What is ARVIN POST ACUTE's CMS rating?

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

Does ARVIN POST ACUTE have any serious inspection findings?

Yes, ARVIN POST ACUTE has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 53 total deficiencies from recent inspections.

What are the staffing levels at ARVIN POST ACUTE?

ARVIN POST ACUTE has a two-star staffing rating from CMS with 0.27 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is ARVIN POST ACUTE located?

ARVIN POST ACUTE is located in ARVIN, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ARVIN POST ACUTE have?

ARVIN POST ACUTE has 81 certified beds.

Who owns ARVIN POST ACUTE?

ARVIN POST ACUTE is a for profit - corporation facility and is part of the PACS GROUP chain.

Is ARVIN POST ACUTE safe?

ARVIN POST ACUTE has documented safety concerns including 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Do nurses at ARVIN POST ACUTE stick around?

ARVIN POST ACUTE has average staff turnover at 40%, which is typical for the nursing home industry.

Was ARVIN POST ACUTE ever fined?

Yes, ARVIN POST ACUTE has been fined $77,675 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is ARVIN POST ACUTE on any federal watch list?

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

What have inspectors found at ARVIN POST ACUTE?

Medicare inspectors have found 53 deficiencies at ARVIN POST ACUTE: 1 critical, 2 serious, 50 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting ARVIN POST ACUTE?

Families visiting ARVIN POST ACUTE should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does ARVIN POST ACUTE compare to other nursing homes?

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

ARVIN POST ACUTE | 8/100 (Grade F)

Jun 2025 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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on abuse, neglect, exploitation or misappropriation reporting and investigating when: 1. The facili...

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Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on abuse, neglect, exploitation or misappropriation reporting and investigating when: 1. The facility did not complete a follow-up investigation report (FIR) after a resident-to-resident altercation (RRA) within five days for two of seven sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to have another altercation, and to develop distress and injuries. 2. The facility did not report an allegation of financial abuse to California Department of Public Health (CDPH) within 24 hours of an allegation for one of seven sampled residents (Resident 3). This failure had the potential for emotional distress for Resident 3. Findings: 1. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation), dated 5/20/25, the SBAR indicated, Resident (1) states he woke up and saw (Resident 2) sitting on the end of the bed, (Resident 2) grabbed (Resident 1's) pillow from behind his head and starting to hit him with the pillow multiple times, then (Resident 2) proceeded to go around the bed, grabbed the water pitcher threatening to hit (Resident 1). During a review of Resident 2's Brief Interview for Mental Status (BIMS), dated 5/16/25, the BIMS indicated Resident 2 had a score of 3 (score 0-7 indicates severe cognitive impairment). During a review of Resident 1's BIMS, dated 5/17/25, the BIMS indicated Resident 1 had a score of 15 (score of 13-15 indicates cognitively intact). During an interview on 6/4/25 at 12:48 p.m. with Resident 1, Resident 1 stated Resident 2 went to his room while he was asleep and hit him with a pillow. During a concurrent interview and record review on 6/4/25 at 2:55 p.m. with the Administrator, the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022 was reviewed. The P&P indicated, Findings of all investigations are documented and reported. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The Administrator stated he did not complete the FIR after Resident 1 and Resident 2's RRA on 5/20/25 and the P&P was not followed. The Administrator stated the FIR should have been submitted to CDPH by 5/25/25. 2. During a review of the SOC-341 (Report of Suspected Dependent Adult/Elder Abuse), dated 6/2/25, the SOC-341 indicated, REPORTED TYPES OF ABUSE. Financial. On 5/15 (Family Member [FM] 1) contacted Social Services via phone call. She stated she was worried about paperwork that was signed by (Resident 3). (FM 2) had brought in paperwork and had (Resident 3) sign without notifying any family. On the same day Social Services went to talk to (Resident 3). (Resident 3) was asked what paperwork she signed and she stated (FM 2) had her sign financial paperwork so he is able to help pay her bills. (Resident 3) did not know much about the paperwork. (Resident 3) stated if she needs to she will get authorities involved. On 6/2/25 Social Services talked to (FM 2) via phone call. (FM 2) stated (Resident 3) did sign POA (Power of Attorney - legal document that grants one person the authority to act on behalf of another person) paperwork. (FM 1) does not want (FM 2) to have any authority over (Resident 3) . Other neighbors have told (FM 1) they do not trust (FM 2) and he may have ill intention. During a review of Resident 3's admission Record (AR), dated 6/4/25, the AR indicated FM 1 was Resident 3's Responsible Party (RP). During a review of Resident 3's BIMS, dated 3/5/25, the BIMS indicated Resident 3 had a score of 13 (score of 13-15 indicates cognitively intact). During an interview on 6/4/25 at 1:11 p.m. with Resident 3, Resident 3 stated FM 1 was her granddaughter and FM 2 was her neighbor. Resident 3 stated she may have given FM 2 the POA after she signed a paperwork he brought. Resident 3 stated she was not sure what the paperwork was about. Resident 3 stated the inheritance should go to FM 1 and that the POA for FM 2 needed to be revoked. During a concurrent interview and record review on 6/4/25 at 2:55 p.m. with the Administrator, Resident 3's Communication Note (CN), dated 5/15/25 was reviewed. The CN indicated FM 1 told the facility she did not agree with FM 2 managing Resident 3's finances and requested to be informed if Resident 3 was asked to sign any further documents. The Administrator stated since FM 1 raised the concern about Resident 3's finances, she maybe is also trying to get Resident 3's assets. The Administrator stated the facility should have notified the California Department of Public Health (CDPH) about the allegation of financial abuse by 5/16/25. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, the P&P indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. 'immediately' is defined as. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Apr 2025 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) responsible party (RP) was notified of a change of condition (COC). This failure had the...

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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) responsible party (RP) was notified of a change of condition (COC). This failure had the potential for Resident 2's RP not to be aware of Resident 2's COC. Findings: During a concurrent interview and record review, on 4/23/25 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's Change in Condition, (COC) dated 4/9/25 was reviewed. The COC indicated Resident 2 had a witnessed fall. Resident 2's admission Record, (AR) indicated Resident 2 had RP. Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 1/31/25 was reviewed. The MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 6 (a score of 0-7 points severely impaired cognition). LVN 1 reviewed Resident 2's progress notes and confirmed no RP notification was documented. LVN 1 stated Resident 2's RP should have been notified regarding Resident 2's fall on 4/9/25. During a review of the facility's policy and procedure (P&P) titled, Change of Resident's Condition or Status, revised February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental conditions or status.

Dec 2024 16 deficiencies 1 IJ (1 facility-wide)

CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Food Safety (Tag F0812)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sanitary condition in the kitchen with kno...

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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 sanitary condition in the kitchen with known infestation of cockroaches as evidenced by: 1. On 12/17/24 and 12/18/24 observed live cockroaches in the kitchen identified as German Cockroaches by the pest control service technician. 2. The kitchen staff do not clean and sanitize the kitchen counters prior to food preparation with known cockroach infestation. This involved nocturnal behavior of cockroaches which are highly likely to be contaminating food contact surfaces during the night. 3. In addition, cockroaches carry germs that can contaminate and had the potential to lead to foodborne illness for highly susceptible residents receiving food from the kitchen. 4. Failed to maintain an effective Pest Control Program. These failures had the potential to place 70 of 72 highly susceptible residents at risk for food borne illnesses in the facility infested with multi-generational German cockroaches which are known to spread 33 kinds of bacteria, six kinds of parasitic worms as well as other kind of human diseases. On 12/18/24 at 11:54 AM, an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has cause, or it is likely to cause, serious injury, harm, impairment, or death to a resident) under Federal tag 812 was declared with the Administrator, Administrator for Bakersfield Post Acute, Director of Nursing (DON), and Nursing Consultant regarding the following identified concerns: 1. On 12/17/24 and 12/18/24 observed live cockroaches in the kitchen identified as German Cockroaches by the pest control service technician. 2. The kitchen staff do not clean and sanitize the kitchen counters prior to food preparation with known cockroach infestation. This involved nocturnal behavior of cockroaches which are highly likely to be contaminating food contact surfaces during the night. 3. In addition, cockroaches carry germs that can contaminate and had the potential to lead to foodborne illness for highly susceptible residents receiving food from the kitchen. 4. Failed to maintain an effective Pest Control Program. These failures had the potential to place 70 of 72 highly susceptible residents at risk for food-borne illnesses in the facility infested with multi-generational cockroaches. On 12/19/24 at 6:12 PM, the California Department of Public Health (CDPH) notified the Administrator, Administrator for Bakersfield Post Acute, DON, Nursing Consultant, and Registered Dietician (RD), the IJ was abated after verifying and confirming on-site the facility had implemented an acceptable written plan of correction. Findings: During a concurrent observation and interview on 12/16/24 at 8:15 a.m. with Dietary Manager (DM) in the kitchen, there were nine dead cockroaches in a floor drain above the sink where food was prepared. DM stated, those are bugs [dead cockroaches in the drain]. During an interview on 12/16/24 at 8:16 a.m. with DM, DM stated she had seen ants, pincher bugs, and cockroaches in the kitchen. DM stated she noticed them (ants, pincher bugs, and cockroaches) during the renovation of the kitchen approximately March 2024. During an observation on 12/17/24 a.m. at 11:19 a.m. in the kitchen, there was peeling paint and a hole under the skink near the dish washer. During a concurrent observation and interview on 12/17/24 at 11:20 a.m. with DM, in the staff bathroom, there was a hole in the staff bathroom. DM stated there was a leak in the ceiling of the staff bathroom in the kitchen in September 2024. DM stated the Maintenance Director (MD) was aware of the hole and was supposed to fix it but did not make the kitchen department a priority. DM stated she had put in a maintenance request to the maintenance department about the peeling paint and the hole on the ceiling of the staff bathroom in the kitchen. During a review of the facility's KERN COUNTY PUBLIC HEALTH SAFE DINER-Inspection Violations Report (KCPHSDIVR) dated 5/24/24, the KCPHSDIVR indicated, OBSERVED A HOLE IN THE CEILING IN THE RESTROOM LOCATED IN KITCHEN DIE [SIC] TO A WATER LEAK. PLEASE REPAIR TO PREVENT VERMIN INFESTATION. During an observation on 12/17/24 at 11:25 a.m. in the kitchen, there was a live cockroach crawling on the wall above the dishwasher. During an interview on 12/17/24 at 11:26 a.m. with Dietary Aide (DA) 1, DA 1 stated that looks like a cockroach. DA 1 stepped on it and killed the live cockroach. DA 1 stated, I've only been seeing pests since the facility's renovation. During a concurrent observation and interview on 12/17/24 at 11:28 a.m. with Administrator, in the kitchen, Administrator stated he was aware of the hole in the kitchen staff bathroom and the hole on the wall under the sink in the kitchen. Administrator stated they have Pest Control Company come every month. Administrator stated the holes were entrance for pests to come into the kitchen. Administrator saw a cockroach crawling on top of the counter near the dishwashing machine and a small brown cockroach crawling on the wall above the handwashing sink. During an interview on 12/17/24 at 2:44 p.m. with DA (2), DA 2 stated he had seen two cockroaches in the kitchen near the dish washer floor today. During an observation on 12/18/24 at 8:34 a.m. in the kitchen staff bathroom, the hole on the ceiling got bigger. During an observation on 12/18/24 at 8:42 a.m. in the kitchen, was a glue trap with one dead cockroach under the sink of the food preparation counter. During an observation on12/18/24 at 8:43 a.m. in the kitchen, a cabinet lined with a silicone-type material where assortment of food utensils was stored, there was one small dead cockroach under the lining. During an observation on 12/18/24 at 8:44 a.m. in the kitchen, across the counter where food preparation is done, there was a hole in a pipe connected to the sink used for cleaning. During an interview on 12/18/24 at 8:45 a.m. with DM, DM stated, I saw live roaches [cockroaches] yesterday crawling from the ceiling down to the bulletin board. The bulletin board was hanging on the wall by the entrance wall in the kitchen. DM stated pest control did the treatment last week due to ''live roaches[cockroaches]. DM stated, they were dark brown, little ones. DM stated she saw 2-4 live roaches[cockroaches], little one's crawling. DM stated she saw bigger in size, dark brown in color yesterday. DM stated she saw more roaches (cockroaches) on Monday (12/16/24) morning. DM stated she came to the dining room; she saw more dead cockroaches. DM stated sometime in November, I saw live roaches (cockroaches) little ones, in the dish area. DM stated, I mentioned to the Administrator and Maintenance about the live and dead roaches in the kitchen every week. I gave verbal report during the stand-up meeting. During an observation on 12/18/24 at 8:47 a.m. in the kitchen behind the oven, there was one glue trap with one tiny (unable to determine size) dead cockroach and one live, dark brown cockroach. During an interview on 12/18/24 at 8:57 a.m. with Cook, [NAME] stated she came in to work at 4:30 a.m. today. When she turned the light on, she saw one live small cockroach as she opened the door. [NAME] stated, I have noticed cockroaches the first two days I've worked. [NAME] stated alive small black and small brown cockroaches. [NAME] stated in the cabinet under the food preparation counter she saw a live cockroach in the morning, last week. During an observation on 12/18/24 at 8:59 a.m. at the kitchen sink beverage station, there was a large hole in the wall near the sink drainage under the sink. There was a dead cockroach under the kitchen beverage sink. During a concurrent observation and interview on 12/18/24 at 9 a.m. with DA 3 in the Janitorial Closet, there was one live medium dark brown cockroach, one dead medium brown cockroach in the hole near mop sink, two cockroach carcasses on the mop sink, one dead cockroach medium brown behind the janitorial door. DA 3 stated she saw a live roach on the preparation counter last weekend on 12/14/24 and 12/15/24 around 5:45 a.m. and she saw dead roaches in the janitorial room last month. During an observation on 12/18/24 at 9:05 a.m. in the kitchen, there was one small live brown cockroach crawling on the ceiling above the dishwasher sink. During an observation on 12/18/24 at 9:07 a.m. in the kitchen, there was a glue trap with five dead medium dark brown cockroaches behind a rack with plate covers. During an observation on 12/18/24 at 9:09 a.m. in the kitchen, there was a mesh-like metal material on the hole with a small dead cockroach under the sink near the dishwasher. During an interview on 12/18/24 at 9:10 a.m. with DA 1, DA 1 stated she saw roaches, one alive and two dead five days ago around the area where staff wash the dishes and saw three dark brown live roaches in the kitchen dishwashing area. During an observation on 12/18/24 at 9:11 a.m. in the kitchen, there was a leaking water pipe connected to the dishwasher found underneath the dishwashing counter. During an observation on 12/18/24 at 9:13 a.m. in the dry storage room, there was a glue trap behind the refrigerator with 7 small brown dead cockroaches and one small dead cockroach on the floor. During a concurrent observation and interview on 12/18/24 at 9:35 a.m. with Activities Assistant (AA) in the dining room, there was two dead roaches on the floor. AA stated she saw one small, brown, dead roach in the dining floor. During an interview on 12/18/24 at 9:38 a.m. with Housekeeper (HK), HK stated she saw roaches in the dining room, some dead, some alive last week. During an observation on 12/18/24 at 9:40 a.m. in the dining room, there was 10 dead cockroaches in a cabinet under the sink. During an interview on 12/18/2024 at 9:50 a.m. with Environmental Specialist (ES), ES stated because of the different sizes of roaches described, the facility has a problem with multi-generational infestation. During the day, so many of them in hiding places to scavenge for food. ES stated even if they (facility) had sprayed they still have live infestation of roaches. During a concurrent observation and interview on 12/18/24 at 9:58 a.m. with DM in the dry storage room, a live brown cockroach was inside a bin which contained sponges. DM stated that is a live cockroach and killed it with a sponge. There was a dead tiny cockroach in a bin with approximately a dozen scoopers. There was a live small cockroach crawling into a silver rectangular tin box, one dead cockroach under a rack with pitchers, and a small dead cockroach under an empty rack. During an interview on 12/18/24 at 10:30 a.m. with Pest Control Company Owner (PCCO), PCCO stated he was aware of the situation. PCCO stated he went out at night and made a thorough inspection of the kitchen on Wednesday [12/11/24]. PCCO stated he found infestation of German Cockroaches. On 12/18/24 at 11:54 AM, an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has cause, or it is likely to cause, serious injury, harm, impairment, or death to a resident) under Federal tag 812 was declared with the Administrator, Administrator for Bakersfield Post Acute, Director of Nursing (DON), and Nursing Consultant regarding the following identified concerns: 1. On 12/17/24 and 12/18/24 observed live cockroaches in the kitchen identified as German Cockroaches by the pest control service technician. 2. The kitchen staff do not clean and sanitize the kitchen counters prior to food preparation with known cockroach infestation. This involved nocturnal behavior of cockroaches which are highly likely to be contaminating food contact surfaces during the night. 3. In addition, cockroaches carry germs that can contaminate and had the potential to lead to foodborne illness for highly susceptible residents receiving food from the kitchen. 4. Failed to maintain an effective Pest Control Program. These failures had the potential to place 70 of 72 highly susceptible residents at risk for food-borne illnesses in the facility infested with multi-generational cockroaches. During an interview on 12/19/24 at 2:01 p.m. with Infection Preventionist Nurse Consultant (IPNC), IPNC stated kitchen staff does not have a designated kitchen sanitation schedule or kitchen sanitation log. According to Dr. [NAME], an advisor for the National Pest Management Association, German cockroaches can spread 33 kinds of bacteria, six kinds of parasitic worms, as well as other kind of human diseases. Https://www.pestworld.org/news-hub/pest-articles/german-cockroaches-101/#:~:text=These%20germs%20are%20then%20transferred,least%20seven%20other%20human%20pathogens. Accessed 12.26.24 On 12/19/24 at 6:12 PM, the California Department of Public Health (CDPH) notified the Administrator, Administrator for Bakersfield Post Acute, DON, Nursing Consultant, and Registered Dietician (RD), the IJ was abated after verifying and confirming on-site the facility had implemented an acceptable written plan of correction. During a review of the facility's Pest Control Invoice (PCI), dated 12/3/24, the PCI indicated, INSPECTION FOR GERMAN ROACHES. During a review of the facility's PCI, dated 12/9/24, the PCI indicated, SERVICE FOR ROACHES IN THE KITCHEN. During a review of the facility's MAINTANENCE REQUEST (MR), dated 12/18/24, the MR request by DM, Pipe (black) from garbage disposal leaking. During a review of the facility's policy and procedure (P&P) titled, GENERAL CLEANING OF FOOD & NUTRITION SERVICES DEPARTMENT, dated 2023, the P&P indicated, Drains.1. FNS staff should remove large debris as it accumulates and are encouraged to clean drains weekly. During a review of the facility's P&P titled, WALLS, CEILINGS, AND LIGHT FIXTURES, dated 2023, the P&P indicated, Walls and ceilings must be free of chipped and/or peeling paint. During a review of the facility's P&P titled, JANITOR'S CLOSET, dated 2023, the P&P indicated, The janitor's closet must be kept clean and orderly. 4. Cleaning of the janitor's closet must be done on a scheduled routine. During a review of the facility's P&P titled, SANITATION, dated 2023, the P&P indicated, 1.The FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. 11. All utensils, counters, shelves, and equipment shall be kept clean .

