, the IPCP is required to be reviewed and updated to ensure quality and compliance with recommendation and practice guidelines. The CNO stated, she did not know that the IPCP is required to be reviewed annually. During a record review of the facility's policies and procedures (P&P) titled, Pediatric Subacute Infection Prevention Program 2024-2025, undated. The P&P indicated: -The infection prevention and control program is part of an overall commitment in quality. The purpose of the infection prevention and control plan is to identify infections, opportunities for disease transmission, implementation of prevention and control interventions and education to reduce the incidences of infection and provide a safe environment for the residents, families and staff on the Pediatric Subacute. -The Pediatric Subacute infection prevention and control plan will be reviewed annually and as needed to ensure quality and compliance with recommendation and practice guidelines.

Based on observation, interview, and record review, the facility failed to ensure the facility's medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, to yield an overall medication error rate of 8 % for one (1) of three (3) sampled residents (Resident 16) observed during medication administration (med pass). This deficient practice had the potential to result in adverse reactions (undesired effect of a drug or other type of treatment), ineffective treatment, worsening of Resident 16's condition, or potentially serious harm or injury. Findings: During a review of Resident 16's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension (is when the pressure in your blood vessels is too high), pulmonary hypertension (high blood pressure in the arteries of the lungs). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 5/03/2026, the MDS indicated Resident 16's cognition (ability to understand and make decisions) could not be assessed. The MDS indicated Resident 6 was dependent (helper does all) with eating, oral hygiene, toileting, shower, upper and lower body dressing. During a review of Resident 16's Order Summary Report dated 6/11/2026, the Order Summary Report indicated the following physician's order: 1.Miralax 8.5 grams (unit of measurement) daily via G-tube (a medical device inserted through the abdomen directly into the stomach) for a diagnosing of constipation, mix with 4-8 ounces of water. 2. Multivitamin chewable tab pediatric 1 time a day via G-tube During a medication pass observation on 6/10/2026 at 9:52 AM with Registered Nurse (RN) 3, RN 3 was observed administering Miralax powder that was mixed in 2 ounces of water. After the administration of Miralax to Resident 16, RN 3 proceeded to flush Resident 16's G-tube with water and then administering Multivitamin via G-tube. After administering Resident 16's Multivitamin that was in a medication cup, the medication cup was observed with left over multivitamins at the bottom and around the medication cup. there was observed medication left in medication cup on the bottom and around the cup. During a concurrent observation and interview with RN 3 on 6/10/2026 at 10:05 AM, RN 3 stated she did not administer all of Resident 16's multivitamin because the multivitamin clumps up and was hard to administer all of the medication via G-tube. RN 3 stated the reason she did not give Resident 16's Miralax with 4-8 ounces of water was because Resident 16 was on fluid restrictions. During a follow-up interview and record review of Resident 16's medical record on 6/11/2026 at 2:30 PM with Registered Nurse Clinical Manager (RNCM), RNCM stated there was no active or canceled order of fluid restrictions in Resident 16's medical record. During an interview on 6/12/2026 at 4:20 PM with the Chief Nursing Officer (CNO), the CNO all licensed nurses administering medications should follow the medication orders to prevent potential undesired side effects. CNO stated RN 3 should have rinsed the medication cup with extra water to ensure of all Resident 16's multivitamin. CNO stated if RN3 thought Resident 16 was on fluid restrictions she should have called Resident 16's physician to clarify the order to ensure Resident 16 gets his medications as prescribed by the physician. During a review of the facility's Policy and Procedure (P&P) titled, Medication Pass, revised 5/2024, the P&P indicated, Administration preparation 1.The 6 rights of medication administration will be observed when administering medications to patients C. right dose of medications

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for one (1) of three (3) sampled residents (Residents 16) observed for medication administration by failing to: Administer Resident 16's Miralax (a medication used to treat chronic constipation) with 4-8 ounces of water as ordered by the physician. Administer all of Resident 16's multivitamin This deficient practice resulted in Resident 16 not receiving medications as ordered by the physician, which could negatively affect the residents' overall wellbeing. Findings: During a review of Resident 16's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension (is when the pressure in your blood vessels is too high), pulmonary hypertension (high blood pressure in the arteries of the lungs). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 5/03/2026, the MDS indicated Resident 16's cognition (ability to understand and make decisions) could not be assessed. The MDS indicated Resident 6 was dependent (helper does all) with eating, oral hygiene, toileting, shower, upper and lower body dressing. During a review of Resident 16's Order Summary Report dated 6/11/2026, the Order Summary Report indicated a physician's order for: 1.Miralax 8.5 grams (unit of measurement) daily via G-tube (a medical device inserted through the abdomen directly into the stomach) for a diagnosis of constipation, mix with 4-8 ounces of water. 2. Multivitamin chewable tab pediatric 1 time a day via G-tube During a medication pass observation on 6/10/2026 at 9:52 AM with Registered Nurse (RN) 3, RN 3 was observed administering Miralax powder with 2 ounces of water and then proceeded to flush Resident 16's G-tube with water and then administering Multivitamin via G-tube. After administering the Multivitamin, the medication cup was observed with left over medication at the bottom and throughout the medication cup. During a concurrent interview with RN 3 on 6/10/2026 at 10:05 AM, RN 3 stated she did not administer all of Resident 16's multivitamin because it clumped up and was hard to give all of the medication via G-tube. RN 3 stated the reason she did not give Resident 16's Miralax with 4-8 ounces of water was because Resident 16 was on fluid restrictions. During a follow-up interview and record review of Resident 16's medical record on 6/11/2026 at 2:30 PM with Registered Nurse Clinical Manager (RNCM), RNCM stated there was no active or canceled order of fluid restrictions in Resident 16's medical record. During an interview on 6/12/2026 at 4:20 PM with the Chief Nursing Officer (CNO), the CNO stated all licensed nurses administering medications should follow the medication orders to prevent potential undesired side effects. CNO stated RN 3 should have rinsed the medication cup with extra water to ensure all of Resident 16's multivitamin was administered without any medications left over in the medication cup. CNO stated if RN 3 thought Resident 16 was on fluid restrictions she should have called Resident 16's physician to clarify the order to ensure Resident 16 was administered his medications as prescribed by the physician. During a review of the facility's Policy and Procedure (P&P) titled, Medication Pass, revised 5/2024, the P&P indicated, Administration preparation 1.The 6 rights of medication administration will be observed when administering medications to patients C. right dose of medications

