Providence Holy Cross Med Ctr D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received care and services for the provision of parenteral fluids (formulated liquids that are injected into a vein) consistent with professional standards of practice for two of two sampled residents (Residents 50 and 2) by failing to: 1.a. Label Resident 50's Dextrose 5 percent (% - one part in every hundred) in Normal Saline (D5 NS, a sterile intravenous [IV - through the vein] solution used to replenish fluids, calories, and electrolytes) and document the administration per facility policy and procedures (P&P). 1.b. Label Resident 50's peripheral intravenous site with a date when it was inserted. 1.c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to store, prepare, and serve food in accordance with professional standards of practice for food service safety by failing to: 1. Dispose green bell peppers pre-cut on its discard date (date out). 2. Dispose burger patties on its discard date. 3. Dispose chopped green onions discard date. 4. Label diced carrots with date in (when a product was prepared, opened, or received) and date out (discard date). 5. Cover and label with date in and date out three (3) cups of water in the Sub-Acute (for residents needing services that are more intensive than those typically received in skilled nursing facilities [SNF] but less intensive than acute care) pantry freezer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for aspiration precautions for one of two sampled residents (Resident 39) reviewed for tube feeding (TF - a method of supplying nutrients directly into the stomach). This deficient practice had the potential to place Resident 39 at risk for respiratory infections such as pneumonia (an infection/inflammation in the lungs). Cross-reference F693.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of accident hazards and adequate supervision and assistance to prevent falls and injury for one of two sampled residents (Resident 7) reviewed during the Accidents care area by failing to ensure the bed was maintained in the lowest position while the resident was left unattended. This deficient practice had the potential to result in falls leading to injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding [TF], a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications by failing to ensure the head of the bed (HOB) was elevated to greater than 30 degrees (a unit of angle measurement) per facility policy and procedures (P&P) for two of two sampled residents (Resident 7 and 39) reviewed for TF. This deficient practice placed Residents 7 and 39 at increased risk for complications of aspiration (when food or liquid enters the airway and lungs instead of the stomach) including aspiration pneumonia (an infection/inflammation in the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one of one sampled resident (Resident 2) reviewed for respiratory care by failing to ensure Resident 2's bubble humidifier, dated 3/12/2026, was changed every three days per facility policy and procedure (P&P). This deficient practice placed Resident 2 at risk for acquiring respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of three sampled residents (Resident 7) reviewed under the urinary tract infection (UTI - an infection in the bladder/urinary tract) care area by failing to ensure intravenous (IV - administered within a vein) piperacillin-tazobactam (also known as Zosyn, an antibiotic [medication used to treat bacterial infections]) was administered per the physician's ordered flow rate (the speed at which IV fluids or medications are delivered to a resident) and time schedule. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to ensure: 1. Drugs were labeled in accordance with currently accepted professional principles to facilitate consideration of precautions and safe administration of medications by failing to ensure intravenous (IV, administered within a vein) piperacillin-tazobactam (an antibiotic [medication used to treat bacterial infections)] was labeled with the flow rate (the speed at which IV fluids or medications are delivered to a resident) for one of three sampled residents (Resident 7) reviewed under the urinary tract infection (UTI- an infection in the bladder/urinary tract) care area. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained in accordance with professional standards that were complete and accurately documented when the facility failed to ensure Resident 20's Certified Nursing Assistant (CNA) documentation every two hours when Resident 20 was repositioned. This deficient practice had the potential for incomplete and inaccurate medical documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure Licensed Vocational Nurse (LVN) 1 disinfected the computer mouse (a small, handheld device used to control a computer) after if fell on the floor and prior to use during the Medication Administration Task for two of four sampled residents (Residents 19 and 24). This deficient practice had the potential to spread communicable diseases and infections among staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to screen for, offer, and administer the pneumonia vaccine (medication used to prevent serious lung infections caused by streptococcus pneumoniae [types of bacteria]) for one of five sampled residents (Resident 5) reviewed during the Infection Control task. This deficient practice had the potential to result in serious respiratory infection from pneumonia in Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the daily staffing posting that contained the total number of staff and actual hours worked per shift information for 7 p.m. to 7 a.m. night shift for four (4) of 4 days reviewed for Sufficient and Competent Staffing Task. This deficient practice had the potential to keep residents and visitors unaware of total number of staff and the actual hours worked by staff in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 24 of 24 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13,Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, and Resident 24) who were on mechanical ventilators (a life-support machine that helps or takes over breathing for people who can't breathe sufficiently on their own, delivering oxygen) was free of contaminants (any physical or chemical substances) when the facility returned the oxygen gas line system back on for service and not had a certified medical gas verifier conduct testing to ensure oxygen is safe, pure and free of contaminants. [...]

