Pacifica Hospital of the Valley Dp SNF

Inspectors wroteBased on interview and record review, the facility failed to review and update their facility assessment at least annually. This deficient practice had the potential to result in residents not receiving necessary care and services in a timely manner due to the facility's failure to evaluate the resident population and identify the resources needed to provide appropriate care and services.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS) in the third quarter (4/1/2025-6/1/2025) of 2025. The deficient practice had the potential to not provide the required staffing to ensure residents' care and safety.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation and demonstrate evidence of an ongoing quality assurance and performance improvement (QAPI) program. This deficient practice increased the risk of failing to identify areas in which the facility needed to improve which had the potential to negatively impact the care residents received as well as their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed transmission-based precautions (rules to prevent spreading infections) in accordance with facility policy and infection prevention standards to prevent the spread of infection, when the facility failed to ensure: 1. Licensed Vocational Nurse (LVN) 3 removed soiled gloves before pressing the call light reset button while giving morning care to Resident 55 who was on Enhanced Barrier Precautions (infection control steps requiring staff to wear gowns and gloves during high-contact care [like bathing, dressing, or changing catheters] for residents with, or at high risk of having, hard-to-treat germs) and did not pour visibly contaminated fluids into the shared sink in Resident 55's room. 2. Resident 22 did not have multiple disposable face masks hanging from the wheelchair or touching its wheels. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity and respect for four out of four sampled residents (Residents 1, 30, 49, and 64) when: 1. The facility failed to ensure Resident 1's Foley catheter (a specific type of tube inserted into the bladder to help drain urine) collection bag (designed to collect urine drained from the bladder via catheter) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible). 2. The facility failed to ensure a Restorative Nursing Assistant (RNA 1) knocked or requested permission before entering Resident 30's room. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for three of four residents (Residents 44, 29 and 55) reviewed under the accident care area by failing to: a. Provide upper bed rail padding for Resident 44, who had a history of seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness). b. Apply bed side rail padding for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions as ordered by the physician for Resident 29. c. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to safely use side rails for five of six sampled residents (Resident 6, 8, 24, 29, 55) by failing to: 1. Having a physician's order for Resident 55 and Resident 6's use of side rails and follow the physician's order for bilateral side rails up at all times, when all four side rails were observed up. 2. Assess Residents 6, 8, 24, 29, and 55 for risk of entrapment from bed rails prior to installation and obtain informed consent prior to use of side rails. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm (mental, emotional, or physical injuries caused by social factors, or stressful interactions, rather than physical accidents), physical harm and risk for entrapment (getting stuck).

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Have immediate access to controlled substances ([CS] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM]) and medication emergency kit ([eKIT] - kit containing medications needed to be used during emergencies) stored in the refrigerator in one (1) of two (2) observed Medication Rooms (Medication Room Subacute 2.) 2. Include the verifying signatures of two (2) licensed nurses on the Facility Medication Destruction Form observed in Medication Room Subacute 2, for four (4) of four (4) sampled records. As a result, control and accountability of medications disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: Label one (1) open insulin (medication used to regulate blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) Solostar pen (a type of device containing insulin) stored at room temperature for Resident 4, in accordance with manufacturer's requirements in one (1) of three (3) inspected Medication Carts (Medication Cart Subacute 2 Cart 2.) Store eye drop and ear drop medications separately, in one (1) of three (3) inspected Medication Carts (Medication Cart Subacute 2 Cart 2.) These deficient practices increased the risk that Resident 4 could receive medication that had become ineffective or toxic due to inadequate storage, and labeling, experience medication adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) and increase the risk of [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when purchased bags of ice, still on their original packaging, were placed on top of the ice made by the ice maker and used for 14 of the 60 residents that eat and drink food prepared by the kitchen, These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) for 14 of the 60 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation for resident needs and preferences for two of four sampled residents (Resident 24 and Resident 5) by failing to: Ensure Resident 5's call light (an alerting device that allows a resident to call for help) was within reach. 2. Ensure Resident 24 was provided with a push button call light despite Resident 24 having wrist contractures (a condition where the muscles, tendons, or skin around the wrist tighten, shorten, and scar, causing the joint to become stiff and locked in a bent position) that limited the ability to grasp and activate the call light. This deficient practice had the potential to prevent Resident 5 and Resident 24 from summoning assistance, placing the residents at risk for unmet needs and delayed care.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy titled, Advance Directives, by not providing assistance with creating an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) for two of four sampled residents (Residents 2 and 27) reviewed under the Advance Directive care area. This deficient practice resulted in Residents 2 and 27 not receiving assistance with creating advance directives, increasing the risk that the residents' wishes regarding their medical care would not be known or honored if they became unable to make or communicate their own decisions

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards for one (1) of one (1) sampled residents (Resident 26) investigated for gastrostomy tube ([G-tube] - a tube inserted through the belly that delivers nutrition and medications directly to the stomach) care by failing to flush the tube with the prescribed volume of water. This deficient practice increased the risk that Residents 26 could experience adverse effects (unwanted, unintended result) from lower volume of water, possibly leading to clogging of the G-tube and requiring procedures for declogging (removing a blockage) or replacement of the tube.

