Does ANAHEIM POINT have any serious inspection findings?

Yes, ANAHEIM POINT has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 90 total deficiencies from recent inspections.

What are the staffing levels at ANAHEIM POINT?

ANAHEIM POINT has a four-star staffing rating from CMS with 0.54 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is ANAHEIM POINT located?

ANAHEIM POINT is located in ANAHEIM, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ANAHEIM POINT have?

ANAHEIM POINT has 154 certified beds.

Who owns ANAHEIM POINT?

ANAHEIM POINT is a for profit - limited liability company facility and is part of the SHLOMO RECHNITZ chain.

What questions should families ask when visiting ANAHEIM POINT?

Families visiting ANAHEIM POINT should ask about how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does ANAHEIM POINT compare to other nursing homes?

ANAHEIM POINT has a 1-star overall rating, which is below average compared to other nursing homes in CA. Families should carefully review inspection findings and consider alternatives.

ANAHEIM POINT

Q: What is ANAHEIM POINT's CMS rating?

ANAHEIM POINT has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Is ANAHEIM POINT safe?

ANAHEIM POINT has documented safety concerns including 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Q: Do nurses at ANAHEIM POINT stick around?

ANAHEIM POINT has low staff turnover at 25%, which means caregivers stay longer and know residents better.

Q: Was ANAHEIM POINT ever fined?

Yes, ANAHEIM POINT has been fined $16,143 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is ANAHEIM POINT on any federal watch list?

No, ANAHEIM POINT is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

3415 W BALL ROAD, ANAHEIM, CA 92804 · (714) 826-8950

For profit - Limited Liability company 154 Beds SHLOMO RECHNITZ Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

29/100

#971 of 1155 in CA

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ANAHEIM POINT nursing home in ANAHEIM, CA - Photo 1 of 3

ANAHEIM POINT nursing home in ANAHEIM, CA - Photo 2 of 3

Photo by Anaheim Point Healthcare & Wellness Center

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Last Inspection: March 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Anaheim Point has received a Trust Grade of F, indicating significant concerns about the facility's overall quality and care. It ranks #971 out of 1155 in California, placing it in the bottom half, and #66 of 72 in Orange County, meaning there are very few local options that are worse. The facility is worsening, with issues increasing from 12 in 2024 to 21 in 2025. Staffing is a relative strength, with a rating of 4 out of 5 stars and a low turnover rate of 25%, which is better than the state average of 38%. However, the facility has been fined $16,143, which is average but still raises some concerns regarding compliance. Specific incidents noted by inspectors included a critical finding where a resident was smoking outside without staff supervision, posing a safety risk. Additionally, the facility failed to complete performance evaluations for CNAs, which could impact the quality of care provided. There were also concerns about kitchen sanitation, including improper storage and labeling of food items, which could lead to foodborne illnesses. Overall, while there are some strengths, the facility faces serious weaknesses that families should consider.

Trust Score: F
In California: #971/1155
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 25% annual turnover. Excellent stability, 23 points below California's 48% average. Staff who stay learn residents' needs.
Penalties: $16,143 in fines. Higher than 85% of California facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for California. RNs are the most trained staff who monitor for health changes.
Violations: 90 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 12 issues

2025: 21 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
4-Star Quality Measures · Strong clinical quality outcomes
Low Staff Turnover (25%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (25%)
23 points below California average of 48%

Facility shows strength in staffing levels, quality measures, staff retention, fire safety.

The Bad

1-Star Overall Rating

Below California average (3.1)

Significant quality concerns identified by CMS

Federal Fines: $16,143

Below median ($33,413)

Minor penalties assessed

Chain: SHLOMO RECHNITZ

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 90 deficiencies on record

1 life-threatening

Mar 2025 21 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure four nonsampled residents (Residents 38, 103, 110, and 144) were safe to self-administer the medications. * The facility failed to ensure a bottle of Refresh eyedrops (used to relieve dry and irritated eyes) was not in Resident 110's nightstand. Resident 110 stated she administered the eyedrops by herself; however, Resident 110 was not assessed for the safe self-administration of the medication. * The facility failed to ensure a container of Biofreeze pain relief cream (a topical rubefacient used to ease muscle and joint aches and pain) was not in Resident 103's nightstand drawer. Resident 103 stated he administered the cream by himself; however, Resident 103 was not assessed for the safe self-administration of the medication. * The facility failed to ensure a bottle of Bactine pain-relieving cleansing spray (a maximum strength antiseptic with 4% lidocaine used to help prevent bacterial contamination and for temporary relief of pain) was not in Resident 144's nightstand drawer. Resident 144 stated she administered the cleansing spray by herself; however, Resident 144 was not assessed for the safe self-administration of the medication. * The facility failed to determine if it was safe for Resident 38 to self-administer the pain relieving creams stored at Resident 38's nightstand. These failures had the potential for Residents 38, 103, 110, and 144 to administer the medications inaccurately and develop adverse reactions from the medications, and to negatively affect the residents' well-being. Findings: Review of the facility's P&P titled Medication - Self-Administration dated 1/1/12, showed the following: - The facility will allow a resident to self-administer medications when determined capable to do so by the IDT and the resident's attending physician; - Upon admission to the facility, the resident will be informed of his/ her right to self-administer the medications; - If a resident wants to self-administer the medications, the IDT will assess the resident's cognitive, physical, and visual ability to carryout this responsibility based on a review of an assessment by a licensed nurse. The licensed nurse uses the Assessment for Self-Administration of Medications form for the assessment and submit the results to the IDT; - For a final determination of the resident's ability to self-administer medications, the assessment for self-administration of medications will be presented to the resident's attending physician. The resident may not begin self-administration of medications prior to the approval of the IDT and attending physician. The attending physician must provide a written order permitting the resident to self-administer the medication; - If the IDT and attending physician approved the self-administration of the medications, the medications will be placed in a secured drawer or cabinet that is easily accessible to the resident; and - The physician's order approving self-administration of medication will be maintained in the resident's medical record. The Assessment of Self-Administration of Medication form will be maintained in the resident's chart. Self-administration of the medications will be documented in the resident's care plan and the MAR. 1. On 3/3/25 at 0848 hours, during the initial tour of the facility, Resident 110 was observed lying in bed. A bottle of Refresh eye drops was observed on the resident's nightstand. Resident 110 stated she administered the eyedrops by herself. On 3/3/25 at 1107 hours, a follow-up observation for Resident 110 and concurrent interview was conducted with RN 1. RN 1 verified the bottle of Refresh eye drops was on the resident's nightstand. Medical record review for Resident 110 was initiated on 3/3/25. Resident 110 was admitted to the facility on [DATE]. Review of Resident 110's MDS dated [DATE], showed Resident 110 had a moderate cognitive impairment and no impairment to the upper extremities. Review of Resident 110's Order Summary Report failed to show a physician's order for the resident to self-administer the Refresh eyedrops medication. In addition, there was no physician's order for the Refresh eyedrops. Review of Resident 110's Plan of Care did not show a care plan problem to address Resident 110's ability to self-administer the medication. Further review of Resident 110's medical record failed to show the resident was assessed for the self-administration of the medication. 2. On 3/3/25 at 0822 hours, during the initial tour of the facility, Resident 103 was observed lying in bed. A container of Biofreeze pain relief cream was observed inside an opened drawer of the resident's nightstand. Resident 103 stated he applied the pain relief cream to his back for a chronic back pain. On 3/3/25 at 1105 hours, a follow-up observation for Resident 103 and concurrent interview was conducted with RN 1. RN 1 verified the container of Biofreeze pain relief cream was inside Resident 103's nightstand drawer. Medical record review for Resident 103 was initiated on 3/3/25. Resident 103 was admitted to the facility on [DATE]. Review of Resident 103's MDS dated [DATE], showed Resident 103 was cognitively intact and had no impairment to the upper extremities. Review of Resident 103's Order Summary Report failed to show a physician's order for the resident to self-administer the Biofreeze medication. In addition, there was no physician's order for the Biofreeze pain relief cream. Review of Resident 103's Plan of Care did not show a care plan problem to address Resident 103's ability to self-administer the medication. Further review of Resident 103's medical record failed to show the resident was assessed for the self-administration of the medication. 3. On 3/3/25 at 0816 hours, during the initial tour of the facility, Resident 144 was observed lying in bed. A bottle of Bactine Max pain-relieving cleaning spray was observed on Resident 144's nightstand. Resident 144 stated she applied the pain-relieving cleaning spray by herself. On 3/3/25 at 1110 hours, a follow-up observation for Resident 144 and concurrent interview was conducted with RN 1. RN 1 verified Resident 144 had a bottle of Bactine Max pain-relieving cleaning spray on the nightstand. Medical record review for Resident 144 was initiated on 3/3/25. Resident 144 was admitted to the facility on [DATE]. Review of Resident 144's Order Summary Report failed to show a physician's order for the resident to self-administer the Bactine Max medication. In addition, there was no physician's order for Bactine Max pain relieving cleaning spray. Review of Resident 144's Plan of Care did not show a care plan problem to address Resident 144's ability to self-administer the medication. Further review of Resident 144's medical record failed to show the resident was assessed for the self-administration of the medication. On 3/6/25 at 1107 hours, a follow-up interview and concurrent medical record review for Residents 103, 110, and 144 was conducted with RN 1. When asked about the facility's process regarding the self-administration of the medications and leaving the medications at the bedside, RN 1 stated if the facility had a resident who desired to self-administer the medications, the IDT would do an assessment for the self-administration of the medication. RN 1 further stated if the resident was able to self-administer the medications safely, the nurses would obtain a physician's order for the resident to self-administer the medications and develop a care plan to address the resident's self-administration of the medications. RN 1 verified Residents 103, 110, and 144 had no assessment, physician's order, and care plan to address the self-administration of the medications. 4. On 3/3/25 at 1020 hours, during the initial tour of the facility, the containers of Living Well Nutraceuticals Rub On Relief fast acting all-natural topical cream (pain reliever), and Real Time Pain Relief [NAME] reliever cream (pain reliever) were observed at Resident 38's nightstand. Resident 38 stated, I have pain on my knees, I used the cream. On 3/3/25 at 1032 hours, a concurrent observation and interview was conducted with LVN 4. LVN 4 acknowledged and verified the presence of two containers of the pain relieving creams at Resident 38's nightstand. LVN 4 told Resident 38 that he would speak to the nursing supervisor to check on her and discuss with the physician. LVN 4 further stated he would remove the creams for now because the resident could not keep the creams at the bedside. Medical record review for Resident 38 was initiated on 3/4/25. Resident 38 was admitted to the facility on [DATE]. On 3/4/25 at 1244 hours, an interview was conducted with RN 1. RN 1 acknowledged and verified the findings of the two containers of the pain relieving creams at Resident 38's night stand. RN 1 stated, I was notified by LVN 4 and saw the creams. Further review of Resident 38's medical record did not show the assessment, physician's order, care plan, and documentation in the MAR for Resident 38's self-administration of the pain relieving medications. On 3/6/35 at 1415 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure one of 29 final sampled residents (Resident 20) needs and preferences were accommodated. * The facility failed to provide the properly fitted diaper to Resident 20. This failure posed the risk to negatively affect the resident's physical and emotional well-being. Findings: On 3/3/25 at 930 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 20. Resident 20 stated the diaper she wore was too small, and the facility's vendor did not carry the Prevail diapers any longer. Resident 20 stated, the diaper does not fit me and my bed was soaked three times a day. Resident 20 showed her diaper and was observed to have the current diaper's waist band below her mid abdominal area and just above the pubic area. Resident 20 further stated, I'm just upset because of my diaper, I have asked them for two weeks, and I feel like I'm wearing a thong. Medical record review for Resident 20 was initiated on 3/4/25. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's MDS dated [DATE], showed Resident 20 had a BIMS score of 14 (cognitively intact), and always incontinent with the bladder and bowel elimination. The MDS further showed Resident 20 was 68 inches in height and weighed 405 lbs. On 3/4/25 at 1130 hours, an observation and current interview was conducted with CNA 3 in Resident 20's room. CNA 3 stated he had been taking care of Resident 20 for more than a year. CNA 3 further stated Resident 20 had been wearing the size of 6x diaper and recently had been provided with the size of 4x or 5x diapers. Resident 20 showed her diaper, and CNA 3 verified Resident 20's diaper was small and did not cover the whole area. On 3/4/25 at 1350 hours, an interview was conducted with the Central Supply In-charge. The Central Supply In-charge stated the facility's diaper supplier did not carry the Prevail diaper brand a couple of weeks ago and was replaced with a comparable diaper size. On 3/6/25 at 1415 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings. The DON further stated the Prevail diapers were not available from the facility's vendor, and the facility would purchase the Prevail diapers to accommodate Resident 20's preference.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the personal property of one nonsampled residents (Resident 100) was protected from loss or theft. * The facility failed to ensure Residents 100's personal items were labeled with the resident's name and included in the resident's inventory list. These failures had the potential for the resident's property to get lost or stolen. Findings: Review of the facility's P&P titled Personal Property revised 7/14/17, showed the following: - The facility will make every effort to maintain the security of the resident's property while helping to create a home-like environment; - During the admission process, the Admissions staff will inform the resident/resident representative of the need to mark the resident's belongings with the resident's name and to notify nursing when additional items are brought to the facility so that they can be added to the resident's inventory list; - A copy of the written inventory shall be provided to the resident or the person acting on he resident's behalf. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the request of the resident, resident's family, or a person acting on behalf of a resident; and - The IDT will review the resident's inventory for accuracy during the resident's quarterly care plan conference. Any changes or additions to the inventory will be made at this time. On 3/5/25 at 0932 hours, an observation and concurrent interview was conducted with Resident 100. Resident 100 was observed fixing her belongings in the room. Resident 100's bed area was observed with multiple belongings. Resident 100 stated it was like home for her. Resident 100 stated the most valuable items she had were the laptop which was brought by her family about two months after she was admitted to the facility, black bluetooth head phones, and lavender lap desk with mouse pad and phone holder which she had since last December 2024, and a music box with moving lights which her family just brought a month ago. The items were observed with no resident name label. When asked if the facility was aware of all the belongings she had in the room, Resident 100 stated she had informed the nurses, nursing assistants, or social workers whenever her family brought in new items for her because she was told everything should be recorded. Resident 100 stated she knew if the items were not in her inventory list, the facility would not be liable if she lost her items. Resident 100 further stated when she got the lap desk, bluetooth head phones, and music box, she handed the list to the social services department because the nursing told her to do so. Medical record review for Resident 100 was initiated on 3/5/25. Resident 100 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 100's Resident Inventory form dated 7/26/23, showed one pair of glasses, one cellphone with charger, one back brace, one hair brush, and one stuff animal. Further review of Resident 100's inventory list did not show any updated list of all the items the resident had in her room including the above valuable items she mentioned. Review of Resident 100's MDS dated [DATE], showed Resident 100 was cognitively intact. On 3/5/25 at 1151 hours, an interview and concurrent medical record review was conducted with CNA 7. CNA 7 stated the CNAs were primarily responsible in checking and documenting the resident's belongings on admission and discharge in the inventory form. CNA 7 stated they would have to update the inventory list if the resident had informed them of the new items brought in by the family. CNA 7 stated Resident 100 had so many belongings in the room. CNA 7 verified the inventory list form for Resident 100 did not show all the belongings that Resident 100 had. CNA 7 stated the inventory list form was not updated and verified Resident 100's personal items did not have the resident's name on it. On 3/6/25 at 0909 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 stated Resident 100 had been in the facility for a long time. LVN 8 stated when the resident was admitted , the charge nurse would give the inventory form to the CNA for the CNA to check the belongings. LVN 8 stated the residents were informed to notify the staff if they have new belongings especially the valuable items so the staff could update the inventory list. LVN 8 further stated the facility staff should update the inventory list if they saw the resident had so many belongings at the bedside. LVN 8 verified the inventory list for Resident 100 was not updated since 7/26/23. On 3/6/25 at 0924 hours, an interview was conducted with the SSD. The SSD stated if the resident or family member let the social services department know a new belonging was brought in the facility, the social services staff could update the resident's inventory list. The SSD stated she was aware Resident 100 had so many belongings in her room. The SSD stated she was not aware Resident 100 handed the social services department any list of the new belongings brought in by the resident's family member. The SSD stated the staff should update the inventory list if the resident had been staying in the facility for long term and if the resident had so many personal items in the room. On 3/6/25 at 1458 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON stated the facility staff should update the resident's inventory list right away when the resident informed them of the new items brought in by the resident's family member. The ADON stated the facility staff should make every effort to update the inventory list especially for the long-term residents in the facility. The ADON further stated during the quarterly care plan meeting with the resident and family, the facility would remind the resident and resident's family member to update the inventory list. The ADON verified during the last care plan meeting for Resident 100 on 1/22/25, the documentation did not show the inventory list was discussed or updated. The ADON was notified and acknowledged the above findings for Resident 100.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, facility documents review, and facility P&P review, the facility failed to ensure the abuse P&P was implemented for one of five sampled residents (Resident 120) investigated for abuse. * The facility failed to ensure two alleged perpetrators (LVNs 2 and 7) were immediately suspended pending the outcome of the investigation for the abuse allegation for Resident 120. This failure had the potential for the resident to be vulnerable for further abuse, mistreatment, and injury. Findings: Review of the facility's P&P titled Abuse Prevention and Management revised 5/30/24, showed the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. Reports of resident abuse, mistreatment, neglect, exploitation, injuries of an unknown source, and any suspicion of crimes are promptly reported and thoroughly investigated. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with facility policies. Furthermore, employees of this facility who have been accused of resident abuse or a crime will be suspended from duty until the results of the investigation have been reviewed by the Administrator. Review of the facility's SOC 341 form(report of suspected dependent adult/elder abuse) dated 2/17/25, showed Resident 120 claimed two nurses were causing him emotional distress. On 2/18/25 at 1010 hours, the CDPH, L&C (California Department of Public Health, Licensing and Certification) program surveyor followed up with the facility to inquire about the alleged perpetrators for Resident 120's allegation of abuse. The DON identified the alleged perpetrators as LVNs 2 and 7. Review of the facility's conclusion report dated 2/20/25, showed two nurses had yelled at him and felt it caused him emotional distress. The facility was not able to substantiate Resident 120's claim regarding LVNs 2 and 7 yelled at the resident. Further review of the conclusion report failed to show LVNs 2 and 7 were suspended pending the outcome of other investigation. Medical record review for Resident 120 was initiated on 3/4/25. Resident 120 was admitted to the facility on [DATE]. Review of Resident 120's H&P examination dated 9/24/24, showed the resident could make needs known but could not make medical decisions. Review of Resident 120's SBAR Communication Form dated 2/24/25 at 1400 hours, showed the resident reported two facility nurses alleged caused him emotional distress. On 3/5/25 at 1609 hours, an interview was conducted with LVN 7. LVN 7 stated she was aware of the allegation of abuse Resident 120 claimed against her. LVN 7 verified she was not suspended from the facility pending investigation. On 3/6/25 at 0804 hours, and interview was conducted with LVN 2. LVN 2 stated she was aware of the allegation of abuse Resident 120 claimed against her. LVN 2 verified she was not suspended from the facility pending the investigation. On 3/6/25 at 1038 hours, a concurrent interview and facility P&P review was conducted with the Administrator and DON. The DON stated the alleged perpetrators were identified by Resident 120. The Administrator stated the abuse investigation was initiated on 2/17/25, and the investigation was concluded on 2/20/25. The Administrator verified he did not suspend LVNs 2 and 7 because he was thinking of knowing what he knew from the information prior, which was Resident 120 was the one yelling at the nurses. The Administrator verified the P&P showed employees of the facility who had been accused of resident abuse or a crime would be suspended from duty until the results of the investigation had been reviewed by the Administrator.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 29 final sampled residents (Resident 82). * The facility failed to implement the bilateral floor mats in accordance with Resident 82's fall risk care plan. This failure placed the resident at risk of not receiving the appropriate, consistent, and individualized care. Findings: Medical record review for Resident 82 was initiated on 3/3/25. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's Care Plan titled At Risk for Falls/Injuries initiated on 5/17/23, showed Resident 82 was at risk for falls related to dementia, impaired cognition, and poor safety awareness. The care plan further showed Resident 82 had a long history of ongoing falls. The interventions included to provide the bilateral floor mats. On 3/3/25 at 0900 hours, an observation was conducted of Resident 82. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed. The opposite side of Resident 82's bed was observed without a floor mat in place. On 3/3/25 at 0937 hours, an observation was conducted of Resident 82. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed. The opposite side of Resident 82's bed was observed without a floor mat in place. On 3/3/25 at 1640 hours, an observation and concurrent interview was conducted with LVN 8. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed. The opposite side of Resident 82's bed was observed without a floor mat in place. LVN 8 verified the findings and stated he would implement the second floor mat in accordance with Resident 82's At Risk for Falls care plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 394 was initiated on [DATE]. Resident 394 was admitted to the facility on [DATE]. Review of Resident 394's MDS dated [DATE], showed Resident 394 had severe cognitive impairment. Review of Resident 394's POLST (in the hospice binder), showed it was blank. Review of Resident 394's Order Summary Report failed to show a physician's order for Resident 394's code status. Review of Resident 394's plan of care did not show Resident 394's code status was addressed. On [DATE] at 1210 hours, an interview and concurrent medical record review for Resident 394 was conducted with LVN 1. When asked what Resident 394's code status was, LVN 1 reviewed Resident 394's electronic health record and did not see any copy of Resident 394's POLST, the code status was not reflected in the physician's orders, and not addressed in the care plan. LVN 1 also reviewed Resident 394's hospice binder and verified the POLST form was blank. LVN 1 further reviewed Resident 394's physical chart and did not see any copy of Resident 394's POLST, but found a copy of Resident 394's Pre-admission Report. Review of Resident 394's Pre-admission Report dated 2/1 showed Resident 394 had a full code status. LVN 1 stated Resident 394 was on hospice services, and one would assume that the family had come to terms and just to provide the comfort care, however, LVN 1 further stated, Resident 394 would be considered a full code because there was no POLST spelled out, so then I would provide the CPR. Further review of Resident 394's medical record showed the POLST form was scanned and uploaded in the resident's electronic health record under the miscellenous documents. Review of the POLST dated [DATE], showed Resident 394 code status was DNR. LVN 1 verified the above findings. On [DATE] at 1250 hours, an interview and concurrent medical record review for Resident 394 was conducted with RN 1. RN 1 verified the POLST form in Resident 394's hospice binder was blank. RN 1 also verified the POLST form dated [DATE], scanned and uploaded in Resident 394's electronic health record, showed Resident 394's code status was DNR. RN 1 further verified Resident 394's DNR code status was not reflected in Resident 394's physician's orders and not addressed in his plan of care. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (final sampled resident, Resident 66) reviewed for IV antibiotic use and one of eight sampled residents (final sampled resident, Resident 394) reviewed for advance directives to attain and maintain their highest practicable well-being. * The facility failed to continuously monitor Resident 66 for the adverse reactions related to the IV antibiotics use and ESBL in the urine. * The facility failed to clearly identify the current code status for Resident 394. These failures had the potential for residents to not receive the necessary care and services in accordance with the resident's needs and treatment wishes. Findings: 1. Review of the facility's P&P titled Change of Condition Notification revised [DATE] showed a licensed nurse will notify the resident's attending physician and legal representative or an appropriate family member when there is any untoward response or reaction by the resident to a medication or treatment, and any significant change in the resident's physical, mental or psychosocial status. The licensed nurse will document each shift for at least 72 hours and the date, time and pertinent details of the incident and the subsequent assessment in the nursing notes. Medical record review for Resident 66 was initiated on [DATE]. Resident 66 was admitted to the facility on [DATE]. Review of Resident 66's H&P examination dated [DATE], showed Resident 66 had the capacity to understand and make decisions. Review of Resident 66's eInteract SBAR Summary for Providers dated [DATE], showed Resident 66's urine test results came back positive for ESBL. The primary physician was notified and ordered for Resident 66 to start on ertapenem (antibiotic medication) IV every 24 hours for 10 days. Review of Resident 66's Progress Notes from 3/1 to [DATE], failed to show documented evidence of continued monitoring of Resident 66 for any adverse reactions related to the IV antibiotic use for ESBL in the urine and further aggravating signs and symptoms of the urine infection. On [DATE] at 1417 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated a new diagnosis of urine infection and the use of the IV antibiotics were considered a change of condition. LVN 2 stated for a change of condition, an assessment of the resident had to be done every shift for three days but if the resident was receiving an IV antibiotic, the assessment had to be done until the completion of the IV antibiotic. LVN 2 stated for Resident 66, the follow-up assessment was important to be done to check if Resident 66 would have any adverse reactions from the IV antibiotic and to check if the symptoms of the urinary tract infection were getting better or worse. LVN 2 further stated the change of condition documentation would also show if the nurses were providing the appropriate nursing care and measures so the condition would not aggravate. On [DATE] at 1517 hours, an interview was conducted with the ADON. The ADON stated for a change of condition such as new urine infection, the licensed nurse should include in the assessment any signs and symptoms of UTI like fever, bladder pain, hematuria (blood in the urine), and any changes in the vital signs and level of consciousness. The ADON stated for the use of IV antibiotic, the licensed nurse should assess the resident for any adverse effects of the medication. The ADON further stated the follow-up assessment for the change of condition was necessary and should be documented to know if there would be any abnormal changes in the resident and the staff would be able to notify the physician and render the necessary interventions sooner. The ADON was notified and acknowledged the above findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 82 was initiated on 3/3/25. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's care plan titled At Risk for Falls/Injuries initiated 5/17/23, showed Resident 82 was at risk for falls related to dementia, impaired cognition, and poor safety awareness. The care plan showed Resident 82 had a long history of ongoing falls. Review of Resident 82's Order Summary Report showed a physician's order dated 7/27/23, for bilateral floor mats for safety. On 3/3/25 at 0900 hours, an observation was conducted of Resident 82. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed. The opposite side of Resident 82's bed was observed without a floor mat in place. On 3/3/25 at 0937 hours, an observation was conducted of Resident 82. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed. The opposite side of Resident 82's bed was observed without a floor mat in place. On 3/3/25 at 1640 hours, an observation and concurrent interview was conducted with LVN 8. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed. The opposite side of Resident 82's bed was observed without a floor mat in place. LVN 8 verified the findings and stated he would implement the second floor mat in accordance with the physician's order. Cross reference to F656. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 29 final sample residents (Resident 82) and one nonsampled resident (Resident 643) remained free from accident hazards. * The facility failed to update the plan of care and provide the adequate supervision and necessary services for Resident 643 to prevent elopement. This failure had the potential for Resident 643 leaving the facility premises undetected. * The facility failed to implement the bilateral floor mats per the physician's order for Resident 82 who was at risk for falls. These failures had the potential to place the residents at risk for serious injury. Findings: Review of the facility's P&P titled Wandering and Elopement revised on 1/31/23, showed the facility will identify the residents at risk for elopement upon admission and when there is a change in condition to minimize the risk of elopement, to enhance the safety of the residents of the facility. Elopement was defined as a behavior that may lead to the resident leaving the facility unsupervised and/or without permission. The P&P further showed the following: 1. The Licensed nurse, in collaboration with the IDT, will assess the residents upon admission, readmission, quarterly and upon identification of a significant change in condition according to the RAI guidelines to determine their risk of elopement. 2. The resident's risk for elopement and preventive interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition according to the RAI guidelines. 3. The IDT will develop a plan of care considering the individual risk factors of the resident. Review of facility's P&P titled Resident Safety revised 4/15/21, showed to provide a safe and hazard free environment. Residents will be evaluated on admission, quarterly, and whenever there is a change in condition to identify circumstance that pose a risk for the safety and wellbeing of the Resident. 1. Medical record review for Resident 643 was initiated on 3/5/25. Resident 643 was admitted to the facility on [DATE], and discharged on 3/3/25. Review of Resident 643's H&P examination dated 2/22/25, showed Resident 643 was confused, had a diagnosis of dementia, and was unable to understand and make decisions due to dementia. Review of Resident 643's MDS dated [DATE], showed Resident 643 had severe cognitive impairment and did not use any mobility device to move from places. Review of Resident 643's Progress Notes showed the following: - dated 2/25/25 at 0318 hours, the resident was intermittently awake, wandering around the unit with unsteady gait, and stated he wanted to go home. The resident was redirected back to his room and assisted by the staff back to bed which was in the lowest position, with the call light within reach; and - dated 2/26/25 at 2158 hours, the resident was awake ambulating in the hallway, alert, oriented x 1 (to name only) with episode of confusion and forgetfulness, and - dated 3/2/25 at 2032 hours, the resident was on monitoring for episode of elopement. Review of Resident 643's Care Plan Report showed a care plan problem initiated on 3/2/25, addressing Resident 643 risk for elopement/wanderer and the episode of leaving the facility without notifying the staff. Further review of Resident 643's medical record failed to show Resident 643 was reassessed and a care plan was developed for the risk of elopement when Resident 643 was observed wandering in the hallway and verbalized wanting to go home on 2/25/25. On 3/6/24 at 0941 hours, an interview was conducted with the ADON. When asked about Resident 643, the ADON stated Resident 643 walked around, stable medically, knew his name but with severe cognitive impairment. When asked if Resident 643 had previous history of elopement, the ADON stated, 'no. However, the ADON stated on 3/2/25 at around 1830 hours, when LVN 3 was doing his rounds, LVN 3 noticed Resident 643 was not in his room. The staff started searching the facility for Resident 643. The ADON stated Resident 643 was observed at the nursing station at around 1800 hours, talking to RN 2. The ADON stated the facility got a call from the police department that they found Resident 643 and brought Resident 643 back to the facility. When asked what interventions were in placed before the incident had occurred, the ADON stated nothing specific aside from monitoring, just like what they did to the other residents at risk for elopement. The ADON further stated Resident 643 was redirectable. When asked further if Resident 643 was adequately supervised, how Resident 643 was out of facility undetected by the staff. The ADON stated, no, unfortunately he was able to get out of the building. On 3/6/25 at 1136 hours, an interview was conducted with CNA 1. When asked about Resident 643's care, CNA 1 stated the resident was continent, and able to stand, sit on chair and walk by himself. CNA 1 stated she was not aware Resident 643 was at risk for elopement, and no one told her that Resident 643 required supervision for possible risk of getting out of the facility. On 3/6/25 at 1146 hours, an interview and concurrent record review was conducted with RN 1. RN 1 was asked regarding the documentation on 2/25/25. RN 1 verified Resident 643 was intermittently waking up and wandering around the unit with unsteady gait, and stated he wanted to go home. RN 1 verified there was no revision of the care plan done. When asked if updating of the care plan was important, RN 1 stated updating the care plan would help. On 3/6/25 at 1155 hours, an interview was conducted with the DON. The DON was made aware regarding the nurse's notes on 2/25/25, showing Resident 643 was intermittently waking up and wandering around the unit with unsteady gait, and stated he wanted to go home. When asked if updating the care for more adequate supervision was needed, the DON stated Resident 643 was not exit seeking, and easily redirectable. The DON further stated the facility should have provided more frequent monitoring and increased visual checks, and more activities to distract the resident and keep him busy; and those interventions should have been a part of the care plan update.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of three final sampled residents (Resident 4) reviewed for dialysis as evidenced by: * The facility failed to ensure Resident 4's dialysis access site was assessed and monitored appropriately and consistently. This failure had the potential for Resident 4 not being provided with the appropriate care and treatment and the possibility of medical complications related to the resident's dialysis access site. Findings: Review of the facility's P&P titled NP37 Dialysis Management revised 1/25/24, showed the facility should assure that each resident receives care and services consistent with professional standards of practice. The vascular access site should be assessed, observed and document care of access sites daily, as applicable, such as auscultation/palpation for pulse, bruit and thrill to assure adequate blood flow. On 3/3/25 at 1005 hours, during the initial tour of the facility, Resident 4 was observed awake and sitting on the bed. Resident 4 stated she was preparing because she would leave soon to go to the dialysis center. Resident 4 stated she received dialysis on Mondays, Wednesdays, and Fridays. Resident 4 stated her dialysis access site was located on the right arm. Medical record review for Resident 4 was initiated on 3/4/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed the following physician's orders: - dated 1/30/24, Dialysis on Monday, Wednesday, and Friday at 1230 hours; and - dated 2/8/24, to monitor the AV shunt in the right arm for bruit and thrill every shift. Review of Resident 4's Care Plan revised 3/13/24, showed a care plan focus problem addressing Resident 4's potential for complications of ESRD/dialysis. The interventions included to auscultate shunt site for bruit and palpate for thrill per protocol or every shift. Document the presence or absence. Notify the physician and dialysis center of absent thrill/bruit as soon as possible. Review of Resident 4's MAR for December 2024, January, February, and March 2025 showed the licensed staff documented Resident 4's AV shunt was - (negative) for thrill and bruit on 12/1/24 and 1/18/25; 0 (zero) on 12/12/24; X on 12/13/24 and 1/29/25; and NA on 2/23 and 3/4/25. Further review of Resident 4's medical record failed to show the physician was notified when the AV shunt was assessed without or negative for thrill and bruit. On 3/6/25 at 1358 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 4 had a right arm AV shunt. When asked about the assessment of the dialysis access site per shift as documented in the MAR, LVN 2 stated the positive sign + meant there was something or present, while the negative sign -, zero 0 and X meant there was none, or absent referring to the bruit and thrill noted from the resident's access site. LVN 2 stated she did not know what the NA would mean. LVN 2 verified Resident 4's AV shunt was assessed without thrill and bruit per record in the MAR but there was no documentation of the physician being notified. LVN 2 stated the licensed staff should have notified the physician because it was an emergency case if the AV shunt was assessed without thrill and bruit. On 3/6/25 at 1512 hours, an interview was conducted with the ADON. The ADON stated the negative sign - meant no thrill and bruit, the zero 0 and X could be interpreted as no thrill and bruit as well. The ADON stated the NA was meant for not applicable. The ADON stated the dialysis access site should be assessed properly to make sure it was functioning well as what was expected and if there was no thrill and bruit, the physician should have been notified as soon as possible. The ADON was notified and acknowledged the above findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (final sampled resident, Resident 394) reviewed for side rail use remained free from accident hazards due to the use of side rails. * The facility failed to ensure Resident 394 who was assessed for no indication for the use of side rails was not provided with the side rails. Resident 394 was provided with bilateral upper ½ (half) side rails. In addition, Resident 394's plan of care showed a care plan problem to address grab bars, not ½ side rails. These failures had the potential to place Resident 394 at risk for entrapment and serious injury from side rail use. Findings: Review of the facility's P&P titled Bed Rails dated 6/12/24, showed the licensed nurse will complete the Bed Rail Evaluation prior to the use and/or installation of any bed rail, upon admission, readmission, change in bed or mattress, and a change in mobility status. On 3/4/25 at 1405 hours, Resident 394 was observed awake, lying in bed with the bilateral upper side rails elevated. Medical record review for Resident 394 was initiated on 3/3/25. Resident 394 was admitted to the facility on [DATE]. Review of Resident 394's Order Summary Report showed a physician's order dated 2/14/25, for a bilateral ½ side rails as enablers. Review of Resident 394's Bed Rail assessment dated [DATE], showed the side rails were not indicated for Resident 394. Review of Resident 394's plan of care showed a care plan problem dated 2/17/25, addressing the use of the grab bars. Review of Resident 394's MDS dated [DATE], showed Resident 394 had severe cognitive impairment and dependent to the facility staff member for bed mobility. On 3/5/25 at 1017 hours, an observation for Resident 394 and concurrent interview and medical record review was conducted with RN 1. Resident 394 was observed in bed with the bilateral upper side rails elevated. RN 1 verified the above findings. RN 1 stated Resident 394 was under the hospice services, and Resident 394's bed was brought into the facility with the bilateral side rails already installed. RN 1 verified Resident 394's Bed Rail Assessment showed the side rails were not indicated for Resident 394. RN 1 also verified the physician's order was for the bilateral side rails; however, a care plan problem was developed to address the use of the grab bars. Cross reference to F909.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmacy services as per the facility's P&P for one nonsampled resident (Residents 34). * The facility failed to ensure the accurate and complete documentation of the controlled medication administered to Resident 34 was maintained. This failure had the potential to pose the risk for the diversion of the medications. Findings: Review of the facility's P&P titled Medication Administration revised 1/1/12, showed the licensed nurse will chart the drug, time administered and initial his/her name with each medication administration. The time and dose of the drug administered to the patient will be record in the patient's individual medication record by the person who administers the drug. Medical record review for Resident 34 was initiated on 3/4/25. Resident 34 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 34's H&P examination dated 2/10/25, showed Resident 34 had the capacity to understand and make decisions. Review of Resident 34's Order Summary Report showed a physician's order dated 2/10/25, to administer hydrocodone-acetaminophen (controlled pain medication) 10-325 mg one tablet by mouth every six hours as needed for severe pain (pain level of 7-10, using the 0-10 pain scale; zero meaning no pain and 10 meaning worst pain). Review of Resident 34's Individual Narcotic Record for the hydrocodone-acetaminophen 10-325 mg tablet showed one hydrocodone-acetaminophen 10-325 mg oral tablet was dispensed and signed out on 2/25/25 at 1808 hours, and 3/1/25 at 2000 hours. Review of Resident 34's MARs for February and March 2025, failed to show the documentation of the administration for the hydrocodone-acetaminophen 10-325 mg oral tablet dispensed on 2/25/25 at 1808 hours, and 3/1/25 at 2000 hours. On 3/4/25 at 1403 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified the above findings. On 3/4/25 at 1410 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the above findings. The DON stated the licensed nurse must document on the MAR when the medication was administered to the resident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were not stored at the bedside for one of 29 final sampled residents (Resident 104). In addition, the facility failed to ensure the proper disposal of the expired treatment supplies for one of five medication/treatment carts inspected for the medication storage and labeling. * The facility failed to ensure the expired culture swabs and dressing were removed from Treatment Cart 1. * Resident 104 was observed with sealed, unopened Wallgreens Redness Relief eye drops (eye redness relief) at bedside. These failures had the potential to result in unsafe medication administration and posed the risk for inaccurate test results and treatments. Findings: Review of the facility's P&P titled Medication Storage in the Facility effective date 4/2008 showed the medications and biologicals are stored safely, securely, and properly, following the manufacture's recommendation or those of the supplier. The medication supply is accessible only to the licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. 1. On [DATE] at 1441 hours, an inspection of Treatment Cart 1 and concurrent interview was conducted with LVN 7. The following supplies were observed inside the treatment cart: - one culture swab (used to collect a sample for a laboratory test to identify bacteria causing an infection) inside the third drawer of the treatment cart, with an expiration date of [DATE], and - five packets of Allevyn Classic Adhesive dressing (a brand of foam dressings, specifically designed for wound care) were inside the third drawer of the treatment cart, with an expiration date of 11/2019. LVN 7 verified the above findings. LVN 7 further stated the expired culture swab and Allevyn dressing could be infective or may be contaminated if used on the residents. LVN 7 stated the expired supplies should be discarded from the treatment cart. On [DATE] at 1430 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. On [DATE] at 815 hours, during the initial tour of the facility, an observation was conducted in Resident 104's room. A sealed, unopened Wallgreens Redness Relief eye drops container was observed on the resident's nightstand. While being inside Resident 104 room, LVN 4 and Resident 104 came inside the room. An observation and concurrent interview was conducted with Resident 104 and LVN 4. When asked about the Wallgreens eyedrops at the beside, Resident 104 stated he bought the eyedrops when he was out on a pass. LVN 4 acknowledged and verified the presence of a sealed, unopened Wallgreens Redness Relief eye drops at bedside. LVN 4 stated he would ask the resident's physician if Resident 104 could have the eyedrops. LVN 4 further stated there should be no medications at the bedside. Medical record review for Resident 104 was initiated on [DATE]. Resident 104 was admitted to the facility on [DATE]. Review of Resident 104's Physician Progress notes dated [DATE], showed Resident 104 was able to understand and make treatment decisions. Review of Resident 104's MDS dated [DATE], showed a BIMS score of 12 (moderately impaired cognition). Review of Resident 104's Order Summary Report did not show a physician's order for the eyedrops for dry eyes. On [DATE] at 1415 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to follow the menu when preparing food for one of 29 final residents (Resident 88). * The facility failed to ensure the recipe for chef salad was followed. Resident 88 requested a chef salad and received only lettuce with shredded carrots and purple cabbage. This failure had the potential for the resident to not receive adequate nutrition based on their diet orders. Findings: Review of the facility's Diet Count dated 3/6/25, showed 123 of 140 residents residing in the facility received food prepared in the kitchen. On 3/3/25 at 0907 hours, an observation and concurrent interview was conducted with Resident 88. Resident 88 was sitting up in bed watching TV. Resident 88 stated she was ordering more salads for her meals because she was trying to lose weight to qualify for her knee surgery. Resident 88 stated she was not receiving enough protein on her salads and did not feel like with enough food. Medical record review for Resident 88 was initiated on 3/3/25. Resident 88 was admitted to the facility on [DATE]. Review of Resident 88's Order Summary Report showed a diet order dated 11/15/25, for NAS (no added salt) diet, regular texture, regular/thin consistency. Review of Resident 88's Care Plan Report dated 11/18/25, showed the resident was admitted with NAS diet, regular texture, regular/thin consistency with the goal of maintaining weight status. The interventions included to give diet as ordered and accommodate food reasonably. On 3/3/25 at 1233 hours, a follow-up observation and concurrent interview was conducted with Resident 88. Resident 88 was sitting up in bed with her lunch tray. The lunch tray included a plate of lettuce with shredded carrots and purple cabbage. There were also a side of ranch dressing, a cup of pears, and a four oz (ounce) cup of orange juice. Resident 88 stated she was disappointed that she did not receive any protein with her salad. Review of Resident 88's lunch meal card dated 3/3/25, showed the resident's diet as NAS, lactose free, consistency regular; beverages: four oz juice; allergies: lactose, fruit, peanuts; dislikes: tomato products, watermelon; and likes: chef salad with ranch only. Review of the facility's recipe for chef salad showed the ingredients included lettuce, turkey, lean ham, cheese, tomatoes, hard cooked eggs, salad dressing, and optional beets and shredded carrots. On 3/3/25 at 1524 hours, an interview was conducted with the Dietary Supervisor and Administrator. The Dietary Supervisor reviewed the recipe card for the chef salad and verified it was incorrectly made for Resident 88.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one of 29 final sampled residents (Resident 8). * Resident 8 was not provided with built-up utensils per the physician's order. This failure had the potential for Resident 8 not having an appropriate assistive device to consume her food. Findings: Review of the facility's P&P titled Restorative Dining Program revised January 2012 showed the residents will be provided a tray with their respected diet. The special adaptive equipment may be recommended by the OT and will be provided by the facility. The equipment may include, but may not be limited to built-up handled utensils, weight utensils, large handled utensils, and angled utensils. The facility staff should consistently place the adaptive equipment in the same position on the tray and encourage use of the adaptive equipment by the resident during the meal. On 3/3/25 at 1315 hours, during the dining observation of the facility, Resident 8 was observed having lunch in the bed. Resident 8 was observed using a regular silver spoon and a light gray colored built-up fork. Resident 8's meal tab showed to have a built-up utensils and lip plate. Medical record review for Resident 8 was initiated on 3/4/25. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 2/21/24, showed Resident 8 had no capacity to make medical decisions. Review of Resident 8's Care Plan revised 11/6/24, showed a care plan focus problem addressing Resident 8's nutritional problem. The interventions included the use of the built-up utensils and lip plate. Review of Resident 8's Order Summary Report showed a physician's order dated 1/22/25, for the built-up utensils and lip plate with all meals. On 3/4/25 at 0815 hours, an observation and concurrent interview was conducted with Resident 8. Resident 8 was observed having breakfast in the bed. Resident 8 was observed using a regular silver spoon, fork, and knife. Resident 8 stated it was hard to eat and grab the spoon and fork. Resident 8 was observed with contracted left hand. Resident 8 further stated her left hand was weak. Resident 8's meal tab showed for devices, to use the built-up utensils and lip plate. On 3/4/25 at 0824 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 stated Resident 8 had a history of stroke and Resident 8's left hand was contracted. LVN 6 stated the built-up utensils would help Resident 8 to have a better grip and control of the utensils since Resident 8 had a limited hand strength. LVN 6 verified Resident 8 required the use of the built-up utensil as per the physician's order. On 3/6/25 at 1615 hours, an interview was conducted with the DON. The DON was notified and acknowledged the above findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility P&P review, the facility failed to ensure the hair restraints were worn by the staff while in the kitchen and failed to ensure kitchen dry storage guidelines were implemented. * The DSS failed to donn a hair restraint while in the kitchen, in accordance with the facility's P&P. * A canister containing brown rice was observed without a lid inside of the dry storage room. These failures had the potential for unsafe food storage and infection control practices in a medically vulnerable resident population. Findings: Review of the facility's Diet Count dated 3/6/25, showed 123 of 140 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Dietary Department - Infection Control for Dietary Employees revised on 11/9/16, showed personal are required to have clean hair covered with an effective hair restraint while in all kitchen and food storage areas, and beard/mustache covering when applicable. On 3/3/25 at 0745 hours, during the initial tour of the kitchen, the kitchen staff was observed preparing breakfast for the residents. The DSS was inside the kitchen and observed with a beard and mustache, however, the DSS was not wearing a hair restraint. The DSS verified the findings and stated he should have donned a hair restraint in accordance with the facility's P&P. 2. Review of the facility's P&P titled Food Storage revised 11/1/14, showed any opened (dry storage) products should be placed in a storage containers with tight fitting lids. The dry storage guidelines include monitoring dry storage areas routinely for pest activity. On 3/5/25 at 0958 hours, an observation of the kitchen dry storage room was conducted. A canister containing the brown rice was observed without a lid, inside of the dry storage room. On 3/5/25 at 1009 hours, an observation and concurrent interview was conducted with the Cook. The [NAME] verified a canister containing the brown rice, in the dry storage room, did not have a lid in place. The [NAME] stated the canister of the brown rice should have had a lid in place to ensure the rice remained clean. On 3/5/25 at 1015 hours, an interview was conducted with the DSS. The DSS stated the canister of the brown rice, located in the dry storage room, required a lid to be in place for infection control.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the provision of hospice services for two of three residents (final sampled residents, Residents 79 and 394), reviewed for hospice services. * Resident 79 was scheduled to receive care from a certified hospice aide twice per week; however, the medical record failed to show documentation the certified hospice aide provided care to Resident 79 twice per week as scheduled. * The facility failed to clarify the frequency of the hospice agency staff visits and to ensure the hospice aide visited and provided care to Resident 394. The facility failed to ensure the flowsheet and clinical notes from the hospice nurses and hospice aides were completed. In addition, the facility failed to ensure Resident 394's POLST and hospice agency's consents were completed. These failures had the potential to delay hospice care for the residents. Findings: Review of the facility's P&P titled Hospice Care of Residents revised 1/1/12, showed the facility and hospice staff will collaborate on a regular basis concerning the resident's care. All documentation concerning hospice services will be maintained in the resident's medical record. 1. Medical record review for Resident 79 was initiated on 3/3/25. Resident 79 was admitted to the facility on [DATE]. Review of Resident 79's Order Summary Report showed a physician's order dated 2/6/25, to admit Resident 79 to Hospice 1 under routine level of care. Review of Resident 79's Physician's Certification for Hospice Benefit effective from 2/6/25 to 4/6/25, showed Resident 79 was currently bedbound and required complete assistance with activities of daily living, with each grooming and bathing session taking approximately one hour to complete. The visit frequency of care included a certified hospice aide visit twice per week. Review of Resident 79's care plan for hospice care initiated 2/7/25, showed the facility would work cooperatively with the hospice team to ensure Resident 79's spiritual, emotional, intellectual, physical, and social needs are met. Review of Resident 79's Hospice 1 Monthly Schedule for February and March 2025 showed a certified hospice aide was scheduled to provide care to Resident 79 twice a week. Review of Hospice 1's (staff) Sign in Sheet for February and March 2025 showed the following documentation: * For the week of 2/9/25 to 2/15/25, the certified hospice aide visited and provided care for Resident 79 on 2/10/25 (one certified hospice aide visit was missing) *For the week of 2/16/25 to 2/22/25, there was no documentation the certified hospice aide visited and provided care for Resident 79. *For the week of 2/23/25 to 3/1/25, there was no documentation the certified hospice aide visited and provided care for Resident 79. *For the week of 3/2/25 to 3/8/25, there was no documentation the certified hospice aide visited and provided care for Resident 79. Further review of Resident 79's medical record failed to show documentation the facility had coordinated with Hospice 1 regarding the missing certified hospice aide visits. On 3/6/25 at 1400 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the findings. 2. Review of the Hospice Services Agreement between the facility and Hospice Provider dated 11/1/21, showed the following: - Under Patient Care section, showed the communication will be documented in the SNF resident chart between the LTC facility and the hospice provider to ensure the needs of the resident are addressed and met 24 hours per day. The clinical notes will cover any significant changes in the resident's physical, mental, social, or emotional status; - Under Documentation of Services Provided section, showed all health care professionals, including but not limited to MSW, dietitians, nurses (including RNs and LVNs), therapists, chaplains, certified hospice aide, homemakers and volunteers, shall submit a progress note with a time sheet signed by the residents. SNFs shall also document accurately in the resident chart in the SNF record, according to the policy of the particular SNF. Documentation of services provided shall include copies of any instructions to the resident. All required documentation shall be submitted within five days of providing any specified service. Medical record review for Resident 394 was initiated on 3/3/25. Resident 394 was admitted to the facility on [DATE]. Review of Resident 394's Order Summary Report showed a physician's order dated 2/17/25, to admit the resident under Hospice Provider 1. a. During the inspection of the hospice binder, the following documents from Hospice 2 were left blank and not signed by the resident/resident representative: - Comfort Medications from Hospice Provider 1; - Policy Section: Administrative Patient Practices for Mortuary; - Informed Consent and Medicare/ Medical Benefit Election Form; - Patient Notification of Hospice Non-Covered Items, Services, and Drugs; - Release of Information and Consent for Treatment; - Patient Acknowledgment; - Patient's [NAME] of Rights and Responsibilities; - Medi-Cal Hospice Program Election Notice; - Telehealth Consent Form; and - Release With Authorization to Record and Photograph b. In addition, review of Resident 394's POLST in the hospice binder showed it was blank. c. Review of Resident 394's medical record did not show the frequency of the visits from Hospice 2's skilled nursing, certified hospice aide, social services, and chaplain. Review of the Hospice 2 calendar for February 2025 showed Hospice 2's MSW visited Resident 394 on 2/18/25, and Hospice 2's RN visited on 2/18 and 2/26/25. There was no Hospice 2's calendar for March 2025. Review of the Hospice 2's Flowsheet showed the handwritten notes showing MSW assessment and RN routine visit on 2/18/25, and RN routine visit on 2/25/25. d. Further review of Resident 394's medical record failed to show documented evidence of certified hospice aide visits conducted for Resident 394 for February and March 2025. On 3/5/25 at 1210 hours, an interview and concurrent medical record review for Resident 394 was conducted with LVN 1. When asked about the Hospice 2 staff visits, LVN 1 stated he was not sure of the schedule. LVN 1 stated he checked the hospice calendar and flowsheet to know who visited Resident 394. LVN 1 verified the Hospice 2 calendar and flowsheet only showed the MSW and RN visits. On 3/5/25 at 1244 hours, an interview and concurrent medical record review for Resident 394 was conducted with Hospice 2 RN and Hospice 2 MSW. Hospice 2 RN and Hospice 2 MSW verified the hospice forms and POLST in the Resident 394's hospice binder were blank. Hospice 2 RN and Hospice 2 MSW also verified the frequency of the hospice agency staff visits were not documented. Hospice 2 RN stated the nursing visits were every Wednesdays, certified hospice aide visits were every Friday, MSW visit was one time per month, and the resident's family declined the chaplain services. On 3/5/25 at 1252 hours, an interview and concurrent medical record review for Resident 394 was conducted with the DON. The DON acknowledged she was the hospice coordinator. The DON verified the hospice forms and POLST in the Resident 394's hospice binder were blank. The DON also verified the frequency of the visits from Hospice 2's skilled nursing, certified hospice aide, social services, and chaplain were not documented in the physician's order nor Resident 394's plan of care. When asked about Hospice 2 calendar, the DON showed a calendar for February and March 2025 from Resident 394's EHR. Review of the Hospice Provider 1 calendar for February and March 2025 showed the following: - One physician visit, one chaplain visit, one certified hospice aide visit, one social worker visit, and two skilled nurse visits for the week of 2/16 to 2/22/25; - One skilled nursing visit and one certified hospice aide visit for the weeks of 2/23 to 3/1, 3/2 to 3/8, and 3/9 to 3/15/25; and - One social worker, one skilled nursing, and one certified hospice aide visits for the week of 3/16 to 3/22/25. The DON stated she would have to verify with Hospice 2 if the calendar was the actual or projected visits. The DON verified there was a missing skilled nursing visit on the week of 2/16 to 2/22/25, and there was no documented evidence to show the certified hospice aide visited Resident 394 for February and March 2025.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases. * The facility failed to implement the testing, monitoring, and establishment of acceptable ranges of disinfectant chemicals levels throughout the facility's water supply in accordance with the facility's water management P&P for water management, and the facility's plan for Legionella control. * The laundry room and equipment were not maintained to ensure a clean area, and free from potential contamination. These failures had the potential for the spread of infection to the residents, staff and visitors in the facility. Findings: 1. According to the CMS QSO-17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated 6/2/17, the facilities must develop and adhere to the policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. - Develops and implements a water management program that considers the ASHRAE (American Society of Heating Refrigerating and Air-Conditioning Engineers) industry standards and the CDC (Centers for Disease Control and Prevention) toolkit; and - Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained. Review of the facility's P&P titled Water Management revised 5/25/23, showed the facility will develop and utilize the water management strategies, using the core elements of a water management plan, to reduce the risk of growth and spread of Legionella and other opportunistic water-borne pathogens in facility water systems. Control measures and corrective actions include quarterly measurement of the water quality throughout the system to ensure changes that may lead to Legionella growth are not occurring. Quarterly maintenance and monitoring of the disinfectant and other chemicals levels in cooling towers and hot tubs. Review of the facility's Water Management Committee Minutes dated 2/27/25, showed the water management testing includes testing of the PH levels, chlorine levels and chloramine levels. The facility will delegate to an outside company (Company 1) to check the levels monthly, starting in March of 2025. On 3/6/25 at 1535 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated the facility had yet to implement the testing and monitoring of the disinfectant chemicals (chlorine and chloramine) levels throughout the facility water supply. The IP stated the implementation would begin this month (March 2025). Additionally, the IP stated the facility would establish an acceptable ranges for the disinfectant chemicals. 2. Review of facility's P&P titled Laundry Services revised dated 1/1/12, showed a clean and safe environment is always maintained. On 3/6/25 at 1530 hours, a laundry room inspection was conducted with the Housekeeping Supervisor. The following was observed in the laundry room: - the outside of Washing Machine 1's door had large amounts of brown stains and white mineral-like residue; - the pipes on the back of Washing Machine 1 had brown stain and hard white substance, mineral-like residue; and - the wall next to Washing Machine 1 showed signs of damage with cracks and gap between the wall and baseboard. The Housekeeping Supervisor verified the above findings and stated she would try to scrape the yellow stains and white mineral-like residue. The Housekeeping Supervisor further stated she would let the maintenance know to repair the damaged wall.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, facility document review, and facility P&P (Policy and Procedure) review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure the infection control data gathered in the surveillance log was accurately documented in the Infection Control Report for January 2025. * The facility failed to provide documentation of the McGeer's criteria used to determine if the residents met the criteria for true infection. * The facility failed to ensure Resident 54 was accurately assessed for true infection when an Ampicillin (antibiotic medication to treat infection) was prescribed. These failures had the potential for inappropriate use of antibiotics and increased risk of drug-resistant organisms. Findings: According to the CDC, the antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Core Elements of Antibiotic Stewardship for Nursing Homes | Antibiotic Prescribing and Use | CDC Review of the facility's P&P titled Antibiotic Stewardship revised 5/20/21, showed the purpose of the Antibiotic Stewardship is to optimize the use of antibiotics by improving prescribing practices and reduce inappropriate antibiotic use. - The facility will implement an Antibiotic Stewardship Program to promote appropriate use of antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve outcomes for residents. - The facility has chosen to use Revisited McGeer's Criteria (2012) for surveillance - The IP (Infection Preventionist/Infection prevention program coordinator) is responsible for tracing the following antibiotic stewardship processes: whether or not the resident's condition met McGeer's Criteria when the antibiotic was ordered - The IP will coordinate the collection and reporting of date for the Infection Control Committee meetings from all members of the team. 1. On 3/6/25 at 1251 hours, an interview and concurrent infection control program review was conducted with the IP. Review of the facility's Infection Prevention and Control Surveillance Log for January 2025 showed 15 residents did not meet the McGeer's criteria for true infection. However, the review of the January 2025 Infection Control Report showed a total of 17 residents who did not meet the McGeer's criteria. The IP reviewed both reports and verified the information on the surveillance log did not match the information documented on the January 2025 Infection Control Report. The IP further stated inaccurate reports affected the infection control process and the teaching and in-services to the staff, and the discussion in the QAPI meeting and the action plans. In addition, the Monthly Infection Control Report showed the facility acquired six HAI: three residents with urine infection, two residents with skin/wound infection; and one resident with eye/ear infection. However, the review of the facility's mapping for HAI infection for January 2025 failed to show the resident with eye/ear infection included in the facility's mapping for infection. The IP acknowledged and verified the findings. 2. On 3/6/25 at 1251 hours, an interview and concurrent infection control program review was conducted with the IP. During the interview, the IP was asked for the facility's process regarding the resident's assessment to determine true infection. The IP stated the facility used the McGeer's criteria. When asked for the documentation of the McGeer's criteria, the IP was not able to provide one. The IP stated she just looked at the facility's infection control surveillance log and the signs and symptoms listed. The IP further stated she referenced the long version of the McGeer's form; however, no documentation was provided. Further review of the Infection Prevention and Control Surveillance Log showed on the bottom of the form, to utilize McGeer's Criteria to determine infections for Infection Control Surveillance Purposes. Review of the facility's Infection Screening Evaluation was provided by the IP. The screening form was being used when an antibiotic was initiated. The form was asking for symptoms and at the end of the evaluation, infection analysis was listed about Loeb's Criteria and McGeer's criteria. However, the assessment screening did not show how the system came up with meeting or not meeting the McGeer's criteria. For example, the facility provided a blank McGeer's screening for GI Tract Infections. The form showed the following: Both of the following criteria must be present: 1. One of the following GI sub-criteria: a) Diarrhea: three or more liquid or watery stools above what is normal for the resident within a 24-hour period b) Presence of toxic megacolon (abnormal dilation of the large bowel, documented radiologically) 2. One of the following diagnostic sub-criteria: a) A stool sample yields a positive laboratory test for C. difficile toxin A or B, or a toxin-producing C. difficile organism is identified from a stool sample culture or by a molecular diagnostic test such as PCR b) Pseudomembranous colitis is identified during endoscopic examination or surgery or in histopathologic examination of a biopsy's specimen. Review of the facility's Infection Screening Evaluation only showed the following assessment: 1. Diarrhea (# of episodes in the last 24 hours) a. Yes, less than three liquid or watery stools (above resident's normal) b. Yes, greater than or equal to three liquid or watery [NAME] (above resident's normal) The facility's Infection Screening Evaluation was not consistent with the McGeer's screening for the GI Tract Infections. The facility's Infection Screening Evaluation was unclear on the basis of meeting or not meeting the McGeer's criteria. The IP acknowledged the findings. 3. On 3/6/25 at 1251 hours, an interview and concurrent facility document review and medical record review for Resident 54 was conducted with the IP. Medical record review for Resident 54 was initiated on 3/6/25. Resident 54 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the facility's Infection Prevention and Control Surveillance Log for February 2025 showed Resident 54 had signs and symptoms of diarrhea with an onset date of 2/17/25. The surveillance log showed Resident 54 was prescribed with Ampicillin and did not meet the McGeer's criteria. Review of Resident 54's Infection Screening Evaluation dated 2/17/25, showed the resident had symptoms (new or marked increase) of diarrhea (within the last 24 hours) and the resident met the McGeer's Criteria for gastroenteritis. Review of Resident 54's medical record showed a physician's order dated 2/22/25, for Ampicillin oral capsule 500 mg one capsule by mouth every six hours for exposure to possible contaminated milk products for seven days; and to start after blood culture collected. Review of Resident 54's Late Entry Note dated 2/25/25 at 1523 hours, showed the NP was made aware regarding the resident not meeting the McGeer's criteria and per the NP, to continue the antibiotic as ordered. Resident 54's information documented in the facility's Infection Prevention and Control Surveillance Log and progress notes about not meeting the McGeer's criteria did not match the assessment on the Infection Screening Evaluation showing Resident 54 met the McGeer's criteria for gastroenteritis. On 3/6/25 at 1445 hours, an interview and concurrent medical record review for Resident 54 was conducted with the DON. The DON acknowledged and verified the above findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the bed inspection and entrapment assessment were conducted for one of five final sampled residents (Resident 394) reviewed for side rail use. These failures had the potential to negatively impact the resident's well-being resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Rails dated 6/12/24, under the Safety and Maintenance section showed the following: - The facility is required to follow the manufacturer's recommendations and specifications for installation and ensure the dimensions of the resident's bed are appropriate for both the resident's size and weight; and - Review of entrapment occurs upon admission, readmission or a change of bed or mattress; and On 3/4/25 at 1405 hours, Resident 394 was observed awake and lying in bed with the bilateral upper side rails elevated. Medical record review for Resident 394 was initiated on 3/3/25. Resident 394 was admitted to the facility on [DATE]. Review of Resident 394's Order Summary Report showed a physician's order dated 2/14/25, for the bilateral ½ side [NAME] as enablers. Review of Resident 394's Bed Rail assessment dated [DATE], showed side rails were not indicated for Resident 394. Review of Resident 394's plan of care showed a care plan problem dated 2/17/25, to address the use of the grab bars. Review of Resident 394's MDS dated [DATE], showed Resident 394 had severe cognitive impairment, and dependent to the facility staff member for bed mobility. Further review of Resident 394's medical record failed to show documented evidence an entrapment assessment was completed prior to the installation of the bilateral upper side rails. On 3/5/25 at 1017 hours, an observation for Resident 394 and concurrent interview and medical record review was conducted with RN 1. Resident 394 was observed in bed with the bilateral upper side rails elevated. RN 1 verified the above findings. RN 1 stated Resident 394 was under the hospice services, and Resident 394's bed was brought into the facility with the bilateral side rails already installed. When asked about the entrapment assessment, RN 1 stated the maintenance department installed the side rails and measured the bed and side rails to assess for entrapment. On 1/24/25 at 1225 hours, a concurrent interview and facility document review for Resident 394 was conducted with the Maintenance Director and the Maintenance Assistant. The Maintenance Director stated the maintenance department was responsible for the monthly bed inspection of all the beds in the facility, where they checked the whole bed, bed functionality, frame, bed control and the side rails which could be halos, U-bars, and the half or quarter side rails. The Maintenance Director stated after the nurses obtained a physician's order for the side rails, the DON or ADON would notify the maintenance department to install the side rails. The Maintenance Assistant further stated if the maintenance department was not notified and he saw a resident bed had side rails, he would measure the bed and the entrapment zones, record in his notebook, and would document later in the log. When asked about the entrapment assessment, the Maintenance Assistant stated he used a measuring tape to measure the entrapment zones on each bed. When asked to show the documentation of the results of the bed inspection including the entrapment assessment, the Maintenance Assistant showed the Bed Side Rail Inspection Log and the Bed Entrapment Risk Checklist. Review of the Bed Side Rails Inspection Log for February 2025 showed the information included the bed make, bed serial, location/ retighten, in good repair, if the mattress size was appropriate and the date of installation of the side rails. The log did not show Resident 394's bed was inspected. Review of the Bed Entrapment Risk Checklist for February 2025 which included the seven zones of entrapment, did not show Resident 394's bed was inspected. The Maintenance Director and the Maintenance Assistant verified the above findings. The Maintenance Director and the Maintenance Assistant stated they were not informed about Resident 394's bed with side rails. On 3/6/25 at 1400 hours, an observation for Resident 394 and concurrent interview was conducted with the Maintenance Director. Resident 394 was lying in bed with the bilateral upper side rails. The Maintenance Director verified the above findings.

MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the MDS was coded accurately for one of three closed record sampled residents (Resident 142) reviewed. This failure had the potential for the resident to not receive appropriate treatment and/or services. Findings: Medical record review for Resident 142 was initiated on 3/6/25. Resident 142 was admitted to the facility on [DATE]. Review of Resident 142's H&P examination dated 12/3/24, showed Resident 142 had the capacity to understand and make decisions. Review of Resident 142's Order Summary Report showed a physician's order dated 12/30/24, to discharge to home with hospice services, may discharge home on 1/3/25, as per the resident and POA's request. Review of Resident 142's Discharge MDS dated [DATE], under section A of the MDS for the discharge status, showed Resident 142 was coded for the Short-Term General Hospital instead of hospice (to home/non-institutional). On 3/6/25 at 1029 hours, an interview and concurrent medical record review for Resident 142 was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings and stated the MDS Assistant coded the Discharge MDS status incorrectly. On 3/6/25 at 1430 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Garbage Disposal (Tag F0814)

Minor procedural issue · This affected multiple residents

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Based on observation and interview, the facility failed to ensure the garbage was properly stored in two of six garbage dumpsters. This failure had the potential to attract pests/rodents that carried a disease. Findings: According to the 2022 FDA Food Code, outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 3/3/25 at 1132 hours, an observation of the facility's garbage dumpsters was conducted. Two of six dumpsters were observed with the lids open and garbage inside. The dumpsters were observed with the lids propped open by garbage, preventing the lids from fully closing. On 3/4/25 at 1601 hours, an interview was conducted with the Administrator. The Administrator verified the findings (via a photograph taken of the findings). The Administrator stated the garbage company was scheduled to pick up the garbage at the facility six times a week.

MINOR (B)

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record was accurately maintained for three of 29 final sampled residents (Residents 79, 84, and 86). * Residents 79 and 84's POLST failed to show documentation as to whether the residents had formulated and advance directive. * Resident 86's medical record was found to have two other residents' medical records. These failures had the potential for the residents' care needs not being met as the medical record was inaccurate and incomplete. Findings: 1. Medical record review for Resident 79 was initiated on 3/3/25. Resident 79 was admitted to the facility on [DATE]. On 3/6/25 at 1049 hours, an interview and concurrent medical record review was conducted with LVN 2. Review of Resident 79's POLST, Section D (advance directive), dated 11/12/24, failed to show documentation as to whether Resident 79 had formulated an advance directive. LVN 2 verified the findings and stated the information specific to the advance directive would be added to Resident 79's POLST. 2. Medical record review for Resident 84 was initiated on 3/3/25. Resident 84 was admitted to the facility on [DATE]. On 3/6/25 at 1049 hours, an interview and concurrent medical record review was conducted with LVN 2. Review of Resident 84's POLST, Section D (advance directive), dated 9/5/23, failed to show documentation as to whether Resident 84 had formulated an advance directive. LVN 2 verified the findings and stated the information specific to the advance directive would be added to Resident 84's POLST. 3. On 3/4/25 at 0953 hours, an interview and concurrent medical record review was conducted with RN 1. During the record review, medical records for two residents were found to be filed in Resident 86's medical record. RN 1 verified the records should not be filed in Resident 86's medical record. RN 1 removed the records of the other residents from Resident 86's medical record.

Nov 2024 3 deficiencies

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Deficiency F0657 (Tag F0657)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current wound care treatment and interventions for each individual wound site as ordered for one of seven sampled residents (Resident 3). * Resident 3's care plan was not revised to address the wound site of left foot first metatarsal base and head arterial wounds. This failure posed the risk of not providing the resident with individualized and person-centered care. Findings: Medical record review for Resident 3 was initiated on 11/5/24. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's physician's order dated 11/1/24, showed the following: - to provide wound care to sacrococcyx Sites #1 and #2 as follows: cleanse with NS, pat dry, apply Santyl (debridement agent) nickel thick layer and oil emulsion gauze, and cover with a dry clean dressing every day shift for 14 days and as needed for 14 days - to provide wound care to the right knee anterior skin tear as follows: cleanse with NS, pat dry, then apply Xeroform gauze (nonadherent dressing to maintain moist wound environment), and cover with a dry clean dressing every day shift for 14 days and as needed for 14 days. - to provide wound care to left inner/medial knee skin tear as follows: cleanse with NS, pat dry, then apply Xeroform gauze, and cover with a dry clean dressing every day shift for 14 days and as needed for 14 days. - to provide wound care to the left foot first metatarsal head and base arterial wound as follows: cleanse with NS, pat dry, then apply Santyl nickel thick layer, cover with moist gauze followed by a dry clean dressing every day shift for 14 days and as needed for 14 days. - to provide wound care to the left elbow skin tear as follows: cleanse with NS, pat dry, then apply Xeroform gauze and cover with a dry clean dressing Review of Resident 3's plan of care dated 11/1/24, showed wound management goals and interventions for the following wound sites: pressure injury to the sacrum coccyx Sites #1 and #2, right foot fifth metatarsal base and head arterial wounds, skin tear on the left inner knee, and skin tears to the right lower leg anterior and left elbow. However, the care plan failed to show goal and interventions of the left foot first metatarsal head and base arterial wounds. On 11/6/24 at 1530 hours, a concurrent interview and medical record review for Resident 3 was conducted with the DON. The DON verified the findings and stated Resident 3's care plan should be revised to reflect all wound sites currently undergoing treatment and monitoring.

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Tube Feeding (Tag F0693)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary tube feeding care and services for one of seven sampled residents (Resident 3). * The facility failed to ensure Resident 3 was positioned safely at 30 to 45 degrees during the enteral feeding via PEG tube. This failure posed the risk for developing complications related to resident's tube feeding and health consequences. Findings: Review of the facility's P&P titled Enteral Tube Management: Nasogastric Tube, Gastrostomy Tube, and Jejunostomy Tube revised on 9/28/23, showed the head of the bed should be elevated 30 degrees during enteral feedings. Medical record review for Resident 3 was initiated on 11/5/24. Resident 3 was initially admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 3's Order Summary Report dated 10/31/24, showed an order to administer Jevity 1.5 at 50 ml per hour for 20 hours = 1000 ml/24 hours via PEG tube and elevate the head of bed at 30 to 45 degrees during the enteral feeding. On 11/6/24 at 1230 hours, Resident 3 was observed lying flat in bed. Resident 3's tube feeding with Jevity 1.5 was observed infusing via a feeding pump at 50 ml per hour. On 11/6/24 at 1232 hours, a concurrent observation and interview for Resident 3 was conducted with LVN 3. LVN 3 verified the finding and stated that the head of the bed should be elevated at 30 to 45 degrees during the enteral feeding. When asked what could happen to Resident 3 if her head of the bed was not elevated during the enteral feeding, LVN 3 stated Resident 3 could aspirate (inhalation of food, saliva, liquids, or vomit into the lungs) if the head of the bed was kept flat during the enteral feeding. On 11/6/24 at 1530 hours, the DON acknowledged the above finding.

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Infection Control (Tag F0880)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment to prevent the transmission of diseases and infections in the facility. * The facility failed to ensure the staff practiced the EBP during high contact-care for one of seven sampled residents (Resident 3). This failure posed the risk for the transmission of diseases and infections. Findings: According to the CDC, EBP promotes the use of PPE to include donning of gown and gloves during high-contact resident care activities that can provide the opportunities for transmission of MDROs to others. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include the following: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator - Wound care: any skin opening requiring a dressing Review of the facility's EBP signage showed everyone must clean hands before entering and after leaving room. All healthcare personnel must wear gloves and gown for the following high contact resident care activities: - Dressing, bathing/showering - Transferring - Changing linens - Providing Hygiene - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy - Wound care: any skin opening requiring a dressing Medical record review for Resident 3 was initiated on 11/5/24. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's care plan showed Resident 3 was on EBP for presence of the PEG tube, Foley catheter, and wounds. On 11/6/24 at 1240 hours, Resident 3's room was observed with an EBP standard precautions signage posted on Resident 3's door. The signage showed EBP, everyone must perform hand hygiene before entering the room, providers and staff must also wear gloves and gown for high contact resident care activities such as: - Dressing - Bathing/showering - Transferring - Changing linens - Providing hygiene - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy - Wound care: any skin opening requiring a dressing. On 11/6/24 at 1241 hours, a concurrent observation of Resident 3 and interview was conducted with CNA 8. CNA 8 was observed handling Resident 3's Foley catheter without proper PPE. CNA 8 verified he should have donned the gloves and gown before handling the Foley catheter for the infection prevention. On 11/6/24 at 1420 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 verified Resident 3 was on EBP or presence of PEG tube, Foley catheter, and wounds. RN 1 further stated for EBP, the staff should wear the gloves and gown when providing Foley catheter care to prevent the infection. On 11/6/24 at 1530 hours, the DON verified the findings and stated the staff were expected to perform hand hygiene, don gloves and gown when providing high contact resident care activities, including Foley catheter care to prevent the transmission of diseases and infection prevention for the residents on EBP.

