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Based on observation, interview and record review, the facility failed to ensure safe and dignified care for one of 35 sampled patients (Patient 9), when: A staff member silenced Patient 9's pulse oximetry (a test used to measure the oxygen saturation level of the blood) alarm.

This failure had the potential for Patient 9 to experience critical changes in his oxygen saturation without staff knowing it.

Findings:

1. During a review of Patient 9's medical record, History and Physical, dated 10/8/24, indicated, Acute respiratory failure due to encephalopathy, (inflammation of brain causing reduced level of consciousness). Patient 9 was admitted to the facility for ventilation (artificial breathing machine) support and was recently being weaned (safely and intermittently taken off ventilator to assess patient's ability to breath on their own) from the ventilator. Patient 9 had a Full Code status (directive to use all resuscitation efforts if patient's heart or respirations stopped).

During a review of Patient 9's medical record, a Respiratory Therapy Progress Note, dated 11/18/24, signed by Licensed Staff DD, indicated Patient 9 had diminished breath sounds and was on continuous pulse oximetry monitoring.

During a review of Patient 9's medical record, an MD order, signed by Licensed Staff EE, dated 10/8/24, indicated to keep SP02 (oxygen level) no less than 90%.

During an observation on 11/18/24 at 10 a.m., in the ICU (Intensive Care Unit) (unit that is staffed by specially trained medical personnel and has equipment that allows for continuous monitoring and life support), Patient 9's pulse oximetry alarm was silenced with an oxygen reading level of 88% on the monitor.

During an interview on 11/18/24 at 10:04 a.m., in the ICU, Licensed Staff CC was queried as to why the pulse oximetry alarm was silenced on patient 9's monitor. Licensed Staff CC stated she checked Patient 9's pulse oximetry adhesive attachment on his finger earlier and found it to be loose and not giving an accurate oxygen reading, so she silenced the alarm. Licensed Staff CC was queried what the risks were to patient safety when a patient in the ICU had their pulse oximetry alarm silenced. Licensed Staff CC stated she knew if the oxygen alarm was silenced, and the patient's oxygen level dropped, the alarm would not sound and, "We wouldn't know the patient's oxygen level was low."

During a review of Patient 9's medical record, Patient Progress Note for Vital Signs, dated 11/18/24, indicated there was no pulse oximetry reading for 10 a.m.

During an interview on 11/18/24 at 10:20 a.m., Director of Nursing O, was queried what the patient safety risks were when Patient 9 had his pulse oximetry alarm silenced by Licensed Staff CC. Director of Nursing O stated he knew the facility policy indicated that no ICU alarm should be silenced without correcting the reason the alarm originally sounded. Poor equipment fitting was not a reason to silence an alarm and leave the bedside. Licensed Staff CC should have her eyes on the patient's respirations while she was changing out the equipment. If the alarm was silenced and no one was at the bedside, the patient could stop breathing, and we would not know they were in trouble. Poor fitting monitoring equipment does happen, but we expect it to be fixed immediately.

During a review of the Job Description for Licensed Staff CC, it indicated, "The ICU Registered Nurse reports to the Director of Nursing. The ICU Registered Nurse is responsible for assessing the needs of each patient on his/her team, planning, and implementing the care to meet those needs, interacting with team member, and reporting to supervisor as appropriate. The ICU Registered Nurse position demonstrates clinical competence when providing care, using technology, administering medications, performing procedures, and managing emergencies, acting as patient advocate in order to monitor and maintain patient rights. Registered Nurse must have the ability to learn function of ALL machines and equipment utilized in a critical care environment."

During a review of the facility's, "ICU Scope of Services," revised 11/24/22, indicated, "The ICU provides Intensive Care monitoring for continuous assessment of cardiac condition, respiratory management with continuous oxygen therapy, including ventilator support. Standards of practice: The American Association of Critical Care Nurses and the American Nurse's Association recognized core curriculum, teaching aids and Standards of Care for Acute and Intensive Care Nursing are used as reference for the development of standards and policies on the Intensive Care Unit."

During a review of the facility's policy and procedure titled, "Telemetry Monitoring Protocol - ICU," revised 11/14/24, indicated, "The ICU nurse will assure that the monitor alarms are set and operational at all times."

During a review of the facility's policy and procedure titled, "Patient Rights," revised 2/1/23, indicated, "Safety: To provide with care and services at this hospital in a safe and secure environment, and be free from all forms of abuse and neglect."

During a review of the facility's policy and procedure titled, "Pulse Oximetry," reviewed on 5/8/23, indicated, "Pulse oximetry has become the most common tool used to determine the gas exchange status of oxygen.....Patients receiving oxygen therapy and/or patients with orders to evaluate oxygen status as indicated." Pulse Oximetry Probes to be used, ear probe, disposable probe, and finger probe as appropriate.

During a review of The American Association of Critical Care Nurse Vol. 38, No. 2, April 2018, titled, "AACN Practice Alert: Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry," indicated, "Provide proper skin preparation for and placement of electrodes and Pulse Oximetry Probe, check alarm setting at the start of each shift and with any change in the patient's condition and customize alarm parameter settings for individual patients in accordance with unit or hospital policy."


41175

Based on observation, interview and record review, the facility failed to: 1. follow and implement its policy and procedure on skin care assessment and maintenance for one sampled patient (Patient 18) out of three sampled patients, when a physician order for wound consult was not carried out, when there was missing documentation regarding nursing assessment underneath Patient 18's foam dressing and there was missing documentation of weekly effectiveness of wound treatment to Patient 18's sacral area; and, 2. implement its policies and procedures on pressure ulcer prevention and managemement, when one unsampled patient (Patient 72) was not repositioned per protocol.

These failures resulted in Patient 18 developing a 7 cm x 4cm wound, increased the potential for the development of pressure injuries to at-risk patients, including Patient 72.

Findings:

1. During a review of Patient 18's, "History and Physical," dated 7/13/23, indicated Patient 18 had become a quadriplegia (a medical condition that causes partial or total loss of movement and sensation in all four limbs) due to a spinal cord injury causing paralysis or loss of muscle function in all four limbs. Patient 18 also required a tracheostomy (surgical procedure which creates an opening in the neck and into the trachea or windpipe to provide an airway to breathe) and requiring a ventilator (device which helps or replaces a person's breathing). The plan was for Patient 18 to continue with supportive care and rehabilitation.

A review of Patient 18's, "Physician Order," dated, 7/14/23, indicated, Wound Consult for Evaluation and Treatment was ordered. Multiple requests to the facility for the completed wound care consult were made on 11/18/24, 11/19/24, 11/20/24, and 11/21/24, but the facility was unable to produce the document.

