**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide food in the correct consistency per physician orders and resident's individual needs for Resident # 168 resulting in a choking incident requiring emergency response and hospitalization. This created an immediate jeopardy situation. This failed practice had the potential to affect more than a limited number of residents. The facility had corrected this situation that began on 12/04/24 on 12/09/24. This issue is cited at past noncompliance. Resident identifiers: #168, #33, #51, #22, #25, #47, #39, #35, and #59. Facility Census: 63. Findings included: a) Resident #168 Review of a Facility Reported Incident (FRI) documentation revealed Resident #168 had a choking episode on 12/04/24. The resident was transferred to an acute care facility and admitted . The resident was hospitalized from [DATE] to 12/11/24. It was reported that the resident was served broccoli that was not chopped. According to the FRI, the resident indicated and gestured he was choking and staff immediately administered Heimlich technique and was able to clear his airway. A statement from a visitor stated, she assisted staff lower the patient to the floor and stated, Patient was choking on broccoli. I put my hands on his throat and felt something and pulled out a chunk of broccoli. The resident was ordered a Dysphagia Advanced texture diet by the physician. According to the facility's Diet and Nutrition Care Manual, Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow. The corporate recipe for broccoli florets stated, Dys. Adv.: Prepare per recipe. Remove needed portions. Transfer to food processor, chop to pea-size pieces. Resident #168's tray card for 12/04/2024 stated Broccoli Florets, Chop. A written statement form [NAME] # 67 on 12/05/2024 stated, If we get suspended then everybody in dietary needs to be suspended bc we never was told to chop broccoli up. In the report the Dietary Manager said she had given him broccoli not chopped bc (because) its usually overcooked. On 06/09/2025 at 7:55 PM, when the surveyor asked who was ultimately responsible for ensuring correct diets are delivered, the Administrator stated, Staff doing the meal .cook and aide check each meal that goes out. Aide reads diet order as they plate it. The facility's Meal Distribution Plan stated, 4. The nursing staff will be responsible for verifying meal accuracy and timely delivery of meals to residents/patients. The facility's plan of correction included: An audit by the Director of Nursing (DON) conducted on 12/05/24 for all residents to ensure diet orders are correct and accurate. - completed. - DON/designees will conduct an observation round on 12/05/24 for all residents to ensure the correct diet is being served. - completed. - Re-education to all staff beginning on 12/04/24 to ensure diet orders are followed and the correct diet is being served with a post-test to validate understanding. - completed 12/09/24. - The Dietary Manager will monitor starting 12/05/24 to ensure diets are correctly served during meal service across all meals for 2 (two) weeks including weekends and holidays, the 5 (five) times a week for 4 (four) weeks, then 3 (three) times a week for 4 (four) weeks the randomly thereafter. Audit was completed 02/13/25, then continued randomly through last documented date during the survey (06/09/25). - Results of monitors will be reported by the DON/designee monthly to the Quality Improvement Committee. On 06/08/25 at 12:17 PM, during the dining observation, the food served to following resident's matched their tray cards: Residents # 33, # 51, #22, #2, #25, #47, #39, #35, and #59. On 06/10/25 at 11:30 AM, the kitchen tray line was observed for all halls. Good communication between all dietary staff members to ensure the correct meals were served was exhibited. The resident's diets were called out to the cook and two errors were caught before the tray was placed on the cart to be transported and served to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . d) Laundry Room Linen Storage The facility failed to store clean linens in a clean and sanitary manner within an area in the laundry room that maintained appropriate infection control standards. On 09/24/19 at 3:24 p.m. during tour of laundry room with Housekeeping Supervisor (HS) #69 observation was made that revealed two (2) clean resident privacy curtains, one (1) pair of resident window curtains, and several clean mop heads hanging in soiled intake laundry room section of laundry. Two (2) bags of dirty linens (kitchen rags and housekeeping rags) were laying in the room on top of a small non-industrial washing machine within the room. HS #69 stated this room was used for sorting Resident linens and washing of housing the kitchen rags and housekeeping rags in the small washing machine. HS #69 agreed the clean linens and mop heads should not be stored in that area of the laundry rooms. During an interview on 09/24/19 at 4:10 p.m. the Administrator stated HS #69 had already informed her of the issue and the clean linens and mop heads are in the process of being laundered and moved into an appropriate clean storage area. Based on record review, staff