BEACH CREEK POST-ACUTE
For profit - Limited Liability company
138 Beds
LINKS HEALTHCARE GROUP
Data: November 2025
Trust Grade
80/100
#21 of 1155 in CA
Photo by Beach Creek Post-Acute
Photo by Beach Creek Post-Acute
Photo by Arvind Patel
1 / 10 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Beach Creek Post-Acute in Anaheim, California, has a Trust Grade of B+, indicating it is above average and recommended for potential residents. It ranks #21 out of 1,155 facilities in California, placing it in the top half, and #3 out of 72 in Orange County, meaning only two local options are better. However, the facility is experiencing a worsening trend, with issues increasing from 1 in 2024 to 11 in 2025. Staffing has a rating of 3 out of 5, and while turnover is below the state average at 32%, the RN coverage is concerning as it is lower than 79% of California facilities. Importantly, there have been no fines reported, which is a positive sign. Specific incidents noted by inspectors include a failure to maintain sanitary conditions in the kitchen, which could lead to foodborne illnesses, and a failure to administer oxygen according to physician orders for a resident, posing a risk for respiratory distress. Overall, while there are strengths such as excellent health inspection and quality measures, the facility has significant areas for improvement, particularly in care plan implementation and kitchen sanitation.
- Trust Score
- B+
- In California
- #21/1155
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 32% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
80/100
Top 1%
No red flags
1 → 11 violations
★★★★★
5.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 11 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (32%)
16 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 32%
14pts below California avg (46%)
Typical for the industry
Chain: LINKS HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 40 deficiencies on record
Jan 2025
11 deficiencies
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
**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 comprehens...
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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 comprehensive care plan for one of 27 final sampled residents (Resident 13).
* Resident 13's At Risk for Respiratory Distress care plan showed to administer the oxygen as ordered by the physician (a rate of two liters per minute); however, Resident 13 was receiving oxygen at a rate of four and a half liters per minute. This failure posed the risk for not providing appropriate an individualized care to the resident.
Findings:
Review of the facility's P&P titled Oxygen Administration revised 6/5/23, showed the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders such as, but not limited to: The type of oxygen delivery system, equipment setting for the prescribed flow rates, monitoring of oxygen saturation levels as ordered, and monitoring for complications associated with the use of oxygen.
Medical record review for Resident 13 was initiated on 1/6/25. Resident 13 was admitted to the facility on [DATE].
Review of Resident 13's physician's orders showed an order dated 1/4/25, to administer a supplemental oxygen at a rate of two liters per minute, to keep Resident 13's oxygen saturation at 92% or greater.
Review of Resident 13's plan of care showed a care plan titled At Risk for Respiratory Distress related to COPD and anxiety revised 12/9/24. The interventions showed to administer the oxygen as ordered. Resident 13's care plan goals showed Resident 13 would have no episodes of oxygen desaturation less than 90%.
On 1/6/25 at 0833 hours, an observation, interview, and concurrent medical record review was conducted with LVN 8. Resident 13 was observed lying in bed with continuous oxygen being administered through an oxygen concentrator, at a rate of four and a half liters per minute via nasal cannula. However, Resident 13's care plan titled At Risk for Respiratory Distress related to COPD and anxiety revised 12/9/24, showed to administer oxygen as ordered by the physician (a rate of 2 liters per minute) and showed Resident 13 would have no episodes of oxygen desaturation less than 90%.
LVN 8 lowered Resident 13's oxygen rate to two liters per minute (in accordance with the physician's order). LVN 8 then obtained Resident 13's oxygen saturation, which yielded a result of 86%.
Cross reference to F695.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**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 two sample...
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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 two sampled residents (final sampled, Resident 13) reviewed for respiratory care, was provided with the appropriate respiratory care when:
* The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 13. This failure had the potential to result in negative health outcomes for the resident.
Findings:
Review of the facility's P&P titled Oxygen Administration revised 6/5/23, showed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician.
Medical record review for Resident 13 was initiated on 1/6/25. Resident 13 was admitted to the facility on [DATE].
Review of Resident 13's H&P examination dated 11/7/24, showed Resident 13 had a diagnosis of COPD.
Review of Resident 13's physician's orders showed an order dated 1/4/25, to administer supplemental oxygen at a rate of two liters per minute, to keep Resident 13's oxygen saturation at 92% or greater.
On 1/6/25 at 0750 hours, an observation was conducted of Resident 13. Resident 13 was observed lying in bed with continuous oxygen being administered through an oxygen concentrator, at a rate of four and a half liters per minute via nasal cannula.
On 1/6/25 at 0833 hours, an observation, and concurrent interview was conducted with LVN 8. Resident 13 was observed lying in bed with continuous oxygen being administered through an oxygen concentrator, at a rate of four and a half liters per minute via nasal cannula. Resident 13 stated she received oxygen for shortness of breath. LVN 8 verified Resident 13 was receiving continuous oxygen at a rate of four and a half liters per minute, however, the physician's order showed to administer continuous oxygen at a rate of two liters per minute (to maintain Resident 13's oxygen saturation at 92% or greater). LVN 8 obtained Resident 13's oxygen saturation, while Resident 13 was receiving continuous oxygen at a rate of four and a half liters per minute, which yielded a result of 92%. LVN 8 then lowered Resident 13's oxygen rate to two liters per minute (as per the physician's order) and obtained Resident 13's oxygen saturation, which yielded a result of 86%. LVN 8 stated he would notify Resident 13's physician of Resident 13's change of condition (Resident 13's oxygen saturation of 86% on two liters per minute of continuous oxygen).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**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 necessary ca...
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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 necessary care and services to attain and maintain the highest well-being for one of three residents (final sampled resident, Resident 106) reviewed for hemodialysis (treatment to remove waste and extra fluid from the blood using a filtering machine).
* The facility failed to monitor Resident 106's fluid restriction as per the physician's order. This failure had the potential to negatively impact the resident's well-being.
Findings:
Review of the facility's P&P titled Fluid Intake and Output revised July 2017 showed the facility will monitor the intake and output as ordered by the physician. Maintaining intake and output for residents on restricted fluid diets, according to specific fluid restriction in the resident's plan of care.
Medical record review for Resident 106 was initiated on 1/6/25. Resident 106 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 106's H&P examination dated 11/22/24, showed Resident 106 had a diagnosis of end stage renal disease (medical condition where the kidneys can no longer function properly) with dependence on hemodialysis.
Review of Resident 106's Order Summary Report dated 1/8/25, showed the following physician's orders:
- dated 11/27/24, to record the intake and output every shift;
- dated 11/22/24, to monitor the LLE for edema; and
- dated 11/22/24, to monitor the RLE for edema.
Review of Resident 106's MAR dated January 2025, showed a physician's order for the fluid restriction of 1200 ml/24 hours related to the hemodialysis and included the following breakdown:
- kitchen to provide 240 ml at breakfast;
- kitchen to provide 240 ml at lunch;
- kitchen to provide 240 ml at dinner;
- nursing to provide 160 ml at AM shift;
- nursing to provide 160 ml at PM shift; and
- nursing to provide 160 ml at NOC shift.
Review of Resident 106's Documentation Survey Report for CNAs for Fluid Intake dated January 2025, showed the following daily fluid intakes (fluids provided from the kitchen for breakfast, lunch and dinner) totals as follows:
- 960 ml on 1/1/25 (more than the alloted total of 720 ml from all three meals);
- 1120 ml on 1/2/25 (more than the alloted total of 720 ml from all three meals);
- 680 ml on 1/3/25 (more than the alloted total of 720 ml from all three meals);
- 980 ml on 1/4/25 (more than the alloted total of 720 ml from all three meals);
- 960 ml on 1/5/25 (more than the alloted total of 720 ml from all three meals); and
- 940 ml on 1/6/25 (more than the alloted total of 720 ml from all three meals).
Review of Resident 106's MAR dated January 2025 showed Resident 106 had the following total daily fluid intakes (total for the fluid intake provided by the kitchen and nursing) as follows:
- 950 ml on 1/1/25;
- 1020 ml on 1/2/25;
- 750 ml on 1/3/25;
- 840 ml on 1/4/25;
-1020 ml on 1/5/25; and
- 780 ml on 1/6/25.
Review of Resident 106's MAR dated January 2025, showed Resident 106 had edema on the following extremities on the following dates:
- LLE on 1/2/25;
- LLE on 1/3/25;
- LLE on 1/4/25;
- LLE on 1/5/25;
- RLE on 1/2/25;
- RLE on 1/3/25;
- RLE on 1/4/25; and
- RLE on 1/5/25.
On 1/9/25 at 1318 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 acknowledged and verified the above findings. LVN 6 stated the CNAs document the resident's fluid intake from the meals on the Documentation Survey Report for CNAs for Fluid Intake.
On 1/9/25 at 1408 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged and verified the above findings. The DON stated the CNAs were documenting the resident's fluid intake on the Documentation Survey Report for CNAs for Fluid Intake in regards to the fluid consumed by the resident from the water pitcher at bedside, nourishments and the fluids served with the meals. The DON further stated the licensed nurses were expected to collaborate with the CNAs to calculate the resident's total intake, including the fluid intake alloted for nursing per the physician's order. The DON verified the inconsistency of the documentation of the resident's intake from the MAR by the licensed nurses and Documentaion Survey Report by the CNA.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**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 ser...
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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 P&P for four nonsampled residents (Residents 63, 77, 85, and 118).
* LVN 6 failed to ensure Residents 63 and 77's scheduled morning medications (at 0900 hours) were administered timely within 60 minutes of the scheduled time.
* The facility failed to ensure the accurate and complete documentation of the controlled medications administered to Resident 85.
* The facility failed to ensure the administration of the controlled medication for Resident 118 was documented in the narcotic and hypnotic record.
These failures had the potential to place the residents at risk for delays in treatment and increased risk for adverse events and posed the risk for diversion of medications.
Findings:
1. Review of the facility's P&P titled Medication Administration revised 12/19/22, showed to administer resident's medications within 60 minutes prior to or after scheduled time, unless otherwise ordered by the physician.
On 1/8/25 at 1030 hours, an observation and concurrent interview was conducted with LVN 6. LVN 6 was observed administering medications to the facility residents. Residents 63 and 77 had yet to receive their morning medications (scheduled for 0900 hours). LVN 6 verified Residents 63 and 77 had yet to receive their scheduled morning medications (at 0900 hours). LVN 6 stated the medications were to be administered within 60 minutes of the scheduled time.
a. Review of Resident 63's Order Summary Report dated 1/2025, showed the following medications were ordered to be administered on 1/8/25, at 0900 hours:
- Apixaban (anticoagulant) 2.5 mg tablet orally two times a day for DVT.
- Megestrol acetate (hormonal drug therapy used as an appetite stimulant) 40 mg tablet orally one time a day for appetite stimulant.
- Multi-vitamin/minerals one tablet orally for supplement.
- Oxybutynin (bladder relaxant) 15 mg extended-release tablet orally for overactive bladder.
- Potassium chloride 20 meq extended-release tablet orally for supplement.
b. Review of Resident 77's Order Summary Report dated 1/2025, showed the following medications were ordered to be administered on 1/8/25, at 0900 hours:
- Lisinopril (antihypertensive)10 mg tablet orally in the morning for hypertension (high blood pressure).
- Metoprolol (antihypertensive) 25 mg tablet orally two times a day for hypertension.
- Norco (analgesic) 5-325 mg tablet orally every 12 hours for pain management.
- Pioglitazone (anti-diabetic medication) 30 mg tablet orally in the morning for diabetes (high blood sugar).
- Calcium 600 mg tablet orally two times a day supplement.
- Cymbalta (medication to treat nerve pain) 60 mg delayed release capsule once a day for neuropathy (weakness, numbness, and pain from nerve damage).
- Docusate sodium (laxative) 200 mg orally once a day for bowel management.
- Donepezil (cognitive enhancer) 15 mg orally once a day for dementia (medical condition affecting a person's ability to think, remember and behave).
- Senokot (laxative) 8.6 mg (two tablets) orally in the morning for bowel management.
- Vitamin D3 125 microgram tablet orally in the morning supplement.
- Multivitamin/mineral one tablet orally for supplement.
2. Review of the facility's P&P titled Administering Oral Medications revised 10/2010 showed the facility shall maintain a medication administration record to document all medications administered.
a. Medical record review for Resident 85 was initiated on 1/7/25. Resident 85 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident's 85 H&P examination dated 3/20/24, showed Resident 85 had the capacity to understand and make decisions.
Review of Resident 85's Order Summary Report dated 1/7/25, showed a physician's order date 5/29/24, to administer oxycodone-acetaminophen (controlled pain medication) 10-325 mg one tablet by mouth every four hours as needed for severe pain (pain level of 5-10, using the 0-10 pain scale; zero meaning no pain and 10 meaning worst pain).
Review of Resident 85's Narcotic and Hypnotic Record showed the oxycodone-acetaminophen 10-325 mg oral tablet was dispensed and signed out on 11/29/24 at 1300 hours.
Review of Resident 85's November 2024 MAR failed to show the documentation of the administration for the oxycodone-acetaminophen medication on 11/29/24 at 1300 hours.
On 1/7/25 at 1111 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 verified the above findings.
On 1/7/25 at 1510 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 needed to document on the MAR when the medication was administered to the resident.
b. Medical record review for Resident 118 was initiated on 1/7/25. Resident 118 was admitted to the facility on [DATE].
Review of Resident 118's H&P examination dated 7/3/24, showed Resident 118 had the capacity to understand and make decisions.
Review of Resident 118's Order Summary Report showed a physician's order dated 7/2/24, to administer buprenorphine HCI (schedule III narcotic analgesic medication to treat opioid or narcotic dependence or addiction) 8 mg one tablet sublingually (under the tongue) in the morning for opioid use disorder.
On 1/7/25 at 1035 hours, a controlled medication count review for Resident 118 was conducted with the TRC DON and LVN 2. Review of 118's buprenorphine HCI sublingual tablet 8 mg Narcotic and Hypnotic Record showed the medication was given routinely in the morning at 0700 hours. However, review of Resident 118's Narcotic and Hypnotic Record for the buprenorphine HCI medication did not show the documentation the medication was signed out on 1/5/25 at 0700 hours. The TRC DON verified the above finding. TRC DON stated he would investigate who was assigned on 1/5/25. LVN 2 checked Resident 118's MAR and stated LVN 3 administered the medication. The TRC DON stated the protocol for administering a narcotic or controlled medication was to pour, pass, and sign the narcotic record sheet then the MAR.
On 1/8/25 at 1051 hours, an interview was conducted with LVN 3. LVN 3 verified she worked on 1/5/25 and was assigned to administer the medication to Resident 118 at 0700 hours. LVN 3 stated she recalled administering the buprenorphine medication to Resident 118 but did not document in the Narcotic and Hypnotic Record sheet after administering the medication. LVN 3 stated she was supposed to document in the Narcotic and Hypnotic Record sheet right after administering the medication.
On 1/9/25 1437 at hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**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 medication er...
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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 medication error rate was below 5%. The facility's medication error rate was 8.33%.
* Resident 4 had a physician's order for vitamin B12 5000 micrograms orally to be administered one time a day for supplement; however, the LVN administered vitamin B12 1000 micrograms to Resident 4. In addition, the LVN applied a nicotine 21 mg transdermal patch to Resident 4's lower back; however, Resident 4 did not have a physician's order for a nicotine transdermal patch.
* Resident 63 had a physician's order for a multi-vitamin/minerals tablet to be administered orally for supplement; however, the LVN administered a multi-vitamin without minerals to Resident 63.
These failures had the potential to negatively affect the residents' health.
Findings:
Review of the facility's P&P titled Medication Administration revised 12/19/22, showed medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice.
1. Medical record for Resident 4 was initiated on 1/6/25. Resident 4 was admitted to the facility on [DATE].
On 1/8/25 at 0839 hours, a medication administration observation for Resident 4 was conducted with LVN 10. LVN 10 prepared and administered Resident 4's medications.
During the medication administration for Resident 4, LVN 10 was observed having applied a nicotine 21 mg transdermal patch to Resident 4's lower back. LVN 10 was also observed having administered vitamin B12 1000 micrograms orally to Resident 4.
Review of Resident 4's physician's orders showed an order dated 12/4/24, to administer vitamin B12 5000 micrograms orally one time a day for supplement. Further review of Resident 4's active physician's orders failed to show Resident 4 had an order for a nicotine 21 mg transdermal patch.
On 1/8/25 at 0946 hours, an interview and concurrent medical record review was conducted with LVN 10. LVN 10 reviewed Resident 4's active physician's orders. LVN 10 verified Resident 4's physician's order showed to administer vitamin B 12 5000 micrograms orally, however, LVN 10 administered vitamin B 12 1000 micrograms orally. LVN 10 also verified Resident 4 did not have an order for a nicotine 21 mg transdermal patch.
2. Medical record review for Resident 63 was initiated on 1/6/25. Resident 63 was admitted to the facility on [DATE].
On 1/8/25 at 1030 hours, a medication administration observation for Resident 63 was conducted with LVN 6.
During the medication administration for Resident 63, LVN 6 was observed having administered a multi-vitamin tablet orally to Resident 63.
Review of Resident 63's physician's orders showed an order dated 1/20/24, to administer multi-vitamin/minerals tablet orally in the morning for supplement. LVN 6 verified she administered a multi-vitamin tablet to Resident 63, however, the physician's order showed to administer a multi-vitamin with minerals tablet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Labeling of Medications and Biologicals revised 12/19/22, showed labels for individual dr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Labeling of Medications and Biologicals revised 12/19/22, showed labels for individual drug containers must include the resident's name, prescribing physician's name, prescription number, prescribed dose, and the appropriate instructions and precautions.
Medical record for Resident 4 was initiated on 1/6/25. Resident 4 was admitted to the facility on [DATE].
On 1/8/25 at 0839 hours, a medication administration observation for Resident 4 was conducted with LVN 10. LVN 10 prepared and administered Resident 4's medications.
During the medication administration for Resident 4, LVN 10 was observed having applied a nicotine 21 mg transdermal patch to Resident 4's lower back.
On 1/8/25 at 0946 hours, an interview and concurrent medical record review was conducted with LVN 10. LVN 10 reviewed Resident 4's active physician's orders. LVN 10 verified Resident 4 did not have an order for a nicotine 21 mg transdermal patch.
The package which contained the nicotine 21 mg transdermal patches was observed without a label. The label had been pealed from the box. The package which contained the nicotine 21 mg transdermal patches was not labeled with a resident's name, prescribing physician's name, prescription number, prescribed dose, or the appropriate instructions and precautions. LVN 10 verified the findings. LVN 10 stated the label should include a resident's name to identify which resident to apply the nicotine patch.
Cross reference to F759, example #1.
3. Medical record review for Resident 63 was initiated on 1/6/25. Resident 63 was admitted to the facility on [DATE].
On 1/8/25 at 1030 hours, a medication administration observation for Resident 63 was conducted with LVN 6.
During the medication administration for Resident 63, LVN 6 was observed having held Resident 63's scheduled morning (0900 hours) carvedilol (antihypertensive medication) 3.125 mg tablet. LVN 6 stated Resident 63's systolic blood pressure was 101 and the physician's order showed to hold the medication if Resident 63's systolic blood pressure was less than 110. The bubble pack (packaging) which contained the carvedilol 3.125 mg tablets showed instructions to hold the medication if Resident 63's systolic blood pressure was less than 100. LVN 6 verified the findings and stated she needed to clarify the discrepancy specific to the hold parameters for the medication.
Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications.
* The facility failed to ensure the orally administered medications were stored separately from the rectally administered medication in Medication Cart 5.
* The facility failed to ensure the medication drawer was kept clean and free of dried white residue in Medication Cart 5.
* A package which contained nicotine 21 mg transdermal patches was not labeled with a resident's name, prescribing physician's name, prescription number, or prescribed dose. Subsequently a LVN applied the nicotine 21 mg transdermal patch to a resident (Resident 4) without a physician's order for the nicotine 21 mg transdermal patch.
* Resident 63's carvedilol (antihypertensive medication) medication order and carvedilol medication packaging had conflicting hold parameters specific to the systolic blood pressure monitoring.
These failures had the potential to negatively impact the residents' well-being, and the potential for the medications to lose the stability and effectiveness.
Findings:
Review of the facility's P&P titled Medication Storage in the Facility revised on 1/2018 showed the following:
- Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, and etc; and
- Medication storage areas are kept clean, well-lit, free of clutter, extreme temperatures and humidity.
1. On 1/7/25 at 1110 hours, a medication cart inspection for Medication Cart 5 was conducted with the TRC DON. The following was observed:
- a bottle of Mylanta (used to treat stomach upset, heart burn, and acid indigestion) and a bottle of Milk of Magnesia (MOM) (used to treat constipation) were stored with a box of bisacodyl (used to treat occasional constipation) suppository.
- dried white residue on side of the drawer where the Mylanta and MOM were stored and under the bottles of Mylanta and MOM.
The TRC DON verified the above findings.
On 1/8/25 at 1500 hours, an interview was conducted with the DON. The DON stated the oral and rectal medications should be stored separately and not mixed in the same storage. The DON was informed 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
Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen when:
* The facility failed to ensure the ice machine was mai...
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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 when:
* The facility failed to ensure the ice machine was maintained in a sanitary condition.
* The facility failed to ensure the raw meat was stored in a sanitary manner.
* The facility failed to ensure the kitchen equipment was clean.
These failures posed the risk for food borne illnesses in highly susceptible resident population of 125 facility residents who received food prepared in the kitchen.
Findings:
Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 1/6/25, showed 125 of 134 residents in the facility received food prepared in the kitchen.
1. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food- Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch.
Review of the facility's P&P titled Food Safety and Food Storage revised on 11/4/24, showed cleaning and sanitizing the internal component of the ice machine according to manufacturer's guidelines.
On 1/6/25 at 0840 hours, an observation and concurrent interview was conducted with the MS for Ice Machine 1. Ice Machine 1's trough (a long container that hold water used to make ice) was observed with approximately half a cup of an unknown white powder substance floating in the water. When touched, the white powder substance was soft, swirled around in the water and did not dissolve. The MS verified the finding and stated it was hard water deposit.
On 1/6/26 at 1059 hours, a follow up interview was conducted with the MS. The MS stated he adjusted Ice Machine 1 because it was not draining properly. The MS stated the white powder substance in the ice machine's trough was chlorine from the water. When asked again what the white powder substance was, the MS stated, I don't know. The MS stated he noticed the white powder substance on 12/27/24, when the ice machine was cleaned. The MS stated the unknown white powder substance accumulated more since the ice machine was cleaned.
2. A review of US Food and Drug Administration titled Food Ingredients and Packaging dated 7/6/23, showed the FDA regulates the safety of ingredients added directly to food and substances that come into contact with food, such as those added to packaging materials, cookware of containers that store food.
On 1/6/25 at 0800 hours, an observation of Freezer 1 was conducted with the DSS. More than six pieces of raw beef chuck were stored inside plastic grocery bags.
On 1/6/25 at 1112 hours, a follow up interview was conducted with the DSS. The DSS stated, the plastic bags used to store the beef chuck were grocery bags purchased from the purveyor. The DSS verified the grocery bags were not approved for food storage.
3. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food- Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch.
On 1/6/25 at 0800 hours, an observation and concurrent interview was conducted with the DSS. One of three residents' meal tray drying rack was observed with a brown residue, which resembled rust and had peeling paint. The DSS verified the finding and stated he will order a new rack today.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 01/07/25 at 1028 hours, during the initial observation of Room A, there was no receptacle to dispose of the used gowns rea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 01/07/25 at 1028 hours, during the initial observation of Room A, there was no receptacle to dispose of the used gowns readily available. Room A was designated as an enhanced barrier precautions room. When asked about any receptacle readily available to dispose of the used gowns, LVN 1 initially was unable to explain, but then stated the used gown would be placed in a bin located outside Room A, approximately 15 feet away.
2. Medical record review for Resident 50 was initiated on 1/6/25. Resident 50 was admitted to the facility on [DATE].
Review of Resident 50's physician's order dated 6/7/24, showed an order for enhanced barrier precautions for a diagnosis of GT (a small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications).
Review of Resident 50's care plan titled Enhanced Barrier Precautions (GT) revised 6/7/24, showed to practice isolation precautions for infection control and to follow infection control procedure.
On 1/7/25 at 1622 hours, an observation and concurrent interview was conducted with CNA 6. At the entrance to Resident 50's room, a sign was posted which showed enhanced barrier precautions were required. The sign showed providers must wear gloves and a gown when bathing and changing Resident 50. Resident 50 was observed inside of her room lying on her bed. CNA 6 was observed providing care to Resident 50. CNA 6 was observed bathing and changing Resident 50's adult brief. CNA 6 was observed only wearing gloves while providing care to Resident 50, however, CNA 6 failed to don a gown while she was bathing and changing Resident 50's adult brief. CNA 6 verified in accordance with the ordered enhanced barrier precautions, she should have donned a gown while bathing and changing Resident 50, for infection control.
On 1/7/25 at 1642 hours, an interview was conducted with the IP. The IP verified in accordance with the EBP, the staff members were required to don gloves and a gown while bathing and changing Resident 50's adult brief, for infection control.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when:
* CNA 1 did not follow the EBP when providing incontinence care for Resident 58.
* The facility failed to ensure the CNA donned the appropriate PPE when providing care to Resident 50.
* There was no receptacle readily available to discard used gowns for the resident on EBP.
These failures had the potential to spread infection in the facility.
Findings:
Review of the facility's P&P titled Infection Control revised October 2018 showed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of our infection control practices are to: Prevent, detect, investigate, and control infections in the facility and establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions.
On 1/6/25 at 0825 hours, an EBP sign was observed outside of Resident 58's room. The EBP sign showed everyone must wear gloves and a gown for high-contact resident care activities for Resident 58. The PPE cart was observed hanging on the door and was fully stocked. CNA 1 was observed changing Resident 58's incontinence brief while wearing gloves; however, CNA 1 was observed without a gown.
Review of CNA 1's Certified Nursing Assistant Competench Checklist dated 8/21/24, showed CNA 1 was competent in the following training categories for the Infection Control:
- Standard Precautions; including application and removal of PPE and location of PPE; and
- Enhanced Isolations, Contact, Droplet, Airborne.
On 1/6/25 at 1457 hours, an interview was conducted with CNA 1. CNA 1 verified she did not don a gown while providing incontinence care to Resident 58 and stated it was an accident.
On 1/8/25 at 0840 hous, an interview was conducted with the IP. The IP stated she provided ongoing education on EBP to the facility staff members. The IP was informed and acknowledge the 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
Garbage Disposal
(Tag F0814)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. This failure posed the threat for pest contamination.
Findings:
Accordi...
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Based on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. This failure posed the threat for pest contamination.
Findings:
According to the US Food Code 2022, Section 5-501.113, Covering Receptacles, receptacle units for refuse shall be kept covered with tight fitting lids after they are filled.
Review of the facility's P&P titled Dispose of Garbage and Refuse reviewed/revised 12/19/22, showed the refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers.
On 1/6/25 at 0926 hours, an observation of trash disposal with DSS was conducted. Two of three dumpsters were observed located outside of the facility with lids not completely close. The DSS stated one of the dumpster lid was bent, and the other dumpster had too much trash in it. The DSS verified the trash was exposed, and the lids of the two dumpsters were not fully closed.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0838
(Tag F0838)
Minor procedural issue · This affected multiple residents
Based on interview and facility document review, the facility failed to conduct and document a facility-wide assessment to determine the resources necessary to care for its residents competently durin...
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Based on interview and facility document review, the facility failed to conduct and document a facility-wide assessment to determine the resources necessary to care for its residents competently during both day-to-day operations and emergencies. This failure posed the risk of the facility not being able to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents required.
Findings:
On 1/6/25 at 0830 hours, an entrance conference was conducted with the Administrator and DON. When the Entrance Conference Worksheet items needed within four hours were read, the Facility Assessment was requested.
On 1/6/25 at 1600 hours, an interview was conducted with the Administrator. The Administrator stated the Facility Assessment had not been completed.
On 1/7/25 at 0730 hours, the Administrator submitted a Facility Assessment to the survey team.
MINOR
(B)
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**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 nonsampled resident (Re...
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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 nonsampled resident (Resident 51) had accurate and complete medical records.
* The facility failed to ensure Resident 51's Pulmonary administration were documented as ordered. This failure had the potential for the resident's health care needs to not be met as the medical record was incomplete and inaccurate.
Findings:
Review of the facility's P&P titled Documentation in Medical Record dated 10/2022 showed the following:
- Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with the state law and facility policy; and
- Documentation can be completed at the time of service, but no later than the shift which the assessment, observation, or care service occurred.
Medical record review for Resident 51 was initiated on 1/8/25. Resident 51 was admitted to the facility on [DATE].
On 1/6/25 at 1301 hours, Resident 51 was observed using the oxygen via nasal cannula during lunch time. Resident 51 stated I used the oxygen when I'm short winded and during the ambulation. LVN 7 verified the above findings.
Review of Resident 51's Order Summary Report showed the following physician's orders:
- dated 9/18/24, to administer Anoro Ellipta (used to help relieve symptoms of COPD) inhalation, one inhalation orally one time a day for COPD;
- dated 9/24/224, to clean the outside of the devices and flow head with 70% isopropyl alcohol impregnated cloth to remove any visible soiling for low level disinfection before and after each patient use every shift for COPD;
- dated 9/24/24, Pulmonary: demonstration and/or evaluation of respiratory treatment (assessment and treatment) every shift related to COPD;
- dated 9/24/24, Pulmonary: Incentive spirometer treatments to sit up straight, breathe out normally. Place mouthpiece in the mouth, seal the lips around the mouthpiece, breath in slowly and deeply with lips sealed tightly around the mouthpiece. Inhale deeply, hold your breath for at least three seconds, remove mouthpiece and breathe out normally, repeat times 10 as needed three times a day every Tuesday, Wednesday, Thursday, Friday, and Saturday for prolonged bedrest/prevent pneumonia and development of atelectasis (medical condition when part or all of the lung collapses);
- dated 11/26/24, Pulmonary: chest physiotherapy via Acapella three times a day every Tuesday, Wednesday, Thursday, Friday, and Saturday for enhance pulmonary function and mucociliary airway clearance related to COPD; and
- dated 1/6/25, to administer the oxygen at two liters per minute via nasal cannula. May titrate up to five liters via nasal cannula as needed to maintain oxygen saturation between 88-92 % for shortness of breath related to COPD.
On 1/8/25 at 1210 hours, a concurrent interview and medical record review was conducted with LVN 5. Resident 51's Pulmonary administration record for January 2025 was reviewed with LVN 5. LVN 5 verified the missing initials by the licensed nurses to show for the administration of the above physician's orders for Resident 51 on the following dates:
- 1/3/24, for incentive spirometer treatment;
- 1/3/24, for chest physiotherapy via Acapella;
- 1/3-1/6/25, to clean outside surface of devices;
- 1/5-1/6/25 at 0900 hours, to administer Anoro Ellipta Inhalation 1 inhalation inhale orally one time a day for COPD;
- 1/5-1/6/25, for pulmonary demonstration; and
- 1/6/25, for the administration of oxygen at two liters per minute via nasal cannula as needed.
On 1/8/25 at 1500 hours, an interview was conducted with the DON. The DON was asked regarding the documentation after administration of the medication and ordered monitoring or assessment. The DON stated the licensed facility staff must document or chart after the administration of the medications and completing any assessments or pulmonary treatments before the shift ended.
On 1/9/25 1437 at hours, the DON and Administrator were informed and acknowledged the above findings.
Jan 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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**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 respiratory s...
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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 respiratory services were provided as ordered for two of five sampled residents (Residents 1 and 2).
* The facility failed to ensure Resident 1 received oxygen 2 liters per minute via nasal cannula as per the physician's order. In addition, the facility failed to ensure the nebulizer (used to deliver vaporized medicine into the airway) mask was stored properly.
* The facility failed to ensure Resident 2's nebulizer mask and BiPAP (bilevel positive airway pressure, a machine used to provide pressurized air into the airways while asleep) mask were stored properly.
These failures had the potential to affect the residents' health and well-being.
Findings:
Review of the facility's P&P titled Administering Medications Through a Small Volume (Handheld) Nebulizer revised October 2010 showed the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Under the Steps in the Procure section showed to rinse and disinfect the nebulizer equipment according to facility protocol, or: (a) wash pieces with warm water, soapy water; (b) rinse with hot water; (c) place all pieces in a bowl and cover with isopropyl (rubbing) alcohol and soak for five minutes; (d) rinse all pieces with sterile water (not tap, bottled, or distilled); and (e) allow to air dry on a paper towel. When equipment is completely dry, store in a plastic bag with resident's name and the date on it.
1. On 1/23/24 at 0827 hours, Resident 1 was observed with the following:
- The oxygen nasal cannula tubing was on top of the mattress and connecting to the oxygen concentrator machine with the flow meter set at five liters per minute; and,
- The nebulizer mask was on the back of the nebulizer machine without a storage bag.
Medical record review for Resident 1 was initiated on 1/23/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Order Summary Report dated 1/23/24, showed a physician's order dated 11/2/23, to administer ipratropium-albuterol solution (breathing treatment medication) 0.5-2.5 mg/3 ml via nebulizer four times a day for shortness of breath.
Review of Resident 1's MAR for January 2024 showed the physician's order dated 11/13/23, to administer oxygen at two liters per minute via nasal cannula continuously to maintain oxygen saturation level greater than or equal to 94%. In addition, the MAR showed Resident 1 was receiving ipratropium-albuterol solution breathing treatments four times a day via nebulizer mask.
On 1/23/24 at 0830 hours, an observation and concurrent interview for Resident 1 was conducted with LVN 1. LVN 1 verified Resident 1's oxygen nasal cannula was on top of the mattress. LVN 1 was then observed placing the oxygen nasal cannula into Resident 1's nose. LVN 1 verified the oxygen concentrator flow meter was set at five liters per minute. LVN 1 stated Resident 1's oxygen treatment was ordered continuously at two liters per minute. LVN 1 was then observed changing the flow meter on the oxygen concentrator to two liters per minute.
On 1/23/24 at 0835 hours, an observation, follow up interview, and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 1's oxygen treatment was ordered continuously at two liters per minute. LVN 1 verified Resident 1's nebulizer mask was stored uncovered on the back of the nebulizer machine. LVN 1 stated the nebulizer mask should be stored inside a plastic storage bag.
2. On 1/23/24 at 0853 hours, Resident 2 was observed with the following:
- The nebulizer mask was inside a plastic storage bag containing two Vitamin A&D (used as a moisturizer) ointment sachets, one lip balm; and another plastic storage bag contained one comb, one toothbrush, and one lip balm;
- Multiple droplets of clear liquid inside the plastic storage bag containing the nebulizer mask; and,
- The uncovered BiPAP facemask and tubing were on top of the BiPAP machine.
Medical record review for Resident 2 was initiated on 1/23/24. Resident 2 was readmitted to the facility on [DATE].
Review of Resident 2's Order Summary Report dated 1/23/24, showed the following physician's orders:
- dated 12/9/23, to administer ipratropium-albuterol solution 0.5-3 mg/3 ml orally via nebulizer every six hours as needed for SOB;
- dated 11/17/23, to apply BiPAP on at bedtime for sleep apnea (sleep disorder in which breathing repeatedly stops and starts); and,
- dated 11/17/23, to remove BiPAP in the morning.
Review of Resident 2's MAR for January 2024 showed Resident 2 was administered ipratropium-albuterol solution via nebulizer on 1/4 at 1357 hours, 1/5 at 1634 hours, 1/7 at 0951 hours, 1/8 at 1638 hours, 1/10 at 0919 hours, and 1/17/24 at 1047 hours. The MAR also showed Resident 2 received the BiPAP at bedtime and the BiPAP was removed in the morning at 0700 hours.
On 1/23/24 at 0909 hours, an observation and concurrent interview for Resident 2 was conducted with LVN 2. LVN 2 verified the above findings and acknowledged Resident 2's nebulizer mask should be stored inside a clean plastic storage bag separate from the resident's toiletries. LVN 2 stated the BiPAP mask should also be stored inside a plastic storage bag.
On 1/23/24 at 1320 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the licensed nurses were expected to store the nebulizer mask and BiPAP mask inside a clean plastic set up bag labeled with the resident's name and date. When asked, the DON stated the licensed nurses were responsible to monitor the residents receiving oxygen treatment per the physician's order.
May 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**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 t...
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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 implement their P&P specific to an investigation for an injury of unknown source for one of two sampled residents (Resident 1).
* Resident 1 sustained a fracture of his right second metacarpal from an unknown source.
* Resident 1's family member claimed and informed the facility that Resident 1 sustained a fall in the facility on 2/18/23 at approximately 1815 to 1830 hours.
* The facility conducted an investigation specific to Resident 1's fracture (an injury of unknown source), however, failed to investigate Resident 1's family member's claim that Resident 1 fell in the facility on 2/18/23 at approximately 1815 to 1830 hours.
The failure to conduct a thorough investigation placed the resident at risk for further injury.
Findings:
Review of the facility's P&P titled Abuse Investigation and Reporting revised 7/2021 showedall reports of injuries of unknown source shall be reported to the state agency and thoroughly investigated by facility management. If an incident of injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The individual conducting the investigation will, at a minimum: Review the resident's medical record to determine events leading up to the incident. Interview the person(s) reporting the incident. Interview any witnesses to the incident. Interview the resident (as medically appropriate). Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Interview the resident's roommate, family members, and visitors. Review all events leading up to the incident. The Administrator will provide the appropriate agencies with a written report of the findings of the investigation within five working days of the occurrence of the incident.
Review of the facility's P&P titled Accidents and Incidents – Investigating and Reporting revised 7/2017 showed all accidents or incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor, Charge Nurse and/or Department Director shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form: The date and time the accident or incident took place. The nature of the injury (e.g., fall). The circumstances surrounding the accident or incident. Where the accident or incident took place. The name(s) of witnesses and their accounts of the accident or incident. The injured person's account of the accident or incident.
Medical record review for Resident 1 was initiated on 4/19/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's H&P dated 9/7/22, showed Resident 1 had the capacity to understand and make decisions. Resident 1 had a diagnosis of CVA with CNS deficits.