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to: 1. Ensure the physician provided the informed consent (the process in which a health care professional educates a patient about the risks,...

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Based on interview and record review, the facility failed to: 1. Ensure the physician provided the informed consent (the process in which a health care professional educates a patient about the risks, benefits, and alternatives of a given procedure or medication) on the use of antipsychotic (drugs that treat psychosis [mental distress, mental disorder] and related conditions and symptoms) medication for one of one sampled resident (Resident 43) prior to the verbal consent obtained from Resident 43's representative. This failure had the potential for the resident and/or the resident representative to not receive the appropriate information regarding the drug, its indication, side-effects, and make the right decision. 2. Ensure licensed personnel witness and validate the verbal consent received from the resident representative for one of one resident (Resident 43) and sign the informed consent form to validate the consent and the material information provided. This failure had the potential for the informed consent to be dismissed. Findings: 1. During a concurrent interview and record review, on 12/18/24 at 2:28 p.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC), Resident 43's Informed Consent -Psychoactive Medication (ICPM), dated 9/23/24, was reviewed. The ICPM indicated, Remeron (medication to treat depression) 15 milligrams (mg) one tablet by mouth at bedtime for depression. MDSC stated verbal consent was obtained from Resident 43's representative on 9/23/24. MDSC stated the physician (MD) 1 signed the ICPM on 9/26/24. MDSC stated the ICPM form was signed prior to the physician providing the informed consent. MDSC stated the doctor signed the ICPM after the verbal consent was obtained. During a concurrent interview and record review, on 12/18/24 at 2:48 p.m. with MDSC, Resident 43's ICPM, dated 4/19/24, was reviewed. The ICPM indicated, Temazepam (sedative [slows down brain activity] and medication to treat insomnia [difficulty falling asleep or staying asleep]) 15 mg one tablet PO (oral) every hs (at bedtime). MDSC stated verbal consent was obtained from the resident's representative on 4/17/24. MDSC stated MD 1 signed the ICPM on 4/19/24. MDSC stated the resident's representative did not receive the informed consent from the physician who prescribed the medication at the time the verbal consent was obtained. MDSC stated the doctor signed the ICPM after the verbal consent was obtained. 2. During a concurrent interview and record review on 12/18/24 at 2:50 p.m. with MDSC, Resident 43's ICPM form for Remeron, dated 9/26/24, was reviewed. The ICPM form did not indicate the licensed nurse signed the ICPM form to verify informed consent was obtained and that the required material information had been provided for the use of Remeron. MDSC stated there was no nurse signature on the form. During a concurrent interview and record review on 12/18/24 at 2:55 p.m. with MDSC, Resident 43's ICPM form for Temazepam, dated 4/19/24, was reviewed. The ICPM form did not indicate the licensed nurse signed the ICPM form to verify informed consent was obtained and that the required material information had been provided for the use of Temazepam. MDSC stated there was no nurse signature on the form. During a review of the facility's policy and procedure (P&P) titled, Psychoactive/Psychotropic Medication Use, [undated], the P&P indicated, 3. Informed Consent: a. Examination and Signature: iii. Prior to administration of a Psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative), and document the consent in the medical record. iv. A licensed nurse must verify informed consent has been obtained from the resident or the resident's representative prior to administering psychotropic medication. v. A licensed nurse must also sign the consent form, declaring that the required material information has been provided.

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure confidentiality of Private Health Information (PHI) was maintained for two of two sampled residents (Resident 25 and Resident 58). T...

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Based on interview and record review, the facility failed to ensure confidentiality of Private Health Information (PHI) was maintained for two of two sampled residents (Resident 25 and Resident 58). This failure resulted in Resident 25 and Resident 58's PHI being compromised and seen by unauthorized personnel. Findings: During a review of Resident 25's Clinical Record (CR), The CR contained Resident 58's clinical note titled, Skilled Nursing Progress Note (SNPN), dated 10/18/24. During a concurrent interview and record review on 12/17/24 at 9:53 a.m. with Medical Records Clerk (DMR), Resident 25's CR was reviewed. DMR stated, Resident 58's SNPN was in Resident 25's CR. DMR stated that was the incorrect clinical record. During a review of Resident 58's admission Agreement (AA), dated 6/21/24, the AA indicated, Resident 58 agreed that she read and understood Resident [NAME] of Rights Section (e) Privacy and confidentiality indicating the resident has the right to personal privacy and confidentiality of his or her personal and clinical records and Section X. Confidentiality of Your Medical Information stating You have a right to confidential treatment of your medical information. During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, dated July 2017, the P&P indicated, 5. Information documented in the resident's clinical record is confidential and may only be released in accordance with state law, the Health Insurance Portability and Accountability Act (HIPAA) and facility policy. During a review of the facility's P&P titled, Protected Health Information (PHI), Management and Protection of. The P&P indicated, 1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release of disclosure.

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** During an interview on 12/18/24 at 3:20 p.m. with CNA 3, CNA 3 stated the resident had some clothing in the closet, but since th...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 12/18/24 at 3:20 p.m. with CNA 3, CNA 3 stated the resident had some clothing in the closet, but since the remodel of the residents' room his [Resident 21] clothing had not been in the closet. During a concurrent observation and interview on 12/18/24 at 3:23 p.m. with Resident 21, Resident 21 stated he had two flannel shirts (Resident does not remember the color), and two pairs of jeans in his room's closet at one time and when the facility remodeled his room the items of clothing were lost or misplaced. There were no items of clothing found in the closet for Resident 21. During an interview on 12/18/24 at 3:37 p.m. with Treatment Nurse (TN) outside Resident 21's room. TN stated she was not aware of the residents' missing items of clothing. During a concurrent interview and record review with Resident 21, Resident 21 reviewed his signed Personal Belonging Inventory (PBI) sheet dated 11/6/24. The personal belonging inventory sheet indicated Resident 21 owed the following personal items of clothing. 1. Boxer (underwear) 2. Two long sleeve shirts 3. One pair jean During a review of the facility policy and procedure (P&P), titled, Personal Property, dated 2001, indicated, Policy Statement Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of other resident . 2. Resident belongings are treated with respect by facility staff, regardless of perceived value . 3. Residents are encouraged to use personal belongings to maintain a homelike environment and foster independence . Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Personal Property, for two of two sampled residents (Resident 30 and Resident 21) when: 1. Resident 30's belongings were not inventoried and documented on admission. 2. Resident 21's clothing went missing in the facility. These failures had the potential to negatively affect the resident's psychosocial well-being and had the potential to result in lack of reimbursement for lost belongings. Findings: During an interview on 12/16/24 at 3 p.m. with Resident 30, Resident 30 stated he had four pairs of underwear when he was admitted to the facility, and he had two left. Resident 30 stated he reported it to a Certified Nursing Assistant (CNA) few days ago and the CNA looked for them in the laundry and did not find them. During a review of Resident 30's admission Record (AR), dated 11/27/24, the AR indicated Resident 30 was readmitted to the facility on [DATE]. During a concurrent interview and record review on 12/18/24 at 3:12 p.m. with the Social Services Director (SSD), Resident 30's Personal Belonging Inventory (PBI), dated 11/1/24 was reviewed. SSD was unable to provide a personal belonging inventory on Resident 30's readmission date 11/27/2024. During a review of the facility's P&P titled, Personal Property, dated 8/2022, the P&P indicated, 10. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Baseline Care Plan (BCP- outlines a process for developmen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Baseline Care Plan (BCP- outlines a process for development of an initial person-centered care plan within the first 48 hours of admission, that will provide instructions for care of the resident) was completed for one of one sampled resident (Resident 12) within 48-hours of admission and a summary provided to the resident and/or resident representative. This failure had the potential for Resident 12 to not receive the care and the safeguards necessary within the 48-hour of admission. Findings: During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted on [DATE] with diagnosis including, Diabetes Mellitus (blood sugar is too high) with diabetic neuropathy (nerve damage that is caused by diabetes), End-Stage Renal Disease (ESRD- final, permanent stage of chronic kidney disease). During a concurrent interview and record review on 12/18/24 at 1:58 p.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC), Resident 12's BCP, dated 8/16/24, was reviewed. The BCP Summary indicated, the BCP Summary was incomplete. MDSC stated the BCP Summary was not provided to Resident 12 and his representative. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, [undated], the P&P indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .4. The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/ representative can understand) .5. Provision of the summary to the resident and/or resident representative is documented in the medical record.

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

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for personal grooming, including care of the fingernails for one of one sam...

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Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for personal grooming, including care of the fingernails for one of one sampled resident (Resident 12). This failure had the potential for unmet care needs. Findings: During a concurrent observation and interview on 12/16/24 at 2:50 p.m. with Licensed Vocational Nurse (LVN) 2 in Resident 12's room, Resident 12 was seated in his wheelchair. Noticed Resident 12's hands were dry. The left-hand fingernails were long and inside the nailbeds were blackish substance. The 5th and 4th fingernails were long, and the nailbeds were black in color. LVN 2 stated Resident 12's fingernails were long and needed trimming. During a concurrent observation and interview on 12/17/24 at 8:50 a.m. with Treatment Nurse (TN) and Resident 12 in Resident 12's room, Resident 12's fingernails remained long and nailbeds black in color. TN stated Resident 12's fingernails have dirt inside the fingernails. TN stated Resident 12's fingernails were long on the left hand; the right hand had some fingernails trimmed on the 3rd and 2nd fingers. TN stated Resident 12 has avulsion (a severe injury where a body structure is torn off by trauma or surgery) on the right thumbnail. Resident 12 stated, I lost my nail. TN measured Resident 12's fingernails. The following were the fingernails measurement: Left Hand Left thumbnail. Length: 1.5 cm Width: 1.5 cm Depth (thickness): 0.1 cm Left Index: L: 1.4 cm W: 1.3 cm D: 0.1 cm Left Middle finger: L: 1.5 cm W: 1.4 cm D: 0.1 cm Left 4th finger: 1.5 cm W: 1.3 cm D: 0.1 cm Left 5th finger: L:1.3 cm W:1 cm D:0.1 cm Right Hand R Thumbnail: L: 0. cm W: 1.2 cm D: 0.2 cm Right Index: L: 1 cm W: 1.2 cm D:0.1 cm Right Middle finger: L: 1.2 cm W: 1.3 cm D: 0.1 cm Right 4the finger: L: 1.2 cm W:1.2 cm D: 0.1 cm Right 5th finger: L: 1.5 cm W:1 cm D: 0.1 cm During a concurrent interview and record review on 12/18/22 at 2:02 p.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC), MDSC was unable to find documentation of a care plan developed for personal grooming, including fingernails. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, [undated], the P&P indicated, The purpose of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nailbeds. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, [undated], the P&P indicated, 7. The comprehensive person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to revise a care plan after a change of status for Hospice (end of life care) services for one of two sampled residents (Resident 25). This fa...

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Based on interview and record review, the facility failed to revise a care plan after a change of status for Hospice (end of life care) services for one of two sampled residents (Resident 25). This failure had the potential for Resident 25 to receive Hospice services when no longer needed. Findings: During a record review of Resident 25's Order Summary Report (OSR), dated November 2024, the OSR indicated, Resident is discharged from [Name of Hospice Company] as of 11/15/24 due to extended prognosis. During a record review of Resident 25's Nursing-Weekly Summary (NWS), dated 12/15/24, the NWS indicated, Currently under hospice care. During a review of Resident 25's End of Life: Care Plans (ELCP), dated 11/15/24, the ELCP indicated, Resident requires Hospice care and is at risk for rapid decline in activities of daily living, sudden onset or worsening skin integrity, weight loss, nausea/vomiting, pain, abnormal breathing, impaired psychosocial wellbeing related to terminal illness. During a concurrent observation and interview on 12/17/24 at 8:19 a.m. with Administrator in Resident 25's room, resident was asleep and resting. Administrator stated, [Resident 25] was in Hospice, but now she is not. During a concurrent interview and record review on 12/17/24 at 8:38 a.m. with Director of Nursing (DON), Resident 25's OSR and ELCP were reviewed. DON stated, Resident 25's ELCP should have been revised to indicate Resident 25 is no longer receiving hospice care. During a concurrent interview and record review on 12/18/24 at 2:15 p.m. with Nursing Consultant (NC) 1, Resident 25's OSR and ELCP were reviewed. NC 1 stated, Resident 25's ELCP should have been revised to indicate Resident 25 is no longer receiving hospice care. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition.

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

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 ensure oral care was rendered for one of one sampled ...

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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 ensure oral care was rendered for one of one sampled resident (Resident 33) to maintain oral hygiene. This failure had the potential for Resident 33 to acquire oral infections, tooth decay, or gum disease. Findings: During a review of Resident 33's admission Record (AR), the AR indicated Resident 33 was admitted on [DATE] with diagnosis including Hemiplegia (complete paralysis) and Hemiparesis (weakness on one side) following cerebral infarction (stroke-[bleeding in the brain]). During a concurrent observation and interview on 12/16/24 at 9:46 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 33's room, Resident 33 was awake sitting in his bed. Resident 33 had weakness on the right side of the body. LVN 2 stated Resident 33 is paralyzed on the right side. Resident 33 was slow in communicating but able to respond to questions. Resident 33's mouth was dry and teeth yellowish in color. Resident 33 stated no one brushes his teeth before or after eating. Resident 33 stated, I do not remember when they [staff] brushed my teeth. LVN 2 stated the resident's toothbrush and toothpaste are stored in the resident's bedside table. LVN 2 opened Resident 33's bedside table and did not find a toothbrush for Resident 33 inside the bedside table. LVN 2 found toothpaste tube that had not been used in a kidney basin (a shallow, kidney-shaped bowl). During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 3/2018, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal, and oral hygiene.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to implement person center quality care for one of one sampled resident (Resident 10) when Resident 10's fingernails were not tr...

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Based on observation, interview, and record review, the facility failed to implement person center quality care for one of one sampled resident (Resident 10) when Resident 10's fingernails were not trimmed, hand splint was not applied and, physician's order for surgical consultant was not procesed. This failure resulted in delayed care for Resident 10 and had the potential for adverse outcomes. Findings: During an observation on 12/16/24 at 10 a.m. in Resident 10's room, Resident 10's left hand was contracted (abnormal bend of the joint) where her middle three fingers were folded in toward her palm. Resident 10's fingernails on her left hand were long, thick, and curled over going into the skin of her left palm. Resident 10 did not have any type of splint on her left arm/hand. During a concurrent observation and interview on 12/18/24 at 10:21 a.m. with Licensed Vocational Nurse (LVN) 3 in Resident 10's room, Resident 10's left hand was observed. LVN 3 stated, I do not know if Resident 10 is supposed to have a hand splint on her left hand or not. I have worked the last three days and have not seen Resident 10 wear a hand splint. Staff clipped Resident 10's nails yesterday but it does not look like the fingernails on her left hand were clipped any time recently. They should not be that long and look like they are going into the palm of her hand. During concurrent observation and interview on 12/18/24 at 1:25 p.m. with Treatment Nurse (TN) in Resident 10's room, Resident 10's left hand was observed. TN stated [Resident 10] got her nails clipped yesterday. TN stated her left fingernails looked like they were not clipped and were long, thick, and curled under her fingers. TN stated, It looks like her fingernails are digging into the palm of her hand with the way her fingers are contracted. TN stated she does not know if Resident 10 requires a hand splint or not, that is an RNA (Restorative Nursing Assistant) thing. During a concurrent interview and record review on 12/19/24 at 8:31 a.m. with Director of Nursing (DON), Resident 10's Care Plans (CP) and Order Summary Report (OSR) were reviewed. The CP dated 9/8/23 indicated, Contracted left 3 fingers r/t [Related To] her diagnosis. Interventions include Fingernails need to be short so avoid injury of the skin around the area. Follow up with hand specialist as ordered. Apply splint to hand/finger to prevent rubbing each other, Monitor the site for any changes and informed [sic] MD [Medical Doctor]. The resident has skin injury to left middle finger r/t rubbing of the mis-aligned fingernail. Protect the affected finger by applying dressing to the area. The OSR dated 10/5/23 indicated, Hand Surgeon Consult. DON stated the care plan should have been implemented to include keeping Resident 10's fingernails short on her left hand and Resident 10 is supposed to be wearing a hand splint to keep the fingers from rubbing. [NAME] stated, I see the physician's order for a hand surgeon consult from 10/2023 and I am not sure why it wasn't followed through with. During a concurrent interview and record review on 12/19/24 at 11:54 a.m. with Nursing Consultant (NC) 1, Resident 10's CP and OSR were reviewed. NC stated the care plans should have been implemented and the Hand Surgeon consult should have been followed through with. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of dated February 2018, the P&P indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Preparation. 1. Review the resident's care plan to assess for any special needs of the resident. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.6. Scope and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and 2. Reflects currently recognized standards of practices for problem areas and conditions.

CONCERN (D)

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

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide foot care and podiatry (foot specialist) referral for one of one sampled resident (Resident 33). This failure resulte...

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Based on observation, interview, and record review, the facility failed to provide foot care and podiatry (foot specialist) referral for one of one sampled resident (Resident 33). This failure resulted in Resident 33's feet and toenails to be left untreated. Findings: During a concurrent observation and interview on 12/17/24 at 8:11 a.m. with Treatment Nurse (TN) in Resident 33's room, Resident's right big toenail appeared deformed, with abnormal growth, yellowish, and had fungus-like appearance. The right 2nd, 3rd, 4th, and 5th toes had long, thick, yellowish toenails. The right 5th toenail had blackish discoloration. The skin on the top of the right foot was dry and flaky. The left big toenail was yellowish in color and thick. The left 2nd, 3rd, 4th, and 5th toenails were long and the nails were curled inwards. TN stated Resident 33's nails needed trimming. TN stated she just checked around the monitoring bracelet to see if there were any abrasions around the lower extremity. TN stated, I check the feet whenever the resident has no socks on; otherwise, no. TN obtained a measuring tape and measured the length, width, and thickness of the toenails on both Resident 33's feet. The following were the measurements: Left foot Left Great toenail: Length: 1.7 centimeters (cm) Width: 2.5 cm Depth (thickness): 0.3 cm Left 2nd toenail: L:1.4 cm W:1.2 cm D: 0.2 cm Left 3rd toenail: L: 1.1cm W: 1.1 cm D: 0.2 cm Left 4th toenail: L: 1.2 cm W:1 cm D:0.1 cm Left 5th toenail: L:1.3 cm W: 0.8 cm D: 0.1 cm Right Foot: Right Great Toenail L:1.3 cm W:1.7 m D: 0.1 cm great toe, black discoloration to the nail Right 2nd toenail L: 0.7 cm W1.1 cm D: 0.1 cm Right 3rd toenail L: 0.8 cm W: 1.1 cm D: 0.1 cm Right 4th toenail L: 1.2 cm W: 1 cm D: 0.1 cm Right 5th toenail: L:0.8 cm W:0.7 cm D: 0.1 cm TN stated [Resident 33] needs podiatry referral. TN stated Resident 33 has not been referred to Podiatry. TN stated each nurse does a nursing weekly assessment. During a concurrent interview and record review on 12/17/24 at 9:11 a.m. with Director of Nursing (DON), DON was unable to find documentation Resident 33 was seen by a podiatrist. DON stated Resident 33 did not have a Podiatry referral. During a concurrent interview and record review on 12/17/24 at 9:29 a.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC), Resident 33's Podiatry referral was reviewed. MDSC was unable to find documentation of Resident 33's Podiatry referral. MDSC stated, I do not see a Podiatry referral. During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated 10/2022, the P&P indicated, Residents receive appropriate care and treatment in order to maintain mobility and foot health. 1. Residents are provided with foot care and treatment in accordance with professional standards of practice .5. Residents with foot disorder or medical conditions associated with foot complications are referred to qualified professionals .