Oct 2024 1 deficiency

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Deficiency F0761 (Tag F0761)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were stored properly for one nonsampled resident (Resident E) when a medication bubble pack was observed at the counter of the nursing station. This failure had the potential for the unauthorized staff and visitors to have access to the medications. Findings: Review of the facility's P&P titled Medication Storage in the Facility dated April 2008 showed the medications and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. Medical record review for Resident E was initiated on 10/16/24. Resident E was admitted to the facility on [DATE]. Review of Resident E's Order Summary Report showed a physician's order dated 9/30/24, for potassium chloride extended release (potassium supplement medication) 20 mEq by mouth in the morning for supplement. On 10/16/24 at 0957 hours, during the facility tour, a bubble pack of potassium chloride extended release 20 mEq with 14 tablets and labeled with Resident E's name was observed at the nursing station counter. On 10/16/24 at 1003 hours, a female staff was observed walking toward the nursing station and stated she was LVN 2 and verified the medications at the counter. LVN 2 stated this medication belonged to Resident E who was at Station 6. LVN 2 stated she did not know why the medications were at the counter and stated it should be stored inside the medication cart. During the interview with LVN 2, the ADON came to the nursing station, LVN 2 handed the medications to the ADON. The ADON acknowledged the above findings.

Aug 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medial record review, and facility P&P review, the facility failed to conduct an inventory of a resident's personal property in accordance with the facility's P&P for one of five sampled residents (Resident 2). * The facility failed to conduct the inventory of Resident 2's personal property when he was admitted and discharged from the facility. This failure had the potential for the resident's property to get lost or stolen. Findings: Review of the facility's P&P titled Personal Property revised 7/14/17, showed the residents are encouraged to retain and use personal possessions, as space permits. During the admission process the admissions staff will inform the resident of the need to mark the resident's belongings with the resident's name and to notify nursing when additional items are brought to the facility, so they can be added to the resident's inventory list. Admissions staff will also inform the resident that items removed from the facility need to be removed from the inventory list. Upon admission the CNA/designee will conduct a personal property inventory of the resident's property and place in the medical record. Upon discharge home, the resident will review the resident inventory to ensure all personal items are taken. The resident will sign the inventory indicating that all personal property is released to them. If an item(s) is missing, the staff will initiate a search and notify social services/designee in accordance with the Theft and Loss policy for resolution. I f the resident is transferred to the acute hospital, and is expected to return to the facility, the resident's CNA will inventory the resident's property at the time of transfer. The facility may decide to keep the resident's personal property in the resident's room during the bed hold or may pack the items and place them in secured storage pending the resident's return. Medical record review for Resident 2 was initiated on 7/31/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Clinical admission note dated 7/8/24 at 2130 hours, showed Resident 2 was alert and oriented, communicated verbally with clear speech, was able to understand, and be understood when speaking. On 7/31/24 at 1507 hours, an interview was conducted with Resident 2. Resident 2 stated he was transferred to the acute care hospital on 7/21/24, and after he was discharged from the acute care hospital, he then returned to the facility to retrieve his personal property. Resident 2 stated when he returned to the facility to retrieve his belongings, the social worker assisted him with loading his vehicle. Resident 2 stated he was given three boxes which contained his personal belongings. Resident 2 stated at the time he loaded his vehicle, he realized several of his personal belongings were missing. Resident 2 stated the following items were missing: a coffee pot, a bathroom kit with medicated shampoo, artist pencils, two beach towels, six pairs of socks, six pairs of hospital socks, a white belt, a bluetooth speaker, and a nebulizer. Resident 2 stated he informed the social worker, and she informed him thatshe would follow up with Resident 2 regarding his alleged missing property; however, Resident 2 stated the social worker failed to follow up with him. On 8/5/24 at 1642 hours, an interview was conducted with Social Worker 2. Social Worker 2 stated Resident 2 returned to the facility to obtain his personal belongings. Social Worker 2 stated the CNAs had boxed up his personal property and then provided Resident 2 with his personal property. Social Worker 2 stated she assisted in carrying some of Resident 2's personal property to his vehicle. Social Worker 2 stated she provided Resident 2 with his amplifier, guitar holder, and clothing. Social Worker 2 was asked if Resident 2 claimed any of his personal property was missing. Social Worker 2 stated Resident 2 informed her that a couple t-shirts were missing, at which time Social Worker 2 retrieved Resident 2's t-shirts from the facility and gave the t-shirts to Resident 2. Social Worker 2 was asked if she documented the items released to Resident 2, to which Social Worker 2 replied, her duties did not consist of inventorying Resident 2's personal property. Social Worker 2 stated the CNAs would usually inventory the resident's property on admission and discharge from the facility. Review of Resident 2's Resident Inventory form dated 7/8/24, failed to show any documentation of Resident 2's personal property upon admission to the facility. Further review of the form failed to show documentation specific to any personal property provided to Resident 2 upon discharge. On 8/6/24 at 1130 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked to describe the facility's P&P specific to safeguarding resident personal property. The DON stated upon admission to the facility, a resident's personal property would be inventoried and documented on the Resident Inventory form. The resident's inventory form was updated with any additional property brought into the facility. The DON stated upon discharge from the facility, all personal property released to the resident would bedocumented on the Resident Inventory form. The DON stated both resident and staff were to sign the inventory form verifying the personal property the resident possessed upon admission, brought into the facility after admission, and the property released to the resident upon discharge from the facility. The DON was asked if she was aware of any personal property Resident 2 claimed missing upon his discharge from the facility, to which she replied, she was not. The DON was asked to review Resident 2's medical record including Resident 2's Resident Inventory form dated 7/8/24, to locate documentation specific to what personal property Resident 2 possessed during his stay at the facility and the personal property provided to Resident 2 when he returned to the facility to retrieve his personal property. The DON reviewed Resident 2's medical record and stated Resident 2's medical record failed to show any documentation specific to Resident 2's personal property, therefore could not determine what personal property Resident 2 possessed during his stay at the facility, or what personal property was provided to Resident 2 when he was discharged from the facility. The DON stated the staff who admitted Resident 2 to the facility should have documented in Resident 2's Resident Inventory Form what personal property Resident 2 possessed at the time of his admission on [DATE]. The DON stated the staff member and Resident 2 needed to sign the Resident Inventory Form, attesting to the property in Resident 2's possession. The DON stated the staff who released Resident 2's personal property upon his discharge from the facility should have documented the property released to Resident 2. The DON stated the facility staff and Resident 2 also should have signed the Resident Inventory form, attesting to the property released to Resident 2. The DON stated the facility was unable to determine what personal property was brought in upon admission and released to Resident 2 upon his discharge from the facility.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility to implement their P&P related to abuse reporting for one of five sampled residents (Resident 1). * The Activities Assistant failed to report the abuse allegation to the Administrator when Resident 1 informed the Activities Assistant that a CNA was mad and threw towels on Resident 1's bed. This failure had the potential for the abuse allegation not investigated thoroughly and posed a risk of not providing appropriate actions to prevent further abuse. Findings: Review of the facility's P&P titled Abuse Reporting and Investigations revised 3/2018 showed the purpose of the facility's policy is to protect the health, safety, and welfare of facility residents, by ensuring that all reports of resident abuse are promptly reported and thoroughly investigated. Allegations of abuse are to be reported to the Administrator or designated representative immediately. When the Administrator or designated representative receives a report of an incident or suspected incident of resident abuse, the Administrator or designated representative, will initiate an investigation immediately. Medical record review for Resident 1 was initiated on 7/31/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 11/3/23, showed Resident 1 had the capacity to understand and make decisions. On 8/1/24 at 1155 hours, an interview was conducted with Resident 1. Resident 1 stated after taking a shower, CNA 4 threw towels at her. Resident 1 stated CNA 4 then told Resident 1 to dry herself. Resident 1 stated CNA 4 brought her out of the shower area while Resident 1 was still wet. Resident 1 stated she was unable to dry her back without assistance. Resident 1 stated she felt cold, and the incident made her feel humiliated. On 8/1/24 at 1318 hours, an interview was conducted with the Activities Assistant. The Activities Assistant stated she interviewed Resident 1 specific to an allegation made involving CNA 4. The Activities Assistant stated Resident 1 told her that CNA 4 would always yell at Resident 1. Resident 1 told the Activities Assistant that CNA 4 was always mad at Resident 1 for anything Resident 1 did. The Activities Assistant stated she documented Resident 1's allegation and reported the allegation to the Administrator who served as the facility's Abuse Coordinator. The Activities Assistant was asked if Resident 1 conveyed additional concerns specific to CNA 4. The Activities Assistant stated Resident 1 told her that CNA 4 would get mad when Resident 1 asked CNA 4 for supplies. The Activities Assistant stated Resident 1 told her there was an incident in which CNA 4 got mad at Resident 1 and threw towels on Resident 1's bed. Resident 1 stated she was scared because CNA 4 was always mad, and Resident 1 did not know why. The Activities Assistant was asked if she informed the Administrator of Resident 1's allegation when CNA 4 was mad and threw towels on Resident 1's bed, to which the Activities Assistant stated she did not. The Activities Assistant was asked if she asked Resident 1 for details specific to this allegation, to which she replied, she did not. The Activities Assistant was asked if she asked Resident 1 how the alleged incident made Resident 1 feel, to which she replied, she did not. On 8/1/24 at 1443 hours, an interview was conducted with the Administrator. The Administrator was asked if he was aware of Resident 1's allegation when CNA 4 threw towels at Resident 1 while in the shower and if he was aware of Resident 1's allegation CNA 4 was mad and threw towels on Resident 1's bed. The Administrator stated he was unaware of the allegations. The Administrator acknowledged and further stated all allegation of abuse should be reported to him.

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the information obtained from the physical assessment was documented in the resident's medical record for one of five sampled residents (Resident 2). This failure had the potential for not knowing the resident's health condition due to incomplete medical record. Findings: Review of the facility's P&P title Change of Condition Notification revised 4/1/15, showed the licensed nurse will assess the change of (resident) condition and determine what nursing interventions are appropriate. Before notifying the attending physician, the licensed nurse must observe and assess the overall condition utilizing a physical assessment and chart review. A licensed nurse will document the following: date, time, and pertinent details of the incident and the subsequent assessment in the nursing notes. Medical record review for Resident 2 was initiated on 7/31/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's SBAR for Change In Condition dated 7/17/24 at 2030 hours, showed RN 3 documented Resident 2 claimed he slipped while he was taking a shower and hit his head on the floor. The documentation showed per Resident 2, he was able to get back up and did not call for help. The documentation further showed Resident 2 complained of pain on the left rib cage, had no head injury noted, vital signs were stable, and the physician was made aware and recommended for neuro checks for 72 hours. Further Review of Resident 2's SBAR dated 7/17/24, failed to show the documentation specific to Resident 2's left rib cage assessment afterResident 2 complained of pain on the left rib cage. On 8/5/24 at 1602 hours, an interview was conducted with RN 3. RN 3 verified she was informed Resident 2 allegedlyslipped while taking a shower on 7/17/24. RN 3 stated she conducted a physical assessment of Resident 2 status post his alleged fall. When asked if RN 3 assessed Resident 2's left rib cage, RN 3 stated Resident 2 would not allow her to complete an assessment of his left rib area. However, RN 3 acknowledged she observed Resident 2 had his shirt off and RN 3 could see Resident 2's left rib cage with one small red line without swelling. RN 3 verified she failed to document her observation of Resident 2's left rib cage with one small red line without swelling in Resident 2's medical record. RN 3 stated she should have documented this information in Resident 2's medical record to ensure an accurate medical record was maintained.

Jun 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure the routine changes of indwelling urinary catheter order were clarified with the physician for one of two sampled residents (Resident 2). This failure had the potential to put Resident 2 at risk for UTI. Findings: Review of the CDC's resource for Infection Control - Catheter-Associated Urinary Tract Infections (CAUTI) dated 2009 showed the Proper Techniques for Urinary Catheter Maintenance include changing indwelling urinary catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Review of the facility's P&P titled Catheter – Care Of revised on 6/2021 showed the indwelling urinarycatheters will not be changed at the arbitrary fixed intervals. The entire system will be changed when it functions poorly, is obstructed, or is the source of odors. Medical record review for Resident 2 was initiated on 6/20/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's admission MDS dated [DATE], showed Resident 2's cognitive skills were moderately impaired. Review of Resident 2's Order Summary Report showed a physician's order dated 5/10/24, to insert the indwelling urinary catheter size FR #18 with balloon via gravity drainage for obstructive uropathy (a disorder due to obstructed urinary flow) secondary to BPH. The order summary report further showed to change the indwelling urinary catheter as per schedule (on Sundays) and as needed for leaking, occlusion, dislodgement, and excessive sedimentation. However, further review of the medical record showed no documented evidence of the clarification of the order to routinely changes the resident's indwelling urinary catheter as the facility's P&P showed not to change at the fixed intervals. On 6/20/24 at 1003 hours, a concurrent interview and medial record review with the IP was conducted. The IP verified Resident 2 had a routine order to change the indwelling urinary catheter weekly on Sundays. The IP acknowledged the weekly indwelling urinary catheter changes increased the risk for infection. Furthermore, the IP stated the routine indwelling urinary catheter changes were not recommended as per the CDC's guidelines. On 6/20/24 at 1030 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified Resident 2 had an indwelling urinary catheter order for routine weekly changes were scheduled on Sundays. The DON stated theindwelling urinary catheters should be changed as needed to help reduce the risk for infection and would follow up with the physician. On 6/20/24 at 1600 hours, an interview with the Administrator and DON was conducted. The Administrator and DON verified the above findings.

Mar 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and the facility P&P review, the facility failed to provide the written information regarding the rights to formulate the advance directives for one of ninesampled residents (Residents 1). In addition, facility failed to ensure the POLST was completed for Resident 1. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advanced Directive revised July 2018 showed upon admission, the admission staff or designee will provide written information to the resident concerning his or her right to make decision concerning medical care, including right to accept or refuse medical or surgical treatment, and the right to formulate advance directive. The P&P further showed during the social services assessment process, the Director of Social Service designee will also ask the resident whether he or she has a written advance directive. Closed medical record review for Resident 1 was initiated on 3/12/24. Resident 1 was admitted to the facility on [DATE], and discharged on 2/26/24. Review of Resident 1's Physician History and Physical examination dated 11/2/23, showed Resident 1 was capable of participating in the plan of care. Review of Resident 1's Clinical admission form dated 11/1/23, showed Resident 1 wasalert and oriented x three (oriented to person place, and time), communicated verbally withclear speech, able to understand, and be understood when speaking. Further review of Resident 1's closed medical record failed to show if Resident 1 and/or Resident 1's representative was asked whether Resident 1 had formulated an advance directive or was provided with the information regarding their rights to formulate anadvance directive. Further review of Resident 1's medical record did not show the POLST was completed. On 3/12/24 at 1510 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the SSD. The SSD verified the above findings and stated she was not able to find documented evidence if Resident 1 and/or Resident 1'srepresentative was asked whether Resident 1 has formulated an advance directive or wasprovided with the written information regarding their rights to formulate anadvance directive. Moreover, the SSD was not able to show if the POLST was completed for Resident 1. The SSD stated upon admission, the residents were asked if they had an advance directive or if they were interested in formulating an advance directive. The SSD stated the social services should provide information and assist with the completion of the advance directive. The SSD further stated the physician should initiate and complete POLST for residents. On 3/12/24 at 1551 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON verified and acknowledged above findings

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 1) was provided the necessary treatment and services to maintain and improve his ROM functions. * The facility failed to ensure the physician was notified of Resident 1's refusal of the PT and OT services and failed to develop the care plan problem to address Resident 1's refusal of the PT and OT services. These failures posed the risk for Resident 1 to develop complications from immobility leading to muscle atrophy and contractures (shortening of the tendons and muscles causing the joints to become stiff and unable to fully function). Findings: Review of the facility's P&P titled Refusal of Treatment revised 1/1/12, showed the facility will honor a resident's request not to receive medical treatment as prescribed by their attending physician, as well as care services outlined on the resident's assessment and care plan. Under the section for procedure showed the attending physician will be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal. The P&P further showed the interdisciplinary team will assess the resident's needs and offer the resident alternative treatment while continuing to provide other services in the care plan. Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised November 2018 showed the facility is to ensure that a comprehensive person-centered care plan is developed for each resident. Further review of the P&P showed the comprehensive care plan will be periodically reviewed and revised by the IDT after each assessment which means after each MDS assessment as required, except discharge assessment. In addition, the comprehensive care plan will also be reviewed and revised at the following times: - onset of new problems; - change of condition; - in preparation for discharge; - to address changes in behavior and care; and - other times as appropriate or necessary. Closed medical record review for Resident 1 was initiated on 3/12/24. Resident 1 was admitted to the facility on [DATE], and discharged on 2/26/24. Review of Resident 1's Physician History and Physical examination dated 11/2/23, showed Resident 1 was capable of participating in the plan of care. Review of Resident 1's Clinical admission form dated 11/1/23, showed Resident 1 wasalert and oriented to person, place, and time;communicated verbally with clear speech; able to understand; and be understood when speaking. Review of the Resident 1's PT Evaluation and Plan of Treatment dated 12/1/23, showed Resident 1 was referred to the PT due to decline in strength, static balance, coordination, functional ambulation, and functional mobility. The document further showed the plan of treatment approaches may include therapeutic exercises, neuromuscular reeducation, gait training therapy, and therapeutic activities to be done daily five times a week for 27 days from 12/1 to 12/27/23. Review of the Resident 1's OT Evaluation and Plan of Treatment dated 12/2/23, showed theplan of treatment approaches may include therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training to be done daily five times a week for 26 days from 12/2 to 12/27/23. Review of Resident 1's Order Summary Report showed the following physician's orders: - On 12/1/23, for PT services to be provided everyday five times a week for four weeks for therapeutic exercise, neuromuscular reeducation, therapeutic activities, and gait training; and - On 12/4/23, for OT services to be provided everyday fivetimes a week for four weeks for therapeutic exercises, therapeutic activities, neuromuscular reeducation, and self-care training effective 12/2/23. Review ofResident 1's PT Missed Visit Details showed Resident 1 refused the PT services despite multiple attempts and encouragement on 12/6, 12/7, 12/8, 12/9, 12/12, and 12/13/23. Review ofResident 1's OT Missed Visit Details showed Resident 1 refused the OT services on 12/6, 12/7, 12/8, 12/11, 12/12, and 12/13/23. Further review of Resident 1's closedmedical record did not show the physician notification of Resident 1's multiple refusal of the PT and OT services. In addition, review of Resident 1's Care Plan did not show the care plan problem was developed to address Resident 1's multiple refusal of the PT and OT services. On 3/13/24 at 1110 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with PhysicalTherapist 1. Physical Therapist1 verified the above findings and stated Resident 1's PT and OT services were terminated after 2/13/24, due to frequent refusal of the PT and OT services. However, PhysicalTherapist 1 was not able to find the documentation if the physician was notified regarding Resident 1's multiple refusal of treatments before the termination of the PT and OT services. On 3/13/24 at 1315 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the Rehabilitation Director. The Rehabilitation Director verified the above findings and stated the physician should have been notified when Resident 1 refused PT and OT services multiple times. The Rehabilitation Director further stated the care plan should have been revised to address Resident 1's frequent refusal of the PT and OT services. On 3/13/24 at 1436 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Feb 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical record for one of four final sampled residents (Resident 1). * The facility failed to ensure the licensed nurse documented the initials in the MAR when the medications were administered to Resident 1. * The facility failed to document when Resident 1 went out on pass and returned to the facility. * The facility failed to ensure the weekly skin/wound assessments were completed weekly in December 2023 for Resident 1. These failures had the potential for the resident's care not being met as the clinical information were not complete. Findings: Review of the facility's P&P titled Medication-Administration revised 1/2012 showed the licensed nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the Medication Administration Record (MAR). Review of the facility's P&P titled Out on Pass revised 1/2016, under the Licensed Nurse section, showed (B) a licensed nurse will document the provision of medications to the resident for use while out on pass (if applicable), the time the resident left the facility, the name of the accompanying responsible person as indicated, destination, contact phone number if possible, and expected time of return. (C) When the resident returns to the facility, a licensed nurse will re-assess the resident to determine the resident's condition and account for any medications returned after going out on pass, if applicable. Review of the facility's P&P titled Pressure Injury and Skin Integrity Treatment revised 8/2016 showed a Skin Integrity Progress Report will be initiated when a resident is admitted with or develops a skin problem such as skin tear, excoriation, rash, surgical wound, discoloration, burn or other skin condition. The Skin Problem Progress Report will be updated weekly by the licensed nurse. Medical record review for Resident 1 was initiated on 1/31/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 was cognitively intact. a. Review of Resident 1's MAR for December 2023 showed the following medications were scheduled to be administered on 12/24/23: * At 0800 hours: - metoprolol tartrate (use to lower blood pressure) oral tablet 100 mg one tablet by mouth two times a day for hypertension, and - pro-stat sugar free (use to increase protein needs) oral liquid (Amino Acids-Protein Hydrolysate) 30 ml by mouth two times a day for supplement. * At 0900 hours: - ascorbic acid (vitamin supplement) tablet 500 mg one tablet by mouth one time a day, - aspirin EC (enteric coated) tablet delayed release 81 mg one tablet by mouth one time a day for CVA (Cerebrovascular Accident) prophylaxis, - buproprion HCl ER (Extended Release) (antidepressant medication) 150 mg by mouth one time a day, - multivitamin oral tablet by mouth one time a day for supplement, - oxybutin chloride ER (use to treat symptoms of overactive bladder) oral tablet 5 mg give three tablets by mouth one time a day for neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), and - vitamin D3 (vitamin supplement) oral tablet 50 mcg one tablet by mouth one time a day. However, further review of Resident 1's MAR for December 2023 showed the spaces for licensed nurses' initials were left blank for the above medications on 12/24/23. On 2/14/24 at 1054 hours, a telephone interview was conducted with LVN 3. LVN 3 stated she worked on 12/24/23, and was Resident 1's assigned nurse for the 3-11 shift. LVN 3 further stated the scheduled 0900 hours medications on 12/24/23, were given to Resident 1 before leaving the facility. LVN 3 stated Resident 1 always asked for his medications before leaving the facility. When asked about how the LVN documented on the MAR when the medications were given, LVN 3 stated there was an option in the electronic MAR to click for additional documentation. LVN 3 verified Resident 1's MAR for December 2023 showed the documentation for 12/24/23 at 0800 and 0900 hours, for the above medications scheduled were missed. LVN 3 further stated if the MAR did not have documentation, the nurses should have documented in the resident's progress notes as late entry. On 2/14/23 at 1115 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the MAR should be signed by the nurses after giving the medications. The DON stated if the MAR was not signed, the nurse should document in the resident's progress notes. The DON verified the 0800 and 0900 hours medications were not signed by the nurse and there was no documentation in the resident's progress notes. b. Review of Resident 1's Order Summary Report showed a physician's order dated 9/19/23, to may go out on pass with supervision and medications. Review of Resident 1's plan of care showed a care plan problem dated 12/13/23, addressing the resident's non-compliant/goes out on pass for more than four hours. Review of Resident 1's Nursing Progress Notes dated 12/29/23, showed Resident 1 returned from an acute care hospital with a physician's order for Macrobid (antibiotic) oral capsule 100 mg two times a day for UTI for 10 days. Review of Resident 1's MAR for December 2023 showed the Macrobid medication was not administered to Resident 1 on 12/29/23 at 1700 hours. Chart code 1 was documented on the MAR for the Macrobid medication, which meant the resident was absent from the facility without medications. Further review of the medical record showed no documented evidence when the resident went out on pass and returned to the facility on [DATE]. On 1/31/24 at 1527 hours, an interview and concurrent medical record review was conducted with RN 1. When asked if Macrobid was given on 12/29/23 at 1700 hours, RN 1 stated Macrobid was not given to Resident 1 because he was maybe out on pass. On 2/1/24 at 1125 hours, a follow-up interview was conducted with RN 1. RN 1 was asked for the facility's process for the residents who were out on pass. RN 1 stated the residents signed the logbook for out on pass, then the nurse should initial in the logbook when the resident left and returned. RN 1 stated if a resident missed the medication while out on pass, the nurse should administer the medication upon returning to the facility, depending on what the medication was for. Furthermore, RN 1 stated it should be documented in the resident's progress notes for the late administration of the medication. On 2/1/24 at 1140 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON verified there was no documentation if Resident 1 was out on pass on 12/29/23 at 1700 hours. The DON further stated the December 2023 Out on Pass logbook could not be found. On 2/14/24 at 1327 hours, a follow-up interview was conducted with the DON. The DON stated the nurse from a registry company was working the 3-11 shift on 12/29/23. The DON was asked for the facility's process for the residents who were out on pass. The DON stated the resident should sign the out of pass logbook, then nurse should sign when the resident left the facility and when the resident came back from the outing. Furthermore, the DON stated the nurse should assess the resident coming back from the outing and if there were any medications that were missed, the medications should be given, if it could still be given. c. Review of Resident 1's plan of care showed a care plan problem dated 9/19/23, addressing Resident 1's sacrococcyx MASD and another care plan problem dated 12/20/23, addressing Resident 1's MASD to the right buttock. Review of Resident 1's TAR for December 2023 showed the following wound treatments: - dated 11/30/23, to cleanse MASD at the left buttock with NS (normal saline), pat dry, apply zinc oxide, then cover with a dry dressing every day shift for two weeks, starting on 11/30/23, and ending on 12/13/23, and - dated 12/19/23, to cleanse sacrococcyx extending to the right and left buttocks MASD with NS, pat dry, then apply triad ointment (a topical corticosteroid), and cover with a foam dressing every day shift for 14 Days. However, review of Resident 1's Weekly Skin/Wound Assessment - V2 for December 2023 showed the skin assessments were completed only on 12/16 and 12/19/23, instead of weekly as per the facility's P&P. On 1/31/24 at 1527 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 confirmed the weekly skin assessments were not done weekly for Resident 1 for December 2023. On 1/31/24 at 1622 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the treatment nurse was to complete the weekly skin assessments for the residents with skin problems and verified Resident 1's wound assessments were not done weekly for December 2023.

Jan 2024 1 deficiency

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Infection Control (Tag F0880)

Minor procedural issue · This affected multiple residents

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Based on observation, interview, and facility P&P review, the facility failed to ensure the hand hygiene practices were performed as per the facility ' s P&P. This failure posed the risk of spreading infectious organism to residents in the facility. Findings: Review of the facility ' s P&P titled Hand Hygiene revised 2/2023 showed the alcohol-based hand hygiene products can and should be used to decontaminate hands: - immediately upon entering a resident occupied area (single or multiple bedrooms, procedure or treatment room) regardless of glove use; - immediately upon exiting a resident occupied area (before exiting into a common area such as a corridor) regardless of glove use; - before moving from one resident to another in a multiple-bed room or procedure area regardless of glove use. On 12/28/23 at 1025 hours, CNA 1 was observed distributing water from Room A to Room B without performing hand hygiene in between Rooms A and B. On 12/28/23 at 1031 hours, an interview was conducted with CNA 1. CNA 1 stated she did not perform hand hygiene in between the rooms. On 12/28/23 at 1059 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 was observed going inside Resident 1 ' s room without performing hand hygiene. LVN 1 later stepped out of Resident 1 ' s room without performing hand hygiene. LVN 1 verified this finding. On 12/28/23 at 1522 hours, an interview was conducted with the DON. The DON verified the above findings. The DON further stated hand hygiene should be observed to prevent spread of infection.

Nov 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) received the pain medication as prescribed in accordance with physician ' s orders. * Resident 1 had a physician ' s order for oxycodone-acetaminophen (a narcotic medication used to treat pain) 5-325 mg two tablets by mouth every four hours as needed for moderate pain; however, Resident 1 received the medication on multiple occasions outside of the ordered parameters. This failure had the potential for Resident 1 to not have their pain adequately addressed and adverse effects. Findings: Review of the facility ' s P&P titled Pain Management revised date 11/2016showed the following: - The licensed nurse will administer pain medication as ordered; and - The licensed nurse will assess the resident for pain and document results on the Medication Administration Record (MAR) each shift using the 0-10 pain scale. Closed medical record review for Resident 1 was initiated on 11/7/23. Resident 1 was readmitted to the facility on [DATE], and transferred to the acute care hospital on [DATE]. Review of Resident 1 ' s Order Summary Report showed an order dated 10/4/23, for oxycodone-acetaminophen oral tablet 5-325 mg two tablets by mouth every four hours as needed for moderate pain. Review of Resident 1 ' s MAR dated October 2023 showed Resident 1 received oxycodone-acetaminophen 5-325 mg with the pain level outside of the parameters set by the physician on several occasions. For example, Resident 1 reported pain as follows: - On 10/5/23 at 0130, 0950, and 1400 hours, Resident 1 reported a pain level of 9 on a 0-10 pain scale (with 0 = no pain and 10 = worst pain). - On 10/6/23 at 0930 and 1342 hours, Resident 1 reported a pain level of 9. - On 10/9/23 at 0030 hours, Resident 1 reported a pain level of 9. - On 10/10/23 at 0630 and 1940 hours, Resident 1 reported a pain level of 9. - On 10/20/23 at 1743 hours, Resident 1 reported a pain level of 10. - On 10/30/23 at 0653 hours, Resident 1 reported a pain level of 10. On 11/7/23 at 1406 hours, an interview was conducted with LVN 2. LVN 2 was asked the facility ' s pain scale used to assess pain. LVN 2 stated they used a 0-10 numerical scale with 0 being the least level of pain and 10 beingthe highest. LVN 2 stated pain was classified as mild, moderate, or severe. When asked which numerical indicators were used for each group, LVN 2 stated mild pain was 1-4, moderate 5-7, and severe was 8-10. On 11/7/23 at 1409 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 was asked about the pain scale used to assess the residents ' pain levels. RN 1 stated the facility used a numerical scale of 0-10. RN 1 stated mild pain was 1-3, moderate was 4-6, and severe 7-10. When asked aboutthe process if a resident reported pain outside of the physician ' s ordered parameters, RN 1 stated the physician should be called and the order was clarified. RN 1 was asked to review Resident 1 ' s closed medical record. RN 1 reviewed Resident 1 ' s MAR and verified the above occasions when Resident 1 received the pain medication outside of the physician ' s orders.

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Comprehensive Care Plan (Tag F0656)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to develop the comprehensive person-centered care plan for one of four sampled residents (Resident 1). * Resident 1 consistently refused showers and hygiene care. The facility did not develop a care plan problem to address the refusal of care. This failure put Resident 1 at risk of not having their care needs met. Findings: Closed medical record review for Resident 1 was initiated on 11/7/23. Resident 1 was readmitted to the facility on [DATE], and transferred to the acute care hospital on [DATE]. Review of Resident 1 ' s Shower Day Skin inspection forms dated 10/6/23 and 10/28/23, showed Resident 1 refused to shower on her scheduled shower days. Review of Resident 1 ' s plan of care failed to show a care plan problem addressing Resident 1 ' s refusal to shower. On 11/7/23 at 1223 hours, an interview was conducted with LVN 1. LVN 1 was asked about care and services provided to Resident 1, specifically hygiene care. LVN 1 stated Resident 1 often refused treatments and showers. On 11/7/23 at 1243 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 1 would often refuse hygiene and would not let the staff change the linens on the bed. On 11/7/23 at 1420 hours, a telephone interview was conducted with CNA 2. CNA 2 stated Resident 1 would usually refuse everything, including hygiene care. CNA 2 stated he informed the charge nurse of the resident ' s refusal. On 11/7/23 at 1426 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 was asked about the process regarding a resident refusing care and services, RN 1 stated part of the process included to update the plan of care. RN 1 stated any licensed nurses could update the plan of care. RN 1 was asked to review Resident 1 ' s closed medical record and show evidence a care plan problem was developed for Resident 1 ' s refusal of care, including showers. RN 1 stated there was no care plan problem to address the refusal of care. On 11/8/23 at 1415 hours, a telephone interview was conducted with CNA 3. CNA 3 stated she was normally assigned to care for Resident 1 on the PM shift (1500 to 2300 hours). CNA 3 stated Resident 1 was assigned to have showers on the PM shift, but only accepted one time. CNA 3 stated she informed the charge nurse of the refusals.

Sept 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were administered in accordance with the standards of practice for one of four sampled residents (Resident 4). * Resident 4's medications were not administered in a timely manner as prescribed by the physician. This failure had the potential for medication errors and to negatively affect Resident 4's health conditions. Findings: Review of the facility's P&P titled Medication – Administration revised 1/1/12, showed it is the facility's policy to ensure the accurate administration of the medications for residents in the facility. The medications may be administered one hour before or after the scheduled medication administration time. Medical record review for Resident 4 was initiated on 9/14/23. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. On 9/14/23 at 1051 hours, an observation was conducted with Resident 4 in Room A. Resident 4 was observed sitting at the edge of the bed. A medicationcup filled with multiple tablets was observed at Resident 4's bedside. Resident 4 stated a nurse gave him the medications in a cup earlier in the morning. Review of Resident 4's Order Summary Report showed the physician's orders dated 8/9/23, for the following medications: - Bumex (medication used to treat fluid retention and high blood pressure) 1 mg one tablet by mouth one time a day - Catapres (medication used to treat high blood pressure) 0.1 mg one tablet by mouth three times a day - docusate sodium (medication used to treat constipation) 100 mg one capsule by mouth in the morning - escitalopram oxalate (medication used to treat depression) 10 mg one tablet one time a day - folic acid (medication used to treat anemia) 1 mg one tablet by mouth one time a day - hydralazine hydrochloride (medication used to treat high blood pressure) 25 mg by mouth two times a day - metoprolol tartrate (medication used to treat to treat high blood pressure) 50 mg one tablet by mouth two times a day - Multivitamin Adult (dietary supplement) one tablet by mouth one time a day - potassium chloride extended release (supplement used to treat or prevent low amounts of potassium in the blood) 20 mEq by mouth one time a day - thiamine hydrochloride (dietary supplement) 100 mg one tablet by mouth one time a day On 9/14/23 at 1058 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 verified a medication cup with multiple tablets was at Resident 4's bedside. LVN 1 stated Resident 4 should not have the medications left unattended at the bedside. LVN 1 further stated Resident 4's medications should have been administered on a timely manner (within an hour before and after the medications were scheduled to be administered) for the resident and other residents' safety. On 9/14/23 at 1103 hours, an interview was conducted with LVN 2. LVN 2 verified the medication cup with multiple tablets at Resident 4's bedside. When asked what the tablets were for, LVN 2 stated they were Resident 4's morning medications and should have been given at 0900 hours. LVN 2 stated he was with Resident 4 earlier and gave his medications, however, forgot to check if Resident 4 had taken his medications. On 9/14/23 at 1448 hours, a follow-up interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated the medications at the resident's bedside were all for Resident 4's morning medications. LVN 2 further stated Resident 4's medications should have been administered on a timely manner as prescribed by the physician. On 9/14/23 at 1459 hours, an interview was conducted with the ADON. The ADON was informed and acknowledged of the above findings. Cross reference to F761.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were stored properly for one of four sampled residents (Resident 4) when a medication cup filled with multiple tablets were observed at the bedside table in Resident 4's room. This failure had the potential for the residents, staff, and visitors to have access to the medication and unsafe administration of medications. Findings: Review of the facility's P&P titled Medication Storage in the Facility dated April 2008 showed the medications and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. Medical record review for Resident 4 was initiated on 9/14/23. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's Self-Administration of Medication form dated 7/18/23, showed Resident 4 was not capable to self-administer his medications. Further review of the medical record showed Resident 4 might not keep the medications at his bedside. Review of Resident 4's Order Summary Report showed the physician's orders dated 8/9/23, for the following medications: - Bumex 1 mg one tablet by mouth one time a day - Catapres 0.1 mg one tablet by mouth three times a day - docusate sodium 100 mg one capsule by mouth in the morning - escitalopram oxalate 10 mg one tablet one time a day - folic acid 1 mg one tablet by mouth one time a day - hydralazine hydrochloride 25 mg by mouth two times a day - metoprolol tartrate 50 mg one tablet by mouth two times a day - Multivitamin Adult one tablet by mouth one time a day - potassium chloride extended release 20 mEq by mouth one time a day - thiamine hydrochloride (dietary supplement) 100 mg one tablet by mouth one time a day On 9/14/23 at 1058 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 verified a medication cup with multiple tablets was at Resident 4's bedside. LVN 1 stated Resident 4 should not have themedications left unattended at the bedside. On 9/14/23 at 1103 hours, an interview was conducted with LVN 2. LVN 2 verified the medication cup with multiple tablets at Resident 4's bedside. When asked what the tablets were for, LVN 2 stated they were Resident 4's morning medications. LVN 2 stated Resident 4's medications should have not been left at bedside. On 9/14/23 at 1459 hours, an interview was conducted with the ADON. The ADON was informed and acknowledged of the above findings.