Review of Resident 1's care plan problem titled Communication Deficits initiated 9/9/22, showed Resident 1 had expressive aphasia.
Review of Resident 1's care plan problem titled At Risk for Fall or Injury initiated 9/7/22, showed Resident 1 had impaired balance during transitions related to the right sided weakness due to CVA.
On 4/19/23 at 1150 hours, an observation was conducted of Resident 1. Resident 1 was observed lying in his bed. Resident 1 was nonverbal. Resident 1's room was observed with bilateral floor mats in place located adjacent to each side of his bed.
Review of Resident 1's SBAR Communication Form and Progress Note dated 4/5/23 1656 hours, showed Resident 1's sister complained to thefacility's Office Manager that Resident 1 had a fall incident on 2/18/23 (around 1815 to 1830 hours) when transferring (with the assistance of Resident 1's brother-in-law and a CNA) from his chair to his bed.
Review of Resident 1's IDT dated 4/7/23, showed an IDT was held regarding the fall claimed by Resident 1's sister. Resident 1's sister stated Resident 1 fell on 2/18/23, while thefamily was visiting. Subsequently, a recommendation for an x-ray of Resident 1's right wrist was made.
Review of Resident 1's Radiology Interpretation dated 4/7/23, showed Resident 1 sustained a spiral undisplaced hairline fracture of his right second metacarpal, suggesting acute or subacute finding.
Review of Resident 1's medical record for February 2023 failed to show documentation specific to Resident 1's family member's claim that Resident 1 sustained a fall at the facility on 2/18/23 at approximately 1815 to 1830 hours, while a CNA and Resident 1's family member were transferring Resident 1 from a chair to his bed.
Review of the facility's investigation (Incident/Accident Investigation Report dated 4/7/23) specific to Resident 1's fracture from an unknown source showed documentation of several interviews conducted with the facility staff. Documentation showed theinterviews were conducted with staff who provided care to Resident 1 during the month of April 2023. However, the facility investigation failed to show the investigation included Resident 1's sister's claim, that Resident 1 had sustained a fall at the facility on 2/18/23 at approximately 1815 to 1830 hours, while a CNA and Resident 1's brother-in-law transferred Resident 1 from his chair to his bed.
The facility's investigation failed to show the interviews were conducted with Resident 1's family members, Resident 1's roommates, or the CNA alleged to have assisted Resident 1's family member with transferring Resident 1 when Resident 1 allegedly sustained the fall on 2/18/23 at approximately 1815 to 1830 hours. Additionally, the facility's investigation failed to show the interviews were conducted with the RN and LVN assigned to care for Resident 1 at the time the alleged fall on 2/18/23 at 1815 to 1830 hours.
On 4/19/23 at 1500 hours, an interview, medical record review, and concurrent facility document review was conducted with the Administrator. The Administrator stated he conducted oversite of the facility's investigation of Resident 1's injury of unknown source. The Administrator stated the investigation should include any viable source, that might provide information which could determine the cause of Resident 1's fracture. The Administrator stated he assigned the investigation to the DON. The Administrator reviewed the facility's investigative findings and verified the staff interviewed by the DON were questioned specific to whether Resident 1 sustained a fall in the Month of April 2023. The Administrator verified Resident 1' SBAR dated 4/5/23 at 1656 hours, showed Resident 1' family member claimed Resident 1 fell at the facility on 2/18/23 at approximately 1815 to 1830 hours. However, the facility's investigation failed to show any information specific to Resident 1 having allegedly fallen on 2/18/23 at approximately 1815 to 1830 hours. The Administrator stated the facility's investigation should have included an interview with Resident 1's family member who claimed Resident 1 fell on 2/18/23, to determine the specifics of Resident 1's alleged fall and if this alleged fall might have caused Resident 1's fracture.
On 4/19/23 at 1544 hours, an interview, medical record review, and concurrent facility document review was conducted with the DON. The DON verified she conducted the facility's investigation specific to Resident 1's injury of unknown source (right second metacarpal fracture). The DON reviewed and verified Resident 1's SBAR Communication Form and Progress Note dated 4/5/23 at 1656 hours, showed Resident 1's family member complained to the facility's Office Manager that Resident 1 had a fall incident on 2/18/23 (around 1815 to 1830 hours) when a CNA and Resident 1's family membertransferred Resident 1 from a chair to a bed. The DON then reviewed her investigation (Incident/Accident Investigation Report dated 4/7/23) and verified all staff interviews conducted were focused on whether Resident 1 had fallen in April of 2023. The DON verified her investigation failed to include documentation specific to Resident 1 sister's claim that Resident 1 fell on 2/18/23, at approximately 1815 to 1830 hours. The DON verified the investigation failed to show any interviews were conducted with thestaff, residents, and Resident 1's family membersspecific to Resident 1's family member's claim Resident 1 fell on 2/18/23 at approximately 1815 to 1830 hours.
Further review of Resident 1's medical record failed to show documentation Resident 1 was assessed at the time of his alleged fall on 2/18/23 at approximately 1815 to 1830 hours. The DON verified the findings.
Mar 2023
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
**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 w...
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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 safely administered to one of 26 final sampled residents (Resident 34). Resident 34 had a bottle of inhalant, decongestant observed at the bedside. This failure had a potential to negatively impact the resident's physiological well-being, and administer medications inaccurately.
Findings:
Review of the facility's P&P titled Medication Administration General Guidelines Policy showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.
Review of the facility's P&P titled Self-Administration of Medications revised December 2016 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy also showed self-administered medications must be stored in a safe and secure place, which is not accessible by other residents.
On 2/28/23 at 1104 hours, an observation and concurrent interview was conducted with Resident 34. Resident 34 was observed (at the bedside) with a box labeled Olbas oil Inhalant Decongestant, relief from catarrh, colds and blocked sinuses. Resident 34 stated she used the Olbas oil to rub on her abdomen when she had pain. Resident 34 stated the nurses were aware. Resident 34 further stated she used it at night for her abdomen and back. The box containing Olbas oil was visible from outside the door.
Review of the Olbas oil Inhalant Decongestant information showed for relief from catarrh (excessive discharge or buildup of mucus in the nose or throat, associated with inflammation of the mucous membrane), colds, and blocked sinuses (a cavity within a bone or other tissue, especially one in the bones of the face or skull connecting with the nasal cavities, the space inside the nose). Further review of the Olbas Oil Inhalant Decongestant showed active ingredients including Methyl Salicylate 3.7% (a topical counter-irritant used for the symptomatic relief of acute musculoskeletal pain in the muscles, joints, and tendons).
Medical record review for Resident 34 was initiated on 2/27/23. Resident 34 was admitted to the facility on [DATE].
Review of the Self Administration of Medication assessment dated [DATE], showed Resident 34 should not self-administer medications because she preferred the charge nurses to administer the medications.
Review of the Resident Care Conference Review dated 1/16/23, failed to show documentation the IDT had determined it was clinically appropriate and safe for Resident 34 to self-administer medications.
Review of Resident 34's physician's orders failed to show the orders for the Olbas Oil and self-administration of medication.
Review of Resident 34's H&P examination dated 1/6/23 showed Resident 34 had the capacity to understand and make decisions.
Review of Resident 34's plan of care failed to show a care plan problem was initiated for the resident's self-administration of medications.
On 2/28/23 at 1110 hours, an observation and concurrent interview was conducted with LVN 7. LVN 7 verified the Olbas oil was at Resident 34's bedside. LVN 7 stated she was not aware Resident 34 had the Olbas oil at bedside. During the interview with LVN 7, Resident 34 stated she had the Olbas oil for a long time. When asked if Resident 34 should have the Olbas oil at the bedside, LVN 7 stated she would check.
On 2/28/23 at 1115 hours, a follow-up interview was conducted with LVN 7. LVN 7 verified there was no physician's order for the Olbas oil and Resident 34 should not have kept it at the bedside.
On 2/28/23 at 1115 hours, an interview was conducted with the Pharmacist. The Pharmacist verified Resident 34's Olbas oil contained Methyl Salicilate 3.7%, which considered as a medication.
On 3/6/23 at 1048 hours, an interview and concurrent record review was conducted with LVN 8. LVN 8 verified there was no IDT conducted for Resident 34 to discuss self-administration of medications and if it was clinically appropriate and safe for the resident. When asked what would have been a potential concern if there was medication left at bedside and other residents were walking by, LVN 8 stated if anybody went to Resident 34's room, the residents would have had an unauthorized access to the specific medication.
On 3/6/23 at 1119 hours, an interview and concurrent record review was conducted with RN 1. RN 1 verified Resident 34 did not have the physician's orders for Olbas oil and self-administer medication, and did not have a care plan for self-administration of the medications. RN 1 further stated the physician's orders and care plan were needed for the self-administration of medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**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 follow the policy for advance directi...
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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 follow the policy for advance directives for two of 26 final sampled residents (Residents 34 and 50).
* The facility failed to obtain a copy of the advance directive for Resident 50.
* The facility failed to to ensure an assistance was provided to formulate an advance directive for Resident 34.
These had the potential for the resident's decisions regarding their healthcare and treatment options not being honored.
Findings:
Review of the facility's P&P titled Advance Directives revised 12/2016 showed if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.
1. Medical record review for Resident 50 was initiated 3/02/23. Resident 50 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 50's H&P Examination dated August 2022 showed Resident 50 did not have the capacity to understand and make decisions.
Review of Resident 50's POLST (Physician Orders for Life Sustaining Treatment) dated 9/6/22, showed Section D was checked for advance directive with no date documented.
Review of Resident 50's medical record failed to show a copy of the advance directive.
On 3/02/23 at 1110 hours, an interview and concurrent medical record was conducted with the Social Serves Director. Review of Resident 50's Social Services Form dated 8/2/22, showed Resident 50's advance directive was formulated by DPAHC, and the facility would obtain from Resident 50's son. The Social Services Director confirmed Resident 50's advance directive was not in the medical record and medical record overflow. When asked why it was important to have the advance directive in the medical record, the Social Services Director stated to make sure the resident's wishes were properly focused and that they had the right advocate to speak on their behalf.
2. Medical record review for Resident 34 was initiated on 2/27/23. Resident 34 was admitted to the facility on [DATE].
Review of Resident 34's H&P examintaion dated 1/6/23, showed Resident 34 had the capacity to understand and make decisions.
Review of Resident 34's POLST dated 12/26/23, showed Resident 34 did not have an advance directive.
Review of Resident 34's medical record failed to show whether Resident 34 was offered assistance to formulate an advance directive.
Review of the Advance Directive Acknowledgement Form electronically signed by the facility's representative on 2/2/23, showed the form was blank. The form did not show whether Resident 34 was provided written materials and informed about her rights to accept or refuse medical treatment; had been informed of her rights to formulate an advance directive; understood she was not required to have an advance directive in order to receive medical treatment at the health care facility; and whether she declined or wished to execute an advance directive.
On 3/6/23 at 1635 hours, an interview and concurrent record review was conducted with the SSD. The SSD stated she was responsible to follow-up on the advance directive. The SSD verified the date written on Resident 34's POLST was 12/16/23, and stated it was supposed to have been written as 12/16/22. When asked if there were documentation to show Resident 34 was offered assistance in formulating an advance directive, the SSD stated she would look somewhere else if the signed Advance Directive Acknowledgement form had not been uploaded in the PCC.
On 3/6/23 at 1655 hours, a follow-up interview was conducted with the SSD. The SSD stated the facility had the blank Advance Directive Acknowledgement form signed by the facility representative on 2/2/23, which indicated Resident 34 declined the advance directive. The SSD also verified she did not document in Resident 34's medical record.
On 3/7/23 at 0900 hours, an interview and concurrent record review was conducted with the Regional Administrator. The Regional Administrator provided a copy of the Social Service Notes dated 1/31/23. The Social Service Notes showed a care conference was held with Resident 34's daughter-in-law since Resident 34 declined to attend due to entrusting her family to advocate on her behalf. The care conference failed to show documentation the advance directive was discussed.
On 3/7/23 at 0904 hours, an interview was conducted with Resident 34. When asked if she had an advance directive or if the facility discussed with her about the advance directive, Resident 34 stated she did not know what an advance directive was and no one had talked to her about advance directive.
On 3/7/23 at 0919 hours, a follow-up interview was conducted with the Regional Administrator. The Regional Administrator verified there was no documentation to show an advance directive was discussed with Resident 34.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a clean home-like environment for one of 26 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a clean home-like environment for one of 26 final sampled residents (Resident 50). Resident 50's floor fan in her room was observed with dust build-up on the vents of the fan. This placed the resident at risk for living in an unkempt environment.
Findings:
Medical record review for Resident 50 was initiated on 2/27/23. Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE].
On 3/2/23 at 1540 hours, an observation and concurrent interview was conducted with Resident 50 and LVN 6. Resident 50's floor fan was on. The fan was noted with dust build-up on the vents of the fan. LVN 6 acknowledged and verified the findings. When asked who was responsible to clean the floor fan, LVN stated it was the housekeeping.
On 3/2/23 at 1545 hours, a follow-up interview was conducted with Resident 50. Resident 50 stated she has had the floor fan since she was admitted to the facility. When asked who cleaned the floor fan and how often it was cleaned, Resident 50 stated the facility did not clean her floor fan.
On 3/2/23 at 1550 hours, an interview was conducted with the Maintenance Director. He stated he was in charge of the housekeeping and maintenance department. When asked who was in charge of cleaning the fans, the Maintenance Director stated it was the housekeeping. When asked if there was a schedule when to clean the fans, the Maintenance Director stated it was once a month, and the facility used compressor air to clean the fans. When asked how his department was notified of which fans needed to be cleaned, the Maintenance Director stated the nurses let his department know; however, the Maintenance Director also stated the janitors and housekeepers also made rounds once a month for cleaning purposes. When asked if he was aware Resident 50's floor fan had dust build-up, the Maintenance Director stated he was only notified on this date at 1545 hours, and no one from housekeeping reported it to him. The Maintenance Director stated he did not know how it was missed. When asked if the facility kept a log of what was cleaned, the Maintenance Director stated he did not keep a log because not every resident used a fan. When asked if he knew which residents used fans, the Maintenance Director stated no.
On 3/6/23 at 0856 hours, a follow-up interview was conducted with Resident 50. When asked how she felt about the dusty floor fan in her room, Resident 50 stated she would prefer for it to be clean.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**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 nonsampled re...
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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 nonsampled residents (Resident 103) was free from unnecessary restraints.
* Resident 103 was diagnosed with dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and had behaviors of hitting, kicking, pushing, scratching, and grabbing directed towards others. Resident 103's bottom portion of the top sheet was observed tied down onto the low air loss mattress straps in a manner which restricted Resident 103's ability to freely move his legs.
* The facility utilized an abdominal binder on Resident 103. The facility failed to complete the comprehensive assessments, provide the appropriate medical diagnoses for the use of the restraint, determine the least restrictive interventions before the abdominal binder (compression belt that encircle the abdomen, used to help protect the gastrostomy tube from getting dislodged) was utilized, and develop and implement the interventions to prevent and address any risks related to the use of the abdominal binder. In addition, the facility failed to ensure the informed consent was obtained when the use of the abdominal binder was initiated for Resident 103.
These failures had the potential for increased risk for physical harm to the residents.
Findings:
Review of the facility's P&P titled Use of Restraints revised April 2017 showed the restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom and never for the prevention of falls. Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Restraints shall only be used upon written order from the physician and after obtaining consent from the resident and/or representative (sponsor). Care plans for the residents utilizing restraints shall include the measures taken to systematically reduce or eliminate the need for restraint use.
Review of the facility's P&P titled Bed Safety revised December 2007 showed the resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment.
Review of the facility's P&P titled Informed Consent revised April 2019 showed the facility will verify informed consent prior to the use of physical restraints or the prolonged use of device in the facility that may lead to the inability to regain use of normal bodily function. Informed consent documentation will be maintained in the resident's clinical record.
Medical record review for Resident 103 was initiated on 2/27/23. Resident 103 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 103's H&P Examination dated 1/09/23, showed Resident 103 had dementia and did not have the capacity to understand and make decisions.
Review of Resident 103's MDS dated [DATE], showed Resident 103 had severe cognitive impairment and needed staff assistance for all his activities of daily living. Resident 103 had physical behavioral symptoms directed to others e.g., hitting, kicking, pushing scratching, and grabbing. Resident 103 had behaviors of rejecting care that necessary to achieve his goals for health and well-being. Resident 103 had no impairment to upper extremity and lower extremity and did not use physical restraints in bed, or when out of bed.
1. On 2/27/23 at 1000 hours, an observation of Resident 103 was conducted. Resident 103 was observed lying in bed and positioned on his back. Resident 103's bottom portion of his top sheet was observed tied down on both sides onto the low air loss mattress straps. The bottom portion of the top sheet was observed tied down taut around Resident 103's ankles and feet.
On 2/27/23 at 1539 hours, an observation of Resident 103 and concurrent interview was conducted with CNA 1. Resident 103 was observed lying in bed and positioned on his back. The bottom portion of Resident 103's top sheet was tied down on both sides onto the low air loss mattress straps. CNA 1 was asked why the top sheet was tied down onto the low air loss mattress straps. CNA 1 stated Resident 103 had his top sheet tied down because he would possibly pull on and remove his blanket. CNA 1 stated the top sheet was tied down when she came in for her shift. CNA 1 verified top sheet should not be tied down.
On 2/27/23 at 1541 hours, an interview was conducted with LVN 6. LVN 6 stated she was not aware Resident 103's bottom portion of his top sheet was tied down onto the low air loss mattress straps during her room rounds and throughout her shift. LVN 6 stated tying down the top sheet could cause discomfort for Resident 103 and restrict him from moving freely.
On 3/01/23 at 1025 hours, an interview was conducted with RN 1. RN 1 was asked what she would do if she saw the top sheet tied down. RN 1 stated she would untie the top sheet for the resident to be able to move freely and feel comfortable. RN 1 verified tying the top sheet tied down onto the bedframe or mattress straps was a restraint. RN 1 verified Resident 103 had no physician's order, consent, or an assessment completed for physical restraints use.
On 3/01/23 at 1133 hours, Resident 103 was observed moving his right leg freely and pulling off his top sheet with his right hand. The top sheet was observed on the floor immediately after.
On 3/01/23 at 1149 hours, a follow-up interview was conducted with LVN 7. LVN 7 stated Resident 103 had a behavior of fighting, pushing away, and grabbing staff when they provided care. However, LVN 7 stated Resident 103 would calm down when a staff who spoke his language explained the procedure.
2. On 3/01/23 at 0925 hours, an observation of Resident 103 and concurrent interview was conducted with CNA 2. Resident 103 was observed pulling on the GT. CNA 2 stated Resident 103 had a behavior of pulling on everything.
On 3/01/23 at 0940 hours, an observation of Resident 103 and concurrent interview was conducted with CNA 2. CNA 2 was observed providing care to Resident 103 while Resident 103 was lying in bed. Resident 103 was observed with an abdominal binder (compression belt that encircles the abdomen, commonly used to help with the recovery process after abdominal surgery) around his chest and stomach area. CNA 2 stated Resident 103 had the abdominal binder on and could not recall when the abdominal binder was initially utilized.