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to manage and document pain accurately for one of one sampled resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to manage and document pain accurately for one of one sampled resident (Resident 12). This failure had the potential for Resident 12 to not be able to function and perform daily activities and improve quality of life. Findings: During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted on [DATE] with diagnosis including, Diabetes Mellitus (blood sugar is too high with diabetic neuropathy (nerve damage that is caused by diabetes), End-Stage Renal Disease (ESRD- final, permanent stage of chronic kidney disease). During a review of Resident 12's Wound Evaluation, dated 11/28/24, the Wound Evaluation indicated, 1. Pressure-Deep Tissue Injury (DTI- purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear), right heel: area 10.19 centimeter (cm), length 5.83 cm, and width 4.4 cm. Present on admission 2. Pressure-DTI, left heel: area 20.26 cm, length 6.18 cm, and width 4.3 cm .4. Pressure-DTI right dorsum, first digit (hallux-big toe) area 1.48 cm, length 1.68 cm and width 1.28 cm. in-house acquired (facility acquired) .8. Pressure-DTI, right lateral malleolus (prominent bone on each side of the ankle), 0.75 cm, length 1.08 cm and width 1 cm. in-house acquired. During a concurrent interview and record review on 12/16/24 at 2:53 p.m. with Resident 12 in Resident 12's room, Resident 12 stated, They (staff) have ignored my pain when I told them that I had pain. I have sores in both my feet. They are very painful. They have not been giving me pain medication. During a review of Resident 12's Physician's Orders (PO), dated 12/16/24, the PO indicated, Acetaminophen tablet 600 milligrams (mg) one tablet every 4 hours as needed for pain. Pain scale 1-3. Hydrocodone-Acetaminophen (narcotic pain medication) oral tablet 5-325 mg, give one tablet by mouth every 4 hours as needed for severe pain; pain scale 7-10. Ultram (pain medication) oral tablet 50 mg, give 50 mg by mouth two times a day for peripheral neuropathy (nerve damage that causes pain, tingling, numbness, or weakness in the extremities). During a concurrent interview and record review on 12/18/24 at 2:44 p.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC), Resident 12's Medication Administration Record (MAR) dated 11/6/24, was reviewed. MDSC was unable to find documentation Resident 12 was medicated for pain at pain scale level 6. MDSC stated she could not find any documentation the nurses called the physician to clarify pain medication order for pain scale level 6 since the medications were ordered for pain scale level 1-3 and pain scale level 7-10. The PO, dated 8/14/24 indicated, Monitor and record pain assessment level every shift: 0-no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain. During a concurrent interview and record review on 12/18/24 at 2:50 p.m. with MDSC, Resident 12's MAR, dated 12/1/24 to 12/18/24, were reviewed. The MAR indicated Monitor and record pain level every shift 0-3 mild pain, 4-6 moderate pain, and 7-10 severe pan. The MAR indicated, Hydrocodone-Acetaminophen 5/325 mg give one tablet every 4 hours as needed for severe pain, pain scale 7-10. MDSC stated pain monitoring is done every shift: 8 AM, 2 PM, and 10 PM. MDSC stated Resident 12 received Hydrocodone-Acetaminophen 5/325 mg for pain level of 5 without a physician's order. MDSC stated she found the following inaccuracy in Resident 12's pain management: 12/1/24 -12/7/24: 0 pain monitoring at 8 AM, 2 PM, and 10 PM 12/1/24: Hydrocodone/Acetaminophen 5/325/mg given at 05:32 a.m. for documented pain scale 5 12/6/24: Level 0 pain on monitoring at 8 AM, 2 PM, and 10 PM 12/6/24: Hydrocodone/Acetaminophen 5/325/mg given at 03:12 a.m. pain scale level 5. 12/14/24: Level 3 pain monitoring at 8 AM, 0 at 2 PM and 10 PM 12/14/24: Hydrocodone/Acetaminophen 5/325 mg given at 05:57 a.m. for pain scale level 5 Policy and Procedure for pain Management was requested; none was provided.

CONCERN (D)

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

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the Dietary Manager (DM) failed to demonstrate competency to carry out the functions of the food and nutrition service for all the residents residin...

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Based on observation, interview, and record review, the Dietary Manager (DM) failed to demonstrate competency to carry out the functions of the food and nutrition service for all the residents residing in the facility when there was a multi-generational cockroach infestation in the kitchen. This failure resulted in no action plan put in place to address and meet the health and safety needs for the residents. Findings: During an observation on 12/16/24 at 8:15 a.m. in the kitchen, there were nine dead cockroaches in a drain above a sink where food is prepared. During an interview on 12/16/24 at 8:16 a.m. with Dietary Manager (DM), DM stated, Those are bugs [dead cockroaches in the drain]. DM stated she has seen ants, pincher bugs, and cockroaches in the kitchen. DM stated she started noticing them (ants, pincher bugs, and cockroaches) when the facility started renovation this year approximately March 2024. During an interview on 12/18/24 at 10:28 a.m. with Registered Dietitian (RD), RD stated she was not made aware by anyone in the facility that there were live cockroaches. During a review of the DM's Job Description: Dietary Manager, (JDDM), dated 1/2019, the JDDM indicated, The primary purpose of your job position is to provide supervision for the Dietary Department ensuring quality food and Nutrition is meet [sic] in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility.

CONCERN (D)

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

Deficiency F0848 (Tag F0848)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure the Admissions Coordinator (AC) had the full understanding of the Binding Arbitration Agreement (BAA-the parties waive their right t...

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Based on interview and record review, the facility failed to ensure the Admissions Coordinator (AC) had the full understanding of the Binding Arbitration Agreement (BAA-the parties waive their right to a trial and agree to accept the arbitrator's decision as final) to be able to explain the content of the BAA for three of 47 sampled residents (Resident 7, Resident 8, and Resident 64) in the manner, form, and language understood by the resident and/or resident representative. This failure had the potential for Resident 7, Resident 8, and Resident 64 and/or their representatives to be misinformed and not fully understand the terms and conditions stipulated in the arbitration agreement. Findings: During an interview on 12/19/24 at 8:21 a.m. with AC, AC stated there were 47 residents who had participated and signed the BAA. AC stated the BAA is part of the admissions packet. AC stated the expectation of the Administrator and Leadership was to ensure the arbitration agreement was signed. AC stated, I inform the resident and/or the resident representative they will go to a mediator meeting and try to resolve the dispute rather than going to court. By not going to arbitration, you pay for your own lawyer and the case can take longer, thus causing you more money. Arbitration is less expensive and quicker way to resolve the dispute. AC stated, I do not explain the 'Articles' in the BAA. I do not know what the Articles in the Agreement meant. I inform the resident or resident representative that arbitration is the cheaper alternative rather than going to court. AC stated he did not discuss the Articles (actual contract of the agreement) included in the Arbitration Agreement. The Articles of the Agreement included: Article 1 - Medical Malpractice Claims Article 2 - Other Claims Article 3 -Scope of Agreement Article 4 - Delegation of Authority Article 5 - Retroactive Effect: (covers services prior to signing the agreement, making the agreement effective on the first day of admission) Article 6 - Right to Rescind (may be canceled) Article 7 - Applicable Law Article 8 - Selection of Arbitrator Article 9 - Convenient Venue Article 10 - Costs of Arbitration Article 11 - Severability (contract independent of one another) During a concurrent interview and record review on 12/19/24 at 8:57 a.m. with AC, Resident 7's BAA, dated 5/3/23, was reviewed. Resident 7's BAA indicated, the section that explained the resident or the resident representative acknowledged the agreement was explained by the facility staff in a manner, form, and language the resident and/or representative understood was not signed by the resident or Resident 7's representative. AC stated the forms were electronically signed and he saw Resident 7's representative signature. AC stated he assumed all the forms were signed. During a concurrent interview and record review on 12/19/24 at 8:59 a.m. with AC, Resident 8's BAA, dated 5/4/23, was reviewed. Resident 8's BAA indicated; Resident 8 signed the BAA herself. A review of Resident 8's Brief Interview of Mental Status (BIMS - a tool used to screen and identify the cognitive condition of the residents upon admission using a point system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact) score indicated 5 (severe cognitive impairment). AC stated he sometimes go to the resident's room. AC stated sometimes the residents' hands have tremors so he would hold the residents' hands and guide them push the signature button in the iPad (a small computer controlled by touch rather than a keyboard) to get the residents' signature. During a concurrent interview and record review on 12/19/24 at 9 a.m. with AC, Resident 64's BAA, dated 5/31/24, was reviewed. Resident 64's BAA indicated, the section that explained the resident or the resident representative acknowledged the agreement was explained by the facility staff in a manner, form, and language the resident and/or representative understood was not signed by the resident or Resident 64's representative. AC stated the forms were electronically signed and he saw Resident 64's representative signature. AC stated he assumed all the forms were signed. During an interview on 12/19/24 at 9:09 a.m. with AC, AC was unable to explain the process in the event a dispute occurred with any of the residents who signed the BAA. AC did not know where the venue for the arbitration would be held. AC stated, It's lack of knowledge on my end. Clearly, I was not given the proper information. AC was not aware the facility has a policy and procedure on Binding Arbitration Agreement. AC stated he had no method or measure if the resident or the resident representative fully understood his explanation of the binding arbitration agreement. During a review of the facility's policy ad procedure (P&P) titled, Binding Arbitration Agreements, dated 11/2023, the P&P indicated, 7. After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the documents: a. A signature alone is not sufficient acknowledgement of understanding. b. The resident or representative must verbally acknowledge understanding, and the verbal acknowledgment documented by the staff member who explained the agreement .Arbitrator/Venue Selection: 6. Arbitration agreements provide for the selection of a venue that is convenient to and suitably meets the needs of both parties .

CONCERN (F)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected most or all residents

During a concurrent interview and record review on 12/17/24 at 10:39 a.m. with Nurse Consultant (NC) 1, Resident 30's medical record, was reviewed. NC 1 was unable to find documentation of an AD for R...

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During a concurrent interview and record review on 12/17/24 at 10:39 a.m. with Nurse Consultant (NC) 1, Resident 30's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 30. During a concurrent interview and record review on 12/17/24 at 10:40 a.m. with NC 1, Resident 59's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 59. During a concurrent interview and record review on 12/17/24 at 10:42 a.m. with NC 1, Resident 64's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 64. During a review of the facility's P&P titled, Advance Directives, dated 9/2022, the P&P indicated,1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. A. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. B. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Based on interview and record review, the facility failed to ensure advance directives (AD- A legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) were offered and completed for 15 of 27 sampled residents (Resident 6, Resident 7, Resident 10, Resident 11, Resident 12, Resident 21, Resident 25, Resident 26, Resident 28, Resident 30, Resident 33, Resident 41, Resident 49, Resident 59, and Resident 64). This failure had the potential for residents' healthcare wishes to not be honored. Findings: During a concurrent interview and record review on 12/16/24 at 3:05 p.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC), MDSC was unable to provide documentation that Resident 33 was offered an AD. MDSC stated, I do not see anything on him [Resident 33]. There is no advance directive and there is no acknowledgment. During a concurrent interview and record review on 12/16/24 at 3:07 p.m. with MDSC, MDSC was unable to provide documentation of an AD for Resident 12. MDSC stated Resident 12 did not have an AD. During a concurrent interview and record review on 12/16/24 at 3:52 p.m. with MDSC, MDSC stated, I do not see an advance directive only POLST (physician order for life sustaining treatment). During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 9/2022, the P&P indicated, Determining Existence of Advance Directives: 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative. During a concurrent interview and record review on 12/17/24 at 2:48 p.m. with SSD, Resident 28's medical record (MR) was reviewed. SSD stated, No [Resident 28] does not have one [an AD]. During a concurrent interview and record review on 12/17/24 at 2:49 p.m. with SSD, Resident 6's MR was reviewed. SSD stated, There is no AD in the chart [medical record]. During a concurrent interview and record review on 12/17/24 at 2:53 p.m. with SSD, Resident 41's MR was reviewed. SSD stated, No AD, I don't see it, it's not uploaded. During a concurrent interview and record review on 12/17/24 at 2:55 p.m. with SSD, Resident 11's MR was reviewed. SSD stated, No AD in the chart. During a concurrent interview and record review on 12/17/24 at 2:56 p.m. with SSD, Resident 21's MR was reviewed. SSD stated, No AD found. During a concurrent interview and record review on 12/17/24 at 2:57 p.m. with SSD, Resident 7's MR was reviewed. SSD stated, No AD in the medical record. During a concurrent interview and record review on 12/17/24 at 2:58 p.m. with SSD, Resident 10's MR was reviewed. SSD stated, No AD in the medical record. SSD stated, I handed them [AD form] out to resident families, but none of the families have returned them. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 9/2022, the P&P indicated, Determining Existence of Advance Directives: 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: 5. During an observation on 12/16/24 at 8:49 a.m. in shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], th...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: 5. During an observation on 12/16/24 at 8:49 a.m. in shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were seven, small, black round circles under the toilet and two brown smears on the bathroom sink. The bathroom had a foul odor. During an interview on 12/16/24 at 9:09 a.m. with CNA 2, CNA 2 stated, black small, round things looks like poop. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, dated 8/19, the P&P indicated, policy Statement. Environmental surfaces will be cleaned and disinfected . 6a. During an observation on 12/16/24 at 9:12 a.m. in Resident 30's room, there was an EBP sign and no PPE supplies in the room or outside Resident 30's room. During a concurrent observation and interview on 12/16/24 at 10:48 a.m. with Nurse Consultant (NC) 2 outside of Resident 30's room, there was PPE supplies in a plastic, three-tiered drawer in front of Resident 30's room. NC 2 stated resident has a history of methicillin resistant staphylococcus aureus (MRSA-bacteria that is resistant to many antibiotics]. NC 2 stated staff put the container with PPE in the resident's room and there should have been PPE supplies in the resident's room upon admission. During a review of Resident 30's Physician Order (PO), dated 12/16/24, the PO indicated, Resident is placed on EBP d/t [due to] MDRO [Multi-drug-Resistant Organisms-bacteria that have become resistant to multiple antibiotics]: Hx [history] of MRSA & Surgical Site to left foot. During a review of Resident 30's Care Plan CP, dated 12/16/24, the CP indicated, Utilize PPE (gown and gloves; face-shield as indicated) during high-contact resident care activities (e.g., dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, toileting assistance, device care, wound care). 6b. During an observation on 12/16/24 at 8:30 a.m. in Resident 379's room, Resident 379 had an indwelling urinary catheter (a tube that goes into the patient's bladder to drain urine) with catheter bag (a collection bag) hanging on the side of the bed. There was no EBP sign posted outside of Resident 329's room. During an observation on 12/17/24 at 8:25 a.m. in Resident 379's room, there was an EBP sign posted and no PPE supplies in Resident 379's room. IP stated resident went three days without EBP precaution. During a concurrent observation and interview on 12/17/24 at 8:30 a.m. with NC 2 outside of Resident 379's room. NC 2 stated there should have been PPE supplies in the resident's (Resident 379) room upon admission. During a review of Resident 379's PO, dated 12/16/14, the PO indicated, Resident to be placed on Enhanced Barrier Precaution d/t Device: Indwelling Catheter. During a review of Resident 379's CP, dated 12/16/24, the CP indicated, Place EBP notification/signage near resident room doorway to alert staff/visitors of precautions. During a review of the facility's policy and procedure (P&P) titled, Enhance Barrier Precaution, dated 11/24, the P&P indicated, EBPs [sic] are indicated .for residents with wounds and/or indwelling medical devices .b. Indwelling medical devices include central lines, urinary catheters . During a review of the facility's P&P titled, Personal Protective Equipment, dated 10/18, the P&P indicated, 4 .PPE required for transmission-based precautions is maintained outside and inside the resident's room . Based on observation, interview, and record review, the facility failed to follow and implement nationally recognized infection prevention and control practices for seven of seven sampled residents (Resident 12, Resident 30, Resident 33, Resident 43, Resident 49, Resident 183, and Resident 379) as evidenced by: 1. Linens stored for two of two sampled residents (Resident 33 and Resident 183) on the bedside table inside Resident 33 and Resident 183's room. 2. Resident 12 and Resident 43's hands were not cleansed prior to eating lunch. 3. The treatment nurse (TN) did not wear proper Personal Protective Equipment (PPE- refers to gowns, gloves, masks, goggles, face shields to protect the wearer from injury or infection) during wound treatment and dressing change for one of one resident (Resident 49) on Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO-bacteria that have become resistant to multiple antibiotics] that employs targeted gown and glove use during high contact resident care activities). 4. TN did not perform hand hygiene during wound dressing and treatment for one of one resident (Resident 49). 5. A shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] had feces under the toilet and smeared feces on the sink. 6. There were no PPE supplies for Resident 30 and Resident 379 on EBP. These failures had the potential to transmit infectious diseases. Findings: 1. During a concurrent observation and interview on 12/16/24 at 11:51 a.m. with Dietary Manager (DM) in Resident 33's room, several linens, such as sheets, blankets, and pull sheets were piled up on top of the bedside table. DM stated the linens should not be stored in the rooms unless the staff were changing and making the residents' beds. During a concurrent observation and interview on 12/16/24 at 11:55 a.m. with DM in Resident 183's room, linens, sheets, blankets were stored on top of the bedside table. DM stated the linens are not supposed to be in the residents' rooms unless brought in to change or make the bed. 2. During a concurrent observation and interview on 12/16/24 at 12:27 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 43's room, Resident 43's lunch tray was delivered and placed on the overbed table. Resident 43 was served Puree (cooked foods ground finely), regular texture, thin liquids with 4 ounces (oz) of house shake. CNA 1 stated Resident 43 was a feeder and waiting to be fed. During a concurrent observation and interview on 12/16/24 at 12:31 p.m. with CNA 2 in Resident 43's room, CNA 2 was sitting at Resident 43's bedside and started preparing to feed Resident 43. CNA 2 placed a towel over Resident 43's chest but did not wash Resident 43's hands before eating. During a concurrent observation and interview on 12/16/24 at 12:57 p.m. with CNA 1 in Resident 12's room, Resident 12's lunch tray was delivered and placed on the bedside table. It was noted the individual who delivered the tray left the meal tray on the overbed table and did not offer Resident 12 any hand wipes to clean his hands before meals. CNA 1 stated the nursing assistants were supposed to provide the residents with rags to clean their hands. 3. During a concurrent observation and interview on 12/18/24 at 10:35 a.m. with TN in Resident 49's room, TN entered Resident 49's room to do wound treatment and dressing change. Resident 49 was in his bed and lying on supine position. TN put on a new pair of gloves without performing hand hygiene. TN laid a blue pad (barrier between the table and the medical supplies for dressing and wound treatment) on Resident 49's overbed table and placed the scissors, the kerlix roll, the gauze, the non-adherent pad, and the cream on the blue pad. TN cut the kerlix roll wrapped around Resident 49's right ankle and heel. It was observed the right heel had a wound with a scab and was yellowish in color. The bottom of the right foot was wrinkled, and the skin and the surrounding tissue were peeling off the right heel. The bottom of the right foot was wrinkled, dried, and had a small necrotic (black dead skin) area on the heel. TN described the wound as deep tissue injury (DTI- caused by damage to the soft tissue beneath the skin from pressure or shear forces). TN removed the used gloves and changed into a new pair of gloves without performing hand hygiene. TN cleansed the right heel with a gauze wet with normal saline, pat-to dry, and applied a Xeroform dressing (non-adhesive dressing) on the heel. TN rewrapped the right ankle and heel with a kerlix dressing and secured it with tape. 4. During a concurrent observation and interview on 12/17/24 at 10:50 a.m. with TN in Resident 49's room, TN continued to do wound treatment. TN put on gloves and turned Resident 49 to his right side. TN was not wearing a gown or a mask except for gloves. TN realized she did not have the appropriate PPE prior to wound treatment. TN stated, I forgot to gown up and wear mask. TN stated Resident 49 has a moisture-associated skin dermatitis (MASD- a condition that occurs when the skin is repeatedly exposed to moisture from bodily fluids, such as urine, stool, perspiration, saliva, mucus, and wound exudate). During a review of the facility's policy and procedure (P&P) titled, Handwashing, dated 10/2023, the P&P indicated, 2. All personnel are expected to adhere to hand hygiene policies and procedures to help prevent the spread of infections to other personnel, residents, and visitors .Indications for hand hygiene: a. immediately after touching a resident, .c. after contact with blood, body fluid, or contaminated surfaces, .d. after touching a resident, .g. immediately after glove removal . During a review of the facility's P&P titled, Enhanced Barrier Precautions (EBP), dated 11/2024, the P&P indicated, Enhanced Barrier Precautions are utilized to reduce the transmission of multi-drug resistant organisms (MDRO) to residents .2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities .a. Gloves and gown are applied prior to performing the high contact resident care activity .3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include a. dressing .h. wound care (any skin opening requiring dressing).