During a review of Patient 18's, "Admission Four Eyes in Four Hours," dated 7/14/23, indicated Patient 18 was assessed by nursing to have sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) on the right side of the neck. The back sacrum (area between the hipbones and the pelvis) was described as intact blanchable (described as when depressed the area turns white momentarily) redness.

During a review of Patient 18's, "Total Braden Score," dated 7/14/23 indicated to be at risk for skin breakdown with a score of 12 out of a score of 20.

During an concurrent interview and electronic record review on 11/18/24 at 9:15 am with Unlicensed Staff FF, there was a physician order for a wound consult evaluation. When a copy of the completed wound consult was requested, Unlicensed Staff FF was unable to locate the completed consult in the electronic medical record and stated it would be found later. Unlicensed Staff FF could not explain if the consult had taken place and the document was unable to be located or if the consult had not taken place at all.

During a concurrent interview and electronic record review on 11/19/24 at 9:55 am, with Licensed Staff GG, Licensed Staff GG observed the wound consult order, dated 7/14/23, and observed a wound care Progress Note, dated 8/11/23, and a Braden Score of 13, dated 8/3/23. Unlicensed Staff GG observed an order for a foam dressing to the sacral area, and Unlicensed Staff GG stated it would be documented in the Medication Administration Record area under Wound Care Reminder. Nursing documentation consisted of date, time and nurses' initials but no further description. Unlicensed Staff GG was asked if there was a wound care Progress Note dated earlier in the medical record, and he stated he could not find one but there was a Braden Assessment score of 13 on 7/14/23, and that should have triggered a wound consult as part of the policy because it [the score] was so low. A copy of the completed wound consult document from the order was requested on 7/14/23, again as part of the medical record requests. Licensed Staff GG observed the picture taken of Patient 18's sacral area measuring 7 cm x 4 cm, where an open wound had developed from intact skin upon admission to the date of the picture on 8/6/23, and could not explain how the wound developed. Licensed Staff GG stated the nurses did not stage wounds, only the wound care team would stage a wound, and the point of the foam dressing was to protect the skin.

During an interview and concurrent record review on 11/22/24 at 9:02 am, with Director of Nursing O, Patient 18's medical record was reviewed including the physician order for wound consult, dated 7/14/23. Patient 18's Admission Four Eyes in Four Hours, dated 7/14/23, was reviewed where it was indicated Patient 18 had sutures and Director of Nursing O stated, based upon the documentation of sutures, Patient 18 should have had a wound consult and could not explain why, when a physician ordered a wound consult, it was not done. Director of Nursing O stated Patient 18 was admitted before he worked for the facility so he could not speak directly to the care, but the wound team did monitor sutures, and the consult should have been done.

During an interview and concurrent record review on 11/22/24 at 9:22 am, with Licensed Staff D, Licensed Staff D stated, in reviewing the records, there was no physician order for a special bed, and Patient 18 should have been on a special bed and it was probably why the wound developed. The foam dressing was almost the same size as the wound in the wound picture, dated 8/6/23, and it was very dark and black; meaning the tissue was dead. The wound had been there a long time, and Licensed Staff D stated the wound was also deep and stated the dressing had not been changed every day, and it was hard to assess what was going on underneath the dressing, and the wound team was not following Patient 18 by the lack of wound notes found in the medical record. Licensed Staff D stated a completed wound consult note was not found when researching the record.

A review of the facility's policy and procedure titled, "Skin Care, Assessment and Maintenance of," dated 11/15/24, indicated, "Skin Assessment shall be performed at least every 12 hours all bedfast patients shall be turned every 2 hours unless contraindicated by physician's order. Any impairment in skin integrity shall be documented in Nursing Flowsheet and Wound Documentation Form...2. Appropriate skilled treatment modalities shall be determined following a comprehensive functional evaluation that will include special wound data..4. The effectiveness of all wound care treatment will be reassessed on a weekly basis. This reassessment will be performed by a designated nurse, and may include other members of the treatment team as appropriate. The team members will make rounds on all patients and perform weekly head to toe skin assessment. 1. turn and position every two hours."


38088

2. During an observation on 11/20/24 at 9 a.m., Unsampled Patient 72 was on his back in his bed.

During an observation on 11/20/24 at 11 a.m., Unsampled Patient 72 was on his back in his bed.

During an observation on 11/20/24 at 2:20 p.m., Unsampled Patient 72 was on his back in his bed.

During an interview on 11/20/24 at 2:35 p.m., with Unlicensed Staff B, she stated the patients were supposed to be turned every two hours to prevent skin problems like pressure wounds.

During an interview on 11/20/24 at 3:15 p.m., Unlicensed Staff NN stated patients were to be turned every two hours to prevent skin problems and prevent contractures (A joint that cannot move. Occurs when patients are bedridden in the same position without moving).

A review of Unsampled Patient 72's medical record indicated he was a 72 year-old male who was admitted to the facility 11/9/24, with diagnoses that included left-sided paralysis related to a surgery for a brain tumor, Diabetes, vascular disease, vascular disease related skin wounds of the lower extremities with swelling, kidney disease with dialysis, and pressure ulcers.

During a record review and interview on 11/20/24 at 4:05 p.m., Licensed Staff Y stated a two hour repositioning form was used to document patient turning performed by staff and wound care nurses. The facility Nursing Supervisor was supposed to audit the form. During a review of a document titled, "2 HOUR REPOSITIONING FORM (12 HOUR (DAY) SHIFT FORM), for Unsampled Patient 72, she stated the documentation on the form indicated it was blank at 6 a.m., 10 a.m., 12 p.m., 2 p.m., and 4 p.m. She stated the form indicated Unsampled Patient 72 was sitting on a chair at 8 a.m. She stated the document was incomplete and turning Unsampled Patient 72 every two hours was not documented. Licensed Staff Y stated Unsampled Patient 72 was very uncooperative with turning and always refused to turn. She stated he was supposed to be up in a chair three times a day for meals. She stated the risk to patients who did not turn every two hours was risk of injury and pressure wounds.

On 11/20/24 at 3:40 p.m. and 4:20 p.m., a request to interview the House Supervisor and Chief Nursing Officer was made and never completed by the facility.

During a review of a facility Policy and Procedure titled, "SKIN CARE ASSESSMENT AND MAINTENANCE OF," revised 11/15/24, it indicated, "Turn and position every two hours."












41175

Based on observation, interview and record review, the facility failed to ensure the dietary needs of one sampled patient (Patient 72), when a significant weight gain of 16 pounds in five days was not assessed, communicated, or responded to by facility staff and providers.

This failure had the potential for patient harm from unrecognized electrolyte imbalance, Congestive Heart Failure (CHF)(A condition that occurs when the heart cannot pump the amount of blood and plasma in an efficient manner resulting in shortness of breath, fatigue, and heat failure), poor wound healing, malnutrition, and potential for death.