On 3/01/23 at 0949 hours, an interview was conducted with LVN 7. LVN 7 verified Resident 103 had an abdominal binder around his stomach area that covered the GT. LVN 7 stated the abdominal binder was applied to prevent Resident 103 from pulling on his GT.
On 3/01/23 at 1025 hours, an interview was conducted with RN 1. RN 1 verified an abdominal binder was applied to Resident 103's stomach area. RN 1 stated Resident 103 pulled out his GT previously but was unable to recall the date when it occurred. RN 1 verified Resident 103 had no physician's orders, consent or assessment completed for the use of an abdominal binder. RN 1 stated a physician's order should be obtained for an abdominal binder and a consent should be completed for the use of an abdominal binder.
Review of Resident 103's medical record failed to show physician's orders, assessments, informed consents and care plan documentations for physical restraint and abdominal binder use.
On 3/7/23 at 1535 hours, an interview with the DON was conducted. The DON verified the findings and stated the top sheet should not be tied down to allow Resident 103 to move freely. The DON stated the facility practice was to tuck the top sheet loosely under the mattress to prevent the linen from falling off. The DON stated an abdominal binder was used for the residents who had the tendency to pull on the GT and at risk for injury. The DON stated the assessment, physician's order, consent, and care plan should be in place prior to placing an abdominal binder on a resident and verified they were not.
Cross reference to F656.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to develop and implement the comprehensive perso...
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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 and implement the comprehensive person-centered care plans for three of 26 sampled residents (Residents 6, 38, and 95) and one nonsampled resident (Resident 103).
* The facility failed to develop the care plan problem for the use of floor padding for Resident 38 who was at high risk for falls. In addition, Resident 38's care plan problem showed Resident 38 should be provided with two-person assistance for transfers; however, Resident 38 was transferred with the assistance of one person from her wheelchair to her bed.
* The facility failed to develop the care plan problem for the use of abdominal binder for Resident 103.
* The facility failed to ensure the care plan problem for Ativan use for Resident 6 was specific and individualized.
* Resident 95's care plan problem showed to administer oxygen as ordered. The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 95. Resident 95 had an order to receive continuous oxygen at 2 liters per minute; however, Resident 95 received continuous oxygen at 4 liters per minute.
These failures placed the residents at risk of not receiving adequate and individualized care to support safety and well-being.
Findings:
1. On 2/27/23 at 1310 hours, an observation of Resident 38 was conducted. Resident 38 was observed being transferred by CNA 5 from her wheelchair to her bed. Resident 38 was observed lying in bed without floor padding on both sides of her bed after CNA 5 left Resident 38's room.
On 3/2/23 at 1343 hours, an observation and concurrent interview was conducted with RNA 1. RNA 1 was observed transferring Resident 38 from her wheelchair to her bed. RNA 1 stated Resident 38 was able to stand and pivot transfer (useful for a person who can support most of their weight by standing but are too weak to take steps to move from one place to another). Resident 38 was observed lying in bed without floor padding on both sides of her bed after RNA 1 left Resident 38's room.
Medical record review for Resident 38 was initiated on 2/27/23. Resident 38 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 38's H&P Examination dated 9/27/22, showed Resident 38 did not have the capacity to understand and make decisions.
Review of Resident 38's Fall Risk assessment dated [DATE], showed Resident 38 was at a high risk for falls.
Review of Resident 38's MDS dated [DATE], showed Resident 38 had severe cognitive impairment and needed the physical assistance of two people with transfers. Resident 38 was not steady and only able to stabilize with staff assistance with moving from seated to standing position, walking, and surface-to-surface transfer (transfer between bed and chair or wheelchair).
Review of Resident 38's Order Summary Report dated 3/2/23, showed a physician's order dated 10/3/22, to place floor padding on the floor both sides of the bed to prevent injury and check for placement every two hours and as needed.
Review of Resident 38's Care Plans showed the following:
* A care plan problem titled Self-care deficit in transferring requires extensive assistance initiated 9/28/22, showed Resident 38 required two people to assist with transfers.
* A care plan problem titled At risk for fall or injury related to impaired balance during transitions, walking and toileting due to weakness initiated 9/27/22, and revised 10/28/22, showed two-person assistance with transfers.
Further review of the care plan failed to show the facility updated the plan of care to include placing floor padding on both sides of Resident 38's bed as ordered by the physician.
On 3/2/23 at 1357 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified Resident 38 had an order for floor padding on the floor both sides of the bed to prevent injury; however, LVN 6 verified there was no care plan developed for the floor padding order. LVN 6 verified Resident 38's care plan problem addressing fall risk revised 10/28/22, showed an intervention to implement two-person assistance with transfers, however, LVN 6 stated she observed RNA 1 transferred Resident 38 from her wheelchair to her bed by himself.
2. On 3/01/23 at 0940 hours, an observation was conducted of Resident 103. Resident 103 was observed with an abdominal binder (compression belt that encircle abdomen, commonly used to help with the recovery process after abdominal surgery) around his chest and stomach area.
Medical record review for Resident 103 was initiated 2/27/23. Resident 103 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 103's H&P Examination dated 1/09/23, showed Resident 103 did not have the capacity to understand and make decisions.
Review of Resident 103's MDS dated [DATE], showed Resident 103 had severe cognitive impairment and needed staff assistance for all his activities of daily living. The document also showed Resident 103 did not use physical restraints in bed, or when out of bed.
Review of Resident 103's care plan failed to show documentation for an abdominal binder use.
On 3/07/23 at 1535 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 103's care plan did not address the use of abdominal binder.
Cross reference to F604.
3. Medical record review for Resident 6 was initiated on 3/1/23. Resident 6 was readmitted to the facility on [DATE].
Review of Resident 6's care plan problem addressing the resident's anxiety manifested by anxiousness revised 2/13/23, failed to show any nonpharmacological interventions for the use of Ativan (also known as lorazepam, a medication used to treat anxiety).
Review of Resident 6's care plan problem addressing the use of antianxiety/anxiolytic medications, at risk for side effects of lorazepam and Xanax (also known as alprazolam, a medication to treat anxiety and panic disorder) related to anxiety disorder revised 12/19/22, showed the interventions included to monitor or record the occurrence of target behavior symptoms (disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc.) and document as per the facility's protocol. However, the care plan problem did not include any nonpharmacological interventions prior to the use of Ativan.
Review of Resident 6's Psychoactive & Sedative/Hypnotic Assessment Tool dated 2/12/23, showed interventions of calm approach at all times, distraction, TV, activities, family visitations, dim lights, music, and conversation.
On 3/2/23 at 1318 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the care plan problem for Ativan use was not individualized for Resident 6.
Cross reference to F758.4. Medical record review for Resident 95 was initiated on 2/27/23. Resident 95 was admitted to the facility on [DATE].
Review of Resident 95's care plan problem titled At Risk for Respiratory Distress Related to Pneumonia (an infection that inflames the air sacs in one or both lungs) initiated 2/14/23, showed to administer oxygen as ordered.
Review of the physician's order dated 9/18/22, showed an order for continuous oxygen to be administered at 2 liters per minute via nasal cannula.
On 2/27/23 at 1307 hours, an observation and concurrent interview was conducted with RN 1. Resident 95 was observed receiving continuous oxygen via nasal cannula at 4 liters per minute; however, the physician's order showed continuous oxygen was to be administered via nasal cannula at 2 liters per minute. RN 1 verified the facility failed to implement Resident 95's care plan problem for risk for respiratory distress which showed to administer oxygen as ordered.
Cross reference to F695.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**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 revise...
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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 revised to reflect specific care needs for one of 26 sampled resident (Resident 50). This failure posed the risk for not providing the resident with individualized and person-centered care.
Findings:
Medical record review for Resident 50 was initiated 3/6/23. Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of coccyx (triangular bony structure located at the bottom of the vertebral column) wound stage 2 (partial thickness skin loss involving epidermis, dermis, or both).
On 3/07/23 at 1013 hours, an interview was conducted with Resident 50. Resident 50 stated she preferred laying on her back and repositioned every few hours on back with once a day on the right side.
On 03/06/23 at 0906 hours, an observation and concurrent interview was conducted with CNA 6. When asked how often Resident 50 was repositioned, CNA 6 responded every two hours. When asked why Resident 50 required repositioning, CNA 6 responded to prevent Resident 50's wound from getting worse. CNA 6 stated Resident 50 did not like to be repositioned every two hours and preferred to be on her back. CNA 6 further stated when Resident 50 refused to be repositioned, CNA 6 reported it to the licensed nurse supervisor.
On 3/06/23 at 1429 hours, an interview and concurrent medical record was conducted with the Treatment Nurse. The Treatment Nurse stated Resident 50 was dependent on staff for repositioning, and the expectation was to reposition from side to side to promote wound healing. The Treatment Nurse confirmed Resident 50 often refused to be repositioned, and verified it should have been reflected on the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to implement the safety interventio...
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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 implement the safety interventions and provide the padded side rails for one of 26 sampled resident (Resident 87) who had a diagnosis of seizure disorder (neurological disorder causing sudden, uncontrolled burst of electrical activity in the brain that leads to convulsions or uncontrollable shaking that is rapid and rhythmic). This failure put Resident 87 at risk for serious injuries during a seizure episode.
Findings:
Medical record review for Resident 87 was initiated on 2/28/23. Resident 87 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 87's H&P Examination dated 12/5/22, showed Resident 87 had seizure disorder and did not have the capacity to understand and make decisions.
Review of Resident 87's MDS dated [DATE], showed Resident 87 had severe cognitive impairment and needed staff assistance for all her activities of daily living.
Review of Resident 87's Order Summary Report dated 3/2/23, showed a physician's order dated 2/2/23, for seizure precaution and to monitor episodes of seizure activity every shift.
Review of Resident 87's plan of care problem addressing the resident's seizure disorder revised on 2/28/23, showed an intervention for padding on bilateral side rails to prevent injury during seizure.
Review of the Progress Note showed on 10/01/22 at 0810 hours, showed the family member reported to the facility that Resident 87 had episodes of seizures at home.
On 2/28/23 at 0850 hours, an observation of Resident 87 and concurrent interview was conducted with RN 1. RN 1 verified Resident 87's bilateral side rails were not padded. RN 1 stated Resident 87 was supposed to have padding on the bilateral side rails for seizure precaution and to prevent her from injury.
On 3/2/23 at 0818 hours, Resident 87 was observed lying in bed and positioned on her right side with bilateral side rails up with no padding.
On 3/2/23 at 0900 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 was asked about Resident 87's seizure precaution. LVN 5 stated Resident 87's side rails should have been padded. LVN 5 verified a care plan problem for seizure disorder showed an intervention for the padded bilateral side rails to prevent injury during seizure; however, Resident 87's bilateral side rails were not padded.
On 3/2/23 at 0924 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified a care plan problem for seizure disorder showed an intervention for padding on bilateral side rails to prevent injury during seizure. RN 2 contacted Resident 87's physician to obtain an order for the padded side rails.
On 3/7/23 at 1423 hours, a follow-up interview was conducted with RN 2. RN 2 stated Resident 87 had seizure activity on 10/1/22, while she was out of the facility at home with the resident's family member.
On 3/7/23 at 1535 hours, the DON verified the findings and stated the residents with seizure disorder needed to have padded side rails to prevent potential injury.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. Medical record review for Resident 50 was initiated 03/02/2023. Resident 50 was admitted to the facility on [DATE], and readm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. Medical record review for Resident 50 was initiated 03/02/2023. Resident 50 was admitted to the facility on [DATE], and readmitted on [DATE]
Review of Resident 50's physician's order showed an order dated 02/20/23, to administer Jevity 1.2 (an enteral feeding formula) at 50 ml/hr for 20 hours to provide 1000 ml and 1200 kcal via GT. The order also showed may substitute with Fibersource HN 50 ml/hr for 20 hours to provide 1000 ml and 1200 kcal via GT.
On 3/6/23 at 0906 hours, an observation and concurrent interview was conducted with CNA 6. Resident 50 was lying in bed with head of the bed elevated receiving enteral feeding via the mechanical pump. CNA 6 had completed Resident 50's morning care. When asked how the enteral feeding was managed when providing care. CNA 6 stated the licensed nurses were responsible for operating the enteral feeding before and after care. CNA 6 confirmed Resident 50's tube feeding was currently infusing. CNA 6 confirmed operating enteral feeding before and after providing care. CNA 6 verified that was not the practice for the CNA to operate the eternal feeding.
On 03/06/23 at 1014 hours, an interview was conducted with LVN 6. When asked who was responsible for managing the enteral feeding when CNA was providing care. LVN 6 stated the licensed nurse was responsible for turning off the enteral feeding 30 minutes prior to changing or repositioning, and the CNA was not allowed to operate the enteral feeding. The expectation was to have the CNA speak with the licensed nurse prior to providing care to the resident.
On 03/07/23 at 1508 hours, an interview was conducted with the DON. When asked who was responsible for managing the enteral feeding when care was being provided. The DON confirmed the license nurses were responsible for operating the enteral feeding when the CNA staff was repositioning or changing the residents, and the CNA was instructed to call for the licensed nurse to manage the enteral feedings.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 26 sampled residents (Residents 50 and 87) and one nonsampled resident (Resident 103) who received enteral (refers to the intake of food through a gastrostomy tube) feeding were provided appropriate treatment and services to prevent complications of the enteral feeding.
* The facility failed to ensure Resident 87 was administered the enteral feeding at the infusing rate as ordered by the physician.
* The facility failed to ensure Residents 87 and 103's head of bed elevated when administering the enteral feeding.
* The facility failed to ensure the enteral feeding mechanical pump was operated by a licensed staff while providing care for Residents 50 and 103.
These failures posed the potential risk for aspiration during feeding and the potential for not meeting the residents' nutritional needs.
Findings:
Review of the facility's P&P titled Enteral Nutrition revised November 2018 showed adequate nutritional support through enteral nutrition is provided to the residents as ordered. The facility's P&P also showed the risk of aspiration is assessed by the nurse and provider and addressed in the individual care plan. The risk of aspiration may be affected by improper positioning of the resident during feeding.
1. Medical record review for Resident 87 was initiated on 2/28/23. Resident 87 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 87's H&P Examination dated 12/5/22, showed Resident 87 had dysphagia (difficulty swallowing) and GT feeding, and did not have the capacity to understand and make decisions.
Review of the MDS dated [DATE], showed Resident 87 was totally dependent on the staff for eating (including intake of nourishment through tube feeding).
Review of Resident 87's Order Summary Report dated 3/2/23, showed a physician's order dated 3/1/23, to administer Diabetisource 1.2 (a type of feeding formula) at 65 ml/hr via J-tube for 20 hours to infuse 1300 ml or 1560 kcals.
Review of a care plan problem to address Resident 87's tube feeding dated 2/3/23, showed an intervention for Diabetisource 1.2 at 65 ml/hr for 20 hours initiated on 3/1/23.
On 3/2/23 at 0818 hours, Resident 87 was observed lying in bed, positioned on her right side with her head of bed flat while receiving enteral feeding via mechanical pump. Resident 87's enteral feeding was infusing at 60 ml/hr.
On 3/2/23 at 0839 hours, an interview was conducted with LVN 5. LVN 5 verified Resident 87's enteral feeding was infusing at 60 ml/hr.
On 3/2/23 at 0930 hours, an interview was conducted with RN 2. RN 2 verified Resident 87's enteral feeding was infusing at 60 ml/hr.
On 3/2/23 at 1036 hours, an interview and concurrent medical record review conducted with LVN 5. LVN 5 verified the enteral feeding rate order was at 65 ml/hr; however, the enteral feeding rate was currently set at 60 ml/hr on the mechanical pump.
2.a. Review of Resident 87's Order Summary Report dated 3/2/23, showed an order dated 2/2/23, to elevate the head of the bed to 30 to 45 degrees when the feeding was on and may hold the feeding when providing ADL care.
Review of a care plan problem addressing Resident 87's tube feeding dated 2/3/23, showed an intervention dated 2/2/23, to elevate the resident's head of the bed while the feeding was on.
On 3/2/23 at 0818 hours, Resident 87 was observed lying in bed, positioned on her right side with the head of the bed flat while receiving the enteral feeding via mechanical pump.
On 3/2/23 at 0826 hours, an observation and concurrent interview was conducted with CNA 8. CNA 8 verified Resident 87's head of bed was flat while the enteral feeding was infusing. CNA 8 was observed raising Resident 87's head of the bed using the bed controller. CNA 8 stated Resident 87 was on enteral feeding and the head of the bed needed to be elevated.
On 3/2/23 at 0839 hours, an interview was conducted with LVN 5. LVN 5 stated Resident 87's head of the bed needed to be elevated while on the enteral feeding to prevent aspiration.
On 3/2/23 at 0930 hours, an interview was conducted with RN 2. RN 2 stated Resident 87's head of the bed should be up to prevent aspiration.
b. Medical record review for Resident 103 was initiated on 2/27/23. Resident 103 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 103's H&P Examination dated 1/09/23, showed Resident 103 had dysphagia and GT placement, and did not have the capacity to understand and make decisions.
Review of Resident 103's MDS dated [DATE], showed Resident 103 needed staff assistance for eating (including intake of nourishment through tube feeding).
Review of Resident 103's Order Summary Report dated 3/1/23, showed a physician's order dated 1/6/23, to elevate the head of the bed to 30 to 45 degrees when the feeding was on and may hold the feeding when providing ADL care.
Review of a care plan problem addressing the nutritional problem dated 1/7/23, showed the resident needed the head of the bed elevated to 45 degrees during and thirty minutes after the tube feeding.
On 3/1/23 at 0925 hours, an observation and interview was conducted with CNA 2. CNA 2 was observed providing care for Resident 103. Resident 103's head of the bed was flat while the enteral feeding was infusing at 65 ml/hr via mechanical pump. CNA 2 verified Resident 103's head of bed was flat while his enteral feeding was infusing.
On 3/1/23 at 0949 hours, an interview was conducted with LVN 7. LVN 7 stated Resident 103's head of the bed must be elevated when his enteral feeding was infusing.
On 3/1/23 at 1025 hours, an interview was conducted with RN 1. RN 1 verified Resident 103's head of the bed should be elevated when the enteral feeding machine pump was on and infusing to prevent the resident from aspirating the feeding.
3.a. On 3/1/23 at 0928 hours, an observation and concurrent interview was conducted with CNA 2. CNA 2 was observed providing care to Resident 103 in bed while his enteral feeding was infusing via mechanical pump. Resident 103 was observed pulling the enteral feeding tubing, causing the pole attached to the enteral feeding machine pump to fall onto the ground. CNA 2 was observed picking up the pole off the floor and turning off the machine. CNA 2 stated she was allowed to pause the enteral feeding when providing care; however, CNA 2 verified the enteral feeding machine was on, not paused, prior to picking up the pole off the ground.
On 3/1/23 at 0949 hours, an observation and concurrent interview was conducted with LVN 7. LVN 7 was observed turning the enteral feeding machine on. LVN 7 verified only licensed nurses could operate the enteral feeding machine pump.
On 3/1/23 at 1025 hours, an interview was conducted with RN 1. RN 1 verified the CNAs could not operate the enteral feeding machine pump and were instructed to ask the licensed nurses to pause the machine when providing care.