Based on observation, interview and record review, the facility failed to ensure one (1) of five (3) sampled residents' (Resident 21) drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) in accordance with the facility's policy and procedure by failing to ensure: 1. Resident 21 had a specific, measurable target behavior related to the use of Sertraline (an antidepressant medicine used to treat depression [a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities]). 2. Resident 21 was monitored for the number of specific occurrences of behavior that was associated with the use of Sertraline. These deficient practices had the potential to place Resident 21 at risk for significant adverse effects (also known as side effects - undesired, unwanted, or dangerous effects that a drug may have, such as nausea and sleep problem) from the use of unnecessary antipsychotic drugs, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. During a review of Resident 21's admission Record (AR), the AR indicated that Resident 21 was admitted to the facility on [DATE] with diagnosis that included depression. During a review of Resident 21's [NAME] Data Set (MDS, a resident assessment), dated 4/26/2026, the MDS stated, Resident 21's cognition (ability to think, remember, and reason) is intact and Resident 21 was dependent (helper does all of the effort, resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to compete the activity) in eating, toileting hygiene and personal hygiene. The MDS indicated Resident 21 is taking high-risk drug class (a group of medications with a heightened potential to cause significant patient harm, severe side effects, or death if misused, miscalculated, or administered in error) for antidepressant. During a review of Resident 21's Order Summary Report (OSR), the OSR indicated that on 12/11/2025 the physician ordered staff to administer 125 mg (milligram, unit of weight) or 6.5 ml (milliliter, unit of volume) of Sertraline HCL solution (20 mg/ml) by mouth every night at 9 PM for a diagnosis of depression. The OSR did not identify the specific behaviors or symptoms exhibited by Resident 21 that were associated with the diagnosis of depression, and there was no order directing staff to monitor for any specific behavior associated with the condition. During a review of Resident 21's Interdisciplinary Team Review of Chemical/Physical restraints (IDTR), the IDTR indicated that IDT meeting was held on 4/17/2026 to review chemical restraint by the use of Sertraline. The ITDR indicated the outcomes of restraint use for the period of 1/17/2026 to 4/17/2026 was left blank. During an observation on 6/9/2026 at 12:05 PM in Resident 21's room, Resident 21 was lying in bed watching in his iPad. During a concurrent interview and record review on 6/10/2026 at 2:55 PM with the Registered Nurse Clinical Manager (RNCM), Resident 21's care plan (CP) was reviewed. The RNCM stated, there was no CP addressing the resident's depression or outlining how staff should monitor the specific behaviors associated with the condition. During an interview on 6/11/2026 at 10:22 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she was the LVN in charge of Resident 21. LVN 1 stated, Resident 21 has been receiving Sertraline for his depression since his admission in 2025. LVN 1 stated Resident 21's depression presented as talking less than usual or refusing to get up into his wheelchair. LVN 1 stated, she only documented in Resident 21's medical record whether the resident was up in his wheelchair or not. During an interview on 6/11/2026 at 10:28 AM with LVN 2, LVN 2 stated that she is familiar with Resident 21 and has cared for him in the past. LVN 2 stated that her understanding of Resident 21's depression was that he would not want to wake up in the morning and would refuse care. LVN 2 stated, Resident 21 had not refused any care from her. During a concurrent record review and interview on 6/11/2026 at 10:34 AM with Registered Nurse (RN) 1, Resident 21's medical record for behavior monitoring was reviewed. RN 1 stated that when Resident 21 was depressed, he would refuse food and would not want to interact with her. RN 1 also stated that there was no monitoring in place for any specific behaviors associated with Resident 21's diagnosis of depression. During a concurrent interview and record review on 6/11/2026 at 2:52 PM with the Chief Nursing Officer (CNO), the CNO stated that for each psychotropic medication used, there must be a clearly identified behavior that the medication is intended to address. The CNO added that the behavior should be specific to Resident 21, as each resident may exhibit depression differently. The CNO further explained that staff should be aware of and monitor the same identified behavior to ensure consistency, noting that consistent monitoring and documentation are essential to determining whether the medication is effective and not causing more harm than benefit. The CNO stated that there should be a documented rationale to justify the continued use of Sertraline for Resident 21 and confirmed that the lack of specific behavior monitoring leads to inaccurate assessments and an inability to measure the effectiveness of psychotropic medications, potentially resulting in unnecessary use and greater harm than benefit to the resident. During a review of the facility's policy and procedures (P&P) titled, Psychotropic Medication Use in Pediatric Subacute, dated 6/2024, the P&P indicated the following: -The use of psychotropic medications for a specific behavior or manifestation of disordered thought process is to be identified in the patient's health record by the physician. -A physician's order is to be written for each specific psychotropic drug indicating the behavior for which the drug is being used. A new physician's order is required to continue the medication and must specify the number of days and rational for use. -The care plan of each patient will identify the specific behavior disorder, with type of psychotropic medication and common side effects to observe for. -Documentation of the effectiveness of the psychotropic medication and any adverse reaction or side effect will be noted in the nursing note and in the Behavioral/Intervention Flow Sheet each time the drug is given. Nursing will tabulate behaviors during the weekly summary report. -A summary of all the all the medications given and behaviors observed, the effectiveness of the drug will be noted weekly in the Weekly Summary.

Based on interview and record review, the facility failed to ensure its staff adhere to the facility's infection control program in accordance to its policy and procedure when three of three sampled residents were found to have a positive rhinovirus (a common cause of the common cold) result within a four day period. This deficient practice had the potential to result in putting residents and staff at risk for more transmissions of infections within the facility.During a record review of Resident 1's History and Physical (H&P), dated 09/02/2025, the H&P indicated Resident 1 was admitted to the facility on [DATE]. The H&P indicated Resident 1's medical history included, but was not limited to, Trisomy 21 (a genetic condition that causes intellectual delays and potential health issues like heart defects), cerebral palsy (a group of permanent disorders affecting movement, muscle tone, and posture caused by damage to the developing brain, typically before birth), global developmental delay (a condition which shows significant delays in sitting, crawling, walking, speech and language difficulty, slower problem-solving skills, poor eye contact, or lack of social smiling), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), gastrojejunostomy dependent (GJ, a tube inserted through the stomach and into the intestines that provides safer, direct feeding into the intestines when stomach feeding is not tolerated), chronic respiratory failure (a long-term condition where the lungs cannot adequately provide oxygen to the blood) with tracheostomy (a surgical procedure creating an opening in the neck into the wind pipe to establish a direct airway or to facilitate long-term mechanical breathing)/ventilator (a medical device to help support or replace breathing) dependence, and recurrent aspiration pneumonia (an infection in the lungs caused by inhaling foreign materials, such as food, liquid, or vomit, into the airway). During a record review of Resident 2's H&P, dated 09/02/2025, the H&P indicated, Resident 2 was admitted to the facility on [DATE]. The H&P indicated Resident 2's medical history included, but was not limited to, 24 week gestation (the development of an embryo or fetus in the mother's womb, usually lasting 37 to 42 weeks to birth) birth, tracheobronchomalacia (a condition where the airway cartilage weakens and collapses the wind pipe and part of the lungs during the time when a patient breathes out), tracheostomy tube placement, ventilator dependent, gastrostomy tube dependent. During a record review of Resident 3's H&P, dated 09/02/2025, the H&P indicated Resident 3 was admitted to the facility on [DATE]. The H&P indicated, Resident 3's medical history included but was not limited to, Hypoxic-Ischemic Encephalopathy (HIE, a serious brain dysfunction caused by lack of oxygen and reduced blood flow to the brain) after a near drowning event, tracheostomy tube placement, gastrostomy tube (a surgical opening fitted with a tube to allow feedings to be administered directly to the stomach, common for people with swallowing problems) placement, tracheostomy and ventilator dependent. During an interview on 3/16/2026 at 2:00 p.m. with the Infection Preventionist (IP), IP stated:Resident 1's initial symptoms on 2/19/2026 included fever (an increase in body temperature), increased secretions (natural fluids, such as saliva or mucus, produced to protect airways; excess secretions can cause congestion or choking), and increased oxygen (a gas transported in the blood stream crucial for breathing) needs. Resident 1's nasopharyngeal [the area connecting the upper part of the throat to the back of the nasal (nose) cavity] specimen was collected on 2/26/2026. Resident 1's specimen resulted positive for rhinovirus (a positive test means one has the virus responsible for the common cold).Resident 2's initial symptoms on 2/26/2026 included rhinorrhea (a runny nose) , labored breathing (a feeling of difficulty breathing), cough (a rapid release of air from the lungs to clear irritants) and wheezing (a high-pitched sound made when breathing is restricted or obstructed in the lungs), increased oxygen demand. Resident 2's nasopharyngeal specimen was collected on 2/26/2026. Resident 2's specimen resulted positive for rhinovirus. Resident 3's initial symptoms on 3/1/2026 were elevated blood pressure (a measurement of the force your blood uses to get through the arteries) readings of 118/75 mm Hg (millimeters of mercury, a unit of measure for blood pressure) and 149/98 mm Hg. Resident 3's nasopharyngeal specimen was collected as a differential diagnosis (a systematic method to distinguish medical conditions from other medical conditions through a process of elimination). Resident 3's specimen resulted positive for rhinovirus. IP further stated through a process of investigation regarding a common factor between Resident 1, Resident 2, and Resident 3 as the source of the rhinovirus outbreak, the common denominator was found to be the use of a common electronic vital signs machine [a medical device that measures blood pressure and pulse rate (the number of heart beats per minute)]. IP stated the staff were observed to not be disinfecting (the process of using a chemical to remove germs, bacteria, and viruses on surfaces) the vital signs machine between resident use, as indicated in the facility's policy regarding vital sign machine use between residents. During an interview on 3/16/2026 at 2:17 p.m. with Certified Nurse Assistant (CNA) 1, CNA stated prior to the rhinovirus outbreak (the occurrence of cases of disease in excess of what would normally be expected in a defined community or season) with Residents 1, 2, and 3, CNA 1 did not practice disinfecting the vital signs machine between residents. CNA 1 stated it was important to disinfect the vital signs machine between residents to prevent the spread of illness to other residents and staff members. During a review of the facility's policy and procedure (P&P) titled, Equipment Cleaning Guidelines, last reviewed 05/2022, the P&P indicated, Medical equipment that is used in a patient room or that comes into contact with the patient or his/her contaminated environment will be cleaned and disinfected before it can be used on any other patient.