CONCERN (F)

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

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective Pest Control Program when live ...

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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 an effective Pest Control Program when live cockroaches were repeatedly found in the kitchen. This failure placed 70 of 72 highly susceptible sampled residents, at risk for foodborne illnesses when receiving food from the kitchen infested with cockroaches. Findings: During a concurrent observation and interview on 12/16/24 at 8:15 a.m. with Dietary Manager (DM) in the kitchen, there were nine dead cockroaches in a floor drain above the sink where food was prepared. DM stated, those are bugs [dead cockroaches in the drain]. During an interview on 12/16/24 at 8:16 a.m. with DM, DM stated she had seen ants, pincher bugs, and cockroaches in the kitchen. DM stated she noticed them (ants, pincher bugs, and cockroaches) during the renovation of the kitchen approximately March 2024. During an observation on 12/17/24 at 11:25 a.m. in the kitchen, there was a live cockroach crawling on the wall above the dishwasher. During an interview on 12/17/24 at 11:26 a.m. with Dietary Aide (DA) 1, DA 1 stated that looks like a cockroach. DA 1 stepped on it and killed the live cockroach. DA 1 stated, I've only been seeing pests since the facility's renovation. During a concurrent observation and interview on 12/17/24 at 11:28 a.m. with Administrator, in the kitchen, Administrator stated he was aware of the hole in the kitchen staff bathroom which was 2 cm x 2 cm (centimeter, unit of measurement) and the hole on the wall under the sink in the kitchen. Administrator stated they have Pest Control Company come every month. Administrator stated the holes were entrance for pests to come into the kitchen. Administrator saw a cockroach crawling on top of the counter near the dishwashing machine and a small brown cockroach crawling on the wall above the handwashing sink. During an interview on 12/17/24 at 2:44 p.m. with DA (2), DA 2 stated he had seen two cockroaches in the kitchen near the dish washer floor today. During an observation on 12/18/24 at 8:42 a.m. in the kitchen, was a glue trap with one dead cockroach under the sink of the food preparation counter. During an observation on12/18/24 at 8:43 a.m. in the kitchen, a cabinet lined with a silicone type material where assortment of food utensils was stored, there was one small dead cockroach under the lining. During an interview on 12/18/24 at 8:45 a.m. with DM, DM stated, I saw live roaches [cockroaches] yesterday crawling from the ceiling down to the bulletin board. The bulletin board was hanging on the wall by the entrance wall in the kitchen. DM stated pest control did the treatment last week due to ''live roaches[cockroaches]. DM stated, they were dark brown, little ones. DM stated she saw 2- 4 live roaches[cockroaches], little one's crawling. DM stated she saw bigger in size, dark brown in color yesterday. DM stated she saw more roaches (cockroaches) on Monday (12/16/24) morning. DM stated she came to the dining room; she saw more dead cockroaches. DM stated sometime in November, I saw live roaches (cockroaches) little ones, in the dish area. DM stated, I mentioned to the Administrator and Maintenance about the live and dead roaches in the kitchen every week. I gave verbal report during the stand-up meeting. During an observation on 12/18/24 at 8:47 a.m. in the kitchen behind the oven, there was one glue trap with one tiny (unable to determine size) dead cockroach and one live, dark brown cockroach. During an interview on 12/18/24 at 8:57 a.m. with Cook, [NAME] stated she came in to work at 4:30 a.m. today. When she turned the light on, she saw one live small cockroach as she opened the door. [NAME] stated, I have noticed cockroaches the first two days I've worked. [NAME] stated alive small black and small brown cockroaches. [NAME] stated in the cabinet under the food preparation counter she saw a live cockroach in the morning, last week. During an observation on 12/18/24 at 8:59 a.m. at the kitchen sink beverage station, there was a large hole in the wall near the sink drainage under the sink. There was a dead cockroach under the kitchen beverage sink. During a concurrent observation and interview on 12/18/24 at 9 a.m. with DA 3 in the Janitorial Closet, there was one live medium dark brown cockroach, one dead medium brown cockroach in the hole near mop sink, two cockroach carcasses on the mop sink, one dead cockroach medium brown behind the janitorial door. DA 3 stated she saw a live roach on the preparation counter last weekend on 12/14/24 and 12/15/24 around 5:45 a.m. and she saw dead roaches in the janitorial room last month. During an observation on 12/18/24 at 9:05 a.m. in the kitchen, there was one small live brown cockroach crawling on the ceiling above the dishwasher sink. During an observation on 12/18/24 at 9:07 a.m. in the kitchen, there was a glue trap with five dead medium dark brown cockroaches behind a rack with plate covers. During an observation on 12/18/24 at 9:09 a.m. in the kitchen, there was a mesh like metal material on the hole with a small dead cockroach under the sink near the dishwasher. During an interview on 12/18/24 at 9:10 a.m. with DA 1, DA 1 stated she saw roaches, one alive and two dead five days ago around the area where staff wash the dishes and saw three dark brown live roaches in the kitchen dishwashing area. During an observation on 12/18/24 at 9:11 a.m. in the kitchen, there was a leaking water pipe connected to the dishwasher found underneath the dishwashing counter. During an observation on 12/18/24 at 9:13 a.m. in the dry storage room, there was a glue trap behind the refrigerator with 7 small brown dead cockroaches and one small dead cockroach on the floor. During a concurrent observation and interview on 12/18/24 at 9:35 a.m. with Activities Assistant (AA) in the dining room, there was two dead roaches on the floor. AA stated she saw one small, brown, dead roach in the dining floor. During an interview on 12/18/24 at 9:38 a.m. with Housekeeper (HK), HK stated she saw roaches in the dining room, some dead, some alive last week. During an observation on 12/18/24 at 9:40 a.m. in the dining room, there was 10 dead cockroaches in a cabinet under the sink. During an interview on 12/18/2024 at 9:50 a.m. with Environmental Specialist (ES), ES stated because of the different sizes of cockroaches identified, the facility has a problem with multi-generational infestation of cockroaches. ES stated during the day, so many of them in hiding places to scavenge for food. ES stated even if the pest control company had sprayed, they still have live infestation of cockroaches. During a concurrent observation and interview on 12/18/24 at 9:58 a.m. with DM in the dry storage room, a live brown cockroach was inside a bin which contained sponges. DM stated that is a live cockroach and killed it with a sponge. There was a dead tiny cockroach in a bin with approximately a dozen scoopers. There was a live small cockroach crawling into a silver rectangular tin box, one dead cockroach under a rack with pitchers, and a small dead cockroach under an empty rack. During an interview on 12/18/24 at 10:30 a.m. with Pest Control Company Owner (PCCO), PCCO stated he was aware of the cockroaches in the kitchen. PCCO stated we went out on Wednesday night and made a thorough inspection of the kitchen. PCCO stated he found infestation of German cockroaches in the kitchen. According to Dr. [NAME], an advisor for the National Pest Management Association, German cockroaches can spread 33 kinds of bacteria, six kinds of parasitic worms, as well as other kind of human diseases. Https://www.pestworld.org/news hub/pest articles/German cockroaches101/#:~:text=These%20germs%20are%20then%20transferred, least%20seven%20other%20human%20pathogens. Accessed 12.26.24 During a review of the facility's Pest Control Invoice (PCI), dated 12/3/24, the PCI indicated, INSPECTION FOR GERMAN ROACHES. During a review of the facility's PCI, dated 12/9/24, the PCI indicated, SERVICE FOR ROACHES IN THE KITCHEN. During a review of the facility's P&P titled, JANITOR'S CLOSET, dated 2023, the P&P indicated, The janitor's closet must be kept clean and orderly. 4. Cleaning of the janitor's closet must be done on a scheduled routine. During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated May 2008, the P&P indicated, Policy Statement. Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Oct 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary shower area was provided for the residents. This failure had the potential for injury and spread o...

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Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary shower area was provided for the residents. This failure had the potential for injury and spread of infectious disease to facility residents. Findings: During a concurrent observation and interview on 10/1/24 at 2:10 p.m. with Certified Nursing Assistant (CNA) 1, in the south shower room stall one. CNA 1 stated, There was a plastic piece (vinyl cover) that fell off over the weekend on Saturday (9/28/24). CNA 1 stated she put the vinyl cover to the side (space just outside of shower room stall one). During a concurrent observation and interview on 10/1/24 at 2:15 p.m. with Housekeeping Manager (HM), in the south shower room stall one. There was a broken and missing tiles and a tan substance noted on the pony wall (half wall) of shower stall one. HM stated the housekeeping staff could not properly clean the area with the missing tiles. There was a black substance noted on the bottom of the shower grout line. HM stated, I do not know what that is but it looks like it will come back if you clean it, probably has mold (a superficial often woolly growth produced especially on damp or decaying organic matter or on living organisms by a fungus) under there. During an interview on 10/3/24 at 10:57 a.m. Maintenance Personnel (MP), MP stated he was made aware of the vinyl cover falling off on the south shower room stall one on 10/1/24. MP stated it was not reported to him nor was the repair request listed in the maintenance log. MP stated the tiles fell off about a year ago and they placed the vinyl cover over it. During a review of the facility ' s policy and procedure (P&P) titled, Hazardous Areas, Devices and Equipment, revised July 2017, the P&P indicated, ll hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Identification of Hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: . c. Sharp objects that are accessible to vulnerable residents; . 2. Any element of the resident environment that has potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. 13. As part of an overall culture of safety, staff, residents, and family will be encouraged to report anything that appears to be an environmental hazard or safety concern. During a review of the facility ' s P&P titled, Bathrooms, revised February 2020, the P&P indicated, 1. Residents . are ensured timely access to a safe, clean, sanitary, and accessible toileting facility. 2. Bathrooms, including showers, sink, commodes, . are cleaned and disinfected daily in accordance with our established procedures.

Apr 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1 and Resident 2) were free from verbal abuse. This failure resulted in Activit...

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Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1 and Resident 2) were free from verbal abuse. This failure resulted in Activity Assistant (AA) verbally abused Resident 1 and Resident 2 during activities and had the potential to cause emotional harm. Findings: During a concurrent observation and interview on 4/9/24 at 4:03 p.m. with Resident 1 in the dining room, Resident 1 had his eyebrows folded and moved his head side to side (right to left) and stated, I was in shock. He [AA] yelled and cursed at him and Resident 2 during activities on 4/7/24. Resident 1 stated AA lead activities at the facility and activities were supposed to be fun and it wasn't that day [4/7/24]. During a review of Resident 1's History and Physical (H&P), dated 10/24/23, the H&P indicated, Resident 1 had the mental capacity to make medical decisions. During a review of Resident 1's Weekly Summary Note (WSN), dated 4/25/24, the WSN indicated, Resident is alert and oriented, able to verbalize needs. During a concurrent observation and interview on 4/9/24 at 4:05 p.m. with Resident 2 in the dining room, Resident 2 had watery eyes with raised eyebrows and stated during activities on 4/7/24, AA picked up my popcorn and threw it at me. Resident 2 stated AA yelled at her and I was terrified and I am afraid he [AA] will come back. During a review of Resident 2's MDS, dated 1/21/24, the MDS indicated, Section C- Cognitive Patterns. C0500. BIMS Summary Score 13 [score 13 is cognitively intact]. During a review of Resident 2's PN, dated 4/7/24, the PN indicated Resident 2 and Resident 1 were both yelled at during activities by AA, Resident 2 was scared and her popcorn was thrown on the floor. During an interview on 4/9/24 at 4:10 p.m. with Administrator, Administrator stated on 4/7/24, Receptionist called him and informed him AA yelled at Resident 1 and Resident 2 during activities. Administrator stated he was the facility abuse coordinator, and the expectation was all staff Cannot yell and mistreat them [residents]. Administrator stated AA was verbally abusive during activities to Resident 1 and Resident 2. Administrator stated, shouldn't have happened and verbal abuse is not tolerated. During an interview on 4/9/24 at 6:18 p.m. with AA, AA stated on 4/7/24 at approximately 11 a.m., during activities I yelled at them [Resident 1 and Resident 2] and lost my cool. AA stated he raised his arms up at Resident 2 and I told her [Resident 2] if you don't want to be here then leave. AA stated, Yeah I might of said a few curse words to Resident 1 and Resident 2. AA stated, I know that I should not have done what I did, it was verbal abuse. AA stated he should not yell at the residents. During a concurrent interview and record review on 4/9/24 at 7 p.m. with Receptionist, Receptionist written incident statement (WIS) dated 4/7/24 was reviewed. The WIS indicated, [AA] threw [Resident 2's] popcorn from the table to the floor. Receptionist stated AA yelled at Resident 1 and Resident 2 Get the Fuck out of the dining room you guys are getting me upset. Receptionist stated, He [AA] was screaming at them [Resident 1 and Resident 2] very bad. Receptionist stated the facility staff are expected to treat them [residents] with respect and the same way you want to be treated. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention, dated 12/31/15, the P&P indicated, Each resident has the right to be free from verbal, sexual, physical, and mental abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff. Purpose To ensure the resident's rights are protected. SECTION 2: DEFINITIONS. VERBAL ABUSE: Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability.

Apr 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to complete an investigation of a verbal abuse allegation within five working days for one of four sample residents (Resident 1). This failure...

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Based on interview and record review, the facility failed to complete an investigation of a verbal abuse allegation within five working days for one of four sample residents (Resident 1). This failure had the potential to place Resident 1 at risk for suffering continuous verbal abuse. Findings: During an interview on 2/28/24 at 10:29 am with Resident 1, Resident 1 stated Certified Nursing Assistant (CNA) 1 was being rude to her. Resident 1 stated she woke up and called CNA 1 for help, and CNA 1 was already in Resident 1 ' s room attending to Resident 2. Resident 1 stated she was in her wheelchair and wheeled herself towards CNA 1. Resident 1 stated CNA 1 told her, Again? You? I hardly want to talk to you. Resident 1 stated she asked CNA 1, What have I done to you? and she stated CNA 1 told her, I don ' t want to have you. If I know you ' re here, I wouldn ' t have come. Resident 1 stated she is worried that it (verbal abuse) will happen again. During a review of Resident 1 ' s Progress Notes (PN), dated February 26, 2024, the PN indicated, Resident [1] was very upset stating that she wanted to leave because the CNA [1] was very mean and rude to her. During an interview on 3/7/24 at 8:44 am with Administrator, Administrator stated he is aware of submitting the facility investigation report within five working days of the (verbal abuse allegation) incident. Administrator stated the (verbal abuse allegation) incident took place on 2/26/24 and as of today 3/7/24 (eight working days after the alleged verbal abuse incident), the facility is still finalizing the (verbal abuse allegation) investigation. During an interview on 3/7/24 at 9:33 am with the Director of Nursing (DON), DON stated, It [completion of the verbal abuse allegation investigation within five working days] was not done within the timeframe. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, the P&P indicated, 9. Investigate and report any allegations within timeframes required by federal requirements.

Feb 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review, the facility failed to ensure laundry was cleaned and sanitized according to the manufacturer's guidelines. This failure had the potential to result ...