On 3/2/23 at 1516 hours, the DON verified the resident's head of the bed should be elevated about 30 degrees while the mechanical pump was on and enteral feeding was infusing. The DON verified only licensed nurses could operate the enteral feeding machine. The DON stated the CNAs were instructed to inform the licensed nurses if they needed the machine paused when providing care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**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 necessary re...
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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 necessary respiratory care for two of 26 final sampled residents (Residents 34 and 95).
* The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 95. Resident 95 had an order to receive continuous oxygen at 2 liters per minute; however, Resident 95 received continuous oxygen at 4 liters per minute.
* The facility failed to label the oxygen tubing for Resident 34.
These failures had the potential to negatively impact Residents 34's and 95's medical conditions.
Findings:
1. Review of the facility's P&P titled Oxygen Administration revised October 2010 showed preparation for oxygen administration includes a review of the physician's order for oxygen administration.
Medical record review for Resident 95 was initiated on 2/27/23. Resident 95 was admitted to the facility on [DATE].
Review of the physician's order dated 9/18/22, showed an order for continuous oxygen to be administered at 2 liters per minute via nasal cannula.
Review of Resident 95's care plan problem addressing COPD initiated 9/18/22, showed Resident 95 would display optimal breathing patterns daily.
Review of Resident 95's care plan problem titled At Risk for Respiratory Distress Related to Pneumonia initiated on 2/14/23, showed to administer oxygen as ordered.
On 2/27/23 at 1251 hours, an observation and concurrent interview was conducted with Resident 95. Resident 95 was observed sitting in his bed and receiving continuous oxygen via nasal cannula at 4 liters per minute. Resident 95 stated he was recently readmitted from the hospital where he was diagnosed with pneumonia. Resident 95 stated he required oxygen for treatment of COPD. Resident 95 stated since his readmission [DATE]) to the facility, he had received continuous oxygen via nasal cannula at 4 liters per minute.
On 2/27/23 at 1307 hours, an observation and concurrent interview was conducted with RN 1. RN 1 verified Resident 95 was receiving continuous oxygen via nasal cannula at 4 liters per minute; however, the physician's order showed continuous oxygen was to be administered via nasal cannula at 2 liters per minute. RN 1 then adjusted the oxygen rate to 2 liters per minute as per the physician's order. RN 1 then obtained Resident 95's oxygen saturation level (while receiving oxygen at a rate of 2 liters per minute). Resident 95's oxygen saturation level was 95%. RN 1 stated Resident 95 had a diagnosis of COPD and the goal was to maintain Resident 95's oxygen saturation level above 90%, while administering the least amount of supplemental oxygen possible.
2. Review of the facility's P&P titled Oxygen Administration revised October 2010 showed nasal cannula tubing will be changed every week and/or PRN basis.
Medical record review for Resident 34 was initiated on 2/27/23. Resident 34 was admitted to the facility on [DATE].
Review of Resident 34's Order Summary Report dated 3/2/23, showed a physician's order dated 2/6/23, to administer oxygen at 2 liters per minute via nasal cannula for shortness of breath.
On 3/2/23 at 1325 hours, an observation and concurrent interview was conducted with Resident 34 and LVN 7. Resident 34 was in bed having lunch. Resident was observed receiving oxygen at 2 liters per minute via nasal cannula. The oxygen tubing was not dated. LVN 7 verified the findings. LVN 7 stated the oxygen tubing was changed every week. When asked when the oxygen tubing was changed for Resident 34, LVN 7 stated she did not know. When asked f the oxygen tubing should have been labeled when it was changed, LVN 7 stated yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 26 final sampled residents (Resident 34).
* T...
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Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 26 final sampled residents (Resident 34).
* The facility failed to ensure the dialysis shunt site (a passage made to allow blood or other fluid to move from one pat of the body to another) was monitored every shift and documented in the medical record.
* The facility failed to ensure the pre and post dialysis communication forms were completely filled out.
* The facility failed to ensure the physician's order for a 1200 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly.
These failures had the potential to negatively impact the resident's well-being.
Findings:
Review of the facility's P&P titled Hemodialysis Access Care revised September 2010 showed the general medical nurse should document in the resident's medical record every shift as follows:
1. Location of catheter.
2. Condition of dressing (interventions if needed).
3. If dialysis was done during shift.
4. Any part of report from dialysis nurse post-dialysis being given.
5. Observations post dialysis.
Review of the facility's P&P titled End-Stage Renal Disease, Care of a Resident With revised September 2010 showed the resident with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Further review of the P&P showed the education and training of staff includes specifically (g)-the care of grafts, fistulas, and central lines.
Review of the facility's P&P titled Intake, Measure and Recording revised October 2010 showed the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. Further review of the P&P showed to verify if there is a physician's order for this procedure and/or that the procedure is being performed as per the facility's policy.
Review of Resident 34's H&P examination dated 1/6/23, showed Resident 34 had a diagnosis of End Stage Renal Failure (ESRF-the final permanent stage of chronic kidney disease, where the kidney function has declined to the point where the kidneys can no longer function on their own) on Hemodialysis (the process by which a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately).
Review of Resident 34's Order Summary Report dated 3/2/23, showed the following physician's orders:
* dated 1/9/23, for dialysis on Monday, Wednesday, Friday at Dialysis Center A at 0915 hours, pick up time at 0800 hours.
* dated 1/28/23, for 1200 ml fluid restriction in a 24-hour period.
Further review of the Order Summary Report dated 3/2/23, did not show an order to monitor Resident 34's dialysis access site.
Review of Resident 34's Plan of Care showed a care plan problem initiated on 1/5/23, for the resident needed hemodialysis related to End Stage Renal Disease. The care plan interventions included the following:
* dated 1/5/23, to check and change dressing daily at access site and document.
* dated 1/5/23, to monitor/document/report PRN any signs and symptoms of infection to access site: redness, swelling, warmth, or drainage.
* dated 1/28/23, to provide 1200 ml fluid restriction in a 24-hour period.
* dated 2/27/23, to assess dialysis access site for bruit and thrill and notify MD with any abnormal findings.
Review of Resident 34's MAR from 3/1 to 3/31/23 failed to show the dialysis access site was being monitored every shift.
Review of the Skilled Charting dated 3/1, 3/3, 3/4, 3/5, and 3/6/23, showed Resident 34's right AV fistula was intact. The Skilled Charting did not show documentation the dialysis access site was assessed for signs and symptoms of infection.
Review of Resident 34's Nurses Dialysis Communication Record showed the forms were not completely filled out on the following dates:
* On 1/13, 1/16, 1/18, 1/20/23, there were no documentation of location of the dialysis access site, if bruit and thrill were present, and the assessment of the dialysis access site.
* On 2/20/23, there were no documentation of the location of the dialysis access site and if bruit and thrill were present.
* On 3/3/23, there were no documentation of the location of the dialysis access site and assessment of the dialysis access site.
Review of Resident 34's Intake & Output Record showed Resident 34 consumed over 1200 ml in a 24-hour period on the following dates:
* On 2/5/23, 1460 ml (260 ml over the fluid restriction ordered)
* On 2/9/23, 1260 ml (60 ml over the fluid restriction ordered)
On 3/6/23 at 1127 hours, an interview and concurrent medical record review was conducted with RN 1. When asked what needed to be assessed if a resident was receiving dialysis, RN 1 stated the resident needed the dialysis site to be assessed for bruit and thrill; the puncture site if there was bleeding or infection; the condition of the resident; and the vital signs. When asked if an order was needed to assess the dialysis site, RN 1 stated there should have been a monitoring order to observe for bleeding, infection, and the presence of bruit and thrill. When asked how often the dialysis site needed to be assessed, RN 1 stated every shift. When asked if the assessment was documented, RN 1 stated the documentation should have been in the MAR; however, RN 1 further stated if there were no orders, it would not be in the MAR. RN 1 verified there was no order to monitor the dialysis access site and no documentation in the MAR for the monitoring of Resident 34's dialysis access site on the right upper arm.
The Nurses Dialysis Communication Records were reviewed with RN 1. RN 1 verified the documents were not completely filled out for 1/13, 1/16, 1/18, 1/20, 2/20, and 3/3/23. RN 1 also verified the forms were missing the location of the dialysis access site and assessment of the dialysis access site.
On 3/6/23 at 1610 hours, an interview and concurrent medical record review was conducted with RN 3. When asked about Resident 34's fluid restriction order, RN 3 verified Resident 34 had an order dated 1/28/23, for 1200 ml fluid restriction in a 24-hour period. RN 3 verified Resident 34 went over the 1200 ml fluid restriction by consuming 1460 ml on 2/5/23, and 1260 ml on 2/9/23. RN 3 stated she did not know if Resident 34's physician was notified of Resident 34 went over the 1200 ml fluid restriction.
On 3/7/22, an interview was conducted with LVN 7. LVN 7 verified Resident 34 went to dialysis every Mondays, Wednesdays, and Fridays from 0800 to 1400 hours. When asked what she monitored for someone receiving dialysis treatment, LVN 7 stated she checked the vital signs and access site, and documented on the dialysis communication form. When asked how often the dialysis access site was checked, LVN 7 stated every shift. When asked what she monitored for the dialysis access site, LVN 7 stated she monitored for bleeding, swelling, bruit, and thrill. When asked where she documented her assessment, LVN 7 stated she usually documented in the dialysis communication form. When asked where she documented when Resident 34 did not receive dialysis treatment, LVN 7 checked the PCC record and verified no order to monitor the dialysis access site and no documentation of the monitoring of the dialysis access site every shift.
On 3/7/23 at 1202 hours, an interview and concurrent medical record review was conducted with the DON. When asked what the nurses monitored for a resident receiving dialysis treatment, the DON stated the nurses checked the site daily; every shift had to check for site, bruit and thrill, and extremities for signs of infection. When asked if the nurses were required to document every shift, the DON stated yes, and also when the resident went out to the dialysis center, the nurses had to fill out the pre and post dialysis. The DON accessed the PCC and verified Resident 34 did not have documentation showing the dialysis access site being monitored every shift. The DON stated only the skilled charting was being done every 24 hours. When asked if an order was needed to monitor the access site, the DON stated there should have been an order and verified the order was only obtained on 3/7/23 at 0904 hours. When asked if the physician was notified when Resident 34 went over the 1200 ml fluid restriction on 2/5 and 2/9/23, the DON verified there was no documentation showing Resident 34's physician was notified. When asked if the physician should have been notified, the DON stated yes because Resident 34 was at risk for fluid overload.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**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 accurate administration an...
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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 accurate administration and documentation of the controlled medications (medications that have some potential for abuse or dependence) for one nonsampled resident (Resident 104). This failure had the potential for exposing residents to ineffective treatment, medication errors, and the potential for diversion of controlled medications.
Findings:
Review of the facility's contracted pharmacy P&P titled Controlled Medications undated showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and MAR: date and time of administration, amount administered, and signature of the nurse administering the dose, completed after the medication is actually administered.
Medical record review for Resident 104 was initiated on 2/27/23. Resident 104 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].
Review of Resident 104's Physician Orders showed an order dated 2/27/23, showed to administer Norco (a controlled medication used to treat pain) 5/325 mg one tablet every eight hours for pain.
a. Review of Resident 104's Record of Controlled Substances showed the Norco 5/325 mg tablet was removed from the bubble pack (a card where medications are placed in individual clear sealed bubbles) on the following dates at times:
- 2/24/23 at 0000, 0600, 1220, and 1800 hours;
- 2/25/23 at 0300, 0925, 1545, and 2145 hours; and
- 2/26/23 at 0300, 1000, 1630, and 2230 hours
Review of Resident 104's MAR for February 2023, failed to show documented evidence the Norco 5/325 mg tablets were documented as administered for the above dates and times when the medication tablets were removed from the bubble pack.
b. Review of Resident 104's MAR for February 2023 showed the Norco 5/325 mg tablet was documented as administered on the following dates and times:
- 2/24/23 at 0500, 1217, and 1820 hours;
- 2/25/23 at 0943, 1545, and 2145 hours;
- 2/26/23 at 0300, 1629, and 2230 hours
Review of Resident 104's Record of Controlled Substances failed to show documented evidence the Norco 5/325 mg tablets were removed from the bubble pack for the above dates and times.
On 3/2/23 at 1330 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and P&P review, the facility failed to follow their P&P for drug regimen review for o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and P&P review, the facility failed to follow their P&P for drug regimen review for one of 26 final sampled residents (Resident 55) and one nonsampled resident (Resident 66).
* The facility's Pharmacy Consultant made multiple recommendations on the Medication Regimen Review (MRR) reports for Residents 55 and 66; however, the facility failed to follow up on the recommendations for the month of January 2023. This failure put the residents at risk for complications and adverse effects from the medications.
Findings:
Review of the facility's contracted pharmacy P&P titled Pharmacist Medication Regimen Review (undated) showed the consultant pharmacist documents potential or actual medication therapy problems and communicates them to the responsible physician and the director of nursing. A written report is provided to the physician within seven working days, with a copy to the facility .The consultant pharmacist medication regimen review and nursing medication documentation review reports are processed as follows: the consultant pharmacist or facility provides the report to the responsible physician and the director of nursing within seven working days of review.
1. Medical record review for Resident 55 was initiated on 3/1/23. Resident 55 was admitted to the facility on [DATE].
a. Review of the Physician Order Summary Report dated 3/1/23, showed a physician's order dated 10/30/22, for Pradaxa (medication used to treat and prevent blood clots) 110 mg one capsule by mouth two times a day.
Review of the MRR dated 1/30/23, showed a recommendation from the Pharmacy Consultant to not open, chew, or crush Pradaxa (blood thinner) as this would lead to a 75% increase in the activity of Pradaxa and therefore, lead to serious adverse reactions; assess if any crushing or opening happened then perhaps change to Xarelto (prevent blood clot) 15 or 20 mg daily that could be crush and given orally or via GT; and document the clinical rationale if this order is to continue.
b. Review of the Physician Order Summary Report dated 3/1/23, showed a physician's order dated 2/8/23, for Remeron (medication used to treat depression) 7.5 mg by mouth at bedtime.
Review of the MRR dated 1/30/23, showed a recommendation from the Pharmacy Consultant to consider GDR of Remeron 7.5 mg to every other bedtime if clinically feasible with the goal of discontinuation.
c. Review of the Physician Order Summary Report dated 3/1/23, showed a physician's order dated 2/18/16, for Lipitor (medication used to lower lipids) 10 mg at bedtime.
Review of the MRR dated 1/30/23, showed a recommendation from the Pharmacy Consultant to review the current laboratory values, reevaluate continued use of the Lipitor, and consider changing therapy if the laboratory values at the desired goal.
d. Review of the Physician Order Summary Report dated 3/1/23, showed a physician's order dated 2/8/18, for Seroquel (medication used to treat behavior) 12.5 mg every other day at bedtime.
Review of the MRR dated 1/30/23, showed a recommendation from the Pharmacy Consultant to ascertain the diagnosis for the use of Seroquel and for the appropriate behaviors to be identified and monitored.
2. Medical record review for Resident 66 was initiated on 3/2/23. Resident 66 was admitted to the facility on [DATE] and readmitted to the facility on [DATE].
a. Review of the Physician Order Summary Report dated 3/1/23, showed the physician's orders dated 10/20/22, for Lexapro (medication used to treat depression) 20 mg one time a day and Remeron (medication used to treat depression) 30 mg at bedtime.
Review of the MRR dated 1/30/23, showed a recommendation from the Pharmacy Consultant to consider discontinuation of Lexapro or consider a non-SSRI agent.
b. Review of the Physician Order Summary Report dated 3/1/23, showed a physician's order dated 10/18/22, for Clonazepam (medication used to treat anxiety) 0.5 mg at bedtime.
Review of the MRR dated 1/30/23, showed a recommendation from the Pharmacy Consultant to consider changing clonazepam to lorazepam or alprazolam, and document the risks/benefits if the current order would be continued.
c. Review of the Physician Order Summary Report dated 3/1/23, showed a physician's order dated 10/18/22, for Propranolol (medication used to treat high blood pressure) 20 mg at bedtime.
Review of the MRR dated 1/30/23, showed a recommendation from the Pharmacy Consultant to reevaluate use of Propranolol, document assessment of risks versus benefits, and the IDT was to monitor for effectiveness and potential adverse consequences.
d. Review of the Physician Order Summary Report dated 3/1/23, showed a physician's order dated 10/18/22, for Robinul (medication used to treat excess secretions) 1 mg one time a day.
Review of the MRR dated 1/30/23, showed a recommendation from the Pharmacy Consultant to clarify the indication for use of Robinul along with the risks and benefits in case of adverse effects.
e. Review of the Physician Order Summary Report dated 3/1/23, showed a physician's order dated 10/18/22, for Aspirin-Acetaminophen-Caffeine (medication for pain) 250-250-65 mg tablet every 12 hours as needed.
Review of the MRR dated 1/30/23, showed a recommendation from the Pharmacy Consultant to discontinue the use of aspirin-acetaminophen-caffeine 250-250-65 mg.
However, review of the MRR reports, under the Physician/Prescriber Response section, showed no check or mark to the boxes showing whether the physician agreed, disagreed, or had other responses; and there was no signature or date. There were no documented evidence to show the physician had documented a change in the orders or a rationale for not changing the drug regimen for all of the above MRR report findings.
On 3/2/23 at 1536 hours, a concurrent interview and facility document review was conducted with the DON. The DON verified the above findings and the MRR reports for January 2023 for Residents 55 and 66 were not received and stated there was a glitch when the reports were sent to the facility.
On 3/6/23 at 1023 hours, a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated the January 2023 MRR reports for Residents 55 and 66 were completed on 1/30/23; however, when she sent them to the facility, the MRR reports did not show up in the email. The Pharmacy Consultant was asked if there was a system to ensure the facility received each report and stated there was not; however, a list of all residents with the MRR reports were sent. The Pharmacy Consultant stated the facility should have followed up on the report since Residents 55 and 66 were on the MRR report list for the month of January 2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of five unnecessary medication sampled 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 two of five unnecessary medication sampled residents (Residents 55 and 66) were free from unnecessary drugs.
* The facility failed to monitor for signs and symptoms of bleeding related to Resident 55's use of Pradaxa (medication used to treat and prevent blood clots).
* The facility failed to ensure Resident 66 was free from duplicate therapy as two antiulcer medications (famotidine and omeprazole) were ordered without evidence or a documented clinical rationale.
These failures had the potential for the residents to receive unnecessary medication and develop significant side effects.
Findings:
1. Medical record review for Resident 55 was initiated on 3/1/23. Resident 55 was admitted to the facility on [DATE].
Review of the Physician Order Summary Report dated 3/1/23, showed a physician's order dated 10/30/22, for Pradaxa 110 mg one capsule by mouth two times a day.
Review of Lexicomp, an online reference for clinical drug information, showed precautions and concerns related to the adverse effects of Pradaxa included bleeding and residents should be monitored closely for signs and symptoms of bleeding.
Review of Resident 55's Medication Administration Record dated February 2023 failed to show documentation of the signs and symptoms of bleeding related to the use of Pradaxa were being monitored.
On 3/2/23 at 1536 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the above findings and stated Resident 55 should have been monitored for signs and symptoms of bleeding.
2. Medical record review for Resident 66 was initiated on 3/2/23. Resident 66 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].
