West Haven Healthcare

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled nursing staff's (Certified Nursing Assistant [CNA] 6's) competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) evaluation was completed annually. This deficient practice resulted in incomplete competency evaluation for CNA 6 and had the potential for CNA 6 to provide inadequate care and services to assure resident safety and physical, mental, and psychosocial well-being of residents. During a concurrent interview and record review on 5/5/2026 at 3:53 PM with the Director of Staff Development (DSD), CNA 6's Competency Evaluation Worksheets (CEWs) in CNA 6's employee file were reviewed. The DSD stated the last CEW in CNA 6's file was dated 7/17/2019. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain written informed consent for two out of two sampled residents (Residents 30 and 3) for the use of psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication. These deficient practices had a potential for Residents 30 and 3 not receiving adequate or sufficient information regarding psychotropic drugs necessary to make an informed health care decision.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light (an alerting device to assist a resident when needed) was within reach and appropriate to the patient's physical ability for two of two sampled residents (Residents 25 and 62). These failures had the potential to delay meeting Resident 25 and 62's needs or result in a fall or accident/injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to promote healing for residents with pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 65) by failing to:a. Ensure Resident 65's Low Air Loss Mattress (LAL - a specialized medical support surface designed to prevent and treat skin ulcers by combining alternating pressure with a steady low-volume airflow) pressure was set consistent with the resident's weight. b. Ensure to turn and reposition Resident 65 every two hours in accordance with Resident 65's care plan. These failures had the potential to result in worsening of Resident 65's existing pressure ulcer/injury and developing new skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was administered oxygen therapy (treatment that provides supplemental oxygen) at the rate ordered by the physician and the resident's care plan (CP) for the use of oxygen was revised for one of one sampled resident (Resident 2). This deficient practice placed Resident 2 at risk for respiratory distress (difficulty breathing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage for one of two resident refrigerators. This deficient practice had the potential to result in pathogen (germ) exposure to residents and places them at risk for developing foodborne illness.

Inspectors wroteBased on interview and record review, the facility staff failed to accurately document the nursing interventions and medication indication on the residents' medical record for four of four sampled residents (Residents 2, 3, 33, and 40) when: a. The facility did not complete Adult Daily Living (ADL, the basic self care tasks an adult performed each day, such as bathing, dressing, eating, toileting, and mobility) documentation for Resident 2 and completed in a timely manner. b 1. Resident 3 was placed on NPO as ordered by MD, on MAR resident was receiving a regular diet from 3/5/2026 to 3/11/2026. b 2. Resident 33 did not have a history or diagnosis of depression but resident was receiving Trazadone for depression. c. The facility did not complete ADL documentation for Resident 2 and completed in a timely manner. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure hospice (compassionate care for people near the end of life) residents received the necessary care and services for one of one sampled resident (Resident 65) by failing to:a. Ensure Resident 65 received two skilled nursing visits every week in accordance with the hospice plan of care order.b. Ensure Resident 65 received two hospice aide visits every week in accordance with the hospice plan of care order. These failures had the potential not to meet Resident 65's hospice needs affecting the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oral care was provided to one of one sampled resident (Resident 2). This deficient practice did not maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had a complete and accurate Advance Directive Acknowledgement Form (a signed form provided to acknowledge that information regarding an Advance Directive [AD, a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitate]) for one of six sampled residents (Resident 2). This deficient practice had the potential for Residents 2 to receive life-sustaining care and/or treatment not desired.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 50), Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment was accurately coded regarding the use of insulin (a hormone that removes excess sugar from the blood). This failure had the potential to result in delays of necessary care and services and inaccurate plan of care and interventions for Resident 50.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to prevent a fall (unintentional coming to the ground) for one of four sampled residents (Resident 2) by failing to ensure Certified Nursing Assistant 5 (CNA 5) provided two-person physical assistance (help from two persons) when turning Resident 2 in bed while changing Resident 2's adult brief. This deficient practice resulted in Resident 2's fall on 11/24/2025 and Resident 2 sustained a right femur fracture (broken thigh bone).