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Based on observation, interview and record review, the facility failed to ensure laundry was cleaned and sanitized according to the manufacturer's guidelines. This failure had the potential to result in the transmission of infection and communicable diseases to all residents. Findings: During a concurrent observation and interview on 1/5/24 at 9:26 a.m. with Laundry Staff (LS) 1 and Housekeeping and Laundry Supervisor (HLS) in the facility laundry room, LS 1 loaded towels and sheets into the washing machine and pressed 19. LS 1 left the room immediately after loading the machine. HLS stated she did not know what the number 19 meant, but stated her staff knew that information. During a concurrent observation and record review on 1/5/24 at 9:32 a.m., an ECOLAB Formula Chart [chart that describes which type of laundry is being washed so the correct chemicals for that type will be automatically dispensed into the machine] was observed on the side of another washing machine. The formula chart indicated Towels Formula 1.Sheets Formula 2. During a concurrent interview and record review on 1/5/24 at 11:21 a.m. with LS 2, the ECOLAB Formula Chart, (undated) was reviewed. LS 2 stated the ecolab system was a new system installed about one month ago. LS 2 stated the number 2 should be used for sheets. LS 2 stated the number 19 is for the old system. LS 2 stated number 19 on the old system was for washing personal clothing. During a review of the facility's policy and procedure (P&P) titled, Laundry and Bedding, Soiled, dated 9/2022, the P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control.Laundry detergents, rinse aids or other additives are used according to the manufacturer's IFU [instructions for use].

Jan 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) care plan was implemented. This failure had the potential for Resident 2 t...

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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) care plan was implemented. This failure had the potential for Resident 2 to have unmet care needs. Findings: During a review of Resident 2 ' s care plan [Resident 2] is high risk for falls ., initiated 12/14/23, interventions included was a falling star program. During a concurrent observation and interview on 12/19/23 at 2:40 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 confirmed Resident 2 did not have a star on his name plate on the door. CNA 1 stated, I don ' t know the criteria you have to have to get the star. [Resident 2] did have a fall he rolled off the side off his bed a week ago. CNA 1 stated a star would normally be on the name plate on the door and wheelchairs of residents at risk for falls. During an interview on 12/19/23 at 4:05 p.m. with Director of Nursing (DON), DON was informed of the findings and stated care plans should be created and implemented. During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised March 2018, the P&P indicated, Based on previous evaluations and current data, staff may identify interventions related to resident ' s specific risks and causes in the attempt to reduce falls and minimize complications from falling.

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

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 and record review, the facility to ensure fall risk assessments were completed for one of three sampled resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to ensure fall risk assessments were completed for one of three sampled residents (Resident 2). This failure had the potential for staff not to be aware of Resident 2 ' s risk for falls. Findings: During a review of Resident 2 ' s Progress Notes, (PN) dated 12/13/23, the PN indicated Resident 2 was admitted on [DATE] at 6:57 p.m. During a review of Resident 2 ' s PN, dated 12/13/23 at 9:45 p.m., the PN indicated Resident 2 had an unwitnessed fall. During a concurrent interview and record review on 12/19/23 at 2:01 p.m. with Director of Nursing (DON), DON reviewed Resident 2 ' s medical record and confirmed there was no fall risk assessment completed upon admission and there was no post fall assessment completed after Resident 2's fall incident on 12/13/23. During an interview on 12/19/23 at 4:05 p.m. with DON, DON stated fall risk and post-fall assessments should be completed. During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised March 2018, the P&P indicated, Based on pervious evaluations and current data, staff may identify interventions related to resident ' s specific risks and causes in the attempt to reduce falls and minimize complications from falling.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a care plan was developed and implemented after a change of condition for one of two residents (Resident 1). This failure had the po...

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Based on interview and record review, the facility failed to ensure a care plan was developed and implemented after a change of condition for one of two residents (Resident 1). This failure had the potential for Resident 1 not to receive need medical treatments. Findings: During an interview on 11/21/23 at 10:43 a.m. with Director of Nursing (DON), DON stated Resident 1 PICC (peripherally inserted central catheter - is a long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart, used to deliver medications and other treatments directly to the large central veins near your heart.) line in place and he pulled the PICC line out twice two days in a row. DON stated the facility staff sent Resident 1 to the emergency room (ER) hoping the ER would admit Resident 1 until treatment was completed. During a review of Resident 1 ' s EMAR (electronic medication administration note), dated 11/4/23 at 10 a.m. the EMAR indicated, [Resident 1] pulled out picc [sic] line. During a review of Resident 1 ' s Nurse ' s Note, (NN) dated 11/8/23 at 12:11 p.m., the NN indicated, [Resident 1] took PICC line out. During a review of Resident 1 ' s NN, dated 11/8/23 at 7:20 p.m. the NN indicated Resident 1 had a new PICC line inserted. During a review of Resident 1 ' s EMAR, dated 11/11/23 at 8:28 p.m. the EMAR indicated, [Resident 1 pulled his picc [sic] line out. During a review of Resident 1 ' s SBAR (Situation, Background, Assessment, and Recommendation- communication form), dated 11/12/23 at 11: 47 a.m. the SBAR indicated, [Resident 1] had pulled out midline [thin plastic flexible tube inserted in the upper arm with the tip located just below the armpit used to deliver medication) on 11-11-23 which was inserted on, 11-09-23. Nurse tried PIV [peripheral intravenous tube is a short plastic tube placed into the vein to give medication or fluid] twice and [Resident 1] pulled out. [Resident 1] has episodes of pulling out IV line [intravenous line-is a soft, flexible tube placed inside a vein, usually in the hand or arm, to give a person medicine or fluids] multiple times . received orders to transfer [Resident 1] back to hospital. During a review of Resident 1 ' s NN, dated 11/13/23 at 2:22 p.m. the NN indicated Resident 1 returned from the hospital. The NN indicate, PICC line in placed on the right upper arm with bandage wrapped around for [Resident 1] not to pull PICC line. During a review Resident 1 ' s care plan with the focus on At risk for infection/injury R/T removing PICC lines. initiated 11/21/23 (17 days after first dislodgement), one of the interventions was Ensure IV site is wrapped to prevent dislodgement. During a concurrent interview and record review on 12/19/23 at 11:15 a.m. with DON stated the first time (11/4/23) the PCC line was found on the floor, so we did not care plan. DON stated the second time (11/8/23) Resident 1 was witnessed pulling it out PICC line. DON stated Resident 1 ' s care plan with the focus on [Resident 1] is at risk for complications due to the presence of a PICC line ., initiated on 10/24/23 was reviewed on 11/10/23. DON reviewed Resident 1 ' s care plans and no dislodgement are plans were initiated prior to 11/21/23 because Resident 1 sent him out to the hospital (11/12/23) so he could be more closely monitored, he was there for two day and when he returned the PICC was place high up on his arm to be wrapped better to prevent dislodgement. During a review of the facility ' s policy and procedure (P&P) titled Goals and Objectives, Care Plans, revised April 2009, the P&P indicated, Care plans shall incorporate goals and objectives that lead to the resident ' s highest obtainable level of independence. 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 2. When goals and objectives are not achieved, the resident ' s clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. 3. Care plan goals and objectives are derived from information contained in the resident ' s comprehensive assessment and: a. is resident oriented; b. is behaviorally stated; . 4. Goals and objectives are entered on the resident ' s care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 5. Goals and objectives are reviewed and or revised: a. when there has been a significant change in the resident ' s condition; b. when desired outcome has not been achieved; .

Jul 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

Medication Errors (Tag F0758)

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 follow their policy and procedure on Antipsychotic Med...

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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 follow their policy and procedure on Antipsychotic Medication Use, for one of three sampled residents (Resident 1), when non-pharmacological interventions (any type of health intervention which is not primarily based on medication, example, removing items that triggers behavior) were not attempted and evaluated for effectiveness before the use of an antipsychotic (used to treat mental disorders) medication. This failure had the potential for Resident 1 experiencing adverse health outcomes from taking unnecessary medication. Findings: During a review of Resident 1 ' s Operative Report (OR), dated June 19, 2023, the OR indicated, Resident 1 underwent an Esophagogastroduodenoscopy (EGD - exam of inside of stomach and intestine) with foreign body removal. The OR indicated, the initial reason for the EGD, was for abdominal pain and PEG (Percutaneous endoscopic gastrostomy - a tube placed into the stomach through the abdomen) replacement. Resident 1's OR indicated, .the patient [Resident 1] had multiple foreign bodies throughout his esophagus. He [Resident 1] had about 20 buttons; these were not batteries but appeared to be clothing buttons. During an observation on 6/29/23, at 1:05 p.m., in Resident 1 ' s room, Resident 1 was lying in bed on his back with his eyes open and head turned toward right shoulder making a chewing motion with his mouth. Resident 1 was dressed in a hospital gown that tied at the back of the neck, Resident 1 did not make eye contact or respond when spoken to. Tube feeding was observed hanging at bedside, was turned off and was not connected to PEG tube. During a review of Resident 1's admission Record (AR), dated June 29, 2023, the AR indicated, the facility originally admitted Resident 1 on 9/11/14. The AR indicated, Resident 1 had diagnoses of traumatic brain injury (brain injury caused by an outside force), gastrostomy tube (tube inserted into stomach through abdomen wall), contracture (tightening of muscle, tendons, ligaments or skin) of right and left hands and lower legs, constipation, and convulsions (uncontrolled shaking of the body). During a review of Resident 1's Minimum Data Set (MDS - an assessment tool) section C, dated June 1, 2023, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status - assess mental processes) score of 2, significant mental impairment (score of: 0-7 means significant cognitive impairment). The MDS section G indicated, Resident 1 ' s functional status was extensive and total dependence for completion of activities of daily living, including bed mobility, dressing, eating, toilet use and personal hygiene. During a review of Resident 1's IDT Note (IDT - interdisciplinary team, a group of facility department heads that make decisions regarding care), dated June 23, 2023, at 11:32 a.m., the IDT indicated, late entry Res [Resident 1] is a [AGE] year old TBI [traumatic brain injury] case with a BIMS of 99 (score of 99 indicates severely cognitively impaired) and severely impaired. The [Resident 1] is nonverbal and has severe contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints] of bilat [bilateral - both] hands and BLE [bilateral lower extremities] with limited range of motion. He [Resident 1] is NPO [nothing by mouth] and nutrition and medications are provided through GT [gastrostomy tube]. Due to contractures resident wears gowns for ease of dressing and less discomfort. The metal snaps on the gowns were identified as possibly the metal buttons mentioned in the MD [medical doctor] notes. IDT requested that Psych [Psychiatrist] assess resident [1], Psychiatrist reviewed and diagnosed Acuphagia [consumption of sharp objects] a form of [NAME] [craving or chewing substances that have no nutritional value] that involves ingesting metal objects. He [Psychiatrist] prescribed Abilify [an antipsychotic medication used to treat mental disorders] 30mg [milligram - a unit of measure] po [by mouth] q [every] day we [sic] are waiting to hear back from the conservator [court appointed person, who makes decisions for individual] for consent. During a review of Resident 1's Social Service Note (SSN), dated June 22, 2023 (the date of Resident 1's return to the facility from hospital), the SSN indicated, a late entry was made at 13:43 (1:43 p.m.). The SSN indicated, DON [Director of Nursing] and SSD [Social Services Director] met with Psychiatrist today to review resident [1] who returned from hospital for PEG placement and was found to have foreign objects (buttons and glass) in his [Resident 1 ' s] esophagus and stomach. Psychiatrist give resident [1] new diagnosis of Acuphagia and is recommending Abilify 30mg PO [by mouth] qd [every day] . During a review of Resident 1 ' s Care Plan (CP), dated June 26, 2023 (four days after Psychiatrist consult), the CP indicated, Resident 1 has new diagnosis of Acuphagia a form of [NAME] M/B [manifested by] consumption of metal objects. The CP indicated, interventions/tasks: meds [Abilify] as ordered. During an interview, on 6/29/23, at 1:20 p.m., with DON, DON stated, Resident 1 likes to place washcloths and towels in his mouth and chew on them. DON stated, Resident 1 does not have fine motor skills to pick items up and place in his mouth. During an interview, on 6/29/23, at 1:35 p.m., with Certified Nurse Assistant (CNA), CNA stated, she has cared for Resident 1 for approximately one year. CNA stated, during this time, Resident 1 has liked to bite at things. CNA stated, she has observed Resident 1 chewing on a rolled washcloth placed in his hands, due to his contractures. CNA stated, [Resident 1 ' s] head is always turned to [Resident 1 ' s] right shoulder and I have seen [Resident 1] chewing the sleeve of his gown. CNA stated, Resident 1 does not walk, and rarely leaves his room. During an interview, on 6/29/23, at 1:50 p.m., with Registered Nurse (RN), RN stated, she has cared for Resident 1 for several years. RN stated, Resident 1 is always picking at the gown or sucking on a washcloth or towel. RN stated, Resident 1 wears gowns due to contractures of his hands, arms and legs, these make it difficult to dress him in regular clothes. RN stated, Resident 1 does not get up, cannot walk, and usually stays in bed. During a review of Resident 1's Order Summary (OS), dated July 25, 2023, the OS indicated, Abilify Oral Tablet 30 MG (Aripiprazole - generic name) Give 30 mg via G-tube one time a day for Acuphagia M/B [manifested by] maneuvering foreign [sic] objects into mouth consent from RP [Responsible Party - conservator] by [Physician] verified 6/30/23, start date 7/1/23. During an interview, on 7/13/23, at 11:16 a.m., with DON, when asked why non-pharmacological (non-medication) interventions were not attempted and evaluated for effectiveness before medicating Resident 1, DON stated, Due to the severity of the problem identified with [Resident 1], the IDT team decided to ' hit this with a hammer ' and do everything they could do to insure it wouldn ' t happen again. During a review of the facility ' s policy and procedure (P&P) titled Antipsychotic Medication Use, (undated), The P&P indicated, Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; OR: (1) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) behavioral interventions have been attempted and included in the plan of care, except on an emergency (see below) . For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: c. not sufficiently relieved by non-pharmacological interventions.

Jun 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to accurately assess one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience possible infecti...

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Based on interview and record review, the facility failed to accurately assess one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience possible infection and delayed healing. Findings: During an interview on 4/28/23, at 1:09 p.m., with Licensed Vocational Nurse (LVN 2), LVN 2 stated when documenting on the Skilled Nursing Notes she goes into the resident rooms and 'lays eyes' on the resident. LVN 2 stated in regards to Weekly Skin Checks (evaluation of the resident's skin condition) she documents the new and the ongoing treatment and marks the area of the body affected, by clicking the picture of the body (in their electronic medical record) to indicate the location of the wound. During an interview on 4/28/23, at 1:19 p.m., with LVN 1, LVN 1 stated she goes into the resident room and physically looks at the resident's whole body and documents the ongoing treatment on the body in their electronic medical record by clicking and indicating the location of any new wound. During a review of Resident 1 ' s SBAR Communication Form, (SBAR- situation, background, appearance, review, and notify) dated 3/25/23, the SBAR indicated Resident 1 had a 1 cm [centimeter- unit of measure] by 2 cm fluid filled blister. During a review of Resident 1 ' s Order Summary Report, (OSR) the ORS indicated, Blister to left thigh front, cleanse area with NS [normal saline], pat dry and paint with betadine [topical antiseptic that provides infection protection against a variety of germs for minor cuts, scrapes, and burns] and cover with dry dressing daily x [times] 14 days. every day shift for tx [treatment] until 04/10/2023 23:59 Order date 03/27/2023 Start Date 03/28/2023 End Date 04/10/2023 During a review of Resident 1 ' s Treatment Administration Record, (TAR) dated 3/23 and 4/23, the TAR indicated Resident 1's treatment were administered daily from 3/28/23 to 4/9/23. During a concurrent interview and record review on 4/28/23, at 1:47 p.m., with the Director of Nursing (DON), DON reviewed Resident 1 ' s SBAR dated 3/25/23. DON reviewed Resident 1 ' s OSR. DON confirmed Resident 1 ' s blister and treatment order. DON reviewed Resident 1 ' s TAR date 3/23 and 4/23. DON confirmed Resident 1's treatment were administered daily. DON reviewed Resident 1 ' s medical record and confirmed the following: Resident 1 ' s Nurses Weekly Look Back Summary: 3/31/23, no documentation of Resident 1 ' s blister. 4/7/23, no documentation of Resident 1 ' s blister. Resident 1 ' s Weekly Skin Checks 4/7/23, no documentation of Resident 1 ' s blister. Resident 1 ' s Skilled Nursing Notes 3/29/23, no documentation of Resident 1 ' s blister. 3/30/23, no documentation of Resident 1 ' s blister. 4/1/23, no documentation of Resident 1 ' s blister. 4/2/23, no documentation of Resident 1 ' s blister. 4/3/23, no documentation of Resident 1 ' s blister. 4/4/23, no documentation of Resident 1 ' s blister. 4/5/23, no documentation of Resident 1 ' s blister. 4/6/23, no documentation of Resident 1 ' s blister. 4/7/23, no documentation of Resident 1 ' s blister. 4/8/23, no documentation of Resident 1 ' s blister. During a concurrent interview and record review on 4/28/23, at 1:47 p.m., with the DON, DON confirmed the above documentation. DON stated the expectation is that the nurses follow the policy. DON stated even if they did not see the blister, the nurses should have seen the dressing. DON gave no other mitigating information. During a review of the facility's policy and procedure (P&P) titled, Resident Examination and Assessment, undated, the P&P indicated, The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Physical Exam . Skin: intactness; . Documentation The following information should be recorded in the resident ' s medical record: . All assessment data obtained during the procedure.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of three sampled residents (Resident 1). This failure had the potential for Residen...

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Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have unmet care needs. Findings: During a review of Resident 1 ' s SBAR Communication Form, (SBAR- situation, background, appearance, review, and notify) dated 3/25/23, the SBAR indicated Resident 1 had a 1cm [centimeter- unit of measure] by 2cm fluid filled blister. During a review of Resident 1 ' s Order Summary Report, (OSR) the ORS indicated, Blister to left thigh front, cleanse area with NS [normal saline], pat dry and paint with betadine [topical antiseptic that provides infection protection against a variety of germs for minor cuts, scrapes, and burns] and cover with dry dressing daily x [times] 14 days. every day shift for tx [treatment] until 04/10/2023 23:59 Order date 03/27/2023 Start Date 03/28/2023 End Date 04/10/2023 During an interview on 4/28/23, at 1:19 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated new wound she notifies the residents medical doctor (MD) and responsibly party (RP), she follows up on orders, updates care plans, and start weekly skin assessments. During an interview on 4/28/23, at 1:35 p.m., with Treatment Nurse (TN), TN stated the nurses will report residents with new wounds to her. TN stated, I will assess and update MD and update care plan. During a concurrent interview and record review on 4/28/23, at 1:47 p.m., with the Director of Nursing (DON), DON reviewed Resident 1 ' s SBAR, dated 3/25/23. DON reviewed Resident 1 ' s electronic medical record and paper medical record. DON confirmed no care plan was developed for Resident 1 ' s blister. DON stated her expectation is appropriate care is given and the nurses ' follow the policy. During a review of the facility ' s policy and procedure (P&P) titled, Goals and Objectives, Care Plans, revised April 2009, the P&P indicated, Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 5. Goals and objectives are reviewed and/or revised: a. when there has been a significant change in the resident ' s condition; .