Review of the Physician Order Summary Report dated 3/2/23, showed a physician's order dated 10/18/22, for famotidine 20 mg in the morning.
Review of the Physician Order Summary Report dated 3/2/23, showed a physician's order dated 10/18/22, for omeprazole 20 mg in the morning.
On 3/2/23 at 1427 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the above orders for duplicate therapy should have been identified and clarified with the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of five unnecessary medication sampled 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 two of five unnecessary medication sampled residents (Residents 6 and 55) free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior).
* For Resident 6, the Ambien PRN order did not have specific duration and exceeded 14 days without prescriber-documented rationale for extending the medication duration. There was no nonpharmacological interventions prior to Ativan use and no physician's clinical rationale documented for renewing the Ativan (antianxiety medication) PRN order. In addition, there were no side effect monitoring for the use of psychotropic medications.
* For Resident 55, the clinical rationale for not attempting gradual dose reduction (GDR) for psychotropic medications were not documented. The monthly behaviors monitoring was not completed for the Seroquel (antipsychotic medication)use. In addition, there were no side effects monitoring for the use of psychotropic medications.
These failures had the potential for the residents having unnecessary side effects from these medications.
Findings:
1. Medical record review for Resident 6 was initiated on 3/1/23. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including depression and anxiety disorder.
a. Review of Resident 6's current medication orders showed Ambien 5 mg at bedtime as needed for insomnia was ordered on 1/12/23, without any specific duration. Further record review failed to show the rationale for using the Ambien as needed for over 14 days.
On 3/2/23 at 1318 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged Resident 6's Ambien PRN order had no specific duration, and no rationale was documented for the use over 14 days.
b. Review of Resident 6's Physician Order Summary Report dated 3/1/23, showed an order dated 2/27/23, for lorazepam (antianxiety) 0.5 mg by mouth every six hours PRN for anxiety for 14 days
Review of Resident 6's MAR for February 2023 showed no evidence of nonpharmacological interventions being implemented prior to administering lorazepam PRN.
On 3/2/23 at 1318 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged there was no nonpharmacological interventions being implemented prior to lorazepam use for Resident 6.
Cross reference to F656.
c. Review of Resident 6's MAR dated January and February 2023 showed lorazepam 0.5 mg one tablet every six hours as needed for anxiety was documented as administered on the following dates and times:
- 12/17/22 at 1945 hours,
- 1/8/23 at 0930 hours,
- 1/9/23 at 1400 hours,
- 1/12/23 at 1915 hours,
- 1/27/23 at 0234 hours,
- 2/12/23 at 1327 hours, and
- 2/27/23 at 1600 hours.
Review of Resident 6's medical record failed to show the physician documented the rationale for continuing and renewing the use of Ativan PRN.
On 3/2/23 at 1318 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged the physician should have provided a clinical rationale for Resident 6's continued use of Ativan PRN.
d. Review of Resident 6's current medication orders showed Ambien 5 mg at bedtime as needed for insomnia was ordered on 1/12/23, lorazepam 0.5 mg as needed every six hours for anxiety was ordered on 2/27/23, and escitalopram 10 mg at bedtime was ordered on 11/28/22, for depression.
Further review of Resident 6's care plan problem addressing the use of the psychotropic medications showed to monitor the side effects of the medications every shift.
Review of Resident 6's Physician Order Summary Report dated 3/1/23, failed to show any orders for the monitoring of the side effects of the psychotropic medications.
Review of Resident 6's MAR dated February 2023 failed to show any monitoring of the side effects of the psychotropic medications.
On 3/2/23 at 1536 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged there was no monitoring of the side effects of the above psychotropic medications for Resident 6.
2. Medical record review for Resident 55 was initiated on 3/1/23. Resident 55 was admitted to the facility on [DATE].
Review of Resident 55's Physician Order Summary Report dated 3/1/23, showed the following orders: Remeron 7.5 mg at bedtime for depression was ordered on 2/8/23, Seroquel 12.5 mg every other bedtime for psychosis was ordered on 2/8/18, and Zoloft 75 mg one time a day for depression was ordered on 11/28/18.
a. Review of Resident 55's H&P examination dated 2/27/23, failed to show the prescriber's rationale for not attempting GDR of the psychotropic medications for Resident 55.
Review of Resident 55's Note to Attending Physician/Prescriber dated 11/30/22, showed under the Physician/Prescriber Response, there were no checked boxes to show the physician agreed, disagreed, or other response.
Further review of the Medication Regimen Review failed to show the physician had documented the rationale for not attempting GDR for the use of Zoloft.
On 3/2/23 at 1536 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged the physician needed to be more specific for the reasons why the GDR was contraindicated for Resident 55.
b. Review of Resident 55's Psychotropic Summary Sheet for Seroquel 12.5 mg for diagnosis of psychosis, failed to show documentation of the behavior episodes during the month of January 2023.
On 3/2/23 at 1536 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged the entry for January 2023 for the Psychotropic Summary Sheet for the use of Seroquel for Resident 55 was blank.
c. Review of Resident 55's current medication orders showed Remeron 7.5 mg at bedtime for depression was ordered on 2/8/23, Zoloft 75 mg one time a day for depression was ordered on 11/28/18, and to monitor the side effects of Zoloft every shift.
Review of Resident 55's Physician Order Summary Report dated 3/1/23, failed to show an order for the monitoring of the side effects of Remeron.
Review of Resident 55's MAR dated February 2023 failed to show documented evidence of the monitoring of the side effects for Remeron use.
On 3/2/23 at 1536 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged there was no monitoring of the side effects of the above psychotropic medications for Resident 55.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility P&P review, and medical record review, the facility failed to ensure the medication error rate was less than 5%. The facility's medication error rate was 12.5...
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Based on observation, interview, facility P&P review, and medical record review, the facility failed to ensure the medication error rate was less than 5%. The facility's medication error rate was 12.5%.
* LVN 1 failed to administer Symbicort (bronchodilator) and ferrous sulfate (supplement) for Resident 40 as per the physician's order.
* LVN 2 failed to administer vitamin C (supplement), vitamin D, and aspirin to Resident 112 as per the physician's order.
These failures had the potential to expose the residents to significant adverse reactions and complications.
Findings:
1. Review of the Premier Pharmacy Services's P&P titled Specific Medication Administration Procedures under the Oral Inhalation Administration not dated showed, Wait one minute between puffs for multiple inhalations of the same medication. Have resident rinse his/her mouth and spit out the rinse water.
On 2/27/23 at 0831 hours, a medication observation pass was conducted for Resident 40 with LVN 1. LVN 1 prepared and administered Resident 40's medications which included the following:
- one small container of Duoneb solution 0.5-3 mg/3 ml with 3 ml of Acetylcysteine (breathing treatment)
- one tablet of amiodarone 200 mg (medication for abnormal heart rhythm)
- one tablet of amlodipine 2.5 mg (medication for blood pressure)
- two tablets of bupropion 75 mg (medication for depression)
- one tablet of digoxin 0.125 mg (medication for abnormal heart rhythm)
- one tablet of Eliquis 5 mg (blood thinner)
- one capsule of gabapentin 300 mg (pain medication)
- one tablet of lisinopril 20 mg (medication for blood pressure)
- one tablet of Effexor 37.5 mg (medication for depression)
- one tablet of ferrous sulfate 325 mg (supplement)
- one softgel of docusate Sodium 250 mg (stool softener)
- one inhaler of Symbicort 160-4.5 mcg (medication for wheezing/shortness of breath)
- one tablet of Mucinex ER 600 mg (use for cough/congestion)
Review of Resident 40's Order Summary Report showed a physician's order dated 12/30/22, to administer Symbicort 160-4.5 mcg two puff inhale orally two times a day.
Review of Resident 40's Order Summary Report showed a physician's order dated 2/28/23, to administer one tablet of ferrous sulfate 325 mg with food.
On 2/27/23 at 1342 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 stated she did not administer the ferrous sulfate with food as ordered by the physician, and Resident 40 had breakfast one hour prior to administration of ferrous sulfate. LVN 1 verified she did not wait at least one minute in between puffs during the Symbicort administration for Resident 40.
2. On 2/27/23 at 0930 hours, a medication observation pass was conducted for Resident 112 with LVN 2. LVN 2 prepared and administered Resident 112's medications which included the following:
- one tablet of Norvasc 5 mg (medication for blood pressure)
- one tablet of vitamin C 500 mg (supplement)
- one tablet of aspirin chewable 81 mg (blood thinner)
- one tablet of Lotensin 20 mg (medication for blood pressure)
- one-half tablet of vitamin D3 50 mcg/2000 IU (supplement)
- one syringe of Lovenox 40 mg/0.4 ml (blood thinner)
Review of Resident 112's Order Summary Report showed the physician's orders dated 2/28/23, for the following medications:
- to administer one tablet of vitamin C 500 mg by GT daily
- to administer one-half tablet of vitamin D 50 mcg/2000 IU by mouth one time a day for supplement
- to administer aspirin EC 81 mg by GT in the morning
On 2/27/23 at 1350 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified there was residue in the medicine cup for vitamin C and she did not rinse the medicine cup after administering the medication. LVN 2 verified she did not administer the vitamin D by mouth as per the physician's order. LVN 2 verified she administered aspirin 81 mg chewable tablet to Resident 112 instead of aspirin 81 mg EC tablet as per the physician's order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manne...
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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 store the drugs and biologicals in a safe manner.
* Multiple opened medications containers with no open dates were observed in Medication Cart 1.
* Two discontinued unopened medication bottles of Lactulose (medication used to treat constipation or high levels of ammonia in the blood) oral solution were stored in Medication Cart 1 instead of being disposed.
* Multiple missing temperature log entries were observed in the refrigerator temperature log book in Medication room [ROOM NUMBER].
* One IV E-Kit with opened date [DATE], was observed in Medication room [ROOM NUMBER].
* Expired wound care supplies were observed in Treatment Cart 2.
* Expired IV supplies were observed in the IV Cart.
* Expired sunscreen and inhaler medications were observed in the TRC Medication Pass Cart.
These failures had the potential to result in unsafe medication administration.
Findings:
Review of the Premier Pharmacy Services's P&P titled Medication Storage in the Facility not dated showed the following:
* Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal.
* Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. Medications requiring refrigeration or temperatures between 2 degrees to 8 degrees centigrade (36 to 46 Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring.
Review of the Premier Pharmacy Services's P&P titled Disposal of Medications and Medications Related Supplies under the Discontinued Medications dated 1/18 showed, When medications are discontinued by a prescriber, a resident is transferred or discharged and does not take medications with him/her, or in the event of a resident's death, the medications are marked as discontinued and destroyed.
Review of the Premier Pharmacy Services's P&P titled Disposal of Medications and Medications Related Supplies, under the Medication Destruction section (undated) showed, Discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed.
Review of the Premier Pharmacy Services's P&P titled Medication Ordering and Receiving from Pharmacy, under Emergency Pharmacy Service and Emergency Kits section dated 1/2018 showed, If exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening.
1. On [DATE] at 1235 hours, an inspection of Medication Cart 1 was conducted with LVN 3, the following was observed:
- one opened bottle of Oyster Shell Calcium 500 mg (supplement), no open date on the container.
- one opened bottle of Latanoprost Ophthalmic solution (medication used to treat Glaucoma), no open date on the container.
- two unopened bottles of Lactulose oral solution (medication used to treat constipation or high levels of ammonia in the blood) belonging to Resident 64 who was discharged to the hospital on [DATE].
LVN 3 verified the above findings and acknowledged the Oyster Shell Calcium and Latanoprost Ophthalmic solution containers should have been dated when they were initially opened. LVN 3 verified the Lactulose bottles should have been discarded.
2. On [DATE] at 1610 hours, an inspection of Medication room [ROOM NUMBER] and concurrent review of the Refrigerator Temperature log was conducted with the DSD. The Refrigerator Temperature log showed multiple missing entries for temperature checking on the following dates:
- 10/3, 10/4, 10/9, 10/13, 10/14, 10/20, 10/21, 10/26, and [DATE].
- 12/1, 12/2, 12/7, 12/8, 12/13, 12/17, 12/18, 12/19, 12/22, 12/27, and [DATE].
- 1/9, 1/11, 1/14, 1/18, 1/24, 1/25, and [DATE].
- 2/3, 2/7, 2/8, 2/9, 2/14, 2/15, 2/20, and [DATE].
The DSD verified the above findings and stated she was not sure why there were no entries.
3. On [DATE] at 0900 hours, an inspection of Medication room [ROOM NUMBER] was conducted with the DSD and RN 1, the following was observed:
- one opened IV E-kit and it was opened on [DATE], according to the E-kit log.
RN 1 verified the above findings and stated the pharmacy was called one day prior for replacement; however, the replacement requests were not documented.
4. On [DATE] at 0925 hours, an inspection of Treatment Cart 2 was conducted with the DSD, the following was observed:
- One opened bottle of Hydrogen Peroxide (a mild antiseptic used on the skin to prevent infection of minor cuts, scrapes, and burns) had expired on 1/2022.
- One opened box of Moisture Wicking Antimicrobial Silver (a skin protectant which [NAME] and moves moisture away from skin to keep it dry) had expired on [DATE].
The DSD verified the above findings.
On [DATE] at 1136 hours, an interview was conducted with the treatment nurse. The treatment nurse stated she checked the treatment carts once a week and the items were missed and should have been discarded.
5. On [DATE] at 0935 hours, an inspection of the IV Cart was conducted with RN 1, the following was observed:
- Two Mini-Spike Vented Dispensing Pins (used for preparing and dispensing diluent or additive from multi-dose rubber-stoppered vials) had expired on 4/2019.
- one Mini-Spike Vented Dispensing Pins had expired on 5/2019.
- one Mini-Spike Vented Dispensing Pins had expired on 2/2020.
- one Mini-Spike Vented Dispensing Pins had expired on [DATE].
- one Low Volume 0.2 um IV Filter had expired on [DATE].
- five Statlock Catheter Stabilization Devices (a more effective alternative to tape in helping improve clinical outcomes, quality of care and economic efficiencies) had expired on [DATE].
- one yellow catheter device (safety device for hypothermic injection or blood collection) had expired [DATE].
- one yellow catheter device had expired on [DATE].
- two blue catheter devices had expired on 9/2021.
RN 1 verified the above findings and acknowledged the items were missed and should have been discarded.
6. On [DATE] at 1000 hours, an inspection of the TRC Medication Pass Cart was conducted with LPT 1 and the TRC Director, the following was observed:
- one opened bottle of Suntek Sunscreen had expired on 7/2022.
- one Albuterol Sulfate inhaler for Resident 91 had expired on [DATE].
LPT 1 and the TRC director verified the above findings and acknowledged the items should have been discarded.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**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 t...
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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 maintain the infection control program and practices to help prevent the development and transmission of diseases and infections.
* The facility failed to ensure the Monthly Infection Surveillance Reports were completed. For example, the information such as the residents' symptoms of infection, type of organisms when a culture was obtained, when the antibiotic was ordered, the duration of the antibiotics, and any laboratory/diagnostic tests were not documented. This had the potential for the antibiotics used were not indicated and the development of the antibiotic resistant bacteria.
* The facility failed to ensure the Sani Hands wipes used on the residents had not expired. This posed the risk for not adequately sanitizing the residents' hands prior to receiving their meals, cross contamination, and spread of infection.
Findings:
According to the Centers for Disease Control, unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper use of antibiotics is the primary cause of the increase in drug-resistant bacteria.
Review of the facility's P&P titled Infection Prevention Quality Control Program dated 2/2021 showed under Section 7, surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. Standard criteria are used to distinguish community acquired from facility acquired infections. Under section 8 Antibiotic Stewardship, culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. Medical Criteria and standardized definitions of infections are used to help recognize and manage infections. Under section 9 for data analysis, data gathered during surveillance is used to oversee infection and spot trends.
Review of the facility's P&P titled Surveillance for Infections dated [DATE] showed the purpose of surveillance of infections is to identify both individual case and trends of epidemiologically significant organisms and Healthcare associated infections to guide appropriate interventions and to prevent future infections. Under the Section Data Collection and Recording:
1. For Residents with infection that meet the criteria for definition of infection for surveillance, collect the following data as appropriate:
a. Identifying information ( i.e., resident's name, age, room number, unit, and attending physician)
b. Diagnosis
c. admission date, date of onset of infection (may list onset of symptoms, if known, or date of positive diagnostic test);
d. Infection site (be as specific as possible, e.g., cutaneous infections should be listed as pressure ulcer, left foot, pneumonia as right upper lobe, etc)
e. Pathogen
f. Invasive procedures or risk factors ( i.e., surgery, indwelling tubes, Foley, etc, fractured hip, malnutrition, altered mental status, etc)
g. Pertinent remarks (additional relevant information, i.e., temperatures, other symptoms of specific infection, white blood cell count, etc); also, record if the resident is admitted to the hospital or expires
h. Treatment measures and precautions ( interventions and steps taken that may reduce risk)
Review of the Antimicrobial or infection control surveillance for [DATE] showed on Pages 2 to 5, all listed residents other than the community acquired infection had a blank clinical sign and symptoms section. For the resident who had urinary tract infection, there were no organism and sign/symptoms documented; and for all the residents ordered antibiotic, there were no documentation or marked if the antibiotic ordered meet the Mcgeer criteria or HAI.
Review of the Monthly Infection Surveillance Report by Sign and Symptoms for [DATE] showed a total of five residents identified for not having true infection using the McGeers criteria. Review of the Antimicrobial or Infection Control Surveillance for [DATE] showed six residents had antibiotic orders that did not meet the Mcgeers criteria.
Review of the Monthly Infection Surveillance Report by Sign and Symptoms for [DATE] showed a total of five residents identified for not having true infection using the McGeers criteria. Review of the Antimicrobial or Infection Control Surveillance for [DATE] showed eight residents had antibiotic orders that did not meet the Mcgeers criteria.
Review of the Monthly Infection Surveillance Report by Sign and Symptoms for [DATE] showed a total of 10 residents identified for not having true infection using the McGeers criteria. Review of the Antimicrobial or Infection Control Surveillance for [DATE] showed 13 residents had antibiotic orders that did not meet the Mcgeers criteria.
Review of the Monthly Infection Surveillance Report by Sign and Symptoms for [DATE] showed a total of seven residents identified for not having true infection using the McGeers criteria. Review of the Antimicrobial or Infection Control Surveillance for [DATE] showed there were residents on the list that were checked for nosocomial inefections; however, some of the residents' clinical signs and symptoms section and the column if it met the McGeer criteria were blank.
Review of the Monthly Infection Surveillance Report by Sign and Symptoms for [DATE] showed there was no resident identified for not having true infection using the McGeers criteria. Review of the Antimicrobial/infection Control Surveillance for [DATE] showed the following:
- line listing #3 showed the resident's sign or symptom was blank
- line listing #7 showed the antibiotic ordered was for UTI ( urinary tract infection); however, the signs and symptoms documented was cough.
- line listing #9 showed the resident had upper respiratory infection; however, the signs and symptoms documented was no short of breath instead of the signs and symptoms that the resident had.
- line listing #18 showed the resident had pneumonia and the clinical sign and symptom documented was no short of breath or no cough noted.