Based on observation, interview, and record review, the facility failed to ensure the head of bed for two (2) of three (3) sampled residents (Resident 2 and Resident 11) was maintained at 30 to 45 degrees (unit of measurement) while receiving gastrostomy tube (g-tube, a small tube inserted through a surgical opening in the abdomen directly into the stomach used to deliver nutrition, fluids, and medications to individuals who cannot eat or drink safely through their mouth) feeding, in accordance with the physician's order and facility's policy and procedure. This deficient practice had the potential to cause complications including aspiration (a medical sense, occurs when food, liquid, or foreign objects enter the airway and lungs) that can lead to hospitalization and death. Findings: 1. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included anoxic brain damage (occurs when the brain is completely deprived of oxygen), respiratory failure (a serious condition where the body cannot get enough oxygen into the blood), and tracheostomy tube (a surgical procedure where a hole is created in the front of the neck) placement. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 3/16/2025, the MDS indicated Resident 2's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 2 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) with oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, putting on/off footwear and personal hygiene. The MDS indicated Resident 2's nutritional approach included was a feeding tube while a resident in the facility. During a review of Resident 2's Order Summary Report as of 3/25/2025, the Order Summary Report indicated the following: Head of bead at least 30 degrees, ordered on 4/24/2024. Compleat pediatric (tube-feeding formula for children), 190 milliliters (ml, a metric unit used to measure capacity) per hour on pump, ordered on 2/11/2025. During a review of Resident 2's Care Plan, the Care Plan indicated alteration in nutrition related to inability to take oral feedings and fluids, revised on 5/3/2025. The staff intervention included was to elevate head of bed during GT feeds at least 30 degrees or more. During an observation on 4/23/2025 at 8:36 AM, in Resident 2's room, Resident 2's head of bed was observed to be almost flat in bed. Tube feeding of Compleat pediatric was observed infusing at the rate of 190 ml/hr. During a concurrent observation and interview on 4/23/2025 at 8:40 AM, with Registered Nurse 5 (RN 5), in Resident 2's room, RN 5 checked and read the settings of Resident 2's head of bed. RN 5 stated that Resident 2's head of bed was positioned at 15 degrees. RN 5 stated the resident's head of bed should not be positioned that low because Resident 2 has excessive secretions and might aspirate (accidental breathing in of food or fluid into the lungs). During an interview on 4/24/2025 at 11:33 AM, with RN 2, RN 2 stated Resident 2 was known for having excessive secretions. RN 2 stated it was important for Resident 2's head of bed to be positioned in upright position, at least 30 degrees to prevent aspiration. During an interview on 4/25/2025 at 9 AM, with Respiratory Therapist 2 (RT 2), RT 2 stated residents on mechanical ventilator (a medical device that provides breathing support) and tube feeding should not be left in flat position, and the head of bed should be raised above 30 degrees. RT 2 added that when a resident's head is not positioned above 30 degrees, risk for aspiration is high, and this might cause discomfort like coughing, choking and changes in breathing to the resident. 47362 2. During a review of Resident 11's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE] with congenital ( a condition or trait that exists at birth) hypoplasia and dysplasia of lung (condition where the baby's lungs have not fully developed) , chronic respiratory disease (diseases that affect the lungs and airways), encounter for attention to gastrostomy. During a review of Resident 11's MDS dated [DATE], MDS indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 11 was dependent with transfers (how resident moves to and from bed, chair and wheelchair), eating, dressing, and personal hygiene. The MDS also indicated Resident 11 's nutritional approach included was a feeding tube while a resident. During a record review of Resident 11's Order Summary Report, the Order Summary Report, dated 4/1/2025, indicated orders dated 3/19/2025, for the following: a. Enteral feed (a feeding tube such as a g-tube) Pediasure Peptide (a type of feeding formula) at 210 milliliter per hour (ml/hr., measurements of volume) every four (4) hours 3 times a day. b. Keep head of bed at 30 to 45 degrees during feeding. During a record review of Resident 11's Resident Care Plan, dated 3/12/2025, the Resident Care Plan indicated a concern and problem for alteration in nutrition related to inability to take in oral feedings and fluids. The staff intervention included was to elevate the head of bed during g-tube feeds at least 30 degrees or more. During concurrent observation in Resident 11's room and interview with Registered Nurse 1 (RN 1) on 4/24/2025 at 7:48 AM Resident 11 was observed lying flat on bed while the resident's g-tube feeding was infusing. RN1stated the head of the bed should be elevated up to 30-35 degrees to prevent aspiration and for safety. During a concurrent interview and record review on 4/25/2025 at 11:45 AM with Licensed Vocational Nurse 2 (LVN 2), the facility policy and procedure (P&P) titled, Gastrostomy Tube Feeding, revised 6/2024. LVN 2 stated the P&P indicated nourishment will be provided to all residents with gastrostomy tubes as ordered. The P&P also indicated 4. Explain procedure to resident and elevate the head of the bed.

Based on observation, interview, and record review, the facility failed to ensure the food service area was maintained in a clean, sanitary, and functional manner while providing proper food handling in accordance with the facility's policy and procedure by failing to ensure: 1. One refrigerator (Refrigerator #10) was clean, without water drippings, and was not rusted (a form of corrosion visible on steel surfaces exposed to moist). 2. One can opener was not chipped and rusted. 3. The food processor was in good condition and without a brown, black to yellowish discoloration and calcium build ups (hard crusty deposit on surfaces and/ equipment). These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization . Findings: 1. During an observation on 4/22/2025 at 7:48 AM in the facility kitchen, Refrigerator #10 was observed dirty with water dripping from condensation (water which collects as droplets on cold surface when humid air is in contact with it). The refrigerator had brownish to yellowish substances on its metal top portion. During a concurrent observation and interview on 4/24/2025 at 9:18 AM with the Food and Nutrition Service Director (FNSD) in the facility kitchen, the FNSD stated the Refrigerator 10 was dirty with water dripping from condensation. FNSD stated the refrigerator had brownish to yellowish substances on its metal top portion. FNSD stated this was not acceptable since it could contaminate the food inside Refrigerator 10. During an interview on 4/24/2025 at 9:46 AM with the dietary staff (DS1), DS 1 stated water dripping and rust in Refrigerator 10 was not acceptable because it can get to residents' food and cause tetanus (uncommon but serious infection caused by bacteria found in the environment), stomachache, and diarrhea. 2. During an observation on 4/22/2025 at 7:51 AM in the facility kitchen, the can opener was observed rusted and chipped. During concurrent observation and interview on 4/24/2025 at 9:19 AM with the FNSD in the facility kitchen, the FNSD stated the can opener was rusted and chipped and was not acceptable because it can cause food contamination (refers to the presence of unwanted materials or substances in food that may harm public health). During an interview on 4/24/2025 at 9:42 AM with the dietary staff (DS1), DS 1 stated a rusty and chipped can opener was not acceptable because it can get to the food and cause sickness like stomachache and possible diarrhea to the residents. 3. During an observation on 4/23/2025 at 6:42 AM in the facility kitchen, the food processor was observed to have a brown, black to yellowish discoloration and calcium build ups. During a concurrent observation and interview on 4/24/2025 at 9:20 AM with the FNSD in the facility kitchen, the FNSD stated the food processor to prepare pureed (smooth, thick liquid or paste made by crushing or grinding solid foods like fruits and vegetables, which is often made using a blender or food processor) food for residents was dirty, cracked, and with calcium build up. FNSD stated the food processor needs to be replaced to prevent food contamination. During an interview on 4/24/2025 at 9:47 AM with the dietary staff (DS1), DS 1 stated the food processor was used to puree food. DS1 stated the food processor was old and has molds from moisture. DS 1 also stated this was not acceptable because it can possibly cause sickness to residents like stomachache and diarrhea. During record review of facility's Policy and Procedure (P&P) titled, Cleaning Schedule use and Cleaning Equipment, revised 3/2021, the P&P indicated its purpose was to ensure proper cleaning procedures and adhered to in order to prevent any cross-contamination bacteria to food prepared. P&P also indicated, A. Equipment and work area are properly cleaned and sanitized . G. All food equipment used to grind, chop, mix or slice will be cleaned, sanitized and re-assembled after using . O. Refrigerators are wiped and food stored are checked daily for freshness.