interview, Center for Disease Control and Prevention (CDC), Facility Policy, and observation,` the facility has failed to ensure and establish and 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. The facility failed to store clean linens in a safe, clean and sanitary manner. Furthermore, the facility failed to appropriately place Residents #59 and #28, diagnosed with Multiple Drug Resistant Organisms (MDRO), in contact precautions, and they also failed to use proper Personal Protection Equipment (PPE) while providing care. In addition, the facility failed to have PPE equipment readily available for staff. Resident #59 currently has a active diagnosis of Carbapenem-resistant Enterobactiaceae (CRE) in his urine. There were not any signs on the door to alert staff or visitors of the type of precautions to use. Resident #28 was diagnosed with having five (5) MDROs, Methicillin-resistant Staphylococcus Aureus (MRSA), Extended Spectrum [NAME]-Lactamases (ESBL), Klebsiella Pneumoniae Carbapenemase (KPC), Vancomycin-resistant Enterococci (VRE), and Acinetobacter baumannii. He also has multiple open non-healing wounds, Foley catheter, colostomy bag, and a feeding tube. Staff did not use PPEs when providing care. These failed practices had the potential to affect more than a limited number residents at risk for serious harm and/or death resulting in a determination of an Immediate Jeopardy situation. --The facility was notified of the Immediate Jeopardy on 09/25/19 at 3:40 PM. --The facility submitted their plan of correction (POC) at 6:40 PM. --The State Agency requested changes at 6:48 PM on 09/25/19. --The facility submitted the second POC at 7:52 PM on 09/25/19. --The State Agency requested changes on 09/25/19 at 7:59 PM. --The facility submitted the third POC at 8:03 PM on 09/25/19 and their POC was accepted by the State Agency at 8:10 PM on 09/25/19. --Implementation of the abatement components of the POC was observed by the state agency at 9:10 AM on 09/26/19 and the immediacy of the situation was abated. An observation for abatement plan implementation on 09/26/19 at 9:00 AM, revealed that the following rooms had a sign on the door to see nurse before entering the room and an isolation cart by the door. room [ROOM NUMBER] Resident #59, room, 200 Resident #28, room [ROOM NUMBER] and 101 for questionable signs and symptoms of urinary infection. Staff was observed using PPE before entering the rooms. Record review for abatement plan implementation found a complete list of staff who have been re-educated about MDRO and Contact Precautions provided by the Infection Control Nurse (ICN) on 09/26/19 at 9:10 AM. After abatement of the immediate jeopardy at 9:10 AM on 09/26/19 the scope and severity of the deficiency was lowered to an E. This had the potential to affect more than a limited number of residents. Facility census 64. Findings included: a) Resident #59 1. CDC guidelines The CDC states the following concerning CRE and contact precautions (units of skilled nursing facilities, rehabilitation facilities), the use of Contact Precautions is more challenging and should be guided by the potential risk: --Contact Precautions (CP) that residents will serve as a source for additional transmission based on their functional and clinical status and the type of care activity that is being performed. For example, Contact Precautions should be considered for residents colonized or infected with CRE, particularly CP-CRE, who are ventilator-dependent (even if not in a ventilator unit), are incontinent of stool that is difficult to contain, have draining secretions or draining wounds that cannot be controlled. --Masks are not recommended for routine use to prevent transmission of MDROs from patients to HCWs. Use masks according to Standard Precautions when performing splash-generating procedures, caring for patients with open tracheostomies with potential for projectile secretions, and when there is evidence for transmission from heavily colonized sources (e.g., burn wounds). --Follow Standard Precautions in all healthcare acute care settings: Implement CP for all patients known to be colonized/infected with target MDROs. --In LTCFs, consider the individual patient's clinical situation and facility resources in deciding whether to implement CP. --Masks are not recommended for routine use to prevent transmission of MDROs from patients to HCWs. --Use masks according to Standard Precautions when performing splash-generating procedures, caring for patients with open tracheostomies with potential for projectile secretions, and when there is evidence for transmission from heavily colonized sources (e.g., burn wounds). --Patient placement in hospitals and LTCFs: When single-patient rooms are available, assign priority for these rooms to patients with known or suspected MDRO colonization or infection. Give highest priority to those patients who have conditions that may facilitate transmission, e.g., uncontained secretions or excretions. When single-patient rooms are not available, cohort patients with the same MDRO in the same room or patient-care area. --When co-horting patients with the same MDRO is not possible, place MDRO