- line listing #26, #27, and #28, showed the residents had upper respiratory infection; however, there was no clinical sign and symptoms documented.
On [DATE] at 0950 hours, an interview and concurrent medical record review was conducted with the IP and DSD. The IP and DSD were asked how they determined if the infections were an HAIs or CAIs, and if the antibiotic ordered met the McGeer's Criteria. The IP and DSD stated they used the McGeer criteria, monitored the residents' sign or symptom of infection, and determined if the infection were HAIs or CAIs. Both stated they gathered the information about the infections in the facility by reviewing the antibiotic orders and monitoring the residents' laboratory results, and conducting the infection surveillance. The IP and DSD were asked about the surveillances for August, [DATE], January, and February 2023. The IP and DSD acknowledged that the surveillances were incomplete. When asked regarding the mappings for the months of August, September, Octorber, and [DATE], both stated the mappings were incomplete. The mapping should be completed to track and trend the infections. The IP and DSD were asked about the documentation if the nurse made a follow up with the physician for the residents with antibiotics that did not meet the McGeer criteria. Both stated they would look for the information.
On [DATE] at 1400 hours, an interview and concurrent medical record was conducted with the IP and DSD. The IP and DSD stated they only could find two residents nursing notes informing the physician for the residents who had antibiotic orders that did not meet the Mcgeer's criteria: one of six residents in [DATE] and one of seven residents in [DATE]. They were unable to locate the nursing notes for all other residents not met the Mcgeer (five residents in [DATE], eight residents in [DATE] residents in [DATE], six residents in [DATE]). The IP and DSD verified the above findings.
2. On [DATE] at 1243 hours, a dining observation was conducted in Station B. LVN 2, Activity Assistants 1 and 2, and CNA 9 were present in the dining room observing and assisting the residents during lunch. During the observation, a container of Sani Hands wipes with the expiration date of 6/2022 was observed on the sink in the dining room. LVN 2 verified the expiration date and stated she did not know the wipes had expired. An interview was also conducted with Activity Assistant 1. When asked if he used the Sani Hands wipes for the residents prior to serving their meals, Activity Assistant 1 stated he handed the Sani Hands wipes to the residents prior to lunch to clean and disinfect the residents' hands. Activity Assistant 1 was shown the container of Sani Hands wipes with the expiration date of 6/2022. Activity Assistant 1 stated he did not even know the wipes had an expiration date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**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 t...
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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 establish and maintain the antibiotic stewardship program designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections.
* The facility failed to identify CAIs and HAIs and failed to address the use of antibiotics for residents whose symptoms did not meet the McGeer's Criteria in the infection control meeting for one final sampled resident (Resident 38). These failures posed the risk of inaccurately identifying if the residents met the criteria for a true infection and inappropriate antibiotic usage.
Findings:
According to the CDC, unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper use of antibiotics is the primary cause of the increase in drug-resistant bacteria.
Review of the facility's P&P titled Antibiotic Stewardship dated March 2020 showed the purpose of our antibiotic Stewardship program is to monitor the use of antibiotics in our residents. When a nurse calls a physician or prescriber to communicate s suspected infection, he or she will have the following information available:
A. Sign and symptoms:
B. When symptoms were first observed
C. Resident's Hydration status
D. Current medication List
E. Allergy Information
F. Infection type
G. Last Creatinine Clearance or serum creatinine if available
H. Time of the last antibiotic dose
When a culture and sensitivity (C and S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if the antibiotic therapy should be started, continued, modified or discontinued.
1. Medical record Resident 38 was initiated on 3/2/23. Resident 38 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].
On 03/06/23 at 1000 hours, Resident 38 was observed laying on her back in bed with head of the bed elevated. The indwelling urinary catheter bag was observed with yellow colored urine and no sedimentation noted in the bag or tubing.
Review of the physician's order dated 2/23/23, showed to administer Septra DS one tablet by mouth two times a day for seven days for UTI.
Review of the Laboratory Result Report dated 2/23/23, showed the urine culture result with more than 100,000 colonies per ml of Escherichia Coli: extended Spectrum Beta.
Review of the progress note dated 2/24/23, showed the resident was noted with dark amber color urine in the indwelling urinary catheter bag. No foul-smelling urine and suprapubic pain were noted. The note also showed the physician was made aware of the findings and started the resident was on an antibiotic therapy.
On 03/06/23 at 0917 hours, an interview and concurrent record review were conducted with the IP. The IP stated she would like to fill out the McGeer tool herself and had not provided the inservice to the licensed nurses on how to use McGeer tool. The IP stated she had not implemented her own process. The IP stated she would make the binders with McGeer's tools inside, bring to the Nurse's station, and provide inservice on how to use the tool. The IP stated the McGeers had not been filled out for Resident 38's use of Septra DS. There was no documented evidence Resident 38's use of the antibiotic met the McGeers criteria or not met. The IP verified the findings.
On 03/06/23 at 0923 hours, the IP stated she checked if there were new orders for antibiotic for the previous day, made sure the resident met the McGeers criteria and documented in the progress note that they met or not met criteria for the antibiotic use. If the resident did not meet the criteria, then the IP would call the physician to inform; and if the physician would order to continue, then she would document.
2. Review of the Antimicrobial or Infection Control Surveillance for August 2022 showed on pages 2 to 5, all the residents listed other than the community acquired infection had a blank clinical signs and symptoms section. For example, for the resident who had urinary tract infection, there were no organisms and signs/symptoms documented. For 17 residents who were ordered antibiotic, there was no documentation or mark showing if the antibiotic ordered had met the McGeers criteria or not an HAI ( Healthcare Associated Infection), and there were no signs and symptoms and/or culture/laboratory results and diagnostic tests documented.
Review of the Monthly Infection Surveillance Report by sign and symptoms for September 2022 showed a total of five residents identified for not having true infection using the McGeers criteria. Review of the Antimicrobial or Infection Control Surveillance for September 2022 showed six residents had antibiotic orders that did not meet the Mcgeers.
Review of the Monthly Infection Surveillance Report for October 2022 showed a total of five residents idenfied for not having true infection using the McGeers criteria . Review of the Antimicrobial or Infection Control Surveillance for October 2022 showed eight residents had antibiotic orders that did not meet the McGeers criteria.
Review of the Monthly Infection Surveillance Report by sign and symptoms for November 2022 showed a total of 10 residents identified for not having true infection using the McGeers criteria. Review of the Antimicrobial or Infection Control Surveillance for November 2022 showed 13 residents had antibiotic orders that did not meet the McGeers criteria.
Review of the Monthly Infection Surveillance Report by sign and symptoms for December 2022 showed a total of seven residents identified for not having true infection using the McGeers criteria. Review of the Antimicrobial or Infection Control Surveillance for December 2022 showed there were residents on the list that were checked for nosocomial inefections; however, some of the residents' clinical signs and symptoms section and the column if it met the McGeer criteria were blank.
Review of the Monthly Infection Surveillance Report by sign and symptoms for January 2023 showed there was no resident listed under not true infection using the McGeers criteria. Review of the Antimicrobial/infection Control Surveillance for January 2023 showed the following:
- listing #3 showed the resident's sign or symptom was blank
- listing #7 showed the antibiotic ordered was for UTI ( urinary tract infection); however, the signs and symptoms documented was cough.
- listing #9 showed the resident had upper respiratory infection; however, the signs and symptoms documented was no short of breath instead of the signs and symptoms that the resident had.
- listing #18, the resident had pneumonia and the clinical sign and symptom documented was no short of breath or no cough noted.
- listing #26, #27, and #28 showed the residents had upper respiratory infection; however, there was no clinical sign and symptoms documented.
On 3/2/23 at 0950 hours, an interview and concurrent medical record review was conducted with the IP and DSD. The IP and DSD were asked how they determined the infections were an HAIs or CAIs, and if the antibiotic ordered met the McGeer's Criteria. The IP and DSD stated they used the McGeer criteria, monitored the residents' sign or symptom of infection, or determined if the infection were HAIs or CAIs. Both stated they gathered information about the infections in the facility by reviewing the antibiotic orders and monitoring the residents' laboratory results, and conducting the infection surveillances. The IP and DSD were asked about the August, December 2022, January, and February 2023 surveillances. The IP and DSD acknowledged that the surveillances were incomplete for the months mentioned. When asked for the mapping for August, September, October, and November 2022, both stated the mapping were incomplete. The mapping should be completed to track trends of infection. The IP and DSD were asked about the documentation if the nurse had followed up with the physician for antibiotic that did not meet the McGeer criteria. Both stated they would look for the information.
On 3/2/23 at 1400 hours, an interview and concurrent medical record was conducted with the IP and DSD. Both stated they only could find two residents' nursing notes informing the physician for the resident who had antibiotic order that did not meet McGeers criteria: one of the six residents in September 2022 and one of the seven residents in December 2022. They were unable to locate the nursing notes for all the other residents that did not meet the McGeers criteria (five residents in September 2022, eight residents in October 2022, 13 residents in November 2022, and six residents in December 2022). The facility was unable to provide documented evidence of the physician notification for the residents on antibiotic that did not meet the McGeers criteria. The IP and DSD verified the 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the foot panel attached to the resident's bed was assembled in accordance with the bed manufacturer's User-Service Manual for one of 26 final sampled residents (Resident 24).
* Resident 24's bed foot panel was observed to be loose as evidenced by moving back and forth. Upon inspection by the Maintenance Director, it was determined the foot panel was not attached to the bed as per the bed manufacture's User-Service Manual.
This failure posed the risk for entrapment between the bed foot panel and bedframe and/or mattress, potentially causing serious injury to the resident.
Findings:
Review the facility's P&P titled Bed safety revised 12/07 showed to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, footboard, and bed accessories), the facility will promote the following approaches: Inspection by maintenance staff of all beds and related equipment, as part of our regular bed safety program to identify risks and problems including potential entrapment risks.
Medical record review for Resident 24 was initiated on 2/27/23. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 24's MDS dated [DATE], showed Resident 24 had no impairment of functional range of motion specific to her upper and lower extremities.
Review of Resident 24's care plan problem titled At Risk for Injury Related to Restless Leg Syndrome initiated on 7/10/18, showed an intervention to provide appropriate safety precautions daily/during care.
Review of Resident 24's care plan problem titled At Risk for Fall or Injury related to impaired balance during transitions, waking and toileting, related to weakness initiated 7/21/20, showed Resident 24 had episodes of sitting at the edge of the bed, a history of getting out of bed, and transferring herself from her bed to her wheelchair without assistance.
On 2/27/23 at 1050 hours, an observation and concurrent interview was conducted with Resident 24. Resident 24 was observed lying in bed. Resident 24 stated the foot panel on her bed was loose, for as long as she could remember.
On 2/27/23 at 1146 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified Resident 24's bed foot panel was loose. Upon further inspection by the Maintenance Director, he determined the foot panel was missing two screws, which caused the foot panel to move back and forth. The Maintenance Director stated he would immediately secure the foot panel that missing the screws to decrease the risk for resident injury.
The Maintenance Director verified the bed manufactures' User-Service Manual showed the bed foot panel bracket required four screws, and Resident 24's bed foot panel only had two screws in place.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and facility document review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following:
* The facility failed to e...
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Based on observation, interview, and facility document review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following:
* The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface.
* The facility failed to ensure the robot coupe blender used for puree preparation was air dried prior to storing.
* The facility failed to ensure the silver metal chopper was clean and free of food particles.
* The facility failed to ensure the kitchen utensils had a smooth cleanable surface and not worn out.
These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.
Findings:
Review of the CMS-672 Resident Census and Conditions of Residents completed by the facility dated 2/27/23, showed 118 of 131 residents residing in the facility received food prepared in the kitchen.
1. According to the 2017 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be smooth; free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; free of sharp internal angles, corners, and crevices; and finished to have smooth welds and joints.
During the initial kitchen tour on 2/27/23 at 1002 hours, a concurrent observation and interview was conducted with the DSS. The red, white, and green cutting boards were observed discolored with deep groves, heavily marred, and fuzzy. The DSS verified the findings and stated they should have been replaced for infection control purposes.
2. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow.
During the initial kitchen tour on 2/27/23 at 1002 hours, a concurrent observation and interview was conducted with the DSS. A robot coupe blender was observed being stored in the counter shelves with lid on and was still wet inside. The DSS verified the findings and stated it was supposed to be air dried to prevent bacteria growth.
3. According to the FDA Food Code, 2017 4-601.11, it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
According to the FDA Food Code Annex 4-602.13, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.
During the initial kitchen tour on 2/27/23 at 1002 hours, an observation and concurrent interview was conducted with the DSS. The silver metal chopper used for vegetables and hash brown stored in a metal drawer was observed with dry, crusted, whitish food residue. The DSS verified the findings and stated it should have been washed good to prevent bacteria and food contamination.
4. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, 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 durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
During the initial kitchen tour on 2/27/23 at 1002 hours, an observation and concurrent interview was conducted with the DSS. Three basting brushes were observed to be worn out with frayed and burnt bristles with hardened and crusted residue at the tip. Two white rubber spatulas were observed to be worn off, discolored with cuts, chipping alongside and partially missing end. The DSS verified the above findings, discarded basting brushes, and stated it should have been replaced to prevent from getting mixed with the food and food contamination purposes.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0574
(Tag F0574)
Minor procedural issue · This affected multiple residents
Based on interview, the facility failed to ensure eight of eight residents interviewed (Residents 15, 33, 35, 58, 62, 66, 72, and 106) knew how to contact the California Department of Public Health to...
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Based on interview, the facility failed to ensure eight of eight residents interviewed (Residents 15, 33, 35, 58, 62, 66, 72, and 106) knew how to contact the California Department of Public Health to file a complaint. This posed the risk of the residents not knowing how to contact the state should the residents require the state services.
Findings:
On 2/28/23 at 1011 hours, a resident group interview was conducted with eight residents. The residents were asked if they knew how to contact the state to file a complaint. Eight of eight residents stated did not how to contact the state to file a complaint.
On 3/7/23 at 1449 hours, an interview was conducted with the AD. The AD verified she had not discussed with the residents on how to contact the state. The AD stated she was unaware the residents could file a complaint with the state.
Feb 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to protect one of two sampled resident ' s (Resident 1) rights...
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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 protect one of two sampled resident ' s (Resident 1) rights to be free from physical abuse by another resident (Resident 2). This had the potential for Resident 1 to be injured or have psychosocial harm.
Findings:
Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 1/26/23, showed Resident 2 entered the TV room where Resident 1 was watching TV. Resident 1 told Resident 2 to leave the room and the two residents then exchanged verbal challenges. Per Resident 1, Resident 2 struck him in the head with a closed fist. The staff entered the room and witnessed Residents 1 and 2 upright and wrestling.
a. Medical record review for Resident 1 was initiated on 2/7/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1 ' s Progress Notes dated 1/26/23 at 1838 hours, showed Resident 1 was the victim of the incident that occurred at 1735 hours, a physical altercation with Resident 2. Upon assessment, Resident 1 had redness around the right eye and slight swelling, but no bruising was observed.
Review of Resident 1 ' s Progress Notes dated 1/26/23 at 2018 hours, showed at 1735 hours,MHS 1 responded to a Code [NAME] and observed Resident 1 being assaulted by Resident 2. MHS 1 separated the residents.
b. Medical record review for Resident 2 was initiated on 2/7/23. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2 ' s Progress Notes dated 1/25/23 at 1349 hours, showed Resident 2 alleged Resident 1 had pushed a bedside table into him in the middle of the night.
Review of Resident 2 ' s Progress Notes dated 1/26/23 at 1836 hours, showed the staff responded to a loud noise from the TV room at 1735 hours. The staff observed Resident 2 holding Resident 1 by the neck as they were fighting. The residents were physically separated from each other and when asked what happened, they both mutually blamed each other. Upon assessment, Resident 2 had 1.5 ich superficial scratch around the right temple withno active bleeding.
On 2/7/23 at 1000 hours, an interview was conducted with the Assistant Administrator. The Assistant Administrator stated Resident 2 was transferred to another facility for behavioral stabilization following the altercation with Resident 1. The Assistant Administrator stated Resident 1 did not feel safe having Resident 2 around; therefore, Resident 2 would not be readmitted to the facility.
On 2/7/23 at 1030 hours, an interview was conducted with the TRC Program Director. The TRC Program Director stated Residents 1 and 2 used to be roommates until Resident 2 reported Resident 1 had purposely pushed a bedside table into him. The TRC Program Director stated then on 1/26/23, Residents 1 and 2 had a physical altercation in the TV room where the staff had to intervene and separate them.
On 2/7/23 at 1218 hours, an interview was conducted with MHS 1. MHS 1 stated he responded to a Code [NAME] in the TV room and observed both residents in the corner of the room fighting. MHS 1 stated Resident 2 was on top of Resident 1 and was punching Resident 1. MHS 1 stated the staff were able to separate the residents without incident.
Sept 2019
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 9/18/19 at 1452 hours, on 9/19/19 at 0843 hours, and on 9/24/19 at 0850 hours, Resident 48 was observed in bed with bilate...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 9/18/19 at 1452 hours, on 9/19/19 at 0843 hours, and on 9/24/19 at 0850 hours, Resident 48 was observed in bed with bilateral upper side rails elevated.
Medical record review for Resident 48 was initiated on 9/16/19. Resident 48 was admitted to the facility on [DATE].
Review of Resident 48's Entrapment Risk Evaluation for Bedrails form showed bilateral 1/8 rails to be used for bed mobility and transfers to promote resident independence. The bilateral rails were referred to as assist handles per facility documentation. Verification of Informed Consent for Bed Rails was obtained on 4/4/19.
On 9/24/19 at 1107 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 48 required total assistance with bed mobility and two persons' assistance with a Hoyer lift (mechanical lifting device) for transfers. CNA 1 stated Resident 48 was able to turn herself in bed at times and hold onto the rails, but other times Resident 48 needed assistance from staff to hold on to the rails. CNA 1 stated when Resident 48 was in bed, Resident 48's bilateral bed rails were always up. CNA 1 stated Resident 48 could not pull herself up in bed and needed assistance from staff.
Based on observation, interview, and medical record review, the facility failed to ensure the appropriate/proper use of side rails for four of 26 final sampled residents (Residents 12, 35, 102, and 48).
* Residents 12 and 35 were unable to use side rails without staff assistance; however the side rails remained elevated when the staff was not providing care.
* Residents 48 and 102 had side rails elevated without a physician's order and were unable to use the bedrails without staff assistance.
Failure to appropriately/properly use the side rails put the residents at risk for serious harm or death.
Findings:
According to the FDA, potential risks of bedrails include strangling, suffocation, serious bodily injury or death when residents or parts of their bodies are caught between rails, the openings of the rails, or between the bedrails and the mattress. Bedrails may create negative psychological effects such as contributing to resident isolation and incontinence. Those most at risk for entrapment include the frail and elderly.
1. On multiple occasions between 9/16 and 9/19/19, Resident 12 was observed in bed with bilateral side rails elevated. For example:
- On 9/16/19 at 1022 and 1509 hours, Resident 12 was observed in bed with bilateral side rails elevated.
- On 9/17/19 at 0952, 1153, and 1346 hours, Resident 12 was observed in bed on her back with bilateral side rails elevated.
- On 9/18/19 at 1405 hours, Resident 12 was observed in bed with bilateral side rails elevated.