Inspectors wroteBased on interview and record review, the facility failed to fully develop and implement an antibiotic (antimicrobial, medicine that inhibits the growth of or destroys microorganisms) stewardship program (ASP- a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics as a part of its overall Infection Prevention and Control Program (IPCP) for one of six sampled residents (Resident 3) reviewed under Infection Control facility task by: a. Failing to establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria for initiating antibiotic treatment b. Failing to identify Resident 3's use of levofloxacin (antibiotic) indicated for urinary tract infection (UTI- an infection in the bladder/urinary tract). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards for two of two sampled residents (Residents 35 and 42) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin for Resident 42, and heparin (an anticoagulant) for Resident 35. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received the appropriate care and services to prevent complications for three of three sampled residents (Resident 2, 35, and 41) reviewed under the tube feeding care area by failing to: 1. Change Resident 35's water flush bag according to the manufacturer's guideline. 2. Indicate the date for Resident 2's medication syringe replacement. 3. Ensure Resident 41 the accurate amount of tube feeding formula was delivered to the resident as ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of five sampled residents (Resident 24, Resident 38, and Resident 40) investigated under the respiratory care area oxygen (type of gas our body needs in order to function) therapy equipment was maintained, and standard infection control practices were followed by failing to ensure: 1. Resident 24 and Resident 38's oxygen tubing did not touch the floor. 2. Resident 40's humidification bottle was labeled and changed per the facility established schedule. 3. Resident 38's Yankauer suction tool (long plastic tool used to remove secretions [thick or thin sticky fluids from the mouth and throat]) was labeled with the date when it was opened. These deficient practices had the potential for Resident 24, Resident 38, and Resident 40 to develop complications such as infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free of any significant medication errors for two of two sampled residents (Residents 35 and 42) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin and heparin (an anticoagulant) administration sites. [...]

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 by failing to: 1. Ensure towels were stored in clean towel bins, sanitation buckets, or dirty towel bins when not in use. 2. Ensure food items in the walk-in Refrigerators #2 and #5 were labeled according to facility policy. 3. Ensure the personal property of staff was not stored in the kitchen area next to an uncovered serrated knife and food items. 4. Ensure Refrigerator #10 and the Subacute Resident Refrigerator/Freezer temperatures were maintained per facility policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and maintain an infection control program by failing to ensure Registered Nurse (RN) 9, accompanied by the Nurse Practitioner (NP) and Medical Doctor (MD), implemented Contact Precautions (an infection control measure aimed to prevent spread of infection by direct or indirect contact by the use of personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments]) during rounding in the residents room for one of five sampled residents (Resident 39) reviewed under the Infection Control task area. This deficient practice had the potential to result in the spread of infectious microorganisms amongst staff, residents, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's right to dignity and privacy was honored for one of one sampled resident (Resident 38) using indwelling urinary catheter (flexible tube inserted in the bladder through the urethra to drain urine), when Resident 38's indwelling urinary catheter drainage bag was not covered to ensure privacy. This deficient practice had the potential for Resident 38 to be embarrassed and affect their self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure to obtained informed consent (voluntary agreement to accept treatment or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sampled resident (Resident 25) reviewed for informed consent, prior to increasing the dose of Seroquel (medication used to help relax someone who is restless [unable to stay calm or still] or agitated [irritated]) from 50 milligrams (mg - a unit of measure) nightly dose to 75 mg. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one (1) of 1 sampled resident (Resident 35) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for two (2) of four (4) sampled residents (Residents 24 and 42) reviewed for restraints by: 1. Failing to complete a restraint assessment prior to application of peek-a-boo mitten (a padded mitten restraint used to prevent patients from pulling out tubes, lines, or other medical devices) on the right hand for Resident 24. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for one (1) of 1 sampled resident (Resident 2) reviewed for urinary catheter or UTI by failing to ensure Resident 2's urinary catheter tubing did not have a loop while hanging on the side the bed. This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI.

Inspectors wroteBased on interview and record review, the facility failed to specify an indication (the reason) for the use of a hypoglycemic medication (lowers blood sugar) for one of five sampled residents (Resident 41) during a review of unnecessary medications when insulin (a hormone that removes excess sugar from the blood) lispro (fast-acting insulin) did not have an indication. This deficient practice had the potential to result in not medically necessary treatments potentially leading to ineffective diabetes management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services during the inspection of one (1) of three (3) medication carts (Medication Cart 1) reviewed during the Medication Storage and Labeling task by failing to discard Resident 1's medication in the bubble pack (a packaged container with compartments that can contain medications) with a broken seal and covered with paper tape. This deficient practice had the potential for medication error and contaminate medications stored inside the medication cart.