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to implement the plan of care for one of four sampled resident (Resident 1) when Resident 1 was high risk for falls and fall pre...

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Based on observation, interview, and record review, the facility failed to implement the plan of care for one of four sampled resident (Resident 1) when Resident 1 was high risk for falls and fall precaution was not in place. This failure had the potential for Resident 1 falling multiple times in the facility and potential for injury. Findings: During a review of Resident 1 ' s Care Plan (CP), dated November 22, 2021, the CP indicated, Resident 1 is high risk for falls (exposed to high level of danger). Under intervention: to follow facility fall protocol (fall injury precautions, e.g., low bed, floor mats). During a review of Resident 1 ' s Fall Risk Assessment (FRA), dated January 15, 2023, the FRA indicated, Resident 1 had a history of multiple falls in the last six months. During a review of Resident 1 ' s Nurse ' s Notes (NN), dated March 28, 2023, the NN indicated, Resident 1 had a fall in the bathroom, and upon observation a small bump is on the back of her head. During a review of Resident 1 ' s NN, dated April 10, 2023, the NN indicated, Resident 1 had an unwitnessed fall as Resident 1 was found on the floor between Bed A and bed B. Resident 1 had bump her head as she fell, and she was sent to the emergency department due to vomiting. During a review of Resident 1 ' s SBAR (Situation, Background, Appearance, Review) Communications Form (SBAR), dated April 11, 2023, the SBAR indicated, Resident 1 was sent to emergency room for further evaluation due to an unwitnessed fall. Resident 1 had decreased mobility with complaint of pain to right leg. Resident 1 was noted grimacing, and other pain information indicated hurts when moved. During a review of Resident 1 ' s CP, dated April 10, 2023 and April 11, 2023, the CP indicated, Unwitnessed Fall and Resident had an actual fall with injury: Right femoral fracture. The CP indicated, bilateral floor mats as an intervention. During an observation on 4/20/23, at 1:45 p.m., in Resident 1 ' s room, Resident 1 was lying on her bed with a quarter right upper side rails up, call light within reach, and there were no floor mats on both sides of her bed. During an interview on 4/20/23, at 1:50 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 1 needed floor mats on both sides of her bed. CNA 1 stated, there is no floor mats right now on both sides of Resident 1 ' s bed. During an interview on 4/20/23, at 1;52 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 needed floor mats on both sides of her bed and LVN 1 stated, there is no floor mats right now on both sides of Resident 1 ' s bed. During an interview on 4/28/23, at 1:25 p.m., on the phone, with LVN 2, LVN 2 stated, Resident 1 had a fall on 4/10/23. LVN 2 stated, she heard Resident 1 calling for help. LVN 2 stated, Resident 1 was found on the floor between Bed A and Bed B. LVN 2 stated, Resident 1 did not have floor mats on either side of her bed. During an interview on 5/3/23, at 3:32 p.m., on the phone, with LVN 3, LVN 3 stated Resident 1 had a fall on 4/11/23, and Resident 1 was calling out for help and was found in the bathroom floor where the toilet bowl was overflowing. LVN 3 stated, Resident 1 ' s clothes were very wet and LVN 3 had to ask for help from another staff to transfer Resident 1 on to the wheelchair and transfer her back to bed. LVN 3 stated, she assessed Resident 1 ' s extremities and Resident 1 complained of pain on the right leg. During a review of Minimum Data Set (MDS – comprehensive assessment tool), dated January 11, 2023, the MDS indicated, Resident 1 needed two persons assist for transfers. During a review of facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated March 2018, the P&P indicated, The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Jan 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) responsible party (RP) was notified of a change of condition (COC). This failure had the...

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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) responsible party (RP) was notified of a change of condition (COC). This failure had the potential for Resident 2's RP not to be aware of Resident 2's COC and treatment plan. Findings: During a concurrent interview and record review, on 12/22/22, at 1:48 PM, with Licensed Vocational Nurse (LVN) 1, Resident 2's SBAR (Situation, Background, Appearance, Review, and Notify - communication tool), dated 12/5/22, was reviewed. LVN 1 confirmed Resident 2 had a fall and was sent out to the hospital for evaluation and treatment on 12/5/22. LVN 1 confirmed there was no documentation indicating Resident 2's RP was notified of the COC or transfer to the hospital or documentation of Resident 2's request for RP not to be notified. During an interview on 12/22/22, at 2:31PM, with LVN 2, LVN 2 stated she notifies the resident's RP or emergency contact when the resident has a COC, unless resident request we do not. LVN 2 stated then she makes a note in the progress notes indicating the resident does not want RP to be notified. During an interview on 12/22/22, at 2:39 PM, with LVN 3, LVN 3 stated the only time she does not notify the resident's RP is, if they are self-responsible and have no other contacts on their face sheet. During an interview on 12/22/22, 2:59 PM, with LVN 1, LVN 1 stated the expectation is RP notification should be done when a resident has a COC and especially when the resident is sent out. During a review of the facility policy and procedure (P&P) titled, Falls Management, revised 11/2012, the P&P indicated, Procedure for responding to a fall: . 3.Responsible party is also to be promptly notified of incident, and informed of hospital location in the event the resident had been transferred for evaluation.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a care plan was developed and interventions were implemented one of three sampled residents (Resident 1). This failure had the poten...

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Based on interview and record review, the facility failed to ensure a care plan was developed and interventions were implemented one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have unmet care needs. Findings: During a concurrent interview and record review, on 12/22/22, at 1:08 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 1's SBAR, (Situational, Background, Appearance, Review and Notify – Communication tool), dated 12/3/22. LVN 1 confirmed Resident 1 sustained a fall on 12/3/22. LVN 1 reviewed Resident 1 's clinical record. LVN 1 confirmed there was no an actual fall care plan developed for the fall incident. During an interview on 12/22/22, at 2:39 PM, with LVN 3, LVN 3 stated after a fall incident, the protocol is to complete a fall risk assessment, change of condition, fall scene investigation, create or update a fall care plan, and monitor the resident for 72-hours for delayed or actual injuries. LVN 3 stated care plans help to isolate the problem, and the intervention help to prevent the future falls. During an interview on 12/22/22, at 2:59 PM, with LVN 1, LVN 1 stated the expectation is care plan should be done timely. LVN 1 stated care plans ensure the resident is getting the care they need to prevent any further issues. During a review of the facility policy and procedure (P&P) titled, Falls Management, revised 11/2012, the P&P indicated, Procedure for responding to a fall: . 8. Recent falls will be reviewed daily by a designated facility fall team, to evaluate cause, determine additional strategies as needed to prevent recurrence for each resident and further revise the care plan if needed. The fall team may document their findings or recommendations on an IDT note or on a fall investigative tool per facility protocol.

Jan 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Facilit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Facility Reported Incident: 809907 Representing the Department: 46958, HFEN 47444, HFEN 27137, HFES The inspection was limited to the specific facility reported incident and does not represent the findings of a full inspection of the facility. One deficiency was written for facility reported incident 809907. Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) was free from sexual abuse. This resulted in Resident 1 being the victim of sexual assault from Resident 2. Findings: During an interview on 11/8/22, at 10:55 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, that on 11/1/22, she saw Resident 1 sitting in wheelchair in the Activity Room with her hands folded together front of her on her lap, and Resident 2 was lifting Resident 1's shirt up and was putting Resident 1's breast in his mouth. CNA 1 stated this happened between 3:30 PM and 4 PM. CNA 1 stated, Resident 1 was in her wheelchair and Resident 2 was in his wheelchair. CNA 1 stated she said to Resident 2, what are you doing? Go away from [Resident 1]! and then Resident 2 stopped. CNA 1 stated that Resident 2 acted surprised and Resident 2 moved away from Resident 1. CNA 1 brought Resident 1 in her wheelchair to licensed nurses at the nurse's station. During an interview on 11/8/22, at 12:15 PM, with Registered Nurse (RN) 1, RN 1 stated, she has been working at this facility for a month and she knows Resident 1. RN 1 stated Resident 1 is unable to make her own decisions. During an interview on 11/8/22, at 12:30 PM with RN 2, RN 2 stated, she has been working here for couple months and she knows both Resident 1 and Resident 2. RN 2 stated, Resident 1 cannot make her own decisions. RN 2 stated, Resident 2 cannot make his own decisions. RN 2 stated after the incident of Resident 2 that he had stated to her, I am sorry and won't do it again. During a review of Resident 1's History and Physical (H&P), dated 2/22, the H &P indicated, Resident 1 does not have capacity to understand choices and make healthcare decisions. The H&P was signed by Resident 1's physician. During a review of Resident 1's Minimum Data Set (MDS, standardized assessment tool), dated 9/12/22, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) indicated severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 had diagnoses that included dementia (a progressive brain disease that effects memory, thinking, and personality change). During a review of Resident 1's Progress Note, dated 11/1/22, at 3:56 PM, the Progress Note indicated Resident 1 was found in dinning [sic] room beside [Resident 2] CNA [CNA 1] observed [Resident 1]'s shirt put up and mouth is on her breast. During a review of Resident 2's H&P, dated 5/22, the H&P indicated, Resident 2 does not have capacity to make decisions. Resident 2's H&P was signed by his physician. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS is 12 which indicates a moderate cognitive impairment. During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 had diagnoses that included dementia, and schizoaffective disorder (a serious mental condition disrupting thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, and a withdrawal from reality). During a review of Resident 2's Progress Note, dated 11/1/22, at 9:49 PM, the Progress Note indicated, [CNA 1] was walking by at [3:30 PM] dinning [sic] room and saw this resident touching inappropriately to another female resident [Resident 1]. [CNA 1] noticed this resident rouching female resident's breast. Residents were separated immediately. No physical injury noted. On asking [Resident 2] stated A girl outside shouting at me. In dining room I touched her but I won't do it again. Progress Note was written by RN 2. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition & Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime Policy and Procedure, dated 8/22, the P&P indicated, This facility prohibits and prevents abuse, neglect, exploitation, misappropriation of property, and mistreatment. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, and any other individuals. It is presumed that instances of abuse for all residents, even those in a coma, can cause physical harm, pain, and/or mental anguish. Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) was free from sexual abuse. This resulted in Resident 1 being the victim of sexual assault from Resident 2. Findings: During an interview on 11/8/22, at 10:55 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, that on 11/1/22, she saw Resident 1 sitting in wheelchair in the Activity Room with her hands folded together front of her on her lap, and Resident 2 was lifting Resident 1's shirt up and was putting Resident 1's breast in his mouth. CNA 1 stated this happened between 3:30 PM and 4 PM. CNA 1 stated, Resident 1 was in her wheelchair and Resident 2 was in his wheelchair. CNA 1 stated she said to Resident 2, what are you doing? Go away from [Resident 1]! and then Resident 2 stopped. CNA 1 stated that Resident 2 acted surprised and Resident 2 moved away from Resident 1. CNA 1 brought Resident 1 in her wheelchair to licensed nurses at the nurse's station. During an interview on 11/8/22, at 12:15 PM, with Registered Nurse (RN) 1, RN 1 stated, she has been working at this facility for a month and she knows Resident 1. RN 1 stated Resident 1 is unable to make her own decisions. During an interview on 11/8/22, at 12:30 PM with RN 2, RN 2 stated, she has been working here for couple months and she knows both Resident 1 and Resident 2. RN 2 stated, Resident 1 cannot make her own decisions. RN 2 stated, Resident 2 cannot make his own decisions. RN 2 stated after the incident of Resident 2 that he had stated to her, I am sorry and won't do it again. During a review of Resident 1's History and Physical (H&P), dated 2/22, the H &P indicated, Resident 1 does not have capacity to understand choices and make healthcare decisions. The H&P was signed by Resident 1's physician. During a review of Resident 1's Minimum Data Set (MDS, standardized assessment tool), dated 9/12/22, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) indicated severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 had diagnoses that included dementia (a progressive brain disease that effects memory, thinking, and personality change). During a review of Resident 1's Progress Note, dated 11/1/22, at 3:56 PM, the Progress Note indicated Resident 1 was found in dinning [sic] room beside [Resident 2] CNA [CNA 1] observed [Resident 1]'s shirt put up and mouth is on her breast. During a review of Resident 2's H&P, dated 5/22, the H&P indicated, Resident 2 does not have capacity to make decisions. Resident 2's H&P was signed by his physician. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS is 12 which indicates a moderate cognitive impairment. During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 had diagnoses that included dementia, and schizoaffective disorder (a serious mental condition disrupting thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, and a withdrawal from reality). During a review of Resident 2's Progress Note, dated 11/1/22, at 9:49 PM, the Progress Note indicated, [CNA 1] was walking by at [3:30 PM] dinning [sic] room and saw this resident touching inappropriately to another female resident [Resident 1]. [CNA 1] noticed this resident rouching female resident's breast. Residents were separated immediately. No physical injury noted. On asking [Resident 2] stated A girl outside shouting at me. In dining room I touched her but I won't do it again. Progress Note was written by RN 2. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition & Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime Policy and Procedure, dated 8/22, the P&P indicated, This facility prohibits and prevents abuse, neglect, exploitation, misappropriation of property, and mistreatment. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, and any other individuals. It is presumed that instances of abuse for all residents, even those in a coma, can cause physical harm, pain, and/or mental anguish.

Dec 2022 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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to accurately assess one of three sampled residents (Resident 1). This failure has the potential for Resident 1 to have unmet care needs. Find...

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Based on interview and record review, the facility failed to accurately assess one of three sampled residents (Resident 1). This failure has the potential for Resident 1 to have unmet care needs. Findings: During an interview on 10/31/22, at 1 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated The weekly skin check list is posted in the nurses station, we perform two resident skin assessments each shift based on their room number, two resident skin assessments on the AM shift and two resident skin assessments on the PM shift. LVN 1 stated, We look at the resident's skin for any new redness, dryness, open areas. We document old wounds and any new wounds. During an interview on 10/31/22, at 1:40 PM, with Registered Nurse (RN) 1, RN 1 stated We perform skin assessments based on room number according to the posted weekly skin check list, we do two resident skin assessments on the AM shift and two resident skin assessments on the PM shift. RN 1 stated, We assess the resident from head-to-toe front to back, we document old wounds and any new skin issues. During a concurrent interview and record review, on 10/31/22, at 1:49 PM, with Interim Director of Nursing (IDON), IDON reviewed Resident 1's Weekly Skin Check, (WSC) dated 10/15/22 and 10/22/22. IDON confirmed WSC dated 10/15/22 and 10/22/22, indicated Resident 1 had No new skin issues noted this time. IDON reviewed the SBAR (situation, background, appearance, and review) Communication Form, (SBAR) dated 10/16/22. IDON confirmed the SBAR indicated Resident 1 had a stage II (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) pressure injury (PI-localized damage to the skin and underlying soft tissue usually over a bony prominence) to the right iliac crest region (the curved area at the top of the largest of three bones that make up the pelvis). IDON confirmed there was no documentation of a PI on the WSC dated 10/22/22. IDON stated, The expectation is the nurse puts eyes on the body, and document what they see. During a review of the facility's policy and procedure (P&P) titled, Skin Assessment, revised June 2018, the P&P indicated, A skin evaluation will be performed on the date of admission and at the following intervals: . 5. Weekly Skin Check: Licensed Nurse weekly summary CA .1. Document all findings, including measurements in the MR (medical record) .

Jun 2021 12 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · 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 provide adequate nutrition for one of 44 sampled resi...

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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 provide adequate nutrition for one of 44 sampled residents (Resident 44) when: 1. The nursing staff did not notify the Primary Care Physician (PCP) and the Family Member (FM) 2 of Resident 44's unplanned weight loss. 2. A care plan addressing unplanned weight loss was not developed and implemented. 3. Ensure the Interdisciplinary Team (IDT - a group of healthcare professionals who work together to provide beneficial care to the residents) addressed the significant weight loss. 4. Dietary recommendations by the Registered Dietician (RD) were not implemented. These failures resulted in Resident 44's unplanned total weight loss of 39 lbs (Pounds-unit of measure) (-15.4%) in 45 days. Findings: 1. During a review of Resident 44's admission Record (AR), undated, the AR indicated, Resident 44 was admitted on [DATE] with a diagnosis of Cutaneous Abscess (Skin infection) of the right lower limb. During a review of Resident 44's Weights and Vitals Summary (WVS), the WVS indicated: 5/1/21: 255.8 lbs 5/8/21: 248.4 lbs 5/16/21: 242.2 lbs 6/1/21: 241.4 lbs (weight loss of 14.4 lbs [-5.6%] in 30 days) 6/13/21: 216.4 lbs (weight loss of 39.4 lbs [-15.4%] in 45 days). During a concurrent interview and record review on 6/23/21, at 8:01 AM, with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), Resident 44's Progress Notes (PN), dated 5/1/21 to 6/15/21 was reviewed. ADON/IP was unable to find documentation the PCP and FM 2 were notified of Resident 44's weight loss. During a concurrent observation and interview on 6/23/21, at 11:37 AM, in Resident 44's room, Resident 44 was observed lying in bed with FM 2 sitting at bedside. Resident 44 and FM 2 stated they were unaware of the weight loss. FM 2 stated, Nobody has talked to us about her [Resident 44] diet or food preference. I'm here every day and I haven't spoken to any dietician [Registered Dietician (RD) a food and nutrition expert]. During an interview on 6/24/21, at 8:53 AM, with Director of Nursing (DON), DON stated the PCP and family should have been notified of Resident 44's significant weight loss. During a review of facility's policy and procedure (P&P) titled, CHANGE OF CONDITION, RESIDENT, dated 11/17, the P&P indicated, It is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. 2. During a concurrent interview and record review on 6/23/21, at 8:40 AM, with the Director of Staff Development/Infection Preventionist (DSD/IP), Resident 44's Care Plan (CP) was reviewed. DSD/IP was unable to provide a weight loss prevention CP for Resident 44. DSD/IP stated a CP should have been developed by the IDT when the 14 lbs weight loss was noted. During an interview on 6/24/21, at 8:53 AM, with DON, DON stated a CP should be in place for Resident 44's weight loss. During a review of the facility's P&P titled, WEIGHT MANAGEMENT SYSTEM, dated 11/12, the P&P indicated, Residents with poor intake, significant weight loss. or other risk factors placing the resident at risk, will have appropriate measures implemented in their plan of care to promote weight gain and increase food and fluid consumption. 3. During a concurrent interview and record review on 6/23/21, at 8:40 AM, with ADON/IP, Resident 44's IDT was reviewed. ADON/IP was unable to provide documentation of an IDT meeting addressing Resident 44's weight loss of 14.4 lbs (-5.6%) in 30 days. During an interview on 6/24/21, at 8:40 AM, with DON, DON stated, We [Social Service Director, DSD/IP, ADON/IP, RD] meet weekly for skin and weight variance every Monday. I was unaware of her 14.4 lbs weight loss on [6/1/21]. We should have caught that on our weekly meeting. During a review of the facility's P&P titled, WEIGHT MANAGEMENT SYSTEM, dated 11/12, the P&P indicated, 8. Significant weight gain or desired weight loss will be reviewed by the IDT to determine clinical appropriateness, and have plans of care established with measurable goals to meet each resident's individual needs. 9. The Interdisciplinary Team will meet weekly to review new admissions, residents with significant weight changes, and residents with significant changes in eating patterns. 4. During a concurrent interview and record review on 6/23/21, at 8:01 AM, with ADON/IP, Resident 44's Nutritional Assessment (NA), dated 4/30/21 was reviewed. The NA indicated, Recommend to add NEM [Nutritional Enhanced Meal] and small portions to current diet, House supplements 120 milliliters [ml - a unit of measurement] TID [three times a day] with meals, & Medpass (fortified nutritional shake) 90 mls QID [four times a day] between meals. ADON/IP verified the NA was completed by the RD on 4/30/21. ADON/IP was unable to provide documentation that the RD's NA dietary recommendations were implemented for Resident 44.