Findings:

During an interview and observation on 11/18/24 at 11:35 a.m., Patient 72 stated he had throat cancer and had radiation therapy that resulted in a vascular port infection. He stated he was on a liquid diet because the pain and discomfort of swallowing was too bad. He stated he lost of ton of weight before his admission to the facility. Patient 72 was lying in bed and appeared thin and pale.

During an interview and record review on 11/18/24 at 410 p.m., Patient 72's medical record was reviewed with the Director of Nursing. Review of the record indicated Patient 72 was admitted 11/11/24 at 2:41 p.m. He stated the admission weight on 11/11/24, was 124 pounds. He stated Patient 72's weight on 11/16/24, was 140 pounds. Licensed Staff PP stated Patient 72 had gained 16 pounds since admission. Licensed Staff PP stated he could not find a Dietary Consult order or any documentation that any facility staff had communicated the 16 pound weight gain to either the physician or Registered Dietician.

During an interview and record review on 11/19/24 at 9:15 a.m., Licensed Staff U reviewed Patient 72's medical record and stated a Dietary Consult was ordered 11/12/24. She stated she was unable to find any notification of physician or dietary for Patient 72's weight gain. She stated no one documented anything in the medical record and staff were supposed to do follow up about a significant 16 pound weight gain to the nurses, physician and dietary.

During an interview on 11/20/24 at 2:35 p.m., Unlicensed Staff B stated, when a patient gets weighed the weight is put in the weight binder at the nursing station. She stated the nurses were supposed to check it. She stated, about the patient weight changes: "If it's a lot we tell them."

During an interview on 11/20/24 at 2:40 p.m., with Licensed Staff OO, she stated, "If a patient has a weight gain or loss, the CNA (Certified Nursing Assistant) is supposed to inform us and then we ask for an RD (Registered Dietician) consult and tell the Physician." She stated the risk to patients for weight gain was cardiac fluid overload, potential dialysis complications, electrolyte imbalances, malnutrition and poor wound healing.

During a record review and interview on 11/22/24 at 9:15 a.m., Licensed Staff U stated the Registered Dietician completed an assessment for Patient 72 on 11/12/24. She stated, on 11/16/24, the Registered Dietician completed a follow up assessment and Patient 72 weighed 142 pounds. She stated the Registered Dietician requested an updated weight and it was documented by staff as 140 pounds which indicated a 16 pound weight gain in five days after admission. Licensed Staff U was unable to find any documentation by staff, Registered Dietician or Physician about the 16 pound weight gain.

During an interview and record review on 11/22/24 at 11 am, the Registered Dietician was never notified of a patient weight gain. She stated Patient 72's medical record did not have any communication about the 16 pound weight gain. She stated the Physician and she should have been notified. She stated a significant weight gain in five days was a risk for Congestive Heart Failure, Electrolyte imbalance, and poor wound healing. She stated she was unsure if the facility had a policy and procedure about reporting weight gain or weight loss. She stated it was a national standard for patient care to monitor patients' weight gain or loss.

During a review of Patient 72's medical record, a document titled, "INITIAL PHYSICAL ASSESSMENT," dated 11/11/24, indicated, "Dietary consult ordered: No - Not at this time."

During a review of Patient 72's medical record, a document titled, "PATIENT PROGRESS NOTES," dated 11/11/24, at 4:14 p.m., indicated, "Weight 124 lb 12.5 oz 56.6 kg ...Bed Scale."

During a review of Patient 72's medical record, a document titled, "PATIENT PROGRESS NOTES," dated 11/13/24 at 10:52 a.m., indicated, "Weight 142 lb 6.4 oz 64.59 kg ... Bed Scale."

During a review of Patient 72's medical record, a document titled, "NURSING ORDERS," dated 11/11/24 - 11/15/24 at 5 p.m., indicated, "Performed Nursing Order Monitor for optimal nutrition."

During a review of Patient 72's medical record, a document tiled, "PHYSICAL ASSESSMENT," dated 11/13/24 at 9:30 a.m., 11/15/24 at 9:45 a.m., 11/16/24 at 9 a.m., indicated, "Nutrition Adequate.....Dietary consult ordered: No - Not at this time."

During a review of Patient 72's medical record, a document titled, "PHYSICAL ASSESSMENT," dated 11/14/24 at 9:15 a.m., 11/17/24 at 7 a.m., indicated "Nutrition: Probably inadequate.....Dietary consult ordered: No - Not at this time."

During a review of Patient 72's medical record, a document titled, "Problems /Goals," dated 11/11/24, indicated, "PROBLEM Malnutrition R/T (related to) inadequate calorie & protein intake....PROBLEM Inadequate oral intake RT altered swallow ability....PROBLEM Altered nutrient utilization R/T diabetes or renal disease.....PROBLEM Alteration in skin integrity related to poor nutrition."

During a review Patient 72's medical record, a document titled, "PATIENT PROGRESS NOTES," dated 11/13/24, indicated, "Were weights obtained? Yes 142.2 via bed scale." Another note, dated 11/16/24, indicated, "Were weights obtained? Yes (via floor scale, 140.3 lbs."

During a review of Patient 72's medical record, a document titled, "Physician Entered Ordered," dated 11/11/24, indicated, "Nursing Order Problem Description: Head and Neck cancer, dysphasia (Difficulty swallowing), PEG (Percutaneous endoscopic gastrostomy tube)(A soft tube into the stomach from the abdomen, that allows for liquid nutrition and medications to be administered) malnutrition....DIETARY CONSULT Tube feed."

During a review of Patient 72's medical record, a document titled, "Dietary," dated 11/12/24, indicated, "Dietitian Assess / Diagnosis: Nutrition Risk : High. Ht: 68 Wt 125 lbs....Dietician Notes C: Goals ... weight maintenance.....F/U (Follow Up) w/n (within) 3-5 days."

During a review of Patient 72's Medical record, a document titled, "Dietary," dated 11/16/24, indicated, "Dietitian Assess / Diagnosis: ...Wt: 142 lbs....Reports of wt loss, sever muscle wasting.....Dietitian Notes ...Unsure of wt gain, req updated weight. "

Review of a facility Policy and Procedure titled, "WEIGHT VARIANCE PROGRAM," revised 11/15/24, indicated, "Obtaining patient weights: ...2. Nursing staff must compare current weight with previous weight. If 3 lb or greater difference is noted (loss or gain), the patient must be re-weighed to check accuracy. 3. 3 lb or greater weight difference must be recorded in the Weight Variance binder. Weight must be recorded in EMR (Electronic Medical Record) by nursing staff. 4. Nursing staff must notify dietitian by sending a diet consult. MD must also be notified. 5. The weight Variance binder is located on Med/Surg nursing unit and is reviewed by the Nursing Supervisor on a daily basis and by the RD (Registered Dietician) on a weekly basis."