Apr 2023 26 deficiencies 1 IJ (1 facility-wide)

CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 4/17/23 at 1655 hours, during an observation and concurrent interview conducted with Resident 40 in his room, Resident 40 stated he was about to go outside to smoke. When asked if he held onto his smoking lighter and cigarette, Resident 40 pulled out two lighters and three boxes of cigarettes from his pouch. Resident 40 stated he had shared and lit cigarettes for other residents in the past. When asked if the staff members were present when he smoked outside, Resident 40 stated no. On 4/17/23 at 1702 hours, Resident 40 was observed smoking in the facility patio without staff supervision. On 4/18/23 at 0848 hours, an interview with Resident 40 was conducted. Resident 40 verified he smoked usually at 1000 and 1600 hours, at the smoking patio near the activities room. Resident 40 verified there were times when the residents were not supervised by the staff during their smoke breaks. In addition, Resident 40 stated the facility had smoking aprons, but the resident denied using it. Resident 40 verified his cigarettes and lighter were kept in his bedside drawer but stated the facility staff removed his cigarettes and lighter from his possession on 4/17/23, because the state surveyors were in the facility. Medical record review for Resident 40 was initiated on 4/18/23. Resident 40 was admitted to the facility on [DATE], with a BIMS score of 11 (8 to 12 means moderately cognitive impaired). Review of the MDS dated [DATE], showed Resident 40 was a current tobacco user. Review of the Smoking assessment dated on 11/29/21, showed Resident 40 had dexterity problems, preferred to smoke in the mornings and afternoon, could not light own cigarette, and needed the facility to store the lighter and cigarettes. In addition, the facility did not conduct a smoking safety evaluation until 4/17/23. On 4/18/23 at 0932 hours, a concurrent interview and record review for Resident 40 was conducted with LVN 6. LVN 6 verified Resident 40's care plan problem dated 1/29/20, showed the resident was a smoker, had some safety issues with using the lighters, and needed to wear an apron. LVN 6 also verified Resident 40's smoking assessment was last updated on 11/29/21, instead of quarterly and annually as per the facility's P&P; and the smoking safety evaluation was recently completed on 4/17/23. LVN 6 stated the admitting nurses completed a smoking assessment and evaluation for the residents who smoke. LVN 6 acknowledged the residents were not to have the cigarettes or lighters in their rooms or their possession. LVN 6 stated it was a safety concern. 6. On 4/18/23 at 0858 hours, an interview was conducted with Resident 87. Resident 87 verified he smoked at midnight and 0200 hours, unsupervised. Resident 87 denied wearing a smoking apron and stated he carried his lighter and cigarettes with him. Medical record review for Resident 87 was initiated on 4/8/23. Resident 87 was admitted on [DATE], with a BIMS score of 9 (score of 8 to 12 mean moderately impaired cognition). Review of the MDS dated [DATE], showed Resident 87 was a current tobacco user. Review of Resident 87's care plan problem dated 12/21/22, showed the resident had been observed to smoke periodically. The care plan did not include interventions related to smoking, monitoring of the resident while smoking, or the safekeeping of the smoking materials. Further review of Resident 87's medical record showed the facility did not conduct a smoking safety evaluation until 4/17/23, and the last smoking assessment was completed on 10/5/21. On 4/18/23 at 1123 hours, an interview was conducted with the Activities Director. The Activities Director stated she was not aware of anyone smoking late at night and stated if there was a resident who wanted to smoke outside of smoking times, they could do so with staff supervision. The Activities Director was informed of the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for seven of seven smoking residents (Residents 40, 52, 55, 62, 73, 87, and 529) who smoked in the facility and one nonsampled resident (Resident 82) who was at risk for falls. 1. The facility failed to ensure the safe smoking practices were followed for seven residents (Residents 40, 52, 55, 62, 73, 87, and 529) who smoked in the facility as evidenced by: - The residents were not accurately and thoroughly assessed and reassessed to determine if they required supervision or any adaptive safety equipment while smoking, nor if they could safely store their own cigarettes or lighters. - The facility failed to ensure the IDT had reviewed and discussed the evaluation of the data gathered in the Resident Smoking Assessment. - The residents who were assessed as required adaptive safety equipment, such as smoking apron (a fireproof apron that protects the resident's body, clothing, and wheelchair from smoking-related injuries), were not provided with the adaptive safety equipment while smoking. - The residents who were assessed as requiring supervision while smoking or those with a history of non-compliance with the facility's smoking P&P were permitted to keep their cigarettes, lighters, and other smoking articles/materials in their possessions. - The facility failed to address safe storage and use of the smoking articles. - The facility failed to ensure individualized care plan problems were developed to address the resident's safe smoking practices. - The residents were permitted to share smoking articles with the other residents. 2. The facility failed to ensure safe environment for one nonsampled resident (Resident 82) who was at risk for fall and liked to keep the bed in high position to watch TV. These failures posed the risk of fire and serious injuries to the residents who smoked and to the residents who resided in the facility. On 4/19/23 at 0946 hours, the Administrator and DON were informed an IJ situation was identified due to the facility's failure to ensure safe smoking practices were followed for seven of seven residents (Residents 40, 52, 55, 62, 73, 87, and 529) who smoked in the facility as evidenced by: * The residents were not accurately and thoroughly assessed and reassessed to determine if they required supervision or any adaptive safety equipment while smoking, nor if they could safely store their own cigarettes or lighters. * The residents who were assessed as requiring adaptive safety equipment, such as a smoking apron (a fireproof apron that protects the resident's body, clothing, and wheelchair from smoking-related injuries), were not provided with the adaptive safety equipment while smoking. * The residents who were assessed as requiring supervision while smoking or those with a history of non-compliance with the facility's smoking P&P were permitted to keep the cigarettes, lighters, and other smoking articles/materials in their possession. * The facility failed to address safe storage and use of the smoking articles. * The facility failed to ensure the individualized care plan problems were developed to address the residents' safe smoking practices. * The residents were permitted to share smoking articles with the other residents. On 4/20/23 at 1156 hours, the IJ was abated after the facility submitted a plan of corrective actions: * Conducted accurate and thorough assessments for all residents who smoked in the facility. * Developed and/or revised the care plan problems for seven smoking residents (Residents 40, 52, 55, 62, 73, 87, and 529) to address safe smoking practices. * In-serviced all staff on the facility's smoking P&P and safety measures related to smoking. * Implemented a supervised smoking schedule and ensured all resident who required adaptive equipment were provided with the equipment while smoking. * Ensured the residents who required supervision were not permitted to keep the cigarettes, lighters and other smoking articles in their possession. * Secured the smoking articles in a box container and kept in a locked area. * Educated the residents who smoked on the facility's smoking P&P and safe smoking practices. * Ensured a log was utilized for smoker residents to reflect the smoking needs for each resident who smoked, which will be included with the smoking materials and nursing assignment book. Findings: Review of the facility's P&P titled Smoking by Residents Nursing Manual-Resident Rights revised January 2017 showed the following: - The facility is to provide a safe environment for residents, staff, and visitors. - The facility will accommodate the residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting non-smoking residents. - Resident and their families/responsible parties are informed of this policy prior to or during the admission process and care conferences. - Smoking by residents is allowed outside the facility in designated, marked smoking areas with following safety measures readily available: ashtrays made of noncombustible material and safe design; metal containers with self-closing covers into which ashtrays can be emptied, portable fire extinguisher, and fire-retardant blanket (smoking blanket). - The facility may develop a smoking schedule to ensure a safe environment. - Using the Resident Smoking Assessment (NP-132-Form A), the Licensed Nurse will assess the residents who express the desire to smoke, upon admission, quarterly, annually, and upon significant change of condition identification, and present it to the Interdisciplinary Team (IDT) for review. - The IDT, consisting of, but not limited to, a licensed nurse, Social Services Designee, Activities Director, MDS Nurse, and/or Rehab representative, using the Resident Smoking Assessment (NP-132-Form A), will review the resident assessment, completed by the licensed nurse, who express the desire to smoke, for safety at minimum at the following intervals: when a resident initially expresses the desire to smoke, upon admission, quarterly, annually, and upon significant change of condition identification. - As identified by the Smoking Assessment, the residents who require assistance and/or monitoring for smoking safety are not allowed to smoke unaccompanied. - The IDT will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision, if necessary, for residents who smoke. This is documented on the Resident Smoking Assessment (NP-132-Form A) and resident's Plan of Care, and discussed with the resident and Responsible Party at the resident care conference meeting. - The resident and/or Responsible Party will be educated regarding the risks of smoking and the smoking safety measures developed by the IDT. This will be documented in the resident's clinical record. 1. On 4/17/23 at 1657 hours, Resident 62 was observed sitting up in his wheelchair in his room. Resident 62 stated he was a smoker and kept his own cigarettes and lighter. Resident 62 reached in his jacket pockets and pulled out a pack of cigarettes, a lighter, and a container with a half-used cigarette inside. Medical record review for Resident 62 was initiated on 4/17/23. Resident 62 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 62's MDS dated [DATE], showed Resident 62 was cognitively intact. Review of Resident 62's Smoking Safety Evaluation dated 6/13/22, showed Resident 62 required supervision while smoking and Resident 62 did not follow the facility's policy on location and time of smoking. However, the assessment did not specify if Resident 62 may keep his own smoking materials or required a smoking apron. Review of Resident 62's plan of care showed a care plan problem dated 3/22/23, addressing Resident's 62's smoking. The care plan problem showed Resident 62 was an identified as a smoker. The care plan failed to address the safe storage and use of Resident 62's smoking materials. Further review of Resident 62's medical record failed to show documentation of Resident 62's education in the facility's smoking P&P and safe smoking practices. There was no documentation to show there was an IDT conference conducted discussing the evaluation of the data gathered in Resident's 62's Resident Smoking Assessment as per the facility's P&P. On 4/17/23 at 1700 hours, an interview was conducted with the DON. The DON stated they encouraged the residents to give up their cigarettes and lighters, but the residents were noncompliant. The DON stated preferably for the residents not to keep their own smoking materials. The DON verified the above findings. On 4/18/23 at 1522 hours, an interview was conducted with MDS Nurse 1. MDS Nurse 1 verified the care plan problem for smoking did not specify Resident 62 may keep his own smoking material. MDS Nurse 1 stated it was important to revise the plan of care to provide appropriate care to the resident. On 4/19/23 at 0905 hours, an interview was conducted with Resident 62. Resident 62 was upset. Resident 62 stated he knew what he was doing regarding his smoking. Resident 62 stated he had been smoking in the facility since he was admitted and had not been supervise before while he was smoking. Resident 62 refused to provide information about his smoking materials. 2. On 4/17/23 at 1655 hours, Resident 73 was observed sitting up in his wheelchair in the dining room. Resident 73 stated he was a smoker and kept his own cigarette and lighter. Resident 73 reached to his pockets and pulled out a pack of cigarettes and a lighter. On 04/17/23 at 1710 hours, during an observation, Resident 73 was observed smoking in the facility patio without staff supervision. When asked if he was aware of the facility's smoking schedule, Resident 73 stated he did not follow the smoking schedule. When asked if the facility's staff follow him to the patio to watch him smoke, Resident 73 stated, They don't follow me. They don't care about us! Resident 73 was further observed pulling out his black lighter and lighting his own cigarette. Resident 73 stated he kept his lighters and cigarettes with him. He stated he also shared lighters and cigarettes with other residents in the past. When asked if the staff had ever taken away his smoking materials, he stated no. Resident 73 was then observed putting out his hot cigarette butt on his wheelchair. Medical record review for Resident 73 was initiated on 4/17/23. Resident 73 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 73's MDS dated [DATE], showed Resident 73's cognition was moderately impaired. Review of Resident 62's Smoking Safety Evaluation dated 8/24/22, showed Resident 73 required supervision while smoking and Resident 73 did not follow facility's policy on location and time of smoking. However, the assessment did not specify if Resident 62 may keep his own smoking materials or required a smoking apron. Review of Resident 73's Smoking Assessment v2-2014-RHCA dated 12/12/21, showed Resident 73 had a visual deficit and Resident 73 needed the facility to store the resident's lighter and cigarette. Review of Resident 73's plan of care showed a care plan problem revised 1/5/23, addressing Resident's 73's smoking. The care plan problem showed Resident 73 was an identified as a smoker. The care plan problem failed to address safe storage and use of Resident 73's smoking materials. Further review of Resident 73's medical record failed to show documentation of Resident 73's education in the facility's smoking P&P and safe smoking practices. Also, there was no documentation to show there was an IDT conference conducted discussing the evaluation of the data gathered in Resident's 73's Resident Smoking Assessment as per the facility's P&P. On 4/18/23 at 1607 hours, an interview was conducted with the Activities Director. The Activities Director was asked where the smoking materials of the residents were kept. The Activities Director pulled out a clear box container from her office cabinet that contained boxes of cigarettes and lighter. However, the Activities Director verified none of the smoking materials belonged to the current smoking residents in the facility. 3. On 4/17/23 at 1650 hours, Resident 52 was observed smoking cigarette in the patio not wearing an apron and with no staff supervision. Resident 52 stated, I always smoke here in the patio by myself or with other residents and keeps cigarette and lighter with me. On 4/17/23 at 1702 hours during an observation, Resident 52 was observed smoking in the facility patio without a staff supervision. Medical record review for Resident 52 was initiated on 4/17/23. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's H&P examination dated 6/21/22, showed Resident 52 was an oxygen dependent. Review of Resident 52's Smoking Safety Evaluation dated 10/10/22, showed the supervision will be required for all residents during designated smoking times. Review of Resident 52's MDS dated [DATE], showed Resident 52 had no cognitive impairment. Review of Resident 52's plan of care showed a care plan problem dated 4/14/23, addressing Resident 52's smoking. The care plan failed to address the safe storage and use of Resident 52's smoking materials. Cross reference to F656, example #4. On 4/18/23 at 1610 hours, Resident 52 was observed smoking in the patio by herself with no staff supervision and not wearing an apron. Resident 52 stated, I smoked whenever I want, and keep cigarette and lighter with me all the time. On 4/18/23 at 1715 hours, interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. The DON verified Resident 52's care plan problem failed to address safe storage and use of smoking materials. 4. Medical record review for Resident 55 was initiated on 4/17/23. Resident 55 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 55's Smoking Safety Evaluation dated 9/22/22, showed the supervision will be required for all the residents during the facility's designated smoking times. Review of Resident 55's plan of care showed a care plan problem dated 1/6/23, showed Resident 55 was an independent smoker. The care plan failed to address the safe storage and use of Resident 55 's smoking materials. Cross reference to F656, example #5. Review of Resident 55's MDS dated [DATE], showed Resident 55 had a BIMS Score of 14 which meant the resident was cognitively intact. On 4/17/23 at 1545 hours, an observation and concurrent interview was conducted with Resident 55. Resident 55 was observed lying in bed. Resident 55 stated he just got back from smoking. Resident 55 stated he kept his cigarettes and lighter and showed the smoking materials inside his sweater. On 4/18/23 at 0931 hours, an interview was conducted for Resident 55 with LVN 6. LVN 6 stated Resident 55 was a smoker, alert, independently went to smoke in the patio, did not require staff supervision during smoking, and kept his own smoking paraphernalia. LVN 6 verified Resident 55 was a smoker and kept his smoking paraphernalia in his own possession. On 4/18/23 at 1515 hours, an interview was conducted with the DON. The DON verified Resident 55 currently had in possession of his cigarettes and lighter. The DON verified the above findings. 7. On 4/17/23 at 1652 hours, Resident 529 was observed in her room and lying in bed, pointed to the pillow on top of her wheelchair, and stated to look underneath; and two pieces of cigarettes and a lighter were observed underneath the pillow. Medical record review for Resident 529 was initiated on 4/17/23. Resident 529 was admitted to the facility on [DATE]. Review of Resident 529's admission MDS dated [DATE], showed Resident 529 was cognitively intact. In addition, Section J Health Conditions showed tobacco used was coded as no which was inaccurate. Cross reference to F641. Further medical record review of Resident 529 failed to show the smoking assessment and documentation of Resident 529's education on the facility's smoking P&P and safe smoking practices. Also, there was no care plan and no documentation to show an IDT conference was conducted to discuss the evaluation of the data gathered in Resident's 529's Smoking Safety Evaluation as per the facility's P&P, until 4/17/23. Review of Resident 529's Smoking Safety Evaluation dated 4/17/23, showed Resident 529 followed the facility's policy on location and time of smoking. However, the assessment for supervision was left blank and did not specify if Resident 529 may keep her own smoking materials or required a smoking apron. Review of Resident 529's plan of care showed a care plan problem dated 4/17/23, addressing Resident's 529's smoking. The care plan focus showed Resident 529 was an identified as a smoker. The care plan problem failed to address the use of adaptive safety equipment for Resident 529. On 4/17/23 at 1656 hours, an interview with concurrent medical record review was conducted with the DON. The DON stated they encouraged the residents to give up their cigarettes and lighters, but the residents were noncompliant. The DON verified Resident 529 did not have a Resident Smoking Assessment and comprehensive care plan. On 4/20/23 at 1504 hours, an interview with concurrent medical record review was conducted with MDS Nurse 1. MDS Nurse 1 verified the above findings and stated the MDS was inaccurately coded. MDS Nurse 1 stated Resident 529 was assessed for smoking on 4/17/23, and she was not aware when Resident 529 started smoking. MDS Nurse 1 stated it was important to modify the MDS to provide the appropriate care to the resident. On 4/20/23 at 1629 hours, an interview was conducted with the DON. The DON verified the findings and stated accurate assessment and care plan were important to provide appropriate care to the resident. 8. Review of the facility's P&P titled Fall Management Program dated 3/13/21, showed the facility will implement a fall management program that supports providing an environment free from fall hazards. For fall risk evaluation, as a part of the admission Assessment, the license nurse will complete a fall risk evaluation. If a fall risk factor is identified, document interventions on the Resident's care plan; and to document interventions for every resident regardless of fall risk evaluation score. Medical record review for Resident 82 was initiated on 4/17/23. Resident 82 was admitted to the facility on [DATE]. Review of the H&P examination dated 9/11/22, showed Resident 82 has increased generalized weakness and limited ROM. Review of the Fall Risk Evaluation for Resident 82 dated 2/7/23, showed the resident had intermittent confusion and was at risk for fall. Review of Resident 82's care plan problem dated 11/23/22, showed the resident was at risk for fall related to psychoactive drug use, diabetes mellitus, history of falls, weakness, forgetfulness, Parkinson, tremors, and ataxic gait. The interventions included to follow the facility's fall protocol, review the information on the past fall, attempt to determine the cause of falls, record the possible root causes, alter remove any potential causes if possible, and educate the resident /family/caregivers/IDT as to the causes. On 4/17/23 at 0830 hours, Resident 82 was observed sitting up in the bed elevated to a high position above the floor and the head of the bed at 60 degrees. There was no floor mattress observed. Resident 82 was asked why his bed was high and how long the bed was in a high position. Resident 82 stated he could see the TV closely, so he needed to raise his bed. On 4/17/23 at 1250 hours, Resident 82 was eating his meal and watching TV in the high position bed. On 4/19/23 at 1030 hours, LVN 6 was summoned to the room. LVN 6 asked Resident 82 why his bed was in a high position. Resident 82 stated he wanted to watch the TV closer. LVN 6 lowered the resident's bed down with the resident's permission. LVN 6 acknowledged there were no floor mattress observed. On 4/19/23 at 1045 hours, an observation and concurrent interview was conducted with LVN 6. LVN 6 stated the resident noncompliance and like to raise the bed. LVN 6 was asked if she knew and asked the resident what the reason for Resident 82 to like his bed in a high position. LVN 6 was not aware of the reason why the resident liked the high position bed. LVN 6 was asked to provide the documentation if the resident was noncompliant or any other intervention to address the resident's needs for his TV adjustment or preventing fall from the high position bed. LVN 6 was unable to provide the documentation. On 4/19/23 at 1110 hours, an interview was conducted with CNA 1. CNA 1 was asked if he was aware of Resident 82's high position bed. CNA 1 stated Resident 82 liked the bed in a high position so he could watch the TV better. No floor mattress had been in placed per the CNA. CNA 1 stated the charge nurse had been informed about Resident 82's high position bed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 101) participated in the development and planning of their care. * Resident 101 was not invited to participate in the care plan conference. This posed the risk of violating Resident 101's rights in choosing the treatment options and making the decisions in care planning. Findings: Review of the facility's P&P titled Resident Rights Operational Manual-Resident Rights revised 1/1/12, showed the facility will promote and protect those rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety. Review of the facility's P&P titled Comprehensive Person-Centered Care Planning Nursing Manual- General, undated, showed the facility must provide the resident and representative, if applicable, reasonable notice of care planning conferences to enable resident and representative participation. Participation in care planning for both parties, if applicable, can be done via conference call, videoconferencing, etc. The facility will notify the resident and his or her representative, as applicable, of the care planning meetings and use its best efforts to schedule care planning at times convenient for the resident and representative. The care planning meeting will be documented on NP-04-Form A-IDT Conference Record. On 4/17/23 at 0936 hours, during an initial tour, Resident 101 stated she did not know the reason why she was in the facility, wanted to go home, wanted more therapy, and had not participated in a care plan conference. Medical record review for Resident 101 was initiated on 4/17/23. Resident was admitted to the facility on [DATE]. Review of Resident 101's H&P examination dated 11/5/22, showed Resident 101 had the capacity to understand and make decisions but fluctuated. Review of Resident 101's Social Services Note dated 4/13/23, showed the resident's family member called and he was aware of Resident 101's request for a care plan meeting, but he felt that the care plan meeting was unnecessary. Review of Resident 101's Multidisciplinary Care Conferences dated 11/3/22 and 1/30/23, did not show if Resident 101 or Resident 101's responsible parties had attended or participated in the care plan meeting. On 4/20/23 at 1210 hours, an interview was conducted with the ADON. The ADON stated Resident 101 was responsible for herself along with her family member. The ADON stated Resident 101 could make her needs known and understand. The ADON stated if Resident 101 requested for a care plan conference, he would set up a scheduled appointment with the Social Services department to discuss Resident 101's concerns. On 4/20/23 at 1236 hours, an interview and concurrent medical record review was conducted with the SSA. The SSA stated Resident 101 spoke to the Ombudsman requesting for a care plan conference with Resident 101's family member. The SSA stated she was informed to call Resident 101's family member. However, the SSA received a call from Resident 101's family member who stated the care plan conference was unnecessary. The SSA verified she was aware of Resident 101's request to schedule a care plan conference. However, the SSA stated she did not visit nor communicated to Resident 101 regarding the care plan conference. The SSA confirmed the Multidisciplinary Care Conference documents did not specify if Resident 101 or her responsible party attended the care conference and were incomplete. The SSA stated the care plan conferences were important to make the residents aware of their overall care. On 4/20/23 at 1520 hours, an interview and concurrent medical record review was conducted with MDS Nurse 1. MDS Nurse 1 stated the care plan conferences should be scheduled upon admission, quarterly, annual, significant changes, or as needed. MDS Nurse 1 verified the above findings.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 48) who was not a candidate for self-administered medication had an ointment medication at the bedside and self-administered it. * Resident 48 pulled out an Aquaphor Itch Relief Ointment (anti-itch ointment) from her drawer which she self-administered to her feet. Resident 48's Self-Administration of Medication Assessment showed Resident 48 was not a candidate for self-administration of medication. Resident 48 did not have a physician's order to self-administer the Aquaphor Itch Relief Ointment. This failure had the potential for poor health outcomes to Resident 48. Findings: Review of the facility's P&P titled Medication- Self Administration Nursing Manual- General revised 12/1/12, showed all self-administered medication will have pharmacy labels with complete directions for use of the medication. No labels may read as directed. Non-prescription (over the counter OTC) medications may be allowed if the medical label is intact. Residents will be reevaluated for the ability to self-administer medications at least quarterly and as needed. The physician's order approving the self-administration of medication will be maintained in the resident's medical chart. The Assessment of Self Administration of Medication will be maintained in the resident's chart. Self-administration of medications will be documented in the resident's Care Plan and the Medication Administration Record. On 4/19/23 at 1119 hours, an observation and concurrent interview was conducted with Resident 48. Resident 48 pulled out an Aquaphor Itch Relief Ointment from her drawer to show to the treatment nurse. Resident 48 was asked what she used the Aquaphor ointment for and she stated she applied the ointment to the skin on her feet for itchiness. Medical record review for Resident 48 was initiated on 4/17/23. Resident 48 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 48's MDS dated [DATE], showed Resident 48's cognition was moderately impaired. Review of Resident 48's Physician's Order Summary Report for March and April 2023 did not show orders for Aquaphor Itch Relief Ointment nor if Resident 48 may self-administer medication. Review of Resident 48's Self-Administration of Medication assessment dated [DATE], showed Resident 48 was not a candidate for self-administration. Review of Resident 48's plan of care failed to show a care problem for Resident 48's self-administration of medication or the use of the Aquaphor Itch Relief Ointment. On 4/19/23 at 1123 hours, an observation, interview, and concurrent medical record review was conducted with LVN 8. LVN 8 was observed taking the Aquaphor ointment from Resident 48. LVN 8 told Resident 48 that the resident was not allowed to have the Aquaphor ointment at her bedside and she had to take the Aquaphor ointment away and make the physician aware to obtain an order for it. LVN 8 verified Resident 48 did not have an order nor a care plan for Aquaphor Itch Relief Ointment. On 4/19/23 at 1157 hours, an interview and a concurrent medical record review was conducted with RN 1. RN 1 verified the above findings and stated Resident 48 was not a candidate for self-administration of medications based on the Self-Administration of Medication Assessment completed on 9/24/19.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 777 was initiated on 4/17/23. Resident 777 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 777's H&P examination dated 4/17/23 showed Resident 777 had the capacity to understand and make decisions. On 4/21/23 at 1004 hours, an interview was conducted with Resident 777. Resident 777 stated during the evening shift of the day prior, the staff took one and a half hours to help him get changed. Resident 777 stated he was feeling frustrated because he pressed the call light and two different staff came in at different times, asked him what he needed, turned off the call light, then stated they would call Resident 777's CNA to come and change him. 4. During an initial tour of the facility on 4/17/23 at 0931 hours, an interview was conducted with Resident 782. Resident 782 stated it took a lot of time for staff to attend to her and she could not get help when she needed it. Resident 782 stated she called for help earlier at 0630 hours, because she had soiled her diaper with urine and feces. Resident 782 stated she did not get changed because the staff were changing shifts. When Resident 782 asked to be changed again, the staff stated they would change her after the breakfast trays were passed to the other residents. Resident 782 stated she did not get her diaper changed until 0900 hours, and waiting that long did not make her feel good. Resident 782 stated she was left in her soiled diaper for hours every day. Medical Record Review for Resident 782 was initiated on 4/20/23. Resident 782 was admitted on [DATE], and readmitted on [DATE]. Review of Resident 782's MDS dated [DATE], showed Resident 782 was cognitively intact and required extensive assistance of two staff for bed mobility and toileting. On 4/19/23 at 0834 hours, an interview was conducted with CNA 3. CNA 3 stated the facility had been short of staff and acknowledged it was very difficult to attend to all her residents on time when there was less staff. On 4/19/23 at 1124 hours, an interview was conducted with CNA 4. CNA 4 stated the facility was sometimes short of CNAs. CNA 4 stated sometimes he was unable to get to his call lights right away because of how many residents he had. 5. Medical record review for Resident 779 was initiated on 4/17/23. Resident 779 was admitted to the facility on [DATE]. Review of Resident 779's H&P examination dated 4/7/23 showed Resident 779 had the capacity to understand and make decisions. On 4/18/23 at 1059 hours, an observation and concurrent interview was conducted with Resident 779. Resident 779 was observed lying in his bariatric bed. Resident 779's bariatric bed was observed to have blankets being used as sheets to cover the mattress. Resident 779 stated he had the bariatric bed since he was admitted to the facility and the facility told him that they did not have a proper fitted sheet for the mattress and would need to order it. Resident 779 stated he and his family member told the staff regarding the need for a fitted sheet, but the facility still did not have it. Resident 779 stated not having a fitted sheet on the bed made him feel uncomfortable, sweaty, and nasty. On 4/19/23 at 0834 hours, an interview was conducted with CNA 3. When asked about the fitted sheets for Resident 779's bariatric bed, CNA 3 stated the fitted sheets that they had in stock did not fit Resident 779's current bed. CNA 3 stated she had never heard of fitted sheets that big. On 4/19/23 at 1129 hours, a concurrent interview and observation was conducted with the Housekeeping Supervisor. The Housekeeping Supervisor stated the housekeeping was responsible for ordering the fitted sheets for the bariatric bed, and the bariatric sheets had been in stock for a couple of weeks in the laundry room. The Housekeeping Supervisor stated the CNAs could request the sheets from her; however, no CNAs had requested for the fitted sheets. An observation of Resident 779's bed was conducted with the Housekeeping Supervisor. The Housekeeping Supervisor acknowledged the blankets on Resident 779's bed were not the appropriate sheets and stated she would get him the correct fitted sheets. On 4/19/23 at 1135 hours, a follow-up interview was conducted with CNA 3. CNA 3 stated she had tried their regular fitted sheets, but they did not fit on Resident 779's mattress. CNA 3 verified she did not ask the housekeeping if they had the correct fitted sheet in stock and did not know that it was in stock in the laundry room. 6. On 4/17/23 at 0936 hours, an interview with Resident 727 was conducted. Resident 727 stated she used the call light to request for pain medications or position changes. Resident 727 stated she had an episode of waiting for one hour before her call light was answered and verified she looked at the clock on the wall to check how long the staff took to answer the call light. Review of Resident 727's care plan problem for falls dated 4/10/23, showed an intervention to ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The intervention also showed the resident needed prompt response to all requests for assistance. During an interview with the IP on 4/21/23 at 1023 hours, the IP stated one hour for the call light to be answered was not a timely manner. The IP verified a timely manner was within 10-15 minutes. Based on observation, interview, and medical record review, the facility failed to ensure six of 25 final sampled residents (Residents 57, 75, 727, 777, 779, and 782) had the rights to receive reasonable accommodation of needs and preferences. * The facility failed to ensure Resident 57's call light was within reach. * The facility failed to ensure Residents 75, 727, 777, and 782's call lights were answered in a timely manner. * The facility failed to ensure Resident 779's bariatric mattress had proper fitted sheets. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's policy and procedure titled Communication- Call System revised 1/2012 showed the facility will provide call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. Call cords will be placed within the residents' reach in the residents' room. Nursing staff will answer call bells promptly in courteous manner. Review of the facility's P&P titled Resident Rights revised 1/2012 showed employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. 1. Medical record review for Resident 57 was initiated on 4//17/23. Resident 57 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 57's H&P examination dated 8/31/21, showed Resident 57 was alert and severely cognitive impaired. Resident 57 did not have the capacity to understand and make decisions. On 4/17/23 at 0843 hours, Resident 57 was observed lying in bed, asleep, with no call light on the pillow or bed. Resident 57's call light was observed on the floor. On 4/17/23 at 1005 hours, Resident 57 was observed lying in bed, eyes minimally open. The call light was observed on the floor. On 4/17/23 at 1007 hours, an concurrent observation and interview was conducted with LVN 8. LVN 8 was asked about Resident 57's call light. LVN 8 found the call light on the floor beside Resident 57's bed. LVN 8 verified Resident 57 did not have the call light accessible for her use. LVN 8 stated Resident 57 was unable to make needs known and was totally dependent on staff with her ADL care. On 4/17/23 at 1010 hours, a concurrent observation and interview was conducted with LVN 7. LVN 7 verified the call light was not within Resident 57's reach. LVN 7 stated due to Resident 57 being at risk for fall, the call light should have been placed on top of Resident 57's abdomen and the resident's right hand placed on top of the call light to press it when needed. 2. During the resident council meeting on 4/18/23 at 1030 hours, an interview with Resident 75 was conducted. Resident 75 stated he waited 45 minutes for the call light to be answered while being soaked in his soiled diaper. On 4/20/23 at 1525 hours, an interview was conducted with the DON. The DON was informed and verified the findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's advanced directive was obtained and maintained in the medical record for one of 25 final sampled residents (Resident 4). This failure had the potential for the resident's decisions regarding her healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directives revised 7/2018 showed the purpose of an advance directive is to ensure the facility respects advance directives. At the time of admission, the admission staff will obtain a copy about the existence of an advance directive. A copy of the advance directive is maintained as part of the resident's medical record. Medical record review for Resident 4 was initiated on 4/17/23. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Advance Healthcare Directive Acknowledgement Form dated 8/28/19, showed Resident 4 received an information regarding her right to make an advance healthcare directive and had an advance healthcare directive attached in the medical record. However, further review of Resident 4's medical record failed to show a copy of Resident 4's advance directive was obtained and maintained in her medical record. On 4/17/23 at 1631 hours, an interview and concurrent medical record review for Resident 4 was conducted with LVN 7. LVN 7 was asked about Resident 4's AHCD and verified the AHCD Acknowledgement form showing Resident 4 had the AHCD completed and attached in the medical records. However, LVN 7 was unable to find the resident's AHCD. LVN 7 stated she would ask the Medical Records Director and Social Services staff. On 4/18/13 at 1200 hours, an interview was conducted with Resident 4. Resident 4 stated she did not remember if she formulated an advance directive specific to her healthcare and designated her family member as the agent to make decisions for her if she was to become incapacitated. On 4/18/23 at 1212 hours, an interview and current medical record review was conducted with the Medical Records Director. The Medical Records Director verified Resident 4's medical record did not contain a copy of Resident 4's advance directive. The Medical Records Director verified the AHCD acknowledgement form was completed when the resident was admitted to the facility, and stated she had reached out to Resident 4's family member and was told Resident 4 had no advance directive formulated. On 4/18/23 at 1218 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the AHCD acknowledgement form was completed but incorrect because Resident 4 did not have an advance directive formulated as per her conversation with Resident 4's family member.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to report the potential abuse for one of nonsampled resident (Resident 57) when Resident 57 was found with a skin discoloration below the left eye. This failure created the risk for a delay in protecting Resident 57 and delay investigation of the alleged abuse. Findings: Review of the facility's P&P titled Abuse: Reporting and Investigations dated 3/2018 showed the facility will report allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. The facility promptly reports and thoroughly investigates allegations of resident abuse, mistreatment, neglect, exploitation abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of unknown source, and suspicion of crimes. On 4/17/23 at 0843 hours, Resident 57 was observed lying in bed and had a skin discoloration below the left eye. Medical record review for Resident 57 was initiated on 4//17/23. Resident 57 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 57's H&P examination dated 8/31/21, showed Resident 57 did not have the capacity to understand and make decision. On 4/24/23 at 1445 hours, an interview and medical record review for Resident 57 was conducted with LVN 7. LVN 7 was asked if she knew about Residents 57's skin discoloration below the left eye. LVN 7 stated Resident 57's skin discoloration below the left eye was reported by the PM shift staff on 4/11/23, and it was an unwitnessed injury. On 4/24/23 at 1453 hours, an interview and concurrent medical record review for Resident 57 was conducted with RN 1. RN 1 was asked about Resident 57's skin discoloration below the left eye. RN 1 reviewed the care plan and risk management report and stated no care plan or incident report was formulated for Resident 57's skin discoloration below the left eye. RN 1 verified above findings. On 4/24/23 at 1501 hours, an interview and concurrent medical record review for Resident 57 was with the DON. The DON was asked about Resident 57's skin discoloration below the left eye. The DON verified Resident 57's skin discoloration below the left eye was an unwitnessed injury and not reported to appropriate agencies.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review and facility P&P review, the facility failed to notify one of three closed record sampled residents (Resident 126) and their representative of their transfer/discharge and the reasons for the move in writing. In addition, the facility failed to send a copy of the transfer/discharge to the representative of the Office of the State Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents). These posed the risk for Resident 126 and the representative not aware of the appeal process for discharge. Findings: Review of the facility's P&P titled Discharge and Transfer of Residents Nursing Manual-General revised date 2/2018 showed the resident/resident representative will be provided with a Notice of Proposed Transfer and Discharge 30 days prior to discharge or as soon as practicable. Review of the Notice of Proposed Transfer/discharge date d 5/4/22, showed, If you believe that the proposed transfer/discharge is inappropriate in your case, and is involuntary, you have the right to appeal. The appeal can be filed in writing to, or by calling the following: DHCS Office of Administrative Hearing and Appeals, State Long-Term Care Ombudsman Office, State Agency for the Developmentally Disabled, and/or the State Agency for the Mentally Ill. The notice further showed if the resident or their representative intended to appeal, it was important to do so within 10 calendar days of being notified. The ability of the Department of Health to render a decision on the appeal, may be jeopardized if the appeal is not submitted within (10) ten calendar days. Closed medical record review for Resident 126 was initiated on 4/19/23. Resident 126 was admitted on [DATE], and discharged on 2/6/23. Review of Resident 126's Physician Order Summary Report dated 2/6/23, showed the orders for amlodipine (antihypertensive medication), heparin (blood thinner), insulin glargine (antidiabetic), and insulin aspart (antidiabetic) as per sliding scale. Review of Resident 126's progress notes dated 2/6/23, showed Resident 126 went on an out on pass and did not return to the facility. The facility tried to contact Resident 126 via telephone but was unable to reach him. On 4/20/23 at 0953 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the Notice of Proposed Transfer and Discharge form was missing from Resident 126's medical record. RN 1 stated the Medical Records Department arranged the packets for the resident's discharge. RN 1 stated the Ombudsman was to be notified via fax upon a resident's discharge and confirmed there was no documentation to show the Ombudsman was notified. On 4/20/23 at 1003 hours, an interview and concurrent medical record review was conducted with the MRD. The MRD verified the Notice of Proposed Transfer and Discharge form was missing from Resident 126's medical record and stated if the form was not in the chart, it was not completed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to accurately complete the MDS for one of 25 final sampled residents (Resident 529). This posed the risk of the resident not receiving an individualized plan of care based on the resident's specific needs. * Resident 529 was a smoker. The facility failed to code the use of tobacco in the admission MDS dated [DATE]. Findings: Medical record review for Resident 529 was initiated on 4/17/23. Resident 529 was admitted to the facility on [DATE]. On 4/17/23 at 1652 hours, Resident 529 was observed in her room lying in bed, pointed to the pillow on top of her wheelchair, and stated to look underneath; and two pieces of cigarettes and a lighter were observed under the pillow. Review of Resident 529's plan of care showed a care plan problem dated 4/17/23, addressing Resident's 529's smoking. The care plan focus showed Resident 529 was an identified as a smoker. Review of Resident 529's admission MDS dated [DATE], showed the tobacco use was not coded. On 4/20/23 at 1504 hours, an interview and concurrent medical record review was conducted with MDS Nurse 1. MDS Nurse 1 verified the above findings and stated the MDS was inaccurately coded. MDS Nurse 1 stated Resident 529 was assessed for smoking on 4/17/23, and was not aware when Resident 529 started smoking. MDS Nurse 1 stated it was important to modify the MDS to provide the appropriate care to the resident. On 4/20/23 at 1629 hours, an interview was conducted with the DON. The DON verified the above findings and stated accurate assessment and care plan was important to provide correct care to the resident. Cross reference to F689, example #7.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to develop the plan of care to reflect the individual care needs for six of 25 final sampled residents (Residents 29, 52, 55, 57, 59, and 777). * The facility failed to ensure Resident 29's care plan problem addressing dialysis included Resident 29's fluid restriction. * The facility failed to develop a care plan problem to address Resident 777's dialysis catheter site care. * The facility failed to develop a care plan problem to address Resident 57's skin discoloration below the left eye. * The facility failed to ensure a care plan problem addressing smoking included the safe storage of cigarettes materials for Resident 52. * The facility failed to ensure a care plan problem addressing smoking included the safe storage of cigarettes materials for Resident 55. * The facility failed to develop a care plan problem for Resident 59's right arm swelling. These failures posed a risk of not providing appropriate, consistent, and individualized care to the residents. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 11/2018 showed the baseline care plan should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. Review of the facility's P&P titled Dialysis Care revised 10/2018 showed the IDT will ensure that the resident's care plan includes documentation of the resident's renal condition and necessary precautions (e.g. shunt site, weights, dietary and fluid restrictions, no B/P on affected side, lab draws, IV, injection on arm with shunt, observe for signs and symptoms of infection, etc.). The resident's care plan will be updated as needed. 1. Medical record review for Resident 29 was initiated on 4/17/23. Resident 29 was admitted on [DATE], with diagnoses including end stage renal disease (kidneys no longer function properly) and dependence on renal dialysis. On 4/17/23 at 0846 hours, an observation and concurrent interview was conducted with Resident 29. Resident 29 stated his left arm had always been swollen and they were concerned at his dialysis center regarding the swelling of his legs. A water jug filled up to 850 ml was observed on the bedside table. Resident 29 stated the jug was given to him the day before. Review of Resident 29's physician's order dated 4/4/23, showed a fluid restriction of 1000 cc per 24 hours, with 360 cc given during meals and 640 cc provided by nursing. Review of Resident 29's plan of care showed a care plan problem initiated on 4/5/23, addressing end stage renal disease requiring dialysis; however, there was no care plan intervention addressing Resident 29's fluid restriction as per the physician's orders. On 4/20/23 at 1012 hours, a concurrent interview and medical record review was conducted with LVN 3. LVN 3 stated Resident 29 was on a fluid restriction of 1000 cc every 24 hours and the nursing staff should monitor for fluid restriction. LVN 3 stated the RNs and LVNs were responsible for updating the care plans for the residents. LVN 3 verified Resident 29's plan of care failed to show a fluid restriction as per the physician's orders. LVN 3 stated Resident 29's plan of care should be updated reflecting Resident 29's fluid restriction since they were monitoring it. Cross reference to F698, example #1. 2. Medical record review for Resident 777 was initiated on 4/17/23. Resident was admitted on [DATE], and readmitted on [DATE], with diagnoses including end stage renal disease and required renal dialysis. Review of Resident 777's H&P examination dated 4/17/23, showed Resident 777 had the capacity to understand and make decisions. Resident 777 had a femoral dialysis catheter for his dialysis access site. Review of Resident 777's order summary report showed an order dated 4/13/23, to monitor access site for redness, [NAME], drainage and pain; however, there was no order regarding where Resident 777's access site was located. Review of Resident 777's care plans failed to show a care plan problem to address dialysis catheter site was developed. On 4/20/23 at 1055 hours, a concurrent interview and medical record review was conducted with LVN 3. LVN 3 stated the LVNs were able to assist with changing and updating Resident 777's plan of care. LVN 3 verified there was no plan of care addressing Resident 777's dialysis access site and how to care for the access site. LVN 3 stated Resident 777's care plan did not address monitoring of the dialysis access site, and there was no physician's order for Resident 777's dialysis access site and care. LVN 3 verified Resident 777's plan of care should address the resident's dialysis access site and how to care for it. On 4/20/23 at 1426 hours, a follow-up interview and concurrent facility P&P review was conducted with RN 1. RN 1 verified the above findings. 3. On 4/17/23 at 0843 hours, Resident 57 was observed lying in bed and had a skin discoloration below the left eye. Medical record review for Resident 57 was initiated on 4/17/23. Resident 57 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 57's H&P examination dated 8/31/21, showed Resident 57 did not have the capacity to understand and make decision. Review of Resident 57's plan of care showed no care plan problem was formulated to address the skin discoloration below the left eye. On 4/24/23 at 1453 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified no care plan was formulated regarding Resident 57's skin discoloration below the left eye. On 4/24/23 at 1501 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked about Resident 57's skin discoloration below the left eye care plan. The DON verified Resident 57's care plan for the skin discoloration below the left eye was not formulated. 4. On 4/17/23 at 1650 hours, Resident 52 was observed smoking cigarette in the patio not wearing apron and with no staff supervision. Resident 52 stated, I always smoke here in the patio by myself or with other residents and keeps cigarette and lighter with me. On 4/18/23 at 1610 hours, Resident 52 was observed smoking in the patio by herself, not wearing apron and with no staff supervision. Resident 52 stated, I smoked whenever I want, and keep cigarette and lighter with me all the time. Medical record review for Resident 52 was initiated on 4/17/23. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's MDS dated [DATE], showed Resident 52 had no cognitive impairment. Review of Resident 52's H&P examination dated 6/21/22, showed Resident 52 was an oxygen dependent. Review of Resident 52's Smoking Safety Evaluation dated 10/10/22, showed supervision would be required for all residents during designated smoking times. Review of Resident 52's plan of care showed a care plan problem dated 4/14/23, addressing Resident 52's smoking. The care plan failed to address safe storage and use of Resident 52 's smoking materials. On 4/18/23 at 1715 hours, interview was conducted with DON. The DON was informed of the above findings and verified the findings. Cross reference to F689, example #3. 5. Medical record review for Resident 55 was initiated on 4/17/23. Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 55's MDS dated [DATE], showed Resident 55 had a BIMS Score of 14. Review of Resident 55's plan of care showed a care plan problem dated 1/6/23, showing Resident 55 was an independent smoker. The care plan failed to address safe storage and use of Resident 55's smoking materials. Review of Resident 55's Smoking Safety Evaluation dated 9/22/22, showed supervision would be required for all residents during designated smoking times. On 4/17/23 at 1345 hours, an observation and concurrent interview was conducted with Resident 55. Resident 55 was observed lying in bed. Resident 55 stated he just got back from smoking. Resident 55 stated he kept his cigarettes and lighter and showed the smoking materials inside his sweater. On 4/18/23 at 1715 hours, interview and concurrent medical record review was conducted with the DON. The DON stated the Smoking Assessment was completed for the residents who wished to smoke upon admission and identification and updated quarterly and as needed. The DON verified the residents' care plans failed to address safe storage and use of smoking materials. The DON verified the above findings. Cross reference to F689, example #4. 6. Medical record review for Resident 59 was initiated on 4/17/23. Resident 59 was admitted on [DATE], and readmitted to the facility on [DATE]. Review of Resident 59's quarterly MDS dated [DATE], showed Resident 59 had moderate cognitive impairment. Review of Resident 59's Change in Condition Evaluation dated 4/17/23, showed Resident 59 had edema of the right arm. Review of Resident 59's plan of care failed to show a care plan problem was developed to address Resident 59's right arm edema when it was observed on 4/17/23. There were no documented care interventions in place to address Resident 59's right arm edema. On 4/24/23 at 1037 hours, an interview was conducted with LVN 9. LVN 9 verified Resident 59 had the right arm swelling and pain. When asked what interventions were in place to address Resident 59's right arm pain and swelling, LVN 9 stated Resident 59 had the physician's orders for Norco 5/325 mg (a medication used to relieve moderate to severe pain) and ultrasound doppler (a special ultrasound technique to evaluate blood flow through a blood vessel, including the body's major arteries and veins in the abdomen, arms, legs, and neck) for the right arm. On 4/24/23 at 1412 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified Resident 59 had no care plan for the right arm edema. The DON acknowledged there was no documented evidence of interventions in place to address Resident 59's right arm edema. The DON stated there should have been a care plan problem developed as it would dictate how to care, what to look for, what had been done and what else could be done for Resident 59.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 777 was initiated on 4/17/23. Resident was admitted on [DATE] and readmitted on [DATE]. Review of Resident 777's H&P examination dated 4/17/23 showed Resident 777 had the capacity to understand and make decisions; and had a femoral dialysis catheter for his dialysis access site. Review of Resident 777's change of condition evaluation dated 4/10/23, showed Resident 777 went to dialysis and per dialysis, they had to transfer Resident 777 to the ER for the dialysis catheter access site evaluation. Review of Resident 777's health status note dated 4/10/23, showed Resident 777's dialysis catheter access site got dislodged/slid out. According to the dialysis RN, Resident 777 will be transferred from the dialysis center to the acute care hospital ER for the catheter evaluation. Review of Resident 777's plan of care failed to address the change of condition on 4/10/23 regarding Resident 777's dislodged dialysis catheter. On 4/18/23 at 1118 hours, an interview was conducted with Resident 777. Resident 777 stated his dialysis catheter located in his groin area partially came out on 4/10/23. Before the incident, Resident 777 stated he did not think the staff knew about where his dialysis catheter was and stated the staff were not careful with transferring him. On 4/19/23 at 0844 hours, a follow-up interview was conducted with Resident 777. Resident 777 stated his dialysis catheter worked fine during his dialysis session on 4/8/23 and then was sent to the hospital on 4/10/23 because the dialysis catheter partially came out. Resident 777 stated on 4/10/23, the staff helped him transfer to the wheelchair, by holding the wheelchair, and he transferred to the wheelchair by himself. Resident 777 stated staff did not checked his dialysis catheter site every time he went and came back from the dialysis center and on 4/10/23, the staff did not check his site prior to sending him to the dialysis center. On 4/21/23 at 1021 hours, an interview was conducted with LVN 1. LVN 1 acknowledged the above findings. LVN 1 verified the plan of care was not updated to address Resident 777's change of condition and there was no plan of care addressing how the resident should be transferred with his dialysis catheter access. 2. Medical record review for Resident 59 was initiated on 4/17/23. Resident 59 was admitted on [DATE] and readmitted to the facility on [DATE]. Review of Resident 59's quarterly MDS dated [DATE], showed Resident 59 had moderate cognitive impairment and was on dialysis treatment. Review of Resident 59's Order Summary Report showed the following physician orders dated 4/1/23: - Resident 59 was to receive dialysis every Monday, Wednesday, and Friday at a dialysis center; - Do not take blood pressure or blood draws on the left arm every shift; - Monitor the dialysis access site for redness, swelling, drainage, and pain. Notify MD if present every shift; - Monitor for presence of bruit and thrill every shift. Review of Resident 59's plan of care showed a focus problem dated 1/3/23, to address the end stage renal failure and at risk for infection or bleeding on catheter insertion site to left upper arm AV shunt. The interventions included to check and change the dressing daily at the access site and document. On 4/20/23 at 1624 hours, an interview was conducted with the DON. The DON stated the dialysis site was not supposed to be manipulated and the dressing can be reinforced when there was bleeding and drainage were present. On 4/24/23 at 1419 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged the above findings and stated care plan should have been revised. 4. Medical record review for Resident 42 was initiated on 4/19/23. Resident 42 was readmitted to the facility on [DATE]. Review of Resident 42's Order Summary Report dated 4/19/23, showed the following physican's orders: - a physician's order dated 3/27/22, for an indwelling urinary catheter bag change as needed, - a physician's order dated 9/13/21, to flush the indwelling urinary catheter with 50 ml of normal saline every day as needed for sedimentation and cloudiness, and - a physician's order dated 9/13/23, for the indwelling urinary catheter care daily and as needed. Review of Resident 42's care plan showed a care plan problem dated 9/14/21, addressing the resident's use of the in indwelling urianry catheter. The interventions included to change Resident 42's indwelling urinary catheter bag every Sunday and to irrigate the indwelling urinary catheter every shift as maintenance. On 4/24/23 at 1027 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 verified there was care plan for Resident 42's use of the indwelling urianry catheter. LVN 8 verified the current physician's order for the indwelling catheter and the care plan should have been revised to show Resident 42's updated plan of care as per the physicians order. On 4/24/23 at 1129 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed of the above findings and verified the findings. Based on interview, medical record review, and facility P&P review, the facility failed to ensure care plans were updated and revised for four of 25 final sampled residents (Residents 42, 59, 100, and 777 ) as evidenced by: *For Resident 100, the care plans for dialysis to administer epoetin (used to treat anemia (a lower than normal number of red blood cells) in people with chronic kidney failure) were not revised timely. * The facility failed to revise the care plan intervention of Resident 59 for the dialysis access care. * The facility failed to revise the care plan of Resident 777 to address the dislodged femoral dialysis catheter. * The facility failed to revise the care plan intervention of Resident 42 for the use of indwelling catheter. These failures had the potential for inadequate treatment and management of residents' medical and health conditions. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 11/2018 showed the comprehensive care plan will be periodically reviewed and revised by IDT after each assessment which means after each MDS assessment as required, except discharge assessments. In addition, the comprehensive care plan will also be reviewed and revised at the following times: onset of new problems, change of condition, in preparation for discharge, to address changes in behavior and care, and other times as appropriate or necessary. 1. Medical record review for Resident 100 was initiated on 4/17/23. Resident 100 was admitted to the facility on [DATE]. Review of the care plan dated 1/3/23 showed a care plan problem addressing the resident needed dialysis related to renal failure at risk for complication from AV shunt insertion sites, left upper extremity AV shunt. The interventions included to administer epoetin as ordered initiated on 10/4/22. Review of the physician's order dated 1/12/23, showed an order for epoetin alfa solution 10000 units per ml inject 10000 units subcutaneously every Monday, Wednesday, and Friday for kidney disease was discontinued. On 4/24/23 at 1030 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was asked regarding the medicine epoetin was ordered in care plan. RN 1 stated the physician ordered for epoetin was discontinued on 1/12/23. RN 1 stated the care plan should have been revised. RN 1 verified the above findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide care and services for one of 25 final sampled residents (Resident 48). * Resident 48 did not have the follow-up appointment for an ENT consult for decreased hearing. This failure had the potential for Resident 48's hearing needs to not be met. Findings: Review of the facility's P&P titled Referrals to Outside Services Operational Manual- Social Services revised 12/1/13, showed to provide residents with outside services as required by physician orders or the Care Plan. The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the facility. To facilitate this process, the facility maintains service provider contracts with variety of providers. The Director of Social Services is responsible for locating agencies and programs that meet the needs of residents, facilitating the execution of service provider contracts, and referring residents to existing contracted providers. Referrals for medical services are only made pursuant to an Attending Physician's order. The Director of Social Services or his or her designee will coordinate with Nursing Staff to ensure that the Attending Physician's order and referral to outside provider is documented in the resident's medical record. On 4/17/23 at 0901 hours, during the initial tour, Resident 48 complaint of having difficulty hearing to her right ear. Resident 48 was observed leaning forward to hear better. Resident 48 stated she was supposed to have an ENT appointment, the staff was aware and had told her that she would be seen at the end of the month, but she was not seen. Medical record review for Resident 48 was initiated on 4/17/23. Resident 48 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 48's MDS dated [DATE], showed Resident 48's cognition was moderately impaired and had minimal difficulty with hearing. Review of Resident 48's Physician's Order Summary Report showed a physician's order dated 2/21/23, for Resident 48 to have an ENT consult. Review of Resident 48's Physician's Progress Note dated 2/24/23, showed an ENT referral due to decreased hearing. Review of Resident 48's Audiologist Progress Note dated 8/2/22, showed a follow-up visit within six months. Review of Resident 48's plan of care dated 8/23/23, showed a care plan problem addressing the problem of Resident 48 having slight hard of hearing. The plan of care interventions included audiology as needed. Further review of the medical record showed no documented evidence Resident 48 had a follow-up appointment within six months after the audiology visit on 8/2/22. On 4/20/23 at 0941 hours, an interview was conducted with MDS Nurse 2. MDS Nurse 2 stated Resident 48 had difficulty hearing when her surrounding environment was noisy. MDS Nurse 2 stated Resident 48 could make her needs known. On 4/20/23 at 1229 hours, an interview and concurrent medical record review was conducted with the SSA. The SSA verified Resident 48 had an ENT consult order and the physician's progress note showed the ENT referral to decreased hearing. The SSA confirmed Resident 48 needed a six month follow-up appointment from her last audiology visit. The SSA stated the nurses did not make her aware of Resident 48's order for an ENT consult and she did not arrange for the ENT appointment. The SSA stated it was important to arrange the referral appointment to make sure the needs of the residents were being addressed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 25 final sampled residents (Residents 48 and 69) received adequate care. * The facility failed to ensure a change of condition and care plan problem were documented when Resident 69 was prescribed erythromycin (antibiotic used to treat infections) ointment to both eyes. * The facility failed to ensure Resident 69 with positive ESBL in urine (urinary tract infection) had a contact isolation order. There were no care plans developed to address prescribed antibiotic medication, Bactrim DS (antibiotic used to treat infections), positive ESBL, and contact isolation for positive ESBL. * The facility failed to address a change of condition and notify the physician when Resident 48 was observed having redness and rashes to bilateral feet. These failures had the potential to not providing necessary care and services to the residents with a change of condition, prescribed antibiotics, and infection that required a contact isolation. Findings: 1. Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 11/2018 showed the comprehensive care plan will be reviewed and revised as the following times: onset of new problems, change of condition, in preparation for discharge, changes in behavior and care, and other times as appropriate or necessary. Medical record review for Resident 69 was conducted on 4/21/23. Resident 69 was admitted on [DATE]. a. Review of Resident 69's physician's orders showed on 3/28/23, erythromycin ointment 5mg/gm was ordered with instructions to instill one strip in both eyes two times a day for eye infection. There was no documented evidence a care plan or change of condition documentation was developed for eye infection and the use of erythromycin ointment. During a concurrent interview and record review with the IP nurse on 4/21/23 at 0924 hours, the IP nurse verified Resident 69 was ordered the erythromycin ointment on 3/28/23. The IP nurse stated erythromycin was an antibiotic, and if there was a new change in the resident's condition, it was considered a change of condition and needed to be documented on a SBAR. During a concurrent interview and record review with the DON on 4/21/23 at 1035 hours, the DON verified erythromycin was an antibiotic and stated if an antibiotic was ordered, there must be a SBAR. The DON verified Resident 69 did not have antibiotics ordered for his eyes upon admission and no SBAR or care plan was completed for the erythromycin ointment ordered on 3/28/23. The DON stated the care plan problems were important because they dictated the care for the resident. 2. Review of the facility's P&P titled Resident Isolation - Categories of Transmission-Based Precautions revised in 1/2012 showed contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with he resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Examples of infections requiring Contact Precautions include, but are not limited to gastrointestinal, respiratory, skin, or wound infections or colonization of multi-drug resistant organisms. In addition, the P&P showed the facility also ensures that the resident's care plan indicates the type of precautions implemented for the resident. Medical record review for Resident 69 was conducted on 4/21/23. Resident 69's medical record showed Resident 69 had a change of condition noted on 8/7/22, for urinary frequency and pain while urinating with new orders from the physician for a urinalysis (urine test). Review of Resident 69's lab report dated 8/11/22, showed a urinalysis result showing positive for ESBL on 8/11/22 at 2131 hours. Resident 69 was ordered a new medication, Bactrim DS 800-160 mg, with instructions to take one tablet by mouth two times daily for ESBL in the urine for 10 days from 8/12/22 to 8/22/22. Further review of Resident 69's medical record failed to show an order for contact isolation for positive ESBL. In addition, there was no documented evidence the care plan problems were developed to address ESBL infection, the use of Bactrim DS medication, and contact isolation precautions for the ESBL. During a concurrent interview and record review with the IP nurse on 4/21/23 at 0924 hours, the IP nurse verified Resident 69 did not have the care plans developed to address Bactrim DS antibiotic medication, testing positive for ESBL, or contact isolation precautions for the ESBL. The IP nurse also verified there was no contact isolation ordered for the ESBL and stated the order was needed to ensure staff were aware of isolation. The IP nurse stated the license nurses were responsible for entering the orders and developing a care plan for the residents. During a concurrent interview and record review with the on 4/21/23 at 1035 hours, the DON acknowledged an order was needed for contact isolation for ESBL in the urine and verified no contact isolation for ESBL ordered for Resident 69. The DON stated if there was no order or no isolation set up, the staff would not know the resident was on isolation unless they were told. The DON also stated Resident 69 needed separate care plan problems for the Bactrim DS antibiotic medication, ESBL infection, and contact isolation for ESBL in urine. 3. Review of the facility's P&P titled Change of Condition Notification Nursing Manual- General revised date 1/2015 showed the facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representatives or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to: an accident, a significant change in the resident's physical, mental or psychosocial status; and/or a significant change in treatment. A Changed of Condition related to Attending Physician notification is defined as when the Attending Physician must be notified when any sudden and marked adverse change in resident's condition which is manifested by signs and symptoms different than usual denote a new problem, complication, or permanent change in status and require a medical assessment, coordination and consultation with the Attending Physician and a change in the treatment plan. On 4/17/23 at 0901 hours, Resident 48 was observed with redness and raised, circular-shaped, rash looking in her bilateral feet. Resident 48 stated she had told staff regarding the itchiness and rash on her feet, but no one had done anything about it. Medical record review for Resident 48 was initiated on 4/17/23. Resident 48 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 48's MDS dated [DATE], showed Resident 48's cognition was moderately impaired. Review of Resident 48's Physician's Order Summary Report for March and April 2023 showed no treatment order for Resident 48's feet skin rashes. Review of Resident 48's eInteract Change of Condition for March and April 2023 failed to show documentation of Resident 48's redness or rashes to bilateral feet. Review of Resident 48's Weekly Skin/Wound assessment dated 2/13, 2/14, 2/17, and 3/3/23, showed skin was in intact and within normal limit. Review of Resident 48's plan of care failed to show documentation of a care problem for Resident 48's bilateral feet redness and rashes. Further review of Resident 48's medical record failed to show documentation the physician was notified of Resident 48's bilateral feet redness and rashes. On 4/18/23 at 1156 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 48 had skin redness and Resident 48 had redness to her skin before when she was initially admitted . On 4/18/23 at 1220 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 48 did not have any skin issues. On 4/19/23 at 1109 hours, an observation and concurrent interview was conducted with LVN 3. LVN 3 confirmed the redness and rashes to Resident 48's bilateral feet and stated he did not notice Resident 48's feet. LVN 3 described Resident 48's bilateral feet as reddened area with scattered rashes and considered Resident 48's bilateral feet redness and scattered rashes as a new change of condition. LVN 3 stated he would notify the physician and initiate the change of condition assessment. On 4/19/23 at 1119 hours, an interview was conducted with Resident 48. Resident 48 stated the treatment nurse provided her A&D ointment to put on her feet and told the other nurse so the nurse could call the doctor in the morning. On 4/19/23 at 1123 hours, an observation and concurrent interview was conducted with LVN 8. LVN 8 verified Resident 48 had complained of the redness on her bilateral feet, but LVN 8 did not see the rashes. LVN 8 verified the redness and rashes on Resident 48's bilateral feet and it was a change of condition. LVN 8 verified the physician was not notified of Resident 48's bilateral feet skin condition. On 4/19/23 at 1157 hours, an interview was conducted with RN 1. RN 1 stated she was not notified of any skin issues of Resident 48. RN 1 stated for a resident's change of condition, the assessment, notification of physician, carrying out physician's treatment recommendation, notification of resident or resident's responsible parties, initiating an eInteract Change of Condition document, monitoring, and formulating a care plan would be needed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the RNA services for one of 25 final sampled residents (Resident 100). This failure had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Restorative Nursing Program Guidelines dated 9/19/19, showed the RNA carries out the restorative program according to the care plan. The RNA documents the frequency of the program, the amount of time the resident spent in the activity and their tolerance to the program. In addition, the RNA completes a written weekly summary for all residents on a Restorative Nursing Program. The Restorative Nursing Program Coordinator co-signs the weekly progress notes. Medical record review of Resident 100 was initiated on 4/17/23. Resident 100 was admitted to the facility on [DATE]. Review of Resident 100's H&P examination dated 2/21/23, showed the resident had the capacity to understand and make decisions. Review of the Order Listing Report dated 4/24/23, showed a physician order dated 3/24/23, RNA for ambulation with FWW every day five times per week. Review of the resident's care plan dated 10/3/22, showed a care plan problem addressing Resident 100's limited physical mobility related weakness and the right above knee amputation (AKA). The interventions included RNA for ambulation with FWW every day five times per week as tolerated. Review of the PT Evaluation and Plan of Treatment dated 2/20/23, showed the following: - walk 10 feet with supervision or touching assistance - gait distance = 150 feet and assistive distance-two wheeled walker - gait pattern/deviations - the resident hops due to the right AKA - RLE ROM impaired and LLE ROM within normal limit - to continue RNA program for ambulation On 4/17/23 at 0845 hours, Resident 100 was observed sitting up in bed. On 4/17/23 at 1245 hours, Resident 100 was observed sitting in wheelchair. On 4/20/23 at 1410 hours, RNAs 1 and 2 were asked if they were working with Resident 100. Both RNAs stated Resident 100 did not have the order in the RNA book. RNA 1 stated she had not provided any RNA services for Resident 100 for almost a month. RNA 2 stated if they had the RNA order from the Rehab in their RNA book, they would do it. Both RNAs were unaware of the RNA program for Resident 100. On 4/20/23 at 1430 hours, an interview concurrent with medical record review, RN 1 was asked if Resident 100 had an active order for RNA services. RN 1 stated the order was active for RNA ambulation with FWW every day five times per week. The PT and OT evaluation completed on 2/20/23, showed to continue with the RNA program. On 4/20/23 at 1535 hours, an interview was conducted with RNA 2. RNA 2 stated the PTA showed how to provide the RNA services for Resident 100 last Monday around 3 PM. RNA 2 stated the PTA did not give her the order that day, but the PTA showed how to provide ambulation for Resident 100. On 4/20/23 at 1545 hours, an interview and concurrent medical record review was conducted with the PTA. The PTA was asked if he had communicated with the RNA about the need for the RNA program for Resident 100. The PTA stated he assumed the order was not discontinued after Resident 100 came back from the acute care hospital. The PTA did not print out the new order and thought the RNA was aware. On 4/24/23 at 1000 hours, an interview was conducted with Resident 100. Resident 100 was asked if he had walked with the facility staff. Resident 100 stated he did only on last Monday. Resident 100 was asked if he would like to walk with walker with the staff. Resident 100 stated yes.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 42) received the appropriate care and services for an indwelling urinary catheter. This failure had the potential for the resident to develop complications associated with the use of indwelling urinary catheter. Findings: Review of the facility's P&P titled Indwelling Catheter revised 9/1/14, showed the drainage system will be maintained and will be changed when it is obstructed or is leaking according to physicians order. On 4/17/23 at 1019 hours, Resident 42 was observed to have an indwelling urinary catheter connected to a urinary drainage bag placed at the side of the bed with cloudy and lot of sediments in the tubing, with no label of when the bag was changed. Medical record review for Resident 42 was initiated on 4/19/23. Resident 42 was readmitted to the facility on [DATE]. Review of Resident 42's Order Summary Report dated 4/19/23, showed the following: - a physician's order dated 9/13/21, to flush the indwelling catheter with 50 ml of normal saline every day as needed for sedimentation and cloudiness. - a physician's order dated 9/13/21, for indwelling catheter care daily and as needed. - a physician's order dated 3/27/22, for the urinary drainage bag change as needed. On 4/19/23 at 1055 hours, an interview and concurrent observation was conducted with LVN 7. LVN 7 was asked about the indwelling urinary catheter care for Resident 42. LVN 7 verified the urine color in the urinary drainage bag was brownish to dark color of urine with a lot of sediments, cloudy, and with whitish appearance on the tubing. LVN 7 acknowledged the urinary drainage bag needed to be changed because the resident was prone to infection. LVN 7 verified there was no label on the urinary drainage bag when it was last changed. On 4/20/23 at 1454 hours, an interview and concurrent medical record review for Resident 42 was conducted with LVN 8 who was also the treatment nurse. LVN 8 verified the urinary drainage bag was cloudy with lots of sediments and dark orange color of urine. LVN 8 verified there was no label of the date when the drainage bag was changed. Further review of Resident 42's medical record failed to show when the urinary drainage bag was last changed. On 4/24/23 at 1129 hours, an interview and concurrent facility P&P review was conducted with the DON. The DON was informed of the observation and above findings. The DON stated the urinary drainage bag should have been changed when any signs and symptoms of infection on the catheter bag was observed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to offer or provide adequate and appropriate pain management for two of 25 final sampled residents (Residents 777 and 779). * The facility failed to ensure Resident 777 was administered pain medication per the physician's order. * The facility failed to consistently provide non-pharmacological interventions for pain prior to administration of a narcotic pain medication to Residents 777 and 779. * The facility failed to monitor Resident 779's implanted pain pump. These failures had the potential for not effectively managing these residents' pain. Findings: Review of the facility's P&P titled Pain Management revised 11/2016 showed the licensed nurse will administer pain medication as ordered and document medication administered on the MAR. Additionally, the P&P showed the nursing staff will also utilize non-pharmacological interventions to address possible issues contributing to pain. Interventions include but are not limited to: apply warm blankets, provide exercise to address stiffness, comfortable seating, and to provide diversion activities. 1. On 4/17/23 at 0920 hours, during an initial tour of the facility, an interview was conducted with Resident 777. Resident 777 stated he took Norco two times a day for his knee and lower back pain, once in the morning and another one when he returned from his dialysis center. Resident 777 stated on Saturday 4/15, the LVN told him that they ran out of his Norco which resulted in him being in pain all night. Resident 777 stated he did not get the Norco until 1000 hours on the next day. Resident 777 stated he could not relax, and it was difficult for him to sleep due to the pain. Medical record review for Resident 777 was initiated on 4/17/23. Resident was admitted on [DATE], and readmitted on [DATE]. Review of Resident 777's H&P examination dated 4/17/23, showed Resident 777 had the capacity to understand and make decisions. a. Review of Resident 777's physician's order dated 4/11/23, showed an order for hydrocodone-acetaminophen (Norco) oral tablet 10-325 mg one tablet every six hours as needed for back pain. On 4/18/23 at 1114 hours, a follow-up interview was conducted with Resident 777. Resident 777 stated after dialysis, his pain at his knees and back was usually a level of 8-9 (pain scale of zero to 10, zero with no pain and 10 = worst) and he required the Norco to help relieve his pain. On 4/19/23 at 0930 hours, an interview was conducted with the DON. The DON stated Norco was available in their E-Kit and the LVNs should be able to get the dose of Norco from the E-kit if the resident's Norco was not available. On 4/20/23 at 1459 hours, an interview, medical record review, and concurrent facility document review was conducted with LVN 3. LVN 3 stated Resident 777 took Norco for his lower back pain and would take it on his dialysis days in the morning and evening. LVN 3 stated if a medication was running out, it should be reordered before it ran out. LVN 3 verified if the resident's Norco was out, they had it available in the E-kit and the on duty LVN should have been able to get it from the E-kit. LVN 3 acknowledged Resident 777 did not get Norco on 4/15 and no documentation on Resident 777's MAR regarding if medication was pulled from the E-kit. Review of the Individual Narcotic Record was conducted with LVN 3. LVN 3 verified Resident 777's last administration of Norco was on 4/14 at 0800 hours, which was the last dose available for the medication. LVN 3 verified the next dose of Norco was not given until 4/16 at 1030 hours, and the Norco was not received until 4/16/23. b. Review of Resident 777's physician's order dated 4/11/23, showed an order for non-pharmacological intervention as needed for pain management, which were coded as follows: 1 = repositioning 2 = dim light/quiet environment 3 = relaxation 4 = distraction 5 = music 6 = massage Review of Resident 777's MAR for April 2023 showed Resident 777 received hydrocodone-acetaminophen 10-325 mg on 4/13, 4/14, 4/16, 4/18, 4/19, and 4/20/23. Further review of the MAR showed Resident 777 received non-pharmacological interventions for pain on 4/20/23; however, there was no documented evidence non-pharmacological interventions were attempted prior to pain medication administration on 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, and 4/19/23. On 4/21/23 at 1015 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked when Resident 777 received non-pharmacological interventions for pain. LVN 1 stated she would offer the non-pharmacological interventions when Resident 777 asked for pain medications. LVN 1 verified there was no documented evidence non-pharmacological interventions were attempted prior to the administration of Resident 777's pain medication. 2. Medical record review for Resident 779 was initiated on 4/17/23. Resident 779 was admitted to the facility on [DATE]. Review of Resident 779's Physicians Orders showed an order dated 4/16/23, for non-pharmacological interventions as needed for pain, which was coded as follows: 1 = repositioning 2 = dim light/quiet environment 3 = relaxation techniques 4 = distraction 5 = music 6 = massage Review of Resident 779's physician's order dated 4/6/23, showed an order for Norco oral tablet 10-325 mg one tablet every eight hours as needed for moderate pain Review of Resident 779's MAR for April 2023 showed Resident 779 received Norco 10-325 mg on 4/6, 4/7, 4/8, 4/9, 4/11, 4/13, 4/14, 4/16, 4/17, 4/18, and 4/19/23. Further review of the MAR showed Resident 779 received non-pharmacological interventions for pain on 4/18/23; however, there was no documented evidence non-pharmacological interventions were attempted prior to pain medication administration on 4/6, 4/7, 4/8, 4/9, 4/11, 4/13, 4/14, 4/16, 4/17, and 4/19/23. On 4/18/23 at 1137 hours, an interview was conducted with LVN 3. LVN 3 stated he did not provide Resident 779 with non-pharmacological interventions for pain today (4/18) and yesterday. LVN 3 stated Resident 779 asked for the pain medications, so he did not offer any non-pharmacological interventions. On 4/18/23 at 1149 hours, an interview was conducted with RN 1. RN 1 stated non-pharmacological interventions for pain should be offered prior to giving pain medications, and the charge nurse should offer them regularly during their rounds. On 4/19/23 at 0930 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged the above findings. The DON verified non-pharmacological interventions should be offered prior to giving PRN pain medications and should be documented in the resident's medical record for every PRN. b. On 4/24/23 at 0943 hours, an interview was conducted with Resident 779. Resident 779 stated he had an implanted Morphine pain pump in his abdomen for more than 10 years. Resident 779 stated he did not know what the settings were on his pain pump and could not adjust it. Review of Resident 779's physician's orders failed to show an order addressing Resident 779's implanted pain pump. Review of Resident 779's plan of care failed to address Resident 779's implanted pain pump. On 4/23/23 at 1010 hours, an interview was conducted with LVN 3. LVN 3 stated he was not aware that Resident 779 had an implanted pain pump. LVN 3 verified there was no orders or care plan addressing Resident 779's implanted pain pump. On 4/23/23 at 1017 hours, an interview was conducted with LVN 3 and the DON. The DON stated she was aware of Resident 779's implanted pain pump. The DON verified they should be monitoring Resident 779 for symptoms of CNS depression, including changes in levels of consciousness. The DON acknowledged there was no physician's orders for the implanted pain pump or order for how to monitor any changes in the resident's condition. The DON verified there should be a physician's order for the implanted pain pump, and they should have a care plan problem addressing how to monitor Resident 779's implanted pain pump.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the fluid restrictions for one of 25 final sampled residents (Resident 29). This failure had the potential to negatively impact Resident 29's health and complication associated with fluid deficit and overload. Findings: Review of the facility's P&P titled Dialysis Care revised 10/1/18, showed dialysis residents are given fluid based on the fluid restriction as ordered by the physician and a water pitcher will be provided at bedside, unless contraindicated. Review of the facility's P&P titled Fluid Restrictions revised 4/21/22, showed for each resident on fluid restriction, complete the fluid restriction guidelines, and keep in the resident's medical record. The Licensed Nurse will initiate strict intake measurement per the Attending Physician order, remove the water pitcher, and notify caregivers of the fluid restriction, and record any fluids given on the intake and output record. CNAs will record all fluid intake and output on the resident's medical record and provide the resident with fresh fluids according to the resident's care plan. 1. On 4/17/23 at 1433 hours, a concurrent interview and observation was conducted with Resident 29. Resident 29 stated the staff did not tell him if he was on a fluid restriction; however, he restricted his fluids himself. Resident 29's dialysis access site was observed on his left arm which was observed to have edema (swelling due to fluid retention). When ssked if the edema was addressed by the facility staff, Resident 29 stated he also had edema on both of legs and feet, and would raise his legs on pillows to help decrease the amount of edema. Medical record review for Resident 29 was initiated on 4/17/23. Resident 29 was admitted on [DATE], with diagnoses including end stage renal disease (kidneys no longer function properly) and dependence on renal dialysis. Review of the physician's order dated 4/4/23, showed a fluid restriction of 1000 ml/24 hours, with 360 ml given during meals and 640 ml provided by nursing. Review of the physician's order dated 3/31/23, showed an order to monitor the resident's intake and output every shift. Review of Resident 29's plan of care showed a care plan problem initiated on 4/5/23, addressing the resident's end stage renal disease requiring dialysis. However, further review of Resident 29's care plan failed to show a care plan intervention included Resident 29's fluid restriction as per the physician's orders. Review of Resident 29's Intake and Output record and Nutrition - Fluids record showed the following 24-hour fluid intake given by the LVNs and the CNAs to Resident 29: - 4/13/23, 650 ml and 1560 ml (total of 2210 ml) - 4/14/23, 690 ml and 1360 ml (total of 2050 ml) - 4/15/23, 600 ml and 780 ml (total of 1380 ml) - 4/16/23, 650 ml and 1370 ml (total of 2020 ml) Review of the change in condition evaluation dated 4/14/23, showed Resident 29 had newly developed bilateral lower extremity +4 edema (having a pitting anywhere over 6 mm in depth, taking over 30 seconds to rebound). On 4/20/23 at 0846 hours, a follow-up observation and concurrent interview was conducted with Resident 29. Resident 29 stated his left arm had always been swollen and they were concerned at his dialysis center regarding the swelling of his legs. A water jug filled up to 850 ml was observed on Resident 29's bedside table. Resident 29 stated the jug was given to him the day before. On 4/20/23 at 1009 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 29 was not on a fluid restriction, and he did not get any report of Resident 29 being on a fluid restriction. CNA 2 stated some dialysis residents had a fluid restriction and some did not. CNA 2 acknowledged there was a filled water jug present at Resident 29's bedside. On 4/20/23 at 1012 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 29 was on a fluid restriction of 1000 ml every 24 hours, and the nursing staff monitored Resident 29's fluid restriction. LVN 3 stated Resident 29 should not have the full amount of fluid at once and fluids should be given throughout the day. LVN 3 verified Resident 29 should not have a water jug at the bedside. On 4/20/23 at 1100 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated Resident 29 had a new onset of +4 bilateral lower extremity edema on 4/14 and no edema was present on admission. RN 1 acknowledged the edema could be caused by excessive fluid intake. RN 1 stated Resident 29 was currently on a fluid restriction and verified the above findings. On 4/20/23 at 1418 hours, a follow-up interview was conducted with RN 1. RN 1 stated Resident 29 had been noncompliant with his fluid restriction and had been taking in too much fluids. RN 1 acknowledged there was a problem regarding the fluid intakes reported by the LVNs and CNAs and acknowledged the records did not follow the fluid restriction ordered by the physician. Cross reference to F656, example #1.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the competency of the licensed nurses in assessing the dialysis access site for one of 25 final sampled resident (Resident 59). LVN 9 was unable to demonstrate competency in the assessment of the AV shunt site of Resident 59. This failure had the potential to put residents at risk for care not provided in a safe and competent manner. Findings: Review of the facility's P&P titled Staff Competency assessment dated [DATE], showed competency assessments will be performed upon hire during the employee's 90-day employment period, annually, or anytime new equipment or a procedure is introduced and as needed. Medical record review for Resident 59 was initiated on 4/17/23. Resident 59 was admitted on [DATE], and readmitted to the facility on [DATE]. Review of Resident 59's Order Summary Report showed a physician order dated 4/1/23, to monitor presence of bruit and thrill every shift. Review of Resident 59's plan of care showed a focus problem dated 1/3/23, to address the end stage renal failure and at risk for infection or bleeding at the catheter insertion site to left upper arm AV shunt. The interventions included to monitor for presence of bruit and thrill every shift. On 4/24/23 at 1037 hours, an interview was conducted with LVN 9. When asked LVN 9 how the dialysis access site was checked, LVN 9 stated to palpate the bruit and listen for the thrill using a stethoscope. On 4/24/23 at 1419 hours, an interview was conducted with the DON. The DON stated the left upper arm AV shunt was assessed by feeling the thrill and listening to the bruit using a stethoscope. The DON verified the above findings and stated the licensed nurses knew to assess the dialysis access site but confused of what it was called or what they were assessing for.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide pharmaceutical services for two of 25 final sampled residents (Residents 529 and 779) and one nonsampled resident (Resident 35) to meet the needs of each resident as evidenced by: * The facility failed to ensure Resident 529's oxycodone-acetaminophen (pain medication) was accurately reconciled. The number of tablets of oxycodone-acetaminophen removed showing on the Individual Narcotic Record did not match the number of tablets in the electronic MAR as administered to Resident 529. This failure had the possibility of diversion of controlled medications. * LVN 2 failed to provide the necessary instructions to Resident 35 for the proper technique on how to rinse her mouth after fluticasone-salmeterol inhaler (medication to decrease the inflammation of the airways) use. This failure had the potential for the resident to experience side effects including fungal infection in the mouth or throat. * The facility failed to ensure the availability of the prescribed medication for Resident 779. This failure had the potential to negatively affect the resident's health. Findings: 1. Review of the facility's P&P titled Medication Administration dated January 2012 showed the licensed nurse will chart the drug, time administered, and initial his/her name with each medication administration. Medical record review for Resident 529 was initiated on 4/20/23. Resident 529 was admitted on [DATE]. Review of the MDS dated [DATE], showed Resident 529 had a BIMS score of 15 (a score of 13-15 indicated cognitively intact). Review of the Order Summary Report dated 4/20/23, showed a physician's order dated 3/23/23, to administer oxycodone-acetaminophen 5-325 mg table by mouth every six hours as needed for moderate to severe pain. On 4/20/23 at 1112 hours, a controlled medication reconciliation for Resident 529 was conducted with LVN 5. Review of Resident 529's Individual Narcotic Record for the administration of oxycodone-acetaminophen showed oxycodone-acetaminophen was signed out by LVN 4 on 4/20/23 at 0430 hours, and by LVN 5 on 4/20/23 at 0730 hours. Resident 529's medication bubble pack (a package used to dispense medications) for oxycodone-acetaminophen showed one tablet remaining. The number of tablets in the bubble pack matched the number of oxycodone-acetaminophen tablets in the Individual Narcotic Record. However, review of Resident 529's electronic MAR dated April 2023 did not show oxycodone-acetaminophen were administered to Resident 529 on the dates and times (4/20/23 at 0430 hours, and by LVN 5 on 4/20/23 at 0730 hours) as shown in the Individual Narcotic Record. On 4/20/23 at 1115 hours, an interview was conducted with LVN 5. LVN 5 stated the facility's process for administering the PRN controlled medication was for the licensed Nurses to sign out the medication from the narcotic count sheet with the date and time, administer the medication to the resident, then document on the electronic MAR. LVN 5 verified she signed out and administered the oxycodone-acetaminophen to Resident 529 on 4/20/23 at 0730 hours; however, she did not document in the electronic MAR. LVN 5 stated not documenting in the electric MAR after administering narcotic medication created the possibility to medication diversion. On 4/21/23 at 0922 hours, an interview was conducted with Resident 529. Resident 529 stated she recalled asking and receiving her oxycodone-acetaminophen for her pain on 4/20/23, around four o'clock in the morning from a licensed nurse. Resident 529 stated she received her morning medications around eight o'clock in the morning on 4/20/23, but did not recall asking or receiving her pain medication oxycodone-acetaminophen. Resident 529 stated her pain was managed by the facility. On 4/21/23 at 1120 hours, an interview was conducted with the DON. The DON stated the licensed nurses should sign a narcotic medication out from the narcotic count sheet, administer the medication to the resident, then sign the electronic MAR. The DON stated signing out the medication on the narcotic count sheet and not documenting in the electronic MAR created the possibility of medication diversion. 2. Review of the manufacturer's instruction titled Patient Information: Instructions for Use for the fluticasone-salmeterol inhaler showed to rinse the mouth with water after breathing in the medicine, spit out the water and do not swallow it. Medical record review for Resident 35 was initiated on 4/20/23. Resident 35 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 35's Order Summary Report showed a physician's order dated 7/29/22, to administer fluticasone-salmeterol aerosol powder breath activated 100-50 mcg one inhalation inhale orally two times a day, and rinse mouth with water after use to avoid oral thrush. On 4/20/23 at 0818 hours, a medication administration observation for Resident 35 was conducted with LVN 2. During the fluticasone-salmeterol inhaler administration, LVN 2 was observed opening the inhaler, pushing down on the lever, then gave it to Resident 35 to use. Resident 35 was observed exhaling then placing her mouth around the mouthpiece of the inhaler and inhaled the medication. Then LVN 2 gave Resident 35 a small cup of water and instructed her to drink the water. LVN 2 did not provide instruction for Resident 35 to rinse her mouth with water as ordered by the physician. On 4/20/23 at 0935 hours, an interview was conducted with LVN 2. LVN 2 acknowledged she did not provide instruction for Resident 35 to rinse her mouth after the use of the inhaler. LVN 2 stated it was important for Resident 35 to rinse her mouth after the use of the inhaler to prevent oral thrush (fungal infection in the mouth or throat). On 4/21/23 at 1120 hours, an interview with the DON was conducted. The DON acknowledged the above findings. 3. Review of the facility's P&P titled Medication-Administration revised 1/1/21, showed the medications and treatments will be administered as prescribed to ensure compliance with the dose guidelines. On 4/17/23 at 1015 hours, during an initial tour of the facility, an interview was conducted with Resident 779. Resident 779 stated he was in a lot of pain, and it had been 20 hours since he got his tizanidine (muscle relaxant). Resident 779 stated in the facility, he got the tizanidine medication two times a day. Resident 779 stated he was not sure when the medication ran out and the facility did not have it in stock. On 4/17/23 at 1151 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 779 was able to make his needs known and took tizanidine for muscle spasms. LVN 3 stated the tizanidine was not available and they did not have it available in the pharmacy refill station. LVN 3 acknowledged the refill for Resident 779's tizanidine was delayed and they should have the medication available if they knew it was going to run out. Medical record review for Resident 779 was initiated on 4/17/23. Resident 779 was admitted to the facility on [DATE]. Review of Resident 779's H&P examination dated 4/7/23, showed Resident 779 had the capacity to understand and make decisions. Review of the physician's order dated 4/12/23 showed tizanidine HCl 100 mg two times a day for muscle spasm. Review of Resident 779's MAR dated April 2023 showed an administration of tizanidine HCl at 0900 hours on 4/16/23, and was not administered again until 2100 hours on 4/17/23. On 4/18/23 at 1046 hours, a follow-up interview was conducted with Resident 779. Resident 779 stated he did not get the tizanidine medication until the night prior and he had been in pain. Resident 779 stated he was very upset that his pain was not controlled properly and the tizanidine medication was the only medication that helped his pain to be tolerable. On 4/18/23 at 1149 hours, an interview was conducted with RN 1. RN 1 stated the expectation for Resident 779's pain level was to keep him comfortable and to not reach the level of severe pain. RN 1 stated LVN 3 was responsible for administering and ordering the medications. RN 1 stated she was not aware the tizanidine medication had run out until the beginning of her shift on 4/17/23. RN 1 verified they should have not run out of Resident 779's medication, and a refill should have been requested prior to the medication running out. On 4/19/23 at 0930 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged the above findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 4) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 4's orthostatic blood pressure (measure the blood pressure while laying down or sitting and again upon standing up) was monitored as ordered by the physician related to the use of an antipsychotic medication. This failure had the potential for the resident to experience adverse consequences from the psychotropic medication. Findings: Medical record review for Resident 4 was initiated on 4/18/23. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed the following physician's orders: - a physician's order dated 12/23/22, for Risperdal (antipsychotic medication) 1 mg one tablet by mouth once a day; - an order dated 12/23/22, for Zyprexa (antipsychotic medication) 10 mg one tablet by mouth in the evening, and - an order dated 12/21/22, to check for orthostatic hypotension by checking the blood pressure in two positions (lying down and sitting) once a day every Sunday related to the use of the Risperdal and Zyprexa. Review of the Medication Administration Record (MAR) for February, March, and April 2023 showed the orthostatic blood pressure (sitting and lying) was scheduled to be monitored every Sunday at 0900 hours. However, the blood pressure readings for both positions (lying and sitting) were the same as follows: - On 2/5/23, the blood pressure reading for sitting position was 124/79 mmHg and for lying position was 124/79 mmHg. - On 2/12/23, the blood pressure reading for sitting position was 124/70 mmHg, and for lying position was 124/70 mmHg. - On 2/19/23, the blood pressure reading for sitting position was 128/70 mmHg and for lying position was 128/70 mmHg. - On 2/26/23, the blood pressure reading for sitting position was 130/74 mmHg and for lying position was 130/74 mmHg. - On 3/5/23, the blood pressure reading for sitting position was 120/80 mmHg and for lying position was 120/80 mmHg. - On 3/19/23, the blood pressure reading for sitting position was 130/80 mmHg and for lying position was 130/80 mmHg. - On 3/26/23, the blood pressure reading for sitting position was 124/79 mmHg and for lying position was 124/79 mmHg. - On 4/9/23, the blood pressure reading for sitting position was 126/80 mmHg and for lying position was 126/80 mmHg. - On 4/16/23, the blood pressure reading for sitting position was 122/70 mmHg and for lying position was 122/70 mmHg. - On 4/23/23, the blood pressure reading for sitting position was 120/80 mmHg and for lying position was 120/80 mmHg. On 4/20/23 at 1619 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed the medical record and verified the licensed nurses were not checking for orthostatic hypotension accurately because of the same blood pressure reading for both positions. RN 1 stated the monitoring of the blood pressure was important and should have been accurate because the resident was taking medications that causes hypotension. On 4/24/23 at 1129 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed of the above findings and verified the findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure the medications and influenza test kits were appropriately stored. * The unopened insulin bottle and insulin pen were stored at room temperature in Medication Cart 1 instead of storing in the refrigerator as per the pharmacy labels. * The facility failed to ensure proper storage of influenza test kits. These failures had the potential to alter the efficacy of the stored medications and cause inaccurate influenza results. Findings: 1. On 4/20/23 at 1112 hours, an observation of Medication Cart 1 and concurrent interview was conducted with LVN 5. A vial of unopened Novolin R (medication used to lower blood sugar) and an unopened insulin glargine pen (medication used to lower blood sugar) were stored at room temperature in Medication Cart 1. The pharmacy label on the Novolin R vial showed to refrigerate the unopened bottle and may store at room temperature after opening. The pharmacy label on the insulin glargine pen showed to refrigerate the unopened cartridges or pens and store the cartridge or pen in use at room temperature. LVN 5 verified the findings and stated the unopened insulins should be stored in the refrigerator. On 4/20/23 at 1418 hours, a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated it was important to store unopened insulin vial and/or pen inside the refrigerator until use to prevent denaturing (altering the natural qualities) of the insulin and decreasing its efficacy. On 4/21/23 at 1120 hours, an interview was conducted with the DON. The DON acknowledge the above findings. 2. On 4/17/23 at 1045 hours, a tour of the resident food storage area and concurrent interview were conducted with the ADON. When asked where the resident food brought in by the visitors were stored, the ADON stated the resident food were kept in the resident nourishment refrigerator which is located inside the medication room. Upon inspection of the resident nourishment refrigerator, three bags filled with multiple specimen testing vials and swabs were observed in the left bottom drawer. A label on the bag showed, Influenza swab only. Do not use for COVID test. When asked for the reason the influenza kits were kept in the resident nourishment fridge, the ADON stated he was unsure. The ADON further stated the nurses stored the IV antibiotics in the resident nourishment refrigerator if the medication refrigerator was full. On 4/17/23 at 1054 hours, a review of the resident nourishment fridge and concurrent interview were conducted with the DON. The DON verified three bags filled with influenza vials and swabs were in the resident nourishment fridge. When asked if the nurses could store medications in the resident nourishment fridge, the DON stated they did not mix medications with the resident nourishment fridge. When asked if it was okay to store the influenza testing supplies in the resident nourishment fridge, the DON stated she would have to ask the IP. On 4/17/23 at 1101 hours, an interview was conducted with the IP. When asked about the influenza testing supplies, the IP stated the influenza supplies did not have to be refrigerated. The IP further stated the influenza testing supplies should not be in the resident nourishment fridge. On 4/19/23 at 1036 hours, the RD Regional Consultant, RD Facility Consultant, Dietary Service Supervisor, and DON were infrofmed and acknowledged the above findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide one nonsampled residents (Resident 44) an entree substitute of similar nutritive value when Resident 44 was served a cheese quesadilla for lunch. This failure posed the risk for Resident 44's nutritional needs to not be met. Findings: Review of the facility's P&P titled Menu revised 4/2014 showed a substituted food item should be comparable in nutritional value. On 4/18/23 at 1155 hours, a concurrent observation and interview with Dietary Staff 3 was conducted during kitchen rounds. Dietary Staff 3 was observed cooking a cheese quesadilla. Dietary Staff 3 stated she was preparing the cheese quesadilla as a menu substitute for the lunch meal. Dietary Staff 3 further stated she prepared the cheese quesadilla with one tortilla and two ounces of shredded cheese. On 4/18/23 at 1215 hours, during the lunch meal tray line observation, Resident 44's meal tray was observed plated with one serving of cheese quesadilla, carrots, and potato salad. Resident 44's meal ticket showed he was on a regular diet. On 4/18/23 at 1230 hours, during the lunch tray line observation, a review of the facility recipe for a cheese quesadilla and concurrent interview was conducted with Dietary Staff 3. The cheese quesadilla recipe showed directions to add ½ cup of cheese per tortilla. When asked to show how she measured the shredded cheese for the cheese quesadilla, Dietary Staff 3 pointed to the facility's Portion Controlled Chart. Dietary Staff 3 stated she used the #16 blue serving scoop, which provided two ounces of cheese equivalent to ¼ cup of cheese and one flour tortilla. Review of the facility's resident menu titled Spring Cycle Menu dated 4/18/23, showed three ounces of BBQ chicken as the main entrée for the regular diet. Review of the facility's document, titled Nutrition Facts - Chicken Controlled Vacuum Packaging Thigh Boneless/Skinless dated 4/18/23, showed three ounces of BBQ chicken served for the lunch meal on 4/18/23, provided 14.62 g of protein. Review of the nutrition fact sheets for the shredded cheese and tortilla used to make the cheese quesadilla served as a lunch substitute on 4/18/23, showed the following: - [Casa Solana] Monterey [NAME] Cheese: 1/3 cup shredded cheese provided seven grams of protein. - [Romero's] Flour Tortillas: one tortilla provided two grams of protein. One tortilla and two ounces of cheese used to make the cheese quesadilla food substitute was equivalent to 7.25 g of protein, which was 7.37 g of protein less than the BBQ chicken which was the main lunch entrée on 4/18/23. On 4/19/23 at 0833 hours, an interview was conducted with the RD Regional Consultant. When asked what the facility standard was for substituted food items, the RD Regional Consultant stated substituted food items should be of equivalent nutritive values to the food listed on the regular menu. On 4/19/23 at 1036 hours, the RD Regional Consultant, RD Facility Consultant, Dietary Service Supervisor, and DON were informed of the findings. They acknowledged the cheese quesadilla was not equivalent in protein content to the BBQ chicken entrée served for the lunch meal.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the policy on resident food brought by visitors was followed. * The facility failed to ensure the staff were aware of the process for storing and discarding the resident food brought by the visitors. * The facility failed to ensure the staff were educated on safe food handling practices when handling the resident food brought in by the visitors. * The facility failed to ensure the policy, guidelines, and safe food handling practices were communicated to the resident's family/visitors who brought the resident food from the outside. These failures had the potential to cause foodborne illness to the residents who received food brought by the visitors. Findings: 1. Review of the facility's P&P titled Food Brought in by Visitors revised 6/2018 showed food brought from the outside must be labeled, dated, and discarded after 48 hours. On 4/17/23 at 1045 hours, a tour of the resident food storage area and concurrent interview were conducted with the ADON. Review of the sign in front of the resident nourishment refrigerator stated, Once the food is open, put the open date, and don't keep for more than three days. Please inform the resident before disposing it. Sealed ones, please check expiration date. When asked what the process was for handling food brought to the residents by the visitors, the ADON stated they stored the residents' food in a fridge for three days. On 4/18/23 at 0933 hours, an interview was conducted with LVN 1. When asked what the process was for handling food brought to the residents by the visitors, LVN 1 stated the facility stored the residents' food in the refrigerator for one day. 2. Review of the facility's P&P titled Food Brought in by Visitors revised 6/2018 showed the facility must ensure safe food handling for food brought into the facility, including safe reheating and hot/cold holding, and handling of leftovers. On 4/18/23 at 0933 hours, an interview was conducted with LVN 1. When asked if she received training on how to reheat the residents' food, she stated she did not receive training on reheating food. On 4/18/23 at 1508 hours, an interview and concurrent facility document review was conducted with the RD Regional Consultant. When asked what should be included in an in-service related to safe food handling, the RD Regional Consultant stated safe food handling in-services should include reheating food guidelines and proper food storage. Review of the facility in-service education form dated 8/5/22, showed the staff were in-serviced to store the resident food brought by visitors for up to 48 hours. When asked if that in-service included safe food handling practices, the RD Regional Consultant verified the in-service did not cover proper reheating food guidelines or storage of resident food. On 4/18/23 at 1523 hours, an interview and concurrent facility document review was conducted with the DSD. When asked if she provided training to the facility staff regarding safe food handling practices, the DSD stated she had not done any in-services. Upon review of the facility in-service education form dated 8/5/22, the DSD verified the in-service did not cover safe food handling, including reheating food guidelines or resident food storage. 3. Review of the facility's P&P titled Food Brought in by Visitors revised 6/2018 showed the resident and families will be provided the policy about food brought in by visitors as part of the admission packet. On 4/18/23 at 1547 hours, an interview and concurrent facility document review was conducted with the Admissions Director. Upon review of the resident admission packet titled California Standard admission Agreement For Skilled Nursing Facilities and Intermediate Care Facilities dated 5/11 showed information regarding the resident food brought in by the visitors was not found. The Admissions Director reviewed the facility's policy, Food [NAME] in by Visitors, revised 6/2018 and verified she could not find information regarding this policy in the resident admissions packet. On 4/19/23 at 1036 hours, the RD Regional Consultant, RD Facility Consultant, Dietary Service Supervisor, and DON were informed and acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of 25 final sampled residents (Residents 75 and 100) were accurate and complete. * Resident 75's and 100's MARs had multiple entries of medication and treatment missing initials of the license nurses. This failure created the risk of not knowing if the medications administered. Findings: Review of the facility's P&P titled Medication Administration dated 1/1/12 showed the license nurse will chart the drug, time administered and initial his or her name with each medication administration and sign full name and title on each page on the MAR. Holding medication: whenever a medication is held for any reason, the hours it was held must be initiated and circled in the MAR by the responsible license nurse. The license nurse will document on the back of MAR, noting the time and reason the medication was held. Refusing medication: if the resident is refusing to take medications, time of refusal must be circled in the MAR and initialed by the license nurse who is passing medications and documentation will be entered on the back of MAR stating the reason for the refusal. 1. Medical record review for Resident 82 was initiated on 4/17/23. Resident 82 was admitted to the facility on [DATE]. Review of the Order Summary Report dated 4/19/23, showed the following: - a physician's order dated 12/27/21, to administer aspirin 81 mg one tablet by mouth one time a day for DVT prophylaxis. - a physician's order dated 11/6/20, to administer Benazepril HCL tablet 20 mg one tablet by mouth one time a day for hypertension, hold if systolic blood pressure less than 110 mmHg or heart rate less than 60 beats per minute. - a physician's order dated 5/27/21, to administer blood sugar check in the morning before breakfast for DM. - a physician's order dated 8/10/22, to administer Januvia tablet 100 mg one tablet by mouth one time a day for DM, give with meals. - a physician's order dated 12/5/22, to monitor temperature, pulse, respiration, blood pressure, and oxygen saturation level and symptoms every day shift daily for Covid screening or monitoring. - a physician's order dated 3/13/21, to administer vitamin C 500 mg one tablet by mouth one time a day for dietary supplement. - a physician's order dated 11/24/22, to administer vitamin D 1000 IU by mouth one time a day for supplement. - a physician's order dated 11/17/20, to administer Sinemet tablet 25-100 mg one tablet by mouth two times a day for Parkinson's disease. - a physician's order dated 11/6/20, to monitor pain. However, review of the MAR for March 2023 showed the following entries were blank or not initialed by the license nurses: - On 3/14 and 3/15/23 at 0900 hours, the entries for Aspirin 81 mg one tablet by mouth one time a day, vitamin D 1000 IU by mouth one time a day, vitamin C 500 mg one tablet by mouth one time a day, Sinemet tablet 25-100 mg give one tablet by mouth two times a day, and Benazepril Hydrochloride tablet 20 mg one tablet by mouth one time a day. - On 3/12, 3/13, 3/14 (night), and 4/15/23 (day), for the pain monitoring. - On 3/8, 3/13, 3/14, 3/15, and 3/20/23 at 0630 hours, for the blood sugar check monitoring in the morning for DM before breakfast. - On 3/14 and 3/15/23 at 0800 hours, for Januvia tablet 100 mg 1 tablet by mouth one time a day. - On 3/14 and 3/15/23 day, for the resident's temperature, pulse, respiration, blood pressure, and oxygen SAT and symptoms daily everyday shift for Covid screening or monitoring. - On 3/15/23 at 0800 hours, for Macrobid capsule 100 mg 1 capsule by mouth two times a day. - On 3/12, 3/13, 3/14 (at night) and 3/15/23 (day time), for bowel and bladder training. On 4/24/23 at 1020 hours, an interview and concurrent medical record was conducted with RN 1. RN 1 was asked regarding the medications on the MAR were not initialed by the license nurse. RN 1 stated they should not have left it blank. The nurse should document if the resident refused, or if went out of the facility, or other code 9 to see progress notes. RN 1 acknowledged the medication record was incomplete . They did not know if the ordered medications or treatment had been given or not. RN 1 verified the findings. On 04/24/23 at 1035 hours, an interview and concurrent medical record was conducted with LVN 5. LVN 5 stated if the nurse needed to call the physician for any change of condition, they should have documented code 2 meaning the residents refused or 9 to see the progress notes. The nurse should not leave the MAR blank, if they did not document that meant the license nurse did not monitor, or they did not give the medicine. LVN 5 verified the above findings. 2. Review of Resident 75's medical record was initiated on 4/17/23. Resident 75 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 75's MAR for March 2023 showed the following entries were left blank or not initialed by the licensed nurses: - On 3/16/23 at 1700 hours, for Amlodipine Besylate 10 mg 1 tablet by mouth in the afternoon for hypertension hold if systolic blood pressure less than 110 mmHg. - On 3/13 and 3/17/23 at 2100 hours, for Insulin glargine subcutaneous solution 100 unit per ml ( insulin Glargine) inject 45 unit subcutaneously in the evening for DM, Morphine sulfate ER extended release 15 mg one tablet by mouth at bedtime for pain management, Tamsulosin Hydrochloride capsule 0.4 mg give one capsule by mouth at bedtime for BPH, and Melatonin tablet 3 mg give three tablets by mouth at bedtime for circadian rhythm. - On 3/13, 3/14, and 3/20/23 at 0630 hours, for Pantoprazole sodium tablet delayed release 40 mg give one tablet by mouth one time a day for GERD before meal. - On 3/13 and 3/16/23 at 2100 hours, for Tamsulosin Hydrochloride capsule 0.4 mg give one capsule by mouth at bedtime for BPH. - On 3/16/23 at 1700 hours, for metropolol tartrate oral tablet 50 mg give one tablet by mouth two times a day for hypertension. - On 3/13 and 3/16/23 in the evening, for pain monitoring scale monitoring level of pain. - On 3/13/23 at 2100 hours, for gabapentin capsule 400 mg one capsule by mouth four times a day for neuropathy. - On 3/13/23, 3/14/23, 3/20/23 at 0630 hours, 3/13/23 and 3/16/23 at 2100 hours, for insulin lispro inject per sliding scale subcutaneously before meals and at bedtime for DM. - On 3/13/23 at 0600, 3/14/ 23 at 0000 and 0600 hours, 3/16/23 at 1800 hours, and 3/20/23 at 0600 hours, for monitoring of blood pressure for Clonidine use. On 4/24/23 at 1050 hours, an interview and concurrent with medical record review was conducted with RN 1. RN 1 was asked if there were any nursing notes or documentation regarding the medications or treatment that were not initialed in MAR, RN 1 stated they should have not been left blank, it should have document if the resident refused or code 9 for progress notes if the resident had a change of condition or went out of the facility. RN 1 acknowledged the incomplete medication record for the resident. RN 1 verified the above findings.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