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to elevate the resident's head of the bed (HOB) while receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) in accordance with the resident's care plan and physician's order for one of two sampled residents (Resident 11). This deficient practice had the potential to result in aspiration (inhalation of foreign materials) and pneumonia (a lung infection) for Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Foods Brought in by Visitors, by failing to label outside food for Resident 88 and ensure outside food adhered to Resident 88's prescribed diet. This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 88 that could lead to serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information on the Nurse Staffing Information Sheet (posted information that contains the facility's current resident census and total number and actual hours worked by licensed and unlicensed nursing staff) was posted in a prominent place readily accessible to residents and visitors. This failure resulted in nursing staffing information not accessible to residents and visitors and had the potential to negatively affect the quality of care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement care plans (CP- a personalized document that outlines a resident's medical and social care needs and the actions required to address them) for four of seven sampled residents (Residents 1, 2, 6, and 7) according to the facility's policy and procedure (P&P) titled, Care Planning, by failing to: 1. Ensure Residents 1 and 6 had CPs developed for the administration of intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) antibiotics (abx- medication that inhibits the growth of or destroys bacteria in the body). 2. Ensure Resident 7 had a CP developed and implemented for the use of peripherally inserted central venous catheter (PICC- a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide clear, complete and signed intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) medication orders, and IV flush (to insert normal saline [NS- a sterile solution of water and sodium chloride (table salt)]) orders according to the facility's policies and procedures (P&P) titled, Medication Orders, Peripheral Catheter (IV) Flushing, and, Continuous Infusion of Medications and Solutions, for seven of seven sampled residents (Residents 1, 2, 3, 4, 5, 6, and 7) by failing to: 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide concise and clear documentation for six of seven sampled residents (Residents 2, 3, 4, 5, 6, and 7) according to the facility's policy and procedure (P&P) titled, Documentation- Nursing, by failing to ensure: 1. Ensure Resident 2's intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream flush (to insert normal saline [NS- a sterile solution of water and sodium chloride (table salt)]) in the IV Therapy medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) (IV MAR) were legible (able to clearly read). 2. Ensure Resident 3's medication name and diagnosis in the IVMAR were legible. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed vocational nurses (LVNs) and certified nurse assistants (CNAs) had the competency (the capability to apply or use the knowledge, skills, and abilities required to successfully perform tasks in the work setting) to understand different infection types in the healthcare setting by failing to: 1. Ensure the Infection Prevention Nurse (IPN), Director of Staffing Development (DSD), LVN 3, LVN 4, CNA 4, CNA 5 and Restorative Nurse Assistant/CNA (RNA) 1 were aware that Group A Streptococcus (GAS- bacteria that enters the body and causes an illness and affects the skin and throat) were bacteria (organism that enters the body and cause illness) that could cause infections through respiratory droplets (respiratory particles created when coughing, sneezing, or talking) or direct contact. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and/or diseases in the healthcare setting) were followed in accordance with the facility ' s policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs [containing 60%-95% alcohol] and hand washing with soap and water), and Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to a variety of hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves), and Resident Isolation- Categories of Transmission-Based Precautions (TBP- set of infection control measures [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe, sanitary, and homelike environment for two of two resident shower rooms (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]). These deficient practices had the potential to expose residents to mold and injury from broken tile and cracked grout when receiving care in Shower rooms [ROOM NUMBERS].

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the quarterly Minimum Data Set (MDS - a resident assessment tool) in a timely manner for three of three sampled residents (Resident 13, Resident 44 and Resident 50) as indicated in the Centers for Medicare & Medicaid Services (CMS - a federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manual. a. For Resident 13, the quarterly MDS was not transmitted within 14 days after the quarterly assessment. b. For Resident 44, the MDS was not transmitted within 14 days after the quarterly assessment. c. For Resident 50, the MDS was not transmitted within 14 days after being admitted to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 41) received treatment and care in accordance with the physician's order for the administration of Chlorpromazine/Risperidone (antipsychotic medications) by failing to ensure Resident 41 was monitored for orthostatic hypotension with two blood pressure readings 5 to 10 mins apart and observed for adverse side effects. This deficient practice had the potential to cause Resident 41's blood pressure to decrease ( hypotension, blood pressure that is too low) with dizziness and fainting that could lead to falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with the facility's Policy and Procedure (P&P) for two of two boxes of potato (hash browns). This failure had the potential to cause food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure its binding arbitration agreements included a selection of a neutral arbitrator and a venue convenient to both the facility and resident/resident responsible party for two of four sampled residents (Residents 15 and 65). These failures placed Residents 15 and 65 at risk for unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist the resident meal at eye level for one of one sample resident (Resident 38). This failure had the potential to result in the Resident 38's dignity was not maintained.

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) on Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) for two of eight sampled residents (Residents 185 and 19) by failing to ensure Advance Directive Acknowledge (ADA) Forms were completed on admission for Residents 19 and 185. These failures had the potential risk for facility staff to provide medical treatment and services against the will of Residents 19 and 185.