Based upon interview and record review, the facility failed to ensure an effective Infection Control Program that reduced the risk of infection when the Infection Preventionist did not meet the qualifications for training and experience.

This failure had the potential for patient infections, staff infections and potential for death.

Findings:

On 11/21/24, at 2:40 p.m., during an interview with Physician AA, he stated he was consulted by phone and monitored staff and patients. He stated he was an Infection Preventionist for the facility, and Licensed Staff BB provided day-to-day Infection Prevention duties. Physician AA stated he had heard that Licensed Staff BB did not have the required training to function as the Infection Preventionist.

During an interview on 11/21/24, at 2:40 p.m., Licensed Nurse BB stated he had worked for the facility as the Infection Preventionist for eight months. He was unable to state what professional standards and / or guidelines he used to guide the infection prevention at the facility. Licensed Nurse BB stated he did not have any training or certification in infection prevention. During the interview he stated he, "thought" the hand hygiene compliance rate was 100%. He stated he completed observations and made the determination of compliance. He did not know if the observations included just nursing staff or physicians, or therapists. He stated he did not do observations of housekeeping staff. He did not answer when asked if he did observations of infection control practices in the Dietary Department. Licensed Staff BB stated he did not know if the facility had a Policy and Procedure (P&P) for wearing artificial fingernails. He stated the risk to patients if staff wore artificial fingernails was infection and skin tears. Licensed Staff BB stated he did not monitor contracted linen services for delivery or processing to ensure the service was compliant with national standards for infection prevention in linen services. He stated he monitored housekeeping twice a week and thought they performed at 90%. He was unable to state what that meant. He was unable to say anything about the approval of cleaning and disinfection products chosen by the hospital and if they were approved and Environmental Protection Agency (EPA) compliant. Licensed Staff BB stated staff were monitored for vaccine and immunization status. He stated they were supposed to wear masks in patient care areas. He did not respond to whether staff had to wear masks in non-patient care areas, like the lounges and non-patient corridors. He did not state if he had a list of all staff who had declined vaccinations / immunizations. He did not state how staff with declinations were monitored for compliance with the facility P&P to wear a mask. He did not state what the national guidelines for infection prevention and staff declination of vaccines and immunizations was.

A review of Licensed Nurse BB's employment file did not indicate any infection training education or training documentation.

A review of, "§482.42(a) Standard: Infection prevention and control program organization and policies," indicated, "The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership."

Based on observation, interview and record review, the facility failed to implement its infection prevention and control protocols, when:

1. Three flying insects were observed in the Dietary Department;
2. Dietary staff did not test the disinfection buckets (Buckets of disinfection solution used to sanitize food preparation surfaces to avoid food Cross-contamination and reduce the risk of foodborne illnesses), according to manufacturer's instruction for use (MIFU) and state law;
3. Staff did not disinfect walkie talkies after use in a patient room, with Contact Precautions (Infection control measures used in healthcare settings to prevent the spread of diseases transmitted through direct or indirect contact with an infected patient or their contaminated environment, typically requiring healthcare workers to wear gloves and gowns when entering the patient's room and interacting with them or their surroundings);
4. Three staff members were observed wearing artificial nails while providing direct patient care; and,
5. Staff who had declined vaccinations and immunizations were not monitored for compliance with facility safety protocols designed to protect the hospital community.

These failures had the potential to increase the risk of spread of disease-causing microorganisms among the vulnerable patients, staff, and visitors.

Findings:


38088

1. During an observation and interview with Unlicensed Staff LL in the Dietary Services kitchen on 11/18/24, at 9:52 a.m., the door to the dry storage area was propped open. A sign on the door indicated, "This door to remain shut." At 10:02 a.m., Unlicensed Staff LL wiped the bottom of a wire storage rack with a white disposable cloth. He stated he observed gray / brown matter on the disposable cloth that, "Looked like dirt and dust." Unlicensed Staff LL stated the shelves were supposed to be dusted and cleaned daily and they were not. He stated the risk to patients was food contamination and foodborne illness."

During an observation and interview in the Dietary / Kitchen Department on 11/18/24, at 11 a.m., the Registered Dietician opened a large door that led to an area which contained a trash dumpster, dirty linens bagged and ready for pickup, a table and chairs and a locked trailer for biohazardous waste pickup. She stated this area was used for staff breaks and all food deliveries. The area was dusty, dirty, and had multiple leaves that gathered under the furniture and in corners.

During an observation and interview in the Dietary / Kitchen Department on 11/19/24 at 11:04 a.m., a fly was on the wall in the food prep counter area in front of the office. Unlicensed Staff KK and a Cook were prepping food for patient lunches and did not respond to the fly. There was a wall-mounted piece of equipment designed to lure and capture flying insects. Unlicensed Staff KK stated she saw the fly and stated the insect trap could not catch everything and did not know if it worked.

During an observation and interview with the Registered Dietician, in the Dietary / Kitchen Department on 11/19/24 at 12:36 p.m., a fly was in the air and on the wall above the desk located near the tray line. At 12:44 p.m., the Registered Dietician stated she saw a fly on the wall above the food prep counter. She stated there was no screen door or air curtain on the door used by staff to enter and exit and for vendor food delivery. She stated the risk to patients from flying insects in the kitchen was cross-contamination and foodborne illness.

During an interview on 11/21/24 at 3:50 p.m., Licensed Staff BB was unable to state what professional standards he followed to manage the facility Infection Control Program. He stated he did not have any training from any professional organization. He stated he performed surveillance on Hand Hygiene. Licensed Staff BB stated he did not perform any observation of the Dietary Services Department.

2. During an observation and interview in the Dietary / Kitchen Department, on 11/19/24 at 8:55 a.m., Unlicensed Staff JJ stated, to test the red disinfection bucket (A bucket of sanitizing solution and water that was used to sanitize food prep surfaces to reduce the risk of foodborne illness), located under the three-basin sink in the food prep area, she would use a strip of HYDRION test paper (A way to measure the concentration of sanitizers, that results in a color match on the test paper to detect when disinfection solution should be replaced and if too much sanitizing solution was used), submerge it in the bucket for, "eleven seconds maybe."

At 9 a.m., she put the HYDRION test paper into the red bucket solution for three seconds. She observed the test paper, and stated it was not the correct reading according to the Manufacturer's Instructions for Use (MIFU) which was posted on the wall above the sink. She placed the test strip back into the red bucket for three more seconds. She pulled the test tape out of the bucket, and the color had changed to reflect a reading of 200, which she stated was, "The safe zone." No clock was visible from the three basin sink area, and Unlicensed Staff JJ stated she knew it was the correct amount of time to submerge the test tape because she, "Counts in her head." She stated she did not look at a clock or watch.