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Based on interview, facility document review, and facility P&P review, the facility failed to ensure the CNAs' performance evaluations were completed every 12 months for the CNAs' competency evaluations reviewed. The lack of CNAs' performance review had the potential for the staff to not maintain competencies to provide the residents with needed and appropriate care and services. Findings: Review of the facility's P&P titled Staff Competency Assessment revised 3/2022 showed competency assessment would be preformed upon hire during employee's 90-day employment period, annually, or anytime new equipment or a procedure introduced and as needed. On 4/21/23 at 1506 hours, the employees' files review was conducted with the DSD. The DSD stated she was not able to find the performance evaluation records for all CNAs who were in the facility for more than a year for 2022 and 2023. The DSD stated she started to work for the facility in September 2023 and was verbally told the performance evaluations for the CNAs were completed in June 2022; and the next performance evaluations were due in June 2023. When asked if she verified the performance evaluations were completed for all CNAs in 2022, the DSD stated no. The DSD stated she should have verified with the previous staff if the yearly performance evaluations for the CNAs were completed in 2022. On 4/21/23 at 1630 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the food preparation equipment was air dried. * The facility failed to ensure the meal trays were in good condition. * The facility failed to ensure the food service spatulas were in good condition. * The facility failed to ensure the food items in the resident refrigerator were labeled and dated. * The facility failed to ensure the backflow prevention of one food preparation sink was maintained. * The facility failed to ensure the door frame of the kitchen walk-in refrigerator was free from residue and in good condition. * The facility failed to ensure the kitchen cleaning equipment were stored off the floor. These failures had the potential to expose the residents who consumed food prepared in the kitchen to foodborne illnesses. Findings: Review of the CMS 672 form completed by the facility on 4/17/23, showed 118 of 127 residents consumed food prepared from the facility's kitchen. 1. Review of the facility's P&P titled Pot and Pan Cleaning revised 10/2014 showed items should be stored once fully air dried. According to the USDA Food Code 2022 Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried . On 4/17/23 at 0830 hours, an initial tour of the kitchen and concurrent interview was conducted with the DSS. One large blender and one small blender were observed covered and stored wet. Three metal steam tray pans were also observed stacked and stored wet. The DSS verified the findings and stated there was not a lot of room in the kitchen to air dry. 2. Review of the facility's P&P titled Discarding of Chipped/Cracked Dishes and Single Service Items revised 10/2014 showed chipped or cracked dish ware shall be discarded. According to the USDA Food Code 2022 Section 4-201.11 Equipment and Utensils, equipment and utensils shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions. On 4/18/23 at 1208 hours, a concurrent observation of the lunch meal tray line and interview was conducted with the RD Regional Consultant. More than 10 green meal trays were observed chipped with sharp edges. The RD Regional consultant verified those resident meal trays were chipped and should not be used. When asked if the chipped meal trays were a cleanable surface, the RD Regional Consultant confirmed those meal trays were no longer cleanable. 3. According to the USDA Food Code 2022 Section 4-101.11 Characteristics, materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: .(E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 4/17/23 at 0830 hours, an initial tour of the kitchen and concurrent interview was conducted with the DSS. Four rubber spatulas in the food preparation area were observed chipped and cracked. When asked if the spatulas should be used to prepare resident meals, the DSS stated the chipped spatulas should not be used because a risk of the chipped spatulas getting into the residents' food. 4. Review of the facility's P&P titled Food Brought in by Visitors revised 6/2018 showed food brought from the outside must be labeled, dated, and discarded after 48 hours. On 4/17/23 at 1045 hours, a tour of the resident food storage area and concurrent interview was conducted with the ADON. Review of the sign in front of the resident nourishment refrigerator showed, Once the food is open, put the open date, and don't keep for more than three days. Please inform the resident before disposing it. Sealed ones, please check expiration date. Inside the resident nourishment refrigerator, one box containing more than 10 pieces of black dried food resembling prunes was observed undated and unlabeled. When asked if he knew what was inside the box, the ADON stated he was unsure what the food item was. The ADON proceeded to discard the contents in the box. 5. According to the USDA Food Code 2022 Section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 4/18/23 at 1503 hours, a kitchen tour and concurrent interview was conducted with the facility Maintenance Director, DSS, and RD Regional Consultant. Upon inspection of the food preparation sink located next to the kitchen stove, the drainpipe of the food preparation sink was plumbed directly into the wall. The Maintenance Director, DSS, and RD Regional Consultant verified the food preparation sink did not have an air gap. When asked about the lack of an air gap, the Maintenance Director stated he did not know the food preparation sink needed an air gap. 6. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-contact surfaces and Utensils.C. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, residue and other debris. On 4/17/23 at 0809 hours, an initial tour of the kitchen and concurrent interview was conducted with the DSS. The wooden door frame of the walk-in refrigerator was observed chipped with a black sticky residue. When asked if the door frame was a cleanable surface, the DSS verified the door frame was chipped and stated it was no longer a cleanable surface. 7. According to the USDA Food Code 2022 Section 6-501.113 Storing Maintenance Tools. Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be: .(B) Stored in an orderly manner that facilitates cleaning the area used for storing the maintenance tools. On 4/17/23 at 0857 hours, a tour of the kitchen and concurrent interview was conducted with the DSS. Two brooms were observed stored on the floor of the janitor closet. When asked if brooms should be stored on the floor, the DSS stated the brooms should not be stored on the floor. On 4/19/23 at 1036 hours, the RD Regional Consultant, RD Facility Consultant, Dietary Service Supervisor, and DON were informed and acknowledged the above findings.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and facility P&P review, the facility failed to ensure multiple waste bins were properly maintained. This failure had the potential to cause unsafe and unsanitary conditions in the facility. Findings: Review of the facility P&P titled Garbage and Trash Can Use and Cleaning revised 10/2014, showed garbage and trash cans must be covered. On 4/17/23 at 1125 hours, during the facility rounds, two large dumpsters and two small trash cans located outside of the building next to the laundry room were observed overfilled with their lids open. Additionally, four large plastic bags of garbage were observed on the floor next to the large, overfilled dumpster. On 4/17/23 at 1133 hours, Housekeeper 1 was observed discarding additional bags of garbage on the floor next to the large, overfilled dumpster. On 4/17/23 at 1140 hours, a tour of the facility's garbage disposal area and concurrent interview was conducted with the Housekeeping Supervisor. The Housekeeping Supervisor stated in total, the facility had five large garbage dumpsters and two small trash cans. During a facility tour, an additional two large dumpsters were observed overfilled with their lids open. The Housekeeping Supervisor verified the four large dumpsters and small trash cans were overfilled. When asked for the reason of the overfilled garbage disposals, the Housekeeping Supervisor stated they did not have Sunday trash service, so their trash bins were overfilled from the weekend. On 4/19/23 at 1036 hours, the RD Regional Consultant, RD Facility Consultant, Dietary Service Supervisor, and DON were informed and acknowledged the above findings.