Inspectors wroteBased on observation, interview and record review, the facility failed ensure the bed grab bar foam pads for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precaution was in good condition for one of two sampled residents (Resident 9). This failure had the potential to put Resident 9 at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide set-up assistance (helper sets up, resident completes the activity) during lunch time for one of one sampled resident (Resident 15). This failure had the potential for Resident 15 to lose weight due to decrease meals/fluid intake, dehydration and electrolyte imbalance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach) site as ordered by the physician and as indicated in the plan of care for one of one sampled resident (Resident 234). This failure had the potential for complications related to tube feeding for Resident 234.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of grab bars (bars installed on the side of the bed)/bed rails/side rails (adjustable metal or rigid plastic bars attached to the bed) for one of one sampled resident (Resident 237) by failing to: a. Ensure appropriate alternative interventions were attempted and did not meet the needs of Resident 237 before the installation of grab bars. b. Ensure to obtain an informed consent to review the risks and benefits before the installation of grab bars. c. Ensure to develop an individualized person-centered care plan on the use of grab bars to meet the resident's specific needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dose reduction for one of 5 sampled residents (Resident 11). This deficient practice put Resident 11 at risk of receiving unnecessary medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection prevention guidelines for an Enhanced Barrier Precaution room (EBP, infection control measure that involve wearing gloves and gowns during high contact patient care to prevent the spread of bacteria) for one of one sampled resident (Resident 78) when the private care giver (PC) was inside Resident 78's room helping other staff member giving Resident 78 a bed bath without wearing a gown. This failure had the potential to result in spreading infections from Residents 78 to the PC, staff members and other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep an electric fan (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) in a safe, operating, and sanitary condition for one of one sampled resident (Resident 19). This failure had the potential to affect Resident's 19 quality of life and overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services, for one of three sampled residents (Resident 1), by failing to: Follow the facility's Policy and Procedure (P&P) to implement interventions to promote the prevention of pressure ulcer/pressure sore (localized damage to the skin and/or underlying tissue usually over a bony prominence (areas where bones are close to the surface) development for Resident 1, who was on a low air loss mattress (LAL, mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) and was at high risk for developing a pressure ulcer. This deficient practice had the potential to result in Resident 1 developing a pressure ulcer and/or worsening of Resident 1's existing pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedures (P&P) on controlled medication storage for one of two sampled Medication Storage (MS) Rooms (MS room [ROOM NUMBER]) when: 1. Two licensed nurses were not present when checking the Controlled Substance Two (II) Emergency Kit (CS II E-kit, emergency medications that require authorization if a medication is not in stock in the facility's pharmacy or medication cart. Substance II medications have a high potential for abuse, potentially leading to severe physical dependence) in MS room [ROOM NUMBER] when five tablets' of 10/325 milligrams (mg, unit of measurement) of Percocet (prescribed controlled medication used to treat moderate to severe pain) and two tablets of 5/325 mg of Percocet were reported missing from the CS II E-kit on [DATE]. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (unintentionally coming to rest on a lower-level surface) for two of three sampled residents (Residents 2 and 3) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 5 kept Resident 2's bedside tray, water pitcher and cup within reach of Resident 2 while in bed. 2. Ensure LVN 1 and CNA 4 provided Resident 3 with adequate supervision while Resident 3 was in the restroom unassisted. 3. Ensure Residents 2 and 3 had a red star emblem placed on/and or located the head of bed, assistive devices such as wheelchairs, outside Residents 2 and 3's room on the name sign and a wrist band indicating Residents 2 and 3 were fall risks, based on the facility's policy and procedure (PP) titled. Fall Prevention Program. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain written informed consent for two of three sampled residents (Residents 16 and 71) for the use of psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication. a. For Resident 16, there was no consent obtained for the use of Clonazepam (medication to treat acute panic disorder) Clozapine (medication to treat psychosis [severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality]), Divalproex Sodium (medication to treat bipolar disorder [mental disorder with periods of depression and periods of elevated mood]) and Bupropion (medication to treat depressive disorder [a feeling of severe sadness or hopelessness]). b. For Resident 71, there was no consent obtained for the use of Remeron (medication used to treat depression). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for four of four sampled residents (Residents 4, 43, 30 and 3) who were at risk for fall, by failing to ensure the residents' call light was within reach as indicated in the facility's Policy and Procedure, titled Call Light and the residents' plan of care. These deficient practices had the potential for the residents not to receive or received delayed care to meet the residents' needs and placed the residents at risk for fall or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site and feedings as ordered by the physician and as indicated in the facility's Policy and Procedure (P&P) and plan of care for two of two sampled residents (Resident 181 and Resident 25). a. The GT site for Resident 181 did not have a drain sponge (pre-cut T-slit sponge dressing that provides a snug fit around catheters, tubes, and tracheotomies) or silicon foam dressing (a soft dressing that forms a seal between the dressing and the wound) as ordered by the physician. b. The GT site for Resident 25 did not have a drain sponge or silicon foam dressing as ordered by the physician. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its binding arbitration agreement included the selection of a venue that is convenient to both facility and resident/responsible party for three of three sampled residents (Residents 36, 51 and 58) who signed the arbitration binding agreements upon admission to the facility. This deficient practice placed Residents 36, 51 and 58 at risk for delayed arbitration hearing in an event of an arbitration dispute.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, provides information to residents/beneficiaries so they can decide if they wish to continue receiving skilled services that may not be paid for by Medicare and assume financial responsibility) for two of two sampled residents (Residents 38 and 42) who were discharged from Medicare Part A skilled services and continue to reside in the facility. This deficient practice placed Residents 38 and 42 at risk for paying out-of-pocket costs for non-coverage services while in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a bed in good condition for two of two residents (Residents 41 and 229.) This deficient practice had the potential to pose a safety risk for Residents 41 and 229.