- On 9/19/19 at 0809 hours, Resident 12 was observed eating breakfast with the head of the bed slightly elevated. Both side rails were elevated.
- On 9/19/19 at 0931 hours, Resident 12 was observed in bed with bilateral side rails elevated.
Medical record review for Resident 12 was initiated on 9/16/19. Resident 12 was admitted to the facility on [DATE].
Review of Resident 12's MDS dated [DATE], showed Resident 12 required extensive physical assistance from two persons for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) and was totally dependent on two persons for transfers (how resident moves between surfaces including to or from bed).
Review of Resident 12's Order Summary Report showed an order dated 5/10/13, for two upper bilateral side rails when in bed for turning and repositioning in bed.
Review of Resident 12's Entrapment Risk Evaluation For Bedrails dated 9/5/19, showed the IDT recommended to continue the bilateral side rails for turning and repositioning with staff assistance.
On 9/19/19 at 1111 hours, an observation and concurrent interview was conducted with CNA 3. Resident 12 was in bed being assisted towards her right side. Resident 12 was observed holding the right side rail. Both side rails were elevated. CNA 3 stated Resident 12 only used the side rails during ADL care with staff assistance.
On 9/19/19 at 1431 hours, an observation and concurrent interview was conducted with CNA 4. Resident 12 was observed in bed with bilateral side rails elevated. CNA 4 was asked about Resident 12's use of the side rails. CNA 4 stated Resident 12 did not use the side rails independently and did not turn or move herself in bed at all.
On 9/19/19 at 1615 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 stated Resident 12 used the side rails independently in the past, but not since 6/19. LVN 6 was asked why Resident 12 had bilateral side rails elevated at all times and not just during ADL care. LVN 6 was unable to answer.
2. On multiple occasions between 9/16 and 9/19/19, Resident 35 was observed in bed with bilateral side rails elevated. For example:
- On 9/16/19 at 1502 hours, Resident 35 was observed in bed with bilateral side rails elevated.
- On 9/17/19 at 0907 hours, Resident 35 was observed in bed with eyes closed. Bilateral side rails were elevated.
- On 9/18/19 at 0808 and 1401 hours, Resident 35 was observed in bed with bilateral side rails elevated.
- On 9/19/19 at 0805 and 0933 hours, Resident 35 was observed in bed with bilateral side rails elevated.
Medical record review for Resident 35 was initiated on 9/16/19. Resident 35 was admitted to the facility on [DATE].
Review of Resident 35's MDS dated [DATE], showed Resident 35 was severely cognitively impaired, required extensive assistance from two persons for bed mobility, and was totally dependent on two plus persons for transfers.
Review of Resident 35's Order Summary Report showed an order dated 10/23/17, for bilateral side rails to be elevated when in bed for turning and repositioning due to weakness.
Review of Resident 35's Entrapment Risk Evaluation For Bedrails dated 9/16/19, showed the IDT recommended the use of bilateral side rails in bed for turning and repositioning with staff assistance.
On 9/19/19 at 1603 hours, an interview was conducted with RN 2. RN 2 stated Resident 35 was able to grab the side rails with his right hand, but only with staff assistance.
3. On 9/17 and 9/18/19, Resident 102 was observed in bed with side rails elevated as follows:
- On 9/17/19 at 0856 hours, Resident 102 was observed in bed with the left side rail elevated.
- On 9/17/19 at 1345 hours, Resident 102 was observed in bed with bilateral side rails elevated.
- On 9/18/19 at 0807 hours, Resident 102 was observed in bed with her eyes closed with bilateral side rails elevated.
- On 9/18/19 at 1403 hours, Resident 102 was observed in bed with the left side rail elevated.
- On 9/19/19 at 0932 hours, Resident 102 was observed in bed watching a show on an electronic device located on her bedside table. The left side rail was elevated.
Medical record review for Resident 102 was initiated on 9/16/19. Resident 120 was admitted to the facility on [DATE].
Review of Resident 102's MDS dated [DATE], showed Resident 120 had severely impaired cognition, required extensive assistance from two persons for bed mobility, and required total assistance from two plus persons for transfers.
Review of Resident 102's physician's orders failed to show an order for the use of bedrails.
Further review of Resident 102's Physician and Telephone Orders showed an order dated 8/26/19, to discontinue the bilateral side rails.
On 9/19/19 at 1429 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 stated Resident 102 did not reposition herself in bed, she required total assistance from the staff. CNA 3 stated Resident 102 was able to grab the side rails with assistance when she was being turned.
On 9/19/19 at 1630 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified Resident 102 did not have a current order for side rails. LVN 6 stated the side rails were discontinued because the resident did not use them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
2. On 9/18/19 at 1508 hours, a review of the facility's controlled drugs was conducted with LVN 3. Review of the Narcotic and Hypnotic Record (a form to ensure the accountability of controlled medicat...
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2. On 9/18/19 at 1508 hours, a review of the facility's controlled drugs was conducted with LVN 3. Review of the Narcotic and Hypnotic Record (a form to ensure the accountability of controlled medications for a resident) showed a handwritten order for Phenergan with codeine syrup 5 ml by mouth every four hours as needed for a cough for three days for Resident 78. The form showed 5 ml = 1 dose. The first dose was signed out on 6/16/19 at 1635 hours. Two doses were signed out on 6/16/19, three doses were signed out on 6/18/19, three doses were signed out on 6/18/19. The last dose was signed out on 6/22/19 at 2100 hours, three days after the medication was supposed to be discontinued. A second Narcotic and Hypnotic Record for the Phenergan with codeine syrup printed out from the pharmacy showed 90 ml of Phenergan with codeine was provided. The first dose signed out on 6/16/19 at 1635 hours showed only 0.5 ml was dispensed, not 5 ml. The second dose signed out on 6/16/19 at 2130 hours showed 0.5 ml was dispensed, not 5 ml. One more dose signed out (illegible date) at 2000 hours showed 5 ml was dispensed.
Review of Resident 78's Medication Record for June 2019 showed two doses of Phenergan with codeine were administered on 6/16/19, three doses were administered on 6/17/19, and three doses were administered on 6/18/19. There was no documentation to show a dose of Phenergan with codeine was administered on 6/22/19. LVN 3 was asked about the Narcotic and Hypnotic Records for Resident 78 but was unable to explain what was entered on the Narcotic and Hypnotic Records. LVN 3 asked RN 1 about the Narcotic and Hypnotic Records for Resident 78 but RN 1 stated she had to ask the DON. The DON stated she was going to find out what happened.
The DON reviewed Resident 78's Medication Record for June 2019 and found the rewritten Narcotic and Hypnotic Record for Resident 78. The DON stated the Narcotic and Hypnotic Record was rewritten due to the error entered in the original record. The DON was asked about the facility's procedure when an error was entered on the Narcotic and Hypnotic Record. The DON stated the licensed nurse should have attached the original record to the rewritten record. The DON stated she did not know what happened; why the original Narcotic and Hypnotic Record was separated.
The DON was asked about the discrepancy on the Narcotic and Hypnotic Record showing a dose of the Phenergan with codeine was dispensed on 6/22/19, for administration to Resident 78. The DON reviewed and confirmed the Narcotic and Hypnotic Record showed a dose of Phenergan with codeine was signed out on 6/22/19. The DON summoned LVN 4 into the office. LVN 4 was asked about the dose of Phenergan with codeine signed out on 6/22/19 on the Narcotic and Hypnotic Record. LVN 4 confirmed she signed the Narcotic and Hypnotic Record showing she removed the Phenergan with codeine, but she did not remember administering it to Resident 78. LVN 4 verified she did not document the administration of Phenergan with codeine on the Medication Record. The DON verified the above findings.
Based on observation, interview, and medical record review, the facility failed to ensure the staff followed their P&P for medication administration for one of 26 final sampled residents (Resident 120) and seven nonsampled residents (Residents 22, 28, 53, 89,104, 123, and 138).
* LPT 1 poured medications for Residents 22, 28, 53, 89, 104, 120, 123, and 138. However, when asked what time he was going to administer the medications to the residents, LPT 1 stated he was not going to administer the medications; the charge nurse was going to administer them at a later time. This posed the risk of the residents not receiving the prescribed medications at the appropriate doses, and the potential for medication errors.
* The facility failed to ensure thecontrolled medication administration for Resident 78 was accurately documented. This failure posed the risk for diversion of controlled medications and medication errors.
Findings:
1. Review of the facility's P&P titled Administering Medications-TRC dated December 2012 showed the medications shall be administered as soon as possible but no more than two hours after doses are prepared or pre-poured and shall be administered by the same person who prepares the doses for administration.
a. Medical Record Review for Resident 22 Physician's Orders showed orders dated 9/3/19, for clonazepam (anti-seizure medication also used to treat anxiety) 0.5 mg by mouth twice a day at 1200 hours and 2100 hours, quetiapine (antipsychotic medication) 400 mg, one tablet three times a day at 0700 hours, 1200 hours, and 2100 hours, and gabapentin (anti-seizure medication used to treat nerve pain) 600 mg, one tablet by mouth twice a day at 1200 hours and 2100 hours.
b. Medical Record Review for Resident 28 showed Physician's Orders with an order dated 3/15/19, for pantropanzole sodium (acid reducer) 40 mg, one tablet by mouth every day before meal at 1100 hours, and an order dated 7/9/19, for hydroxyzine (antihistamine also used to treat anxiety) 50 mg, one capsule by mouth twice a day at 0900 hours and 1300 hours.
c. Medical Record Review for Resident 53 showed Physician's Orders with an order dated 12/3/18, for vitamin D3, 1000 units, one tablet by mouth twice a day at 1200 hours and 2100 hours.
d. Medical Record Review for Resident 89 showed Physician's Orders with an order dated 9/2/19, for Benadryl (antihistamine) 50 mg by mouth twice a day at 0700 hours and 1300 hours.
e. Medical Record Review for Resident 104 showed Physician's Orders with an order dated 6/7/16, for Artificial Tears 1.4% one drop into both eyes four times a day at 0700 hours, 1200 hours, 1700 hours, and 2100 hours, and an order dated 3/1/16, for benztropine mesylate (medication to treat Parkinson's disease) 1 mg, one tablet by mouth three times a day at 0700 hours, 1200 hours, and 2100 hours.
f. Medical Record Review for Resident 120 showed Physician's Order with an order dated 5/26/19, Nicotine 4 mg chew gum, four times a day at 0700 hours, 1200 hours, 1700 hours, and 2100 hours.
g. Medical record review for Resident 123 showed Routine admission Orders dated 9/15/19, with a physician's order for Nicotine Gum 4 mg by mouth three times a day. Review of the Med-Pass form showed the Nicotine gum was to be administered at 0700 hours, 1200 hours, and 1700 hours. Review of the Physician and Telephone Orders showed an order dated 9/17/19, to administer Keflex (antibiotic) 500 mg by mouth, one tablet three times a day. Review of the Med-Pass form showed the Keflex was scheduled to be administered at 0700 hours, 1200 hours, and 1700 hours.
h. Medical Record Review for Resident 138 showed Physician's Orders with an order dated 8/13/19, for lorazepam (anti-anxiety medication) 0.5 mg, one tablet by mouth twice a day at 1200 hours and 2100 hours.
On 9/19/19 at 1015 hours, an interview and observation was conducted with LVN 1 and LPT 1. Medication Tray 2 was observed with medication cups with pills for residents. LPT 1 stated he pre-poured routine medications with LVN 1 and narcotic medications with LVN 2. When asked when he prepared the medications, LPT 1 stated he pre-poured the medications at 0945 hours and finished for his medications on Tray 2. The medication cup for Resident 22 contained quetiapine 400 mg, one tablet, gabapentin 600 mg, one tablet, and clonazepam 0.5 mg, one tablet. The medication cup for Resident 120 contained one Nicotine gum. The medication cup for Resident 123 contained one tablet of Keflex and one Nicotine gum.
On 9/19/19 at 1104 hours, an interview was conducted with LPT 1. LPT 1 was asked when he would administer the medication he had pre-poured. LPT 1 stated around 1200 hours and he was not the one who was going to administer the medication because he was a new staff member, the charge nurse was going to administer the medications.
On 9/19/19 at 1200 hours, an interview was conducted LVN 1. LVN 1 stated LVN 2 was going to administer the medications from Medication Tray 2.
On 9/19/19 at 1220 hours, an interview was conducted with LVN 2. LVN 2 was observed administering the medications to Residents 22, 120, and 123.
On 9/20/19 at 1033 hours, an interview and medical record review was conducted with LVN 1 and LPT 1. LVN 1 and LPT 1 were asked which residents they pre-poured medications for on Medication Tray 2 around 0945 hours. LVN 1 and LPT 1 stated Medication Tray 2 was prepared for Resident 28, with hydroxazine 50 mg, to be administered at 1300 hours and protonix 40 mg to be administered at 1100 hours. Medications for Resident 22 were clonazepam, gabapentin, and quetiapine scheduled to be administered at 1200 hours. Medications for Resident 120 was Nicotine gum 4 mg scheduled to be administered at 1200 hours. Medications for Resident 104 were benztropine mesylate 1 mg scheduled to be administered at 1200 hours and Artificial Tear scheduled to be administered at 1200 hours. Medication for Resident 89 was Benadryl 50 mg scheduled to be administered at 1300 hours. Medications for Resident 123 were Nicotine gum 4 mg scheduled to be administered at 12 hours and Keflex 500 mg scheduled to be administered at 12 hours. The medication for Resident 53 was vitamin D3 scheduled to be administered at 12 hours, and for Resident 138 was lorazepam scheduled to be administered at 12 hours. LPT 1 and LVN 1 were informed the observation time for pre-pouring the medications was more than 2 hours before the medications were administered. LVN 1 and LPT 1 verified all the medications from Medication Tray 2 were administered by LVN 2, but LVN 1 and LPT 1 pre-poured and prepared the medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure three pots used to prepare food for the residents were maintained in safe condition. This had the potential for all parts of foods not...
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Based on observation and interview, the facility failed to ensure three pots used to prepare food for the residents were maintained in safe condition. This had the potential for all parts of foods not being evenly cooked.
Findings:
Review of the facility's CMS 672 Resident Census and Conditions of Residents showed 126 of 132 residents received meals prepared in the kitchen.
On 9/16/19 at 0810 hours, a concurrent observation and interview of the facility's kitchen was conducted with the DSS. Three six-quart pots were observed next to the facility's stove. The bottom surface of the three pots were observed to be bowed, making them set unevenly on the stove top. The DSS verified the findings.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
Based on interview and facility document review, the facility failed to provide one of 26 final sampled residents (Resident 108) and two nonsampled residents (Residents 119 and 540) with the Notice of...
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Based on interview and facility document review, the facility failed to provide one of 26 final sampled residents (Resident 108) and two nonsampled residents (Residents 119 and 540) with the Notice of Medicare Non-Coverage (NOMNC) Form CMS 10123. The NOMNC form informs beneficiaries when the facility has determined their Medicare covered services are ending and notifies them of their right to appeal. This failure had the potential of not allowing the residents to make an informed decision regarding their Medicare services.
Findings:
Review of the current guidelines for the CMS instructions for the NOMNC letters of notice showed, .The NOMNC must be delivered at least two calendar days before Medicare covered services end .The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice .
Refer to https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Instructions-for-Notice-of-Medicare-Non-Coverage-NOMNC.pdf.
a. Review of the CMS Form 20052 SNF Beneficiary Protection Notification Review (BPNR) for Resident 108 showed Medicare part A skilled services episode started on 7/20/19, and the last covered day was 8/31/19. Review of the BPNR failed to show Resident 108 was provided with a NOMNC form.
b. Review of the BPNR for Resident 119 showed Medicare part A skilled services started on 7/25/19, and the last covered day was 8/9/19. Review of the BPNR document failed to show Resident 119 was provided with a NOMNC form.
c. Review of the BPNR for Resident 540 showed Medicare part A skilled services started on 5/9/19, and the last covered day was 5/23/19. Review of the BPNR document failed to show Resident 540 was provided with a NOMNC form.
On 9/24/19 at 0953 hours, an interview and concurrent facility document review was conducted with the Bookkeeper. The Bookkeeper was asked to review the BPNR forms for Residents 108, 119, and 540. The Bookkeeper stated the residents received a SNF Advance Beneficiary Notice of Non-coverage (SNFABN) form; however, Residents 108, 119, and 540 were not provided with a NOMNC form. The Bookkeeper stated she was not aware she needed to provide the residents with the NOMNC form.
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the MDSs for discharge were completed and transmitte...
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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 MDSs for discharge were completed and transmitted to CMS for two of five closed record sampled residents (Residents 2 and 3). This failure had the potential to affect the provision of care or services for the residents.
Findings:
1. Review of Resident 2's closed medical record showed Resident 2 was admitted to the facility on [DATE], and was discharged from the facility on 6/25/19.
Review of Resident 2's discharge MDS with signatures dated 6/25/19, showed MDS in Progress. The section addressing Discharge Status was not completed and the MDS was not submitted.
On 9/18/19 at 1506 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 was asked to review the MDS for Resident 2. LVN 5 stated Resident 2 was discharged from the facility on 6/25/19. LVN 5 stated the MDS assessment for discharge was incomplete and never transmitted to CMS. LVN 5 verified the assessment was 71 days overdue.
2. Review of Resident 3's closed medical record showed Resident 3 was admitted to the facility on [DATE], and was discharged from the facility on 5/24/19.
Review of Resident 3's discharge MDS failed to show signatures and a date it was completed. The MDS showed MDS in Progress. The section addressing Discharge Status was not completed and the MDS was not submitted.
On 9/18/19 at 1506 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 was asked to review the MDS for Resident 3. LVN 5 stated Resident 3 was discharged from the facility on 5/24/19. LVN 5 stated the MDS for discharge was missing signatures required for completion and was not transmitted to CMS. LVN 5 verified the assessment was 103 days overdue.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (80/100). Above average facility, better than most options in California.
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
- • 32% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Beach Creek Post-Acute's CMS Rating?
CMS assigns BEACH CREEK POST-ACUTE an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Beach Creek Post-Acute Staffed?
CMS rates BEACH CREEK POST-ACUTE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 32%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Beach Creek Post-Acute?
State health inspectors documented 40 deficiencies at BEACH CREEK POST-ACUTE during 2019 to 2025. These included: 34 with potential for harm and 6 minor or isolated issues.
Who Owns and Operates Beach Creek Post-Acute?
BEACH CREEK POST-ACUTE 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 LINKS HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 138 certified beds and approximately 130 residents (about 94% occupancy), it is a mid-sized facility located in ANAHEIM, California.
How Does Beach Creek Post-Acute Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, BEACH CREEK POST-ACUTE's overall rating (5 stars) is above the state average of 3.2, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Beach Creek Post-Acute?
Based on this facility's data, families visiting should ask: "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?"
Is Beach Creek Post-Acute Safe?
Based on CMS inspection data, BEACH CREEK POST-ACUTE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Beach Creek Post-Acute Stick Around?
BEACH CREEK POST-ACUTE has a staff turnover rate of 32%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Beach Creek Post-Acute Ever Fined?
BEACH CREEK POST-ACUTE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Beach Creek Post-Acute on Any Federal Watch List?
BEACH CREEK POST-ACUTE 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.