Inspectors wroteBased on observation, interview and record review the facility failed to provide preventative care for one of one sampled resident (Resident 64) by not applying sequential compression device (SCD-inflatable sleeves wrapped around the legs that automatically inflate and deflate to mimic muscle movement, increasing blood flow and preventing deep vein thrombosis [DVT-a condition where a blood clot [clump of blood cells in blood stream] forms in a deep vein]) at all times to prevent DVT as ordered by the physician. This deficient practice had the potential to increase the risk of developing blood clots, causing pain, poor blood circulation and serious harm to Resident 64's health.

Inspectors wroteBased on observation, interview and record review the facility failed to provide appropriate services, equipment and assistance to one of three residents (Resident 8) reviewed under the care area of Position/Mobility, to maintain or improve mobility by not applying ankle-foot orthosis ([AFO] - a brace made of plastic or metal to support the lower leg and foot) in accordance with the facility's splinting protocol (rules for temporary, rigid immobilization of a joint to prevent further damage, reduce pain, and protect soft tissue) and physician's order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder received appropriate treatment and services to prevent urinary tract infections (UTI- an infection in the bladder/urinary tract) for two of three sampled residents (Resident 1 and Resident 8) by failing to keep Resident 1 and Resident 8's urinary indwelling catheter (a tube inserted into the bladder to drain or collect urine) in a manner that prevents urine backflow. This deficient practice had the increased potential for Resident 1 and Resident 8 to develop catheter associated urinary tract infection (CAUTI - UTI developed in a resident with an indwelling catheter).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one of four sampled residents (Resident 13) when Respiratory Therapist 2 (RT 2) documented on the Medication Administration Record (MAR - a daily documentation record used by licensed staff to document medications and treatments given to a resident) that Resident 13's bubble humidifier (a medical device that includes a plastic bottle partially filled with distilled water to add moisture to supplemental oxygen given to residents) was changed when the bubble humidifier had not changed. This deficient practice resulted in inaccurate documentation in Resident 13's medical record.

Inspectors wroteBased on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship Program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [medications that fight infections caused by bacteria]) for one of one sampled resident (Resident 8) by not completing an Antibiotic Time-Out (a scheduled check-up, treatment is paused to re-evaluate if the medication is still necessary, effective, or needs adjustment) between 48 to 96 hours of therapy initiation as indicated in facility's policies and procedures (P&P). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled Certified Nursing Assistant (CNA) reviewed for sufficient and competent nurse staffing was provided the required annual in-service training for dementia (a condition characterized by decline in mental ability such as memory, reasoning and communication) management. The deficient practice had the potential to negatively affect the quality of care received by residents with dementia.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1's conservator was included in the decision to cancel a long-awaited medical appointment. This failure had the potential to result in Resident 1 to have a delay in his medical care due to the unplanned rescheduling. During a review of Resident 1's History and Physical (H&P), dated 6/8/2022, the H&P indicated Resident 1 admitted to the facility on [DATE] for long term care and management related head trauma (bodily injury) resulting in cerebral (relating to the brain) swelling (abnormal enlargement of a part of the body, typically as a result of an accumulation of fluid) and right temporal (portion of brain) contusion (bruising). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to inform the family of Patient 1 ' s plan of care and change of condition. This deficient practice led to anxiety while the family had no input into Patient 1 ' s treatment for an extended period of time.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the Centers of Medicare and Medicaid Services [CMS, a federal government agency that manages the Medicare and Medicaid programs, which provide health coverage to millions of Americans]) for two of four fiscal quarters (3rd quarter [April 1 to June 30, 2024] and 4th quarter of 2024 [July1- September 30, 2024]. The deficient practice prevented the provision of complete and accurate direct care staffing information to the public.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for three of three sampled residents (Resident 46, Resident 55 and Resident 57) by failing to: 1. Develop and implement a comprehensive person-centered care plan addressing Resident 46`s Restorative Nursing Assistant program (RNA-nursing aide program that helps residents to maintain their function and joint mobility). This deficient practice had the potential to result in Resident 46`s inadequate care. 2. [...]