CONCERN (D)

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

Deficiency F0561 (Tag F0561)

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 provide and facilitate smoking activity for one of 44...

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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 provide and facilitate smoking activity for one of 44 sampled residents (Resident 49). This failure resulted in Resident 49's inability to exercise his rights regarding activity preferences. Findings: During a review of Resident 49's admission Record (AR), undated, the AR indicated, Resident 49 was admitted on [DATE]. The Minimum Data Set (MDS-an assessment tool), dated 5/12/21, was reviewed. The MDS indicated, Resident 49 was able to think coherently, clearly, logically and had no altered level of consciousness. During a concurrent observation and record review, on 6/22/21, at 11:11 AM, with Resident 49, in his room, Resident 49 was observed lying in bed with a smoking schedule signage posted on the wall. Resident 49 stated, They put the schedule up so I can see the times when to go out and smoke. I used to smoke, but the facility doesn't allow me to smoke anymore. I don't mind getting up to smoke, but they won't let me. It makes me mad and flustered that they won't let me smoke. Resident 49 stated he never informed staff he wished to stop smoking. During a concurrent observation and interview on, 6/22/21, at 11:24 AM, with Resident 49 and Activities Director (AD), in Resident 49's room, AD stated, During the pandemic, [Resident 49] stopped smoking. We don't have any patients who smoke. Resident 49 stated, I was smoking even then. You guys just made me stop, told me I couldn't smoke anymore. During an interview on 6/22/21, at 9:13 AM, with Assistant Director of Nursing/Infection Preventionist (ADON/IP), ADON/IP stated, [Resident 49] was a previous smoker. They [administration] don't want him to smoke . [Resident 49] should be allowed to smoke. It's his right. During an interview on 6/23/21, at 10:05 AM, with Certified Nursing Assistant (CNA) 3, CNA 3 stated, Nobody is allowed to smoke here. They stopped letting the residents smoke. During an interview on 6/23/21, at 10:08 AM, with CNA 4, CNA 4 stated, [Resident 49] used to smoke, but they told us the facility doesn't allow smoking anymore. [Resident 49] is always asking to go out to smoke. During a concurrent interview and record review on 6/24/21, at 10:15 AM, with AD, Resident 49's annual and quarterly Activity Participation Review (APR), dated 5/13/21, 2/15/21, and 11/13/2020 were reviewed. The APR's indicated it was very important for Resident 49 to go outside and get fresh air with specific preference: To go smoke. AD verified the findings and stated Resident 49 had been smoking since his admission to the facility and never verbalized he wanted to stop. During a concurrent interview and record review on 6/24/21, at 10:21 AM, with Minimum Data Set Coordinator (MDSC), Resident 49's smoking Care Plan (CP), dated 10/11/18, was reviewed. The CP indicated the smoking CP was discontinued on 12/8/20. MDSC verified the findings. MDSC stated, I was informed by them that [Resident 49] no longer smokes. MDSC was unable to provide documentation or name of who informed her Resident 49 no longer smoked. MDSC stated she did not assess Resident 49 or verify the information. MDSC verified Resident 49's smoking assessment was completed and no smoking cessation plan was implemented per policy and procedure (P&P). During an interview on 6/22/21, at 11:24 AM, with Director of Nursing (DON), DON stated, For residents who were previous smokers like [Resident 49], if they want to continue smoking, it is their rights to do so. During a review of the facility's P&P titled, SMOKING POLICY, dated 10/24/17, the P&P indicated, It is the policy of the facility to allow residents to exercise their individual rights with regard to smoking in a manner that does not jeopardize other residents, facility property and the individual resident exercising that right.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive assessment (CA) after a significant change...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive assessment (CA) after a significant change in the resident's condition for one of 44 sampled residents (Resident 44). This failure had the potential to result in delay of treatment, planning of care, and provision of appropriate services for Resident 44. Findings: During a review of Resident 44's admission Record (AR), undated, the AR indicated Resident 44 was admitted on [DATE] with a diagnosis of Cutaneous Abscess (Skin abscess) of the right lower limb. During a review of Resident 44's Wound Nursing Home Visit Notes (WN), dated 5/21/21, the WN indicated, Resident 44 developed a Stage 2 Pressure Ulcer (PU-partial thickness loss of skin) to sacral area (base of the spine to the tailbone). During a review of Resident 44's Weights and Vitals Summary (WVS), dated 5/21 and 6/21, the WVS indicated, the weights as follows: 5/1/21: 255.8 pounds (lbs-unit of measurement) 5/8/21: 248.4 lbs 5/16/21: 242.2 lbs 6/1/21: 241.4 lbs (weight loss of 14.4 lbs [-5.6%] in 30 days) 6/13/21: 216.4 lbs (weight loss of 39.4 lbs [-15.4%] in 45 days) During a concurrent interview and record review on 6/23/21, at 8:40 AM, with Assistant Director of Nursing/IP (ADON/IP), Resident 44's Treatment Administration Record (TAR), dated 5/1/21 to 5/31/21 and WVS dated 5/21 and 6/21 were reviewed. The TAR indicated Resident 44 developed a PU to sacral area on 5/21/21. The WVS indicated a weight loss of 14.4 lbs (-5.6%) in 30 days. ADON/IP verified the finding and stated the weight loss and development of PU should have been identified as a significant change in condition. During an interview on 6/23/21, at 2:16 PM, with Minimum Data Set Coordinator (MDSC), MDSC verified a comprehensive assessment was indicated after Resident 44's significant change weight of 14.4 lbs (-5.6%) in 30 days and development of a Stage 2 PU. During a concurrent interview and record review, on 6/24/21, at 8:56 AM, with Director of Nursing (DON), Resident 44's TAR, dated 5/21/21 and WVS, dated 6/1/21 were reviewed. DON verified Resident 44 developed a Stage 2 PU on 5/21/21 and had a significant weight loss of 14.4 lbs (-5.6%) in 30 days documented on 6/1/21. DON stated the Interdisciplinary Team (IDT-a group of healthcare professionals who work together to provide beneficial care to the residents) failed to address Resident 44's weight loss and development of the PU during the weekly skin and weight variance meetings. DON stated a significant change assessment should be completed in a timely manner. During a review of facility's policy and procedure (P&P) titled, CHANGE OF CONDITION, RESIDENT, dated 11/17, the P&P indicated, It is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. During a review of the facility's P&P titled, INTERDISCIPLINARY TEAM (IDT)/RESIDENT CARE PLAN CONFERENCE REVIEW (RCC), dated 11/17, the P&P indicated, IDT meetings are an ongoing process throughout a resident's stay and is an integral part of the daily IDT discussion/communication to best meet the needs of the resident.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities to identify health p...

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Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities to identify health problems) reflected the accurate status for one of 44 sampled residents (Resident 49). This failure had the potential to negatively affect Resident 49's plan of care and delivery of services. Findings: During an interview on 6/22/21, at 11:22 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 49 refuses to get out of bed, eat, and take his medications. During a concurrent observation and interview on 6/22/21, at 1:10 PM, with Resident 49, in his room, Resident 49 was observed lying in bed. Resident 49 stated he does not like to take his medications at times. No other staff members except the nurses who give him his medications have addressed this issue with him. During a concurrent interview and record review on 6/24/21, at 2:29 PM, with MDS Coordinator (MDSC), Resident 49's MDS (Section E - Behavior), dated 5/12/21 was reviewed. The MDS indicated, Resident 49's Rejection of Care - Presence & Frequency was 0 (0 - Behavior not exhibited). MDSC verified the findings and verified assessment for this question should reflect seven days back (5/6/21 to 5/12/21) from the date of assessment. During a concurrent interview and record review on 6/24/21, at 2:34 PM, with Social Service Director (SSD) and MDSC, Resident 49's Progress Notes (PN), dated 5/5/21 to 5/12/21 and Medication Administration Record (MAR), dated 5/5/21 to 5/12/21 were reviewed. The PN indicated, Resident 49 refused to take his medications on 5/5/21, 5/6/21, 5/7/21, 5/8/21, 5/9/21, 5/10/21, 5/11/21, and 5/12/21. The MAR indicated, Resident 49 refused to take his medications on 5/8/21, 5/9/21, 5/10/21, 5/11/21, and 5/12/21. MDSC stated, I do the oversight of the overall MDS assessment. SSD verified he completed the assessment on 5/12/21 and his assessment should reflect seven days back. I should've assessed it [Resident 49's refusal to take medications] correctly and discussed it during IDT (Interdisciplinary Team - a group of healthcare professionals who work together to provide beneficial care for residents) care conference. During a review of the facility's policy and procedure (P&P) titled, RESIDENT ASSESSMENT INSTRUMENT (RAI/MDS), dated 11/12, the P&P indicated, Policy: The Resident Assessment Instrument will be completed timely and accurately, per Federal Guidelines, and will serve as a foundation for the comprehensive care planning process.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to follow a physicians order for one of 44 sampled residents (Resident 39) when a positioning device was not implemented. This fa...

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Based on observation, interview and record review, the facility failed to follow a physicians order for one of 44 sampled residents (Resident 39) when a positioning device was not implemented. This failure had the potential for skin breakdown. Findings: During a review of Resident 39's Order Summary Report (OSR), dated 6/22/21, the OSR indicated, Turn resident (Resident 39) every 2 hours, float heals [sic] in the morning During a concurrent observation, interview, and record review, on 6/22/21, at 9:33 AM, with LVN l, in Resident 39's room, Resident 39 was lying in his bed with no positioning device to float his left heel. Resident 39's OSR, dated 6/22/21 was reviewed. LVN 1 verified Resident had an order to float heels in the morning. LVN 1 verified there was no positioning device underneath Resident 39's left heel as ordered. During a review of the facility's policy and procedure (P&P) titled, Physician orders, accepting, transcribing and implementing (Noting), the P&P indicated, Licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure assistive care was provided for two of 44 sampled residents (Resident 26 and Resident 39). This failure had potential ...

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Based on observation, interview, and record review, the facility failed to ensure assistive care was provided for two of 44 sampled residents (Resident 26 and Resident 39). This failure had potential for emotional discomfort and decline in functional abilities. Findings: During a concurrent observation and interview on 6/21/21, at 10:28 AM, with resident 26, in Resident 26's room, Resident 26 was lying in his bed wearing a facility gown. Resident 26 stated, he had not been out of his bed for a few days and a staff member was supposed to get him out of bed. During a concurrent observation and interview on 6/22/21, at 11:49 AM, with Resident 26, in Resident 26's room, Resident 26 was lying in his bed wearing a facility gown. Resident 26 stated, he would like to get up and out of his bed. Resident 26 stated, he would also like to be changed into his own personal clothes. During a review of Resident 26's Minimum Data Set (MDS-an assessment tool), dated 4/13/21, the MDS indicated, Section G - Functional Status. Activities of Daily Living (ADL) Assistance.1. Self - performance. extensive assistance with one-person physical assist. B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position.G. Dressing - how resident puts on, fastens and takes off all items of clothing.extensive assistance with one-person physical assist. During a concurrent observation and interview on 6/24/21, at 12:42 AM, with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), in Resident 26's room, Resident 26 was lying in his bed. Resident 26 stated, the staff are not getting him dressed and out of bed, and he would like to get out of bed at least every other day. ADON/IP verified Resident 26's request to get up and out of bed and dressed into his personal clothing. During a concurrent observation and interview on 6/21/21, with Resident 39, in Resident 39's room, Resident 39 was lying in his bed, dressed in a facility gown. Resident 39 stated, he would like to get up and get dressed every day. Resident 39 stated, he was unable to move his left arm or left leg. During a concurrent observation and interview on 6/21/21, at 2:51 PM, with Family Member (FM) 1, and Resident 39, FM 1 stated, Resident 39 wanted to get up and out of bed everyday but they do not get him up until I get here which is in the afternoon. Resident 39 was tearful when FM 1 expressed these concerns. During a review of Resident 39's Minimum Data Set (MDS-an assessment tool), dated 4/28/21, the MDS indicated, Section G - Functional Status, G0110. Activities of Daily Living (ADL) Assistance . 1. Self - performance . extensive assistance with two-person physical assist. B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . extensive assistance with two-person physical assist. two person's physical assist. G. Dressing - how resident puts on, fastens and takes off all items of clothing . extensive assistance with two-person physical assist. During an interview on 6/23/21, at 3:11 PM, with Resident 39, FM 1, and Director of Nursing (DON), Resident 39 was tearful when he told the DON he was not being dressed or helped out of bed. DON validated Resident 39's concerns. During a review of the facility's policy and procedure (P&P) titled, Resident Care, Routine, dated 11/12, the P&P indicated, It is the policy of this facility that basic nursing care tasks will be provided for each resident based on resident needs. These tasks are associated with the resident's personal cleanliness, routine activities of daily living, nutrition, elimination, comfort, activity, rest and sleep. All these nursing activities may be modified to suit each resident's preferences and individual needs. 5. a. Assist residents with grooming, as needed. (1) Perform grooming task for those residents unable to function independently. (6). Each resident shall be out of bed daily unless the physician has issued specific orders for bed rest.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure restorative nursing services (person-centered care designed to improve or maintain the functional ability of residents...

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Based on observation, interview, and record review, the facility failed to ensure restorative nursing services (person-centered care designed to improve or maintain the functional ability of residents) were provided for one of 44 sampled residents (Resident 39). This failure had the potential for Resident 39 to not maintain his highest level of physical function. Findings: During a concurrent observation and interview on 6/21/21, at 11:12 AM, with Resident 39, in Resident 39's room, Resident 39 was lying in his bed and stated he was unable to move his left arm and left leg. Resident 39 stated, he had been admitted to the nursing facility after having a stroke (when blood supply to a part of the brain is interrupted or reduced) to receive physical therapy. Resident 39 stated, his physical therapy had stopped, and he had been told he was going to have someone come in to exercise his body, but this had not occurred. During an interview on 6/21/21, at 2:51 PM, with Resident 39, and Family Member (FM) 1, FM 1 stated, the reason we came to this facility was because we were told they had excellent therapy services. FM 1 stated, Resident 39 had physical therapy for a short time when he first was admitted but therapy had stopped. During a concurrent interview and record review, on 6/23/21, at 2:30 PM, with Assistant Director of Nursing/Infection Preventionist (ADON/IP), Resident 39's Order Summary Report (OSR), dated 6/22/21 was reviewed. The OSR indicated physical therapy was ordered 4/22/21. The PT order indicated, [Resident 39] will be seen 6/week (6 times a week) for 4 weeks. ADON/IP stated a restorative nursing program (RNP-Nursing interventions to improve or maintain function ability) should have been implemented after PT was completed. ADON/IP was unable to provide an order for RNP. During a review of Resident 39's Physical Therapy Discharge Summary (PTDS), dated 5/5/21, the PTDS indicated, Prognosis to Maintain CLOF [current level of function] = Good with consistent staff follow-through. During an interview on 6/23/21, at 3:11 PM, with the Director of Nursing (DON), Resident 39, and FM 1, DON stated, RNP for Resident 39 should have been implemented. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Program, dated 1/14, the P&P indicated, The facility provides restorative nursing services by trained nursing staff, in a safe and effective manner, to help residents maintain or regain the highest practicable and functional level possible, within constraints of the resident's disease process .V. Identification and Evaluation of Residents Restorative Needs C. Residents may be referred to the Restorative Nursing Program by the Rehab (rehabilitation) Department prior to, or at the completion of, licensed therapy services, (i.e., Speech Therapy, Occupational Therapy, Physical Therapy). VI. Types of Restorative Nursing Services Provided A. The RNA (Restorative Nursing Aide) is trained to provide services which include restorative techniques that will assist the resident to improve or maintain abilities in the area of : Range of Motion (passive, active, active assistive), Splint or Brace Assistance, Bed Mobility, Transfers, Ambulation/Walking, Dressing or Grooming, Eating or Swallowing, Amputation/Prosthesis Care, Communication.

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, and record review, the facility failed to ensure medication error rate was five percent or less when two medication errors were observed out of 26 medication administr...

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Based on observation, interview, and record review, the facility failed to ensure medication error rate was five percent or less when two medication errors were observed out of 26 medication administration opportunities, which yielded a medication error rate of 7.69 percent. These failures had the potential for residents to not receive the therapeutic effects of the medications. Findings: During a medication pass observation on 6/23/21, at 12:05 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 removed Resident 20's Terazosin (for high blood pressure) 2 mg (milligrams-unit of measure) capsule from the medication bubble pack (MBP) (medication capsule in individual compartments), opened capsule and placed contents in medicine cup. LVN 2 did not review Resident 20's MBP label. LVN 2 gave Terazosin 2 mg via G tube (gastric tube - tube inserted into stomach for food and medication administration). During a concurrent interview and record review on 6/23/21, at 12:05 PM, with LVN 1, the MBP label was reviewed. The MBP label indicated Terazosin 2 mg capsule, 1 capsule via G tube every morning and take 2 capsules 4 mg at bedtime. The information was verified by LVN 2. LVN 2 stated the eMAR (electronic medication administration record) has Resident 20's dose of Terazosin 2 mg scheduled at noon. LVN 2 stated the eMAR and the label on the bubble pack should match. LVN 2 stated she should have checked the Resident 20's eMAR, label, and physician orders to ensure they were correct prior to giving medication. During a concurrent interview and record review, on 6/23/21, at 2:21 PM with Director of Nursing (DON), Resident 20's physician's order (PO) summary, dated 5/19 was reviewed. The physician order indicated Terazosin HCL capsule 2 mg give 1 capsule via G tube one time a day. DON stated one time a day administration time is 9 AM. DON stated the medication nurse (LVN 2) should have checked the medication orders prior to medication administration. During a concurrent medication pass observation and interview on 6/23/21, at 8:14 AM, with LVN 1, in Resident 56's room, LVN 1 stated Resident 56's Travatan Z Solution (medication to treat high pressure in the eye) was unavailable for administration. During a review of Resident 56's Order Summary Report (OSR), dated 6/24/21, the OSR indicated, Travatan Z Solution. instill 1 drop in both eyes two times a day. During a concurrent interview and record review on 6/23/21, at 12:14 PM, with DON, Resident 56's medication administration record (MAR), dated 6/24/21, was reviewed. DON verified Travatan Z Solution eye drops were ordered two times a day for Resident 56. DON stated Travatan Z Solution was not given to Resident 56 as ordered. During a review of the facility policy and procedure (P&P) titled, Medication Administration-General Guidelines, dated 8/18, the P&P indicated, Medications are administered as prescribed. A. Preparation 4) Five Rights-Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. During a review of the facilities policy and procedure (P&P) titled, PREPARATION AND GENERAL GUIDELINES, dated 8/18, the P&P indicated, Prior to administration of any medication, the medication and dose schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different. the physician's orders are checked for the correct dosage schedule.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to implement infection control standards, when staff didn't perform hand hygiene. This failure had the potential to spread illne...