During an interview on 11/19/24 at 9:15 a.m., the Registered Dietician stated the HYDRION test paper was supposed to be submerged in the disinfection solution for 30 seconds. She stated, if staff did not test the solution according to MIFU, the risk to patients was the solution would not have enough sanitizer, and there would be risk of foodborne illness from
cross-contamination of food prep surfaces.

During an observation and interview in the dishwashing area of the Dietary Department on 11/19/24 at 12:08 p.m., Unlicensed Staff S demonstrated how to test the solution in the red bucket located in the dishwashing area. He walked to three-basin sink located in the food prep area, got a three-inch strip of test paper, walked back to the dishwashing area and submerged the paper test strip into the red bucket containing disinfection solution, for eight seconds. He did not have a watch, and no wall-mounted clocks were visible in the dishwashing area. He removed the paper test strip, and it was very pale. Unlicensed Staff S took the red disinfectant bucket with solution to the three-basin sink, emptied it and refilled it with the vendor-supplied solution dispenser. He got a new paper test strip and submerged it in the fresh disinfectant solution for 20 seconds. He removed the test paper, and it was a dark bluish-green. He stated it was good. He stated he counted in his head.

3. During an interview on 11/20/24 at 2:45 p.m., with Licensed Staff II, he stated walkie talkies were used to answer call lights or communicate location if anyone needed help. He stated they were supposed to be turned off in patient rooms. Licensed Staff II stated the walkie talkies were supposed to be cleaned after being inside a patient room with contact precautions (A set of infection control practices used in healthcare settings to prevent the spread of infectious agents that could be transmitted through direct or indirect contact with a patient or their environment, typically requiring healthcare workers to wear gloves and gowns when interacting with the patient and properly cleaning contaminated surfaces).

During an observation and interview on 11/20/24 at 3:16 p.m., staff were inside a patient room. On the doorway a sign was posted which indicated, "Contact Precautions." They wore disposable gowns, and face masks and gloves, while they attended the patient. During patient care, one staff member's walkie talkie went off very loudly, and she reached with a gloved hand to pick-up her walkie talkie affixed to her scrub pants and pulled it out from underneath the disposable gown. She held it up to her face, spoke with someone, and then returned it to her cargo pants. At the end of patient care she removed her gown and gloves and walked out of the patient room without disinfecting the walkie talkie she carried. Licensed Staff Y stated she was helping a patient in a contact precautions room. She stated the purpose of contact precautions was to protect patients and staff from infections. She stated she forgot to disinfect the walkie talkie after she finished providing care. She stated she was not supposed to use the walkie talkie in any patient room, and she did not follow facility Policy and Procedure for walkie talkie use. She stated the risk to patients and staff was
cross-contamination and the spread of infection to other patients and staff.

During an interview on 11/21/24 at 3:50 p.m., Licensed Staff BB stated, as the Infection Control Nurse, he monitored staff for putting on and taking off of disposable gowns and gloves in precautions rooms. He stated he monitored the hand hygiene practices and use of walkie talkies in the patient rooms. He stated he did not have any data on walkie talkie use in contact precautions rooms and there were no issues.

4. During an observation and interview on 11/20/24 at 9:45 a.m., Licensed Staff V had artificial nails. She stated she liked her fingernails and, "I know I am not supposed to wear artificial nails, but I use gloves anytime I provide direct patient care during dialysis." She stated she did not know what the facility Policy and Procedure for artificial nails was. She was unable to state what infection control standards were used for infection prevention.

During an interview and observation at the nursing desk, on 11/20/24 at 10:25 a.m., Licensed Staff Y had artificial nails. She stated she did not know the facility Policy and Procedure for wearing fake fingernails. She stated the risk to patients was infection.

During an observation and interview on 11/19/24 at 11:46 a.m., Licensed Staff Q was wearing artificial nails. She stated she liked her nails. She stated she thought the facility Policy and Procedure for artificial nails was she was not supposed to wear them because of infection control concerns. She stated she did not follow the facility Policy and Procedure.

During an observation and interview on 11/19/24 at 11:50 a.m., Unlicensed Staff R was carrying a patient breakfast tray out of a patient room. She stated she had artificial nails and did not know the Policy and Procedure. She stated she thought they were not supposed to wear them for infection control concerns.

During an interview on 11/20/24 at 3:50 p.m., Licensed Staff BB stated as the Infection Control Nurse he monitored staff hand hygiene and reported all his findings. He stated he thought the hand hygiene monitoring was at 100%. He did not respond when asked what exactly he was monitoring. He stated he did not know if the facility had a Policy and Procedure for the wearing of artificial nails. He stated the risk to patients if staff wore fake fingernails was skin tears and infection. When asked what professional standards he used to guide the Infection Control Program he was silent. He stated he did not have any training.

5. During an interview on 11/20/24 at 9:30 a.m., Unlicensed Staff W stated she worked in employee health and was responsible for completing requirement documentation for each employee. She stated employees were checked for Tuberculosis testing, Vaccinations, titers (A test to determine if someone had antibodies for a disease) for MMPR (Measles, Mumps, Pertussis and Rubella) (Contagious illnesses), varicella (Chicken Pox), influenzas and Covid immunizations, upon hire. She stated if an employee refused vaccination or immunizations, they would have to sign a waiver and wear a mask. She did not know if staff who had refused vaccinations or immunizations had to wear masks in the break room or non-patient care areas. She stated she had no direction from infection prevention on staff declinations and did not know what the facility Policy and Procedure was. She stated she did not know who had declined vaccination or immunizations but could maybe find it. Unlicensed Staff W stated she did not know who monitored staff who declined vaccinations or immunizations.

During an interview on 11/21/24 at 3:50 p.m., Unlicensed Staff BB stated, as the Infection Prevention Nurse, he did monitor staff practices. He stated staff could decline Covid, influenza and other vaccinations. He stated they had to wear a mask in patient care areas. He did not respond when asked if staff who had declined vaccinations were allowed to be in non-patient care areas without a mask. He did not answer if he monitored staff who had declinations, to determine if they were compliant with mask wearing. He did not answer if he had the names of staff who had declinations for vaccines and immunizations. He stated he did not know what the Centers for Disease Control recommended for staff who declined vaccinations or immunizations.