Based on observation, interview and record review the facility failed to observe infection control measures for one of four sampled residents (Resident 13) by failing to ensure that the Staff 1 washed hands after touching the floor while picking up the table napkin and continued to assist on feeding Resident 13. This deficient practice had the potential to transmit infectious microorganisms (microbes that are temporarily harbored on the superficial surface of the body) and increase the risk of infection for the residents. Findings: During a review of Resident 13's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE] dysphagia (difficulty swallowing), seizure (sudden burst of electrical activity in the brain), chronic respiratory failure (not enough oxygen travels from the lungs into the blood). During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool), dated 2/9/2025, the MDS indicated the resident was severely with cognitive skills for daily decision making (never/rarely make decisions). Resident 13 was dependent (with transfers (how resident moves to and from bed, chair and wheelchair), eating, dressing, and personal hygiene. During a record review of Resident 13's Order Summary Report, dated 3/5/2025, the Order Summary Report indicated order date 11/11/2025, diet, regular, puree and minced vegetable for all meals. During an observation on 4/22/2025 at 1:28 PM at the activity room, Certified Nursing Assistant (CNA1) and the Staff 1 were feeding Resident 13. Observed Resident 13 threw the table napkin on the floor and Staff 1 while wearing the same gloves used during feeding Resident 13 touched the floor while picking up the napkin, threw the napkin on the trashcan and continued to assist CNA1 on feeding Resident 13 without washing hands and/ or changing gloves. Staff 1 touched Resident 13's hands, the resident's ice cream and apple juice before giving it to the resident. During an interview on 4/24/2025 at 2:27 PM with Staff 1, Staff 1 stated she did not wash her hands and changed gloves after touching the floor when Staff 1 picked up the table napkin. Staff 1 stated she continued to assist CNA 1 on feeding Resident 13 and Staff 1 touched Resident 13's hands, ice cream and apple juice. Staff 1 also stated she should have washed her hands to prevent spreading germs that can possibly cause sickness to the resident. During an interview on 4/25/2025 at 2:23 PM with the Infection Preventionist Nurse (IPN), IPN stated hand washing before and after feeding resident was important. IPN also stated staff should wash their hands after touching the floor to prevent cross contamination (physical movement or transfer of harmful bacteria from one person, object or place to another) and spread of infection. During a review of facility's policies and procedure (P&P) titled Hand Hygiene revised date 5/2022 indicated effective hand hygiene removes transient microorganisms, dirt and organic material from the hands and decreases the risk for cross contamination from patients, patient care equipment and the environment. The P&P also indicated, cleaning hands promptly and thoroughly between patient contact and after contact with blood, body fluids, secretions, excretions, equipment and potentially contaminated surfaces is an important strategy for preventing healthcare associated infection.

Based on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable, sanitary and environment by: 1. Facility failed to ensure three (3) of six (6) restroom sinks (rooms [ROOM NUMBER]) have no yellowish, brownish, and chipped sideboard. 2. Facility failed to ensure the table in activity classroom was in good condition and did not have edges that were peeling off, exposing the wood part of the table and chipped off leaving sharp and rough edges 3. Facility failed to ensure the trash can in room [ROOM NUMBER] was not overflowing. These deficient practices caused an unsanitary and had potential for residents to be placed at risk of injury and/ or infection. Findings: 1. During an observation on 4/22/2025 at 10:02 AM in room [ROOM NUMBER]'s restroom, the back splash in the restroom was damaged. Observed that the linoleum was lifted exposing the wound underneath and the sink has yellowish, brownish colored substance and the sideboard was chipped. During an observation on 4/22/2025 at 10:23 AM in room [ROOM NUMBER]'s restroom, the back splash in the restroom was damaged. Observed the formica (hard durable plastic laminate used for countertops, cupboard doors, and other surfaces) was lifted, wood was exposed, and the sink had yellowish and brownish colored substances. During an observation on 04/22/2025 at 12:23 PM in room [ROOM NUMBER]'s restroom, the back splash in the restroom was damaged. Observed the formica was lifted, and wood was exposed and the sink with yellowish, brownish, and blackish colored substances. During a concurrent observation and interview on 4/24/2025 at 1:01 PM to 1:05 PM in room [ROOM NUMBER], 2 and 3's restroom with the certified nursing assistant (CNA 2), room [ROOM NUMBER]'s back splash in the restroom was damaged. Observed that the linoleum was lifted exposing the wound underneath and the sink has yellowish, brownish colored substance and the sideboard was chipped. Observed in room [ROOM NUMBER] the back splash in the restroom was damaged. Observed the formica was lifted, and wood was exposed and the sink with yellowish, brownish, and blackish colored substances. Observed in room [ROOM NUMBER], the back splash in the restroom was damaged. Observed the formica was lifted, wood was exposed, and the sink had yellowish and brownish colored substances. CNA 1 stated room [ROOM NUMBER], 2 and 3's restroom sinks back splash were damaged. CNA 1 stated, the formica was lifted, and wood was exposed, and it was not acceptable. CNA 1 stated, this can grow molds, and the tiny white particles on the wood, can go anywhere, to residents' eyes, nose, and it was not safe for residents. CNA 1 also verified, the side of the sinks in room [ROOM NUMBER], 2 and 3 's bathroom sink has yellowish, brownish and/ or blackish discoloration and was peeling. 2. During an observation in the activity room on 4/22/2025 at 1:30 PM, the table edges were peeling off, exposing the wood part of the table and chipped off leaving sharp and rough edges. During a concurrent observation in the activity room and interview on 4/25/2025 at 9:37 AM with the Director of Support Services (DSS), the DSS stated the table has rough and sharp edges, it can cause cuts or injury to the residents, and it is not acceptable. 3. During an observation in room [ROOM NUMBER] on 4/23/2025 at 5:35 AM, room [ROOM NUMBER]'s trashcan was overflowing with used Personal Protective Equipment (PPE- equipment worn to minimize exposure to bacteria or viruses that cause serious illness), and gloves. During a concurrent observation and interview on 4/24/2025 at 1:07 PM with CNA 2, CNA2 stated room [ROOM NUMBER]'s trashcan was overflowing with used PPE, and it was not acceptable, and it was unsanitary. During an observation in room [ROOM NUMBER] on 4/25/2025 at 6:05 AM room [ROOM NUMBER]'s trashcan was not closed/ sealed properly with PPE yellow gown hanging outside the trash can. During a concurrent interview and record review on 4/25/2025 at 1:54PM with the infection preventionist nurse (IPN), the facility's Policy and Procedure (P&P) titled Subacute Pediatrics revised date 2/2006, the IPN stated the P&P indicated Policy: To the highest practicable extent the subacute pediatric unit shall provide a safe, clean, comfortable and nurturing homelike environment designed to promote normal child development. The IPN stated the facility did not follow their P&P.