Jan 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to immediately notify the family member of a change in condition for one of six sampled residents (Resident 1). This had the potential to negatively impact to Resident 1's psychosocial and physical wellbeing and prevent the family from being fully aware of the resident's treatments and understand the course of actions. Findings: Review of the facility's P&P titled Change of Condition Notification revised date 4/1/15, showed the facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative or an interested family member if known when the resident endures a significant change in their condition caused by, but not limited to a significant change in the resident's physical, mental, or psychosocial status among others. The policy also showed the licensed nurse will notify the family or surrogate decision-makers of any changes in the resident's condition as soon as possible. Closed medical record review for Resident 1 was initiated on 12/22/22. Resident 1 was readmitted to the facility on [DATE], and discharged from the facility on 12/16/22. Review of Resident 1's face sheet showed one family member was listed as the emergency contact with the telephone numbers. Review of Resident 1's MDS dated [DATE], showed Resident 1 had intact cognition. Review of Resident 1's Change in Condition Evaluation dated 12/16/22 at 0150 hours, showed Resident 1 had low blood pressure of 88/63 mmHg and elevated heart rate of 130 beats per minute. There was no documented evidence to show Resident 1's family member was made aware of the change in condition. Further review of Resident 1's medical record failed to show documentation the family member was notified when the resident had a change in condition and was sent to the hospital. On 12/23/22 at 0735 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified the above findings and stated she assumed RN 1 called the family since the RN 1 called all the time. On 12/23/22 at 0746 hours, an interview and concurrent medical record review was conducted with RN 1. When asked what the process was regarding notifying the responsible party or emergency contact during a change of condition, RN 1 stated it was usually a challenge to call late at night or early morning, but she usually called the family member as soon as possible regardless of if the resident was the responsible party. When asked about Resident 1's change of condition on 12/16/22, RN 1 verified the above findings and stated she felt bad. RN 1 stated she wanted to make sure which hospital Resident 1 was transferred to and if Resident 1 was admitted , but things got in the way. RN 1 stated she also assumed LVN 4 called the family member since she saw LVN 4 doing her own documentation. On 12/23/22 at 0900 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the findings and stated for a change in condition, the family/emergency contact should be notified.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper accounting and safeguarding of the controlled medications for two out of six sampled residents (Residents 2 and 4) in order to prevent loss, diversion, or accidental exposure. * LVN 1 failed to sign Residents 2 and 4's narcotic count sheetsto show when the LVN had administered the controlled medications. This failure posed the risk for loss or diversion of controlled medications. Findings: According to the facility's P&P titled Controlled Substance (undated) showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): - date and time of administration, disposition, and at the end of each shift - amount administered - signature of the nurse administering the dose, completed after the medication wasactually administered. On 12/22/22 at 1120 hours, a concurrent inspection of Medication Cart A, interview, and medical record review was conducted with LVN 1. 1. Review of Resident 2's medical record was initiated on 12/22/22. Resident 2 was readmitted to the facility on [DATE]. Review of the Medication Administration Record from 12/1/22 to 12/31/22, showed an order dated 12/29/22, to administer oxycodone hydrochloride (a controlled narcotic medication for pain) 10 mg one tablet by mouth every eight hours as needed for pain management. The medication was administered on 12/22/22 at 0853 hours. Review of Resident 2's Individual Narcotic Record showed the remaining quantity for the oxycodone hydrochloride immediate release 10 mg was 60 tablets. However, review of Resident 2's medication bubble pack for the oxycodone hydrochloride immediate release 10 mg medication showed only 59 tablets remained in the bubble pack instead of 60 tablets. 2. Review of Resident 4's medical record was initiated on 12/22/22. Resident 4 was admitted to the facility on [DATE]. Review of the Medication Administration Record from 12/1/22 to 12/31/22, showed an order dated 5/26/22, to administer oxycodone hydrochloride 10 mg by mouth every four hours as needed for severe pain. The medication was administered on 12/22/22 at 1033 hours. Review of Resident 4's Individual Narcotic Record showed as of 12/22/22, the remaining quantity for oxycodone hydrochloride immediate release 10 mg was 14 tablets. However, review of Resident 4's medication bubble pack for oxycodone hydrochloride immediate release 10 mg showed only 12 tablets remained in the bubble pack instead of 14 tablets. On 12/22/22 at 1120 hours, a concurrent observation, interview, and facility record review was conducted with LVN 1. When asked about the process on how to dispense the narcotic medications, LVN 1 stated to pour, sign, then administerthe medication. LVN 1 acknowledged the findings and stated no excuse, she should have signed Residents 2 and 4's Individual Narcotic Records as soon as she removed the medication in the bubble pack to ensure the narcotics were not diverted. On 12/22/22 at 1146 hours, a concurrent interview, medical record, and facility record reviews were conducted with the DON. The DON verified the findings.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medication was administered as ordered for one of three sampled residents (Resident 1) when LN 1 failed to verify the correct medication was taken from the E-kit as per the facility's P&P and administered the wrong medication to Resident 1. This failure had the potential to negatively impact Resident 1's well-being. Findings: Review of the facility's P&P titled Medication Administration dated 1/2012 showed the nursing staff will keep in mind the seven rights of medication when administering the medications. The following are the seven rights of medication: right medication, right amount, right resident, right time, right route, the resident has the right to know what the medication does, and the resident has the right to refuse the medication (unless court ordered). Review of Resident 1's medical record was initiated on 1/4/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed an order dated 12/16/22, to administer potassium chloride 40 mEq (a supplement that is used to prevent or treat low levels of potassium) by mouth for one time from the E-kit. Review of Resident 1's Change in Condition Evaluation form dated 12/16/22,showed LN 1 pulled four tablets of clonidine 0.1 mg (medication used to treat high blood pressure) from the E-kit and administered to Resident 1 instead of four tablets of potassium chloride 10 mEq as ordered. On 1/4/23 at 1055 hours, an interview was conducted with the DON. The DON verified LN 1 had administered the wrong medication to Resident 1 on 12/16/22. On 1/4/23 at 1122 hours, an interview was conducted with LN 1. LN 1 acknowledged she did not check if the medication taken from the E-kit was the right medication prior to administering to Resident 1. LN 1 verified the wrong medication had been administered to Resident 1.

Nov 2022 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to report an allegation of resident-to-resident abuse between two of four sampled residents (Resident 3 and Resident 4) to the Long-Term Care (LTC) Ombudsman. This failure put the resident at risk for further abuse. Findings: Review of the facility's P&P titled Abuse - Reporting and Investigations revised March 2018 showed the Administrator or designated representative will send a written report of Suspected Dependent Adult/Elder Abuse (SOC 341) to the Ombudsman, law enforcement, and CDPH, L&C within two hours. On 10/24/22, CDPH, L&C Program received the SOC 341 form. Review of the SOC 341 form (undated) showed on 10/23/22 at 0725 hours, Resident 3 alleged her roommate (Resident 4) pushed her. Resident 3 sustained a skin tear on the right eyebrow. However, there was no documented evidence the SOC 341 was sent to the LTC Ombudsman as per the facility's P&P. Review of the facility's internal investigation report dated 10/27/22, failed to show documented evidence a fax confirmation received when the SOC 341 was sent to the LTC Ombudsman. a. Medical record review for Resident 3 was initiated on 10/25/22. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's History and Physical examination dated 8/10/22, showed Resident 3 did not have the capacity to understand and make decisions. Review of Resident 3's Change of Condition note dated 10/23/22 at 0725 hours, showed Resident 3 was found on the floor with a laceration and bump on the right forehead. Further review of Resident 3's medical record showed Resident 3 was sent out to the acute care hospital. b. Medical record review for Resident 4 was initiated on 10/25/22. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MDS dated [DATE], showed Resident 4 had severe cognitive impairment. On 10/25/22 at 0944 hours, a telephone interview was conducted with the LTC Ombudsman. When asked, the LTC Ombudsman denied receiving the SOC 341 form regarding Residents 3 allegation of abuse by Resident 4. On 10/25/22 at 1720 hours, an interview was conducted with the DON. When asked, the DON was unable to provide documented evidence of a fax confirmation received to show when the SOC341 was sent to the LTC Ombudsman. On 10/28/22 at 1529 hours, an interview was conducted with RN 1. RN 1 stated she completed the SOC 341, however, forgot to fax the report to the LTC Ombudsman. RN 1 further stated she was not sure if the incident should be reported to the LTC Ombudsman. On 10/28/22 at 1608 hours, an interview was conducted with the Administrator. The Administrator acknowledged the above finding and verified the abuse allegation should have been reported immediately to the LTC Ombudsman as per the facility's P&P.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate information was provided to the receiving healthcare provider when one of four sampled residents (Resident 1) was transferred to the acute care hospital emergency department. This failure had the potential for the receiving hospital to not have the necessary information to ensure a safe and effective transition of care. Findings: Review of the facility's P&P titled Discharge and Transfer of Residents revised February 2018 showed when a resident is discharged , the nursing staff must document the following information in the resident's medical record including the condition and diagnoses of the resident at the time of discharge or final disposition. Medical record review for Resident 1 was initiated on 10/25/22. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's SNF/NF to Hospital Transfer Form dated 10/18/22 and 10/19/22, showed Resident 1 was transferred to the acute care hospital emergency department. The skin/wound care section showed Resident 1 had no other wound or bruise present. However, the Treatment Administration Record for October 2022 showed Resident had a right heel diabetic ulcer and a moisture associated skin disorder on his buttocks. On 10/28/22 at 1058 hours, an interview and concurrent medical record review was conducted with Treatment Nurse 1. Treatment Nurse 1 verified and acknowledged the above findings and further stated that it should have been documented for the continuity of care when transferring residents to the acute care hospital. On 10/28/22 at 1239 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified and acknowledged the above finding. The ADON further stated it was a good practice to document the skin condition on Resident 1's transfer form for continuity of care. On 11/18/22 at 1605 hours, an interview was conducted with the DON. When asked about what condition of the resident at the time of discharge meant, the DON replied it was the head-to-toe assessment of the resident upon discharge. The DON was informed and acknowledged the above finding.

Jan 2020 22 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 62 was initiated on 1/28/2020. Resident 62 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Physician Orders for Life-Sustaining Treatment (POLST) dated 11/21/16, under Section D, Information and Signatures, showed Resident 62 had no advance directive. The form was signed by Resident 62 and a family member. Review of Advance Healthcare Directive (AHCD) Acknowledgement form dated 10/16/19, showed Resident 62 had signed the paperwork, but nothing on the form had been completed by the facility. The form did not show if Resident 62 had a current advanced directive. The form also did not show if the facility had discussed with Resident 62 his rights to receive information regarding an advanced directive. Review of the MDS dated [DATE], showed Resident 62 was cognitively intact. On 01/28/2020 at 1005 hours, an interview was conducted with Resident 62. Resident 62 stated he had signed several things presented to him on his admission in October 2019, but could not recall if the facility had discussed an advance directive with him. On 01/29/2020 at 0918 hours, an interview and concurrent facility document review for Resident 62 was conducted with the SSD. The SSD stated the process was to have a resident upon admission, complete the advanced directive acknowledgement form with a licensed staff member. The licensed staff member was to ask about an advanced directive and offer information to the resident if they were interested in completing an advanced directive. The SSD verified Resident 62's POLST was dated 11/21/16, and showed no advanced directive. The SSD reviewed the Advance Healthcare Directive (AHCD) Acknowledgement Form dated 10/16/19, and verified it was blank except for the signatures of Resident 62 and a staff member. The SSD stated Resident 62 could have formulated an advanced directive between the date on the POLST and the date on his most recent admission. The SSD was unable to show documentation the facility provided Resident 62 with written information regarding his right to formulate an advance directive. The SSD verified the above findings. Based on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding the advance directives and/or obtain and maintained copies of the advance directives in the medical records for four of 29 final sampled residents (Residents 45, 62, 527, and 528). These failures had the potential for confusion or failure to provide care and life sustaining measures in accordance with the residents' treatment wishes. Findings: 1. Review of the facility's P&P titled Advance Directives revised July 2018 showed the admission staff or designee will provide written information to the resident concerning his or her right to make decisions including the right to formulate advance directives. The admission staff or designee will obtain a copy of a resident's advance directive upon admission. A copy of the advance directive will be included in the resident's medical record. Medical record review for Resident 45 was initiated on 1/28/2020. Resident 45 was admitted to the facility on [DATE]. Review of the Physician Orders for Life-Sustaining Treatment (POLST) dated 5/8/18, under Section D Information and Signatures, showed the section was blank. The form was signed by Resident 45's family member. Review of Advance Healthcare Directive (AHCD) Acknowledgement form dated 12/13/18, showed Resident 45 had an AHCD and a copy was requested by the facility. Review of the MDS dated [DATE], showed Resident 45 was cognitively intact. Review of Resident 45's medical record failed to show a copy of Resident 45's advance directive. Review of the Psychosocial Assessment/Social History/Discharge Planning dated 11/15/19, showed Resident 45 had an advance directive and a copy was requested from Resident 45's responsible party. On 1/30/2020 at 0816 hours, an interview was conducted with Resident 45. Resident 45 stated he did not recall if the facility had discussed an advance directive with him, but his family member would know. On 1/30/2020 at 1420 hours, a telephone interview was conducted with Family Member 1, who was the responsible party for Resident 45. Family Member 1 stated she submitted Resident 45's advance directive to the facility staff, but was unable to remember who she submitted it to. On 1/31/2020 at 0937 hours, an interview and concurrent medical record review for Resident 45 was conducted with the SSD. The SSD reviewed Resident 45's medical records and verified the above findings. The SSD verified the facility did not have a copy of Resident 45's advance directive in the medical record. 2. Medical record review for Resident 527 was initiated on 1/28/2020. Resident 527 was admitted to the facility on [DATE]. Review of the Physician Orders for Life-Sustaining Treatment (POLST) dated 1/2/2020, under Section D Information and Signatures, showed Resident 527 had an advance directive available dated 1/1/2020. Review of Advance Healthcare Directive (AHCD) Acknowledgement form dated 1/6/2020, showed Resident 527 had an advance directive and a copy was requested by the facility. Review of Resident 527's medical record failed to show a copy of Resident 527's advance directive. On 1/30/2020 at 1401 hours, a telephone interview was conducted with Family Member 2, who was the responsible party for Resident 527. Family Member 2 stated she submitted Resident 527's advance directive to the SSD. On 1/31/2020 at 0930 hours, an interview and concurrent medical record review for Resident 527 was conducted with the SSD. The SSD reviewed Resident 527's medical records and verified the above findings. The SSD verified the facility did not have a copy of Resident 527's advance directive in the medical record. 3. Medical record review for Resident 528 was initiated on 1/28/2020. Resident 528 was admitted to the facility on [DATE]. Review of the Physician Orders for Life-Sustaining Treatment (POLST) dated 1/13/2020, under Section D Information and Signatures, this section showed Resident 528 had no advance directive. The form was signed by Resident 528. Review of Advance Healthcare Directive (AHCD) Acknowledgement form dated 1/13/2020, showed Resident 528 had an advance directive and a copy was requested by the facility. Review of Resident 528's medical record failed to show a copy of Resident 528's advance directive. On 1/30/2020 at 0753 hours, an interview was conducted with Resident 528. Resident 528 stated he submitted the copy of his advance directive to the social services staff, but was unable to remember the staff's name. On 1/31/2020 at 0943 hours, an interview and concurrent medical record review for Resident 528 was conducted with the SSD. The SSD reviewed Resident 528's medical records and verified the above findings. The SSD verified the facility did not have a copy of Resident 528's advance directive in the medical record. On 1/31/2020 at 1503 hours, an interview and concurrent medical record review for Residents 45, 527, and 528 was conducted with the DON. The DON was informed of the above findings and verified the findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on interview and facility document review, the facility failed to provide three of three nonsampled residents (Residents 98, 582, and 583) with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 and/or the Notice of Medicare Non-coverage CMS-10123 (NOMNC) forms. The SNF ABN CMS-10055 and the NOMNC CMS-10123 forms are used to inform residents of their potential financial liability, appeal rights, and protections, should they decide to receive care and services that may not be covered by Medicare. This posed the risk of these residents not being allowed to make an informed decision concerning their Medicare services. Findings: On 1/31/20 at 1000 hours, an interview and concurrent facility document review was conducted with the Business Office Manager who provided and verified the following information: 1. Resident 98's Medicare Part A skilled services episode start date was 11/1/19, and the last covered day of Part A service was 12/20/19. Resident 98 was currently residing at facility. The Business Office Manager verified Resident 98 did not receive the SNF ABN and NOMNC forms. 2. Resident 582's Medicare Part A skilled services episode start date was 9/28/19, and the last covered day of Part A service was 11/8/19. Resident 582 was discharged on 1/3/2020. The Business Office Manager verified Resident 582 did not receive the SNF ABN form. 3. Resident 583's Medicare Part A skilled services episode start date was 7/25/19, and the last covered day of Part A service was 8/13/19. Resident 583 was discharged on 8/13/19. The Business Office Manager verified Resident 583 did not receive the SNF ABN and NOMNC forms. The Business Office Manager verified there was no documentation to show Residents 98, 582, and 583 received the required CMS forms.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to complete the comprehensive MDS assessments timely for two of 29 final sampled residents (Residents 527 and 428). * Resident 527's admission assessment dated [DATE], was not completed. This was 23 days past the required completion date of 1/7/2020. * Resident 428's admission comprehensive assessment was not completed within 14 days from the date of admission to the facility, and was four days past due. These failures had the potential for the staff not identifying the residents' preferences and goals of care, functional and health status, and strengths and needs. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2019 showed a comprehensive MDS assessment (admission, annual, and significant change) must be completed on an annual basis (at least every 366 days). Also, the completion date must be no later than 14 days after the assessment reference date. Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain or maintain the highest practicable well-being. This means it is imperative for nursing homes to assess a resident upon the individual's admission. 1. Medical record review for Resident 527 was initiated on 1/30/2020. Resident 527 was admitted to the facility on [DATE]. Review of Resident 527's MDS admission assessment dated [DATE], showed an assessment reference date of 1/7/2020. However, Resident 527's comprehensive MDS admission assessment was not completed. On 1/31/2020 at 1117 hours, an interview and concurrent medical record review for Resident 527 was conducted with MDS Coordinator 1 and the ADON. MDS Coordinator 1 and the ADON reviewed Resident 527's MDS with the assessment reference date 1/7/2020. The MDS Coordinator verified the MDS for Resident 527 was incomplete. The ADON verified the findings and stated the assessments should have been completed. 2. Medical record review for Resident 428 was initiated on 1/28/20. Resident 428 was admitted to the facility on [DATE]. On 1/30/20 at 1057 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 1. MDS Coordinator 1 verified Resident 428 was admitted to the facility on [DATE]. MDS Coordinator 1 stated a comprehensive assessment of Resident 428 was to be completed within 14 days from the date Resident 428 was admitted to the facility. MDS Coordinator 1 stated Resident 428's initial comprehensive assessment was due to be completed on 1/26/19. MDS Coordinator 1 verified Resident 428's initial comprehensive assessment was incomplete and was four days past due.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 80 was initiated on 1/29/2020. Resident 80 was admitted to the facility on [DATE]. On 1/29/2020 at 1039 hours, an observation and concurrent interview was conducted with Resident 80. Resident 80 was observed in the patio smoking a cigarette with an apron on. The Activities Director was supervising the residents smoking. Review of Resident 80's Smoking assessment dated [DATE], showed Resident 80 was a non-smoker. Review of the MDS dated [DATE], showed Resident 80 had moderate cognitive impairment. Review of Resident 80's plan of care failed to show a care plan problem was developed to address Resident 80 smoking. On 1/29/2020 at 1531 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked to review Resident 80's smoking assessment dated [DATE]. LVN 1 verified Resident 80 was assessed as a non-smoker, but smoked cigarettes in the patio smoking area. When asked if Resident 80 had a care plan formulated for smoking, LVN 1 acknowledged there was no care plan developed to address smoking. On 1/31/2020 at 1502 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed of the above findings and verified the findings. Cross reference to F689, example #2 Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement a plan of care to reflect the individual care needs for four of 29 final sampled residents (Residents 115, 428, 80 and 9). * The facility failed to ensure Resident 115's side rails were padded for safety, as per Resident 115's seizure care plan. * The facility failed to develop a comprehensive care plan to address smoking for Residents 428 and 80. * The facility failed to develop a care plan problem to address Resident 9's activities and use of an indwelling urinary catheter. These posed the risk of not providing appropriate and individualized care to the residents. Findings: Review of the facility's P&P titled Smoking by Residents revised date January 2017 showed the licensed nurse will assess the residents who express a desire to smoke, upon admission, quarterly, annually, and upon significant change of condition identification and present it to the Interdisciplinary Team (IDT) for review. The IDT will develop an individualized plan for safe storage, use of smoking material, assistance and required supervision for residents who smoke. 1. Medical record review for Resident 115 was initiated on 1/28/20. Resident 115 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed a physician's order dated 3/29/13, to administer Keppra (anti-seizure medication) 1000 mg orally two times a day for epilepsy. Review of Resident 115's plan of care showed a care plan problem dated 2/4/14, to address Resident 115's seizure disorder. The care plan problem showed an intervention intimated on 3/27/14, to provide Resident 115 with padded side rails. Review of the Order Summary Report showed a physician's order dated 5/2/17, for bilateral side rails for turning and repositioning. On 1/28/2020 at 1127 hours, an observation and concurrent interview was conducted with Resident 115. Resident 115 was observed lying in bed with bilateral side rails elevated. Resident 115 stated she used the side rails for bed mobility. The side rails were made of metal bars. The side rails were observed with padding which only covered one half of the metal bars. Resident 115 stated the side rails used to have padding covering all of the metal bars, however, the padding kept falling off. On 1/28/2020 at 1135 hours, an observation and concurrent interview was conducted with the ADON. The ADON verified Resident 115's metal side rails were only partially padded. The ADON stated Resident 115's side rails should be completed padded for safety, as per Resident 115's seizure care plan. 2. Medical record review for Resident 428 was initiated on 1/28/10. Resident 428 was admitted to the facility on [DATE]. Review of Resident 428's Smoking assessment dated [DATE], showed Resident 428 smoked one to two times per day. The section of the smoking assessment that determined whether a plan of care was used to assure Resident 428 was safe while smoking was blank. Review of Resident 428's medical record failed to show a care plan problem was developed to address whether Resident 428 could smoke unsupervised, who was responsible for keeping his smoking materials, and what education was provided to Resident 428 regarding the designated smoking area at the facility. On 1/30/2020 at 1205 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 1. MDS Coordinator 1 stated when a resident at the facility was identified as a smoker, a care plan problem was developed to ensure the safety of the resident who smoked and the other residents at the facility. MDS Coordinator 1 verified the facility failed to develop a care plan to address smoking for Resident 428. 3. Medical record review for Resident 9 was initiated on 1/28/2020. Resident 9 was admitted to the facility on [DATE]. On 1/29/2020 at 1008 and 1136 hours, Resident 9 was observed lying in bed with her eyes closed. The television was off and there was no sensory stimulation in the room. An indwelling urinary catheter was observed attached to a drainage bag by the side of the bed. Review of the Order Summary Report showed a physician's order dated 1/13/2020, for an indwelling urinary catheter for wound management. Review of Resident 9's plan of care failed to show comprehensive care plan problems were developed to address Resident 9's activities and use of an indwelling urinary catheter. A care plan problem to address Resident 9's incontinence of bowel and bladder was created on 1/13/2020. On 1/29/2020 at 1120 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 reviewed Resident 9's medical record and verified the above findings. LVN 5 stated Resident 9's care plan problem for bladder incontinence was incorrect because Resident 9 had an indwelling urinary catheter.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure a communication book (a book with symbols or pictures and words in the resident's native language used to communicate basic care needs between nonverbal or non-English speaking residents and the staff) was provided for one of 29 final sampled residents (Resident 578) who did not speak English. This failure had the potential for Resident 578 to not have the ability to communicate her needs to the healthcare staff. Findings: On 1/28/2020 at 0802 hours, during the initial tour of the facility, Resident 578 was observed seated on the side of her bed fully dressed and was well groomed. When asked about the facility, Resident 578 stated she did not speak English, she only spoke her native language. Bulletins observed posted in Resident 578's room advertising group events within the facility were in English. During the interview with Resident 578, Resident 578 pushed her call light. CNA 3 who responded to Resident 578's call light verified Resident 578 did not have a communication book. Medical record review for Resident 578 was initiated on 1/29/2020. Resident 578 was admitted on [DATE]. Review of Resident 578's MDS dated [DATE], under Section A, showed Resident 578 required an interpreter to communicate with the physician and healthcare staff and preferred to communicate in her native language. The MDS showed Resident 578's cognition was severely impaired, but she was able to make herself understood and had clear comprehension (was able to understand others).

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide an ongoing activities program to meet the needs and interests of two of 29 final sampled residents (Residents 9 and 124). This had the potential to negatively impact the residents' well being. Findings: On 1/28/2020 at 0816, 0920, 1036, and 1624 hours, Resident 9 was observed lying in bed in the dark, with the curtains by the window closed and the visual privacy curtain drawn. The television was observed turned off. There was no in-room stimulation observed. Medical record review for Resident 9 was initiated on 1/28/2020. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's Activity Participation Review assessment dated [DATE], showed Resident 9 enjoyed watching television and movies including action, comedies, and soap operas, and listening to the radio. Review of Resident 9's plan of care failed to show a comprehensive care plan problem was developed to address Resident 9's activities. On 1/29/2020 at 1008 and 1136 hours, Resident 9 was observed lying in bed with her eyes closed. The television was turned off. There was no sensory stimulation in the room. On 1/29/2020 at 1148 hours, an interview and concurrent medical record review was conducted with the Activities Director and the Activities Assistant. The Activities Director verified the above findings and stated Resident 9 did not participate in group activities and was provided room visits by the activities staff. The Activities Director stated the residents were asked during the assessment what their favorite activities or preferences were to determine the type of activities they will be provided in the facility. The Activities Assistant stated she went to see Resident 9 today, however, Resident 9 refused to have her television turned on. On 1/29/2020 at 1227 hours, Resident 9 was observed lying in bed with her eyes open and was staring at the ceiling. The television was turned off. When asked if she wanted her television on, Resident 9 stated yes. 2. On 1/28/2020 at 0829, 1012 and 1610 hours, Resident 124 was observed lying in bed with her eyes closed. Resident 124's room was dark with the visual privacy curtain drawn on both sides. The television was turned off. There was no in-room stimulation observed. Medical record review of Resident 124 was initiated on 1/28/2020. Resident 124 was admitted to the facility on [DATE]. Review of the Activity Participation Review assessment dated [DATE], showed Resident 9 enjoyed listening to music and socializing. Activities staff provided one-to-one room visits. Review of Resident 124's plan of care showed a care plan problem initiated on 4/11/19, to address Resident 124's activities. One of the goals was for Resident 9 to actively pursue her desired independent activities one to two times a day, two to three times a week. The interventions included to encourage Resident 124's participation by utilizing what she liked, such as listening to soft music, reading magazines, and watching basketball. On 1/29/2020 at 0827 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 124 stayed in bed all of the time and was always asleep. CNA 2 stated Resident 124's television was never turned on. On 1/29/2020 at 1219 hours, an interview and concurrent medical record review was conducted with the Activities Director and the Activities Assistant. The Activities Director verified the above findings and stated Resident 124 was provided one-to-one room visits three times a week and contact visits daily. However, review of the Room Visit Response Form for the months of November and December 2019, and January 2020, showed room visits were not provided three times a week. For example, in December 2019 there were no room visits provided from December 7 to 15, and from December 26 to 31, 2019. When asked for documentation of the daily contact visits, the Activities Assistant stated Resident 124 was not provided with daily contact visits.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for four of 29 final sampled residents (Residents 17, 20, 61, and 115) and two nonsampled residents (Residents 23 and 581) to ensure the residents maintained their highest physical well-being. * The facility failed to follow the physician's order to monitor Resident 581's blood sugars before meals and to administer insulin as needed. * The insulin injection sites were not consistently rotated for Residents 20, 17, and 61. * The facility failed to follow the physician's order to obtain laboratory studies of renal function and Keppra (anti-seizure medication) levels for Resident 115. * Resident 23 had a physician's order written on 8/25/19, for a daily multivitamin with minerals. From 8/25/19 through 1/28/2020, the facility failed to administered the supplement to Resident 23. These failures posed the risk of the residents not being provided appropriate care and treatment. Findings: 1. Medical record review for Resident 581 was initiated 1/30/2020. Resident 581 was admitted to the facility on [DATE]. Review of the Order Summary Report showed an order dated 12/26/19, to inject Insulin Lispro (medication to treat diabetes) per the sliding scale, before meals and at bedtime. Review of the MDS dated [DATE], showed Resident 581 was cognitively intact. On 1/29/2020 at 1030 hours, during the resident council meeting, Resident 581 reported the nurses checked her blood sugar levels while she ate her meals. Resident 581 stated she found it annoying. On 1/29/2020 at 1311 hours, Resident 581 was observed eating lunch in her room. RN 1 entered Resident 581's room during the observation. When asked about Resident 581's blood sugar levels, RN 1 verified Resident 581's blood sugar levels were usually checked during meal times. On 1/30/2020 at 1018 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the order dated 12/26/19, showed to administer Insulin Lispro before meals. RN 1 stated lunch was usually served between 1200 and 1230 hours. RN 1 verified the blood glucose levels obtained after Resident 581 already ate were not accurate and placed Resident 581 at risk for hypoglycemia (abnormally low blood glucose levels). Cross reference to F760. 5. Medical record review for Resident 23 was initiated on 1/28/2020. Resident 23 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the Order Summary Report showed a physician's order dated 8/25/19, to administer multivitamins with minerals 15 ml orally one time a day (at 0900 hours) as a supplement. Review of Resident 23's Medication Administration Records dated 8/19, 9/19, 10/19, 11/19, 12/2019, and 1/2020 failed to show documentation the multivitamins with minerals was administered to Resident 23 from 8/25/19, through 1/28/20. On 1/29/2020 at 0921 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 23 had a physician's order dated 8/25/19, for multivitamins with minerals 15 ml orally one time a day (at 0900 hours) as a supplement. RN 2 verified Resident 23's Medication Administration Records dated 8/19, 9/19, 10/19, 11/19, 12/19, and 1/2020 failed to show documentation the multivitamins with minerals was administered to Resident 23 from 8/25/19 through 1/28/20. RN 2 stated an error was made when the order was entered into the facility's computer, and as a result, Resident 23's supplement had not been administered as ordered. RN 2 then fixed the error. Cross reference to F759, example 1b. 6. Medical record review for Resident 115 was initiated on 1/28/2020. Resident 115 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the Order Summary Report showed a physician's order dated 3/29/13, to administer Keppra 1000 mg orally two times a day for epilepsy. Review of the Order Summary Report showed a physician's order dated 3/10/14, to obtain laboratory studies of Keppra levels on the first Monday of every March and September. The physician's order showed to call the physician with the results. Review of the Order Summary Report showed a physician's order dated 11/12/13, to obtain laboratory studies of renal function on the first Monday of every March and September. Review of Resident 115's medial record failed to show Keppra levels or renal function laboratory studies were obtained for one year. On 1/28/2020 at 1140 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON reviewed Resident 115's medical record and the facility's laboratory records and verified laboratory studies for Keppra and renal function were not obtained for one year. 2. Medical record review for Resident 20 was initiated on 1/28/2020. Resident 20 was readmitted to the facility on [DATE]. Review of Resident 20's Medication Administration Record dated January 2020 showed Resident 20 was administered regular insulin (medication to treat diabetes) subcutaneously every six hours, per the sliding scale. The Medication Administration Record showed to rotate the injection sites for each dose. Review of Resident 20's Location of Administration Report dated January 2020 showed Resident 20's injection sites for regular insulin were not consistently being rotated. 3. Medical record review for Resident 61 was initiated on 1/28/2020. Resident 61 was readmitted to the facility on [DATE]. Review of Resident 61's Medication Administration Record dated January 2020 showed Resident 61 was administered Lantus (medication to treat diabetes) subcutaneously at bedtime. The Medication Administration Record showed to rotate the injection sites for each dose of Lantus. The Medication Administration Record also showed Resident 61 was administered regular insulin two times a day, per the sliding scale. The Medication Administration Record showed to rotate the injection sites for each dose of regular insulin. Review of Resident 61's Location of Administration Report dated January 2020 showed Resident 61's Lantus injection sites were not rotated a total of two times. Resident 61's Location of Administration Report also showed the injection sites for regular insulin were not consistently being rotated. 4. Medical record review for Resident 17 was initiated on 1/28/2020. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Medication Administration Record dated December 2019 showed Resident 17 was administered Lantus subcutaneously two times a day. The Medication Administration Record showed to rotate the injection sites. Review of Resident 17's Location of Administration Report dated December 2019 showed Resident 17's Lantus injection sites were not rotated a total of two times. Review of Resident 17's Medication Administration Record dated January 2020 showed Resident 17 was administered Basaglar (medication to treat diabetes) subcutaneously two times a day. The Medication Administration Record showed to to rotate the injection sites. Review of Resident 17's Location of Administration Report dated January 2020 showed Resident 17's Basaglar injection sites were not being consistently rotated. On 1/30/2020 at 1600 hours, an interview and concurrent medical record review for Residents 20, 61, and 17 was conducted with the DON. The DON verified the above findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to follow the physician's orders to provide daily restorative nursing treatment and apply a hand splint, daily, for one of 29 final sampled residents (Resident 24), who had a hand contracture. This failure had the potential for Resident 24 to not receive necessary care and services to prevent the worsening of an existing hand contracture. Findings: 1. Review of the facility's P&P titled Restorative Nursing Program Guidelines revised 9/19/19, showed restorative nursing is the delivery of services by nursing personnel designed to encourage and enable individuals to be as independent as possible based on their condition, resources, and desires. It includes nursing interventions that promote a patient's ability to attain, and maintain their optimal functional potential. Restorative care implies that the possibility for progress exists and that improvement can be expected, or there is a risk of imminent decline which can be prevented. Medical record review for Resident 24 was initiated on 1/28/2020. Resident 24 was originally admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 24 had bilateral impairments to her upper and lower extremities and required extensive assistance from two or more staff members for bed mobility, transfers, and ADL care. Review of Resident 24's plan of care showed a care plan problem dated 11/1/19, to address Resident 24 requiring RNA services and risk for further decline in range of motion to the right upper extremity. The interventions included to apply the right hand splint daily for four to six hours, seven days a week as tolerated. The interventions also showed to provide RNA services as ordered for PROM exercises to the right upper extremity every day. Review of Resident 24's Order Summary Report showed the following physician's orders dated: - 10/18/19, right resting hand splint for contracture, - 11/1/19, for RNA services for right upper extremity PROM exercises every day as tolerated, - 12/2/19, for right upper extremity right hand splint daily for four to six hours, seven days a week, as tolerated, and - 12/3/19, for RNA services for PROM to both lower extremities daily, seven days a week as tolerated. Review of the facility's untitled documentation for RNA services for December 2019 and January 2020 failed to show documentation Resident 24 received RNA services every day as ordered by the physician, including application of the right hand splint and PROM exercises to the right hand and bilateral lower extremities. Entries under multiple days were blank and had no documentation and multiple other entries showed No RNA. On 1/29/2020 at 0728 and 0811 hours, 1/30/2020 at 0734, 0857, 1156 hours, and 1333 hours, Resident 24 was observed without the hand splint to her right hand. On 1/30/2020 at 1114 hours, an interview and concurrent medical record review was conducted with RNA 1. RNA 1 stated each resident in the RNA program was assigned a RNA. RNA 1 stated the residents were provided RNA services when their assigned RNA was working. RNA 1 verified the above physician's orders for Resident 24. RNA 1 verified RNA services including application of the right hand splint and passive range of motion to the right hand and bilateral lower extremities were not provided to Resident 24 when entries on the RNAs' documentation was blank or showed No RNA. RNA 1 stated if the resident's assigned RNA was not working, the resident did not receive their ordered RNA services. On 1/30/2020 at 1344 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 24 had a contracture on her right hand. CNA 5 stated Resident 42 was to wear a hand splint four to six hours every day to prevent the hand contracture from worsening. CNA 5 stated he did not apply Resident 24's hand splint. CNA 5 stated the splint was to be applied by the RNAs daily. CNA 5 verified Resident 24 was not currently wearing her hand splint. On 1/30/2020 at 1349 hours, an interview was conducted with Resident 24. Resident 24 verified she was not wearing her right hand splint and stated it was not applied all week. Resident 24 stated she did not receive RNA services or the hand splint for her right hand for the week of 1/27/2020. Resident 24 stated she often did not receive RNA services or the hand splint and it made her feel forgotten. Resident 24 stated she did not refuse RNA services when offered it. Resident 24 stated she wanted her daily PROM exercises and the right hand splint. On 1/30/2020 at 1418 hours, an interview and concurrent medical record review was conducted with RNA 2. RNA 2 stated a splint was used when a resident had a contracture. RNA 2 stated the staff needed to apply the hand splint as ordered to prevent the contracture from worsening. RNA 2 verified Resident 24 was to receive RNA services daily and was to have a hand splint placed on her right hand daily for a contracture. RNA 2 stated Resident 24 was assigned to another RNA. RNA 2 verified he had not provided therapy or the hand splint to Resident 24 for the month of January 2020. RNA 2 stated they were short-staffed and were unable to provide therapy to all the residents as ordered. RNA 2 stated if the resident's assigned RNA was not working, the resident would not receive therapy. RNA 2 stated he had reported these staffing problems to the nursing staff. On 1/30/2020 at 1630 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated she was overseeing the RNA program. The DON stated the RNAs were to report to the nursing staff whenever a resident did not receive their restorative nursing treatment. The DON verified Resident 24 was to have a hand splint applied daily for four to six hours and was to receive daily restorative nursing therapy. The DON was unable to show documentation Resident 24 received RNA services every day as ordered by the physician.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 29 final sampled residents (Resident 43) remained free from accident hazards due to the use of elevated side rails. * The facility failed to obtain informed consent prior to the use of elevated side rails for Resident 43. This failure had the potential to put the resident at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. Medical record review for Resident 43 was initiated on 1/28/2020. Resident 43 was readmitted to the facility on [DATE]. On 1/28/2020 at 0907 hours, an observation of Resident 43 was conducted. Resident 43 was observed lying in bed with bilateral side rails elevated by the head of the bed. Resident 43 stated he used the side rails for bed mobility. Review of Resident 43's Bed/Side Rail IDT dated 7/28/19, showed Resident 43 utilized side rails as an enabler for bed mobility and repositioning. Review of Resident 43's care plan problem titled cognitive loss revised 11/20/19, showed Resident 32 had impaired decision making, anxiety, and agitation. Review of Resident 43's medical record failed to show informed consent prior to the use of elevated side rails was obtained. On 1/28/2020 at 1040 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 43 was readmitted to the facility on [DATE], and consent for the use of elevated side rails was not obtained.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the availability of prescribed medications for one of 29 final sampled residents (Resident 428). * Resident 428 had a physician's order for clopidogrel bisulfate (medication used to prevent blood clots) for CVA prophylaxis. The licensed nurse was unable to administer clopidogrel bisulfate as ordered due to the unavailability of the medication. This failure posed the risk for inhibiting the therapeutic effects of the medication and had the potential to negatively affect the resident's health. Findings: Medical record review for Resident 428 was initiated on 1/28/2020. Resident 428 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 1/13/2020, to administer clopidogrel bisulfate 75 mg orally once a day (at 0900 hours) for CVA prophylaxis. On 1/29/2020 at 0750 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 428 had an order for clopidogrel bisulfate 75 mg orally scheduled to be administered at 0900 hours. LVN 3 stated he was not be able to administer the medication as scheduled, due to the unavailability of the medication. LVN 3 stated the facility practice was to order a refill from the pharmacy approximately three days in advance of the medication running out, however, the medication refill had not been submitted to the pharmacy. LVN 3 stated he would contact the pharmacy and order a refill. On 1/29/2020 at 1011 hours, an interview was conducted with LVN 3. LVN 3 verified Resident 428's clopidogrel bisulfate 75 mg had yet to be administered, as LVN 3 was waiting for the pharmacy to deliver the medication. LVN 3 stated resident medications were required to be administered one hour before and up to one hour after scheduled administration times. [Cross reference F759, Example 1a]