patients in rooms with patients who are at low risk for acquisition of MDROs and associated adverse outcomes from infection and are likely to have short lengths of stay. --For other residents with CRE (CP-CRE or non-CP-CRE) who are able to perform hand hygiene, contain their stool and secretions, and are less dependent on HCP for their activities of daily living, use of gowns and gloves should be based on the type of care provided. This consists of using gowns and/or gloves when there is potential for exposure to their fluids or secretions or there is a risk of the healthcare provider contaminating their clothes, etc. Examples of when gowns and/or gloves might be used include the following: bathing residents; assisting residents with toileting; changing residents' briefs; changing a wound dressing; and manipulating patient devices (e.g., urinary catheter). --Gowns and gloves might not be needed if there is minimal potential for cross-contamination from residents or their environment (e.g., setting a tray down in the room, entering the room without contacting the resident or their immediate environment). In addition, residents with CRE at lower risk for transmission (as described above) do not need to be restricted from common gatherings in the facility (e.g., meals, group activities). Further work is needed to define the risk of contamination of HCP hands and clothing with the range of activities performed in these settings. 2. Record Review and Observation Resident #59 currently has a active diagnosis of Carbapenem-resistant Enterobactiaceae (CRE) in his urine. He has a Foley catheter and is receiving an antibiotic currently for the urinary tract infection (UTI). He is not on contact precautions for this MDRO to prevent transmission of communicable diseases and infections. 3. Staff Interview On 09/25/19 at 3:00 PM, an interview with Administrator and DoN, stated, It is contained in his catheter and he does not need to be on precautions. They were asked how the staff knew when a resident was in contact precautions. DON stated, the nurses will tell the aides they need to take extra precautions because of the infection and the staff passed the information about the residents in report at change of shift from nurse to nurse and nurse aide to nurse aide. On 09/25/19 at 3:12 PM, the Nurse Aide (NA)#43 (who normally assigned to Resident #59) stated, that she needed to wear a gown when providing care to the resident because he had a super bug right now. When asked where she would get a gown, she stated they are usually right here in a cart, but I don't see them right now. The NA did not indicate any other areas that she could get a gown other than the cart. On 09/25/19 at 3:15 PM, DON was asked where the NA would get a gown from, she stated, we have some back here referring to a room on the 200 hall and the central supply room. When asked where the cart the NA referred to was, she said, these are them. She pointed to carts which were stored in the Central supply room that was in the back of the room with boxes stacked in front of them and the carts were stacked on top of each other. Not accessible for the staff to use. During an interview on 09/25/19 at 3:20 PM, Administrator and Director of Nursing (DoN) were asked about not placing residents in contact precautions for MDROs. The DoN stated, that she did not believe that they have use contact precautions for these residents because it is contained in a catheter. b) Resident #28 1. Record Review and Observation Resident #28 was diagnosed with having five (5) MDROs, Methicillin-resistant Staphylococcus Aureus (MRSA), Extended Spectrum [NAME]-Lactamases (ESBL), Klebsiella Pneumoniae Carbapenemase (KPC), Vancomycin-resistant Enterococci (VRE), and Acinetobacter baumannii. He has multiple open wounds on his coccyx, gluteal folds, and his right foot, feeding tube, Foley catheter, colostomy bag. 2. Staff interview On 09/25/19 at 12:30 PM, Infection Control Nurse (ICN), was asked if Resident #28 was placed in Contact Precautions in July when the Urinary culture was positive for ESBL. She stated, No because it is contained in his catheter. She further stated, that the facility had 30 to 35 people in the facility who had MRDOs', and she said, I think that is a lot. She went on to say, The aides know they need to wear gowns when caring for him. She was asked if she monitored the staff to make sure that the staff are wearing gowns while providing care. She said, that she had not, but she is sure they are. According to the facility's Infection Control Monthly Line Listing sheet, Resident #28 has a history of the following: ESBL, MRSA, VRE, Acinetobacter baumannii, KPC and open areas. Resident #28 currently shares room with Resident #20 who has no history of having any MRDO's. On 09/25/19 at 8:41 AM, Licensed Practical Nurse (LPN) #17 stated, that Resident # 28 was going to the wound clinic, but in May the clinic said, that there was nothing else they could do for him. She cleaned the bedside table, washed her hands, she removed supplies from the treatment cart with the reusable items were placed on the table still inside of the bags with the resident's name on the bag. She proceeded