Inspectors wroteBased on interview and record review, the facility failed to fully develop and implement an antibiotic (antimicrobial, medicine that inhibits the growth of or destroys microorganisms) stewardship program (ASP- a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics as a part of its overall Infection Prevention and Control Program (IPCP) for one of six sampled residents (Resident 3) reviewed under Infection Control facility task by: 1. Failing to establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria for initiating antibiotic treatment 2. Failing to identify Resident 3's use of levofloxacin (antibiotic) indicated for urinary tract infection (UTI- an infection in the bladder/urinary tract). [...]

Inspectors wroteBased on interview and record review, the facility failed to document that pneumococcal vaccine was offered for the resident and education was provided to the family/decision-maker per its pneumococcal vaccine (an injected medicine that can protect against and often prevent pneumococcal [a type of bacteria] infections [when the immune system fights off the bad germs to get better]) policy and procedures (P&P) for one of five sampled residents (Resident 19) reviewed for immunizations under Infection Control facility task. This deficient practice had the potential to result in increased risk for pneumococcal infections which may lead to serious health complications such as pneumonia (an infection that inflames the lungs' air sacs), meningitis (inflammation of brain and spinal cord membranes, typically caused by an infection), and bloodstream infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's Minimum Data Set (MDS - a resident assessment tool) accurately reflected resident status by failing to ensure the MDS indicated the use of physical restraints (use of manual methods or physical devices to limit an individual movements) for one of five sampled residents (Resident 25) using physical restraints. This deficient practice had the potential to negatively affect Resident 25's plan of care and the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of one of one sampled resident's (Resident 37) who continued to have blood in the urine (hematuria) with presence of clots. Resident 37, who had an indwelling urinary catheter (IUC, a hollow flexible tube inserted in the bladder [the organ that stores urine] to drain urine) and was on blood thinner medication, was having hematuria from 1/12/2024 at 11:40 a.m. to 1/15/2024 and the attending physician (Physician 1) was not informed. As a result, on 1/15/2024 at 9:11 p.m., Resident 37 required emergency transfer to General Acute Care Hospital 1 (GACH 1) where Resident 37 was found with elevated body temperature (fever) and abdominal distention (abnormally swollen outward) requiring removal of the IUC with significant hematuria draining immediately after its removal. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 37), who had an indwelling urinary catheter (IUC, a hollow flexible tube inserted in the bladder [the organ that stores urine] to drain urine), was on blood thinner medication, and had recent hematuria (blood in the urine) with presence of clots, received care and services to prevent complications including continued hematuria, urinary retention (inability to urinate) and/or obstruction (blockage), urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the bladder to the outside of the body], and infect the urinary tract). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to three out of four sampled residents (Residents 24, 23, and 5) investigated during review of physical restraints care area by: 1. Failing to complete an assessment for risk of entrapment prior to use of four bed siderails (SR) up (raised [up] position on bilateral [two sides] upper [area including arms, shoulders, and head] and bilateral lower [area including legs]). 2. Failing to obtain a physician's order for the use of four bed SR up and bed alarms (warn caregivers when residents leave or attempt to leave their beds). 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Develop and implement a care plan for bed alarm (device that warns caregivers when residents leave or attempt to leave their beds) use to two of four sampled residents investigated during review of restraints (Residents 23 and 5). 2. Develop and implement a comprehensive person-centered care plan for use of four bed siderails (SR) to three of four sampled residents (Resident 23, 24 and 5) investigated during review of restraints. These deficient practices had the potential for residents to not receive the proper and necessary care regarding SRs and bed alarm use with the potential to result in injury of the resident by failing to provide ongoing assessment, monitoring, and re-evaluation of SRs and restraints. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to three of three sampled residents (Residents 23, 27, and 14) being investigated under pressure ulcers by failing to consistently: 1. Assess and follow facility's policy and procedure of taking pictures and documenting the measurement of the stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle) of Resident 23 on the sacrum (a triangular bone at the base of the spine) and the occipital area (the back of the head). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) for three of three sampled residents (Residents 24, 26, and 191) investigated under the tube feeding care area by: 1. Failing to ensure Resident 24's EF bottle indicated the correct date and time the current bottle was started, and the water flush bag indicated the date and time started and the rate prescribed by the physician. 2. Failing to ensure Resident 26's and 191's EF bottle indicated the rate as prescribed by the physician. 3. Failing to ensure Resident 26' and 191's water flush bag indicated the date and time started and the rate prescribed by the physician. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safe and appropriate use of four (4) bed side rails (SR) for three of four sampled residents (Resident 24, 23, and 5) investigated during review of physical restraints by: 1. Failing to conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from side rails. 2. Failing to review the risk and benefits of side rails with the resident or resident representative and obtain informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment). These deficient practices had the potential to result in psychosocial harm and physical harm from entrapment and death of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by: 1. Failing to ensure food service attendant wore a hair restraint while working in the food production line. 2. Failing to ensure food items not in their original package were labeled and dated. 3. Failing to ensure an open food product that is in its original packaging was labeled and dated. These deficient practices had the potential to place six out of 43 residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). 1. During an initial observation of the kitchen on 4/13/2023 at 8:14 a.m., observed a Food Service Attendant (FSA) working in the food production line placing food on meal trays, not wearing a hair restraint. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures for antimicrobial stewardship (AMS- a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics, drugs used to treat infections caused by bacteria and other microorganisms], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) for one of six sampled residents (Resident 2) when clindamycin (an antibiotic) was ordered on 1/29/2024 as indefinite and the facility failed to monitor the antibiotic use for 77 days. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care in a manner that honor the resident's right to a dignified existence to two of two sampled residents (Resident 23 and 238) investigated during review of dignity care area by: 1. Failing to ensure Resident 23's indwelling urinary catheter (flexible tube inserted in the bladder through the urethra to drain urine) drainage bag was covered with a dignity bag (a bag used to cover the urinary catheter drainage bag, so it is not visible). 2. Failing to ensure Certified Nursing Assistant 1 (CNA 1) was not standing over Resident 238 while assisting the resident with feeding. These deficient practices had the potential to affect the residents' self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents resident receive care and services for the provision of parenteral fluids (medicines or fluids that go directly into the vein) consistent with professional standards of practice to two out of two sampled residents (Residents 21 and 238) investigated during random observations of residents receiving parenteral/intravenous (IV, within a vein) fluids by failing to label the peripheral IV (indwelling single-lumen plastic conduits that allow fluids, medications and other therapies such as blood products to be introduced directly into a peripheral vein) dressing with the date of when the IV was inserted or when the dressing was changed and the licensed nurse's initials who inserted the IV or changed the dressing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to one out of one sampled resident (Resident 34) investigated during review of respiratory care by failing to connect the trach collar (used to hold a tracheostomy tube [a tube constructed of polyvinyl chloride that is placed between the vocal cords through the wind pipe] in place) to the oxygen humidifier (medical devices used to humidify supplemental oxygen) and oxygen regulator to ensure delivery of oxygen required to keep the resident's oxygen saturation (O2 sat, measures what percentage of the blood is saturated with oxygen) above 92%. [...]