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of 29 final sampled residents (Residents 22 and 124) were free from unnecessary medications. * Resident 124 was administered blood pressure medications when the resident's blood pressure was below the parameters prescribed by the physician. The facility failed to ensure Resident 124 was administered the PRN (as needed) pain medication according to the physician's order. * The facility failed to ensure Resident 22 was administered Depakote (antiseizure medication, also used as mood stabilizer) with appropriate indication for its use. These failures posed the potential of complications related to unnecessary medications. Findings: 1. Medical record review for Resident 124 was initiated on 1/28/2020. Resident 124 was admitted to the facility on [DATE]. a. Review of Resident 124's Order Summary Report showed a physician's order dated 3/27/19, to administer one tablet of losartan potassium (blood pressure medication) 100 mg by mouth one time a day. Hold the losartan potassium for SBP (systolic blood pressure, the top number on the blood pressure reading) less than 110. Another order dated 6/25/19, for furosemide (diuretic) 20 mg one tablet by mouth two times a day, showed to hold the furosemide for SBP less than 110. Review of the Medication Administration Record for December 2019 and January 2020, showed the licensed nurses administered the losartan and furosemide tablets to Resident 124 when her SBP was below 110. For example, on 1/26/2020, Resident 124 was administered furosemide at 1700 hours with a SBP of 100, and on 1/27/2020, Resident 124 was administered losartan at 0900 hours, with a SBP of 100. b. Review of Resident 124's Order Summary Report showed a physician's order dated 10/30/19, for morphine sulfate 20 mg/ml. Administer 0.25 ml every two hours as needed for moderate pain and administer 0.5 ml every two hours as needed for severe pain. Review of the Medication Administration Record for January 2020 showed Resident 124 was administered 0.5 ml of morphine (prescribed for severe pain) for pain levels of 0 to 6 (on a pain scale of 0 to 10 with 0 = no pain and 10 = severe pain). For example, on 1/1, 1/2, 1/10, 1/13, 1/14, 1/19, and 1/22/2020, Resident 124 was administered the morphine 0.5 ml for a documented pain level of zero. On 1/3, 1/4, 1/5, 1/8, and 1/26/2020, Resident 124 was administered the morphine 0.5 ml for a pain level of 5. On 1/29/2020 at 0809 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 reviewed Resident 124's medical record and verified the above findings. LVN 4 stated moderate pain was level 4 to 6 and severe pain was 7 to 10. LVN 4 stated this was not specified in the order and should have been clarified with the physician. 2. Medical record review for Resident 22 was initiated on 1/28/2020. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Order Summary Report showed a physician's order dated 7/13/19, to administer two tablets of Depakote 125 mg by mouth two times a day for seizures. Review of the physician's progress notes from the general acute care hospital dated 7/8/19, failed to show Resident 22 had a diagnosis of seizure. Review of Resident 22's History and Physical Examination dated 7/15/19, failed to show Resident 22 had a diagnosis of seizure disorder. Review of the Psychiatric Note showed an entry by the nurse practitioner dated 7/25/19, showing Resident 22 was on Depakote for mood stabilization. On 1/30/2020 at 1032 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON reviewed Resident 22's medical record and verified the Depakote was indicated for mood stabilization and not for seizure.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 58 was initiated on 1/28/2020. Resident 58 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 58's Medication Administration Record dated January 2020 showed the following orders dated 8/28/19: -Zyprexa 10 mg, give 1 tablet by mouth daily for schizoaffective disorder, -Risperdal 1 mg, give 1 tablet by mouth every 12 hours for schizoaffective disorder, and -buspirone 15 mg, give 1 tablet by mouth three times a day for anxiety disorder. Review of the facility document titled Note To Attending Physician/Prescriber dated 11/20/19, showed the Pharmacy Consultant noted the use of dual antipsychotic therapy for Resident 58 with the prescription of both Risperdal and Zyprexa 10. The Pharmacy Consultant's note recommended either using one antipsychotic medication for Resident 58's therapy or providing a documented rationale for the continuation of both antipsychotic medications. Under the section, Physician/Prescriber Response, the prescriber's response was just continue both without a rationale documented. Review of the facility document titled Note To Attending Physician/Prescriber dated 12/17/19, showed the Pharmacy Consultant noted a GDR was due for Zyprexa 10 mg, Risperdal 1 mg, and buspirone 15 mg. The primary care physician's only written response on the facility document was refer to the psychiatric evaluation. Review of Resident 58's Psychiatric Evaluation Note dated 12/27/19, failed to show a documented rationale for not attempting a GDR for Zyprexa, Risperdal, and buspirone. Review of the progress note by Resident 58's primary care physician dated 1/7/2020, failed to show a documented rationale for the continuation of dual antipsychotic medications Zyprexa and Risperdal. The progress note also failed to show a documented rationale for not attempting the GDRs for Resident 58's psychoactive mediations Zyprexa, Risperdal, and buspirone. On 1/31/2020 at 1146 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 stated she called the prescriber regarding the Pharmacy Consultant's recommendations. LVN 5 stated the prescriber only stated to continue both antipsychotic medications for Resident 58. LVN 5 verified the physician did not provide a rationale for the use of both antipsychotic medications. On 1/31/2020 at 1158 hours, an interview and concurrent medical record review was conducted with the ADON. After reviewing Resident 58's medical record, the ADON verified there was no documented clinical rationale from the physician for the continuation of the dual antipsychotic therapies. The ADON was also unable to provide a documented clinical rationale for not attempting a GDR for Resident 58's psychoactive medications Zyprexa, Risperdal, and buspirone. Based on interview and medical record review, the facility failed to ensure two of 19 final sampled residents (Residents 22 and 58) were free from unnecessary psychotropic medications. * Resident 22 was receiving Risperdal (antipsychotic medication) for behavior manifestation of aggressive behavior. The Psychiatrist doubled the dose of the Risperdal despite the resident not exhibiting any episode of behavior for which the Risperdal was prescribed. In addition, the facility failed to ensure the as needed order for a psychotropic medication for Resident 22 was limited to 14 days or had a documented rationale from the physician for the appropriateness of extending the medication beyond 14 days. * The facility failed to show a documented rationale from the physician for the continuation of the duplicate antipsychotic therapy for Zyprexa and Risperdal for Resident 58. In addition, the facility failed to attempt a GDR for Resident 58's antipsychotic medications Zyprexa, Risperdal, and Buspirone Hcl. These failures had the potential for Residents 22 and Resident 58 to experience adverse effects or receive unnecessary antipsychotic medications. Findings: Medical record review for Resident 22 was initiated on 1/28/2020. Resident 22 was admitted to the facility on [DATE]. Review of the History and Physical Examination dated 7/15/19, showed Resident 22 had a diagnosis of Alzheimer's (a form of dementia that specifically affects parts of the brain that control thought, memory, and language). Review of the quarterly MDS dated [DATE], showed Resident 22 had severe cognitive impairment. a. Review of the Order Summary Report showed a physician's order dated 10/31/19, to administer one tablet of Seroquel (antipsychotic medication) 25 mg by mouth two times a day for behavior manifestation of resistive to care. Another physician's order dated 12/27/19, showed to administer one tablet of Risperdal 1 mg by mouth two times a day for aggressive behavior. Review of Resident 22's Medication Administration Record for September 2019 showed an order dated 7/13/19, to administer one tablet of Risperdal 0.5 mg by mouth two times a day. Review of the Psychoactive Summary Sheet for the use of Risperdal for aggressive behavior showed Resident 22 did not have any episodes of aggressive behavior for the months of August, October, November, and December 2019. Resident 22 had 36 documented episodes of aggressive behavior for the month of September 2019. Review of Resident 22's Medication Administration Record for September 2019, showed Resident 22's episodes of aggressive behavior were manifested from 9/12 to 9/23/19. Resident 22 did not have behaviors for the rest of the month of September 2019. Further review of the Medication Administration Record showed Resident 22 received Cephalexin (antibiotic) tablet 500 mg, three times a day for urinary tract infection from 9/15 to 9/22/19. Review of the Psychoactive and Sedative/Hypnotic assessment dated [DATE], for the use of Risperdal, showed the dose of the medication was doubled (from 0.5 mg to 1 mg two times a day) on 12/27/19, due to increased behavior. Review of the Psychiatric Evaluation Note dated 12/27/19, showed Resident 22 was seen by the Psychiatrist because Resident 22 scratched herself which resulted in a skin tear. The evaluation failed to show documentation Resident 22 had an episode of aggressive behavior or had an increase in aggressive behavior. The Psychiatrist documented to increase the dose of Resident 22's Risperdal. On 1/30/2020 at 1024 hours, an interview was conducted with CNA 4. CNA 4 stated Resident 22 was never aggressive, even though she always screamed for help. CNA 4 stated Resident 22 was never resistant to care, she was cooperative and would always say thank you. On 1/30/2020 at 1032 hours, an interview and concurrent medical record review was conducted with LVN 6 and the ADON. The ADON verified the above findings. The ADON stated the Psychiatrist doubled the dose of the Risperdal on 12/27/19, despite Resident 22 not having any episodes of aggressive behaviors. Resident 22 scratched herself which resulted in a skin tear. The ADON stated Resident 22 was not monitored for the behavior of scratching. On 1/31/2020 at 1045 hours, an interview was conducted with the Psychiatrist. The Psychiatrist was asked why he doubled the dose of Risperdal on 12/27/19, when Resident 22 did not have any episodes of aggressive behavior. The Psychiatrist stated he increased the dose of the Risperdal because Resident 22 scratched herself which resulted in a skin tear. The Psychiatrist stated the Risperdal is for scratching, and not for the aggressive behavior. The Psychiatrist stated Resident 22 gave her consent to increase the dose of the Risperdal. b. Review of Resident 22's Order Summary Report showed an order dated 7/13/19, to administer one tablet of lorazepam (antianxiety medication) 1 mg by mouth every six hours as needed for anxiety. The order did not have a stop date. Review of Resident 22's medical record failed to show the physician or prescribing practitioner documented a rationale for the appropriateness of extending the as needed order lorazepam beyond 14 days. On 1/3/2020 at 1032 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 reviewed Resident 22's medical record and verified the above findings. LVN 6 stated the order needed to be clarified.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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2a. On 1/29/2020 at 0742 hours, a medication administration observation for Resident 73 was conducted with RN 1. RN 1 administered five medications to Resident 73, including two tablets of docusate sodium 100 mg via the GT. Review of Resident 73's Order Summary Report showed a physician's order dated 8/20/19, to administer two tablets of docusate sodium 100 mg via the GT every 12 hours for bowel management, hold the medication for loose stools. On 1/29/2020 1115 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified she administered Resident 73 two tablets of the docusate sodium 100 mg via the GT. RN 1 was asked if she checked if Resident 73 had loose stool prior to administering the docusate sodium. RN 1 stated she forgot to check if Resident 73 had loose stool. b. On 1/29/2020 at 0742 hours, RN 1 was observed administering five medications to Resident 73. The medications administered did not include artificial tears solution. Review of Resident 73's Order Summary Report showed a physician's order dated 11/7/19, to administer one drop of artificial tears solution 0.4% in both eyes, two times a day for dry eyes. On 1/29/2020 at 1115 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified she did not administer Resident 73's artificial tears at 0900 hours. On 1/31/2020 at 1500 hours, an interview and concurrent medical record review was conducted with DON. The DON was informed of the above findings and verified the findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 13.79%. Two of two licensed nurses (LVN 3 and RN 1) were found to have made errors during the medication administration observations. * Resident 428 had a physician's order for clopidogrel bisulfate (medication used to prevent blood clots) for CVA prophylaxis. LVN 3 failed to administer the clopidogrel as ordered due to unavailability of the medication. * Resident 23 had a physician's order for multivitamins with minerals; however, LVN 3 failed to administer the supplement. * RN 1 failed to check whether Resident 73 had loose stool prior to administering docusate sodium (stool softener medication) and failed to administer artificial tears solution (eye drops medication) to Resident 73 during the medication administration observation. These failures had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Medication Administration revised date 1/1/12, showed the licensed nurse may administer medications one hour before or after the scheduled medication administration time. On 1/29/2020 at 0750 hours, a medication administration observation for Residents 428 and 23 was conducted with LVN 3. 1a. LVN 3 prepared and administered Resident 428's medications. LVN 3 stated Resident 428 had a physician's order for clopidogrel bisulfate 75 mg orally scheduled for 0900 hours, however, he could not administer the medication as it was not available and he needed to reorder clopidogrel bisulfate from the pharmacy. Review of Resident 428's Order Summary Report showed a physician's order dated 1/13/2020, for clopidogrel bisulfate 75 mg orally once a day (to be administered at 0900 hours) for CVA prophylaxis. [Cross reference to F755.] b. LVN 3 prepared and administered Resident 23's medications. After having administered Resident 23's scheduled mediations, a medical record review was conducted with LVN 3. Review of the physician's order dated 8/25/19, showed an order for multivitamins with minerals 15 ml orally once a day as a supplement. LVN 3 verified he failed to administer the multivitamin with minerals as ordered and was unaware Resident 23 had an order for multivitamins with minerals. On 1/29/2020 at 1011 hours, an interview was conducted with LVN 3. LVN 3 stated resident medications were to be administered one hour before or after scheduled medications times. LVN 3 stated the pharmacy had not delivered Resident 428's clopidogrel bisulfate and the clopidogrel bisulfate had not been administered. LVN 3 stated he did not administer Resident 23's multivitamin with minerals.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 581) was free from significant medication errors when the licensed nurses did not administer insulin as ordered by physician. This deficiency placed the resident at risk for hypoglycemia (abnormally low blood sugar levels). Findings: Review of the facility's P&P titled Medication Administration revised 1/1/12, showed the licensed nurse may administer medications one hour before or after the scheduled medication administration time. On 1/29/2020 at 1030 hours, during the resident council meeting, Resident 581 stated the nurses checked her blood sugar levels while she ate her meals. Resident 581 stated she found it annoying. Medical record review for Resident 581 was initiated on 1/29/2020. Resident 581 was admitted to the facility on [DATE]. Review of the History and Physical Examination dated 1/6/2020, showed Resident 581 had the capacity to make decisions. Review of the MDS dated [DATE], showed Resident 581 was cognitively intact. On 1/29/2020 at 1311 hours, Resident 581 was observed eating lunch in her room. RN 1 entered Resident 581's room as Resident 581 was eating and checked Resident 581's blood sugar level. RN 1 stated Resident 581's blood sugar level was usually checked during meal time. RN 1 stated lunch was usually served between 1200 and 1230 hours. Review of Resident 581's Order Summary Report showed a physician's order dated 12/26/19, to administer Insulin Lispro subcutaneously per the sliding scale before meals and at bedtime for diabetes. Review of the undated facility document titled Dining Locations and Times (provided by the facility's Administrator during the entrance conference) showed the scheduled meal times were at 0700, 1200, and 1700 hours. Review of Resident 581's Medication Administration Records and Location of Administration Reports for December 2019 and January 2020 showed Resident 581's blood sugar levels were supposed to be checked at 0630, 1130, 1630, and 2100 hours, and Insulin Lispro administered per the sliding scale. However, further review of the Medication Administration Records and Location of Administration Reports showed the following dates and times Resident 581's blood sugar levels were assessed and Insulin Lispro was administered outside of the prescribed times: - 12/27/19, at 1852 hours, - 12/29/19, at 1401 hours, 4 units of Insulin Lispro was administered, - 12/30/19, at 1451 hours, 2 units of Insulin Lispro was administered, - 1/2/2020, at 1233 hours, - 1/5/2020, at 1233 hours, - 1/6/2020, at 1409 hours, - 1/9/2020, at 1312 hours, - 1/15/2020, at 1605 hours, - 1/18/2020, at 1230 hours, 2 units of Insulin Lispro was administered, and - 1/20/2020, at 1412 hours. On 1/30/2020 at 1018 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the physician's order was to check Resident 581's blood sugar levels and administer Insulin Lispro prior to Resident 581 eating her meals. RN 1 verified the blood glucose levels obtained after or as Resident 581 was eating were not accurate and placed Resident 581 at risk for hypoglycemia (abnormally low blood glucose levels). Cross reference to F684, example #1.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

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Based on interview and medical record review, the facility failed to notify one of 29 final sampled residents' (Resident 115) physician of the resident's laboratory results. This had the potential for the resident not receiving appropriate care. Findings: Review of Resident 115's laboratory results, collection date of 1/22/2020, showed Resident 115's hemoglobin A1c (test measuring the amount of blood sugar attached to hemoglobin, used to check for diabetes or prediabetes) results were above the normal range of 4-6%. There was no documentation to show Resident 115's physician was notified of the abnormal hemoglobin A1c results. On 1/30/2020 at 1547 hours, an interview and concurrent medical record review was conducted with the Medical Records Director. The Medical Records Director verified there was no documentation to show Resident 115's physician was notified of the abnormal hemoglobin A1c results.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure dental services were provided for one nonsample resident (Resident 581). Resident 581 did not have any natural teeth or dentures. The facility failed to assist Resident 581 in obtaining routine dental care. This deficient practice resulted in Resident 581 experiencing unnecessary pain. Findings: Medical record review for Resident 581 was initiated on 1/30/2020. Resident 581 was admitted on [DATE]. Review of the History and Physical dated 1/6/2020, showed Resident 581 had the capacity to make decisions. Review of the MDS dated [DATE], under Section L, showed Resident 581 did not have natural teeth or tooth fragments. Review of the Order Summary Report showed a physician's order dated 12/26/19, for a dental consultation and treatment follow-up as needed. Another physician's order dated 12/26/19, showed for social services to arrange dental consultations as needed. On 1/29/2020 at 1244 hours, an interview was conducted with Resident 581. Resident 581 reported she was experiencing pain on the left upper side of her gums. Resident 581 reported she requested to have her vegetables steamed soft. Resident 581 stated the vegetables are often hard and uncomfortable to chew. 1/29/2020 at 1251 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified Resident 581's physician's orders. The SSD verified Resident 581 did not receive dental services. The SSD stated she was not aware Resident 581 did not have any teeth.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility document review, the facility failed to ensure the tray line staff followed the menu for the residents participating in the RNA feeding program. The residents on the RNA feeding program did not receive the parsley garnish on their plates. This failure had the potential for the residents on the RNA feeding program not have an appetizing, attractive meal, which could cause them not to eat. Findings: Review of the CMS-672 Resident Census and Conditions of Residents signed by the DON and dated 1/28/2020, showed 133 of the 147 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Dietary Department - General revised date 6/1/14, showed the primary objective of the dietary department included to provide nutritionally adequate and attractive meals, which are consistent with physician's orders. Review of the facility's document titled Winter Menus, Week 4 Wednesday dated 1/29/2020, showed all the plates served were to be provided with a parsley garnish. On 1/29/2020, starting at 1130 hours, an observation of the tray line production was conducted. It was observed on the first two dining room carts that no residents' plates received the parsley garnish. On 1/29/2020 at 1157, an interview was conducted with the DSS. The DSS was asked about the first two dining carts. The DSS stated the first two carts were provided for the dining room. The DSS stated the dining room included residents on the RNA feeding program and early diners. The DSS was asked about the tray line staff following the menus. The DSS stated the expectation was for the cooks and the tray line staff to follow the menus and the residents were to receive all items on the menu unless their diet or preferences precluded the menu item. The DSS was also asked the purpose of garnishing the plates. The DSS stated the garnish was to make the plate look more attractive to the residents. The DSS stated more attractive plates would be more appetizing, and the residents would be more likely eat to the food on them. The DSS was asked to look at the plates on the second cart. The DSS verified the plates on the second cart had not be garnished with parsley. The DSS verified the first cart also did not receive the parsley garnishes.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the medical record for one nonsampled resident (Residents 581) was accurate. This deficient practice resulted in incorrect information regarding Resident 581's healthcare. Findings: On 1/29/2020 at 1244 hours, an interview was conducted with Resident 581. Resident 581 stated she did not have teeth and forgot to bring her dentures to the facility. Resident 581 stated she informed the nurse who admitted her to the facility of this. On 1/29/2020 at 1452 hours, a follow-up interview was conducted with Resident 581. Resident 581 stated the food was too hard for her to chew without teeth. Resident 581 stated she complained to the staff it was difficult for her to chew her food, but nothing was done. Medical record review for Resident 581 was initiated on 1/29/2020. Resident 581 was admitted to the facility on [DATE]. Review of Resident 581's Dietary Profile dated 12/31/19, showed Resident 581 had her own teeth and did not have chewing problems. The Dietary Profile showed Resident 581's current diet order was a controlled carbohydrate diet with regular texture. Review of the MDS dated [DATE], under Section L, showed Resident 581 did not have natural teeth or tooth fragments. The MDS also showed Resident 581 was cognitively intact. On 1/30/2020 at 1427 hours, an interview and concurrent medical record review was conducted with the DSS. The DSS verified the Dietary Profile Assessment was inaccurate and should have reflected that Resident 581 did not have teeth and had chewing problems.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility document review, the facility failed to ensure the bed remote control cord for one nonsampled resident (Resident 98) was maintained in safe operating condition. This had the potential to compromise the resident's safety when using the bed remote control. Findings: On 1/29/2020 at 1140 hours, Resident 98 was observed in bed and stated her bed remote control cord was broken. The cord attached to Resident 98's bed remote control was observed broken and frayed with wires exposed in three different areas. Resident 98 stated she was afraid she might get hurt from the exposed wires. Resident 98 stated she did not want to use her bed remote control because it was damaged. On 1/29/2020 at 1145 hours, an observation of Resident 98's bed remote control and the attached cord was conducted with CNA 1. CNA 1 verified the the cord attached to Resident 98's bed remote control was damaged and stated it was not safe for Resident 98 to use. CNA 1 stated she would inform the maintenance department. On 1/29/2020 at 1209 hours, The Maintenance Supervisor verified the cord attached to Resident 98's bed remote control was frayed and the wires were exposed. The Maintenance Supervisor stated he would change the bed remote control cord right away. On 1/31/2020 at 1506 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was informed of the above findings and verified the findings.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the Consultant Pharmacist's identified drug irregularities and medication recommendations were addressed for four of 29 final sampled residents (Residents 24, 55, 62, and 124) and four nonsampled residents (Residents 32, 34, 71, and 90). * The facility failed to ensure the Pharmacy Consultant's recommendation to add folic acid supplement for Resident 124 to reduce possible toxicity from methotrexate (arthritis medication) was communicated to the physician. * The facility failed to ensure the Pharmacy Consultant's recommendations for Residents 2 and 35 were carried out since they were recommended on 10/1/19. * The facility failed to ensure the Pharmacy Consultant's recommendations for Residents 24, 34, 62, 71, and 90 were carried out since they were recommended on 12/17/19. These failures had the potential for the residents to experience adverse drug reactions and unnecessary medications. Findings: Review of the facility's P&P titled Drug Regimen Review revised date 12/2016 showed any irregularities noted by the Pharmacy Consultant during the monthly drug regimen review will be documented on a separate written report that is sent to the physician, the facility's medical director, and the DON. The attending physician will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician will document his or her rationale in the resident's medical record. 1. Medical record review for Resident 124 was initiated on 1/28/2020. Resident 124 was admitted to the facility on [DATE]. Review of the Consultant Pharmacist's Medication Regimen Review dated 12/17/19, showed Resident 124 was taking methotrexate tablets and the manufacturer recommended folic acid supplementation to lower possible toxicity. The Pharmacy Consultant recommended for Resident 124 to be evaluated if folic acid should be started. Further review of the medication regimen review showed, on the right side of the page, where the facility documented the follow-through with the physician, the hospice on-call was called, but no one picked up. Review of the Order Summary Report showed a physician's order dated 6/25/19, for methotrexate 2.5 mg tablet, give seven tablets by mouth every Thursday morning. The Order Summary Report did not show an order for folic acid. Review of the medical record failed to show documentation Resident 124's physician was informed of the Consultant Pharmacist's recommendation to add folic acid supplementation to reduce toxicity from the methotrexate. On 1/29/2020 at 1056 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings and stated there was no documentation to show the physician was informed of the Pharmacy Consultant's recommendation. On 1/29/2020 at 1102 hours, an interview was conducted with the DON. The DON was informed of the above findings and verified the findings. The DON stated after the facility received the Pharmacy Consultant's monthly drug regimen review, they had seven days to act upon the recommendations. 2. Review of the Drug Regimen review binder provided by the DON, showed the Consultant Pharmacist's Medication Regimen Review dated 10/1/19, with the following recommendations: a. For Resident 32, who was receiving Lovenox (blood thinner) injections, the Pharmacy Consultant recommended to update the order to read as maintenance for long term DVT (deep vein thrombosis, a blood clot in a deep vein) prophylaxis. Further review of the medication regimen review showed, where the facility documented the follow-through with the physician, was blank. Review of Resident 32's Order Summary Report showed a physician's order dated 7/23/19, for Lovenox 40 mg, inject subcutaneously (under the skin) one time a day. The Pharmacy Consultant's recommendation to update the order to read as maintenance for long term DVT prophylaxis was not carried out. b. Resident 55 had a physician's order for aspirin 81 mg by mouth. The Pharmacy Consultant recommended to update the order to reflect either aspirin 81 mg enteric coated or chewable. Another recommendation showed to clarify the hold parameter for metoprolol (blood pressure medication) to read hold for SBP (systolic blood pressure, the top number of the blood pressure reading) less than 110 OR heart rate less than 55, instead of a comma, for more accurate and consistent interpretation of when the hold should apply. Review of Resident 55's Order Summary Report dated 1/30/2020, showed an order dated 10/20/19, for aspirin 81 mg tablet by mouth, one time a day. The order did not specify whether to administer an enteric coated or chewable tablet. Another order dated 10/20/19, to administer half a tablet of metoprolol 25 mg by mouth two times a day showed to hold for SBP less than 110, pulse less than 60. The Pharmacy Consultant's recommendation to change the comma to OR was not carried out. 3. Further review of the Drug Regimen review binder showed the Consultant Pharmacist's Medication Regimen Review dated 12/17/19, with the following recommendations: a. For Residents 24, 62, and 71, the Pharmacy Consultant recommended to provide a duration of therapy for Lovenox. There was no documentation of the follow-through with the physician for the recommendations. Review of Residents 24, 62, and 71's medical records failed to show the recommendations by the Pharmacy Consultant to add the duration of therapy for Lovenox were carried out. b. For Resident 90, the Consultant Pharmacist recommended to provide a duration of therapy for heparin (blood thinner). There was no documentation of the follow-through with the physician for the recommendation. Review of Resident 90's medical record failed to show documentation the recommendation by the Pharmacy Consultant to add the duration of therapy for heparin was carried out. c. For Resident 34, who was receiving Tylenol 650 mg three times a day for pain management, the Pharmacy Consultant recommended for the physician to assess the effectiveness of the medication and evaluate if dose reduction or adjustment was warranted. Review of the Order Summary Report showed a physician's order dated 7/25/18, to administer two tablets of Tylenol 325 mg by mouth after meals. Review of Resident 34's medical record failed to show documentation the physician assessed the effectiveness and evaluated if dose reduction or adjustment of the Tylenol tablet was warranted. On 1/30/2020 at 1606 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON reviewed the medical records of Residents 24, 32, 34, 55, 62, 71, and 90, and verified the above findings. The ADON failed to show documentation Residents 24, 32, 34, 55, 62, 71, and 90's physicians were informed of the Pharmacy Consultant's recommendations. The ADON stated he and the DON were responsible in ensuring the Pharmacy Consultant's recommendations were carried out in a timely manner.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and facility P&P review, the facility failed to follow proper sanitation, food handling, and storage practices. * The expired food was found in the freezer. * The facility failed to ensure the kitchen stove hood was clean. * The facility failed to ensure kitchenware and tableware were presented so only the handles were touched by the dietary staff. * The facility failed to ensure four muffin pans were maintained in sanitary and safe condition. * The trash receptacle with a foot peddle was not provided by the handwashing sink in the kitchen. * The food blender was not allowed to air dry. These had the potential to result in foodborne illnesses in the highly susceptible resident population. Findings: Review of the CMS 672 Resident Census and Conditions of Residents signed by the DON dated 1/28/2020, showed 133 of the 147 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Freezer Storage Guidelines (undated) showed all foods which need to be kept in the freezer could be stored frozen for six months with the following exceptions: baked goods including pastries for three months, and processed meats including bacon, sausage, and luncheon meats for one month. On 1/28/2020 beginning at 0734 hours, an initial tour of the kitchen was conducted with the Food Service Assistant Manager. During the initial tour, a container of pastry items dated 7/23/19, was found in the freezer. The container was shown to the Food Service Assistant Manager. The Food Service Assistant Manager stated per the facility P&P, frozen baked goods were expired after 3 months. The Food Service Assistant Manager stated the pastries were expired and should have been removed from the freezer. A bag of pepperoni sausage with the handwritten date 8/11/19, and a blurred expiration date was found in the freezer. The Food Service Assistant Manager stated processed meats, according to the P&P, could be kept for one month, then discarded from the freezer. The Food Service Assistant Manager was unable to verify the expiration date written on the bag. 2. According to the USDA Food Code 2017, 4-602.13, Non-Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's P&P titled Hood and Filter - Operation and Cleaning revised 10/1/14, showed the hood and filter system should be cleaned at least weekly or more often as necessary. The hoods will be kept free of grease and dust. During the initial tour of the kitchen, two white paper towels were wiped along the edge of the stove hood. A brown, oily substance was observed on each paper towel. The Food Service Assistant Manager was uncertain when the stove hood was cleaned. The Food Service Assistant Manager verified the brown, oily substance. 3. According the USDA Food Code 2017, 4-904.11, Kitchenware and Tableware, knives, forks, and spoons that are not pre-wrapped shall be presented so only the handles are touched by employees. During the initial tour of the kitchen, three drawers on the preparation tables were opened. The three drawers were found to contain serving utensils and food scoops. The serving utensils and food scoops were observed in the drawers placed in different directions without uniformity to the handles. The Food Service Assistant Manager stated the utensil handles and food scoops should be in the drawer in a uniform direction, to ensure all utensils were touched by the handles and not by the part which touched the food. The Food Service Assistant Manager verified the findings. 4. During the initial tour of the kitchen, four muffin pans coated with food particles and brown matter were observed in the clean pans area. The Food Service Assistant Manager verified the four muffin pans had baked-on food and should have been discarded. The Food Service Assistant Manager verified the findings. 5. According to the USDA Food Code 2017, 6-301.20, Disposable Towels, Waste Receptacle, a handwashing sink that is provided with disposable towels shall be provided with a waste receptacle as specified under 5-501.16(C), which shows if disposable towels are used at handwashing lavatories (sink), a waste receptacle shall be located at each lavatory (sink). During the initial tour of the kitchen, a handwashing sink with disposable towels in the kitchen was noted to not have a trash receptacle. The Food Service Assistant Manager stated the expectation was to wash hands at the sink and dry them with the paper towels. The towels were to be disposed by removing the lid from the covered trash cans (no foot control peddle) under the dirty dish counter in the dish area. When asked about maintaining hand hygiene, the Food Service Assistant Manager stated one couldn't maintain clean hands after touching the trash lid in the dirty dish area. The Food Service Assistant Manager stated a foot-controlled trash receptacle was needed by the hand washing sink to prevent hand contamination after handwashing. The Food Service Assistant Manager verified the findings 6. According to the USDA Food Code 2017, after cleaning and sanitizing, equipment and utensils are to be air dried before contact with food. Review of the facility's P&P titled Food Processor Use and Cleaning revised 10/1/14, showed the food processor and its attachments should be allowed to air dry. On 1/30/2020 at 0958 hours, [NAME] 1 was observed using a wet blender instead of allowing it to air dry. [NAME] 1 was asked what the procedure was for drying the blender in between use. [NAME] 1 stated the procedure was to allow the blender and the attachments to air dry before use. [NAME] 1 verified the findings.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 25% annual turnover. Excellent stability, 23 points below California's 48% average. Staff who stay learn residents' needs.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
• 90 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $16,143 in fines. Above average for California. Some compliance problems on record.
• Grade F (29/100). Below average facility with significant concerns.

Bottom line: Trust Score of 29/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Anaheim Point's CMS Rating?

CMS assigns ANAHEIM POINT an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Anaheim Point Staffed?

CMS rates ANAHEIM POINT's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 25%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Anaheim Point?

State health inspectors documented 90 deficiencies at ANAHEIM POINT during 2020 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 79 with potential for harm, and 10 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Anaheim Point?

ANAHEIM POINT is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by SHLOMO RECHNITZ, a chain that manages multiple nursing homes. With 154 certified beds and approximately 141 residents (about 92% occupancy), it is a mid-sized facility located in ANAHEIM, California.

How Does Anaheim Point Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, ANAHEIM POINT's overall rating (1 stars) is below the state average of 3.1, staff turnover (25%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Anaheim Point?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is Anaheim Point Safe?

Based on CMS inspection data, ANAHEIM POINT has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Anaheim Point Stick Around?

Staff at ANAHEIM POINT tend to stick around. With a turnover rate of 25%, the facility is 21 percentage points below the California average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.

Was Anaheim Point Ever Fined?

ANAHEIM POINT has been fined $16,143 across 1 penalty action. This is below the California average of $33,240. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Anaheim Point on Any Federal Watch List?

ANAHEIM POINT is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 154
Avg. Residents: 141
Occupancy: 91.6%
Ownership: For profit - Limited Liability company
Chain: SHLOMO RECHNITZ
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
Low Turnover: +3
1 Immediate Jeopardy citation: -12
90 Deficiencies: -10
Fines ($16,143): -2
Final Score: 29/100

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555688