Based on observation, interview, and record review, the facility failed to ensure the head of bed for two (2) of six (6) sampled residents (Resident 2 and Resident 11) who were on continuous mechanical ventilator (a medical device that provides breathing support) was maintained at 30 to 45 degrees (unit of measurement) in accordance with the physician's order and facility's policy and procedure. This deficient practice had the potential to cause complications including aspiration (a medical sense, occurs when food, liquid, or foreign objects enter the airway and lungs) and ventilator- associated pneumonia (serious lung infection that can occur in mechanically ventilated residents) that can lead to hospitalization and death. Findings: 1. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included anoxic brain damage (occurs when the brain is completely deprived of oxygen), respiratory failure (a serious condition where the body cannot get enough oxygen into the blood), and tracheostomy tube (a surgical procedure where a hole is created in the front of the neck) placement. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 3/16/2025, the MDS indicated Resident 2's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 2 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) with oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, putting on/off footwear and personal hygiene. The MDS indicated Resident 2 was on continuous oxygen therapy, required suctioning, tracheostomy care, and mechanical ventilator while in the facility. During a review of Resident 2's Order Summary Report as of 3/25/2025, the Order Summary Report indicated the following: Synchronized Intermittent Mandatory Ventilation (SIMV, mode of mechanical ventilation where the ventilator delivers a set number of breaths at a set rate and volume, but the patient can also take spontaneous breaths in between the mandatory breaths) settings, ordered on 4/24/2024. Head of bead at least 30 degrees, ordered on 4/24/2024. During an observation on 4/23/2025 at 8:35 AM, in Resident 2's room, Resident 2's head of bed was observed to be almost flat in bed. During a concurrent observation and interview on 4/23/2025 at 8:39 AM, with Registered Nurse 5 (RN 5), in Resident 2's room, RN 5 checked and read the settings of Resident 2's head of bed. RN 5 stated that Resident 2's head of bed was positioned at 15 degrees. RN 5 stated the resident's head of bed should not be positioned that low because Resident 2 has excessive secretions and might aspirate (accidental breathing in of food or fluid into the lungs). During an interview on 4/24/2025 at 11:33 AM, with RN 2, RN 2 stated Resident 2 was known for having excessive secretions. RN 2 stated it was important for Resident 2's head of bed to be positioned in upright position, at least 30 degrees to prevent aspiration. During an interview on 4/24/2025 at 2:21 PM, with Respiratory Therapist 1 (RT 1), RT 1 stated residents on mechanical ventilator should not be left in flat position, and the head of bed should be raised above 30 degrees. 47362 2. During a review of Resident 11's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE] with congenital ( a condition or trait that exists at birth) hypoplasia and dysplasia of lung (condition where the baby's lungs have not fully developed) , chronic respiratory disease (diseases that affect the lungs and airways), encounter for attention to gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 11's MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 11 was dependent on transfers (how resident moves to and from bed, chair and wheelchair), eating, dressing, and personal hygiene. The MDS also indicated Resident 11's respiratory treatments included oxygen therapy, suctioning, and tracheostomy care while in the facility. During a record review of Resident 11's Order Summary Report, dated 4/1/2025, the Order Summary Report indicated an order dated 3/22/2025 for Respiratory LTV (long term vent) mechanical ventilation: SIMV. During a record review of Resident 11's Resident Care Plan, dated 3/12/2025, the Resident Care Plan indicated Resident 11 with ineffective breathing and airway related to tracheostomy dependent and ventilator dependent. During a concurrent observation in Resident 11's room and interview with RN 1 on 4/24/2025 at 7:48 AM, Resident 1 was observed lying flat in bed while connected to an LTV vent mechanical ventilation and G-tube feeding while RN 1 suctioned (removal of mucus and secretions that cannot be cleared with coughing to open the airway and help so the resident can breathe better) the resident. RN1 stated Resident 11's head of bed should be elevated up to 30 to 35 degrees to prevent aspiration and for safety. During a concurrent interview and record review on 4/25/2025 at 11:45 AM with Licensed Vocational Nurse 2 (LVN 2), the facility policy and procedure (P&P) titled, Prevention of ventilator-associated pneumonia ([NAME]), dated 2003 was reviewed. LVN 2 stated the P&P indicated to maintain patient's head of bed at 30 to 45 degrees. LVN 2 also stated the facility did not follow their P&P. During a review of the facility P&P titled, Prevention of ventilator-associated pneumonia ([NAME]), dated 2003, the P&P indicated to maintain patient's head of bed at 30 to 45 degrees.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of four sampled residents (Resident 17) in accordance with the facility policy by failing to administer Resident 17's 8 AM due medications on 4/25/2025 as indicated on the physician's order. This deficient practice had the potential for Resident 17 to experience tachycardia (a fast heartbeat of more than 100 times per minute), high blood pressure (when your blood pressure is consistently higher than normal), pain and decline in overall health status. Findings: During a review of Resident 17's Admission Record, the Admission Record indicated Resident 2 was originally admitted to the facility on [DATE]. Resident 2's diagnoses included chronic respiratory failure with hypoxia (a condition where the body cannot get enough oxygen). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 4/13/2025, the MDS indicated Resident 17's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 17 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 17's Physician's orders, the Physician's Orders indicated the following: o Catapres (a medication used to treat high blood pressure) patch, 0.3 milligram (mg, a unit of measurement of mass) every 24 hours, topically, weekly on Friday at 8 AM hypertension (HTN-high blood pressure). Ordered on 6/4/2024. o Ergocalciferol 15 mcg (unit of measurement) via gastrostomy tube (G-tube, is a small, flexible tube that's surgically inserted into the stomach through the abdomen to provide nutrition, fluids, and medicine), for supplement, ordered 1/11/2023. o Potassium (mineral that is important for many body functions) liquid 20 milliequivalent (unit of measurement)/15 milliliters (ml, metric unit used to measure capacity) give 15 ml via G-tube twice a day for hypokalemia (low potassium levels), ordered on 4/3/2023. o Baclofen (medication used to treat muscle spasms and stiffness) tablet, 20 mg, four times a day, via G-tube, for spasticity (condition characterized by stiff muscles), ordered on 1/11/2023. o Multivitamin 1 tablet, via G-tube, daily for supplement, ordered on 1/11/2023. o Ocean spray (medication to treat dryness inside the nose) nasal (nose) spray, 1 spray to each nostril, twice a day for allergies, ordered on 1/11/2023. o Omeprazole (a medication that reduces the amount of acid produced in the stomach) 20 mg, twice a day, via G-tube, for gastroesophageal reflux disease (GERD the backward flow of liquid from the stomach into the esophagus), ordered on 12/11/2023. During a medication administration observation on 4/25/2025 at 10:21 AM with the Registered Nurse 6 (RN 6), RN 6 was observed preparing the following medications for Resident 17: Catapres patch. Ergocalciferol 15 mcg. Potassium liquid 20 milliequivalent, 15 ml. Baclofen 1 tablet. Multivitamin 1 tablet. Ocean spray. Omeprazole 20 mg suspension. During an observation on 4/25/2025 at 10:38 AM, in Resident 17's room, RN 6 administered all of Resident 17's seven (7) medications. RN 7 was at bedside when RN 6 administered Resident 17's medications, During an interview on 4/25/2025 at 10:41 AM with RN 7, RN 7 stated their medication administration time in the morning is scheduled at 8 AM, and medications can be administered one hour before or after 8 AM. RN 7 stated if the medications were administered late or early, the charge nurse should be informed, MD should be notified, and medication nurse should document a justification. RN 7 stated administering medications late, and close to the next scheduled dose might cause reaction and might harm the resident. During a concurrent record review of Resident 17's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and interview with RN1 on 4/25/2025 at 11:49 AM, RN 1 verified that the following medications were due to be given at 8 AM: o Catapres patch. o Ergocalciferol 15 mcg. o Potassium liquid 20 milliequivalent, 15 ml. o Baclofen 1 tablet. o Multivitamin 1 tablet. o Ocean spray. o Omeprazole 20 mg suspension. RN 1 stated RN 6 failed to administer Resident 17's 8 AM scheduled medications on time because RN 6 administered it late, after 9 AM. RN 1 stated failing to administer medication to a resident per the physician's order can lead to medical complications possibly resulting in hospitalization . RN 1 stated all 7 routine medications that were due to be given at 8 AM were given at 10:38 AM. RN 1 confirmed there were no justifications documented for the late administration of Resident 17's 7 medications. RN 1 stated missed blood pressure medications might lead to uncontrolled high blood pressure. RN 1 stated RN 6 informed her that Resident 17's 8 AM medications were administered late because she was assisting a Certified Nurse Assistant (CNA, unidentified) with cleaning another resident. RN 1 stated, it was important to give the medications on time and as ordered by the physician to ensure efficacy of the medications and to avoid possible adverse reactions or side effects that resident can experience. During a review of the facility's Policy and Procedure (P&P) titled, Medication Pass, revised 5/2021, the P&P indicated its objective is to provide guideline for the safe and effective administration of medication as ordered by the prescriber. The P&P indicated that all routine orders will be given within 60 minutes before or after the scheduled time. Nursing judgment may allow some variance, and explanation for variance should be documented.