A review of the facility Policy and Procedure titled, "Infection Prevention & Control," revised 9/9/22, indicated the facility, "Shall ensure that this organization develops, implements and maintains an active, organization wide program for the prevention, control and investigation of infections and communicable disease to reduce the risks of ....infections in patient, visitor and healthcare workers .... [Facility Name] Hospital's Infection Prevention and Control program shall be conducted in accordance with all applicable federal and state rules and regulations, accrediting body standards, as well as nationally recognized infection prevention and control practices.....All hospital staff shall participate and support the Infection Prevention and Control Program through compliance with infection prevention and control practices, policies and procedures .....The infection Preventionists(s) and the Infection prevention and Control Committee shall be responsible for identifying, investigating, reporting, preventing and controlling infections and communicable diseases through the following activities: Maintenance of a sanitary hospital environment.....Active Surveillance: ...Conducting surveillance (reliable sampling or other mechanism) on a hospital wide basis in order to identify infectious risks or communicable disease problems at any particular location or department. Conducting surveillance activities in accordance with infection control surveillance practices utilized by the CDC's National Healthcare Safety Net (NHSN) and shall include infection detection, data collection and analysis, monitoring, and evaluation of preventive interventions."

A review of the facility Policy and Procedure titled, "Dietary Services Kitchen Sanitation and Cleanliness," reviewed 5/10/24, indicated, "The kitchen shall be maintained in food repair, clean, sanitary, and free of pests.....Dietary staff will follow a cleaning schedule and be trained to properly keep the kitchen clean. Staff will inspect the kitchen for any signs of pests and report any findings to the Dietary Manager.....All kitchens and kitchen areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies and other insects."

Review of a facility Policy and Procedure titled, "Dietary Services Multi-Quat Sanitizer," revised 5/10/24, indicated Multi-Quat Sanitizer must be tested for ppm (Parts per million) levels per manufacturer's instructions. PROCEDURE: ...Test ppm level by using a HYDRION QT-40 test strip. Hold strip in water for 10 seconds. Use the strip to compare to the color guide to determine PPM levels."

Review of HYDRION QT - 10 product information titled, "Hydrion QT-10 Quaternary Test Paper," indicated, "A simple, reliable means to measure the concentration of Quaternary Sanitizers, with color matches at 0-100-200-300-400 ppm (parts per million), the test paper measures concentrations between 0-400 ppm, detecting exhaustion of solutions that should be replaced as well as helping to avoid using excessive amounts of sanitizing agents.....Federal, State and Local health regulations require users of Quaternary Ammonium Sanitizer Solutions to have appropriate test kits available to verify the strength of sanitizer solutions. Sanitizer solutions are essential in the food service industry to ensure that sanitizers are at the proper concentration specified by the individual manufacturer....In California, the required quat level for manual sanitization is 200 parts per million (ppm) of quaternary ammonium (quat) for at least one minute. This is outlined in the California Health and Safety Code, HSC § 114099.6. To verify the quat level, you use a test strip. Here's how: Stir the sanitizer and water solution. Dip the test strip paper into the diluted quat solution. Compare the color of the test strip to the color chart after 10 seconds. The test strip should read 200 ppm."

Multiple requests for manufacturer's instructions for use and the requirement for test levels for prevention of foodborne illness were made and not received by the end of survey.

Review of a facility Policy and Procedure titled, "Infection Prevention & Control Hand Hygiene," revised 9/9/22, indicated, "PURPOSE: To provide guidelines for the use of hand hygiene as the single most effective action in the prevention of transmission of infection. Hand hygiene includes washing with soap and water or use of alcohol based hand rub, and the care of staff's hands and fingernails.....Artificial nails, nail tips, wraps, or acrylic overlay or polish are prohibited for healthcare worker who provides patient care."

Review of a facility Policy and Procedure titled, "Human Resources Dress Code," reviewed 12/12/23, indicated, "PERSONAL GROOMING All direct patient care providers must follow CDC (Centers for Disease Control) recommendations for rings, fingernails and facial hair.... Artificial nail enhancements are prohibited. This includes, but is not limited to, artificial nails, tips, wraps, acrylics, gels and any additional items applied to the nail surface."

Review of a facility Policy and Procedure titled, "Administration Communications Walkie Talkie," effective 2/3/23, did not indicate use in patient rooms or use in isolation rooms.

Review of a facility Policy and Procedure titled, "Infection Prevention & Control Precautions: Standard, Airborne, Droplet, Contact, Enteric, Sars-COV-2," revised 9/8/22," indicated,
"Compliance with Standard and transmission specific precautions is required of all [Facility Name] physicians, healthcare disciplines, ancillary staff and volunteers who have contact with patients or body substances.....Handle used patient care equipment soiled with blood or body fluids in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfers of microorganisms to other patients and environments."

Review of a facility Policy and Procedure titled, "Employee Health Vaccination Declination," revised 2/3/24, indicated, "Employees who decline a required vaccination must follow the steps outlined below and may be subject to additional safety protocols to protect the hospital community. Procedure for Vaccine Declination 1. Submission of Vaccine Declination Form: Employees who choose to decline a recommended or required vaccine must complete the Vaccine Declination Form. 2. Mandatory Counseling: Individuals declining vaccination must undergo counseling with an [Facility Name] employee health representative to discuss: The benefits of Vaccination. Risks associated with declining the vaccine. Infection prevention and control measures.....Failure to follow this policy, including providing false information or non-compliance with alternative safety measure, may result in disciplinary action up to and including termination of employment."

Review of a document titled, "CDC The National Healthcare Safety Network (NHSN) Manual 2025 Healthcare Personnel Vaccination Module Protocol: Influenza Vaccination Summary Division of Healthcare Quality Promotion National Center for Emerging and Zoonotic Infectious Diseases Atlanta, GA, USA," indicated, "Healthcare facilities should provide influenza vaccine to HCP using approaches that have demonstrated effectiveness in increasing vaccination coverage. [1, 2] Healthcare administrators should consider the level of vaccination coverage among HCP to be one measure of a patient safety quality program and consider obtaining signed declinations from personnel who decline influenza vaccination for reasons other than medical contraindications. [2; 9-12] Influenza vaccination rates (including ward-, unit-, and specialty-specific coverage rates) among HCP within facilities should be regularly measured and reported to facility administrators and staff [2, 12]."

Based on interview and administrative document review, the Governing Body (GB) failed to exercise oversight and administrative control over the facility's total operation when it failed to ensure;

1. Patient rights to receive care in a safe setting for two patients (Patient 1 and Patient 9), when safety alarms were turned off in the Intensive Care Unit and the movement of patient equipment in patient rooms occurred without assessment for adequate space.

2. Patient rights for confidentiality of medical information, when one patient's (Patient 36) medical record was displayed and unattended in the hallway.

3. Facility Policy and Procedures were followed by staff, when; wound care was performed and documented for one patient (Patient 36), and a weight gain of 16 pounds by one patient (Patient 72) was not documented, assessed or followed up by nursing, dietary and other providers.