Inspectors wrote2. During a review of Resident 38's History and Physical (H&P) dated 6/25/2024, the H&P indicated that the facility admitted the resident on 5/23/2022, with diagnoses including hemorrhagic stroke (a life-threatening emergency that happens when a blood vessel in your brain breaks and bleeds), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and recurrent Urinary Tract Infection (UTI- an infection in the bladder/urinary tract). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement accident risk and hazard interventions for three of five sampled residents (Residents 30, Resident 34, and Resident 18) by failing to: 1. Ensure padding was applied to Resident 30 and 34`s bed side rails for seizure precaution (the safety measures taken before an individual experiences a seizure). 2. Repair or replace Resident 18`s broken wheelchair. These deficient practices had the potential to place Residents 30, 34 and 18 at risk for injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Check the gastrostomy tube (G-tube, a tube inserted through the abdomen] to deliver nutrition and medications directly to the stomach]) residual volume (the amount of fluid in the stomach after a feeding) before administering a medication to one of five residents (Resident 7) observed during medication administration This deficient practice had the potential to place Resident 7 at increased risk for aspiration pneumonia (a type of lung infection that occurs when food, saliva, or other substances are inhaled into the lungs, which occurs when medication is accidentally delivered into the lungs instead of the stomach because an improperly placed tube could be in the esophagus or trachea, allowing medication to enter the airway). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician sign and date all orders in the physical or electronic record, during visits of three out of 23 sampled residents (Resident 4, Resident 13, and Resident 51). This deficient practice had the potential to cause a delay in a resident's plan of care.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure titled, Patient Care Services-Assessment, for one of two sampled residents (Resident 46) by failing to conduct a social service assessment within 48 hours of the resident`s admission to the facility. This deficient practice placed the residents at risk of not receiving sufficient and appropriate social services to meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) affecting Resident 6 and Resident 42 in one of three inspected medication carts (subacute unit two medication cart 3). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services in accordance with professional standards by failing to: 1. Ensure an open (in-use) potassium chloride (supplement used for treatment of hypokalemia [lower than normal potassium level]) solution was labeled with an open date to readily identify the beyond use date for one of one sampled resident (Resident 44). 2. Discard an open and discontinued chlorhexidine 0.12% (antiseptic [slows or stops growth of microorganisms] used to treat skin infection), solution stored in the medication cart for one of one sampled resident (Resident 54). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food storage practices by failing to ensure food stored in the facility's freezers were labeled with the date they were placed in the freezer. This deficient practice had the potential to place 17 out of 58 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wrote3. During a review of Resident 8's Inpatient Information Form, the Inpatient Information Form indicated that the facility admitted Resident 8 on 1/25/2013. During a review of Resident 8's H&P dated 3/15/2024, the H&P indicated the resident was admitted with diagnoses including chronic respiratory failure, gastroparesis (a condition that affects the stomach muscles and prevents proper stomach emptying), and hemiplegia and hemiparesis (weakness or paralysis of one side of the body). During a review of Resident 8's MDS dated [DATE], the MDS indicated that the resident had moderately impaired cognition (thought processes). The MDS further indicated that Resident 8 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - activities related to personal care). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for one out of one sampled resident (Resident 11). This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being

Inspectors wroteBased on interview, and record review, the facility failed to follow the facility`s policy and procedure titled Advanced Directives, for two of five sampled resident (Resident 46 and Resident 35) by failing to: 1. Ensure that Resident 46 was provided written information concerning the right to refuse or accept medical or surgical treatments and formulate an Advanced Directive (AD-a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themself) upon admission. 2. Maintain a current copy of Resident 35`s advance directives in the resident's clinical record. These deficient practices had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment and had the potential to cause conflict with Resident 35 and 46's wishes regarding health care.