Cross reference: F755 Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Seven (7) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 30 opportunities (observed administered medications) for error, which yielded a facility medication error rate of 23.33 % for one (1) of four (4) sampled residents (Resident 17) observed during medication administration (med pass). Resident 17's scheduled 8 AM medications were not administered timely as indicated on the physician's order and facility policy. This deficient practice had the potential to result in adverse reactions (an undesired harmful effect resulting from a medication or other intervention) to Resident 17. Findings: During a review of Resident 17's Admission Record, the Admission Record indicated Resident 2 was originally admitted to the facility on [DATE]. Resident 2's diagnoses included chronic respiratory failure with hypoxia (a condition where the body cannot get enough oxygen). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 4/13/2025, the MDS indicated Resident 17's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 17 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 17's Physician's orders, the Physician's Orders indicated the following: o Catapres (a medication used to treat high blood pressure) patch, 0.3 milligram (mg, a unit of measurement of mass) every 24 hours, topically, weekly on Friday at 8 AM hypertension (HTN-high blood pressure). Ordered on 6/4/2024. o Ergocalciferol 15 mcg (unit of measurement) via gastrostomy tube (G-tube, is a small, flexible tube that's surgically inserted into the stomach through the abdomen to provide nutrition, fluids, and medicine), for supplement, ordered 1/11/2023. o Potassium (mineral that is important for many body functions) liquid 20 milliequivalent (unit of measurement)/15 milliliters (ml, metric unit used to measure capacity) give 15 ml via G-tube twice a day for hypokalemia (low potassium levels), ordered on 4/3/2023. o Baclofen (medication used to treat muscle spasms and stiffness) tablet, 20 mg, four times a day, via G-tube, for spasticity (condition characterized by stiff muscles), ordered on 1/11/2023. o Multivitamin 1 tablet, via G-tube, daily for supplement, ordered on 1/11/2023. o Ocean spray (medication to treat dryness inside the nose) nasal (nose) spray, 1 spray to each nostril, twice a day for allergies, ordered on 1/11/2023. o Omeprazole (a medication that reduces the amount of acid produced in the stomach) 20 mg, twice a day, via G-tube, for gastroesophageal reflux disease (GERD the backward flow of liquid from the stomach into the esophagus), ordered on 12/11/2023. During a medication administration observation on 4/25/2025 at 10:21 AM with the Registered Nurse 6 (RN 6), RN 6 was observed preparing the following medications for Resident 17: Catapres patch. Ergocalciferol 15 mcg. Potassium liquid 20 milliequivalent, 15 ml. Baclofen 1 tablet. Multivitamin 1 tablet. Ocean spray. Omeprazole 20 mg suspension. During an observation on 4/25/2025 at 10:38 AM, in Resident 17's room, RN 6 administered all of Resident 17's seven (7) medications. RN 7 was at bedside when RN 6 administered Resident 17's medications, During an interview on 4/25/2025 at 10:41 AM with RN 7, RN 7 stated their medication administration time in the morning is scheduled at 8 AM, and medications can be administered one hour before or after 8 AM. RN 7 stated if the medications were administered late or early, the charge nurse should be informed, MD should be notified, and medication nurse should document a justification. RN 7 stated administering medications late, and close to the next scheduled dose might cause reaction and might harm the resident. During a concurrent record review of Resident 17's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and interview with RN1 on 4/25/2025 at 11:49 AM, RN 1 verified that the following medications were due to be given at 8 AM: o Catapres patch. o Ergocalciferol 15 mcg. o Potassium liquid 20 milliequivalent, 15 ml. o Baclofen 1 tablet. o Multivitamin 1 tablet. o Ocean spray. o Omeprazole 20 mg suspension. RN 1 stated RN 6 failed to administer Resident 17's 8 AM scheduled medications on time because RN 6 administered it late, after 9 AM. RN 1 stated failing to administer medication to a resident per the physician's order can lead to medical complications possibly resulting in hospitalization . RN 1 stated all 7 routine medications that were due to be given at 8 AM were given at 10:38 AM. RN 1 confirmed there were no justifications documented for the late administration of Resident 17's 7 medications. RN 1 stated missed blood pressure medications might lead to uncontrolled high blood pressure. RN 1 stated RN 6 informed her that Resident 17's 8 AM medications were administered late because she was assisting a Certified Nurse Assistant (CNA, unidentified) with cleaning another resident. RN 1 stated, it was important to give the medications on time and as ordered by the physician to ensure efficacy of the medications and to avoid possible adverse reactions or side effects that resident can experience. During a review of the facility's Policy and Procedure (P&P) titled, Medication Pass, revised 5/2021, the P&P indicated its objective is to provide guideline for the safe and effective administration of medication as ordered by the prescriber. The P&P indicated that all routine orders will be given within 60 minutes before or after the scheduled time. Nursing judgment may allow some variance, and explanation for variance should be documented.

Based on interview and record review, the facility failed to ensure one of four resident's skin integrity was assessed and treated by wound care services when consulted by nursing staff in accordance with the facility's policy and procedure. This failure resulted in Resident 1's persistent redness to the chest area for five days, which did not get assessed and treated by wound care services, which compromised Resident 1's health and well-being. Findings: During a review of Resident 1's History and Physical (H&P), dated 9/21/23, the H&P indicated that Resident 1 was an 8-month-old patient with a medical history including chronic lung disease, tracheostomy (an incision in the windpipe made to aid in breathing), and ventilation (a machine aiding in air exchange in and out of the lungs) dependent. During a review of Resident 1's Patient Progress Notes (an ongoing record of a patient's illness and treatment), dated from 7/20/24 through 7/25/24, the progress note indicated the following: On 7/20/24 at 5:02 p.m., the nursing notes indicated, Pt (Patient 1) has multiple scratches and red spots to the chest. On 7/20/24 at 5:06 p.m., the nursing notes indicated, Called patient's mother to update. Pt had x (times) 1 emesis (vomit). Pt (patient) also had a red spot on the RT (right) chest due to Pt (patient 1) scratching and visible scratches on the left side of the abdomen. Mother aware. Placing wound care consult. On 7/22/24 at 6:10, the nursing notes indicated redness on chest. On 7/23/24 at 7:00 p.m., the nursing notes indicated rashes. On 7/24/24 at 7:06 p.m., the nursing notes indicated, Mom, request for patient to be dressed in clothing that will cover her right chest and left thigh to prevent pt (patient) further scratching the area . Please place a moist pillowcase over the chest and thigh to create a barrier. Mom asked for contact information for the wound care nurse; the charge nurse was notified. House supervisor aware. On 7/25/24 at 1:35 a.m., the nursing notes indicated, Wound consult entered for right upper chest and left thigh self-inflicted scratches. During a concurrent interview and record review on 8/30/24, at 10 a.m., with the Chief Nursing Officer (CNO), Resident 1's Wound Care Consult, dated 7/20/24 and 7/25/24, was reviewed. The consult order on 7/20/24 indicated, Right chest and left abdominal redness due to scratching constantly. The CNO stated a second consult was placed by the charge nurse for wound care to assess the resident on 7/25/24 and indicated, Please check right upper chest and left thigh scratches, caused by self-inflicted scratching. The CNO confirmed that there was no documentation that the wound team assessed Resident 1. During a review of the facility's policy and procedure (P&P) titled Skin Screening, Prevention, and Treatment, dated April 2012, the wound care specialist job description indicated, Responsibilities serve as a clinical wound specialist/consultant/mentor to staff through formal and informal training of staff . Evaluates and treats patients upon physician referral in the hospital and outpatient setting. This policy/procedure was not implemented for Resident 1.