4. The Infection Control Nurse had the qualifications to effectively monitor patient and staff health.

5. The Infection Control program assessed and monitored the Policy and Procedures and portocols for the use of Personal Protective Equipment (Masks, gowns, gloves for use in contact precaution rooms), disinfection of dietary surfaces and walkie talkies used by staff in contact precaution rooms, monitoring of staff who declined required vaccines and immunizations and staff who wore artificical nails in patient care areas.

Findings:

(Cross Reference A144, A147, A398, A692, A748, A 749)

During a document review on 11/18/24 at 9 a.m., the facility Chief Nursing Officer and Chief Operating Officer were requested to provide a copy of the Governing Body Minutes for review. They were not received by the end of the day.

During a document review on 11/19/24 at 2:15 p.m., the Corporate Consultant was requested to provide copies of the Governing Body agendas, minutes, and board membership for review. They were not received by the end of the day.

During a document review on 11/19/24, the facility provided documents titled AD HOC MEDICAL STAFF MEDICAL EXECUTIVE/ GOVERNING BODY MEETING," dated 1/19/24 - 11/30/24. Review indicated no attendance, agenda, standing items, actions and follow-up discussion was documented. The Corporate Consultant was requested to provide copies of the Governing Body agendas, minutes, and board membership for review. They were not received by the end of the day.

During an interview and document review on 11/22/24 at 4 p.m., via phone and in person attendance, the Governing Body members were asked to detail how they prepared the facility for survey readiness, and stated they heard about grievances and reviewed pharmacy data submitted to them. The Governing Body was asked what was the facility Policy and Procedure for approval of medical staff. Physician QQ unable to address. Licensed Staff RR stated the Governing Body reviewed audits to ensure compliance with all Condition of Participation with the Centers for Medical Services. None of the Governing Body members were able to speak to what audits were conducted, what monitoring was performed, or how the facility performed. They stated a Provider was approved for priveldges and credentials at the facility, and the Infection Prevention Nurse was approved on 3/2024. The Governing Body was requested to provide documentation of the minutes where audits were reviewed, Providers were approved, the Infection Control Nurse was approved, what infection control data was reviewed, and any follow-up on anything that was presented to the Governing Body in 2024. No documents were provided for Governing Board Membership, Governing Body By-Laws or Policies and Procedures, Governing Body Minutes, review of audits and follow-up, or Infection Prevention Program status by the end of the meeting.

Requests for Governing Body Membership, Policy and Procedures, By-Laws, Documentation of meetings that showed evidence of attendance, agenda, discussion, action and follow-up were made repeatedly throughout the survey and were not provided by the end of survey.

Based on interview and record review, the facility failed to provide timely Speech Therapy services for five (Patient 29, 28, 51, 34 and 33) out of 11 sampled patients. These failures resulted in delay in care and missed crucial timely rehabilitation therapy.

Findings:

1. During a review of Resident 29's, "History and Physical," dated 8/23/24, indicated Patient 29 was admitted to the facility on 8/23/24, for rehabilitation care.

A review of Patient 29's, "Physician Orders," dated 9/10/24, indicated a swallow evaluation had been ordered for Patient 29. Patient 29 had opportunities to be evaluated by Speech Therapy but was unable to work with Therapist due to copious amount of secretions on 9/23, 9/24 and 9/26/24.

A review of Patient 29's Speech Therapy Notes, dated 9/10/24, indicated to require continued treatment for swallowing dysfunction to be seen three to five times a week for eight weeks. Patient 29 was evaluated by Speech Therapy on 9/13/24. Patient 29 was seen by Speech Therapy on 9/16, 9/18 and 9/19/24. The week of 9/29/24 to 10/5/24, there were no documented encounters where Speech Therapy had interacted with Patient 29, meaning completed therapy encounters or attempted therapy encounters with Patient 29. The week of 10/6/24 to 10/12/24, there was one documented encounter, dated 10/6/24, where Patient 29 was asleep prior to the encounter and remained sleepy throughout the session, and there were no other attempted therapy encounters. The week of 10/13/24 to 10/19/24, there was one documented encounter, dated 10/13/24, where Patient 29 was indicated to have large amount of secretions during the session, and there were no other attempted therapy encounters.

During a concurrent interview and record review on 11/21/24 at 9:48 am., with Licensed Staff HH, the facility's October patient schedule for Speech Therapy, was reviewed. The first week of the schedule, dated 9/29/24 -10/5/24, where Patient 29 was observed to have scheduled a therapy session (three to five times a week), the boxes corresponding for each date were blank; meaning no initials or Therapist had evaluated Patient 29 or numbers/x were observed to indicate an attempt to evaluate Patient 29 was made. Licensed Staff HH stated it was not good that Patient 29 did not have any Speech Therapy services for a week, meaning Patient 29 missed a minimum of three opportunities to have Speech Therapy. Licensed Staff HH stated the Speech Therapist had to leave because of a family emergency, and it was important but there was only one Speech Therapist for the department. The second week of the schedule was reviewed, and Unlicensed Staff HH thought Patient 29 did have therapy on Sunday 10/6/24, when a Speech Therapist from another facility helped out but agreed that Patient 29 would have only had one session compared to three opportunities (the schedule did not indicate any other attempts at therapy were made). Week three of the schedule, dated 10/13/24-10/1924, where Patient 29 was observed to have one scheduled Speech Therapy session on 10/13/24, and no further opportunities were observed during the week. Licensed HH totaled the amount of opportunities for the three weeks Patient 29 had therapy, two times (10/6/24 and 10/13/24) out of nine minimal and 15 maximal opportunities. Licensed HH stated that would have the effect of delaying the overall goal of therapy but could not explain how.

2. During a review of Patient 28's, "History and Physical," dated 9/20/24, indicated Patient 28 was admitted to the facility on 9/20/24, for wound care, dialysis and rehabilitation.

A review of Patient 28's, "Physician Order," dated 9/22/24, indicated a swallow evaluation was ordered.

A review of Patient 28's, "Speech Therapy Treatment Encounter Notes," dated 9/24/24, indicated Patient 28 was seen at the bedside, on 9/26/24. Patient 28 was not seen due to medical instability. There was no Speech Therapy note found for the week of 9/29- 10/5/24. Patient 28 was seen by Speech Therapy on 10/6/24 and 10/13/24. The facility did not provide the initial speech evaluation as requested on 11/21/24.