into the room without using any PPE's and provided wound care. An interview with NA #40, (who was assigned to care for Resident #28) on 09/25/19 at 3:15 PM, found she was not aware of him having any infection in which she needed to take extra precautions for. She confirmed she had worked with him in July of 2019 and does not recall ever being told that he had a MRDO infection. She went on to say she was not aware if she needed to take extra precautions while providing him care. She stated, everybody has a little bit of something, so we just need to be careful. She confirmed, she did not wear a gown when providing care to this resident and could not recall wearing a gown in July when he was actively being treated for ESBL in his urine or currently with all of the open wounds, Foley catheter, colostomy bag and feeding tube. Even though he has a diagnosis of five (5) MDROs. During an interview on 09/25/19 at 3:20 PM, Administrator and Director of Nursing (DoN) were asked about not placing residents in contact precautions for MDROs. The DoN stated, that she did not believe that they have use contact precautions for these residents because it is contained in a catheter. She was asked about the opened and draining wounds on Resident #28 and if the staff should be using PPE's while providing care. She stated, that they do when it is indicated. She was informed that the Wound Treatment Nurse and the NA's were observed not using PPE's today. The DoN went on to say, that the nurse aides would not know what MDROs' were, because she does not even know about all of them herself. The catheters do contain the urine, but while emptying and providing care for the resident the urine is no longer contained and there is risk for the staffs clothing, shoes, and etc. coming in contact with the resident's infectious urine and then could be spread throughout the facility. The same for the wounds while they are covered and the drainage is contained, when the wounds are being cleaned and dressing changes the infectious drainage is no longer contained. c) Review of the facility infection control monthly line listing During a review of the infection control monthly line listings through April 2019, it was revealed that the following residents were known to have MDROs: 1. 300 Hall: --On 09/16/19 Resident #59 was positive for CRE in his urine, and was facility acquired, and the type of precaution was Standard (S). --On 07/03/19 Resident #266 was positive for CRE in the urine, facility acquired and was placed in standard precautions. --On 06/25/19 Resident #55 was positive for ESBL in the urine, facility acquired, and placed in standard precautions. --On 05/20/19 Resident #46 was positive for VRE in the urine, community acquired, and placed in standard precautions. --On 05/16/19 Resident #22 was positive for ESBL in the urine, facility acquired, and placed in standard precautions. --On 05/09/19 Resident #267 was positive for VRE in the urine, facility acquired, placed in standard precautions. --On 04/29/19 Resident #267 was positive for ESBL in a wound, facility acquired. placed in standard precautions. --On 04/22/19 Resident #266 was positive for MRSA in a wound, facility acquired, and placed in standard precautions. --On 04/09/19 Resident #22 was positive for ESBL in the urine, facility acquired. and placed in standard precautions 2. 200 hall: --On 08/13/19 Resident #8 was positive for ESBL in the urine, and was facility acquired, the type of precaution was S. --On 08/04/19 Resident #50 was positive for ESBL and KPC in the urine, and was facility acquired, and placed in standard precautions, --On 08/19/19 Resident #29 was positive for ESBL and KPC in the urine, facility acquired, and placed in standard precautions. --On 07/30/19 Resident #34 was positive for MRSA in an abscess, community acquired. and placed in standard precautions. --On 07/19/19 Resident #32 was positive for ESBL in the urine, facility acquired, and placed in standard precaution. --On 07/03/19 Resident #50 was positive for ESBL in the urine, facility acquired, and place in standard precaution. --On 06/03/19 Resident #65 was positive for CRE in the urine, facility acquired, and placed in standard precautions. --On 05/29/19 Resident #65 was positive for CRE in the urine, facility acquired, and placed in standard precautions. --On 05/18/19 Resident #32 was positive for ESBL in the urine, facility acquired, and placed in standard precautions. --On 05/09/19 Resident #27 was positive for ESBL in the urine, facility acquired, and placed in standard precautions. --On 04/16/19 Resident #65 was positive for VRE in the urine, facility acquired, and placed in standard precautions. --On 04/13/19 Resident #16 was positive for ESBL in the urine, facility acquired, and placed in standard precautions. 3. 100 Hall: --On 07/03/19 Resident #28 was positive for ESBL in the urine, facility acquired, placed in standard precautions. d) Administrator Interview During an interview on 09/25/19 at 3:45 PM, Administrator said, that they knew that the infection control was not being done correctly at this time. But they have been waiting on the cooperate office to release the new policies and protocols. .