Based on interview and record review the facility failed to ensure two (2) of 4 sampled residents (Residents 15 and 19) had a completed advanced directive acknowledgment form (a form indicating to the resident or responsible party the right to give written directions about future treatment before becoming seriously ill or unable to make healthcare decisions). This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: 1. A review of Resident 15's Admission Record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included anoxic brain damage (a brain injury caused by lack of oxygen to the brain resulting in brain cells death). During a concurrent interview and record review on 4/13/2024 at 12:40 PM, with the Social Services Director (SSD) of Resident 15's medical records, the SSD stated she was unable to find Resident 15's Advance Directive in Resident 15's records. The SSD stated she did not know when Resident 15's responsible party had signed an Advance Directive Decision form because Resident 15 had previously been admitted to the facility. 2. A review of Resident 19's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included spastic quadriplegic cerebral palsy (a condition that affects both arms and legs and often the torse and face). During a concurrent interview and record review on 4/13/2024 at 11:47 AM, with the SSD, the SSD stated she was unable to find Resident 19's Advance Directive Decision form in Resident 19's medical record. The SSD stated upon admission, Resident 19's responsible party had not signed the Advance Directive Decision form and had not had a chance to follow up with the responsible party. During an interview on 4/14/2024 at 7 PM with the Director of Nursing (DON), the DON stated it was important to have Resident 15 and Resident 19's Advance Directive on file in the resident's records so that it was easily accessible in case of an emergency. A review of the facility's Policy and Procedure titled, Advance Directives, revised 10/2021, the P&P indicated, the facility policy supports patient ' s right to self-determination in their healthcare decision through the use of an Advance Directive. Each adult patient or surrogate decision maker, is provided with pertinent information regarding the requirements necessary to execute, and limitations attached to, various Advance Directives.

Based on observation, interview, and record review, the facility failed to provide the appropriate care to four of four sampled residents (Resident 4, 9, 11, and 12) who had a gastrostomy tube (G-Tube, a tube placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medications) by failing to: 1. Ensure the tube feeding syringe was labeled with date opened for Resident 4, 9, 11, and 12. 2. Ensure a new bottle of Peptide-Based Nutrition ( nutritional formula) was used for Resident 4, feeding was used for more than 24 hours. These deficient practices placed Resident 4, 9, 11, and 12's G-tube at risk for getting clogged and contaminated which had the potential to cause discomfort and infection. Findings: 1a. A review of Resident 9's Admission record indicated an admission to the facility on [DATE] with a diagnosis of atresia (absence or abnormal narrowing of an opening or passage in the body) of foramina (an opening that allows passage of structures from one region to another) of Magendie and Luschka (the [NAME] cyst (congenital [happening before birth] condition where the cerebellum [an area at the back of the brain that controls movement and balance] does not develop normally). A review of Resident 9's Minimum Data Set (MDS, a standardized resident assessment and care planning tool) dated 3/10/2024, indicated Resident 9 had diagnoses that included respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) and gastrostomy status (G-tube). The MDS indicated Resident 9 had impaired functional limitation in range of motion for both sides of upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. A review of Resident 9's Order Summary indicated a physician order dated 2/9/2024 for G-tube size: 12 French/ 1.7 centimeter (cm, unit of measure). During an observation in Resident 9's room on 4/12/2024 at 1:13 PM, Resident 9's tube feeding syringe was observed in a clear plastic cup with no label of date opened on top of bedside dresser. Observed opened syringe bag with no label of date opened. 1b. A review of Resident 11's Admission record indicated an admission to the facility on [DATE] with a diagnosis of congenital hypoplasia (rare neurological condition present at birth, characterized by the underdevelopment or incomplete development of the cerebellum). A review of Resident 11's MDS dated [DATE], indicated Resident 11 had diagnoses that included chronic respiratory failure with hypoxia and gastrostomy status (G-tube). The MDS indicated Resident 11 had impaired functional limitation in range of motion for both sides of upper and lower extremities. A review of Resident 11's Order Summary indicated a physician order dated 3/16/2020 for G-tube size: [NAME] 12 French/ 1.0 cm, 5 milliliter (ml, unit of measure) balloon. During an observation in Resident 11's room on 4/12/2024 at 1:17 PM, Resident 11's tube feeding syringe was observed in a bag with no label of date opened on top of bedside dresser. During a concurrent observation and interview in Resident 9 and 11's room on 4/12/2024 at 1:28 PM, Licensed Vocational Nurse (LVN) 1, confirmed she opened new packages and did not label Resident 9 and 11's tube feeding syringes. LVN 1 stated she would label them right now. LVN 1 stated it was important to label the syringes with the date opened so they would not get mixed with other patients, to make sure it was not in use for too many days, and to avoid cross contamination. 1c. A review of Resident 12's Admission record indicated an admission to the facility on [DATE] with a diagnosis of disorders of copper metabolism ([NAME] disease, defect makes it hard for the body to properly distribute copper throughout the body). A review of Resident 12's MDS dated [DATE], indicated Resident 12 had diagnoses that included epileptic spasms (sudden abnormal movements of the body) and gastrostomy status (G-tube). The MDS indicated Resident 12 had impaired functional limitation in range of motion for both sides of upper extremities. A review of Resident 12's Order Summary indicated a physician order dated 7/31/2019 for G-tube size: 16 French silicon. During an observation in Resident 1's room on 4/12/2024 at 1:28 PM, Resident 12's tube feeding syringe was observed in a bag with no label of date opened on top of bedside dresser. 1d. A review of Resident 4's Admission record indicated an admission to the facility on [DATE] with a diagnosis of encephalopathy (brain disease that alters brain function or structure). A review of Resident 4's MDS dated [DATE], indicated Resident 4 had diagnoses that included anoxic brain damage (lack of oxygen to the brain which results in death of brain cells) and encounter for gastrostomy status (G-tube). The MDS indicated Resident 4 had impaired functional limitation in range of motion for both sides of upper and lower extremities. A review of Resident 4's Order Summary indicated the following physician orders: On 12/21/2016 to hang new bottle of Pediasure Peptide as needed. On 1/22/2017 for G-tube [NAME] 12 French/ 2.0 cm change every 3 months and as needed for dislodge or plugging as needed. On 2/22/2024 for Pediasure Peptide 1.0 calorie (cal, unit of measure), give 190 ml per hour for 30 minutes to give 95 ml every 4 hours with 190 ml of water every 4 hours. During an observation in Resident 4's room on 4/12/2024 at 1:31 PM, Resident 12's tube feeding syringe was observed in a bag with no label of date opened on top of bedside dresser. 2. At 1:33 PM, observed Resident 4's Pediasure Peptide bottle dated 4/10/2024 timed at 7:30 PM. During a concurrent observation and interview in Resident 12 and 4's room on 4/12/2024 at 1:47 PM, LVN 2 stated she would label Resident 12 and 4's tube feeding syringes to indicate it was opened today. LVN 2 stated the purpose of labeling the syringes was for infection control. At 1:50 PM, LVN 2 stated Resident 4's feeding was decreased, but the Pediasure Peptide bottle should be changed every 24 hours to prevent infection or growth of bacteria. During an interview with the Director of Nursing on 4/14/2024 at 4:45 PM, the DON stated all equipment used for g-tube including the syringe should be labeled with the date opened. The DON stated the staff must dispose of the syringe and bottle feeding at 24 hours to minimize bacteria growth. A review of the facility's policy and procedure titled Tube Feedings, dated 5/31/2007 indicated the maximum hanging time for closed system (bottle) was 24 hours.