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Based on observation, interview, and record review, the facility failed to implement infection control standards, when staff didn't perform hand hygiene. This failure had the potential to spread illness and disease to two of 44 residents (Resident 21 and Resident 221). Findings: During a concurrent observation and interview on 6/21/21, at 12:51 PM, with Certified Nursing Assistant (CNA) 1, in the South Hallway, CNA 1 pushed a meal tray cart into the South Hallway. CNA 1 opened the door to the meal tray cart and removed the tray for Resident 221 without performing hand hygiene. CNA 1 knocked on the door before entering the room and delivered Resident 221's tray. CNA 1 exited the room and did not perform hand hygiene. CNA 1 removed Resident 21's tray from the meal cart and entered the room. CNA 1 retrieved a bedside table from another room for Resident 21. CNA 1 arranged the bedside table for Resident 21 and placed the meal tray on the table. CNA 1 then came out of the room and removed a third tray from the cart without performing hand hygiene. CNA 1 verified she did not perform hand hygiene and stated she should have washed my hands before touching each meal tray. During an interview on 6/24/21, at 8:41 AM, with Assistant Director of Nursing/Infection Preventionist (ADON/IP), ADON/IP stated her expectation is for hand hygiene to be performed before removing first tray from cart, exiting room, touching inanimate objects, and before removing the next tray. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene Program, dated 1/10/19, the P&P indicated, Indications for performing hand hygiene [:] Before and after contact with resident or their environment. Before or after preparing food (includes before eating or serving food to residents).

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to revise the care plan for one of 44 sampled residents (Resident 50). This failure had the potential for unmet care needs. Find...

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Based on observation, interview, and record review, the facility failed to revise the care plan for one of 44 sampled residents (Resident 50). This failure had the potential for unmet care needs. Findings: During a concurrent observation and interview on 6/21/21, at 1 PM, with Resident 50, in the dining room, Resident 50 was observed eating a mechanical soft diet (foods made easier to chew and swallow). Resident 50 stated, I do not know why I am still eating a mechanical soft diet. I want to eat real food. During a review of Resident 50's Order Details (OD), dated 11/7/20, the OD indicated, Mechanical Soft, chopped meat texture, Nectar Thick Consistency [fluids thickened for residents with difficulty swallowing]. During a concurrent interview and record review on 6/24/21, at 9:28 AM, with Assistant Director of Nursing/Infection Preventionist (ADON/IP). ADON/IP was unable to provide a care plan addressing Resident 50's need for mechanical soft diet. During a review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team (IDT), dated 11/17, the P&P indicated 1. The interdisciplinary team (IDT), in conjunction with the resident and/or resident representative, as appropriate, shall meet to develop a comprehensive person-centered care plan with quantifiable objectives for the highest level of functioning the resident may be expected to attain, to meet the resident's medical, nursing, mental and psycho-social needs that are identified in the comprehensive assessment and CAA [Care Area Assessment - designed to assist in information recorded in the MDS] Summary.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to label a multiple-dose insulin (regulates the amount of glucose in the blood) pen (an injection device with a needle that deli...

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Based on observation, interview, and record review, the facility failed to label a multiple-dose insulin (regulates the amount of glucose in the blood) pen (an injection device with a needle that delivers insulin underneath the skin) in the medication cart. This failure had the potential for medication to be given to the wrong resident. Findings: During a concurrent observation and interview on 6/23/21, at 9:10 AM, with Licensed Vocational Nurse (LVN) 1, at medication cart 1, an unlabeled Novolog (brand of insulin) Insulin Pen was noted with a labeled date of 6/22/21. LVN 1 stated, she had removed the insulin pen from the emergency kit (E-Kit - medication that can be dispensed when pharmacy services are not available) yesterday, and dated it with the date opened and administered a dose of insulin to a resident. LVN 1 stated, she did not label the insulin pen with the resident's name. During a concurrent observation and interview on 6/23/21, at 9:40 AM, with the Director of Nursing (DON) and LVN 1, the unlabeled Novolog Insulin Pen was observed. DON verified the insulin pen was not labeled with the Resident's name. DON stated the insulin pen should should have been labeled with the resident's name. During a review of the facility policy and procedure (P&P) titled, Medication Ordering and receiving from Pharmacy, dated 8/18, the P&P indicated, Medications are labeled in accordance with facility requirements and state and federal laws. B. Each prescription medication label includes: 1) Residents name.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to properly maintain sanitary kitchen and food storage areas. These failures had the potential to spread food borne illness to r...

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Based on observation, interview, and record review, the facility failed to properly maintain sanitary kitchen and food storage areas. These failures had the potential to spread food borne illness to residents. Findings: During a concurrent observation and interview on 6/21/21, at 9:59 AM, with Cook, in the facility kitchen, the handwashing sink had dried debris and food crumbs in the basin and rim of the sink. [NAME] verified the findings. A stainless-steel tray was located on the immediate left side of the handwashing sink. The tray held cylinders of eating utensils. The top portion of the tray had dried water spots and food crumbs around the cylinder utensil holders. [NAME] stated the utensils being stored in the tray were clean. [NAME] verified the tray holding the clean utensils was not clean. During a concurrent observation and interview on 6/21/21, at 10:03 AM, with Cook, in the kitchen near the dishwasher, two bowls on drying racks had food crumbs on their exposed surface. [NAME] stated the bowls on the drying racks were clean and verified the findings. A stainless-steel counter, on the clean side of the dishwasher, had food crumbs on its surface. A slotted rack below a stainless-steel counter had orange-colored stains, food crumbs, and debris in the slots. A large black bin, stored on the slotted rack, had a large amount of debris, pieces of paper, plastic, used individual pepper packet, and two torn pieces of an artificial sweetener packet, in the storage portion of the bin. The floor, on the clean side of the dishwasher, beneath the stainless-steel counter had food crumbs on it. [NAME] verified the findings. During a concurrent observation and interview on 6/21/21, at 10:09 AM, with Cook, in the dry food storage area, two large plastic storage bags filled with croutons were on the top shelf of a stainless-steel storage shelving. Neither storage bag was labeled or dated. [NAME] verified the findings. During a concurrent observation and interview on 6/21/21, at 10:14 AM, with Cook, Director of Nursing (DON), and dietary aide (DA) in the kitchen, grease, grime, and food crumbs buildup was noted on stove tops, oven frames, and can opener. DON and [NAME] verified findings. DA stated cleaning was to be done after each meal prep. During a concurrent observation and interview on 6/21/21, at 10:20 AM, with Dietary Manager (DM), the dry storage area was observed. The stainless-steel storage shelves near the door had kitchen supplies stored on them. On one shelf there was a bin of coffee carafe lids. On top of the lids was a stainless-steel knife tray which was soiled with food crumbs and an orange colored substance. There was also a roll of Christmas wrapping paper on top of the coffee carafe lids. To the immediate right of the shelving was a column of metal employee storage lockers. DM verified the findings. During a concurrent observation and interview on 6/21/21, at 10:25 AM, with DM and Cook, in the kitchen, a dead insect was noted on the left inner portion of the lid of the ice machine. A double-chambered stainless-steel plate holder on the end of the tray line counter near the ice machine was noted. The DM and [NAME] stated the plates inside the holder were clean. The inside of both chambers had food debris and crumbs. DM and [NAME] verified the findings. During an interview on 6/21/21, at 10:45 AM, with DM, the DM stated kitchen was in need of cleaning from the floor to the walls. During a review of the facility's policy and procedure (P&P) titled, Equipment, dated 9/17, the P&P indicated, All foodservice equipment will be cleaned, sanitary, and in proper working order. 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff members will be trained in the cleaning and maintenance of all equipment. 3. All food equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. During a review of the facility's P&P titled, Food Storage: Dry Goods, dated 2/17, the P&P indicated, All dry goods will be appropriately stored. in accordance with the FDA Food Code. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate.

Jul 2019 8 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

Based on interview and record review, the facility failed to implement a person-centered care plan for Bupropion (psychotropic [affects mental status] medication used for depression) for one of 36 sam...

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Based on interview and record review, the facility failed to implement a person-centered care plan for Bupropion (psychotropic [affects mental status] medication used for depression) for one of 36 sampled residents (Resident 11). This failure had the potential for unmet care needs. Findings: During an interview with the Director of Nursing (DON) and review of the clinical record for Resident 11, on 7/25/19, at 10:01 AM, she verified the physician orders dated 6/25/19, indicated Bupropion was ordered to treat Major Depressive Disorder. The DON reviewed the clinical record and was unable to locate a care plan for the use of psychotropic medication. She stated, I cannot locate a care plan. The facility policy and procedure titled PSYCHOTROPIC MEDICATION MANAGEMENT dated 10/24/17, indicated 3. When psychotropic medications are prescribed for a specific condition or targeted behavior, the clinical record will be reflective of the diagnosis, reasons for use (functional impairment), and have a care plan in place with medication use and non-drug interventions that had been attempted to alleviate the condition .

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to monitor behavior and side effects for one of 36 sampled residents (Resident 11) receiving psychotropic (drugs that affect mental state) med...

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Based on interview and record review, the facility failed to monitor behavior and side effects for one of 36 sampled residents (Resident 11) receiving psychotropic (drugs that affect mental state) medication. This failure had the potential for Resident 11 to receive unnecessary medications. Findings: During an interview with the Director of Nursing (DON) and review of the clinical record for Resident 11, on 7/25/19, at 10:01 AM, the DON verified the physician orders dated 6/25/19, indicated Bupropion (used for depression-mood disorder that causes a persistent feeling of sadness) . M/B [manifested by] sad facial expressions related to Major Depressive Disorder. The DON reviewed the Medication Administration Record (MAR) and was unable to locate documentation for behavior monitoring of sad facial expressions and potential side effects of medication. She stated, I cannot locate monitoring for potential side effects or for sad facial expressions. The facility policy and procedure titled PSYCHOTROPIC MEDICATION MANAGEMENT dated 10/24/17, indicated It is the policy of this facility that residents in need of psychotherapeutic medications receive appropriate assessment and intervention . 11. Medication effects will be monitored and documented on the medication administration record, to include targeted behavior monitoring, and monitoring for adverse effects when the medications are used.

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, and record review, the facility failed to ensure medication error rate was five percent or less when two medication errors were observed out of 35 medication administr...

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Based on observation, interview, and record review, the facility failed to ensure medication error rate was five percent or less when two medication errors were observed out of 35 medication administration opportunities, which yielded a medication error rate of 5.71 percent. These failures had the potential for residents to not receive the therapeutic effects of the medications. Findings: During an observation of medication administration on 7/23/19, at 9:15 AM, Registered Nurse (RN) 1 gave Resident 16 one Memantine (for dementia) 5 mg (milligrams) tablet by mouth and one Zoloft for (depression) 25 mg tablet by mouth. During a review of the clinical record for Resident 16, the physician's order dated 7/13/19 indicated Memantine 10 mg one time a day and the physician order dated 6/07/19 indicated Zoloft 75 mg once a day. During an interview with RN 1, on 7/23/19, at 3:15 PM, she reviewed the clinical record and verified the total dose of Zoloft should have been 75 mg. RN 1 verified the total dose of Memantine should have been 10 mg. The facility policy and procedure Preparation and General Guidelines undated, indicated, B. 2) Medications are administered in accordance with written orders of the attending physician.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to: 1. Store medications at the manufacturer's recommended temperature. 2. Label individual resident medications correctly. T...

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Based on observation, interview, and record review, the facility failed to: 1. Store medications at the manufacturer's recommended temperature. 2. Label individual resident medications correctly. These failures had the potential to result in administered medications not to be effective. Findings: During an observation and interview with Licensed Vocational Nurse (LVN) 1, on 7/23/19, at 10:11 AM, in the medication storage room behind the nurse's station, there was a Vancomycin (treatment for infections) 1 g (gram-unit of measurement) and 50% Dextrose (management of low blood sugar) injection (shot), with a manufacture suggested storage temperature between 68 to 77 degrees Fahrenheit (F). LVN 1 verified the temperature in the medication storage room was 80 degrees F. During an observation and interview with Registered Nurse (RN) 1, on 7/24/19, at 10:33 AM, in medication cart number one, an opened box of artificial tears (moistens eyes), dated 7/23/19 was not labeled with a resident name. RN 1 verified the finding. The facility policy and procedure titled Medication Storage in the Facility undated, indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to follow directions on one of 36 sampled residents (Resident 45) meal tray identification card. This failure had the potential ...

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Based on observation, interview, and record review, the facility failed to follow directions on one of 36 sampled residents (Resident 45) meal tray identification card. This failure had the potential for decrease food consumption. Findings: During a review of the meal ticket, dated 7/23/19, for Resident 45, the meal ticket indicated SOFT/ GRAVY ON EVERYTHING . Special Note GRAVY ON EVERYTHING During an observation and interview with Dietary Aide (DA) 1, on 7/23/19, at 12:45 PM, during tray line, Resident 45's plate had carrots, lima beans, and meat. DA 1 placed gravy over the meat then placed the plate on the tray and placed the tray in the tray cart. DA 1 reviewed the meal ticket and verified she did not place gravy on the carrots or lima beans. During an interview with the Dietary Services Supervisor (DSS), on 7/23/19, at 12:50 PM, the DSS stated another dietary aide is not always available to double check trays. The DSS verified DA 1 should have followed the directions on the meal tray identification card and should have added the gravy. The facility policy and procedure dated 7/08, titled Tray Identification indicated . Procedure: 1. To assist in setting up and serving the correct food tray/diet to the resident , clearly labeled tray cards are used to identify the various diets.

CONCERN (D)

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

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to maintain the microwave in a sanitary manner. This failure had the potential for contamination of foods. Findings: During an interview with ...

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Based on observation and interview, the facility failed to maintain the microwave in a sanitary manner. This failure had the potential for contamination of foods. Findings: During an interview with Certified Nursing Assistant 1, on 7/23/19, at 8:55 AM, she stated when family brings in food from home for the residents, the food is heated up in the employee break room microwave. During an interview with the Dietary Service Supervisor (DSS), on 7/23/19, at 9:20 AM, she verified residents' food brought from home is heated up by staff in the microwave in the employee break room. During an observation and interview with the DSS, on 7/23/19, at 9:25 AM, in the employee break room, the microwave had a build up of thick brown crusty substance inside the microwave. The DSS verified the findings. During an observation and interview with the Housekeeping and Laundry Supervisor (HLS), on 7/23/19, at 10:20 AM, in the employee break room, he verified the microwave had a thick crusty brown substance and stated house keeping was responsible to clean the microwave. During an observation and interview with Housekeeper (HK) 1, on 7/23/19, at 10:30 AM, in the employee's break room, he stated the microwave is rusty, corroded, and discolored. HK 1 stated, The microwave is old and rusty, cleaning doesn't help. The HLS was unable to provide a cleaning policy.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean homelike environment. This failure had the potential...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean homelike environment. This failure had the potential to negatively impact the dignity and safety of the residents. Findings: During an observation on 7/22/19, at 9 AM, in the [NAME] Bear Mountain Avenue hallway, the floor had paper, staples, syringe cap and other debris. Several large stains were noted on the carpet. The floor on the outside of resident room [ROOM NUMBER] had a hole in the carpet that measured approximately 12 inches long by 3 inches wide. The hole left the grid-like backing of the carpet exposed. There was an odor of urine in the back end of the hallway. During an observation and interview with the Administrator, on 7/25/19, at 9:36 AM, in the [NAME] Bear Mountain Avenue hallway, he confirmed the hole in the carpet outside of resident room [ROOM NUMBER]. There was an odor of urine in the back end of the hallway. The Administrator stated, It's [the odor of urine] better than it used to be. During an observation and interview with the Housekeeping and Laundry Supervisor (HLS), on 7/25/19, at 2:07 PM, in the South Administration hallway near the facility entrance, pieces of paper and staples were observed on the vinyl flooring. The HLS verified the findings. He stated hallway carpets are not cleaned on weekends. The HLS was unable to provide a facility cleaning policy and procedure.

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 record review, the facility failed to maintain industrial sized fan, light fixture covers, and vents located in the kitchen in a sanitary manner. This failure had ...

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Based on observation, interview, and record review, the facility failed to maintain industrial sized fan, light fixture covers, and vents located in the kitchen in a sanitary manner. This failure had the potential for cross contamination of food service equipment and exposed food. Findings: During an observation and interview with the Dietary Services Supervisor (DSS), on 7/22/19, at 10:05 AM, in the kitchen, the light fixture covers on the ceiling, vents and industrial fan were noted to have thick substance build up. The DSS verified the findings and stated maintenance was responsible for cleaning on a monthly basis. During an observation and interview with the Registered Dietician (RD), on 7/22/19, at 10:10 AM, in the kitchen, the light fixture covers on the ceiling, vents and the industrial fan were noted to have thick substance build up. The RD verified the findings. During an observation and interview with the Maintenance Supervisor (MS), on 7/22/19, at 10:19 AM, in the kitchen, the vent directly over the ice machine had thick substance build up and the vent over dishwasher had hanging substance (dust). The industrial fan, the fan blades, and the light fixture covers had a thick substance build up. The MS verified all findings and stated, They need to be cleaned. During an interview with the DSS and record review on 7/22/19, at 10:30 AM, the form titled Monthly Cleaning Schedule dated 2019, indicated there was no cleaning for the month of 6/19. Findings verified by the DSS. The DSS was unable to provide a maintenance cleaning policy and procedure.

ARVIN POST ACUTE

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ARVIN POST ACUTE

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