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to ensure licensed nurse did not leave an insulin pen (an injection device that you can use to deliver preloaded insulin [controls the amount of sugar in the blood by moving it into the cells, where it can be used by the body for energy]) unattended on top of a computer on wheels (WOW). This deficient practice had the potential to result in unwanted serious side effects if placed in undesired hands which can lead to harm. 2. Failed to ensure licensed nurses' account of a controlled drug record (accountability record of medications that are considered to have a strong potential for abuse) was accurately documented per facility policy for one of two sampled residents. This deficient practice had the potential for medication errors.

Inspectors wroteBased on interview and record review, the facility failed to ensure if needed (PRN) orders for psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, and behavior) were only used when the medication was necessary and PRN use was only limited to two of five residents (Residents 23 and 5) selected for unnecessary medications review. The deficient practice had the potential to result in the use of unnecessary psychotropic drugs for residents and can lead to side effect and adverse (unwanted) consequence such as a decline in quality of life and functional capacity.

Inspectors wroteBased on observation, interview, and record review the facility staff failed to implement its infection control program to two out of 23 sampled residents (Residents 5 and 3) during resident screening by failing to ensure: 1. The suction canister (a temporary storage container for secretions or fluids removed from the body) of Resident 5, labeled 4/5/2024 was discarded and replaced per facility policy. 2. The urinal bottle (frequently used in healthcare for residents who find it impossible or difficult to get out of bed) was labeled with the name, date, and room number of Resident 3. These deficient practices had to potential to spread infection among residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and screening tool) assessments were successfully transmitted timely to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers major healthcare programs) for four out of 14 sampled residents (Residents 12, 18, 23, and 27) investigated under the resident assessment care area. This deficient practice had the potential to negatively affect the provision of necessary care and services needed by the residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the Minimum Data Set (MDS-a resident assessment and care screening tool) accurately reflected the resident's status in one of four sampled residents (Resident 24) investigated during review of physical restraints by failing to document the resident's use of a mitten restraint (used to prevent residents who are prone to disrupting medical treatment or to self-harm from pulling out any lines or tubes such as feeding tubes, intravenous [administered into a vein] lines) This deficient practice has the potential to negatively affect Resident 24's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one sampled resident (Resident 1), Resident 1's oxygen delivery via tubing was secured and maintained. This deficient practice had the potential to result in Resident 1 suffering from hypoxemia (low level of oxygen in the blood) and may lead to the resident's deterioration of medical condition.