Based on observation, interview and record review, the facility failed to meet professional standards of quality for 1 of 4 sampled (Patient 2), a pediatric patient who was unable to verbalize needs and unable to move extremities, did not suffer from burns of being laid on top of a heated humidifier tubing for unknown length of time. This deficient practice resulted in patient 2 suffering burn injury on his right arm and right back. Finding: A review of patient 2's admission record indicated the patient was originally admitted to the facility on [DATE] with admit diagnosis chronic respiratory failure (condition when lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem) dated 6/29/2023, the H&P indicated Patient 2's past medical history included Anisocoria eye's pupils are not the same size. Acute Hemorrhagic encephalomyelitis (a rare disorder that cause rapid neurologic deterioration and death, tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the windpipe), and gastrostomy (a surgically placed device used to give direct access to stomach for feeding, hydration, or medicine) dependence. Patient 2's H&P indicated under the physical examination, Neruo: Encephalopathic (disturbance of brain function) without purposeful movement, hypertonic and spastic. The H&P indicated the plan for respiratory care, Tracheostomy dependent . During an interview with the Director of Pediatric Subacute Unit (DIR) on 3/7/2024 at 1:18 p.m., the DIR stated patient 2 sustained a burn injury at the right middle lateral back and right posterior forearm on 1/2/24. The DIR stated Patient was found lying on a ventilator humidifier tube and the WCN noted that Patient 2 was found with blister on the back and right forearm. During an interview with the Wound Care Nurse (WCN) on 3/7/2024 at 2:45 p.m., stated that she was asked to initial a wound consult for Patient 2; found serous exudate intact blisters at Patient 2's right posterior foreman and rupture blister with partial thicken at right lateral back, no one witness what had happened, but facility investigated that the cause from the blister could be from lying on the ventilation heated tubing with unknown time. A review of Patient 2's medical record titled Wound Care Specialist Evaluation notes, dated 1/2/24, the WCN validated that she was consulted on Patient 2 for evaluation of lesions on the right arm and right back. A serous filled bulla (fluid under a thin layer of your skin) presents on the right forearm measuring 1.3 cm (centimeters - unit of measurement) x (by) 5 cm x 0.1 cm. Erythema (redness of the skin caused by injury) with a small serous (clear to yellow fluid that leaks out of a wound) blister noted on the right upper back. A rupture bulla noted on the mid right lateral back 1.5 cm x 1.5cm x 0.1 cm and Erythema with intact ruptured blisters present on the mid right lateral posterior back measuring 2.5 cm x 15 cm x 0.1 cm with small amount of serous exudate (fluid that leaks out of blood vessels into nearby tissues). During interview with Licensed Vocational nurse (LVN1) on 3/7/2024 at 2:33 p.m , stated that they found Patient 2 had redness and blisters at his right forearm and right upper back during the charge nurse round in the morning on 1/1/24. Staffs are supposed to do hourly round to check patient to make sure patient is not lying on any tubing or anything that can cause pressure on the skin. During interview with certified nurse assistant (CNA1) on 3/8/2024 at 12:30 p.m., stated that CNA are supposed to do the hourly round with their assigned patients. During an interview with the Director of Pediatric Subacute Unit (DIR) on 3/7/2024 at 3:18 p.m., the DIR stated the hourly rounding is a practice that all staff adhere in the pediatric sub-acute unit. This practice was existing for a long time before the incident happened. They do not document on the hourly round before the incident. The hourly round is not assigned to a specific person. Charge nurse, license nurse, CNA, and respiratory therapist are supposed to performing the hourly check. A review of Patient 2's nursing notes dated 1/1/24, indicated, Upon morning assessment, Patient 2) was found lying on the heated ventilator tubing for an unidentified amount of time. Patient was found with visible redness and elevated skin under the back, on the right side and up the middle upper back. During a review of the facility's policy and procedure (P&P) titled, Skin care, prevention of skin breakdown reviewed in 04/2021, the P&P indicated that Our goal is to maintain skin integrity and to prevent tissue breakdown and the development of pressure ulcers .the licenses nurse will document the overall condition of the resident's skin every shift in the resident record, utilizing the shift physical. During a review of the facility's policy and procedure (P&P) titled, Safety measures for pediatric residents, reviewed in 04/2021, the P&P indicated that All caregivers are to observe the safety measures for Pediatric residents in order to provide a safe and secure environment for pediatric residents. During a review of the facility's policy and procedure (P&P) titled, Mechanical Ventilation, with last reviewed date 12/2022, the P&P indicated, In order to ensure that patient-ventilator monitoring are being performed according to these guidelines an indicator should be created to monitor this activity as part of the department's quality assurance program.

Based on observation, interview and record review, the facility failed to ensure 1 of 4 sampled (Patient 2), a pediatric patient who was unable to verbalize needs and unable to move extremities, did not suffer from burns of being laid on top of a heated humidifier tubing for unknow length of time. This deficient practice resulted in patient 2 suffering burn injury on his right arm and right back. Finding: A review of Patient 2's admission record indicated the patient was originally admitted to the facility on [DATE] with admit diagnosis chronic respiratory failure (condition when lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of Patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem) dated 6/29/2023, the H&P indicated Patient 2's past medical history included Anisocoria eye's pupils are not the same size. Acute Hemorrhagic encephalomyelitis (a rare disorder that cause rapid neurologic deterioration and death, tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the windpipe), and gastrostomy (a surgically placed device used to give direct access to stomach for feeding, hydration, or medicine) dependence. Patient 2's H&P indicated under the physical examination, Neruo: Encephalopathic (disturbance of brain function) without purposeful movement, hypertonic and spastic. The H&P indicated the plan for respiratory care, Tracheostomy dependent . During an interview with the Director of Pediatric Subacute Unit (DIR) on 3/7/2024 at 1:18 p.m., the DIR stated Patient 2 sustained a burn injury at the right middle lateral back and right posterior forearm on 1/2/24. The DIR stated Patient was found lying on a ventilator humidifier tube and the WCN noted Patient 2 was found with blister on the back and right forearm. During an interview with the Wound Care Nurse (WCN) on 3/7/2024 at 2:45 p.m., stated that she was asked to initial a wound consult for patient 2; found serous exudate intact blisters at patient 2's right posterior foreman and rupture blister with partial thicken at right lateral back, no one witness what had happened but facility investigated that the cause from the blister could be from lying on the ventilation heated tubing with unknown time. A review of Patient 2's medical record titled Wound Care Specialist Evaluation notes, dated 1/2/24, the WCN validated that she was consulted on Patient 2 for evaluation of lesions on the right arm and right back. A serous filled bulla (fluid under a thin layer of your skin) presents on the right forearm measuring 1.3 cm (centimeters - unit of measurement) x (by) 5 cm x 0.1 cm. Erythema (redness of the skin caused by injury) with a small serous (clear to yellow fluid that leaks out of a wound) blister noted on the right upper back. A rupture bulla noted on the mid right lateral back 1.5 cm x 1.5cm x 0.1 cm and Erythema with intact ruptured blisters present on the mid right lateral posterior back measuring 2.5 cm x 15 cm x 0.1 cm with small amount of serous exudate (fluid that leaks out of blood vessels into nearby tissues). During interview with Licensed Vocational nurse (LVN1) on 3/7/2024 at 2:33 p.m , stated that they found patient 2 had redness and blisters at his right forearm and right upper back during the charge nurse round in the morning on 1/1/24. Staffs are supposed to do hourly round to check patient to make sure patient is not lying on any tubing or anything that can cause pressure on the skin. During interview with certified nurse assistant (CNA1) on 3/8/2024 at 12:30 p.m., stated that CNA are supposed to do the hourly round with their assigned patients. During an interview with the Director of Pediatric Subacute Unit (DIR) on 3/7/2024 at 3:18 p.m., the DIR stated the hourly rounding is a practice that all staffs adhere in the pediatric sub-acute unit. This practice was existing for a long time before the incident happened. They do not document on the hourly round before the incident. The hourly round is not assigned to a specific person. Charge nurse, license nurse, CNA, and respiratory therapist are supposed to performing the hourly check. A review of Patient 2's nursing notes dated 1/1/24, indicated, Upon morning assessment, patient 2 was found lying on the heated ventilator tubing for an unidentified amount of time. Patient was found with visible redness and elevated skin under the back, on the right side and up the middle upper back. During a review of the facility's policy and procedure (P&P) titled, Skin care, prevention of skin breakdown reviewed in 04/2021, the P&P indicated that Our goal is to maintain skin integrity and to prevent tissue breakdown and the development of pressure ulcers .the licenses nurse will document the overall condition of the resident's skin every shift in the resident record, utilizing the shift physical. During a review of the facility's policy and procedure (P&P) titled, Safety measures for pediatric residents, reviewed in 04/2021, the P&P indicated that All caregivers are to observe the safety measures for Pediatric residents in order to provide a safe and secure environment for pediatric residents. During a review of the facility's policy and procedure (P&P) titled, Mechanical Ventilation, with last reviewed date 12/2022, the P&P indicated, In order to ensure that patient-ventilator monitoring are being performed according to these guideline and indicator should be created to monitor this activity as part of the department's quality assurance program.