Inspectors wroteBased on interview, and record review the facility failed to follow the facility's Policy and Procedure (P&P) titled Discharge Planning, for one of two sampled residents (Resident 60) investigated under closed record review by failing to: 1. Develop a care plan (a document outlining a detailed approach to care customized to an individual resident's need) addressing Resident 60`s discharge plan. 2. Initiate a discharge planning assessment prior to Resident 60`s discharge. These deficient practices placed Resident 60 at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on interview and record review the facility failed to follow the physician's order by failing to check a resident's orthostatic hypotension (a condition where blood pressure drops significantly upon standing or sitting up from a lying position) on 10/23/2024 and 11/27/2024 for one of one (Resident 33) sampled resident. This deficient practice had the potential for Resident 33 to experience dizziness, lightheadedness, or even fainting when standing up, which can lead to falls and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' pain was assessed before and after administration of pain medication for two of two sampled residents (Resident 6 and Resident 42). This deficient practice resulted in Resident 6 and Resident 42's pain not being assessed and placed the residents at risk for having unmanaged pain that may diminish the residents' quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR - review of a resident's drug therapy to assure appropriateness of medication usage completed each month by the consultant pharmacist) was acted upon for two of five sampled residents (Resident 17 and 35) by: 1. Failing to act upon the facility consultant pharmacist's recommendation to assess the need for the medication, FeroSul (also known as ferrous sulfate, medication given for those with an iron [a mineral that the body needs for growth, development, and transporting oxygen] deficiency) for Resident 17. 2. Failing to act upon the facility consultant pharmacist's recommendation to order blood testing for the medication, levetiracetam solution (Keppra [brand name], medication that treats seizures) for Resident 35. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident for side effects for the use of Cymbalta (medication used for depression [mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of five sampled residents (Resident 11) investigated under the care area of unnecessary medications. This deficient practice had the potential to place the resident at increased risk of taking an unnecessary medication and experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain acceptable room temperature ranging from 71 to 81 degrees Fahrenheit (°F, unit of temperature) for 51 of 51 residents (Resident 1 to Resident 51) in the Sub-Acute (a medical facility that provides medical care to chronically ill patients who are medically stable) Unit. 2. Maintain the chiller (a cooling water circulation device that is connected to the air conditioning [A/C] system) for two of two chillers in working condition. 3. Monitor and record room temperatures in accordance with facility's policy and procedures, titled Daily Maintenance Log and Out of Range Temperatures, and Temperature Monitoring of Patient Room. 4. Ensure the rental chillers, which were used temporarily to replace the broken chillers of the air conditioner, were working properly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents' call lights (a device used by patients in hospitals, nursing homes, and other healthcare facilities to request assistance from staff) were within reach while the residents were in bed for three of three sampled residents (Residents 54, 25, and 15) investigated for accommodation of needs. This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet professional standards of practice by failing to label the gastrostomy tubes (G-tube -a plastic tube inserted into a resident's stomach to administer nutrition and medications for one who has swallowing problems) feeding bottle for three (3) of 15 residents sampled residents (Resident 9, Resident 39, Resident 41). This deficient practice had the potential to result in nosocomial infections (infections that develop while a person is receiving medical attention) for Resident 9, Resident 39, and Resident 41.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Provide range of motion (ROM - exercises that improve the movement of a joint) exercises as prescribed by the physician for two of seven sampled residents (Residents 1 and 34) investigated for position and mobility. 2. Ensure one of seven sampled residents (Resident 42) received their prescribed Restorative Nursing Assistant (RNA, a program designed to ensure each resident maintains their physical and functional abilities) order for bilateral (both sides) hand rolls (used to prevent contractures [permanently shortened muscles that resist stretching] of the fingers) as ordered by the physician. These deficient practices had the potential to decrease the residents' range of motion and mobility which could affect their overall function.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensuring the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR, a record of all medications taken by a resident on a day-to-day basis) for four of six sampled residents (Resident 2, Resident 15, Resident 26, and Resident 209). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents (Resident 19 and 22), who were reviewed for psychotropic medication (medications that affect mental processes, resulting in temporary changes in perception, mood, consciousness, and behavior) use, were free from unnecessary medications by failing to: 1. Ensure Resident 19's physician order for Ativan (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed had a duration and documented evidence that the physician indicated the clinical rationale why the medication is being used longer than 14 days. 2. Provide Resident 22 with non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering lorazepam (Ativan [brand name]) as needed. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered comprehensive care plan (a written document that summarizes a patient's needs, goals, and care) for a resident's use of lorazepam (Ativan [brand name]- medication used to treat anxiety [(intense, excessive, and persistent worry and fear about everyday situations]) by failing to include non-pharmacological interventions (therapies that do not involve drugs or medicine) in the care plan for one of five sampled residents (Resident 22) investigated for unnecessary medications. This deficient practice had the potential to result in failure to deliver necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to renew and revised the resident's comprehensive Care Plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) for Range of Motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point) for one of three sampled residents (Resident 44) investigated under Care Planning. This deficient practice resulted to the resident not being evaluated if the desired outcome or care plan goals have been met or if the plan of care needs to be updated with new interventions to prevent further decline in range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the low air loss mattress (LAL - a medical-grade mattress designed to prevent and treat skin breakdown) for a resident at high risk for developing a pressure ulcer (a wound that develops when skin is damaged by constant pressure or fiction) was set correctly according to the resident's weight for one of five sampled residents (Resident 43) investigated for pressure ulcer/injury. This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure two transparent plastic bins containing poultry meat (chicken) in one of two facility refrigerators (Refrigerator 1) were labeled and dated while being thawed. This deficient practice had the potential to place 14 of 59 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure staff labeled a wash basin found on the sink countertop of a shared resident bathroom with a resident identifier for three of eight sampled residents (Residents 25, 54, and 15) investigated for infection control. 2. Ensure soiled linens, soiled blankets, and soiled towels were placed in the soiled linen hamper and not on top of the red biohazard waste container bin (used for the disposal of waste that may be contaminated with pathogens [any organism or agent that can produce disease] that present a danger to people and the environment) for one of four contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) rooms (Room A). [...]