Inspectors wroteBased on interview and record review, the facility failed to obtain information from prior employers for one of five randomly selected employees (Licensed Vocational Nurse 2[LVN2]) before hiring, in accordance with the facility's policy and procedure, titled Abuse and Neglect Prohibition. This deficient practice had the potential for the facility to hire employees with history of abuse, neglect or mistreatment of residents which could lead to possible harm and abuse of residents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide assistance with oral hygiene to one of one sampled resident (Resident 229). This deficient practice had the potential to affect Resident 229's sense of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan with interventions to address the resident's refusal to turn and reposition to help prevent the recurrence (re-open) of a healed pressure ulcer and prevent the development of a Stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer; the wound bed is viable, pink, or red, moist) on the coccyx (tailbone) for one of three sampled residents (Resident 71). This deficient practice placed Resident 71 at risk for developing new pressure ulcer and recurring Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present).

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date the intravenous catheter (IVC, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids, and/or blood products) for one of one sampled resident (Resident 18). This failure had the potential to result in infection to Resident 18 and worsen the resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental oxygen) for two of three sampled residents (Resident 65 and Resident 180) according to standards of clinical practice and the facility's Policy and Procedure titled, Oxygen Therapy. a. Resident 65's nasal cannula (tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) while not in used, was not stored in a clean plastic bag, and left hanging on resident's bed with nasal prongs touching the residents head of bed. b. Resident 180's oxygen tubing was left hanging on a portable oxygen tank while not being used. The oxygen tubing was not labeled with the resident's name and not dated when it was changed. These deficient practices placed Residents 65 and 180 at risk for respiratory complications and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing information posted on 1/15/2024 accurately reflected the actual hours worked and the total number of staff, as indicated in the facility Policy and Procedure titled Staff Posting Requirements. This deficient practice had the potential to result in misinformation to the residents and the public of the facility's nursing staffing data.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 62) on psychotropic drugs (any drug that affects brain activities associated with mood, emotions, and behavior) was free from unnecessary medication by failing to ensure staff attempted a gradual dose reduction (GDR, the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident 62's Seroquel (antipsychotic drug [use to treat symptoms of psychosis or disconnection from reality) 50 milligrams (mg, unit of measurement) since ordered on 8/16/22. This deficient practice placed Resident 62 at risk for adverse drug reaction (a harmful and unintended response to a medicine).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 40) was provided with carbohydrate-controlled (diet that restricts carbohydrates, such as those found in pasta, bread, and sugary foods) diet per physician's order. This deficient practice had the potential to result in high blood sugar for Resident 40.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure food delivered were within temperature range and within the food temperature preferred for one of two sampled residents (Resident 57). This deficient practice had the potential for decreased appetite and food intake for Resident 57 and placed the resident at risk for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate care with the hospice care (focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) provider for one of one sampled resident (Resident 23) by failing to ensure hospice services were provided as scheduled. This deficient practice placed Resident 23 at risk of not receiving appropriate hospice care in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of Corona Virus 19 (COVID 19, a mild to severe respiratory illness that spread from person to person) by failing to ensure Certified Nurse Assistant 5 (CNA 5) performed hand hygiene ( way of cleaning one's hands that substantially reduces pathogens [harmful microorganisms] on the hands) and don (to put on) gown and gloves before entering Resident 17's room, which was located in the Red Zone (an area dedicated for residents who are COVID 19 positive) in accordance with the local Public Health guidelines and facility's Policy and Procedure on Transmission Based Standard. This deficient practice had the potential to result in the transmission of COVID 19 to the residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 77's Minimum Data Set (MDS, a resident assessment and care-screening tool) dated 11/22/2023, accurately reflect the resident's discharge destination. Resident 77, who was discharged home, was coded in the MDS assessment dated [DATE], as discharged to the acute hospital. This failure had the potential to result in Resident 77 not to receive interventions to address specific care concerns.