During a concurrent interview and record review on 11/21/24 at 9:48 am, with Licensed Staff HH, the facility's October patient schedule for Speech Therapy, was reviewed. The first week of the schedule, dated 9/29/24-10/5/24, where Patient 18 was observed to have scheduled a Speech Therapy session (three to five times a week) showed no documentation for any of the corresponding days, meaning initials would have indicated a Therapist had seen Patient 28 or a number/x would have indicated an attempt was made to provide therapy to Patient 28. There was no indication a Therapist provided therapy or an attempt to provide therapy was made since the boxes for the week were all blank. Licensed Staff HH stated the boxes were blank because the Therapist was on vacation, and there was only one Speech Therapist in the department at the time. The second week of the schedule, dated 10/6/24-10/12/24, Patient 28 was observed to have one speech therapy session on 10/6/24. Licensed Staff HH stated the Therapist was from another facility and was helping out and agreed that Patient 28 had one session that week and no further documentation about other attempts of therapy (all other boxes were blank). The third week of the schedule, dated 10/13/24-10/19/24, was reviewed where Patient 28 had one Speech Therapy session on 10/13/24, and no further documentation about other attempts of therapy (all other boxes were blank). Licensed Staff HH stated, per the schedule, Patient 28 had not been receiving his scheduled therapy sessions and again stressed the department had one Speech Therapist. Licensed Staff HH stated it was not ideal for a patient to miss therapy sessions and he could not further explain why the facility did not provide Speech Therapy sessions as ordered.

3. During a review of Patient 51's, "History and Physical," dated 10/7/23, indicated Patient 51 was admitted to the facility for abdominal wound management on 10/7/24, and had been on a dysphagia (mechanical soft diet to make it easier for people having difficultly swallowing to reduce the risk of food or liquid going into the airway instead of the throat).

During a review of Patient 51's, "Physician Orders," dated 10/7/24, indicated a swallow evaluation had been ordered for Patient 51.

During a review of Patient 51's, "Speech Therapy Initial Evaluation," dated 10/13/24, indicated Patient 51 was evaluated by a Speech Therapist who recommended remaining on the least restrictive diet (soft, bite size diet) and referred back to Speech Therapy when Patient 51's alertness had improved. "Speech Therapy Initial Evaluation," dated 10/25/24, indicated Patient 51 had graduated with trial of a regular diet and thin liquids so his diet order was upgraded, and no further speech services were recommended.

During a concurrent interview and record review on 11/21/24 at 9:48 am, with Licensed Staff HH, the facility's October patient schedule for Speech Therapy, was reviewed. The second week of the schedule, dated 10/6/24-10/12/24, where Patient 51 was observed to have a scheduled Speech Therapy evaluation, the boxes corresponding for each date were blank; meaning no initials or Therapist had evaluated Patient 51 nor numbers/x were observed to indicate an attempt to evaluate Patient 51 was made. Licensed Staff HH stated the only Speech Therapist for the department was on vacation. The third week of the schedule, dated 10/13/24-10/19/24, Patient 51 was observed to have his speech evaluation completed on 10/13/24, and Unlicensed Staff HH stated it usually did not take that long, but the Speech Therapist was on vacation. Unlicensed Staff HH stated waiting a week would delay therapy but could not expand further.

4. During a review of Patient 34's, "History and Physical," dated 10/6/24, indicated Patient 34 was admitted to the facility on 10/6/24, for wound management, tracheostomy (surgical procedure which creates an opening in the neck and into the trachea or windpipe to provide an airway to breathe) management and ventilation (device which helps or replaces a person's breathing) management and rehabilitation.

A review of Patient 34's, "Physician Orders," dated 10/6/24, indicated a swallow evaluation was ordered.

A review of Patient 34's, "Speech Therapy Initial Evaluation," dated 10/13/24, indicated Patient 34 was evaluated and recommended to continue speech therapy one to five times a week but Patient 34 was not a candidate for oral trial due to weak shallow breaths.

During a concurrent interview and record review on 11/21/24 at 9:48 am, with Licensed Staff HH, the facility's October patient schedule for Speech Therapy, was reviewed. The second week of the schedule, dated 10/6/24-10/12/24, where Patient 34 was observed to have a scheduled Speech Therapy evaluation, the boxes corresponding for each date were blank; meaning no initials or Therapist had evaluated Patient 34 or numbers/x were observed to indicate an attempt to evaluate Patient 34 was made. Licensed Staff HH stated the only Speech Therapist for the department was on vacation, and that was probably why Patient 34 was not evaluated that week. The third week, dated 10/13/24-10/19/24, was reviewed, and Patient 34 was observed to have his speech evaluation completed on 10/13/24. Unlicensed Staff HH stated it usually did not take a full week to have an evaluation but thought it was due to the only Therapist for the department being on vacation. Licensed Staff HH stated he was not sure of the exact time frame but it could take a few days to complete a swallow evaluation.

5. During a review of Patient 33's, "History and Physical," dated 9/27/24, indicated Patient 33 was admitted for ventilator management and rehabilitation.

Records were requested on 11/22/24, for Physician Orders for a swallow screen but the facility did not provide any Physician Orders.

A review of Patient 33's, "Speech Therapy Initial Evaluation," dated 10/6/24, indicated Patient 33 was evaluated and deemed not appropriate for an oral trial at this time and, due to lack of cognition, no further trials were indicated.

During a concurrent interview and record review on 11/21/24 at 9:48 am, with Licensed Staff HH, the facility's October patient schedule for Speech Therapy, was reviewed. The first week of the schedule, dated 9/29/24- 10/5/24, where Patient 33 was observed to have a scheduled Speech Therapy evaluation, the boxes corresponding for each date were blank; meaning no initials or Therapist had evaluated Patient 33 nor numbers/x were observed to indicate an attempt to evaluate Patient 33 was made. The second week of the schedule, dated 10/6/24-10/12/24, Patient 33 was observed to have a scheduled Speech Therapy evaluation, dated 10/6/24. Licensed Staff HH stated he was not sure when Patient 33 had been admitted but stated he thought the evaluation was delayed a week due to the single Speech Therapist being on vacation and the evaluation took place on 10/6/24, because a Speech Therapist from another facility helped out.

During an interview on 11/22/24 at 9:53 am, with Licensed Staff MM, Licensed Staff MM stated she had been the only Speech Therapist in the building for some months now. Licensed Staff MM stated the hours were Monday through Friday so if there was a time to take off during the week, the time could be made up on the weekend. The new admission speech evaluations usually took a day or two but not much more than that, and the case load was not that bad. Licensed Staff MM stated there was a family emergency, and she had to take some time off so maybe some of the Speech Therapy evaluations were delayed; it was not planned, and she was not aware of what took place when she was gone.

During a review of the facility's Policy and Procedure titled, "Rehabilitation Therapy," dated 9/18, indicated, "Speech Language Pathologists shall respond to MD orders for Speech Language pathology ...Patients will be evaluated, and a plan of care established to remediate goals. Documentation will be timely, shall be completely in CPSI by days end and meet all outside payer source guidelines ...Treatment including skills remediation, family and caregiver training and equipment recommendation to optimize patient function status."